“The secret of change is to focus all of your energy not on fighting the old, but on building the new.” – Socrates
All of us who have lost a loved one deal not only with grief but with the nagging question “what should I have done differently?”. The truth is that we will never know what may or may not have helped but that doesn’t stop those thoughts from intruding at the most inopportune times. I believe that some people are capable of learning to manage their addiction with support and structured help alone. But I also believe that there may be people for whom addiction is too powerful and they need therapeutic drugs to help them. Was our son one of those people? Would he still be alive today if we had convinced him to try medication-assisted treatment (MAT)? That is the major “what if” that nags at me. The last post discussed Narcan and I want to follow that up with a discussion of MAT, therapeutic drugs used to combat substance use disorders. So, please join me in this post, “Narcan and Friends Part 2”.
How does Medically-Assisted Treatment Work?
The short answer to how MAT works is that it depends on the therapeutic drug that is being used, but there is more to it than just that. I found this excellent summary on the Psychology Today blog:
MAT is most useful when combined with intensive one-on-one psychotherapy, group support, and complementary therapies. The way in which MAT affects the brain effectively gives the addict breathing room and time to address the underlying causes of their addiction. MAT allows the addict to focus on their recovery instead of being compelled to use by co-opted neurological processes. MAT is a tool to be used in reaching that goal of long-term abstinence from drugs and alcohol. However, if MAT is used on its own, without other forms of supportive therapy, it is unlikely that recovery will last.
https://www.psychologytoday.com/us/blog/ending-addiction-good/201701/what-you-need-know-about-medication-assisted-treatment
Did you catch those two phrases, “gives the addict breathing room” and “instead of being compelled to use by co-opted neurological processes”? Not that I think you need an explanation, but we remember things when they are stated in language that we use. In other words, the person suffering from addiction has a brain that has been physically changed to believe that it needs the substance to survive and he/she needs breathing room from the thoughts, the cravings, the triggers, drug-dreams, etc. The other important concept in that summary is that MAT alone usually will not result in lasting recovery.
What are the Therapeutic Drugs used in MAT?
Methadone
Methadone is the therapeutic drug/MAT that people are most familiar with. We have seen in movies and heard in songs how a junkie goes to the methadone clinic every day to help them get off of heroin. That is not too far from accurate. In the early stages of methadone treatment, a person suffering from addiction to opioids must go to a facility to receive their daily dose of methadone. Methadone is a full opioid agonist, meaning that it functions by attaching to the opiate receptors in the brain and it causes a similar response. Therefore, methadone can be abused and that is why in early stages of recovery it is only dispensed one day at a time.
Methadone is a synthetic opioid that changes the way that your brain responds to pain. It gives your brain the same feelings that other opioids give but at a slower rate. It also blocks the high that you get from other opioids like codeine, heroin, hydrocodone, morphine, and oxycodone. In short, methadone tricks your brain into believing that it is getting what it thinks it needs and it holds off withdrawal, while not allowing you to get high. It gives you breathing room. Some people/groups oppose the use of methadone because they believe that you are “substituting one drug for another”. To a degree, this is true but if it allows someone struggling with addiction who could not have handled it otherwise to ease into recovery, maybe it is not a bad option.
Buprenorphine (Suboxone)
Suboxone is a new and improved methadone-type treatment. Suboxone is a partial opioid agonist, which means that it attaches to an opiate receptor and provides some opiate-like feelings, but it has other features that reduce the opioid-like response. Buprenorphine (Suboxone) functions similarly to methadone except buprenorphine has a ceiling effect, that is, it reaches a level at which increasing the dose does not increase the effect. This makes buprenorphine difficult to abuse and so it does not require daily distribution.
Suboxone also contains naloxone (Narcan) which is added to prevent abuse by injecting. Under proper use, the naloxone is not well absorbed so it has no effect, but if it is misused by injection, the naloxone dominates, and the user is immediately thrown into withdrawal. Obviously, not the desired result.
Naltrexone
Naltrexone, like Narcan, is a competitive antagonist for opiates, so it functions very differently from methadone and buprenorphine. This means that naltrexone pushes the opioid molecule off of the receptor and the naltrexone then occupies the receptor, keeping the opioid molecule from reattaching. Naltrexone does not provide the opiate response in the brain, rather it prevents the euphoria and sedative effects of opioids, so abusing opioids while on naltrexone has no effect. The person with substance use disorder is not tempted to use because it has no effect and if they relapse, the naltrexone prevents the feelings of euphoria. Naltrexone not only works for opioids but it has a similar effect for alcohol, it blocks the euphoric feelings and feeling of intoxication associated with alcohol abuse.
Vivitrol
Vivitrol is a long acting, injectable form of naltrexone. In order to combat the need to take a pill daily and the likelihood that someone battling addiction might fail to take the pill, Vivitrol was developed. Vivitrol is a monthly injection that cannot be started until the individual has refrained from using for at least a week. It is naltrexone, so it does the same thing, that is, block the euphoric and sedative effects of opioids and the euphoric and intoxicated feelings of alcohol.
Disulfiram
Disulfiram is used to treat chronic alcohol abuse and it cannot be used before detoxification is complete. Disulfiram works by causing very unpleasant side effects if an individual drinks alcohol while on disulfiram. It can cause nausea, headache, vomiting, and difficulty breathing shortly after consuming even a small amount of alcohol. And this can last for an hour or more. Remember your first hangover when you swore you would never drink again? Imagine that occurring as soon as you took your first drink, that would be quite effective at keeping you sober, if you continue to take it.
Acamprosate (Campral)
Acamprosate is used to treat chronic alcohol abuse, frequently in combination with naltrexone or disulfiram. Like other addictive substances, chronic alcohol abuse results in changes to the brain that that cause extreme responses when alcohol is no longer consumed (withdrawal). While the mechanism is not well understood, we know that acamprosate helps to stabilize the brain and reduce the impacts of withdrawal.
MAT is Not Perfect
You probably noticed that the drugs that I discussed above are used for opioid addiction and/or alcoholism. There are currently no FDA-approved medications to treat other types of addiction such as, methamphetamines, marijuana, or cocaine. Even for the substances that MAT is designed to address there are issues:
- For the medication to be effective, it must be taken regularly. Individuals may forget to take their medicine or may intentionally not take it.
- When we discussed suboxone treatment with our son, he pointed out that people who are not strongly invested in getting and staying sober will frequently turn to another (non-opioid) drug to get high when the cravings get too much for them to handle.
- An integral component of MAT, noted above, is support such as 12-step programs, counselling and cognitive behavioral therapy. The drugs by themselves will not cure addiction because we have not yet found a drug that can undo the changes that the brain has gone through as a result of addiction.
My Personal Bottomline
Would my son still be here if we had gotten him into an MAT program? We will never know. The drug doesn’t stop your addiction, it just gives you breathing room, it is your desire and the support of others that gets you to lasting recovery. Is it wrong to replace a drug with a less dangerous drug? I think that the answer is no if that is the only way to keep that person alive until they can manage lasting recovery. You cannot succeed in recovery if you are dead.
Many people have very strong opinions regarding MAT and some even have experience with it. Please share your thoughts or experiences. We learn best when we learn from each other.