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Jan. 30, 2019 7:40 am

Philly’s behavioral health team: The stigma against this addiction treatment is undeserved

Why the city mandated that medication-assisted treatment for opioid use disorder be made available at every residential substance use treatment provider it works with.

Wintry City Hall.

IPhoto by A. Ricketts for Visit Philadelphia)

This is a guest post by Dr. Geoffrey Neimark, chief medical officer of Community Behavioral Health.
What’s in a name?

For those following news about the opioid epidemic in Philadelphia and beyond, medication-assisted treatment, or MAT for short, is a frequently encountered phrase.

Medication-assisted treatment, the provision of one of three FDA-approved medications (methadone, buprenorphine or vivitrol) in conjunction with psychosocial interventions (cognitive behavioral therapy or contingency management) for people diagnosed with an opioid use disorder (OUD) is the gold standard of treatment.

Medication-assisted treatment is the treatment of choice for OUD owing to its robust evidence base. In study after study, MAT has been shown to have meaningful outcomes across multiple domains including mortality, physical health indicators, employment and crime rates.

In short, if you have an opioid use disorder and receive MAT, you are more likely to live longer, gain employment, not go to jail and stay healthier physically.

Beyond being an effective intervention, medication-assisted treatment is also a very peculiar term. Nowhere else in medicine is “medication” separated out explicitly from overall “treatment.” For persons diagnosed with diabetes, treatment typically consists of medication combined with dietary modification and exercise. Yet, with diabetes, as with other physical illnesses, the healthcare establishment doesn’t refer to a bundle of interventions as medication-assisted treatment.

Additionally, in separating “medication” from “treatment,” one inference might be that the actual treatment is not the medication and that medication is in fact secondary to the bona fide treatment. Nothing could be further from the truth. In fact, it is likely that medication is the crucial ingredient in the treatment of opioid use disorder.

For nearly two centuries, substance use disorders in America have been understood through a religious/moralistic lens and largely as sinful behavior.

So, what then is the deal with the use of the phrase “medication-assisted treatment” for opioid use disorder?

Medication-assisted treatment terminology reflects the thinking of the paradigms through which opioid use disorder, and substance use disorders more generally, have been understood. For nearly two centuries, substance use disorders in America have been understood through a religious/moralistic lens and largely as sinful behavior with the implication being that treatment and cure are realized only through abstinence. Behavioral change, in this case promoting abstinence through restraint, constituted the backbone of treatment, and everything else was secondary.

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Such approaches for substance use disorders marginalized empirical methods, contributed to a dearth in the development of evidence-based practices and explain the ascendancy, primacy and staying power of abstinence-based treatment models in the world of substance use disorders.

Moreover, a general averseness of psychiatry toward medication until relatively recently — a legacy of the therapy-laden psychoanalytic era — as well as the de-medicalization of the substance use treatment infrastructure further contributed to the marginalization of medication-based intervention.

Nowhere is this history and resultant ambivalence of the substance abuse treatment establishment toward medication more evident than in the term medication-assisted treatment.

Beyond the phraseology, the implications of these historical phenomena are profound and extend beyond language to deeply embedded attitudes and cultures. A recent article in Health Affairs indicated that nationally, only 36 percent of drug and alcohol providers offered medication-assisted treatment. Consider that during the greatest public health epidemic of this generation more than two thirds of substance abuse providers nationally do not even offer the most efficacious treatment.

It is why in Philadelphia we have mandated that all city-contracted residential substance use treatment providers make MAT available by January 1, 2020, to remain a part of our network of provider agencies.

The term MAT illuminates much about the history and the beliefs of the American drug treatment system and is a reminder of where our treatment system has been, is, and where it needs to go. Beyond that, it reminds practitioners that many elements need to be addressed in a successful treatment approach — never just one.

At the end of the day, no matter what it’s called, effective treatment of opioid use disorder needs to be individualized and holistic, and to incorporate the best of what medication, psychological and social interventions have to offer.

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