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Jan 2 2020

A brief introduction to MAT for opioid use disorder

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MAT is currently one of the “buzziest” terms 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 opioid 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: 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: Is MAT an effective treatment for opioid use disorder?
A: In a word, yes. Numerous studies have documented that patients receiving MAT for opioid use disorder are significantly less likely to die from opioid overdose and more likely to remain in treatment that patients with substance use disorder who do not receive MAT. In addition, patients receiving MAT demonstrate reduced illicit opioid use and other criminal activity associated with substance use disorder, along with an increased ability to remain employed.

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 prescribe 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: What are the requirements to 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 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. Find MAT training opportunities at www.ncmedboard.org/MAT.

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