Does MAT really work? Abundant evidence from decades of randomized trials, clinical studies, and meta-analyses suggests that agonist or partial-agonist opioid treatment used for an indefinite period of time is the safest option for treating OUD. 147, 155 (The evidence base for extended-release naltrexone is much less robust.) 147 A small randomized trial and a large cohort study demonstrated that people with OUD treated with methadone or buprenorphine are less likely to die, less likely to overdose, and more likely to remain in treatment. 153,161 MAT is also associated with lower risks for HIV and other infections, and improved social functioning and quality of life compared to people not on MAT. 30 Data suggest that MAT is more effective than psychotherapeutic interventions alone, and is just as effective whether psychotherapeutic interventions are used concurrently with medication treatment or not. For example, data from Massachusetts Medicaid beneficiary claims between 2004 and 2010 show significantly lower relapse rates with both buprenorphine and methadone compared to a behavioral health intervention alone. 162 Although the evidence base for intramuscular naltrexone is less robust than for methadone or buprenorphine, it has been shown to significantly decrease opioid misuse in patients with mild- to-moderate OUD. 147 For example, one trial randomized 250 patients with OUD who completed inpatient detoxification (≥ 7 days off all opioids) to 24 weeks of naltrexone intramuscular injection (380 mg/month) vs. placebo. 163 At follow-up, 90% in the naltrexone group were abstinent compared to 35% in the placebo group. Psychosocial treatments Psychosocial and/or behavioral interventions can be used in combination with medications in order to treat the “whole patient” (e.g., comorbid psychiatric symptoms, social support needs). The National Academy of Sciences, however, notes that
psychosocial services may not be available to all patients and recommends that the lack of such supports should not be a barrier to using MAT. 147 For example, a 2012 trial randomized 230 adults with OUD to one of three groups: methadone without extra counseling vs. methadone with standard counseling vs. methadone with counseling in the context of smaller caseloads. 164 At one-year follow-up there were no significant differences between the groups in rates of retention in treatment or urine tests positive for opioids. Three other randomized trials comparing buprenorphine with medical management alone vs. buprenorphine plus cognitive behavioral therapy or extra counseling sessions also found no significant differences in key opioid-related outcomes. 165-167 Nonetheless, psychosocial, behavioral, and peer-support interventions may have many profoundly important benefits for patients beyond strictly opioid-related outcomes, such as improving self-confidence, self-advocacy, general quality of life, and improvements in legal, interpersonal, and occupational functioning. 141 Some guidelines and authors advocate for the use of psychosocial interventions, but suggest that the lack of such interventions at a given place or time should not be a barrier to the use of MAT. 147,169 Tapering protocols OUD guidelines do not recommend a duration of MAT treatment, which could be for an indefinite period of time because of the high risk of relapse with discontinuation. 147 For example, a population- based retrospective study of 14,602 patients who discontinued methadone treatment found that only 13% had successful outcomes (no treatment re-entry, death, or opioid-related hospitalization) within 18 months of taper. 169 Nonetheless, some patients may want to stop opioid agonist therapy. An ideal time frame for a trial of MAT tapering has not been established. Tapering should always be at the patient’s discretion, and all decisions should be based on a thorough dialogue between patient and provider.
Goals should be framed functionally, for example maintaining employment, avoiding using illicit opioids or other drugs, continuing with social/ emotional support programs, etc. Misconceptions about OUD Treatment Stigma and misunderstanding surround the issues of addiction in general and OUD in particular. 147 These include counterproductive ideologies that portray addiction as a failure of will or a moral weakness, as opposed to understanding OUD as a chronic disease of the brain requiring medical management, which is no different, in principle, from the approach used to manage other chronic diseases such as diabetes or hypothyroidism. Some stigma and misunderstanding may arise from a lack of awareness of how treatment of OUD has evolved in the past 15 years. 170 Table 8 summarizes some common misconceptions about OUD treatment. Addressing stigma High levels of stigma persist among some medical professionals and recovery communities toward people with OUD and medications used to treat OUD. 147 A 2016 national opinion survey (n=264) found that 54% of respondents thought people addicted to opioid pain relievers were to blame for their addiction, 46% felt such people are irresponsible, and 45% said they would be unwilling to work closely with such people. 162 A 2014 survey of 1,010 primary care physicians found similar, or even higher, levels of stigma related to people with OUD. 167 Interviews with patients using methadone for OUD confirm that this group experiences high rates of stigma and discrimination related to their medication use in interactions with the public and with health care professionals, 174 which erodes their psychological well-being and may inhibit them from entering treatment. 147
Table 8. Misconceptions vs. realities of OUD treatment 171
Misconceptions
Reality
Buprenorphine treatment is more dangerous than other chronic disease management.
Buprenorphine treatment is less risky than many other routine treatments, such as titrating insulin or starting anticoagulation and easier to administer. It is also safer than prescribing many opioids (e.g., oxycodone, morphine). Addiction is compulsive use of a drug despite harm. When taken as prescribed, methadone and buprenorphine improve function, autonomy, and quality of life and patients using these drugs do not meet the definition of addiction. No data show that detoxification programs are effective for OUD, and, in fact, such interventions may increase the risk of overdose death by eliminating tolerance. Buprenorphine treatment can be readily managed in a primary care setting, and in-office induction or intensive behavioral therapy are not required for effective treatment.
Using methadone or buprenorphine is simply a “replacement” addiction.
Detoxification for OUD is effective.
Prescribing buprenorphine is time consuming and burdensome.
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