Commentary: Medication-Assisted Treatment for Opioid Dependence

Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.

The scientific evidence is incontrovertible: addiction is a brain disease – and can be especially severe when substance abuse starts early in life. Since the brain continues to grow and develop through the twenties, it’s very vulnerable to the effects of any exogenous substance. Early drug use makes almost permanent changes to both the structure and function of the brain, which has profound implications for the rest of a person’s life.

A parent bringing their child into treatment wants to maximize the chance that the child can abstain from the drug so the brain can heal and preclude the lifelong struggles of adult addiction. Scientific studies show that psychosocial treatments alone (i.e. without medication) show relatively poor results. Part of the reason has to do with cravings. Here’s why.

When a person takes a drug, the brain feels an enormous “high” in the reward system. It then implants a memory in the limbic system — the “lizard brain” — where memories of pleasures such as food and sex are stored. Anything having to do with procuring or using the drug becomes part of the memory and can produce a craving years later, even if a person hasn’t used the drug. The “trigger” could be a happy event, sadness, or seeing a syringe or some white powder or smelling an alcohol wipe. All of a sudden that memory flooding in generates an enormous craving to use the drug again.

One of the medications used in treatment, buprenorphine, is a partial agonist of the brain’s opiate receptors: when it “locks in”, it both eliminates cravings and blocks the “high” should someone inject heroin or take an opioid painkiller. As a partial agonist, buprenorphine has advantages over methadone, a full agonist, whose side-effects can include sleepiness, shallow breathing, or even death.

Studies suggest that over 60 percent of people on buprenorphine therapy have very positive outcomes. In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.

In my 30-plus years as a pediatrician, I’ve always believed that the best treatment occurs in the least restrictive environment. Therefore our clinical program is outpatient-based. These children are living at home, and their parents are an integral part of the treatment team. We empower parents to supervise the prescription-taking, and both adolescents and parents participate in a 13-week education and support group.

As far as stigma, it breaks my heart when kids hear that “You’re not really clean and sober. Buprenorphine is just a substitute addiction.” I tell them, “Listen, you’re on replacement therapy. It does not make you high. It stabilizes your brain cells until they can recover. Please give it a year. Then we can talk about tapering off. OK?”

My advice to parents and teens is: check out medication in a reputable program. It could make the big difference in helping your child turn the corner and find sobriety. Over time medication can be tapered down. Does it always work? No. Are there accounts of abuse and unscrupulous practices? Unfortunately yes, and they must be investigated. But these negatives don’t negate MAT’s lifesaving value in helping treat the disease of addiction.

If someone says, “Well your child isn’t really clean,” walk away because those people just don’t know. The folks disseminating this misinformation are really doing a disservice because if we dissuade families from using this life-saving therapy we’re going to lose kids. We have to remember the tragedies: when kids are taken off or deprived of this medication they can die. And we don’t have any teens to spare. Not one. I’m not willing to see any more needless deaths.

John R. Knight, MD with Melissa M. Weiksnar

John Knight, MD, is a leading pediatrician at Harvard Medical School, specializing in the diagnosis and treatment of adolescent substance abuse. He is the Director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston, and a nationally recognized advocate for families’ involvement in adolescent addiction treatment.

Melissa Weiksnar is a Program Coordinator at the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children’s Hospital. She is a also a writer, speaker, and advocate for substance abuse prevention and treatment. She earned an S.B. in Economics from MIT and an MBA from Harvard. 

PHOTO CREDIT: Courtesy of Anders Brun and colleagues, Neuroimaging Research Center, McLean Hospital, Belmont, MA. ©Copyright Anders Brun/McLean Hospital 2013. All rights reserved.


 

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15 Responses to Commentary: Medication-Assisted Treatment for Opioid Dependence

  1. Skip Sviokla MD ABAM | December 6, 2013 at 11:46 am

    It is encouraging to see a physician of Dr. Knight’s stature endorse buprenorphine for young adults as he has done. The place of MAT needs a boost in credibility such as this. Thank you Dr. Knight.
    Skip Sviokla MD ABAM author “From Harvard to Hell and Back”

  2. cindy bergh | December 6, 2013 at 2:09 pm

    Even amoungst the professionals in the addictions field MAT still struggles with stigma and misinformation, then you add MAT for youth and the topic heats up significantly. If you are a professional in addictions and you are one of those against MAT for youth. Investigate the research and form your voice from that. Challenge yourself to speak from what we know, and not what you think.

  3. Zac Talbott BA CMA | December 6, 2013 at 2:13 pm

    While I fully agree with the premise of this editorial, and I believe it is imperative that buprenorphine treatment be expanded & made more accessible. However, I find it wrote disheartening that the MOST evidence-based medication – methadone – which the National Institutes of Health (NIH) has deemed the timeless “gold standard treatment” for opioid addiction wasn’t mentioned a single time. Methadone Maintenance Treatment is, quite simply, one of the most evidence based and proven effective treatments in ALL of medicine. Buprenorphine isn’t always effective, particularly with individuals with longer and more severe addiction histories. The CDC has made it clear that Methadone Maintenance Treatment is the “most effective treatment” for opioid addiction available, and for a piece about MAT for opioid addiction to totally leave out the gold standard, most proven, most researched and most effective medication option is beyond puzzling to an independent and inquisitive mind.

    • Charles L Dick Jr | December 6, 2013 at 4:49 pm

      I agree that methadone is as effective and time proven with history and research to support this statement. It is also accurate to state that methadone is much more effective with longer term users of opiates; I also agree with the author of the article, that buprenorphine therapy, managed in an environment as described would be a first choice for adolescents and teens due to the fact that if managed properly, it carries with it the potential to become as effective as methadone on this certain type user. After reading this editorial, I suspect that methadone was not mentioned because that particular medication is not used within the author’s program, and for the reasons stated.

    • Eric Wood, MA LCAC CADAC II | December 8, 2013 at 10:02 am

      It is interesting that the term “gold standard” continues to be thrown about when we’re talking about methadone. People going to a methadone clinic tend to share that sentiment… Until they get off methadone. The last patient I had coming to our clinic for Suboxone from a methadone clinic called it “the devil.” Patients leaving methadone programs routinely report they were continuing to abuse drugs while in “treatment.” They also routinely report little or no counseling and psychosocial support was offered. The so-called gold standard may have had it’s day as a form of harm-reduction, but it’s utility as an adjunct to actual recovery has been supplanted by newer treatments.

      Suboxone treatment is definitely not without its own downside. Many clinics in our area are dispensing it without the requisite counseling and psychosocial support. Plus, the longer one remains on the medication, the harder it is to taper. Still, patients report numerous advantages over methadone.

      The author fails to mention a MAT with an even brighter future: Vivitrol. Vivitrol is a non-narcotic blocking agent administered once a month via injection. Vivitrol patients report similar benefits in the reduction of cravings and fewer relapse episodes, without any of the challenges inherent in narcotic-based therapies (namely, dependence).

      The sad news is we are about 10 years behind the curve on combating the opioid abuse epidemic. MAT provides the most effective means of promoting early stability and recovery that we have seen to date.

  4. Jason Schwartz | December 6, 2013 at 3:18 pm

    Could the author provide a source(s) for the following statement? “Studies suggest that over 60 percent of people on buprenorphine therapy have very positive outcomes.”

    His reporting on the outcomes in his own program don’t provide a timeframe. That would be helpful too.

  5. Alan Wartenberg MD | December 6, 2013 at 3:28 pm

    Dr. Knight works with adolescents, with most of his patients under age 16, where methadone cannot legally be used (under 18 can be used with parental consent). There is no evidence base for methadone efficacy in this age group, and the use of buprenorphine allows the treating physician immense flexibility, which is unfortunately lost when a patient is referred to a methadone treatment program.

  6. robert newman | December 6, 2013 at 3:35 pm

    Agree fully with Zac’s comments – - – -EXCEPT that he has overlooked ONE reference to methadone. Alas, it is a reference that is terribly misleading, and decidedly harmful, in its assertion of “advantages [of buprenorphine] over methadone.” Methadone does not result in side-effects of “sleepiness, shallow breathing, or even death” any more than does buprenorphine – in the tolerant individual. And adherence to the exceedingly simply adage “start low, go slow, aim high” ensures the patient indeed will be tolerant. Just imagine the effect of such a statement on those receiving or contemplating seeking treatment with methadone . . . and on their families, employers, teachers, etc.!

    It is indeed sad to see an effort – especially by experienced and authoritative experts in the field – to lessen the misunderstanding and stigma associated with one medication heighten the misunderstanding and stigma associated with another. The authors really should issue a clarification.

    • Alan Wartenberg MD | December 7, 2013 at 3:22 pm

      I have been involved in five cases of adolescents treated in hospital based programs for opioid dependency, where very modest doses of methadone resulted in death (30 mg in three cases, and 40 and 50 mg in 2 others). There were no other drugs involved. I think there is significant reason to believe that buprenorphine is safer in this age group, and would not concur with Dr. Newman, an esteemed colleague, on this issue. I am in the process of writing up these cases for publication, and have been on the speaker circuit warning people that usual adult doses may be highly toxic in younger patients.

  7. Zac Talbott BA CMA | December 6, 2013 at 8:45 pm

    In response to Charles and Alan – Whatever the reason for not mentioning the most researched, proven, evidence-based & effective gold standard option for the medication assisted treatment of opioid addiction (other than one inaccurate and stigmatizing comment that is not supported by research or personal experience), IF Methadone is not mentioned then perhaps a title choice resembling “Buprenorphine-assisted treatment for opioid dependence” would be more accurate. Titling this piece as though it is about medication – assisted treatment for opioid addiction in general and then not only failing to mention the gold standard and most effective pharmacotherapy available can fastly result in the author’s credibility and/or motives to be called in to question. I fully agree with Dr. Newman and feel the author(s) of this piece and/or editor(s) of this website should issue a clarification, ESPECIALLY in regards to the anti-evidence-based and stigmatizing comment insinuating that some of the potential complications of abusing illicit methadone are equally potential in a controlled and proper treatment plan based on best practices. Buprenorphine, when abused or mixed with other sedatives, carries many of the same risks. The MAT community, especially respected professionals, must start being aware of the damage that could be done to an individual’s health and/or life by pitting one medication against another. Both Buprenorphine and Methadone have a place and should be supported to the greatest extent possible, but if we are to pit one medication against the other methadone will come out on top 9 times out of 10.

    Also, minors CAN be treated with methadone with a waiver/consent from a parent or legal guardian. To suggest buprenorphine is the only option for this age group under the law is not accurate. I’m currently working with a 15 year old patient in methadone maintenance treatment who has supportive parents that is doing extremely well. Also the federal regulations allow for methadone in an office-based setting should the treating physician obtain the necessary approval from the appropriate regulatory and/or governmental agencies.

  8. paul Bowman | December 6, 2013 at 8:53 pm

    Great article and I would think buprenophine should be first choice for young addicts but have methadone also available if the buprenophine therapy fails.
    Paul Bowman

  9. Judy Kirkwood | December 9, 2013 at 12:51 pm

    Thank you Dr. Knight for speaking out. Medication Assisted Treatment is such a volatile and political issue, even though I know so many parents who credit Suboxone for keeping their children alive and allowing them to quit relapsing on heroin and other opioids. My own son included. He has had trouble getting a sponsor in AA due to prejudice against MAT. My understanding about addiction and about mental illness is that they are brain disorders that don’t correct themselves if you don’t do anything. They are not manageable only through a spiritual program. One sensitive therapist described medications to my son thus when he was a young teen addict: Your body is your vehicle, but it is not you (your essence). Just like you need to get your car tuned up and add oil or replace parts, sometimes we need to do that with our body. It doesn’t change who you are, it keeps the vehicle in good working order. Amen

  10. Waismann Method Rapid Detox | December 9, 2013 at 6:08 pm

    I concur that addiction is a disease. Many times, we don’t treat it as such. With that said, we need to address the issue with care, respect, and understanding for those involved.

  11. Angelo | January 7, 2014 at 11:26 pm

    No, she mentioned methadone. She mentioned it can cause death. I see she has a preference for Buprenorphine. I wonder how much she gets every time she prescribes it.Maybe I’ll do a little research and see who’s paying the good Doctor.I’ll be back.

  12. Charles Johnston Ibogaine | March 26, 2014 at 11:21 am

    Great take on these drugs as addiction treatments. I tried using these “taper off” methods and unfortunately it didn’t work for me. However, I think that the stigma of “not really clean” does follow with many of these drugs, unfortunately. It shouldn’t matter the process if the outcome is being free from drugs.

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