Abstinence Based Medication Assisted Treatment (MAT)
Addiction treatment has, for the last forty years, relied on various medications to enhance safe detoxification. Medications, like benzodiazepines (Valium, Klonipin, Ativan, etc.) allow physicians to, slowly, help the brain to achieve homeostasis and avoid life threatening seizures or delirium tremens. Other medications, like Disulfiram (Antabuse), have served to dissuade alcoholics from drinking by creating severe sickness if used in conjunction with alcohol.
More recently, after much resistance from the addiction treatment field, anti-depressants like Prozac, Paxil, Zoloft, etc. became acceptable to the addiction industry. Now, we see the emergence of medications like Campral and Naltrexone, with the promise of diminishing cravings. The point is that medications have been a part of “abstinence based” treatment for years. The ultimate goal, however was abstinence based. This philosophy was reinforced by 12 step programs like AA and NA, which often served as the personal recovery foundation for many management and clinical staff in treatment programs. A small group of treatment programs believed that, opiates were best treated with Methadone. An uneasy acceptance existed between these two schools of thought. However, Methadone programs were viewed as pseudo-treatment, and those on methadone were “considered not really in recovery.” All of this was about to change in 2004.
2004 ushered in an epidemic of opiate addiction. Medications like Hydrocodone, Oxycodone and others resulted in a flood of pain pill users admitted to treatment facilities, jails and emergency rooms. The truce gave way to open conflict and criticism. The addiction field formed into two adversarial camps, resulting in name calling and further division.
It was during 2004 that our own outpatient program decided to use Buprenorphine (Suboxone), receiving much criticism. We considered it patient centered treatment instead of program driven. Unfortunately, even today, ASAM reports that less than thirty percent of treatment programs offer medication assisted treatment. For us, the positive outcomes were irrefutable. Ironically Buprenorphine was approved and championed by the federal government. It was also demonstrated, in study after study, to work. As the DEA clamped down on the national spread of pain meds, addicts discovered that heroin was cheaper and easier to acquire. Thus, this current epidemic of heroin dependence.
Programs willing, in 2004, to use Buprenorphine MAT programming were few. However, they saw their recovery rates sky rocket with greater patient retention and found unique ways to use Buprenorphine, in conjunction with treatment; thus, enhancing outcomes from single digits, to high double digits. The inpatient programs were having their philosophical and financial foundations rocked, while many potential patients were now going into outpatient treatment or seeing individual Buprenorphine certified physicians.
Science caught up with the addictions industry. Ironically, organizations like the National Association of Alcohol Treatment Providers (NAATP) were threatening to boycott the American Society of Addiction Medicine (ASAM) because of their support of Buprenorphine and its confirmed success at helping to save lives. Simultaneously, the federal government and the most prestigious physician’s groups were in direct conflict with the largest inpatient treatment provider’s group, over a medication that was demonstrating to save lives and serve to help opiate addicts find their way to recovery. Then, the unthinkable happened. The Hazelden Institute directed by Marv Seppala, MD; bought the Betty Ford Center (both formerly staunch critics of Buprenorphine) and announced that they were going to begin to open Betty Ford Center outpatient programs and embrace medication assisted treatment, along with long term use of Buprenorphine. This proved to be a game changer, as both were key figures in NAATP.
Today, the field of addiction treatment is at another crossroads, as we begin to integrate science deeper and deeper into our field. We must acknowledge that abstinence from addictive substances can be enhanced by the schooled and studied embrace of medication enhanced recovery.
It is important to note the key factors that allow Buprenorphine to be so effective and safe for opiate addiction. Buprenorphine creates no tolerance, produces no high, and rarely leads to overdose. It serves as a blocker on the Mu and Kappa receptor sites, while still eliminating the acute and post-acute withdrawal from opiates, where anhedonia often causes the relapse for so many patients. A secondary gain is that Buprenorphine produces significant pain relief for 0-6 pain levels and serves as a major source in reducing stress hormones like cortisol. Its sublingual administration makes its highly advantageous for patients who have had gastric bypass procedures or other esophageal disease.
We need, as a field, to define the parameters, goals and standards that define “recovery”. By splitting into warring camps, we’ve confused patients and diluted the care that patients legitimately deserve. Ultimately, the future of treatment will increasingly consist of medication assisted treatment, with the goal being abstinence, and life function enhancement. Too many people are dying, and losing loved ones in this epidemic of opioid addiction. We need more leaders like Hazelden and The Betty Ford Center, with a greater understanding that medication assisted treatment can, in fact, be the source of full functioning recovery. Saving lives must supersede filling beds.
Abstinence based medication assisted treatment is here to stay and will serve to continue to save thousands of lives. Additionally, outpatient treatment has proven its effectiveness by integrating families into treatment while helping their loved ones establish community based recovery connections.
Charles “Rocky” Hill, MA, NCAC-II, CADC II CEO
Hill Alcohol and Drug Treatment