How the shift to Medication-Assisted Treatment (MAT) influences (or doesn’t) conventional views of addiction and treatment

…by Nick Jaworski…

After nearly 80 years, addiction treatment in America is slowly warming to the idea of multiple pathways to recovery, after viewing the 12 steps as the only “real” way to recover. MAT (medication-assisted treatment) is among the most promising.

This is a guest-post by Nick Jaworski, owner of Circle Social Inc., a marketing and consulting firm specializing in addiction treatment. (See bio information at bottom)

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Quite recently, MAT has gained recognition as the gold standard for care in treating opioid use disorder (OUD) among researchers, legislators, and even the general populace. But the acceptance of MAT by the professional treatment community has not been nearly as fast.

Many providers I speak with are still very reluctant to accept MAT in their centers or as a viable component of treatment within the field in general. Even if facility leadership is on board, there’s a good chance staff or referral partners won’t be.

Other providers, such as Hazelden, were also reluctant at first but looked at the  research and made their own determination that they had to change their approach (other providers, even today, still look down upon them for it).

Congress and many States have also recognized the efficacy of MAT and so have begun to pump serious money into programs that offer it (like this large grant from SAMHSA). Insurance providers often prefer MAT as well.

Cost is a very significant factor for legislators and insurance providers. MAT protocols can be provided to those struggling with opioid addictions at a fraction of the cost of a residential program ($4,000 or less a year versus $28,000 a month for your average residential program).

Since the majority of those struggling with addiction lack resources or are on Medicaid, MAT also opens the doors for the demographic with the greatest need to access care.

There are two additional drivers of the increase in the use of MAT in the US — Wall Street and parents.

Wall Street has seen great opportunities because the opioid crisis is constantly in the news and the addiction treatment industry has an estimated market cap of at least $35 billion per year. These investors come from outside the field and do not have the same biases. They look at the data and see what’s effective and where trends are going.

And then there are the parents referring their adult children into treatment. Many parents, especially mothers, have become completely disenchanted with the addiction treatment industry as it has existed since the late 1990’s.

Their Children Are Dying from Overdoses, and Parents Aren’t Taking It Lying Down

The bottom-line is that length of care is one of the highest predictors of success for treatment, so any 28- to 90-day program has very slim chances of success for the first round or two of treatment, regardless of what model they are using. To move away from abusive substance use requires extensive development of new neural pathways that drive new habits and patterns of thought.

As outlined in my article on a Brief History of Addiction Treatment Marketing, it was not uncommon for these young adults to go through 10-plus rounds of treatment. My team and I actually just interviewed a client who was currently on his 27th round of treatment!

As you can imagine some parents have become extremely skeptical after 10-plus rounds of failed treatment (not to mention that they’re paying as much as $30,000 a pop). But, more importantly, many parents have lost children to opioid overdose. The 18-26-year-old age demographic has always had the highest prevalence of drug and alcohol abuse. Most of the time, this is alcohol or marijuana, with smaller percentages using meth, cocaine, and other substances.

However, with the rise in availability of opioid-derived prescription pills, more young adults were switching to these painkillers, which have a high potential for overdose when mixed with other drugs. A subset of these users would go on to heroin, especially when prescription regulations reduced the availability of legal drugs. As most readers know, the extremely high overdose rates of the last few years have been driven primarily by fentanyl-laced (or -replaced) heroin. Unlike in the past, when young adults using drugs or alcohol mostly survived to go on and live normal lives (probably like most of those reading this blog), these kids were dying instead.

So parents were sending their children to multiple rounds of rehab, paying tens of thousands of dollars, and then losing their children to overdose anyway. As you can imagine, this created a lot of anger and resentment.

But that was nothing compared to the anger many parents felt when they learned there was this option called MAT that decreased overdose deaths by roughly 40-60% and they had never heard about it! It’s not uncommon for parents who have lost a child to overdose to tell me that the first time they’d heard about MAT was after their child’s death.

Imagine how you would feel if you sent your child to the hospital and you weren’t even told of a readily available and cost-effective method of preventing your child’s death because the doctor personally didn’t care for the treatment.

This is the kind of anger we see from parents such as Gary Mendell, who created Shatterproof, or Justin Phillips, who created Overdose Lifeline. Parents are simply giving up on the traditional rehab industry as a whole because they feel lied to.

American Addiction Treatment Perspectives Are Shifting, But in What Direction?

All of this has started to open the window to different conversations surrounding effective addiction treatment. Programs relying solely on 12-step and abstinence-based models are regularly being called into question.

However, I am not yet seeing an attendant shift in the disease model of addiction. Conferences premised on non-disease models are still small, and advocates of this approach are still few and far between.

I am on the board of Above and Beyond Family Recovery Center in Chicago, one of the most innovative treatment programs in the country. We focus on providing free, high-level outpatient treatment to Chicago’s homeless and disadvantaged, but we have had a hard time gaining the support of other treatment programs in the city because we do not focus solely on 12-step programming or disease models of treatment (although these are offered alongside our other programs).

Americans have a long history of deterministic thinking when it comes to human behavior. Starting with Calvinistic predeterminism in colonial America and then evolving into Eugenics, the American view of genetic influences rarely goes beyond a limited and simplistic notion of Mendel’s pea experiments (perhaps a topic for a future blog post).

With this misconception, most Americans still view addiction as some kind of genetically predetermined disease, one that is chronic, progressive and incurable.

In the context of our conversation here, MAT is seen as some kind of fix for an ingrained defect, one that perhaps rebalances out-of-whack or deficient neurochemicals in the brain. What most Americans have not yet grasped is that MAT, or any other substance that alters the brain’s neurochemicals, simply combats symptoms, which is not so different from how cold medicines alleviate symptoms rather than cure the actual cold. The key difference here is that OUD symptoms induce so much suffering that users are often driven to continue using. Opioids are of course the best (if not only) way to control opioid withdrawal symptoms. In this respect, relieving symptoms, though not a cure, can change behavior patterns that exacerbate the underlying problem.

In order to truly find recovery, you must rewire the neurological pathways in the brain, which will, in turn, drive changes in neurochemical balances. Just as one cannot lose weight or get fit by taking a diet pill, individuals cannot overcome addiction by taking a prescription. The pill can help, but lasting behavioral change requires focused effort over extended periods of time, as Dr. Lewis has often pointed out.

It is only through an accurate understanding of the interplay between genes, environment, and human experience that we can create effective solutions which help individuals and communities. It’s a goal I strive towards every day and I hope others reading this will do the same. For a much more in-depth discussion on how unconscious processes involved in learning and development (rather than genes or choice) drive addictive behaviors, see my article You’re Thinking about Addiction and Choice All  Wrong.

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Nick Jaworski is an internationally recognized executive in the field of behavioral health marketing and operational consulting, with experience building organizations world-wide. As the owner of Circle Social Inc., he has helped healthcare organizations perform turnarounds and accelerate growth. He and his team spend most of their days in and out of treatment programs across the country. They do extensive analysis of trends, observe programs, interview patients and families, and analyze data from marketing campaigns. Nick is an advisor to the board for The Behavioral Health Association of Providers, and is also on the board for one of the most innovative treatment programs in the country – Above and Beyond Recovery.

19 thoughts on “How the shift to Medication-Assisted Treatment (MAT) influences (or doesn’t) conventional views of addiction and treatment

  1. CM July 12, 2019 at 4:13 am #

    Makes sense working with the whole issue along the whole continuum. It takes as long as it takes and whatever it takes. It’s realistic and pragmatic and should be the mainstay of any integrated approach! Thanks

  2. gary July 12, 2019 at 7:51 am #

    I really appreciate and embrace “recovery” as a “process” and not an event for sure. It is so very important to influence the neuropath ways in order to adopt a whole new way of being, thinking and/or behaving which sustains change/becomes the new norm. Long before I developed a “drinking problem” I had developed a “Thinking Problem” about drinking. Once the alcohol was introduced “like magic” I was hooked-in. Removing the alcohol, in my opinion, was only dealing with the symptom of my Thinking Problem. However, over time, and actively involved in the A.A. Program my Neuropath-Ways were influenced. It was the modeling that took place and folks sharing similar struggles together like a “family-of-affiliation” that really impressed me. So! in many respects, this was more of a “discovery process” versus a “recovery process”.

    I also believe Medicated assisted treatment is essential in terms of savings lives especially with the risk of overdose from using Fentanyl or Fentanyl-laced drugs etc. Hope and recovery, or perhaps “discovery”, is open to the many possibilities of healing and health not stuck in the past. Changing neuropath-ways isn’t just for patients or “clients” but is also extremely important for treatment facilities and/or systems.

    Thanks!~

    • Nick Jaworski July 12, 2019 at 10:37 am #

      I really like that comment on AA Gary. It’s a good connection I think a lot of people miss. When AA works, it’s because of that rewiring. “First thought wrong” is a great example. People have built up pathways connected to their experience surrounding abusive use and that’s what they’ll default to until a new pathway is built. So “first thought wrong” is actually a great CBT technique to stop, think about your thought process more consciously, and then decide if you need to change it. Do that long enough and you’ve built a new default pathway!

      Another aspect of AA that works incredibly well is the community aspect and, as you mentioned, the modeling. Much of our neural wiring is influenced by those around us.

  3. Jo Gill July 12, 2019 at 8:16 am #

    Thanks for presenting this – I too wish there were more providers who would buy in. I have a cousin who works for a company that manufactures cutting edge technologies in the medical equipment field and he told me several years ago that studies had proven MAT is incredibly more successful. My own son has been in treatment for over 4 years and is working towards discontinuing the medication within the next year or two. He is on a very low dose now and has found it extremely helpful.(In his particular case though he also found he had to move geographically to escape the “people, places, things” aspect of addiction). I feel badly though for many people who cannot afford the treatment. There are many addicts who are, simply by virtue of their addictions, unable to work and therefore uninsured. I suppose that’s the next threshold needed to cross. Meanwhile, where is the pain medication that supposedly was being researched that would NOT have addictive properties? I suppose big pharma is not as anxious to bring that to market……

  4. Maia Szalavitz July 12, 2019 at 9:11 am #

    Please, can we stop calling it medication *assisted* treatment, when it is very clear that the medication is the component that reduces the death rate by 50% or more? We don’t have “medication assisted treatment” for depression—we have medication and talk therapies and some people are fine with just meds, some are fine with just talk and some need both or vary over time. Same is true here and this is just silly.

    The National Academy of Medicine recently urged this change as well:

    http://www.nationalacademies.org/hmd/Reports/2019/medications-for-opioid-use-disorder-save-lives.aspx

    Also, Big Pharma has been looking for a non-addictive opioid ever since it thought heroin was a non-addictive replacement for morphine, it’s a genuinely hard problem!

    • Nick Jaworski July 12, 2019 at 10:58 am #

      While I do agree with you that the medication is an important component in terms of preventing overdose and saving lives, I disagree that we should remove “assisted.”

      I’m actually speaking on this topic at the National American Mental Wellness Conference coming up in PA in November. There is a false assumption in the US, which you’re echoing here, that the pills are the fix, because the entire emotional or regulatory problem is stemming from some kind of balance issue or chemical deficiency. This is incorrect.

      There are feedback loops between the neurochemicals and the neuropathways, so there is an interaction process here, but prescriptions can only modify symptoms, not change the underlying neural pathways causing the issues. What a pill can do, just like methadone and bup do, is provide an opportunity for clarity, to re-engage the PFC, and build out new pathways.

      To use depression as an example, if you’re so depressed you can’t get out of bed or are constantly engaging in suicidal thoughts, an SSRI can push you into a state where you have a positive enough mental state to now engage in the hard work of changing pathways so that, eventually, you could stop the SSRI if you wished.

      Related to your comment, the major misconception is that we do not describe depression treatment using SSRIs as MAT. We absolutely should as that would be a more effective conceptualization. Your brain isn’t broken. It’s operating completely normally according to everything we know about neuroscience. The problem is that the current configuration is not optimal for living a successful life as the broader culture would define it.

      So building out new modes of thinking and behavior through therapy, springboarded by prescriptions as needed, is engaging in that same standard process in the brain. The same processes that created the downward spiral can lift you right back out.

  5. Maia Szalavitz July 12, 2019 at 11:39 am #

    I still disagree. There is no evidence that *forced* counseling adds anything other than costs. Obviously, most people with addiction will benefit from all types of support from housing to job training to psychiatric care— but those “assist” the medication, which is the thing that reduces mortality. And not everyone wants or needs those things— they should be triaged to the people who *do* want and need them. Medication can be harm reduction or stabilization— we need to meet people where they are and provide what they are ready for, not what we think they should do.

    We have a deadly overdose crisis and these theoretical wonderful supportive counseling groups that people are being forced to participate in are a barrier to saving lives. And, they are much better in theory than in practice, as anyone who has ever been on methadone can tell you.

    Addiction is the only condition for which we *require* people to participate in other treatment in order to get lifesaving medication. Do you want to be forced to show up for mental health care that you don’t find beneficial in order to get your Prozac? I sure don’t.

    Doing anything different for people with addiction is infantilizing and dehumanizing. Oh, and also ineffective— do you really want to sit in a group and talk about being abused as a child when everyone else there is watching the clock?

    • Nick Jaworski July 12, 2019 at 12:00 pm #

      I think we’re referring to two different points.

      – Must behavioral therapy be a requirement to receive medication? No, the research is clear that the prevention of OD is the same with or without therapy in the short-term.

      – My point is that medication should not be considered a fix or sole solution as it’s unlikely to be effective long-term (though short-term studies are positive).

      In terms of coercing in to treatment, I agree that it’s not beneficial, though there is some data suggesting that recovery rates for those forced into treatment vs. not are the same. I’ve seen studies stating the opposite was well, so jury is out there from a research standpoint. However, my gut sense is that coercion is not as effective.

    • Marc July 12, 2019 at 12:42 pm #

      Maia, who said anything about “forced”? The most effective treatment programs, I think Nick and I would agree, offer decision trees at every step of the treatment process. The trajectory of treatment should always be negotiated between client and treatment provider. And of course counselling-free methadone should always be an option for opioid addicts.

      The newer models are founded on harm reduction principles, not a misguided insistence on abstinence. I think you’re arguing with a favorite phantom here.

      Also, since you brought up depression meds, let’s recall that the effectiveness of SSRIs is minimal if not nil for many people. I agree with Nick that depression meds are most often useful as a bridge. Since both opioid addiction and depression are consolidated through emotional, physiological and behavioural elements, and both can lead to premature death, combining pharmaceutical and psychological approaches to intervention may be a useful general model.

      Sitting around looking at the clock, or looking at people looking at the clock, is obviously useless. Nick and I met at Andrew Tatarsky’s centre, where psychological treatment is far more sophisticated than your state-run rehab is likely to provide (though that raises other difficulties, e.g., when it comes to who’s paying).

  6. Maia Szalavitz July 12, 2019 at 11:42 am #

    P.S. It’s very nice to talk about theoretically rebuilding thinking patterns and self regulation, but that’s very hard to do when someone is dead.

    • Maia Szalavitz July 12, 2019 at 12:51 pm #

      Everyone pretends that this stuff is just about getting decent care to people— but in the real world, the idea of “medication assisted treatment” is used to support the current system of requiring people to get counseling, etc. in order to get meds. Try visiting a typical methadone clinic or look at what happens to buprenorphine patients who don’t want counseling.

      I’m not talking about old phantoms, you guys are ignoring the real hassles that are imposed on patients in the name of treatment having to be “assisted” if you are going to get medication.

      That is the reality: the reality of emphasizing that people need more than just meds is supporting a coercive, harmful system that is far from optimal.

      • Marc July 12, 2019 at 12:56 pm #

        Okay, point taken. But you are talking about the public health system in one very particular country whose public health system is famous for its deficiencies. You’re talking about life on the ground in American inner cities. Sure, it’s important to report on how certain practices are used and abused by specific social/economic interests. But it’s far from the big picture.

      • Marc July 12, 2019 at 1:02 pm #

        Also, I really wish that you’d occasionally remind people that you’re talking about opioid dependency — a physiological dependency with nasty withdrawal symptoms. You don’t address “addiction” per se. I’m not mincing words. There are vast numbers of meth, coke, and alcohol addicts (not to mention porn addicts, food addicts, and compulsive gamblers) for whom these sweeping admonitions have no meaning.

        PS. You know I’m a fan of yours.

      • Nick Jaworski July 12, 2019 at 2:44 pm #

        I can see your point about requiring counseling to get meds in the sense that it’s not required for other treatments and the meds, in this case, are often life saving. So I’ll agree with you there.

        But that topic isn’t the focus of the article. One of the main points here, especially in our discussion in these comments, is that behavioral change is absolutely needed for successful recovery long-term, whether that’s done on one’s own or with professional help. The drugs alone simply can’t provide that.

        Helping individuals and the broader culture understand that behavioral change is a long and difficult process that cannot be realized through meds alone is extremely important in order to institute more evidence-based practice. Also, there is a very large value in helping people understand everyone has the capability to change. They are not locked into some horrible destiny due to genes or current chemical balances in the brain.

        So you’re right that current policies in the US are doing harm by not allowing people access to medication without other hoops to jump through, but we cannot simply throw out behavioral change techniques and supports because that’s currently the case as that would also be detrimental.

  7. Michael Abbott July 12, 2019 at 11:48 am #

    I will defer on the discussion about using the term “assisted” treatment. The controversy about concepts and advocacy that recognize the very important but limited role of psychoactive substances as an integral part of recovery is not new. I became involved in addressing the stigma around mental health and the recovery process 20 years ago. I think that an important element that needs to be emphasized is the understanding of the person in recovery about the role and function of medication in his/her recovery process. If the individual doesn’t have a real understanding of how medication assists in his/her recovery, then the use of medication is a passive process, with the provider being the one receiving the “assistance”. How about using “medication-empowered recovery”?

  8. Gary July 12, 2019 at 1:31 pm #

    I hope I’m not naïve in thinking that every participant, of this particular discussion, holds in their best interest the health and welfare of those impacted by SUD and/or MHD’s. Getting “caught-up” in terms of semantics and/or terminology isn’t helpful or even hopeful. As I had mentioned in my previous post, perhaps real-change starts with our own neuropathways not being bogged down or narrow minded in thinking.

    Regardless of ones’ perspective, the bottom-line is, we all want what is best for those impacted by addiction and/or mental health disorders.

    In reflecting upon AA one of their great “proverbs” and/or sayings was; “first you come”, then “you come to” and then you come to believe.

    I agree that perhaps a person suffering from an addiction or in severe withdrawal cannot grasp concepts such as CBT, at least in the beginning. Once stabilized though, with permission and as a joint partnership you may start to introduce the idea of better decision making, better coping skills, ways of thinking and behaving that enhance the quality of their lives.

    Medication most certainly can and hopefully reduces the symptoms, however, as part of a continuum is a way of living with little or no dependence on meds ideally.

    However, if ones’ culture of care is reflective of emergence due to a crisis or epidemic then it is reasonable to believe that getting medication is critical, this also makes perfect sense. Again, regardless of your lens, we all want what would be best, effective and long lasting.

    • Marc July 13, 2019 at 6:29 am #

      Sure we do, Gary. But I don’t see this argument as getting stuck in semantics. What Nick, Maia and I are discussing are fundamental principles for helping people at perhaps different stages of opiate addiction. You seem to agree that readiness for psychotherapy and behavioural change may not appear until people achieve physiological stabilization. These are important distinctions, but I think semantics helps rather than hinders, as long as we are conscientious in how we use words.

  9. Terry John McGrath July 14, 2019 at 6:35 pm #

    why do we talk about “treatment’ at all – we’ve been sucked into the medicalisation of a behavior for years – what other behavior do we treat like addiction (or actually just plain drug use) – do we treat elite sportsmen who are addicted to their sport, or workaholics, or successful businessmen addicted to money – there’s big questions for mine over this whole idea

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