Ask the Experts: Understanding Medication Assisted Treatment
By Alex Peak
Editor and Publications Manager
Addiction Technology Transfer Center Network Coordinating Office
Medication Assisted Treatment (MAT) plans incorporate medication in conjunction with counseling and behavioral therapy as a means to comprehensively treat patients with substance use disorders. The most commonly prescribed medications are methadone, naltrexone and buprenorphine. Although each medication works differently, they're all intended to subside cravings and mitigate withdrawal symptoms.
MAT is designed to be a stepping stone toward the ultimate goal of full recovery, including the ability to live a self-directed life. According to Substance Abuse and Mental Health Services Administration (SAMHSA), this treatment approach has been shown to improve patient survival, increase retention in treatment, decrease illicit opiate use and other criminal activity among people with substance use disorders, increase patients’ ability to gain and maintain employment, and improve birth outcomes among women who have substance use disorders and are pregnant.
The ATTC Network invited three experts to convey their experiences and perspectives of utilizing MAT in their practices.
Frances Rudnick Levin, MD
Kennedy-Leavy Professor of Psychiatry in the Division of Substance Abuse at CUMC
Director of the Addiction Psychiatry Fellowship Program at New York Presbyterian Hospital
Sharon Levy, MD, MPH
Director, Adolescent Substance Use and Addiction Program
Boston Children’s Hospital
Drew Lieberman, MD
Chief Medical Officer
Compass Detox (South Florida)
Why was it important for you to integrate medications into your treatment of opioid use disorders?
Dr. Levin: Integrating medications for treatment of opiate use disorders has strong evidence in reducing overdose deaths, as well as relapse. There are substantial consensus and guidelines from the World Health Organization, as well as federal guidelines, supporting that medications for opioid use disorders is the standard of care. It doesn't mean that psychotherapeutic options aren’t useful; but to prevent overdose, medications for opioid use disorder are critical in reducing this risk.
Dr. Lieberman: I think that medication is only a portion of the treatment. I do believe that if patients don't address their psychosocial issues or mental illness, that medication is not the cure-all panacea. I'm a big believer in coordinating counseling, therapy, psychiatric medication and other medication. The medications for opioid use disorder is not the only way to be in recovery. Many people think it's too much about medications. But that's really not the answer — it’s only part of it.
Were you resistant to offering medication-assisted treatment (MAT) to your patients with opioid use disorder? If so, what helped you overcome that resistance?
Dr. Levy: I was not at all resistant; though when we first started offering Medications for Addiction Treatment back in 2004, my hospital was concerned. There was a worry that we would start having patients with more severe substance use disorders and our teenage patients with addiction would overdose in the waiting room. One of the senior physicians in the hospital asked if there was “a New England Journal of Medicine article” showing that medications for opioid use disorder are effective. The question is funny because it is so specific and a very high bar — we use lots of medications that have not been published in the NEJM. But ironically, David Feillin had just published a landmark article in NEJM that I was able to share, and so our plan to offer MAT was accepted. Of course within a few months, everyone recognized that their fears were not realized — our patients were completely indistinguishable from anyone else in the clinic. And over time, our services have gained greater and greater appreciation. Now the hospital is asking large groups of physicians to get their waiver so they can prescribe!
Dr. Levin: Early on in my career, I was excited by the idea of viewing substance use disorders as medical illnesses and noting that we don't have this kind of debate over things such as diabetes or hypertension, of course, and medication is part of those illnesses’ treatment plans. When you have medications that are effective, it should be part of treatment. There are going to be some patients who are going to say no — and you work with that and you come up with alternatives. For me, medication was never something that I was resistant toward. I’ve always thought it made sense, given our understanding of addiction as a disease.
Did you have to secure buy-in for MAT from your staff? If so, what strategies worked best for getting their buy-in?
Dr. Levin: What I've seen in working with medical treatment facilities throughout the country is that up until recently, (and I think it’s mostly prompted by the opiate epidemic and overdoses) many programs were ”drug-free,” meaning medication free. It was a heavy lift to convince staff that medication for alcohol dependence could be helpful. Many programs did not have it as part of the treatment plan. And still don't in many cases. It's been changing rapidly, but there are still many programs that will simply detoxify patients and not put them on medications that have been approved for certain substance use disorders — despite the fact that in the case of opioids, the risk of overdose is high. I think there's still a lot of work to be done. And people come with their set of beliefs rather than what the available data supports.
Dr. Lieberman: I believe in right patient, right time, right treatment, The first thing you have to do when you evaluate these patients is to reduce harm. You have to take the risky behavior out of their situation. So what the medication assisted treatment allows you to do is really buy more safety margin. As the head of the medical team, I get the input from the nurses, counselors and everything else. But usually, we agree on a treatment plan. Ultimately, it's my decision, but I don't really get pushback from the team.
Can you give an example of a process within your clinic or practice that you had to change when you began to offer MAT?
Dr. Levy: Because MAT is so highly regulated, our clinic has a number of procedures to make sure we remain in compliance. Actually some of that is burdensome, but the hospital has supported us in making it all work. Someone in the compliance department once told me that our substance use disorders program is one of the three most highly regulated in the entire hospital — the other two being bone marrow transplant and dialysis. Which is a remarkable comparison considering that when I ask kids if they are using drugs, I get the same level of compliance scrutiny as the transplant team that puts new organs into patients and the dialysis team that runs a patient’s entire blood volume through a machine. Fortunately, the hospital has provided the support that we need to make it all work — with a bit of infrastructure, it is manageable.
For some prescribers, diversion of medications is a big concern. What do you recommend to prevent diversion?
Dr. Levy: Our program has a number of strategies, including smaller prescriptions (one month with no refills for stable patients) asking parents to hold medications for younger kids, counting pills at visits, and testing for buprenorphine and norbuprenorphine (a metabolite) in urine tests. We don’t worry as much about diversion of naltrexone since it isn’t psychoactive.
The bottom line, though, is that we know how important it is to keep kids on meds, so we don’t make them jump through hoops to get their medications. And we never want to put them in a position where they might withdraw. If someone calls for an early prescription, we generally ask for an additional drug test and then write a prescription that will get them through their next appointment. Overall, I think the risk of diversion of a small number of pills from a small prescription is lower than the risk of overdose for someone who runs out of medications and goes into withdrawal (especially if the patient has been stable and lost tolerance).
Dr. Levin: I think it depends on what you're talking about. If you're talking about naltrexone, there's really no concern about diversion. I think there is the possibility of diversion with buprenorphine and methadone — although it’s a little harder with a methadone program where there are daily interactions with staff and administration of the medication. At present, I think the medication that people are most concerned about diversion is with buprenorphine.
One way to reduce diversion is to check the Physician Monitoring Program for your state. Having a practice in both New Jersey and New York, I am mandated to check the program and find it very helpful. I think it is also critical to talk to patients about carefully safeguarding their medication. Also, pill counts and urine testing can be implemented to revise treatment plans and if there are concerns regarding nonadherence and diversion.
Although there are ways to reduce diversion, you’re never totally going to eliminate it. If patients want to mislead their physician, it's always possible. But I think as a physician or other prescriber you have to weigh the risk of diversion against the risk of not prescribing the medication and the loss of accumbent therapeutic benefit and, in the case of opioids, higher risk of overdose. The choice of medication requires careful attention to the advantages and disadvantages of each of the available choices and shared decision making between the patient and physician.
What are a few things that you would like prescribers to know about MAT?
1. It is lifesaving. I know because I have seen it.
2. It is very easy to prescribe. It is very well-tolerated in my experience, and there are few contraindications.
3. It is MUCH less dangerous than many of the other medications (including pain medications) that prescribers use routinely.
Dr. Lieberman: When prescribed correctly, MAT shouldn’t allow patients to achieve a high or euphoric event. I think there are prescribers out there who don’t have enough experience and are prescribing unnecessary high doses of buprenorphine. And that just makes it that much harder for either detoxification from that or to get them on to a different treatment modality.
About the experts:
Frances Rudnick Levin, MD, is the Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University and Chief of the Division on Substance Use, and Director of the Addiction Psychiatry Fellowship Program at New York Presbyterian Hospital. Dr. Levin graduated from Cornell University Medical College and completed her psychiatric residency at the New York Hospital-Payne Whitney Clinic.
She is the principal investigator on several federally funded grants, including a Medication Development Center, a T32 NIDA funded Substance Use Research Fellowship, a K24 Mid Career Investigator Award and collaborates on several other grants. Her research interests include pharmacologic and psychotherapeutic treatment interventions for cocaine and marijuana abuse, and treatment approaches for substance abusers with attention-deficit hyperactivity disorder and other psychiatric illnesses.
Sharon Levy, MD, MPH is a board certified Developmental-Behavioral Pediatrician and an Assistant Professor of Pediatrics at Harvard Medical School. She is the Director of the Adolescent Substance Abuse Program (ASAP) in the Division of Developmental Medicine at Boston Children's Hospital, which is comprised of clinical, research, training and policy arms. She has evaluated and treated thousands of adolescents with substance use disorders, and has taught national curricula and published extensively on the outpatient management of substance use disorders in adolescents, including screening and brief advice in primary care, the use of drug testing and the outpatient management of opioid dependent adolescents. She is currently the co-PI of a SAMHSA-funded adolescent SBIRT project, an NIAAA-funded study validating the youth alcohol screening tool in a population of youth with chronic medical illness, and a Conrad N. Hilton funded study that aims to validate adolescent SBIRT measures and test a brief intervention for medically vulnerable youth.
Drew Lieberman, MD, is the Chief Medical Office at Compass Detox in South Florida. Dr. Lieberman graduated from State University of New York Downstate Medical Center College of Medicine. He completed his residency at the Albert Einstein - Montefiore Medical Center. Dr. Lieberman has worked as a physician leader and educator in his community for three decades. His prior focus was on the improvement of surgical outcomes in outpatient settings with his background as an anesthesiologist and medical director. Recently, he's been fighting the national epidemic of opioid abuse. Direct patient care and the possibility of saving lives is what drives him every day.