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Medication-Assisted Treatment Models

Medication-assisted treatment (MAT) is the use of pharmacological medications, combined with counseling and behavioral therapies, to treat SUD. Research shows that combining medication, counseling, and/or behavioral therapies can be effective for substance use disorder (SUD) treatment. Therefore, medications prescribed as part of MAT models are one component of a comprehensive treatment plan that focuses on the "whole patient." This model describes medications involved in MAT and the following model describes behavioral therapies that be used in combination with medications as part of MAT.

As of 2020, there are three medications approved by the Food and Drug Administration (FDA) for the treatment of opioid use disorder. There are no medications approved by the FDA for the treatment of cannabis, hallucinogen, or stimulant use disorders.

Medications for Opioid Use Disorder

Three medications have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of opioid dependence: methadone, buprenorphine, and naltrexone. These medications are effective for treating people with opioid use disorders, as well as legally prescribed opioid pain relievers that are misused, such as oxycodone, hydrocodone, and morphine. The medications work by easing withdrawal symptoms from opioids and blocking its euphoric effects.

  • Methadone – Methadone has been used since the 1960s for the treatment of opioid use disorders by reducing cravings and preventing withdrawal symptoms. Patients who take methadone must receive the medication while under physician supervision and the medication can only be dispensed through an opioid treatment program certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Demand for methadone treatment often exceeds availability, leading to extensive waitlists. One methadone clinic in rural Vermont reported a waitlist of over 900 people, which meant an approximate 1.9-year delay in accessing methadone treatment. Learn more about the benefits and costs of methadone maintenance treatment.
  • Buprenorphine – Buprenorphine allows for the reduction or elimination of withdrawal symptoms that can accompany the discontinuation of opioids. The benefit of buprenorphine is that, unlike methadone treatment, it can be prescribed or dispensed by certified healthcare providers in clinics, community hospitals, health departments, or a correction facility, making it a more accessible treatment option. Buprenorphine is closely regulated, and healthcare providers must qualify for a waiver in order to prescribe the medication. In order to qualify for a waiver, the healthcare provider must receive certification and training on the dispensing of this medication for the treatment of opioid use dependency. The Comprehensive Addiction and Recovery Act of 2016 included a provision that, for the first time, allows not only physicians but also physician assistants and nurse practitioners to prescribe buprenorphine. SAMHSA provides extensive information on certifications and trainings, as well as buprenorphine waiver management. Additionally, SAMHSA's Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction provide information about screening, assessing, and treating opioid use disorder with buprenorphine. Buprenorphine can be administered as sublingual tablets, injection, transdermal patch, or in a combination formulation with naloxone. In May 2016, the FDA approved Probuphine, the first implantable buprenorphine for the treatment of opioid dependence. Implantable buprenorphine may help with treatment adherence as well as prevent the stealing and misuse of tablet or film forms of the medication. Learn more about the benefits and costs of buprenorphine treatment.
  • Naltrexone – Unlike methadone and buprenorphine, naltrexone is an opioid antagonist, which means it works by blocking opioid receptors and preventing their euphoric effects. While it can help reduce cravings, naltrexone should only be used seven to ten days after medically managed withdrawal (detoxification) from opioids has been completed. Naltrexone can be prescribed by any healthcare provider licensed to prescribe medications. It does not require special training like buprenorphine and methadone. Naltrexone can be delivered as a daily oral dose or as a long-acting injection. The long-acting injection only needs to be administered once per month, which has shown an increase in adherence and retention rates.

Examples of Rural Medication-Assisted Treatment Models

  • Project Lazarus, which began in Wilkes County, North Carolina, has created a series of toolkits designed for care managers, primary care providers, and emergency department staff about opioid use disorders. The Project Lazarus training addresses common misconceptions about opioid use disorders and addresses resistance of some providers to prescribing medication-assisted treatments. The program encourages healthcare providers to obtain buprenorphine waivers and provide this treatment option in their communities.

Considerations for Implementation

Buprenorphine and methadone are opioids; these treatment options are sometimes viewed as a method of replacing one addictive substance for another. However, under the supervision of healthcare providers certified to dispense the medications, these drugs can reduce and eliminate withdrawal symptoms and reduce the high-risk behaviors often associated with drug use, particularly injection drug use. In addition to reducing risk behaviors, these medications can increase retention rates for treatment.

One 2015 study in The American Journal of Drug and Alcohol Abuse found that rural treatment centers were less likely to prescribe buprenorphine, which could indicate opportunities for provider education on its benefits. A 2015 study from the Annals of Family Medicine found that 82.1% of counties that reported no physicians who could prescribe buprenorphine were rural counties. As a result, rural residents must travel long distances to receive treatment. Buprenorphine may have especially beneficial outcomes in rural communities where there is opposition to the establishment of methadone clinics or where transportation barriers prevent patients from accessing the methadone clinic. Even among prescribers who have obtained the SAMHSA waiver for prescribing buprenorphine, certified providers may only treat 30 patients at a time in the first year, followed by up to 100 patients in subsequent years. Although a final rule published in July 2016 increased access to buprenorphine by increasing treatment caps for eligible providers to up to 275 patients annually, it still may not be adequate to meet the growing demand for the medication.

Program Clearinghouse Example

Resources to Learn More

Buprenorphine Treatment Physician Locator
Website
A directory of practitioners authorized to dispense buprenorphine by state.
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)

Comparison of Rural vs Urban Direct-to-Physician Commercial Promotion of Medication for Treating Opioid Use Disorder
Document
Describes outcomes from a study examining opioid use disorder medication promotion in urban versus rural settings.
Author(s): Nguyen, T., Andraka-Christou, B., Simon, K., & Bradford, W.
Citation: JAMA Network Open. 2(12)
Date: 12/2019

Implementing Medication-Assisted Treatment for Opioid Use Disorder in Rural Primary Care: Environmental Scan
Document
Describes the challenges and barriers restricting access to MAT in rural primary care settings. Identifies practices and innovative models of care effective in implementing MAT services and includes a comprehensive collection of tools and resources to help providers, patients, and communities for implementing MAT in rural practices.
Organization(s): Agency for Healthcare Research and Quality
Date: 10/2017

Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers Within the Treatment System
Document
Discusses the key barriers to accessing evidence-based opioid use disorder care and offers strategies to address these barriers.
Author(s): Madras, B., Ahmad, N., Wen, J., & Sharfstein, J.
Citation: NAM (National Academy of Medicine) Perspectives
Organization(s): Prevention, Treatment, and Recovery Working Group of the Action Collaborative on Countering the U.S. Opioid Epidemic, National Academy of Medicine
Date: 4/2020

Medication for the Treatment of Alcohol Use Disorder: A Brief Guide
Document
Provides guidance on the use of MAT for patients with an alcohol use disorder. Includes information on screening and assessment, developing a treatment plan, medication selection and monitoring patient progress.
Organization(s): Substance Abuse and Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism
Date: 10/2015

National Institute on Alcohol Abuse and Alcoholism
Website
Provides a variety of resources focused on alcohol use disorder including research articles, fact sheets, training, presentations, and funding opportunities for research and conferences.
Organization(s): National Institute on Alcohol Abuse and Alcoholism

National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
Document
Provides guidance for primary care providers when evaluating and treating opioid use disorder, and managing opioid overdose with a focus on using evidence-based pharmacotherapy treatment.
Organization(s): American Society of Addiction Medicine
Date: 06/2015

Providers Clinical Support System
Website
Compiles educational resources, training modules, online trainings, information on MAT waivers, and clinical resources for healthcare providers involved with opioid use disorder pharmacotherapy treatment.
Organization(s): Providers Clinical Support System (PCSS)

A Systematic Review of Rural-Specific Barriers to Medication Treatment for Opioid Use Disorder in the United States
Document
Discusses implementation issues for medication assisted treatment for opioid use disorder in rural areas. Identifies the need for additional rural-specific medication treatment studies.
Author(s): Lister, J., Weaver, A., Ellis, J., et al.
Citation: The American Journal of Drug Alcohol Abuse, 46(3), 273-288
Date: 05/2020