De-bunking myths about medication assisted treatment
State and local governments are responsible for providing treatment, prevention, and recovery efforts for substance abuse disorders (a.k.a. addiction). But they have tragically been overlooking a key element that can help millions of people affected by opiate and opioid addiction: prescription medications!
Here, we speak with Paul Samuels, the Director and President of the Legal Action Center (LAC), about why and how people SHOULD access vital medications for addiction treatment. Then, we invite your questions or comments at the end. In fact, we try to respond to all legitimate questions with a personal and prompt reply.
ADDICTION BLOG: Can you give us a brief overview of the current FDA approved medications – methadone, buprenorphine/naloxone, and injectable naltrexone – and how they help people address opiate and opioid addiction?
PAUL SAMUELS, LAC: There are three types of medications that are currently used for the treatment of opioid addiction: agonists, partial agonists, and antagonists.
1. Agonists – Agonists are opioids that have a less intense and longer lasting effect than opioids that are commonly misused. Agonists turn on the same receptors as other opioids but the lower intensity and longer duration prevent the cycle of withdrawal and escalation that are part of addiction.
2, Partial agonists – As the name implies, partial agonists work similarly but produce an even weaker effect.
3. Antagonists – Conversely, antagonists work by blocking the receptors in the brain on which opioids act, so that if a patient does relapse and use the formerly misused drug, it will have a completely blocked or diminished ability to trigger that receptor.
Methadone is an agonist and has been successfully used as part of methadone maintenance therapy for over 40 years. Buprenorphine is a partial agonist. It has also been combined with naloxone, an antagonist, and marketed under the name Suboxone. This combination suppresses cravings and provides an additional deterrent by causing unpleasant withdrawal symptoms in patients who relapse and inject an opioid drug.
Naltrexone is an antagonist medication that binds to and blocks the opioid receptors in the brain so that a patient cannot experience the effects of opioid drugs except at doses so high that patients are unlikely to override the medication. For the treatment of opioid addiction, naltrexone must be administered through a monthly injection under the brand name Vivitrol.
The important thing about all these medications is that they can reduce opioid misuse when administered as part of a treatment plan that also includes close monitoring and counseling and have been proven to be more effective than monitoring and counseling alone for many patients.
ADDICTION BLOG: In an ideal scenario, what might medication-assisted treatment (MAT) prescription, use, and transitions look like? What is a best-case scenario or outcome?
PAUL SAMUELS, LAC: In an ideal scenario, a wide-range of treatments including medication-assisted treatments (MAT) would be available to all patients with opioid dependence and other substance use disorders. Not every person with an opioid misuse issue needs to be treated with MAT. But the decision of how best to treat a substance use disorder should be left to the patient and their healthcare provider, informed by the best available science.
Here are some key points essential to increased access and use of MAT:
1. Increased insurance coverage: Making MAT available means increasing public and private insurance coverage so that people have coverage for all three currently FDA-approved medications for the treatment of opioid dependence and any addiction medications that receive approval in the future.
2. Reduced stigma: Reducing the stigma that keeps people from seeking help or staying in treatment is vital to increased use of MAT.
3. Improved policies: Eliminating policies in the criminal justice system that prohibit the use of MAT and barriers in insurance plans that make it more difficult to get approval for addiction medications and other substance use disorder treatments than it is for comparable medical and surgical health services.
People need options that can be tailored to their treatment needs, just like we try to give them for other health issues. When a person and their healthcare provider determine that it is the right treatment option to try or continue, MAT should be available on demand, affordable, and accessible. We also should be doing more to identify and approve additional medications to treat opioid addiction and other substance use disorders.
ADDICTION BLOG: Critics want to know: Is use of medication addiction treatment substituting one addiction for another?
PAUL SAMUELS, LAC: No, medication-assisted treatment is absolutely not substituting one addiction for another.
People may view addiction medication this way because some MAT medications are opioid-based. People who take them are physically dependent on them and will experience withdrawal symptoms if they discontinue use. An important point to remember is that there is a huge difference between physical dependence on a medication that helps a person live a normal, healthy life and addiction to a harmful drug that diminishes a person’s health and well-being and carries a high risk of criminal justice involvement or death.
Addiction medications are fundamentally different from short-acting opioids such as heroin and prescription painkillers. The latter go right to the brain and narcotize the individual, causing sedation and the euphoria known as a “high.” In contrast, addiction medications like methadone and buprenorphine, when properly prescribed, reduce drug cravings and prevent relapse without causing a “high.”
All three FDA-approved medications can help patients disengage from drug-seeking and crime and become more receptive to behavioral treatments. One of the three, Vivitrol, blocks the brain’s opioid receptors and does not cause physical dependence at all.
ADDICTION BLOG: Why do you think the public looks at methadone treatment programs negatively?
PAUL SAMUELS, LAC: I’d like to amend the premise. While there are certainly members of the public who view methadone negatively, there are also substantial numbers of people who understand the decades of science proving the effectiveness of methadone maintenance therapy. Unfortunately, too many people have seen firsthand the devastation that opioid addiction can cause, but they have also seen the chance for recovery that methadone and other medications can offer.
With respect to the negative perceptions out there, to the extent people believe that methadone is substituting one drug for another, they may view methadone treatment programs as part of the problem, not the solution. People who hold these views are likely unfamiliar with the science behind methadone and other medications. For example, many do not know that continuous methadone maintenance therapy has been associated with drops in heroin use of over 80%.
Even supportive members of the public often do not realize that methadone programs are subject to extensive regulations that require them to monitor their patients for illicit drug use and provide them counseling and support services. A lot of people may be surprised to learn that many people who attend methadone programs are successful parents and employees. They go straight from their program to their jobs, where no one even knows that they are in recovery from opioid addiction.
ADDICTION BLOG: How can this opinion be turned around?
PAUL SAMUELS, LAC: More people need to be exposed to the overwhelming evidence supporting the effectiveness and safety of methadone and other medications, the heart-wrenching stories of friends, family members, and neighbors lost to the scourge of opioid addiction, and the incredible stories of lives restored by these powerful treatments. We are losing about 100 people a day to opioid overdoses in our country, more than die in traffic crashes, and these medications can significantly reduce those numbers. When people know that, it’s hard to argue with.
ADDICTION BLOG: What are some other known barriers related to medications used for addiction treatment, especially related to insurance? What about FDA approval of new medicines?
PAUL SAMUELS, LAC: On the insurance side, we have Medicaid coverage for all three opioid addiction medications in only 28 states. In addition, while most insurance plans covered by the Affordable Care Act are required to cover substance use disorder treatments, many plans still impose difficult to surmount bureaucratic hurdles for medication-assisted and other treatment, including:
- onerous prior authorization requirements
- limits on dosage and length of treatment that have no basis in science
- requirements that patients “fail first” at other treatment options before they can receive MAT
This is the equivalent of telling a cardiac patient that unless he has a heart attack while receiving other treatments, he cannot receive the medications his doctor says may save his life. Some of these plans exclude methadone maintenance therapy entirely from coverage. Plans must cover all of the FDA-approved medications for addiction, including both those we have now and any approved in the future.
In the criminal justice system, many jails, prisons, parole and probation departments, courts, and other programs prohibit the use of medication-assisted treatment or even require people who have been successfully receiving MAT to discontinue the treatment that is working for them.
Addiction is a chronic disease. Like other chronic diseases, when you abruptly discontinue treatment that is working, the results are predictable. With opioid addiction, patients whose treatment is cut off are likely to relapse, and because opioid addiction can lead to fatal overdoses, I am sad to say that some of our friends and neighbors will die as a result.
ADDICTION BLOG: The Comprehensive Addiction and Recovery Act of 2014 aims to improve the health system for individuals with addictions and their families. How?
PAUL SAMUELS, LAC: The Comprehensive Addiction and Recovery Act, CARA for short, is a great piece of federal legislation that takes a comprehensive approach to address the opioid and overdose epidemic. Among other things, CARA would create grant programs to demonstrate the effectiveness of medication-assisted treatment in the community as well as for those involved in the criminal justice system and expand opportunities to address drug-related crimes in the community instead of through incarceration.
It would support a range of drug treatment options, educate the public and first responders about heroin and other opioids and options for treatment and recovery, and support additional activities to prevent and treat addiction and support recovery. Equally important, because CARA is one of the relatively few pieces of legislation in Congress with bi-partisan sponsorship and support, it has a real chance of becoming law.
ADDICTION BLOG: LAC recently published A REPORT on more effective use of medication-assisted treatment. Can you explain to our readers the main suggestions contained in the report and the legislation might be improved?
PAUL SAMUELS, LAC: Our recent report, “Confronting an Epidemic: The Case for Eliminating Barriers to Medication-Assisted Treatment of Heroin and Opioid Addiction,” made a number of concrete recommendations that would immediately expand access to MAT and reduce the stigma and misinformation that keep these treatments from being more widely available.
1. First, public and private insurance must provide good coverage for all three FDA-approved medications for opioid addiction: buprenorphine, methadone and injectable naltrexone (Vivitrol).
2. Consumer protections like the parity law need robust enforcement. Attorneys general across the country should look to New York’s Attorney General Eric Schneiderman who has been a leader in this regard.
3. We need to divert people away from incarceration and justice system involvement and into treatment and eliminate policies in the criminal justice system that prevent people from getting MAT even when a healthcare provider says it is the right treatment for them.
4. Finally, we have to educate healthcare providers, criminal justice practitioners, and the general public about how these medications work and the human lives we put at risk when we deny access to them. As I said before, when you know the facts, it’s hard to argue for anything but more access to MAT.
ADDICTION BLOG: The report also speaks about the influence of medication-assisted treatment on employment and marriage too. What are your thoughts in this area?
PAUL SAMUELS, LAC: For many people, employment and family are significant parts of a fulfilling life. They are also two potential sources of the stability and motivation that are critical to a person’s sustaining long-term recovery, The evidence shows that when people who are addicted to opioids receive medication-assisted treatment, their employment and marriage rates go up. When patients relapse, employment and marriage rates go down; people are less likely to relapse when they receive MAT.
ADDICTION BLOG: How do you think this new piece of legislation might influence criminal behavior?
PAUL SAMUELS, LAC: CARA expands access to MAT and other types of addiction treatment that have been shown to reduce crime and recidivism rates. If passed, the law would contribute to safer, healthier communities and also help us reduce mass incarceration and the dangerous overcrowding we see in many prisons and jails.
ADDICTION BLOG: Regarding the business aspect, what kinds of benefits do you see to improved access to medication-assisted treatment on the economy? What are possible downsides?
PAUL SAMUELS, LAC: First, I’d like to say that this issue is about the value of human life and our moral responsibility to look out for our neighbors and family members. It’s literally about mortality and morality.
Opioid misuse has been on a frightening upward trajectory in this country. Deaths from overdose have nearly tripled (tripled!) in just the last few years. Improved access to medication-assisted treatment will save lives and preserve and heal families and communities across the country.
The business case also is straightforward. With opioid addiction, we are not just talking about people who are poor or unemployed, although they certainly need help and deserve our compassion. We are talking about businesspeople, white – and blue – collar workers, teachers, nurses, bus drivers: the people who make the economy work.
The National Drug Intelligence Agency has reported that illicit drug use in the United States cost the economy over $193 billion in 2007 alone, before the recent dramatic upswing in opioid misuse. If you want healthy, productive workers and consumers, you should favor better access to MAT. Studies have shown that treatment with medications can increase employment among former heroin users by as much as 27%. We really do not see a business downside.
ADDICTION BLOG: In what ways are you helping specific clients and what kind of obstacles are you facing in the process?
PAUL SAMUELS, LAC: People contact us from all over the country when they are being forced off their addiction medication by judges and probation officers or when they cannot obtain MAT in jails and prisons. The stories are heart-breaking. They usually involve people who are doing well on MAT and abstaining from illicit drug use, often for the first time in years. They have been given the unimaginable choice of tapering off their medication against their doctor’s recommendation, with high statistical odds of relapse and future incarceration and the possibility of dying from an overdose, or defying the order and being immediately incarcerated.
We also hear from people whose private or public insurance doesn’t cover medication-assisted treatment or creates enormous obstacles to obtaining approval for payment even when their treating physician determines it’s what they need.
We don’t have the capacity to represent all the people who come to us, but we provide them and their advocates with information to protect their rights and their recovery. The obstacles are numerous. Many of the judges and officials are not familiar with the science behind these medications or have attached stigma to the disease of addiction and the medications that can treat it. Some defense lawyers are similarly misinformed or biased. Many insurance plans are not parity – or ACA- compliant.
ADDICTION BLOG: Would you like to add anything else for our readers?
PAUL SAMUELS, LAC: Yes, one last thing. The Administration of President Obama, including the White House Office of National Drug Control Policy, SAMHSA and other parts of HHS, and other federal agencies have put the nation’s drug policy on a new path that emphasizes health and treatment over stigma and criminalization. As part of this approach, they are promoting the use of MAT as one of the scientifically proven effective treatment options for opioid addiction.
We would like to see the rest of the executive branch follow suit. That means the federal Bureau of Prisons should be a model corrections system that offers MAT as a treatment option to people in its custody. Medicare should cover medication-assisted treatment. The Department of Transportation should change its regulation that allows a physician to certify that their patient can safely operate a commercial motor vehicle if the patient is under that physician’s care and receiving any medication whatsoever unless that medication is methadone. It makes no sense. It’s not based on science. It puts DOT between doctors and their patients. And it should be changed.