MANSFIELD, Ohio–Medication-assisted treatment (MAT) is becoming more prevalent, especially locally. Richland County professionals, including Dr. Brett Toward of Third Street Family Health Services; Elaine Surber of Catalyst Life Services and New Beginnings Alcohol and Drug Treatment Services; Mansfield Police Chief Ken Coontz; Mansfield Municipal Court Magistrate Phil Naumoff; Richland County Common Pleas Judge Brent Robinson; and Mary Bolin, a parent who has secondhand knowledge about MAT, each shared their perspective about this form of treatment.
What is MAT?
MAT is the use of medications, coupled with counseling and other support, to provide treatment for substance use disorders.
“It’s medication to help people in the treatment process, generally to address some type of physical symptom like withdrawal or cravings. It’s not unique to narcotics; it’s been around for decades for both narcotics and alcohol,” explained Dr. Toward.
“People who are in acute withdrawal aren’t very receptive or even physically able to do a lot of treatment activities. They’re sick, so using medications to help manage those symptoms can help them get into active engagement of their treatment plan a little bit quicker.”
Among the FDA-approved medications for substance use disorders include acamprosate (Campral®), disulfiram (Antabuse®), naltrexone (ReVia®, Vivitrol® and Depade®), buprenorphine (Suboxone® and Subutex®), and methadone.
Disulfiram, acamprosate, and naltrexone are commonly used for alcohol dependence. Buprenorphine and methadone are typically used for opioid dependence.
Methadone and Suboxone both are narcotics and are used as replacement therapies. Toward said individuals using either of these medications are given a certain dosage and are tapered off the medication slowly overtime to avoid severe withdrawal symptoms.
“The fine line though is not creating a new addiction because it’s still a narcotic and they could become dependent on it as well, and that’s why typically the thought is that replacement therapy, at least with Suboxone, is that it’s not life-long,” he said.
Naltroxone, Campral, and Antabuse are not replacement therapies, but they can help people with withdrawal symptoms and cravings for alcohol. “They have very good track records,” noted Toward.
Buprenorphine can be prescribed only by a physician who has received special training and a Drug Enforcement Administration (DEA) license number. “Any other part of MAT is just part of primary care or medicine practice,” said Toward.
Toward is one of three physicians at Third Street Family Health Services who are qualified to prescribe buprenorphine. Each doctor is limited by law to helping 30 patients at any one time during the first year of certification and up to 100 after that. The Third Street physicians have the capacity to handle 230 patients among the three of them.
The number of patients in Third Street’s MAT program has increased from this time last year. “If I were to turn the clock back a year ago, our census in MAT was probably about 30 or 40 [patients]. Our census today is probably closer to 100 [patients] in MAT,” Toward said. Of the approximately 100 patients who are currently involved in the MAT program, about 50 or 60 of them are prescribed buprenorphine.
According to the Substance Abuse and Mental Health Services Administration website, the final cost of medication such as buprenorphine is determined by several factors, including the pharmaceutical manufacturer, the insurer, the health plan (if any) or prescribing clinic, and by the retail pharmacies that typically dispense the medication.
“It is important to note that the cost of buprenorphine itself is only one part of the cost of outpatient opioid treatment, which also includes the cost of each physician visit, any charges for laboratory analyses or emergency detoxification or stabilization, and any necessary ongoing service referrals and visits that are determined by the physician who prescribes the medication,” the website states.
How MAT is administered can differ among physicians. Toward said Third Street works closely with treatment facilities to ensure that patients receive counseling and support, in addition to the medication.
“We believe the patient can be helped and be taught new decision making skills and problem-solving skills; how to manage their illness without relying on others to do it for them. And because of that, we also believe that being on medication is probably a temporary state as well,” he said.
Patients may make self-referrals, but they will still need to be assessed before they are approved to use MAT.
While using MAT, patients are extensively monitored, he said. If patients, for instance, refuse to attend their counseling sessions, Toward said they will begin to taper individuals off the medication.
“I think we hold them very accountable for being engaged in that treatment and we stay involved in the treatment. We don’t just prescribe medicine. We get weekly updates from their treatment team; we talk to their treatment team weekly. If the patient is struggling with something, we’re aware of it and [the treatment team] is aware of it.”
The results of the treatment are often affected by the patient’s investment, Toward indicated.
“We have found that about two-thirds of patients that come to us are genuinely involved in getting treatment, and about one-third are just generally interested in avoiding consequences of their old bad behavior,” he said.
“Of the two-thirds that are really engaged and motivated for change, we have about an 80 percent adherence rate. That means about 80 percent of them will stick will with treatment and progress though the stages of treatment.”
“For that one third that are just kind of going through the motions, it’s about 25 percent adherence rate.”
Some people, he said, are unwilling to change, but “the whole point of treatment is to change everything,” he noted. “You’ve got to change your habits, your environment, your relationships, and definitely your attitude about medication or drugs.”
Each person differs in how much medication he or she is prescribed, as well as how long he or she is able to use the treatment. Toward said at Third Street, “They could be on as much as two eight-milligram [Suboxone] films in that first 30 days. At the end of 30 days, our protocol is that they would be down to a maximum of eight milligrams, but many people are on less than eight milligrams,” he said.
At the 60-day mark, the patients’ medication is reduced by one or two milligrams and their response to this change would then be monitored. “This process could be as little as six months to as long as twelve months,” Toward said.
Toward said the state took on an initiative (Common Sense Initiative) this summer to reform Suboxone prescribing. “Last I knew it was pending approval at the state and medical board level,” he said.
He explained, “That reform gave some guidelines to dosing and duration of therapy for Suboxone. It has basically given us, at least in the preview stage, the suggestion that we shouldn’t be prescribing more than one film (or eight milligrams) a day to a patient for longer than 30 days, and in that first 30 days we probably shouldn’t be using in an outpatient setting more than two films.”
He’s heard of other facilities (out of the area) that prescribe their patients up to five Suboxone films a day “with no real accountability for how they’re using those medicines,” he said.
Toward said Third Street already uses the Common Sense Initiative guidelines in their MAT program.
Partnership
Catalyst Life Services is among the facilities that partners with physicians, including those from Third Street, in the administration of MAT.
Surber, associate director of Catalyst, said they manage patients’ assessments. When assessing a patient, she said they consider a number of variables, including the patients’ drug and alcohol history, mental health issues, their environment, and past treatment experiences before they make referrals to the physicians.
After the patients are prescribed a medication by a physician, they go to counseling sessions as part of their treatment program, which could be through Catalyst’s New Beginnings Alcohol and Drug Treatment Services.
“They have to come to groups several times a week, they have to meet individually with their counselor, they might have to bring their [medicine] packages back, they would be drug-screened to make sure [the medicine] is in their system and to make sure there aren’t other chemicals in their system as well that would interfere with the medication,” noted Surber, who is also the director of New Beginnings.
“We have to be very careful with medication-assisted treatment in that we’re not just giving people prescriptions willy-nilly and not checking on them, not drug testing them, not making sure they’re taking it as prescribed—those things are critical to medication-assisted treatment being something positive,” Surber stated.
Surber said Catalyst started getting involved in helping people access MAT a couple years ago. She said that MAT is slowly emerging as a viable treatment option within the area.
“There are several doctors in our community that can prescribe [the medications associated with MAT], and we have seen an upswing in people who have access to the medications with the Medicaid expansion and the Affordable Care Act,” she said.
When asked about the results she’s witnessed by patients who use MAT, she responded, “I’ve seen a wonderful change in people. That’s not to say it’s for everyone, but I think it’s important to give people options to help them save their lives.”
She said she’s watched people who could barely keep their head up, “and then we get them connected and they later come in clean, clothed, smiling, thankful, eating…”
“We have had some people who have been on medication-assisted treatment and who are no longer with us. They may still be on medication, but they don’t need the counseling aspect anymore because they’ve stabilized.”
Relapse can happen, she said, and when it does, the facility works with the patients to maybe adapt their treatment program to increase their chances of success.
“Sometimes we see people that we think are doing wonderful and then they’re gone for awhile, and then we find out that they relapsed and maybe they’re in jail, but that doesn’t mean that we give up on them,” she noted.
Court System
MAT is also cropping up in the local court systems, including the Mansfield Municipal Court and the Richland County Common Pleas Court.
Mansfield Municipal Court
Naumoff said MAT, specifically Suboxone, was introduced at the Mansfield Municipal Court close to two years ago.
“It’s working, and we’re keeping them sober longer,” he said.
First and sometimes repeat offenders are possible candidates for getting involved in an MAT program, said Naumoff.
“For a first-time offender, by all I means I think we should put them in a diversion program where they can get their treatment,” said Naumoff. “We can erase that record for them so they have a chance to turn their life around.”
He said, “If somebody has been a criminal before, been through the system and if they already have a record and get caught using drugs, then we’ll still treat them because that’s what we want ultimately.”
“The thing is when an addiction has caused you to go to the extreme criminal behavior, in other words you’ve broken into somebody’s house, you’ve stolen from somebody, you’ve hurt somebody, then obviously prison is what you have to do.”
“I wish we could say that we would treat everybody, but there are some people who have let their behavior and their addiction go beyond that.”
Potential candidates will need to be assessed by a clinician, who will then make a referral to a physician. Everyone—the court, clinician, physician, and offender—need to agree to the treatment terms before the individual can be prescribed the treatment, he said. If the individual does not want to use MAT, then he or she is not forced to do so.
Once a treatment plan is finalized, the individual will then be required to follow all of the rules and guidelines instructed by the physician and take part in some form of counseling or support therapy.
“Just the use of medicine alone doesn’t work,” Naumoff said, which is why individuals are required to take part in counseling in addition to using the medicine.
“When they are being medically treated, you can help treat them through counseling because they have a clearer mind. They’re not high on heroin or on an opiate, so you’re able to have effective counseling with them and get to the root of the problem,” he added.
He said, “There’s always a worry about Suboxone being abused. Well, I’m telling you right now the people that are within the court system, they’re monitored. They get treated by a physician, then the physician monitors them, they get tested to make sure they’re not using any other substance and that they’re using their medication properly.”
“There are some safeguards in place and that really helps.”
“When you see people that are in private treatment, in other words the court doesn’t have any control over them, that’s where the abuse of the Suboxone tends to take place. People think they can get by on less. They sell off the other stuff; they use other stuff with it. That’s a concern….but the ones under our control, generally speaking, are the ones that are monitored and are taking it properly.”
He said MAT was not something the court “jumped into;” however, he said, “You have to keep an open mind.”
“We’re trying to make sure that we look at all of the alternatives and use whatever is the best available treatment out there.”
He added, “If you take care of that issue (substance abuse) then a lot of criminality that happens in this community gets taken care of.”
Richland County Common Pleas Court
Prior to Robinson taking the bench in February of this year, MAT was not implemented in the Richland County Common Pleas Court. Robinson said he’s slowly allowed people who are on probation to use MAT.
“We have several people that are under physician’s direction taking Suboxone that are on probation. We don’t have anybody in Drug Court yet, but we haven’t had any physicians tell us that anybody in our Drug Court should be on it,” he said.
“We will have people on Suboxone eventually in Drug Court, but it will only be if it’s physician-recommended and it will only be people who are not already clean. If you’re no longer using, there’s no reason to put you on Suboxone.”
“The only problem with Suboxone and Subutex,” he added, “is I have heard from individuals who are on it that said getting off it is harder than it was getting off heroin.”
He noted, “My preference would be that if you’re on Suboxone that we wean you off, that you’re not on it for 10, 15, 20 years.”
“I’m not opposed to it. I just know there are some drawbacks to medication-assisted treatment, but I’m for anything that will help people get clean and sober,” he said.
Law Enforcement
Chief Coontz provided input about MAT, noting, “I believe that it’s worth trying as long as it’s monitored by medical personnel and has built-in follow-up and supervision, along with a solid prevention plan and counseling/rehab.
He commented, “I do not condone methadone clinics, where they pass out medication that is only considered a ‘maintenance’ drug to just subside the effects of heroin. We must do more than rely upon a pill to cure all.”
The chief reported at the annual METRICH meeting in October that the 10-county decentralized drug task force had confiscated 1,336.72 grams of heroin so far in 2014.
Coontz stated, “I have always said that if we are going to impact heroin in our community then we will need to take a multifaceted approach. No one single action is going to do it alone, such as only enforcement.”
Secondhand experience
Mary Bolin, parent, has secondhand knowledge about what it means to use MAT. Her twenty-four-year old son, Alex Bolin, was prescribed Suboxone to help with his heroin addiction.
“I think Suboxone’s great for getting people through withdrawal because withdrawal is horrible,” she said.
“If you’ve ever seen anybody go though withdrawal, it’s sweating, vomiting, shaking, mood-changes, very, very sick, can’t eat, can’t sleep—it’s awful.”
She said she’s glad MAT is available; however, she noted, “I think people need to realize it’s not going to fix everybody.”
“When this first affected our family, my frustration was that I thought there was a way to fix him. What I didn’t realize with addiction is it’s so much more confusing and so much more complex,” she said.
She said when her son began using the treatment, “It was probably successful for four months and then he started to relapse.” She said he tried using the treatment a second time, but still didn’t have positive results.
“I think in our case it’s about him being sober without medication-assisted treatment, but I don’t dispute it; I’m not against it. I know people that have used it successfully.”
She added, “I’m for it, but I think I’m more for it in the short-term to help with withdrawal and to help people figure out their treatment, to figure out how they’re going to get well.”
