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Aug 30 2019

A brief introduction to MAT for opioid use disorder

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MAT may just be the “buzziest” term in medicine. Anyone who follows the opioid overdose epidemic and efforts to address it, even casually, has likely heard those three letters, which stand for “medication-assisted treatment”. Expanding access to MAT for opioid use disorder by increasing the number of qualified prescribers who provide it is a core strategy of the state’s Opioid Action Plan.

But what exactly is MAT and why is it considered so important in our state’s efforts to address the opioids crisis? This article explains the basics in a “Q & A” format. The Substance Abuse and Mental Health Services Administration (SAMHSA), which is the federal agency that authorizes MAT prescribers, is the primary source of information presented.

Q: What is MAT?

A: Medication-assisted treatment or MAT is the use of medications, together with counseling and other behavioral therapies, to treat substance-use disorders. Although the focus of this article is on MAT for opioid use disorder (OUD), MAT is also used to treat alcohol use disorder and to aid in smoking cessation.

Q: What medications are used in MAT for opioid use disorder?

A: There are three main prescription medicines used to treat opioid use disorder: methadone, buprenorphine and naltrexone. Each works in a different way. Methadone and buprenorphine are both controlled substances, but methadone is administered daily by the prescriber in a clinical setting, such as a treatment center, while buprenorphine is prescribed on an outpatient basis in many settings, including private practices. A third medication, naltrexone, is not a controlled substance and may be prescribed by any clinician with prescriptive authority.

Q: Who can provide MAT and prescribe the necessary medications?

A: Under federal law, methadone may only be lawfully dispensed by federally-authorized treatment centers, or opioid treatment programs (OTPs). Buprenorphine may be prescribed in many outpatient settings, but only by clinicians who have completed comprehensive training and received authorization to prescribe it from SAMHSA. Authorized or “waivered” prescribers are permitted to dispense or prescribe specifically approved Schedule III, IV, and V narcotic medications, including buprenorphine. Naltrexone may be prescribed by anyone who prescribes medications but, for optimal safety and efficacy, should be offered as part of a comprehensive treatment plan.

Q: Do I have to be a physician to prescriber MAT medications?

A: No. MAT medications may be lawfully prescribed by physicians, physician assistants (PAs) or nurse practitioners who have completed mandatory training and obtained specific authorization from SAMHSA. Opioid treatment programs that administer methadone (e.g. a methadone clinic) must also be authorized by SAMHSA.

Q: How can I become an authorized MAT prescriber?

A: Efforts to expand access to MAT are primarily focused on increasing the number of buprenorphine prescribers. In accordance with the Drug Addiction Treatment Act (DATA) of 2000, physicians must hold a current professional license and valid DEA registration, complete eight hours of required training and apply for a waiver to become authorized to prescribe buprenorphine. An authorized physician holds a “DATA 2000 waiver”. The Comprehensive Addiction and Recovery Act (CARA) of 2016 extended buprenorphine prescribing to PAs and NPs who complete 24 hours of required training and obtain a waiver. All new buprenorphine prescribers are limited to treating no more than 30 patients with MAT during their first year.

Q: How can North Carolina make a meaningful impact on the opioid addiction crisis if MAT prescribers are limited to treating relatively small numbers of patients?

A: You might be surprised. The number of buprenorphine prescriptions dispensed in North Carolina increased by more than 41 percent to more than 181,000 prescriptions during the three-month period ending March 31, 2019, according to the latest publically posted metrics for the NC Opioid Action Plan. The plan uses data from the three-month period ending Dec. 31, 2016, as its baseline. The Opioid Action Plan was formally released in June 2017 so increases are thought to reflect, at least in part, the effects of efforts to strengthen recovery resources in the state. During the same period (Dec. 31, 2016, through Mar. 31, 2019), the number of uninsured and Medicaid patients with opioid addiction receiving care through a treatment program – another metric tracked by the state – increased by more than 32 percent. Robyn Jordan, MD, medical director for UNC Project ECHO for MAT, which provides education and support to clinicians statewide, firmly believes that community MAT providers are the ultimate answer to the opioid addiction and overdose crises. "We're going to get there by having lots of people prescribing to a small number of patients." Private practices need not open their doors to patients with addiction to provide MAT, Jordan said. "Just look within your own practice - chances are there is a need."

Q: How do the medications used in MAT work?

A: Methadone is an opioid agonist that reduces or eliminates withdrawal symptoms and relieves drug cravings by acting on opioid receptors in the brain. Essentially, methadone fools the patient’s brain into believing it is still getting the drug that is being misused or abused, while blocking the euphoric “high” associated with opiate drugs. The brain thinks it is getting the abused drug and, thus, the patient does not experience withdrawal. Methadone has been used for decades to treat people who are addicted to heroin and narcotic pain medicines and, when taken as directed, it is safe and effective. However, methadone can be addictive, which is why it must be administered, at least in the initial stages of treatment, by a physician, typically at a treatment center. After a period of stability, patients may be permitted to take methadone home between visits.

Buprenorphine is a partial opioid agonist. Like commonly abused opioids, buprenorphine stimulates opioid receptors in the brain, producing euphoria. With buprenorphine, however, the “high” is much weaker than those of drugs such as heroin or prescription opioids. Also, buprenorphine’s opioid effects increase with each dose until at moderate doses they level off, even with further dose increases. This reduces the risk of misuse and dependency. As buprenorphine is a long-acting agent, many patients may not have to take it daily. Buprenorphine is a more recent addition to the opioid treatment arsenal, winning FDA approval to treat opioid use disorder in 2002. It has the unique advantage of being authorized for prescribing or dispensing from outpatient setting, including private medical practices. This affords patients more privacy that receiving care through a drug treatment center.

Naltrexone is a prescription medication approved to treat opioid use disorder (and alcohol use disorder). Unlike methadone and buprenorphine, which activate the brain’s opioid receptors, naltrexone binds and blocks opioid receptors, which reduces opioid cravings. Additionally, there is no abuse potential with naltrexone because it does not produce a “high”. If a patient relapses and uses opioids, naltrexone prevents the feeling of euphoria; However, patients taking naltrexone may develop reduced tolerance to opioids. Previously-used or even lower doses of opioids may have life-threatening consequences. Naltrexone is not a controlled substance and can be prescribed by anyone who may lawfully prescribe medications. For safety reasons, it is best for naltrexone to be prescribed as part of a comprehensive treatment plan.

Q: How can I complete the required training to obtain a buprenorphine waiver?

A: Free and low-cost training is offered through multiple organizations in North Carolina. Some training is offered online, some is held in person and some courses require a combination of online and live training. NCMB has established a MAT resource page on its website and links to free and low cost meetings, courses and other training as it becomes aware of opportunities. Many buprenorphine training programs encourage participants to apply for buprenorphine waivers, even if they have no immediate plans to begin offering MAT to patients. That way, as waivered clinicians get more comfortable with the idea of providing treatment to patients with addiction, they will be ready to go.

Q: Is there support available to help me get started providing MAT to patients?

A: Yes. There are many agencies and organizations in North Carolina working on increasing the number of buprenorphine prescribers in the state, and free and low cost buprenorphine waiver training courses are widely available, either online or as part of conferences and other in-person meetings.

Upcoming opportunities include: Mountain Area Health Education Center (MAHEC) in Asheville, which offers numerous trainings on MAT, addiction and treatment of chronic pain, is offering a “half-and-half” waiver training on Sept. 27. Participants attend a four-hour seminar in person and also complete four hours of online training. UNC Project ECHO for MAT in Chapel Hill offers a free 8-hour online waiver training, and also provides practice coaching and one-on-one mentoring for clinicians getting started with MAT. Physicians are waiver-eligible upon completion of either 8-hour training.

PAs, who must complete 24 hours of MAT training to be waiver-eligible, may complete the same eight-hour training that is required for physicians and then earn the remaining 16 hours at a later time. The Providers Clinical Support System (PCSS), a national SAMHSA-funded organization that trains clinicians to provide MAT, offers a free online 16-hour course for PAs. PCSS also offers a free online 8-hour training if PAs prefer to receive their training from a single organization.

Another possible professional development opportunity is the Addiction Medicine Essentials conference in Durham, Oct. 4-5. While not specifically focused on qualifying attendees for buprenorphine waivers, this Governor's Institute-sponsored conference is designed to train clinicians to work with patients with addiction.

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