Medication Assisted Treatment (MAT) for Opioid Use Disorder

Danesh A. Alam, MD

Medication Assisted Treatment Case Study

ISMS Members Making it Work: Danesh A. Alam, MD
June 2018

Danesh A. Alam, MD, divides his time equally in three areas of medicine. As a clinician, he is a psychiatrist with 15 years of experience. His practice focus is psychopharmacology and addictive disorders. He has an interest in treating health care professionals dealing with addictive disorders. As a researcher, he is an Adjunct Clinical Assistant Professor of Psychiatry at the University of Illinois at Chicago and is actively involved in pharmaceutical and other clinical trials. As the Principal Investigator of over 25 studies, he was involved in the studies that led to the FDA approval of Transcranial Magnetic Stimulation for depression. He has been funded by the National Institute on Drug Abuse. As an administrator, he is Medical Director of Behavioral Health Services at Central DuPage Hospital. In addition to being an active ISMS member, Dr. Alam is President of the Illinois Psychiatric Society and Past President of the Illinois Society of Addiction Medicine. He was nominated as a distinguished fellow of the American Psychiatric Association and the American Society of Addiction Medicine. In his various roles, Dr. Alam has always been involved in advocacy for his patients.

“It’s difficult for people to change in the midst of an addiction.”
Dr. Alam

The United States has the highest rate of substance abuse¹ in the world, and individuals are exposed to drugs in a way that is unprecedented. Opioid abuse, in particular, has become perhaps the largest public health crisis of our time. Efforts are underway at all levels of government to address this epidemic and reverse skyrocketing levels of morbidity and mortality.

How can Illinois physicians address the alarming public health issue of opioid addiction and provide help for their patients who may be suffering from opioid use disorder?

MAT as a solution

According to Danesh A. Alam, MD, the best evidence currently available to address the opioid crisis is to use medication assisted treatment (MAT) for patients. There are currently three MAT approaches for treating patients with opioid use disorder: methadone, buprenorphine/Suboxone and Vivitrol (naltrexone).

"But first, individualize the treatment after assessing the patient’s strengths and weaknesses," says Dr. Alam.

"Primary treatment alone is not a measure of success. Long-term treatment and engagement are critical. Little attention is paid to follow-up care and monitoring. This is often noted in cases in which patients seek out-of-area abstinence-based treatment."

The challenges of transitioning patients from Suboxone to Vivitrol

Dr. Alam explains that one approach to treating opioid use disorder is through the use of Suboxone maintenance.

While some policymakers see this as a logical treatment protocol, health care professionals, including Dr. Alam, are discovering that some patients need to be on Vivitrol. One area of recent research is transitioning patients from Suboxone to Vivitrol.

"Currently, few clinicians are really comfortable transitioning people from Suboxone to Vivitrol" says Dr. Alam.

Dr. Alam is conducting research in this area. He hopes that the results will support best practices for transitioning patients from Suboxone to Vivitrol.

Becoming a "waived physician"

A licensed physician can, after completing eight hours of training and obtaining a Drug Enforcement Administration (DEA) waiver, write a prescription for buprenorphine right from his or her office. Those physicians are then referred to as "waived physicians."

With the option for the waiver, many internal medicine/primary care physicians began to develop large Suboxone practices. But there is concern that there are relatively few psychiatrists who practice in the area of substance use disorders – despite having obtained a waiver.

Providers' Clinical Support System (PCSS)² offers a free eight-hour training for physicians to obtain a waiver from the DEA in order to prescribe Suboxone for the treatment of opioid use disorder.

Physician assistants and nurse practitioners may also obtain a waiver. To do so, they are required to take the eight hour waiver training, plus an additional 16 hours of training – all at no cost.

Learn more.³

MAT as a lifelong treatment

Do patients need to stay on MAT for the rest of their lives?

"Care needs to be individualized," says Dr. Alam. One strategy is to detox the patient with Suboxone and then transition the patient to Vivitrol, along with a focus on psychosocial therapies.

One of the biggest challenges with any drug treatment is relapse. In Dr. Alam's experience, the number one reason for relapse is availability of the drug. "If it is available, it will be abused," says Dr. Alam.

Looking ahead

Dr. Alam says more can be done. "This public health crisis needs to be addressed. Our policymakers must find ways to ensure that patients suffering from substance use disorder receive the help they need."

He believes there is a strong need for a state mandate that would require insurance companies to cover patients who could benefit from MAT.

Finally, Dr. Alam would like to see the rehabilitation aspect of drug treatment receive much greater emphasis. "When we have young adults who get off drugs, we have to help these kids find jobs again," he said. "Typically, the work force doesn’t take them because they have no skills – and the patients have lost five or six years of their life due to drugs. These individuals need training to get back into the workforce. Rehabilitation is about getting them back to being productive citizens – not just stopping drug use."

MAT options and their risks and benefits

The three most common MAT-based options for treating patients with drug addictions all have risks and benefits. There is no one solution that fits everyone.

Methadone is the best-known version of MAT and has been around since the 1800s. Patients must continually visit a clinic seven days a week and take the methadone under visual monitoring. By law, patients may only receive take-home doses on days when the clinic is closed, and must meet certain criteria before they are allowed to do so.

The benefit of methadone is that it has been shown to reduce relapse, cost of care, risk of disease and crime. Methadone also improves patients' level of day-to-day function and reduces the chaos of illicit drug use in their lives.

Treatment with methadone is not very convenient, however, especially if the patient is employed. Some clinics open very early in the morning in order to accommodate patients' work schedules.

Methadone carries a risk of diversion when patients are given "take home" doses; however, most diversion of methadone comes during chronic pain treatment regimens rather than through MAT.

In the early 2000s, buprenorphine became available on the market, making a splash as the new "miracle drug" for treating substance use disorder.

Suboxone is the commercial brand name for buprenorphine, a partial opioid agonist, combined with naloxone, an opioid antagonist.

Suboxone made it possible for the first time for patients to have the option to see their primary care physician in the physician’s office for drug addiction treatment instead of having to go to a drug treatment center or methadone program.

"Waived physicians" may treat up to 30 patients with Suboxone, and can also apply to the federal Substance Abuse and Mental Health Services Administration to treat up to 100 patients. After one year of treating 100 patients, physicians can apply to treat up to 275 patients under newly updated federal regulations.

In 2005, the arrival of Vivitrol gave physicians an important tool – the shot. Instead of taking a pill each day from a 30-day supply, the patient receives a monthly shot, which slowly releases the medication into his or her system.

Vivitrol is a form of naltrexone, a non-addictive opiate antagonist. Because Vivitrol is an antagonist, opioids become much less desirable to patients, which can help them avoid a relapse. Also, as an antagonist of opioids, there is no risk of diversion.

An important factor to consider when treating patients with Vivitrol is that the patient must discontinue the use of opioids for two weeks before beginning treatment with this medicine. The reason they must stop first is that Vivitrol causes powerful withdrawal symptoms almost immediately, which patients may see as a difficult side effect to endure.

Methadone

Methadone is the best-known version of MAT and has been around since the 1800s. Patients must continually visit a clinic seven days a week and take the methadone under visual monitoring. By law, patients may only receive take-home doses on days when the clinic is closed, and must meet certain criteria before they are allowed to do so.

The benefit of methadone is that it has been shown to reduce relapse, cost of care, risk of disease and crime. Methadone also improves patients' level of day-to-day function and reduces the chaos of illicit drug use in their lives.

Treatment with methadone is not very convenient, however, especially if the patient is employed. Some clinics open very early in the morning in order to accommodate patients' work schedules.

Methadone carries a risk of diversion when patients are given "take home" doses; however, most diversion of methadone comes during chronic pain treatment regimens rather than through MAT.
Buprenorphine

In the early 2000s, buprenorphine became available on the market, making a splash as the new "miracle drug" for treating substance use disorder.

Suboxone is the commercial brand name for buprenorphine, a partial opioid agonist, combined with naloxone, an opioid antagonist.

Suboxone made it possible for the first time for patients to have the option to see their primary care physician in the physician’s office for drug addiction treatment instead of having to go to a drug treatment center or methadone program.

"Waived physicians" may treat up to 30 patients with Suboxone, and can also apply to the federal Substance Abuse and Mental Health Services Administration to treat up to 100 patients. After one year of treating 100 patients, physicians can apply to treat up to 275 patients under newly updated federal regulations.
Vivitrol (naltrexone)

In 2005, the arrival of Vivitrol gave physicians an important tool – the shot. Instead of taking a pill each day from a 30-day supply, the patient receives a monthly shot, which slowly releases the medication into his or her system.

Vivitrol is a form of naltrexone, a non-addictive opiate antagonist. Because Vivitrol is an antagonist, opioids become much less desirable to patients, which can help them avoid a relapse. Also, as an antagonist of opioids, there is no risk of diversion.

An important factor to consider when treating patients with Vivitrol is that the patient must discontinue the use of opioids for two weeks before beginning treatment with this medicine. The reason they must stop first is that Vivitrol causes powerful withdrawal symptoms almost immediately, which patients may see as a difficult side effect to endure.

Other barriers to drug addiction treatment

Very few health care professionals can take on new MAT patients because these patients often reach their limit in terms of insurance coverage for such treatments. After that limit is reached, the patient has to pay cash for MAT, which becomes a disincentive for patients to
pursue treatment.

Vast areas of our country have no substance abuse health care professionals, including much of central, southern and western Illinois. This is particularly unfortunate given that people in rural areas of the country also suffer from substance use disorder.

It is challenging for those treating patients with opioid use disorder to gather research to better help patients. Some drug rehabilitation programs do not want to share their "outcomes data" because there are high rates of relapse and recidivism. Programs competing in a given market may worry that publicly sharing that data may adversely impact their reputation and their future business opportunities.

Health care professionals have been conditioned to accept the standard of a 30-day time frame for treatment regimens, but there is a lack of evidence to support a 28-day⁵ or 30-day model.