Introduction to Medication-Assisted Treatment

The misuse of opioids has become a national epidemic. It touches communities across the United States and poses a dangerous threat to the public’s health. Opioid use disorder (OUD) is defined as a “problematic pattern of opioid use leading to clinically significant impairment or distress."1 It may be characterized by2:

  • Physical effects (e.g., tolerance and withdrawal);
  • Difficulty reducing use;
  • Risky use behaviors;
  • Failure to fulfill obligations; and
  • Social problems.

About 2.1 million people had an OUD in 2017.3 Prescription opioids, heroin, and other synthetic opioids (e.g., fentanyl) all contribute to the opioid epidemic. In some cases, substance use disorder may lead to a fatal overdose. In 2017, an estimated 134 people died each day in the United States from drug overdoses involving opioids.4 The rise of OUD also contributes to other important public health concerns, including the spread of infectious diseases such as HIV and hepatitis C.

What Is Medication-Assisted Treatment?

Medication-assisted treatment (MAT) is an evidence-based treatment approach for OUD. MAT is defined as the “use of medications, in combination with counseling and behavioral therapies to provide a ‘whole-patient’ approach to the treatment of substance use disorders.”5

Often, people mistakenly believe MAT just substitutes one drug for another, but when properly administered, these medications normalize brain chemistry. This approach can help decrease cravings and withdrawal symptoms.

What Medications Are Used in Medication-Assisted Treatment?

The Food and Drug Administration has approved three medications to treat OUD: methadone, buprenorphine, and naltrexone.

Methadone is a full opioid agonist that fully binds to opioid receptors in the brain, which activates the receptors and helps reduce withdrawal symptoms. Methadone carries a risk for diversion or overdose. Therefore, only opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the U.S. Drug Enforcement Administration may dispense methadone to treat OUD.

Buprenorphine is a partial opioid agonist, so it does not fully activate the opioid receptors. Therefore, it results in less euphoria or breathing problems. Buprenorphine still involves some risk of misuse or lethal overdose when combined with other substances.

To lessen the risks of misuse, providers often prescribe a medication that combines buprenorphine with naloxone, an antagonist that blocks opioid receptors when injected intravenously. If these buprenorphine-naloxone combination products are taken properly as a pill or film under the tongue, the naloxone is not absorbed through the lining inside the mouth or digestive tract. But if someone tries to inject or snort the medication, the naloxone will become bioavailable (i.e., activated) and they will go into withdrawal.

The Drug Addiction Treatment Act of 2000 (DATA 2000) requires physicians to obtain a waiver to prescribe buprenorphine to treat OUD. Under this law, doctors must receive training and acknowledge they have access to counseling services. In 2016, the Comprehensive Addiction and Recovery Act (CARA) allowed qualified nurse practitioners and physician assistants to also seek waivers to prescribe buprenorphine.

Naltrexone is an antagonist that blocks opioid receptors. This medication prevents the rewarding effects and euphoria from any other opioids in the brain. Unlike methadone or buprenorphine, naltrexone cannot be used to manage symptoms of opioid withdrawal. It can help with craving. Because it is an opioid antagonist, starting this medication requires abstinence from all opioids to prevent triggering a severe opioid withdrawal episode. If given before resolution of withdrawal, it may worsen withdrawal symptoms. There are no restrictions on the setting or qualifications to prescribe naltrexone as it does not carry a risk for misuse or overdose.

The table below summarizes medications used to treat OUD.

Name Mechanism of Action Forms Uses Restrictions
Methadone Agonist Oral tablet or liquid Reduces withdrawal symptoms; prevents relapse Dispensed only in certified opioid treatment programs
Buprenorphine (e.g., Subutex, Belbuca, Probuphine, Sublocade) Partial agonist Oral tablet, buccal film, extended-release implant, or depot injection Reduces withdrawal symptoms; prevents relapse Prescribed in any setting with appropriate waiver
Buprenorphine/naloxone (e.g., Suboxone, Zubsolv, Bunavail) Combination Oral tablet or buccal film Reduces withdrawal symptoms; prevents relapse Prescribed in any setting with appropriate waiver
Naltrexone (e.g., Revia, Vivitrol) Antagonist Oral tablet or extended-release injectable Prevents relapse None noted

Do People Receiving Medication-Assisted Treatment Need Counseling or Therapy?

Although people often focus on the role of medications in MAT, counseling and behavioral therapies that address the psychological and social (i.e., psychosocial) needs of individuals with OUD are embedded in its definition. In the United States, regulations and legislation, such as the Code of Federal Regulations, Federal Guidelines for Opioid Treatment Programs, and DATA 2000, require psychosocial services to be a component of MAT.6-8 Similarly, clinical practice guidelines from the World Health Organization and the American Society of Addiction Medicine (ASAM) recommend psychosocial services in addition to pharmacotherapy.9,10

However, there is ongoing debate in the field about the evidence base for and role of psychosocial supports in MAT. Several systematic reviews, including those of Drummond and Perryman11 and Amato, et al.12,13 had mixed findings about the added benefit of psychosocial supports in MAT. More recently, Dugosh, et al. concluded that their findings generally support the effectiveness of psychosocial interventions in combination with medications to treat OUD. However, they note that the “incremental utility [of psychosocial supports in MAT] varied across studies, outcomes, medications, and interventions.”14

These studies and systematic reviews have a number of limitations, such as:

  • Control interventions that include some basic elements of psychosocial support, so the study is not truly evaluating whether there are added benefits of psychosocial support compared with medications alone;
  • Outcome measures that do not address the effect of psychosocial interventions on functional outcomes (e.g., mental health symptoms, quality of life);
  • Varying skills and training of the psychosocial providers; and
  • Evidence based on short-term outcomes, although treatment is recommended for long-term maintenance.

Because of these limitations, further research is needed to give clear guidance on the methods or levels of psychosocial services needed across patient groups.

Despite conflicting evidence, psychosocial supports may help patients manage challenges and stressors they face as a result of their substance use disorder or other mental health challenges. Counseling and behavioral therapies can also teach patients strategies and techniques for healthy, positive behavior change. But not all patients will require intensive counseling or psychosocial supports to meet treatment goals and work toward recovery. Ideally, providers should tailor the type and intensity of psychosocial supports to the patient’s needs and preferences.

The types of psychosocial supports in MAT vary widely depending on the setting, providers, treatment model, and availability of services. A range of methods may be used, including individual or group counseling, self-help groups, family therapy, peer services, case management, and enhanced medication management.

While a comprehensive approach to treatment that includes therapy and psychosocial supports may ultimately be a patient’s best chance for long-term success and recovery, the fundamental starting place for MAT is access to medication. Patient preferences and limited locally available behavioral health services may limit providers’ abilities to ensure engagement in psychosocial supports. However, withholding medications for OUD because a patient refuses psychosocial interventions is not warranted and will place patients at an unnecessary risk for accidental overdose and death.

In some cases, it may be appropriate to take a phased approach with patients. Providers should first start patients on a treatment plan with medications for OUD and then consider next steps. After stabilizing on the medication, patients may be more ready to engage in therapy and address other aspects of their addiction. If local psychosocial supports are not readily available, providers should do their best to support behavior change in their patients. The Principles of Substance Use Treatment section of the Playbook will further discuss the need to strike a balance between access to medications to treat OUD and comprehensive services.

Learn more about connecting patients with behavioral health services in AHRQ’s Playbook on Integrating Behavioral Health in Primary Care.

Does Medication-Assisted Treatment Work?

MAT is an effective treatment that can stabilize and save lives. Research has demonstrated that MAT can:

  • Reduce opioid use,15
  • Increase retention in treatment,15 and
  • Decrease overdose-related and all-cause mortality.16

What Is the Playbook?

The Playbook is a step-by-step guide for care teams to implement MAT for OUD. While the Playbook aims to help providers in rural primary care, the information in the Playbook should apply to other ambulatory care settings. This interactive, web-based product has the latest guidance, tools, and resources that address key aspects of implementation.

Why Offer Medication-Assisted Treatment in Ambulatory Care?

MAT is the standard of care for the treatment of OUD no matter the setting and is commonly, safely, and effectively delivered in ambulatory settings for many patients.17 Primary care practices are often a patient’s first point of entry into the healthcare system and address most patients’ care needs, so incorporating MAT into primary care gives providers tools to meet a wider range of their patients' needs. Individuals with OUD may also prefer to get treatment in primary care because stigma can discourage people from seeking treatment in specialty substance use settings.18

ASAM says that OUD is a chronic, relapsing disease that cannot be cured but can be effectively treated and managed.19 Primary care providers already know how to treat other chronic diseases, such as diabetes. It requires both medication management and some brief counseling to motivate behavior change. Integrating substance use treatment into ambulatory care also promotes a comprehensive, whole-person approach that allows providers to manage complex medical conditions, mental health conditions, and substance use disorders at the same time.

Primary care physicians are "on the front lines” of the healthcare system and of the opioid epidemic. They provide first-line therapies for chronic pain and account for 50 percent of all opioids dispensed."20 Primary care providers may not realize that some of their current patients are already struggling with OUD. Developing an OUD is not an intentional choice, and many of these individuals want help. Treating patients with OUD can be challenging, but many providers say it is very rewarding to see patients change their lives. The Providers Clinical Support System (PCSS) shares real success stories that show how treatment for OUD works.

What Else Can We Do?

While some providers may not be ready to fully implement MAT, many other strategies can be used to help those with or at risk for an OUD.

Prescribing and Pain Management

  1. Follow the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain to provide safer, more effective treatment while reducing the risk of an OUD or overdose.
  2. Seek additional training on safe prescribing of opioids, such as CDC’s training for providers or the PCSS training on treating chronic pain and preventing OUD.
  3. Explore nonopioid treatments for chronic pain (PDF—1.53 MB) and alternative treatment methods.
  4. Use prescription drug monitoring programs (PDMPs) before prescribing to help identify patients who may be at risk of misuse or overdose from prescription opioids.

Harm Reduction

  1. Connect patients with local harm reduction programs, such as needle exchange programs, to decrease risks of infectious disease and overdose.
  2. Prevent overdose fatalities by prescribing naloxone to those at risk of having or witnessing an opioid-related overdose. SAMHSA offers an Opioid Overdose Prevention Toolkit to prevent opioid-related overdoses and deaths.

Patient Education

  1. Discuss the risks and expectations for opioid therapy with patients, including the risks of opioid use during pregnancy (PDF—1.01 MB). SAMHSA provides additional guidance on how to talk to patients about opioids.
  2. Educate patients on the safe storage and disposal of prescription opioids.

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association; 2013.
  2. Providers Clinical Support System. Opioid Use Disorder: What Is Opioid Addiction? 2017. https://pcssnow.org/resource/opioid-use-disorder-opioid-addiction/. Accessed May 13, 2019.
  3. Center for Behavioral Health Statistics and Quality. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health. NSDUH Series H-53. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. HHS Publication No. SMA 18-5068, https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf. Accessed May 13, 2019.
  4. National Institute on Drug Abuse. Overdose Death Rates. 2018. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed May 13, 2019.
  5. Substance Abuse and Mental Health Services Administration. Medication and Counseling Treatment. 2015. https://www.samhsa.gov/medication-assisted-treatment/treatment. Accessed May 13, 2019.
  6. Medication Assisted Treatment for Opioid Use Disorders. 42 C.F.R. Chapter I, Part 8; 2001. https://www.law.cornell.edu/cfr/text/42/part-8.
  7. Federal guidelines for opioid treatment programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. https://store.samhsa.gov/product/Federal-Guidelines-for-Opioid-Treatment-Programs/PEP15-FEDGUIDEOTP. Accessed May 13, 2019.
  8. Drug Addiction Treatment Act of 2000 with Amendments. 2016. http://www.naabt.org/data2000.cfm. Accessed May 13, 2019.
  9. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva, Switzerland: World Health Organization; 2009. https://www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf. Accessed May 13, 2019.
  10. National practice guideline for the use of medications in the treatment of addiction involving opioid use. Chevy Chase, MD: American Society of Addiction Medicine; 2015. https://www.asam.org/resources/guidelines-and-consensus-documents/npg. Accessed May 13, 2019.
  11. Drummond C, Perryman K. Psychosocial interventions in pharmacotherapy of opioid dependence: a literature review. London, UK: Section of Addictive Behaviour, Division of Mental Health, St George's University of London; 2007. https://www.who.int/substance_abuse/activities/psychosocial_interventions.pdf. Accessed May 13, 2019.
  12. Amato L, Minozzi S, Davoli M, et al. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev 2011 Sep 7;(9):CD005031.
  13. Amato L, Minozzi S, Davoli M, et al. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database Syst Rev 2011 Oct 5;(10):CD004147.
  14. Dugosh K, Abraham A, Seymour B, et al.. A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med 2016;10(2):93-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795974/. Accessed May 13, 2019.
  15. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014;6(2):CD002207.
  16. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: a systematic review and meta-analysis of cohort studies. BMJ 2017;357: j1550. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5421454/. Accessed May 13, 2019.
  17. Larson E, Patterson D, Garberson L, et al. Supply and distribution of the behavioral health workforce in rural America. Data Brief #160. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; 2016. http://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf. Accessed May 13, 2019.
  18. Barry C, Epstein A, Fiellin D, et al. Estimating demand for primary care-based treatment for substance and alcohol use disorders. Addiction 2016;111(8):1376-84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940268/. Accessed May 13, 2019.
  19. Treating opioid addiction as a chronic disease. Rockville, MD: American Society of Addiction Medicine; 2014. https://www.asam.org/docs/default-source/advocacy/cmm-fact-sheet---11-07-14.pdf. Accessed May 13, 2019.
  20. Bachhuber MA, Weiner J, Mitchell J, et al. Issue Brief. Primary care: on the front lines of the opioid crisis. Philadelphia, PA: Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV; 2016. https://ldi.upenn.edu/brief/primary-care-front-lines-opioid-crisis. Accessed May 13, 2019.