Secretary 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.
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.
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.
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.”
About the Author Reprints
For “Anselm”. Didn’t you forget shooting it up? That is another reason folks are negative to MAT. The harm in diversion is to those diverting, not to the users. 95% are desperately trying to avoid the miseries of withdrawal. Diverting to sell is because the patient is not being honest with themselves or their Doc. They need more work on their recoveries, not to be fired. Frequent visits and pill counts are the solution, even daily sometimes.
Stating that low-lives and homeless are the ones responsible is INCORRECT AND VERY PREJUDICIAL AGAINST ADDICTS. The disease, Substance Use Disorder, has a lifetime incidence of 15-20% of the population. That includes us docs, teachers, lawyers, etc. You don’t escape genetic predisposition (or diversion) if you are rich or educated, so stop with the stigmatization already.
Oh, and lets remember how many died from abusing buprenorphine; one if used without CNS issues or use with other meds (Invidior stats).
Those posting about the suffering need Docs who know how to use buprenorphine and a multidiscipinary approach to attain functionality.
Hey doc, I meant in my post not to blame the lower SES and homeless population as being responsible. That would be naive and incendiary to make. I was offering another aspect to the general topic which you wrote to very well. That, there is also a more sub specific concern where it impacts these populations because in my work I have seen a syndicate of some sorts in various clinics as well as MAT clinics where patients come in asking for pain meds only to turn around and sell to sustain their basic living needs. I agree that the concern is two folds. One to the diverter and second to the ones receiving the drugs. I have far too much respect working with addicts and supporting their recoveries to make such a sweeping statement which seemed to be misunderstood. In any case, you have written a very good article that is commendable. I appreciate your reply and no, my intentions of contributing to this reply was not to incite more stigma; rather, I am reminded always to be mindful of not contributing to the stigmatisation of the disease. Again, I appreciate your passion in the work that you do; as are my efforts in helping addicts recover.
I had 11 surgeries long story short I became addicted to opioids for three years along with therapy I been on suboxone that enabled me to find my purpose in life which is substance abuse counselor. I completed my casac and undergrad in human services. suboxone was a real miracle drug.
When first manufactured, seemed like adding Naloxone to Buprenorphine would be a helpful idea. Time has proved that unnecessary. Its own antagonist ceiling restricts the usual opioid high. Without CNS dysfunction or the addition of alcohol, benzos, or other sedatives, there has only been one OD death in an elderly patient. Even with other additives, there have not been many deaths, including the accidental deaths in kids.
Buprenorphine deserves it’s Sched. lll assignment. It is generally safe and works well for both acute and chronic pain. Trouble is, it does have more side effects than the monoproduct when you add naloxone, over 30% of patients. Those patients should have the option of taking the monoproduct, which is approved for the first week of therapy during “induction,”(Martin, et al, Annals Int. Med, 10/23/18) which many studies have proved unnecessary, and it is also preferred for pregnancy. Combination product 3x as expensive. Medicaid and other insurances are reading 20 year old unchanged drug inserts and limiting dosage for pain patients needing function and relief.
Why aren’t we helping with the epidemic by prescribing Buprenorphine for pain for everyone? Is it too pricey, or is it a “drug for addicts”, or is it that docs don’t want addicts in their offices, or it is unfamiliar to them? All the above and more (see the studies). Getting providers to change is challenging, like turning the Titanic with a 5hp outboard. Maybe eventually.
Diversion? 95%+ to treat opiate withdrawal for those on the streets with OUD.
Solution? Make it cheaper and more available to those in need.
Absolutely great post Robert! It is refreshing to see a physician with accurate, factual knowledge on this topic. There is soooo much misinformation out there. If you’re ever looking to change the MAT world, give me a call…..seriously.
Thanks,
Marc Burrows
Greenville, S.C.
People can absolutely overdose on buprenorphine/naltrexone just like methadone or Tylenol for peaks sake .Buprenorphine/Naltrexone are higher risk for abuse/misuse because it easily obtained by a doctor or easily bought on the streets. Methadone is must more tightly regulated. So whoever wrote this article was misinformed and wrong saying you cant overdose on Subs.
Those are two different issues. Yes, one can overdose on buprenorphine but it is highly unlikely. There are very few reported bup overdoses. However on methadone, it is much easier to overdose, as it is a much more “dangerous” drug. But yes, methadone as a whole, is more regulated and therefor is less of it on the streets.
Also consider the impact of diversion culture. In lower SES or homeless population, folks are taking these drugs and selling it on the streets or giving it away.
I would like to be on board with calling B.S. on this buprenorphine treatment mentality. I have watched my spouse use AND abuse buprenorphine (which supposedly “isn’t possible”). I have also watched him try and FAIL (miserably) to be appropriately removed from this medication that this article deems easier to be removed from than methadone (don’t be mistaken, methadone is horrid too). Mark my words; buprenorphine will be the new crisis/epidemic in 10 years.
It’s unfortunate you saw negative experiences with buprenorphine treatment. But luckily for us, we don’t use one experience to judge treatment as a whole. Science backs up the use of MAT 100%. No one is saying it is perfect. But it is the best response we have to this opioid problem. The only crisis we will have is getting people off buprenorphine. Addiction can largely be solved though, as the two are different issues. A person on MAT can live a normal, healthy life, despite being dependent to buprenorphine. Technology is already starting to find new ways of getting people off the meds.
In our community there is a problem with this form of treatment. The clinics and prscribing physicians are not thorough enough with the counseling and client assessments. Young people are not working the plan to eventually be substance free. Some are using the treatment as a way to continue to abuse. This is leading to more and more criminal charges, as well as continued abuse.
I am a 68 year old female with degerative disc disorder. I was getting a low dose of pain pill that allowed me to take care of myself. As I had a back fusion 9 years ago, I don’t expect any more surgery. The specialist want me to turn my bones to dust with steroid injections. It is sad buy I have resorted to self medication. The street dealers are getting rich. I never thought the government would be able to tell my DR. what he can and can’t treat me with. Way to go !
alot of your data is misleading and incomplete. Suboxone/Subutex treatment is not “replacing one opiate with another”. It does not have the same euphoric effect as methadone, which itself does not compare to the high of heroin. These are maint. medications. One aspect that you tragicly neglected was chronic pain sufferers with Substance Use Disorder. This is an all too often ignored problem in treating addiction.
I watched my spouse abuse suboxone and YES it does have a euphoric effect especially when taken inappropriately as a specific means to get high.
I agree totally with that comment .
I Have Neuropathy in my feet, got hooked on Oxy260mg/day and Fentanyl100mic which was prescribed by Pain Specialist ,after over 2 years the Oxy/Fentanyl nearly killed me, booked myself into a clinic , was put on Suboxone and walked out 7 days later. I am still on a maintainance dose of 4mg Suboxone/day along with Lyrica but they do not take the pain away like the Oxy’s did but I can thank God for getting me into the clinic and off those painkillers . I am not really convinced the Suboxone help, but my head tell me it might so I try to convince head to ignore any pain signals😀
I am very pro-Suboxone
I am a 37-year-old woman that has been on pain medication since I was in high school, 16 years old, due to a car accident on my first date. Anyways, after three hip surgeries and a c-section, I found myself in pain as the dr. Started to wean me down. It wasn’t just pain in my hip, it was all over my entire body. Long story short I ended up on heroin and made a complete mess of my life. I have been on methadone for almost two years on June 23, after so many attempts I lost count, and I have not used any other substance. My boyfriend and I got clean together, but he relapsed and overdosed last June 9th. I will never feel whole again. He knew my deepest darkest moments. Anyways, I really feel at this point whatever it takes for someone to quit buying junk on the streets and then leaving you loved ones to clean up your mess because that last one did it. It will if you give up. I believe as long as you keep trying to get sober that one day it will stick. It’s a formula really, everyone is different. I have counseling once a month now, but I did go once a week for a long time. I went to 3 or 4 meetings a week for the first year and now I go to a trauma group once a week and my homegroup once a week. I also started taking online classes last May to get my bachelor degree in Human Services; it’s my time to give back and help someone like I was helped. Sorry if I rambled, but people are dying like every 16 minutes I read somewhere. And children are the silent victims. #NEVERGIVEUP
Awesome keep going! Baby steps are the way to success. I’ve been fighting food addiction for most of my life and I have had close calls with various other methods of self medicating. The last 3 years I’ve been really taking a whole health approach to my medical needs. I am working on my Bachelors Degree in human services, A Direct transfer Associates degree first and my life experience is all I have right now but. I will never quit on life.
i have been on suboxon for over 5 years. I was on it without treatment and my life was no different than when i was using opiates. The term dry dunk is used to describe an alcoholic who isnt drinking but acts the same as when they were when drinking. I was a dry addict so to speak. After two years i started a treatment with the suboxone and my life has completely turned around. I have not used others drugs and most importantly have changed my behavior. i am a different better person now. i am proud of the person i am now and love my life. I think treatment is a must to have real recovery
That is a great story of success! Suboxone on the street can help momentarily but I agree that treatment makes the real changes. Thanks for sharing.
When I was on suboxone for a year, I was forced to do group therapy for addiction in order to get suboxone, the medication that allowed me to function and help my chronic pain. The suboxone itself was a miracle right away and I was productive and happy, but after months of being forced to do group therapy in order to get my medication I felt trapped and became very depressed. Others in my group who where there longer than I also felt trapped and would cry in the coffee room about being forced to be there. I couldnt take it anymore I was very depressed. I started weaning off after 7 months and stopped the suboxone at 11 months. I wanted to do it slower but the therapy forced me off sooner just as it did another man in my group, he was going mad being forced into endless therapy and so was I. Now iam living in chronic pain and anxiety, both of which I had since 17 years old. Pain is due to a car accident. The anxiety must be something I was born with. Over the years my doctors tried just about every medication and i seen a psychologist (which by the way doesn’t count for therapy when on suboxone, only an addiction therapist which is useless when on suboxone because you are well, can’t fix what is not there). Only after suboxone when your issues surface again can addiction therapy be helpful in my opinion. Also an addiction therapist doesn’t know much at all but how to treat addiction so forget about it being helpful for at least any underlying issues that cause you to self medicate such as pain, anxiety, or depression. Alot of addiction treatment facilities are cashing in on suboxone treatment by forcing people to come there 4 times a month or more. Sometimes it comes down to someone exhausting so many options without finding an answer to a chronic problem, than finding opiates and realizing that this allows to me function and have a quality of life, but instead of being able to get proper guidance or answers, they are forced by more government regulations to hide, lie and self medicate.
I am an addict in recovery from alcohol and opiates, including herion. I went to school to help ppl in addictions. When I started working in the field, I was told to keep my experience out of treatment. The boss was an insecure control freak. Went to work at other places. Most clients that came in wanted meds without therapy. Others wanted to step down fast but the doc wanted them on suboxone long term. I have never spoke to any person in long term recovery that felt like methadone or suboxone really helped them. Imho, self help groups (like AA/NA) are where recovery is at. Just stopping doesn’t stop the mental nature of addiction. That’s why “changing drugs- may reduce harm but is ultimately like switching seats on the titanic.” Without stopping, the addict won’t get recovery. Without addressing the underlying issues the addict will relapse, change drugs (relapse), be miserable (sometimes suicidal). Many treatment centers are money making businesses. Some are good, most are terrible except to detox. If drug assisted centers got ppl off drugs sooner, had daily, long term treatment and didn’t cater to judges, doctors, probation/parloe, they might be more successful in real treatment. Addiction is widely misunderstood, even by most addicts. This is what I’ve experienxed getting clean/sober, as well as trying to help ppl who are madeto get treatment with no real desire to stop active drug/alcohol abuse. Best wishes. Comnents are not directed to any one person, just a personal/professional opinion on the issue at hand.
Jason, I Disagree, One Size Does No Fit All, and the Titanic remark I Disagree with as well, you should know this too, No one’s Body or Brain functions are the same, just as one person likes sweets another likes salt, just like we know for other conditions, diseases, one med my work for one but not the other, one person may be able to lower their cholesteral by exercise and diet alone while it may take meds for another! Funny I see some folks on 5 or 6 different meds, all doing who knows what to other organs etc in their bodies, harming their bodies, but what thats OK because its not an Opioid! Hey, folks do what works and is Positive in your Life, we miss the important point here, if totally medicine free is the best positive route for you then that is Awesome, but if help with MAT is the best positive route for another than that’s Awesome! As my Mom told me once and I always will remember Thank The Good Lord we are not all alike, what a crazy and boring world this would be! Thank goodness our brains don’t function the same! Just remember people become dependent on all kinds of medications for various reasons, dependency does not equate to Addiction unless it is creating Negative consequences, and I don’t know about you all, but I’m yet to find a Perfect Person here on earth, the only Perfect One I know of IS JESUS CHRIST! Well Wishes To All!