Raul J. Rodriguez M.D., DABPN

addict talking to nurse about MAT

The mechanisms of addiction have a very strong biologic and physiologic basis, in addition to the psychological and spiritual components. It makes perfect sense then that the right kinds of medical interventions would have a strong positive impact on sobriety. These types of treatments, especially when coupled with effective psychological treatment modalities, have consistently yielded previously never seen higher success rates. New interventions have been developed and implemented over the last several years and have become the new standards of care in addiction treatment. These therapies have become increasingly relevant and have collectively started to be referred to as Medication Assisted Treatment or “MAT”.

Naltrexone is a medication that has existed for a number of years and finally has been implemented as one of the major modalities for Medication Assisted Treatment. Naltrexone is a partial opioid receptor antagonist. It was first released under the trade name Revia as an agent to decrease alcohol cravings. Revia was found to be effective in reducing alcohol cravings as well as reducing the neurochemical reward from actual drinking. It has been used for many years successfully for this indication. Because of the opiate receptor antagonist properties, this medication has also been highly useful in treating opiate addiction. Naltrexone will effectively block the effects of an opiate, including heroin. This blocking ability helps prevent sudden and impulsive relapses. This blocking ability is even more pronounced in the long- acting depot injection formulation.

Vivitrol is the brand name of the long-acting injectable form of naltrexone. It was first indicated for alcoholism and later received the FDA indication for opiate dependence. The Vivitrol shot lasts up to 4 to 5 weeks, making impulsive relapses even less likely. If someone wants to relapse onto opiates, they essentially have to maintain that intention until the shot wears off. This forced delay allows the patient the opportunity to seek out support and use recovery skills to prevent the relapse from happening. Even just knowing that a full relapse is not chemically possible already reduces the amount of time and mental energy someone would be willing to devote to contemplating a relapse. This helps reduce cravings for opiates. The Vivitrol also is effective in reducing alcohol cravings and seems to have a greater effect than Revia. Individuals who use Vivitrol for 1 to 2 years have dramatically higher success rates overall. Other even longer acting formulations such as implants that can last several months are currently in development

A treatment modality really needs to work if it is to receive a medical indication by the FDA, even more so if it is to become the standard of care. Subutex and Suboxone, for the treatment of opiate or “pain pill” addiction, have also emerged as the new standard of care for opioid dependence with unparalleled success rates. These medications have revolutionized addiction treatment, creating a major shift from the old “28 day” inpatient care model to an outpatient model. Patients no longer have to go “away to rehab” and can actually detox while still working and caring for their families. Both of these medications have Buprenorphine, an opiate agonist-antagonist that binds to the opiate receptor and exerts an effect while blocking conventional opiates, as the primary active ingredient. Buprenorphine neutralizes much of the extreme and exaggerated biological drive to use opiates, resulting in a drastic reduction in cravings. Some receive Subutex just for detoxification. Others benefit from a daily dose or “maintenance” with Suboxone, which profoundly suppresses opiate cravings and would actually interfere with any opiates consumed in a relapse. These daily doses have a stabilizing effect and are in no way intoxicating when taken correctly.

Patients that are properly treated with Buprenorphine are usually perfectly alert, energetic and generally feel very good. They do not get or look “high” while taking this medication, remaining fully functional. The leveling of the playing field created by these medications gives individuals a fair chance at working on their sobriety without the burden of obsessive cravings. Patients that are relieved of this craving burden have a better probability of maintaining full abstinence from illicit substances and increasingly distancing themselves from the drug life. After an extended period of sobriety, the elements of the drug world that use to repeatedly pull them back in, becomes a distant memory. A person taking Subutex or Suboxone appropriately, as prescribed by a qualified physician, is considered to be fully “clean and sober”.

There are some groups in the recovery community who argue that patients that are on Suboxone are not sober. Some of this is due to having witnessed the potential drawbacks to buprenorphine. Buprenorphine has a very limited ability to induce intoxication on its own. Overuse typically will not do much, other than cause severe constipation. It usually would have to be mixed with something else, such as a benzodiazepine, to get some type of intoxication out of it. Much like with any other medication with even the smallest potential for abuse, someone, somewhere, has found a way to exploit that potential. The other concern with buprenorphine is diversion. This is really the bigger problem. When dispensed in large quantities, buprenorphine gets traded, sold, and otherwise distributed in some illegal manner. Most of this diversion ends up in the hands of people trying to detox themselves or trying to hold themselves over between opiate binges. This is the primary challenge in developing MAT halfway houses. New medical technology has been developed to address these issues, dramatically reducing the risks of misuse and diversion.

New long acting formulations of Buprenorphine have been developed that completely eliminate diversion and overuse. Sublocade, the most relevant of these new developments, was approved by the FDA on November 30th, 2017 for the treatment of severe Opioid Use Disorder. Sublocade is a subcutaneous injection of a buprenorphine formulation that quickly solidifies underneath the skin. The solidified buprenorphine releases medication slowly over 4 weeks. This provides a steady blood level for a very long period of time. This also eliminates any psychological reinforcement related to daily pill taking. Since the dose can be administered only by a qualified and licensed medical professional, there is no opportunity for self-dosing and thus no over-consumption. Since it can only be administered in a medical setting there is also no opportunity for diversion. With these key advantages, Sublocade is considered the ideal option for MAT in the community and even a MAT halfway house. Relapse rates fall drastically when these medical treatments are combined with psychological treatments, greatly improving the prognosis for motivated and compliant patients.

Strong motivation and treatment compliance are essential for successful treatment of any type. Knowledge of available treatment options is equally as important. Anyone who seeks treatment needs to be informed and not limit his or her options due to ignorance or fear of something new. Individuals suffering from addiction should be encouraged to do their own research and speak to qualified professionals when making major treatment decisions. Medication Assisted Treatment has come a long way with some key developments in just the last 12 months. Considering the increasingly lethal evolution of the opioid epidemic, these new forms of MAT could not have come at a better time. MAT is an invaluable tool available to patients that make the difference between life and death.

Dr Rodriguez is the founder and Medical Director of the Delray Center for Healing, the Delray Center for Brain Science, and the Delray Center for Addiction Medicine. He is board certified in both Adult Psychiatry and Addiction Medicine, with a clinical focus
on Treatment Resistant Depression, Bipolar Disorder, Anxiety Disorders, Eating Disorders and Addiction. The Delray Center is a comprehensive outpatient treatment center that incorporates the most advanced psychotherapeutic and medical modalities, such as Medication Assisted Treatment (MAT), Dialectical Behavioral Therapy (DBT) and Transcranial Magnetic Stimulation (TMS), in the treatment of addiction and complex and dual-diagnosis cases.,