The United States is in the midst of a public health crisis. Opioid use disorder (OUD) is a chronic medical condition of epidemic proportions, yet one of the most promising, evidence-based treatments for OUD is underused.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), medication-assisted treatment (MAT), combined with evidence-based behavioral interventions, is an effective treatment for OUD. Yet fewer than half of individuals struggling with opioid or heroin use disorders receive MAT (Volkow, N.D., Frieden, T.R., Hyde, P.S., Cha, S.S. 2014. Medication-assisted therapies: tackling the opioid-overdose epidemic. New England Journal of Medicine; 370:2063–2066).
For those who do receive MAT to help with their addiction, common medications include methadone, buprenorphine and naltrexone. Prescriptions are based on an individual’s personal and clinical needs. Though MAT may be used during inpatient treatment, it is more often administered in an outpatient setting.
The positive effects of MAT are well documented. MAT is associated with a marked reduction in overdose deaths (Schwartz, R.P., Gryczynski, J., O’Grady, K.E. et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. American Journal Public Health. 2013;103(5):917–922). And — critically important — MAT has proven successful at retaining patients in treatment (Mattick, R.P., Breen, C., Kimber, J., Davoli, M. 2009. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002209. DOI: 10.1002/ 14651858.CD002209.pub2).
In addition, a recent peer-reviewed study, reported by the National Institute on Drug Abuse, revealed promising long-term outcomes for MAT participants. The research showed 61 percent of participants once addicted to prescription opioids were still clean more than three years later. About half the participants still received a maintenance dose of buprenorphine-naloxone. Overall participants reported a general improvement in their health and a decline in chronic pain (National Institute on Drug Abuse. 2015. Long-term follow-up of medication-assisted treatment for addiction to pain relievers yields “cause for optimism”).
Unlike MAT, the traditional approach to treating OUD has individuals undergo a medically supervised detoxification process. They are then weaned off the opioid and return home. But this approach doesn’t treat the chronic nature of substance opioid use disorder, or its effects on the brain. Without appropriate maintenance medication to subdue cravings and adequate psychosocial support, most people relapse (Volkow et al., 2014). The results are often tragic. Even a brief abstinence from opioids can reduce a person’s tolerance level, which leads to a greater chance of overdose with later opioid use (Knopf, A. 2016. Even a low dose of opioids after a short period of abstinence can result in overdose. Alcoholism & Drug Abuse Weekly).
Given that OUD is a chronic medical condition, it can’t be cured by short-term interventions. A more effective approach is to manage it over an extended period of time. MAT pairs therapies such as counseling or cognitive behavior therapy with FDA-approved medications to treat substance use disorders and prevent opioid overdose (SAMSHA. 2015. Medication-assisted treatment: Medication and counseling treatment).
So why is MAT not used more often in treating OUD?
Barriers to MAT
Despite MAT’s powerful outcomes, it has been adopted in fewer than half of private-sector treatment programs. Even in programs that do offer MAT, only 34.4 percent of patients receive it (Knudsen, H.K., Abraham, A.J., Roman, P.M. 2011. Adoption and implementation of medications in addiction treatment programs. Journal of Addiction Medicine. 2011;5:21–27).
Barriers to MAT may include lack of treatment capacity and a lack of providers certified in MAT, deficits most profound in rural areas. To address this problem, Optum has developed one of the most robust MAT networks in the nation. Further, some providers seem reluctant to take the eight-hour training required for MAT and apply for the federal waiver because they, or their office neighbors, do not want people with substance use disorders frequenting their practice. This may explain why a substantial number of providers who have undergone the required training still are not treating patients with MAT (American Society of Addiction Medicine. 2013. Advancing access to addiction medications: Implications for opioid addiction treatment).
The stigma about using drugs to treat opioid use disorder also creates a barrier. Many providers, patients, and members of the substance use treatment and 12-step communities object to MAT. They mistakenly believe that it replaces one dangerous drug with another. But we wouldn’t withhold insulin from a diabetic, for example. MAT drugs block cravings, allowing individuals to lead normal lives —with family, work or school — while undergoing treatment.
Treatment for a Chronic Medical Condition
Dr. Dan Karlin, an Optum Behavioral Health provider board-certified in psychiatry and SUD medicine, is an advocate for MAT and more specifically, for buprenorphine. “Buprenorphine is the single most effective medication in psychiatry. It’s more effective than antidepressants for depression,” Dr. Karlin says.
Along with buprenorphine, “the treatment of comorbid conditions is incredibly important,” he says. Through psychotherapy, patients can start addressing their substance use disorder and then move on to other underlying and emerging troubles.
When people engage in MAT and a moderate level of psychosocial counseling, they have better outcomes than individuals who only receive MAT or MAT with minimal counseling (Center for Substance Abuse Treatment. 2005 Medication-assisted treatment for opioid addiction in opioid treatment programs. SAMHSA).
Therefore, a comprehensive treatment plan consists of three elements:
- Medication used to manage the effects of withdrawal from the opiates
- Therapy or counseling, such as cognitive behavioral therapy, that may also help provide the patient with skills to aid in recovery
- Connection to long-term support that will encourage patients to stay engaged in treatment, preventing the risk of relapse
MAT medications can alleviate cravings and withdrawal symptoms, and block the effects of opioids in the event of relapse. They also adjust the chemical imbalances in the brain created throughout the development of an addiction.
At the proper dose, MAT substances do not impair a person’s intelligence, mental capability, physical functioning or employability. On the contrary, they allow people to more fully engage in such proven behavioral interventions as counseling and begin to reclaim their lives. Many people stay on a maintenance dose of medication for years.
To overcome barriers and the stigma of MAT treatment for OUDs, Optum Behavioral Health is working to educate providers, health plans, the recovery community, and the public in general to see MAT as a safe and accessible path to recovery. We believe in the effectiveness of MAT, and have developed a nationwide network of MAT providers; 95 percent of our members are an average of 20 miles away from a MAT provider.
Working together, we can take on this public health crisis by advancing proven treatment methods and bringing dignity to those who suffer from the chronic medical condition that is OUD.
Dr. Martin Rosenzweig is chief medical officer for behavioral solutions at Optum, and the head of the substance use disorder treatment initiative across the company’s behavioral health business. A practicing physician for more than 30 years, he received his medical degree from the University of the Witwatersrand in South Africa.
