Medication-Assisted Treatment for Substance Use Disorders

This article provides a detailed overview of medication-assisted treatment for substance use disorders, including the benefits, how it works, what medications are used, and how MAT is integrated into a comprehensive treatment plan.

Key Takeaways:

• Medication-assisted treatment (MAT) is the use of specific medications to help with substance use disorder withdrawal, recovery, and relapse prevention.

• Alcohol and opioids are the most common substances that benefit from MAT, while it may also help with tobacco/nicotine and other substances.

• MAT is combined with psychotherapy, counseling, and/or other strategies as part of a comprehensive treatment program for the best results.

Understanding Medication-Assisted Treatment (MAT)

Medication-assisted treatment (MAT) refers to the use of specific medications alongside part of a broader substance use disorder treatment program. Medications are implemented in various types of substance use disorders due to their potential to help manage cravings, mitigate withdrawal symptoms, and prevent use or relapse, among other benefits. ^[1]

Is MAT the Same as MOUD?

MAT includes treatment for opioids and other substances, such as alcohol, nicotine, or cocaine. By contrast, MOUD (medication for opioid use disorders) refers to medications specifically used within opioid use disorder alone. So, they’re not the same. ^[2]

Why Substance Use Disorders Can Require Medication to Treat

Substance use disorders are often very difficult to treat, in part because of the way they alter the structure and function of the brain. Chronic substance use leads to significant alterations in dopamine sensitivity, reward pathways, and effects on other neurotransmitters, such as GABA, depending on the drug involved. ^[2]

Over time, individuals require more of the drug to achieve the same rewarding or pleasurable effects (known as tolerance). If this continues, chronic drug use eventually leads to dependence and addiction, in which withdrawal symptoms arise when the drug is not present or to an adequate level. Due to the combination of intense drug cravings and highly uncomfortable withdrawal symptoms, this makes it very difficult to stop using these substances. Thus, medications are often necessary to help with these symptoms and consequences. ^[2]

Managing Withdrawal Symptoms During Detox

The first step in substance use treatment is detox, in which the substance is initially removed from the body. This can produce highly uncomfortable, and sometimes dangerous, withdrawal effects.

Thus, one of the goals of MAT is to reduce withdrawal symptoms, such as anxiety, insomnia, irritability, tension, lack of appetite, and tremors. These medications primarily work by targeting the specific neurotransmitters that were negatively impacted by drug usage, which in turn helps decrease withdrawal symptoms. ^{[2] [3] [4]}

Tapering

After detox, substance use disorder treatment programs help the individual gradually decrease the amount of the substance that they’re taking over time, in a process called tapering. Similar to their roles in detox, medications are often used during the tapering process to help with any withdrawal symptoms that may arise as the addictive substance is lowered.

This is due to their ability to act on the specific neurotransmitters that were affected by the addictive substance. For example, medications to help with nicotine dependence commonly act on dopamine receptors, while medications to help with alcohol dependence commonly act on GABA and opioid receptors. ^[2]

Craving Management

MAT is also essential for helping patients manage cravings, which can become very strong and sometimes seemingly uncontrollable. Drug cravings can be caused not only by physiological factors (e.g. increased stress response, dopamine signaling), but also psychological and environmental factors, which makes them very important to manage. ^[1]

Medications used within MAT for substance use disorders are believed to help manage cravings by balancing neurotransmitters that are involved in cravings, which can also decrease the stress response. For example, naltrexone can help with alcohol cravings, while methadone can help control opioid-related cravings. ^[4]

Substance Addictions That Require MAT

Several substance addictions often require MAT, due to their complexity, severity, and significant potential for relapse. The most common substance use disorders that often require MAT are:

• Opioid use disorder (OUD)

• Alcohol use disorder (AUD)

• Tobacco/nicotine use disorder (TUD)

Cocaine, marijuana, and methamphetamines may also be treated with certain medications, although there are no FDA-approved medications specific for MAT in these cases.

The Opioid Epidemic and Increased Need for MAT Access

Opioids are some of the most damaging substances, due to their strong potential for abuse and overdose. Recent data on the United States shows that, of the 110,000 overdoses in 2023, 76,000 were due to synthetic opioids. ^[1]

MOUD are effective, but only 20% of individuals with OUD are prescribed them. And of the people given a prescription, up to half discontinue them. Therefore, there’s an urgent need for greater accessibility for MOUD, as well as better treatment plans to help with discontinuation rates. ^[1]

Where is MAT Used?

MAT can be used in a variety of settings, such as:

• Inpatient care

• Residential treatment centers

• Outpatient treatment

• Intensive outpatient programs (IOPs)

• Primary care

• Community services (e.g. federally-qualified health centers [FQHCs])

The exact setting where MAT is utilized depends on several factors, such as the severity of the substance use disorder, expected treatment duration, relapse history, and each person’s available resources and finances. Ultimately, the goal is to utilize the least intrusive setting possible, while still providing the most appropriate and effective level of care. ^[2]

Types of Medication Used in SUD Treatment

There are several types of medications implemented when treating SUDs. The exact medication(s} implemented depends on the specific problematic substance involved. Some of the most common medications are: ^{[1] [2] [3] [4]}

• Naltrexone

• Methadone

• Buprenorphine

• Acamprosate

• Varenicline

• Disulfiram

Naltrexone acts as an opioid antagonist, which blocks the rewarding effects of opioids in the brain, whether from alcohol or opioids. Thus, it’s s often used within OUD and AUD. ^{[2] [4] [5]}

Methadone is an opioid agonist, whereby it binds to the same receptors as synthetic opioids. It helps control withdrawal symptoms and cravings, without providing euphoria or other opiate-like effects, when used at prescribed doses. It is commonly used within OUD, especially long-term. ^{[2] [4] [5]}

Buprenorphine has both agonist and antagonist effects on opioid receptors. This combination of effects may help control withdrawal symptoms and cravings, while also minimizing euphoria and overdose. It is used within OUD. ^{[2] [4] [5]}

Acamprosate acts on NMDA receptors and helps to balance levels of glutamate and GABA. These effects can help minimize withdrawal effects from alcohol and restore balance to the brain after chronic alcohol use. Thus, it’s used within AUD. ^{[2] [4] [5]}

Varenicline is used for TUD due to its role as a partial nicotine receptor agonist. This drug helps control cravings and withdrawal symptoms from nicotine use, while also blocking the rewarding effects of tobacco/nicotine. ^{[2] [4]}

Disulfiram is an aldehyde dehydrogenase inhibitor, which blocks the breakdown of alcohol. In turn, this blockage creates unpleasant effects, such as flushing, sweating, and nausea, which helps to deter alcohol consumption. Thus, it’s used for AUD. ^{[2] [4]}

Challenges and Risks of MAT

MAT offers several benefits, although there are possible challenges and risks as well. For one, it’s sometimes difficult to get patients to strictly follow their medication plans. In addition, some medications, such as methadone, are only available through licensed clinics, which may limit the availability and implementation of such medications. ^[2]

Medications also pose the risk of adverse effects. Medications with agonist effects may increase the risk of overdose or other heightened responses, particularly with excessive doses or when combined with other substances. Additionally, medications with antagonistic effects may increase the risk of withdrawal and related symptoms. MAT also needs to be used cautiously in individuals with certain medical conditions, such as liver or heart problems. ^{[2] [4]}

MAT and Co-Occurring Disorders

MAT can be particularly challenging to implement in individuals with co-occurring disorders (or comorbidities). In part, this is because comorbid cases often require multiple medications to treat an array of symptoms, which in turn increases the risk of drug-drug interactions and side effects. ^{[1] [2]}

Similarly, medications that may be theoretically beneficial for SUDs may lead to a worsening of certain mental health conditions, or otherwise negative effects. This is due to the effects that medications have on neurotransmitters and mental health in general. ^{[1] [2]}

Integrating MAT and Behavioral Therapy Programs

For the most beneficial outcomes, MAT is used alongside behavioral therapy as part of a broader treatment plan. Behavioral therapy may consist of a variety of interventions, such as cognitive-behavioral therapy (CBT), motivational interviewing, medication compliance therapy (MCT), community reinforcement approach, contingency management, and twelve-step models. While there are many goals of these therapies, they’re primarily used to help with medication/treatment adherence, and addressing any barriers to such adherence. ^{[2] [4]}

MAT takes priority during the detox and withdrawal phases. After the initial phases, MAT is used simultaneously alongside psychotherapy and behavioral interventions. Overall, there is evidence that combination treatment is the most effective for improving treatment outcomes and reducing the risk of relapse long-term, compared to either treatment alone. ^{[3] [4]}

Accessing MAT and SUD Treatment

Limited accessibility to MAT and SUD treatment has historically been an issue, although accessibility has increased in recent years. MAT and SUD treatment are often carried out at specific treatment facilities, although the initial process typically starts with an examination by your primary care provider. There are several resources that can help you find SUD treatment programs near you, including:

• FindTreatment.gov

• SAMSHA’s National Helpline: 1-800-662-HELP (4357)

The American Addiction Centers also offers a detailed article on common barriers to addiction treatment, such as finances, geographic limitations, or stigma, and ways to address these barriers, so you can get the care you need.

Takeaway

MAT can be very valuable for helping individuals overcome substance use disorders, especially in the context of a comprehensive SUD treatment program. The right treatment can help individuals recover from SUDs, increasing the chances of leading a healthy, successful life.

Medication-Assisted Treatment FAQs

Is MAT covered by my health insurance?

Yes. Most insurance plans offer at least partial coverage for MAT. However, your plan may not provide full coverage, so always check with your insurance provider.

Do I have to inform my employer if I’m receiving a MAT?

No. You do not have to disclose your MAT to your employer, although you have the option to do so.

Do I still need an X-waiver to be prescribed buprenorphine?

No. As of January 12, 2023, you no longer need an X-waiver to be prescribed buprenorphine.

Is medication-assisted recovery the same as MAT?

Yes. Medication-assisted recovery generally refers to the same treatment as MAT.