People are dying in record numbers from opioid overdose. According to NIDA (National Institute on Drug Abuse), overdose deaths involving an opioid rose from 8,048 in 1999 to 47,600 in 2017. Despite these alarming statistics, people desperately needing treatment fail to seek it. The reason? Stigma. Need proof? According to the 2018 National Survey on Drug Use and Health, there were about 21.5 million people in the U.S. over the age of 12 that reported having a substance use disorder, but only 2.5 million of those actually sought out medical assistance and treatment for their issues. To clarify, 19 million people that needed treatment did not seek it because of the stigma associated with addiction and treatment. Stigma and judgment are killing people.Despite all of the data showing that Medication Assisted Treatment (MAT) is the gold standard for treating Opioid Use Disorder, and the related success rates of MAT, judgment abounds. The widespread myth that patients in MAT are simply “trading one drug for another,” or “trading one addiction for another” creates a substantial barrier to treatment. As an addictions therapist working in MAT for over 11 years, I have been relentlessly advocating for MAT, and educating patients, their families, counselors, medical professionals, and the general public regarding MAT in order to break the stigma that MAT has been so firmly entrenched in. Now serving as both the Program Director over two MAT facilities in Upstate SC, and as the Region 1 Representative for SCAADAC (South Carolina Association of Alcoholism and Drug Abuse Counselors), and due to the continuing reports of the ever-rising rates of opioid overdose deaths, I feel the need for an urgent call to action. Please allow me to educate you.
The first and most common misconception of MAT is that these patients are simply trading one drug for another. That’s not the whole story. After years of using and/or abusing opioids, a person’s opioid receptors become dysregulated. Methadone and buprenorphine work on a patient’s dysregulated receptors to normalize the patient. Patients are not getting high in treatment, they are getting normal. You wouldn’t tell a diabetic person, “Just lock yourself in a room for ten days, tough it out, and you’ll be fine. You won’t need that insulin anymore.” Nor would you say something similar to someone on medication for chronic high blood pressure. I can hear you saying, “That’s different.” It isn’t. Insulin normalizes the system of the diabetic person and keeps him/her from being sick. Blood pressure medication does the same. Methadone and buprenorphine normalize the system of the person with Opioid Use Disorder and also keep him/her from being sick …with withdrawals. You say, “But the opioid addict did that to themselves; he/she shouldn’t use medication.” Okay, then, I suppose then that you also believe that someone who smokes like a chimney for a lot of years and gets lung cancer shouldn’t get treatment either then? …Thought provoking, isn’t it?
Methadone Maintenance Treatment is for people that have been dependent on opioids for at least a year. That does not mean using opioids for a year; it means dependent on opioids for a year and exhibiting observable signs of opioid withdrawal. Opioid withdrawal symptoms include sweating, hot flashes, chills, watery eyes, runny nose, excessive yawning, goose bumps, muscle pain, headache, nausea, diarrhea, vomiting, crawly skin, irritability, anxiety…the unpleasant list goes on. Suffice it to say that opioid withdrawal is like the very worst case of flu you have ever had multiplied by a factor of 12, and it doesn’t relent. Imagine feeling that way and knowing that you could feel better in a matter of about 15 minutes if you could get your hands on a few pills of Vicodin, or Percocet (or whatever other opioid you have access to). Hmm, let’s see…flu symptoms…or…take a couple of pills and feel normal again? No brainer, huh?
This is the dilemma people with Opioid Use Disorder face daily. They can be hellaciously ill and in bed, unable to be a parent, or employee, or functional anything, or they can score a few pills (or fentanyl, or heroin) and be normal…for a few hours anyway. If you are in this situation, therein lies the rub: you have to amass enough medication to keep you normal. That’s what the “chase” is all about. You chase more pills in hopes of having a sufficient amount to keep you functional so that you can be whoever it is you are required to be. That is what keeps you using. You want to stop, but you don’t have the time or the inclination to be sick for very long. So you get a few pills, or grams, or whatever “just to get you through the day.” Then you’ll quit…later. The problem is, tolerance builds and the amount you used to take to be fine, no longer works, and you need more at a time to keep you fine. This costs more money, and more of your time. Then, the more you use, the more your tolerance builds, and the more you need to keep you fine. The other problem is, at some point you’ll reach your fatal dosage.
Methadone has been around for a really long time, and has been intensely studied and tested, and retested. Can it be abused? Yes, like a lot of helpful medications, it can be abused. Does that mean it isn’t suitable for use? No. Methadone is a miracle drug for many, many people suffering from Opioid Use Disorder. When patients come into a clinic for treatment, they are evaluated for their appropriateness for the program, and if appropriate, they see the clinic physician, and are started on an initial dosage, which cannot exceed 30 mgs on their first day. They are required to attend the clinic daily to have the effectiveness of their dosage assessed and adjusted up or down as needed, to be monitored for signs of sedation or possible over-medication, and to begin treatment planning and counseling.
Buprenorphine has a different protocol and depends on the program being used at the facility. OBOT (Office-based Opioid Treatment) patients are seen the way patients at any physician’s office are seen. They see nurse for their monthly urine drug screen and then see the physician and walk out with their prescription of buprenorphine to have filled at their local pharmacy. OBOT patients are strongly encouraged to use the counseling provided at the facility, but are not required to. DATA 2000 (Drug Addiction Treatment Act 2000) patients may be seen as OBOT patients are seen, or, depending on the clinic, may be required to attend clinic daily and earn their takeout medication privileges after showing progress in treatment and continued compliance, and after meeting time-in-treatment requirements, as is done with methadone prescribed patients. (Please see: https://www.buprenorphine-doctors.com/what-is-data-2000.cfm for further information on DATA 2000.)
What’s the difference between buprenorphine and methadone then? Why choose one over the other? That is a great question. Buprenorphine and methadone are both very long acting with a very long half life. The main difference between the two is that Buprenorphine works best on patients with mild to moderate withdrawal symptoms. I have heard arguments that both medications work equally well on all patients. That is simply not true, at least not in my 11 years of experience in MAT. Patients with “heavier” and longer-term use tend to do better when prescribed methadone. Of course each patient is individual and his/her treatment should also be individual, but in general, this is true. Buprenorphine also has a “ceiling” effect, meaning that once you reach a certain dosage (usually 24 mgs), it is pointless to increase it, as there is no additional benefit or additional relief from symptoms. Buprenorphine has less risk of overdose when taken on its own, but still has significant potentiation risk. Buprenorphine is also more widely covered by insurance. Overall buprenorphine is viewed as the “safer” medication, but if a patient is not getting adequate relief from withdrawal symptoms and submits to the urge to supplement his/her medication with other drugs, then it really is not any safer. The other safety issue with OBOT patients, because the program works like a regular physician’s office, positive drug screens are only addressed once per month, and are done so with the physician and not with a counselor. The other difference is that, as previously mentioned, depending on the program and the clinic, the patient may not be required to engage in counseling at all while in treatment.
The initial goals of treatment include harm reduction and stabilization of the medication. Stabilization refers to the point at which the patient’s dosage keeps him/her from craving the drug of choice and alleviating withdrawal symptoms for a 24 hr period. Stabilization takes time. Methadone stays in the system (i.e., will keep a patient from withdrawal symptoms and cravings) for 24-36 hours. (It may stay in the system regarding showing positive on a drug screen for much longer than that.) This is the reason for the initial dosage not exceeding 30 mgs, and the reason that the dosage has to be adjusted slowly, in order to avoid overdose. It is also crucial for a patient to be educated on the dangers of potentiation. Potentiation refers to two or more substances increasing the effect of each other when consumed together. Certain substances potentiate each other, including opioids, benzodiazepines (like Xanax, Valium, or Ativan), alcohol, and barbiturates (like Phenobarbital, or Fiorocet). Basically, it means that taking two of these together leads to an equation of one plus one equals six, or eight, or ten. The amount of medication in the system is exponentially increased, and this substantially increases the risk of overdose and death. The risk of overdose is highest during the stabilization period because a patient who may not yet be getting 24 hours of relief can be tempted to supplement his/her methadone with other substances in an attempt to get additional relief. This is why most clinics require a new patient to see the counselor daily in order to learn about what to expect to feel physically, emotionally and psychologically while they are stabilizing, and to learn how to manage symptoms without resorting to illicit substance use.
Patients in Methadone Maintenance Treatment are required to submit to random weekly urine drug screens to monitor whether they are still using other illicit substances or alcohol, until they show compliance in the program as evidenced by having an observed urine drug screen whose results indicate no illicit substance use. (An observed drug screen is one where a counselor of the same sex as the patient goes into the restroom with the patient to ensure that the urine sample given is authentically that of the patient, and that the urine has not been obtained and brought into the facility.) An alternative to the observed urine drug screen, for patients who might have a history of sexual trauma, is to have the patient submit to an oral swab drug screen done concurrently with the (unobserved) urine drug screen to rule out falsification of drug screen results. If they show compliance for a period determined by the facility (usually for a minimum of 30 days), the patient is then placed on a random monthly drug screen schedule, where he/she is asked at a random and unannounced point once each month to provide a sample. If he/she continues to test positive for illicit substances after the 30 days, he/she is required to remain on a random weekly drug screen schedule to closely monitor the illicit use and to provide more interventions as needed. Patients that have shown compliance in MAT and have earned takeout privileges are subject to random unannounced medication callbacks at least twice per year, whereby a patient is phoned by the counselor or a nurse in the middle of a pickup cycle and told to come in the next day to take that day’s medication at the dosing window in front of the pharmacist, and then to have his/her bottles checked and counted by the pharmacist to ensure that the medication is being taken as prescribed and that it has not been sold, tampered with, or taken in any way other than as prescribed. In addition to the medication callback, a urine drug screen is also done, either observed, or with an oral swab drug screen to cross check the results, in order to ensure compliance and rule out falsification of drug screen results.
It is worth mentioning that, aside from the monitoring being done by the MAT clinical and medical staff, MAT facilities are accountable to many outside agencies, moreso than other non-MAT treatment facilities. MAT facilities are monitored by DHEC, the DEA, the Board of Pharmacy, CARF, and the Joint Commission, to name a few. Audits by these agencies happen regularly and may be announced or unannounced. They monitor for compliance in all areas from recordkeeping and documentation to storage and administration of the medication, and in every area that falls in between. This is notable especially because of the number of reported deaths that are attributed to methadone. MAT facilities are automatically assumed to be the source of the originating prescriptions, but it might surprise you to know that the majority of those deaths are related to methadone prescribed by pain management physicians and not by MAT facilities. This is partly because pain management facilities do not monitor patients as closely as MAT facilities are required to do, and because many physicians are not trained adequately regarding methadone and the prescribing of methadone.
There are many MAT facilities in the Upstate for people seeking treatment. The facility at which I am Program Director, Clear Skye Treatment Center in Clinton, SC offers MAT, and has a unique collaboration with Gateway Counseling, which greatly benefits patients in ways other MAT facilities cannot. Gateway Counseling is the sole Laurens County authority for alcohol and drug abuse services, and is a quasi-governmental nonprofit agency that offers a variety of services related to the prevention, intervention and treatment of substance use disorders. Charlie Stinson, the director of Gateway (and all-around awesome human being) worked diligently with the owners of Clear Skye to develop a collaboration in which Gateway obtains state funding to assist low-income patients in affording treatment services. These patients get the assessments, care, and higher-level counseling they require, and receive medication and case management services at Clear Skye. Clear Skye also offers regular MAT treatment services and counseling for those that can self-pay, have Medicaid, or that have private insurance. If regular MAT patients require higher levels of counseling, they are referred to Gateway, and once Gateway patients are stable and are able to obtain employment, they are referred to Clear Skye and transferred to the regular MAT program. This unique collaboration allows for increased access to treatment services for more individuals suffering from Opioid Use Disorder.
I know that I have given you a lot of information. I have attempted to sum up for you what MAT is, what it isn’t, and how it is (properly) done. I am hopeful that this article may assist in the stomping out of stigma and judgment related to MAT, that it may increase patient access to treatment services, and that it will, ultimately, save lives. To that end, you should know that some reported studies show MAT success rates as high as 80%, which is more than any other treatment option can boast. That’s pretty impressive. How ya like MAT now? (insert wink here)