S

ecretary of Health and Human Services Tom Price sparked a firestorm last week with his comments about medication-assisted treatment, saying that “if we’re just substituting one opioid for another, we’re not moving the dial much” in the nation’s opioid epidemic. Notably, the former surgeon general, Dr. Vivek Murthy, took him to task on Twitter for, as he put it, moving away from evidence-based treatment protocols.

A spokesman for HHS later said that Price supports expanding access to various treatment and recovery services, including medication-assisted treatment, and was only arguing that the treatment that’s right for one person isn’t necessarily right for another.

But how much do we know about the effectiveness of medication-assisted treatment, or MAT, and what do we not know? Here’s STAT’s guide to the science.

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What is MAT? How does it work?

Understanding what heroin does in the brain and in the body is crucial to understanding why medication-assisted treatment — sometimes called medication-assisted therapy— works, said Dr. Nora Volkow, the director of the National Institute on Drug Abuse. (NIDA is one agency of the National Institutes of Health, which is part of HHS.)

Opiates work by crossing the blood-brain barrier and attaching to receptors on brain cells, which triggers a cascade of neurotransmitters and brain activity and produce the high that people feel. That brain activity can contribute to physiological dependence — and, only if combined with genetic and psychological factors that modify the way a drug is perceived, addiction.

For those struggling with opioid addiction, breaking the habit can be demanding. Dr. Scott Lukas is researching and developing drugs to treat the condition. Alex Hogan

MAT can work in one of two ways. Doctors can give people opiates that activate the same receptors but are absorbed into the blood over a longer period of time — staving off withdrawal symptoms and breaking a psychological link between taking a drug and immediately feeling high. Doctors can also give someone an opioid antagonist — a non-opioid drug that sits on those same receptors and blocks them — so that if someone relapses, he or she won’t feel anything. (If someone goes off the drug and relapses, however, that can have deadly consequences. A person’s tolerance for the drug decreases after long periods of sobriety — especially after antagonist treatment.)

That means most of these treatments just substitute one opiate for another, as Price correctly noted. Doctors think this is a good thing?

Yes, they do. “The drug that we’re replacing is a dangerous one that will kill you, and we’re replacing it with a drug that allows you to go back to work and have money in your pocket and allow you to live normally again,” said Dr. Stuart Gitlow, past president of the American Society of Addiction Medicine.

Price’s argument that “what’s right for one person isn’t necessarily right for another person” is a valid point, experts say; data have shown that MAT is effective for the general population, but that doesn’t mean it will be equally effective for every individual, given the particulars of someone’s life and someone’s addiction.

How strong is the body of evidence behind MAT?

“I don’t think that there’s any areas where the data is shaky. It clearly shows better outcomes with medication-assisted therapy than without it,” Volkow said. “Studies have shown that outcomes are much better when you are on medication-assisted therapy. For one, it decreases risk of relapse — significantly. Second, MAT has also been shown to be effective in preventing infectious diseases like HIV. Third, medication-assisted therapy has been shown to be effective in preventing overdoses,” she said.

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Though it’s hard to point to one seminal paper in the field, there is a substantial body of literature. For example, one paper found deaths from opioid overdoses fell as treatment with buprenorphine, one of three drugs often used for MAT, became more popular in Baltimore — a “statistically significant and strong” correlation. Multiple meta-analyses compared MAT to plans without any replacement therapies. (Methadone wasn’t correlated with reducing deaths in the paper or in a 2009 meta-review, but it did seem to decrease heroin use.)

While there’s plenty of evidence supporting the efficacy of MAT, there are still gaps in the scientific literature that researchers want to see addressed.

What are those gaps?

One big gap in the research is how to pick the right drug and the right dose for an individual patient. According to 2015 national practice guidelines from the American Society of Addiction Medicine, “there is some evidence supporting the relative efficacy of one medication over another, but in many cases, there are no good-quality studies comparing the relative benefits of one medication over another.”

Each drug does carry different risks and benefits. People can overdose and die on methadone, whereas they can’t with buprenorphine or naltrexone. Buprenorphine and naltrexone can be taken orally; naltrexone also comes in an injectable form. And people who need surgery can be taken off buprenorphine more quickly than they could be if they took methadone.

Ultimately, the choice will be based on a doctor’s conversation with his or her patient, Gitlow said.

Also, there’s been no clinical research done about MAT for people who have become addicted to fentanyl. Volkow thinks she knows which drugs should be most effective, but there will be an NIDA meeting on July 6 to discuss how to do the kinds of studies needed in this area.

What about talk therapy or psychotherapy?

Some studies, including one funded by NIDA, have shown that MAT resulted in some benefits even without psychotherapy. According to reviews published in the American Psychological Association’s journal, Psychiatric Services, studies found that adding psychotherapy or cognitive behavioral therapy had no effect on the outcomes of buprenorphine- and methadone-based treatment. Still, support programs are often a standard part of addiction treatment in addition to MAT.

“For every major, chronic, life-threatening disease, there’s always a combination of therapeutic modalities that are used. For instance, in hypertension, we tell people to exercise and lose weight and quit smoking and don’t eat salt in their diet and by the way, take this antihypertensive [drug],” Gitlow said. “For opioid use disorder, it’s really the same thing.”

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  • Speaking from personal experience, I can tell you that bupenorphine is a miracle drug! And to understand why, you have to understand exactly why opiates have the highest relapse rate. Opiates work by forcing tremendous amounts of serotonin out of your producers, and into your receptors. Those are your bodies natural reward center. When you eat something, it releases it and your body feels good and says, Yes, this is good for me, I did something good! You breathe, same thing, you sleep, same thing, exercise, same thing. Almost everything in your life activates it to one degree or another. You NEED it. Opiates FORCE some much of it, you experience euphoria, and don’t notice your pain. But it damages the producers at the same time. So over time, they become unable to produce on their own. When you stop, not only do you have withdrawals, but when they are gone, they still can’t produce. So EVERYTHING hurts, and is unenjoyable! It hurts to breathe, sleep, heck, your HAIR hurts! Your skin, muscles, TOE NAILS hurt! And the real kicker is, it takes UP TO A WHOLE YEAR of not using them at all for them to repair enough to start working! So you would rather die than feel the way you feel, so it’s almost no choice in whether you relapse or not. Die/use, those are your choices. But with bupenorphine, it COVERS your producers, and spots out a fake opiate to trick your brain. And for long term opiate users, those who have tried quoting a million times, till the US say they will not even consider that pain anymore, it’s a miracle! But even better, it slowly STOPS giving you any of the ‘high’ that your mind thought it was getting. But it leaves the user with absolutely no NEED to get high. No urge at all. Because you feel normal! And for someone who never thought they could feel normal again, that is the best miracle. So, you have a fake opiate, tricking you to think your getting high, while letting your body heal itself. There is no reason to take opiates, because you won’t feel them, so useless. No chance of overdosing, and if you have the kind with nalaxone in it, you would acting into withdrawals if you DID try an opiate. And it slowly takes away the high over time to leave you feeling just normal after a few months on it. You can live a normal life, and not commit crimes to get drugs. You can work a normal job, and you can even talk about your addiction in treatment or therapy, because it won’t give you any urges! So, as I said, it is a miracle drug!

  • I guess the medication useful for drag addicts and can help them to cure. But not only medication addicts need he can use a support of their family and other mental help. My brother after taking some medication to stop gaming visits center where he can get some moral support https://www.interventionservicesinc.com/ . I see that it helps him but all that process will be continue and I don’t know how long it will be.

  • Also, there’s been no clinical research done about MAT for people who have become addicted to fentanyl. Volkow thinks she knows which drugs should be most effective, but there will be an NIDA meeting on July 6 to discuss how to do the kinds of studies needed in this area.Visit us https://www.igotsober.com/

  • Ask any mother who has lost a child why MAT is a good thing!
    As we continue to see, especially now with the development of synthetic drugs, anything can and will continue to be abused!
    MAT SAVES LIVES!

  • This is another example of an incompetent administration ignoring science and objective evidence. Dr. Price was a surgeon, not even close to being an expert in addiction. He should educate himself before speaking publicly on an important public health issue. There can be improvements in current treatments for opioid use disorders (by the way, fund NIH if you want to develop those), but his original statement was not well crafted if this is what he meant (it disparaged the effects of current treatments, which are imperfect but life-saving for many people), and that original statement had nothing to do with arguing for individualized care–nice try at spinning that, but we are not that stupid.

  • The comments made by HHS secretary were narrow-minded and uneducated. Make no mistake, there will be push-back from segments of public and behavioral health, due to their concerns for personal financial losses.

  • Great educational article but I feel that you need to provide statistics for no medication treatments as well. Is there any data regarding how successful psycptherapy alone is? MAT has definitely proved to be successful and there are many peer-reviewed articles on it. However, tapering of the medication can be complicated and a long process, and many patients do not successfully complete the treatment and therefore relapse. Do we know what the completion success and relapse rates are for psychotherapy-only-no-medication type strategies are?

  • I am not talking about science. But there are more and more reports of this anointed preacher on TBN who has helped more than a few thousands addicts (may be more than a million now) with simple Gospel preaching for since 2008 over all continents by TV or Youtube effortlessly. They are naturally not scientific. But they are supernaturally real.

    • “Reports” ? I would also say there are more and more reports of alien abductions, but it does not make it true. Spirituality is important for a lot of people’s recovery from addiction, but framing it is this way–that a single person has the power to heal–is not helpful for this discussion. Spirituality comes from within–not from a single paid television preacher.

  • “Buprenorphine is taken orally, while naltrexone is injected.”

    Naltrexone is also taken orally. The injectable form, Vivitrol, is for long-term blockade — a single shot is effective for 90 days.

    • Buprenorphine is not administered orally for the treatment of opioid use disorder. Most formulations are combination formulations where buprenorphine is combined with naloxone. It is either sublingual (under the tongue–suboxone and zubsolv), in buccal form (Bunavail), and recently a new formulation of implants was FDA approved as well–lasting 6 months–Probuphine. There are other delivery mechanisms used for pain such as transdermally (butrans)–but that is a different indication. It’s important to point out that naltrexone is both oral and intra-muscular—and does NOT last 90 days as stated above, Vivitrol is FDA approved for monthly injections (30d) and oral naltrexone (Revia) is to be dosed daily. These medications can be complicated to understand. Particularly, how they fit in what is called “harm reduction.” But it’s important to be accurate so I offer these corrections. These medications are effective when used correctly–especially when a comprehensive biopsychosocial approach is taken looking at the whole person, not just on the medications. Dr. Mario

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