How Does MAT for Opioid Use Disorder Work?

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To understand the importance of MAT for opioid addiction, it’s good to have a basic knowledge of how opioids affect the brain. Opioids such as oxycodone, heroin, fentanyl, Percocet and Vicodin attach to certain receptors on brain cells, igniting neurotransmitters and sending signals that block pain, slow breathing, and promote a feeling of calmness.

When misused, they also flood the brain’s circuits with dopamine—that “feel-good” chemical that sends the brain feedback about rewards—creating a feeling of euphoria. For the sake of survival, our brains are naturally wired to repeat behaviors associated with pleasure or reward. So, when that reward system is over-stimulated by the effects of opioids, the brain remembers that behavior and records it as something that should be repeated without even thinking about it.

In short, opioids change the brain on a physiological level. When misuse leads to addiction, a person continues to use these drugs despite negative consequences in their lives. Recovering from this complex medical condition requires more than just individual will power.

FDA-approved medications—methadone, buprenorphine, and naltrexone—can either safely replace the opioids, or block the opioid effects on the brain. These medications can also relieve physiological cravings.

Before starting MAT, authorized clinicians screen patients to be sure they are prepared to undergo treatment, both physically and psychologically. Before beginning MAT, patients will need to stop taking anti-anxiety medications including Xanax or Valium which, when combined with MAT meds, could be fatal.

Naltrexone (Vivitrol or ReVia), buprenorphine (Suboxone), and methadone are three effective medications used to help treat opioid use disorder. MAT strategies vary because each patient is unique. That’s why it’s important to seek a licensed practitioner to determine what the best treatment plan is in each case.

 

Medications for opioid use disorder treatment: quick facts for patients

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Buprenorphine

• Uses & effects: Taken orally once daily, or via sustained-release forms like an implant or injection. Reduces cravings and withdrawal symptoms.

• Advantages/Disadvantages: Available by prescription, eliminating the need to go to an authorized clinic every day. But, finding a provider who is licensed to prescribe buprenorphine can be challenging.

• Where to find: Via prescription from certified clinicians at ERs, general practice offices, and treatment clinics. Prescriptions can be filled at the pharmacy.

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Naloxone / Naltrexone

• Uses & effects: Taken orally or via a monthly sustained-release injection. Reduces withdrawal effects and cravings. Blocks the effects of opioids.

• Advantages/Disadvantages: Does not require daily visit to authorized clinic. But, patients must be completely substance-free for 7 days prior to beginning naltrexone treatment.

• Where to find: Via prescription from certified clinicians at ERs, general practice offices, and treatment clinics. Prescriptions can be filled at the pharmacy.

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Sources: New England Journal of Medicine + US Department of Health and Human Services

Buprenorphine is a partial agonist—it replaces opioids, and blocks the effects of any other opioids that are taken in addition. While allowing patients to taper off opioids gradually, Buprenorphine (or “bup”) also reduce the debilitating side effects of withdrawal. Specially licensed clinicians can prescribe buprenorphine in pill form, allowing patients to take their medication without supervision. Buprenorphine is also available as a monthly injection and as a time-released implantable device, administered by a specially licensed clinician.

Unlike Buprenorphine, naltrexone is an opioid antagonist. Naltrexone binds to receptors in the brain in order to fully block the effects of opioids. In the U.S., naltrexone is available in prescription pill form and as a monthly extended-release injectable. Extended-release naltrexone is available as in implantable device in Russia and other countries and has proven effective at reducing impulsive behavior leading to relapses and fatal overdoses.  

Every patient’s needs are different. While buprenorphine and naltrexone are very convenient and eliminate the need for daily dosing at a clinic, methadone is highly effective for many patients. Working closely with a coordinated care team, including family, friends, counselors, and clinicians to identify the best strategy will help ensure the chances of successful treatment and recovery.

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Common Hurdles That Obstruct MAT Access

Despite overwhelming expert support for evidence-based addiction care, only 20 percent of the 2.1 million Americans who meet the clinical criteria for opioid addiction are receiving specialty treatment. Why is there such a disconnect? There are 3 main types of hurdles standing between patients with addiction and effective medical care.

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Stigma

There is widespread misinformation about addiction treatment—even among clinicians. For many years, most clinicians and addiction treatment specialists prescribed total abstinence from any substance, believing that this was the only way for patients to recover. Even though many scientific studies have proven that medications are highly effective in treating substance use disorders, stigma persists, keeping patients from accessing the most effective treatment for their illness.

From doctors to family members to recovery coaches, many Americans think of MAT as crutch, a cop-out, or a way for people with addiction to continue using drugs.
These misconceptions couldn’t be farther from the truth. MAT is not replacing one drug with another. When used as directed, addiction medications do not trigger euphoria, or have dangerous adverse effects. In fact, MAT is designed to make it possible for patients to be productive, to become healthier, to secure employment, or to return to work or school. People taking medications to treat their substance use disorders can work, drive, and care for their families. And that’s what recovery is all about.

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Training, Authorization, and Coordinated Care

It’s a puzzling fact, but a fact nonetheless: Even though most physicians in America can prescribe addictive and dangerous opioid painkillers with few if any restrictions, doctors must become specially certified in order to prescribe addiction medications.

The training and certification of clinicians, including family physicians, is a huge hurdle that stands in the way of widespread MAT access. There are many restrictions on where MAT can be offered, and who can administer it. And due to these restrictions, many clinicians and facilities have limited capacity for the number of patients they can accept at one time. In many communities, only some of the MAT medications are available, which limits patients’ options.

Some clinicians refuse to administer MAT medications—even when they are authorized to do so—because of personal beliefs, the lack of coordinated care with mental health professionals (especially in rural communities), the additional time commitment required, and the potential threat of raids by the Drug Enforcement Administration and the FBI.

What’s more, it’s hard to access medications even within traditional addiction treatment centers. Few inpatient treatment facilities offer all three FDA-approved medications for opioid use disorder. While the American Society of Addiction Medicine (ASAM) has defined detailed standards of care, there is no established national accreditation program for treatment facilities in the U.S. 

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Medicaid and CHIP Payment Access Commission has also detailed key obstacles to patient access to MAT, including finding prescribers who take Medicaid as payment for treating opioid use disorder, Medicaid drug formularies that only offer some of the MAT medications, and time limits on MAT treatment.

As the opioid epidemic draws increasing attention to the lack of addiction treatment in America, there’s a new focus on finding ways to ease these restrictions. The newly passed SUPPORT for Patients and Communities Act, helps knock down some of these access barriers. 

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Insurance Coverage for Substance Use Disorders

Insurance coverage for addiction treatment varies by plan and by state. While the Affordable Care Act requires most insurance providers to cover addiction treatment, not all plans cover all three FDA-approved MAT medications. Some limit the number of doses and prescription refills for MAT patients.  Many insurance companies limit what they cover. For example, some patients must pay out of pocket to see a psychiatrist and get prescriptions for their MAT medications. Each of these visits can cost upwards of $400.  

Substance use disorders are chronic, often lifelong medical conditions. In spite of this, some insurance companies restrict how long they will cover MAT medications, as well as any other care that patients need to support their ongoing recovery. The Mental Health Parity and Addictions Equity Act requires health insurance providers and group health plans to cover behavioral health just as they do any other medical conditions. Still, finding medical and behavioral health clinicians certified to provide MAT is an obstacle to comprehensive treatment for substance use disorders. 

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Advocating for MAT in Your Community

Want to advocate for access to addiction medications in your community? Here are some helpful resources.

• Challenging the Myths, a one-page PDF from the National Council on Behavioral Health

• MAT Support Organizations, a list of nonprofits and government agencies from SAMHSA

• Advancing Access to Addiction Medications, a comprehensive guide from The American Society of Addiction Medicine

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Lead the MAT Conversation with Your Doctor

Your doctor may not know about Medication-Assisted Treatment  (MAT), may not be authorized to administer it or may not support it. Lead the discussion. Declare that MAT is what you need. Advocate for yourself. Be armed with evidence. Know your rights.

Here are some talking points and sources to cite when you discuss the importance of MAT with health care professionals.

• The American Medical Association, The American Association of Family Physicians, The World Health Organization, the American Society of Addiction Medicine (ASAM), the Centers for Disease Control (CDC) and many others have identified MAT as the standard of care for Substance Use Disorder (SUD), including Opioid Use Disorder (OUD).

• MAT helps save lives and prevent relapses and overdoses, according to several clinical studies.

• MAT is patient-centered, built around a coordinated care team of clinical, vocational + psychotherapeutic experts with the active participation and support of loved ones.

• Opioid Use Disorder (OUD) is a chronic condition, much like diabetes and asthma. MAT provides ongoing treatment for this chronic condition.

• Stigma can kill.  How we talk about OUD matters. OUD is not a moral failing.

•  MAT drugs, if administered properly, can save lives. MAT is NOT trading one drug for another.  Each patient responds differently to MAT, requiring individualized approaches.

• FDA approved medications—Buprenorphine and Naloxone can regulate brain chemistry and/or block the euphoric effects opioids produce.  These medications can also relieve physiological cravings.

• Many clinicians consider MAT too much trouble.  Many are keen to refer patients with OUD out to other clinicians or programs. When patients’ own doctors and even emergency rooms won’t help administer MAT, OUD goes untreated and fatal overdoses and relapses increase.

• Primary care and other practitioners need to step up. A growing number of clinicians can get authorized to prescribe MAT. 

• MAT Saves Lives presentation, produced by the National Academies of Science Engineering and Medicine.

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