Make America Green Again: What is Medication Assisted Treatment for Opioid Use Disorder?

The last column that I wrote was about five months ago as I planned my re-entry into aNewsCafe with a discussion about my frustration with our divisive political climate. My column was poised and ready to go when a lack of raking our forests set Redding ablaze. Politics no longer seemed so important. Now, as life returns to normal in Redding, I’ve decided to follow the advice of the NRA and stay in my lane. Don’t worry, I will still take a few political jabs from my lane. After a recent mass overdose left one dead and twelve in the hospital, it’s time to talk about drugs. This column is about the treatment of opioid use disorder – addiction to heroin or other opioids, usually pills.

Photo source: Opioids | National Institute on Drug Abuse (NIDA)

Methadone has always seemed like a joke to me. My view of methadone clinics was that they are a place where addicts could gather, trade drugs and exchange information on how to work the system. Instead of using heroin, they were just using another drug, getting high on the government’s supply. If I were asked to picture a methadone patient, it would be an unemployed, disheveled addict nodding off on a street corner. It turns out that I was wrong.

First, it’s important to understand what addiction really is. Deep in your brain lies the nucleus accumbens, the part of your brain that is responsible for pleasure. The main neurotransmitter, dopamine, is released in response to pleasurable activities. This makes sense from an evolutionary standpoint as activities that encourage us to thrive as an organism and reproduce give us pleasure. Did you also just have to re-read that word to see that it’s organism and not orgasm? If you have a good meal, the amount of dopamine released in these synapses may increase to 150 percent of baseline levels. If you have sex, they may rise to 200 percent. Perhaps you would like to combine both activities and push the needle a little past twice baselines levels. Perhaps you want to up the ante and indulge in some of your favorite Kentucky bourbon and watch those levels climb to three times the baseline level. Does heroin look like fun? That will get you to five times your baseline levels of dopamine in the pleasure center of your brain, far higher than any experience in life can provide naturally. Even when using it alone, it will give you a sense of well-being and connection. Enjoying your perfect teeth and hair? Methamphetamines will get you to over ten times your baseline dopamine levels. These substances quickly hijack the pleasure center of your brain. Because your body constantly strives for homeostasis, those synapses and receptors change with repeated drug exposure and your baseline levels without the drug are really low, making you feel awful and unable to function without the drug. Then you find yourself using the drug just to try and feel normal again. That drug has hijacked your brain and your prefrontal cortex, the part of your brain that makes decisions, is powerless against your nucleus accumbens.

According to the American Society of Addiction Medicine, “Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” This means is that you’re not addicted to a substance just because you have physical symptoms when stopping it. You’re not addicted to metoprolol although stopping it after taking it for some time will cause increased heart rate and blood pressure. That also means that you’re not addicted to pain pills if you feel sick and hurt worse when you stop taking them. If you then throw a brick through the window of Walgreen’s to get your next fix, then you’re addicted.

Addiction has a strong genetic component. Studies of twins that were separated at birth show us that about half of addiction is because of genetic factors and half is environmental (the actual number varies by substance). We know that adverse childhood experiences (ACEs) are associated with addiction and people with 4 or more ACEs have a much higher rate of addiction. When I hear stories of many of my patients’ childhoods, I can’t imagine how they would not have become addicted to something. I hear stories of physical abuse, neglect, sexual abuse, parental substance abuse, and some of my patients never had much of a chance of sobriety.

Medication Assisted Treatment (MAT) is the use of buprenorphine, methadone, or naltrexone for the treatment of opioid use disorder (OUD). For the purposes of this article, I won’t discuss naltrexone, a medication that is not optimal for most patients. Methadone is a typical opioid and has been used for many decades in the treatment of OUD. For the treatment of addiction, it can only be given by a methadone treatment program (MTP). Buprenorphine (the main component of Suboxone, Subutex, Zubsolve, etc.) is also an opioid but doesn’t have full effect on the receptor. Because of this, it has a ceiling effect on respiratory depression and alone will generally not cause a lethal overdose in adults. It’s affects also have a ceiling affect, making this a safer medication. It can be lethal to children and has packaging that makes it difficult for children to open. These medications, when taken appropriately, do not get people “high” but they do keep them feeling normal again, able to function in daily activities with little to no cravings to use opioids. I’m definitely biased towards buprenorphine/naloxone because it doesn’t get my patients with OUD high and has a lower risk of overdose. The naloxone doesn’t have any clinical effect unless it’s inappropriately injected where the naloxone blocks all opioids. When it’s diverted (sold or given to others), it’s diverted to prevent withdrawal or even treat addiction, not usually for intoxication.

MAT is effective. If we simply get someone off of opioids, even without them being in withdrawal, and provide standard drug and alcohol counseling, most studies show less than ten percent are abstaining from opioid abuse in a year. However, with MAT, the numbers are greater than fifty percent. Methadone and suboxone have been demonstrated consistently to reduce criminal activity, transmission of diseases such as HIV and hepatitis C, increase employment, and improve quality of life. They work well to treat addiction to opioids. Although counseling/therapy is part of treatment, it is ineffective without medication. This is why the treatment of OUD is a medication first model.

How long patients stay on MAT is individual. Usually we recommend at least six months to a year in order to have the opportunity to respond to stressors in life, anniversaries of traumatic events, and time for the brain chemistry to normalize. Some people need to stay on medication longer in order to maintain sobriety. We don’t tell a diabetic that we will put them on insulin for a year and then wean them off and see how they do. For some people, addiction is a disease that they must deal with all of their lives. For others, they may successfully wean off of MAT.

Put aside your biases and stigma of people with substance use disorder and look at the science. Putting them all on an island, locking them up, or trying to shove them into someone else’s back yard won’t work. Treating their addiction with evidence-based treatment, however, does work. A lot of them are nice, caring people who want nothing more to be responsible citizens and contributing members of society but find their prefrontal cortex hijacked by a drug that has turned their nucleus accumbens into a real asshole. Before you throw out the age old argument that they chose to take a drug in the first place, what do you say to the 10 year old whose father was high and decided to shoot him up with meth or the 11 year old who was given heroin to shut her up while she was being pimped out by her mother for drugs? If you have ever tried an alcoholic drink, experimented with a drug, took a pain medication that your doctor told you was safe, took a medication to help your anxiety, you should be thankful that your genetics and childhood experiences didn’t predispose you to get addicted. We’re the lucky ones and we should try to help those who are not so lucky.

Greg Greenberg
Greg Greenberg grew up in Santa Monica, California. After undergraduate training at UCLA he attended medical school at Ohio State University and completed a residency in family medicine in Columbus, Ohio. He moved to Redding after residency in 2004 and has served the Redding community as a family physician, hospitalist, emergency physician, and, most recently, in addiction medicine. When he’s not enjoying the calm atmosphere of the emergency department he enjoys the chaos of being a full-time parent as well.
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15 Responses

  1. Avatar Alice Bell says:

    What an edifying article! You explain it so well that a non-science oriented mind can understand. I am thankful that I am one of the lucky ones re genetics and ACES.

  2. Avatar Beverly Stafford says:

    What an eye-opener! Thanks for the science-based explanation of addiction. I assume alcohol addiction has the same basis, that the prefrontal cortex is compromised. Is there a MAT for alcohol addiction?

    • Greg Greenberg Greg Greenberg says:

      Thank you Beverly. The best treatment for alcohol use disorder is the social model of treatment — AA, smart recovery, etc. There are medications that can supplement that treatment that are proven to decrease the amount of drinking and increase the rate of sobriety. While the treatment for opioid use disorder is a “medication first” model, the treatment for alcohol use disorder is medication to supplement the social model.

  3. Adrienne Jacoby Adrienne Jacoby says:

    HOORAY . . . .and let’s hear it for the practicing doctor that can still explain stuff in lay terms that even the most insulated old lady can understand!!! Great article Greg. Valuable information.

  4. Adrienne Jacoby Adrienne Jacoby says:

    HOORAY . . . let’s hear it for a practicing doctor that can explain stuff in terms that even the most insulated old lady can understand. Most excellent, informitive article Greg . . . welcome back!!

  5. Avatar sue says:

    Tremendous article, Greg. Thank you for the education and your compassion.

  6. Heads up that Dr. Greenberg’s replies will be delayed because he’s in the middle of a long shift, you know, saving lives and stuff like that.

    Dr. Greenberg, thank you for this informative, insightful important piece. I hope our region embraces this MAT method asap. Too many lives have been ruined and wrecked because of opioid addictions.

    Welcome back. We’ve missed you!

  7. Avatar Tim says:

    Reports from first responders indicate that mass overdose occurred from a mix of fentanyl and cocaine – a modern day speedball… Apparently the stimulating effect of cocaine allows the body to temporarily tolerate greater levels of depressing opiods for that bigger high. But cocaine wears off faster so it is possible to have that opiod overdose unexpectedly kick in hours later (in this case, the overdose was called in at 9am from a 2-4am afterparty).

    • Greg Greenberg Greg Greenberg says:

      Tim, you are correct. We knew this was coming, San Francisco has seen quite a few deaths from fentanyl that was in the cocaine supply. I hate when my drugs are tainted with drugs! Other cities have been seeing this because fentanyl is much cheaper than cocaine and heroin. We’ve been getting fentanyl cheap from China that’s sneaking in through the dark web. This is also why we are promoting people at high risk having Narcan. Fortunately, our law enforcement in Redding now carries nasal Narcan and have been trained in its use.

  8. Steven Towers Steven Towers says:

    Is there any effort being made to hold the pharmaceutical industry financially responsible for pimping synthetic opioids as safe and creating a generation of opioid addicts? I’m not saying it’s 100% their fault, but if it’s 75% their fault for not revealing how extremely addictive these drugs are, and pushing them…

    I’ve gone years having surgeries and such where I’m given a pain-killing opioid prescription for post-procedure pain, as if it’s a given that nobody should have to suffer discomfort. I never fill them, mainly because I don’t want my dopamine receptors to get a taste. That’s how it starts, as they say.

    • Greg Greenberg Greg Greenberg says:

      Steven, there are many law suits underway, especially directed towards Purdue. That being said, it’s always too little, too late. Hopefully this will open our eyes that pharmaceutical companies have too much political power. Let’s not forget that the Joint Commission leaned hard on hospitals to address pain, leaning far in the direction of over-treatment. California required all physicians to get 12 hours of medical education on pain which was basically a day and a half of being told that we need to believe patients’ subjective complaints of pain and give them these wonderful, safe opioids that have a low risk of addiction.

  9. Avatar Candace C says:

    Great article, especially the “put aside your bias and stigmas” part. We all have them, including myself ( even if I like to think I don’t) and this article is a good reminder to knock it off. Thank you

  10. Hal Johnson Hal Johnson says:

    This was an illuminating article. I hope that we can some day get to the point that education and treatment get much more emphasis than incarceration. Yeah, it’s more compassionate, but it also just makes more sense.

  11. Joanne Snyder Joanne Snyder says:

    Thank you for an excellent article Dr. Greenberg. A friend related an experience she had while trying to fill a prescription for a drug she had been taking following surgery. Though know for her intelligence and calm nature, she found her self shouting at the pharmacy technician and and bursting into tears when her prescription wasn’t ready as promised. She was shocked at her own behavior and apologized to the technician. She started leaning more about that drug and slowly decreased the amounts she was taking. The addicts it is easy to look down on because of poor hygiene and dirty clothes were a different person before they became addicted. There is hope. Your article proves that there are effective treatment options for people who are addicted, and that that there are still compassionate people working in healthcare.