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The Argument For MAT

Group of People Silhouettes at Sunrise

The position of the Department of Public Health in Massachusetts is that Medication Assisted Treatment (MAT: Methadone, Buprenorphine, Naltrexone), is not Harm Reduction (eg. safe injection equipment, condoms for HIV). While its benefits may indeed not be limited to harm reduction, it is undeniable that MAT clearly reduces many potential injuries associated with opioid addiction. It does so in 4 ways:

1) It immediately eliminates any withdrawal from opioids. This point cannot be overstated. When addicted to opioids, the individual is in a constant race against time. If the person doesn’t find and take in more opioids, within 24 hours or so he will start a slide into incredibly painful and uncomfortable withdrawals that can last many days. As the quantity of opioids increases – which it necessarily does due to tolerance and the strength of the opioids on the streets (especially fentanyl) – so does the agony of the withdrawals. This makes it very hard to successfully wean oneself off the opioids. The brain is constantly screaming for some opioids to end the pain of withdrawal. Imagine this battle in your head stretching out for days, even weeks. It is incredibly hard to stay with the discomfort. At one point in the film The Good Thief, Nick Nolte’s character has someone handcuff him to the bed so that he won’t give in during these agonizing withdrawals.

An individual wishing to come off opioids can check him or herself into a detoxification program, but by definition detoxification units are designed and paid for by insurance to withdraw a person from any drug only until the medical dangers of withdrawal have passed. The length of stay is not long enough to protect someone from the harmless yet longer-lasting ill effects of the withdrawal, such as what I call “restless body syndrome” or insomnia. This abbreviated stay thereby increases the chances that the person will give up and use.

2) Methadone and Buprenorphine fill the receptor sites on the neurons the illicit opioids previously filled, and so reduces much of the craving for the opioid that accompanies that slide into withdrawal. Naltrexone – Vivitrol is the name of the monthly shot – does not. It is only an opioid blocker.

3) There are many well-designed studies that show that Methadone and Buprenorphine reduce by roughly half all opioid overdose deaths. Here are two meta-analyses (meta = analysis of multiple studies); Cochrane Database Syst Rev.

4) There is also good evidence that Methadone and Buprenorphine cut the number of relapses to opioids in half, when the dosage is right. For Buprenorphine, the study authors note that Buprenorphine must be given at doses 16mg or greater for relapse rates to drop.

Given the high overdose death rates we are seeing across this country, the strength of the street drugs, and the weight of the above evidence – regardless of whether you are a novice or have been using opiates for 10 years – the first thing I always recommend to families is to get your Loved One on MAT as a first line of defense.

But here’s the problem. I see it in my own work with jails, in the recent literature, and the direction policy is headed. The emphasis on a carefully designed, integrated treatment plan is dwindling. Efforts made to implement such plans are less robust.

MAT was designed as part of a three-legged stool: medication, psychosocial support and mutual aid. The full spelling of MAT in fact is: Medication-Assisted Treatment, that is, medication in support of substance use disorder treatment. You have but to look at the report of a SAMHSA/NIH sponsored Buprenorphine summit in 2014 for evidence that two of the three legs are dropping away. In over 80 pages, the words therapy/counseling/self-help appear just 8 times.

One reason this is happening is due to the rather surprising finding that adjunctive therapy combined with the medication doesn’t seem to improve outcomes. However the authors note this is an area in need of further research on this, particularly around which psychosocial interventions seem to be most effective within various populations.

A white paper by the Hazelden/Betty Ford Organization argues that until MAT clients are carefully matched to quality, need-specific, evidence-based psychotherapies, we are doing opioid use disordered clients serious harm. We are not providing clients with a carefully tailored integrated plan that will address the long-term needs of living life free of illicit opioids (never mind the other drugs of abuse that so many individuals struggle with and sometimes turn to when opioids are off the table).

To address the question recently posted on this blog of whether someone needs to be put on MAT for a lifetime: The American Society of Addiction Medicine recently came out in favor of medication for life. The analogy you often hear equates MAT for addiction with insulin for Diabetes. For some this may be true. There are those who physically need or want to stay on the drug. There are those who don’t want to make any lifestyle changes and prefer to rely on the medication. And then there are others who, after getting stable with the help of the medication, want a fighting chance to eventually come off the medication. I follow the blog of a MAT prescriber whose common sense and care for her patients helps them taper off when they are ready. It is indeed possible to live a good life without MAT, but I believe success largely depends on the willingness to work a program of recovery.

The same can be said of other prescription medications for various health conditions. Expecting to stay on a medication for life goes along with a certain perspective about one’s health. People approach this prospect differently based on a variety of factors, again, having to do with what lifestyle changes they may or may not be willing to explore to address their health condition or conditions. Wherever one falls within this spectrum, quality of life remains a relevant consideration – for any medication. For those who remain on MAT for life, the quality of life that allows them should not be minimized in this discussion.

Side-effects have not been fully studied at this point. In MAT with Buprenorphine: Assessing the Evidence, however, a number of findings are discussed, including the safety profile of buprenorphine especially in relation to cardiac electro-physiology. These findings were positive (Martin et al. 2011) The authors also note that buprenorphine “has fewer drug interactions than methadone, especially with HIV medications.” And the article cites various maternal and neonatal studies on buprenorphine, showing promising numbers related to neonatal abstinence syndrome and infant development. (Jones et al., 2012)

While long-term side effects remain to be fully studied, based on the evidence that is immediately available, there are many reasons to consider MAT as a first line of defense. Given the scale of the opioid epidemic, and the potency of what is on the street, those afflicted stand a fighting chance with the addition of MAT to their arsenal. Emphasis is on the use of MAT as it is intended – within the context of that three-legged stool: medication, psychosocial support and mutual aid.

One of our members recently wrote in about her work managing two sober homes. She reports that, when taken as directed, Suboxone has about a 70% success rate in this setting. This is a very good outcome. I have just started crunching the numbers for one of my jail grants, and "success," defined as 4 weeks of urine tests that are negative for illicit opiates, is just under 30%. Out of 125 inmates who leave jail, and who are either started on MAT while in jail and/ or case-managed to a community MAT program, 91 go to their first MAT appointment, and 27 are clear of opiates in month 2 (so just under 30% of the 91). This is with ongoing case management and bus tokens for transport. They are not clear of other drugs necessarily. In comparing our outcomes, one could argue that sober housing is boosting outcomes by 40%!!!  Folks in those sober housing programs may not be so different than inmates leaving a county jail. In Springfield, 1  in 7 pass through the local jail every year.

Neither the sober houses mentioned nor the jail grant is a rigorously designed randomized clinical study but the differences are suggestive of how important safe, structured housing may be to addressing opioid addiction.

If only we were asking questions like this in the research: how much does safe sober housing increase the success of suboxone?

As a treatment system we are not actively and intensively case-managing people into quality psychosocial therapies and mutual supports. Instead the field is dividing between “Drug-free” and MAT, as though being abstinent of illicit drugs and on MAT is not “drug free.” Followers of the above-mentioned blog on tapering note that we should be celebrating the sobriety of anyone who is able to stay off drugs in the long term, not discounting the success of those who are doing so with the assistance of medications.

If this blog does nothing else, I hope it sheds a light on the sheer complexity of addiction and the need to create treatment plans tailored to the individual. Such plans would need to include medications (both for addiction and mental illness), evidence-supported psychosocial therapies, connection with a community of concern, and help meeting the basic needs of life: through safe housing, finding and maintaining work that pays a living wage, help with children, transportation, and the family training we provide at Allies in Recovery.



In your comments, please show respect for each other and do not give advice. Please consider that your choice of words has the power to reduce stigma and change opinions (ie, "person struggling with substance use" vs. "addict", "use" vs. "abuse"...)

  1. Thank you for this detailed report. I too will go back and read the links you provided. I will also share this with those in my recovery community where many grapple with these issues.

    You nailed it when you state that the current treatment system does not case manage people into quality therapies and supports. I cringe when I see those I know who struggle with the umpteenth relapse detox cycle return to the same one-size-fits-all recovery plan that didn’t work well the last time or 2 or 10. They often do get better over time and their “runs” get shorter but it’s often due to their individual learning curve, not because of their supports. Sadly, the treatment community often seems fine with this model.

    I completely agree that we should be celebrating the sobriety of anyone who stays off of drugs for the long term no matter how they do it. I have my own soap box position about my son’s recovery from opioid addiction using medical marijuana and how his success is discounted, but I have heard the same kinds of opinions expressed about those who use MAT. That they aren’t sober unless they are abstinent.

    I also agree that treatment plans have to be individualized to address the underlying reasons a person became addicted in the first place, whether it was childhood trauma, self-medicating a mental illness, thrill seeking, etc. I see a few who are able to uncover these issues about themselves in church basement meetings, but most probably need more individual guidance. The need for support for living (housing, work, family) realistically take a back seat to achieving a good stretch of sobriety, but in my experience, there comes a time when the person in recovery bumps up against the reality that life is hard. Paying bills, keeping a car running, staying motivated at a dead end minimum wage job, facing that your criminal record may always limit your options. As I’ve heard many addicts say, when you’re using, life is simple and all you worry about is your next fix. I’ve been personally trying to address this with those I know in longer term recovery by taking with them about plans for the future such as school, job training, mentoring, etc. They sometimes brush this off as if they still don’t think they have a future but I think it’s a vital shift in self identity to see oneself beyond a recovering addict.

    Just my two cents worth. As you say addiction is complicated. We are all doing the best we can with the knowledge we have. I hope we all as a community of treatment professionals and loved ones of those who suffer from SUD, continue to ask questions and seek answers from each other without judgement. Your site provides such valuable support and education to families. Thank you.

  2. Please accept my gratitude for your explanation about withdrawal and how hard it is. I have known about my son’s addiction for the last two years of a ten-year addiction to smoking heroin. He hates it and attempted to withdraw many times on his own, and with me. He said he never got high from smoking, only when he was taking pills which he eventually could not afford. He described it as being a slave to a cruel and relentless master. He refused treatment, finally lived with me, and I think both of us survived only because of the support of this website. I learned to speak compassion even when I was as angry and depressed as I have ever been. Today he finally sees an addiction doctor after buying Suboxone on the street for six months. He is proud to have gotten the Master off his back, finally talking about the process and his thoughts. I am finally letting myself hope the very hard part could be over. I see him composing music again, which he said he could never do on drugs, laughing again, and expressing joy about the simple things. My angry and cynical son has retreated leaving a happy person. He still has trouble sleeping, but he is working a job and hopeful. And I am hopeful and full of gratitude for the lack of judgment I found here in the most isolated and sad period of time in my 70 years.

  3. What a great response!!!!! From my experience with my daughter there is a lot of ignorance surrounding MAT. In Texas (south) the recovery community do not accept MAT. Wrongly they do not feel that being on MAT is being sober. They have shamed her and turned their backs on her. Hazelden Betty Ford is on the leading edge of treatment for opioid addiction. They saved my daughter’s life. Two years ago when my daughter was there they told us about MAT. I will tell you I was not thrilled about it and I was fearful but after seeing how well my D did I was amazed. The added benefit of MAT is it helps with depression especially those who have not responded to medications. My D was happy for the first time in years. She was on MAT for a few months and was working at a detox center but because of her inability to find support and a sponsor she slowly weaned off. Within a month she relapsed. After a pretty rough summer she went to treatment and back on MAT. Again we saw huge improvements and it gave her time to recover and build her life again. She did slowly wean off but was able to stay sober. She has a great job and is doing great. We are close to the 9 month sobriety mark and that is a record for her. Today is her 22nd bday and I was not sure she would live this long.

    Don’t listen to the uneducated that say being on MAT is not being sober. It is a lifesaver. All the best to you. Stay hopeful. Miracles happen everyday ❤️

    1. shelleybobelley,
      your comment brought tears to my eyes. happy birthday to your daughter, and may you all cherish the celebration of this day – of every day – and of what she has achieved. thank you for sharing your story and your perspectives with us. this is incredibly valuable for everyone.

  4. I am grateful, yet not surprised, by the diligent and wise treatment of my honest question. My question was thoroughly answered and with the links I can go back to and study in depth. We are all very blessed by your resourcefulness and devotion. I am eternally and sincerely grateful that you respect all of us on here Dominique. Best wishes to everyone.