Medication-Assisted Treatment (MAT) for Substance Use

Disorders

I have to admit something I’m not really proud of. Most substance abuse, “treatment,” today really gets under my skin.  Just about every week, I’m arguing with a psychiatrist or other treatment provider about why what is being recommended is unlikely to work. I don’t understand much of the reasoning. As a general rule, if someone comes into my office for a substance use disorder (SUD), and a medication assisted treatment (MAT) option is available for that specific substance, my initial recommendation is that the client pursue that as an adjunct treatment. Doing so recognizes the inherent complexity of SUD’s and therapy, and carries almost immediate benefit.

The Problem

Addiction is a complex behavior with physical, psychological, and, more importantly, emotional, relational, and attachment components. With these components in mind, it is incredibly important to understand that a SUD is rarely a singular diagnosis. Co-occurring issues are the rule, rather than the exception. I use the term, “issues,” rather than, “disorders,” because there are numerous relational, attachment, and trauma-related issues for which we have no clinical diagnoses, yet those issues continue to significantly impact a person’s life.

The idea that we can remove someone from their environment and treat substance use unilaterally, has proven time and time again to be futile. Over time, substance use becomes tangled up in any number of other issues, and trying to address addiction without addressing those issues is equivalent to untangling a knotted ball of yarn by pulling on a single thread. When the pulling only makes the knot grow tighter, we assume we should pull harder by increasing the level of care (i. e. outpatient to IOP,  IOP to short-term residential, short-term to long-term) rather than taking a step back and looking at the bigger picture.

Why MAT?

The argument against MAT is usually based on the understandable belief that substance abuse treatment should be curative, and MAT is not viewed as curative. MAT is viewed as substitution, or replacement, or enabling. However, and this may come as a shock to some; as a whole, across all available modalities (e. g. outpatient, IOP, PHP, short-term residential, long-term residential, MAT), substance abuse treatment is not now, has never been, and is unlikely to ever be, primarily curative. Due to the complexities mentioned above, statistically speaking, when removed from treatment most return to use, and that is a trend that is likely to continue as long as the primary method of treatment is relapse prevention, coping skills, and indoctrination into disease propaganda.

Despite being the ubiquitous solution of well-meaning friends, loved ones, families, significant others, partners, treatment centers, therapists, and doctors, rehab and 12-step meetings are not the panaceas of recovery they are believed to be. Earlier this year, a New York Times article on the effectiveness of addiction treatment reported,

“Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Anyone with an addicted family member knows that no manner of pleading, arguing, coercing, bribing, manipulating, or threatening has ever borne any fruit. The same is true for doctors and therapists. SUD’s do not respond well to prescriptive therapies based in direction and instruction.  As a therapist, unless acuity demands otherwise, I’m always playing the long game. I may believe that I know what a client needs, and may be able to tell the client what that is within one session, but unless the client comes to that realization on his/her own, which could take months, it can be detrimental to our ultimate goal to try to force someone to see what I see.  Many providers never realize that one simple principle.

I spoke with a psychiatrist a couple of weeks ago, who declined to prescribe naltrexone to one of her/his long-term clients who was seeing me for an alcohol use disorder. Instead of naltrexone, I was told that the client needed intensive outpatient treatment and daily meetings. Although the psychiatrist never directly stated the reasoning, and it is admittedly possible that I’m wrong, our conversation followed what has become a predictable pattern. A succinct summation of that pattern is, “MAT doesn’t fix what’s wrong.”

That summation is factually accurate. MAT doesn’t fix what’s wrong. That’s why it’s recommended as an adjunct treatment.  Progress is made within individualized therapy. What MAT does, is significantly reduce or eliminate symptom expression within a matter of days, improving the likelihood of therapeutic progress.  In addition, that change in expression can be continued for as long as necessary.  Instead of completion of a 28 day program, or 90 day program, MAT terminates when the client is ready. Client and therapist are then free to begin untangling the knot, a process that could take months, or sometimes even years.  What we know, however, is that the longer someone can abstain from substance abuse, the less likely that person is to return to abusing substances.

I want to be clear that I’m not devaluing residential programs. Those programs offer a vital service, and provide some clients with a much-needed change in environment necessary for making better decisions. My concern is that traditional, often antiquated, methods are the default choice rather than the informed choice. It is incumbent upon addiction professionals to, as a primary role, stay continual students, always looking for improved methods of treatment. We cannot remain mired in old ways of doing things.  As professionals, we like to tell clients, “Insanity is repeating the same behavior and expecting different results.” Maybe it’s time we took that advice ourselves.

Medication-Assisted Treatment (MAT) for Substance Use Disorders – Part 2

Next week, we’ll look more at the benefits of medication assisted treatment and why, even when it doesn’t appear to be, “working,” it probably is.