We recently engaged Dr. Barclay as a consulting partner with Integrated Services for Behavioral Health. He is helping us to think about the role of medical assisted treatment (MAT) as we build a science-based, relationship-centered response to the opioid addiction and overdose epidemic. The following represents a simple explanation of MAT, intended for non-medical professionals.
What is an addiction?
The harmful use of substances does not, in and of itself, indicate addiction. Harmful and risky substance use, repeated time-after-time despite serious adverse consequences, is a better way to think about addiction. Taking a drug as directed under the care of a credentialed prescriber that results in relief from a disease or management of symptoms, represents effective medical care. Repeatedly misusing a prescribed medication in a way that perpetuates health and life problems, is an addictive behavior.
Research shows that psychosocial approaches, including counseling and behavioral supportive services, represent the mainstay of addiction treatment. However, research also shows that people who experience significant opioid addiction are rarely able to participate in psychosocial care without medication to stabilize brain abnormalities generated by chronic exposure to opioids.
How does addiction affect the human brain?
Normal human consciousness depends on regulated brain function, just like all other body systems. The healthy human brain generally remains stable due to the body’s complex mechanisms that support balance. This is referred to as homeostasis. Many factors, including disease and harmful substance use, can provoke body systems out of homeostasis. Sometimes when harmful substance use behavior is repeated and continues over time, abnormal equilibriums become stable and enduring. This is referred to as, allostasis.
In the person with an addiction, normal consciousness no longer exists. Rather the person lives in three alternating allostatic states of consciousness: intoxication, withdrawal, and craving. In states of withdrawal and craving, the prime motivation for behavior typically becomes, seeking the drug. All other considerations are secondary. And when intoxicated, people’s judgment and functioning are impaired. Short term, this often renders a person unable to carry out routine tasks of life, things like job and family. Long term, it can erode core values, confidence, and basic citizenship. Addiction also adds to many of the pre-existing psychiatric problems prevalent among people who have substance use disorders. It can all add up in a very unhealthy way.
The medical assisted treatment approach for opioid addiction
Research shows that people diagnosed with opioid-related substance use disorders (opioid addiction) who are maintained on buprenorphine/naltrexone (suboxone) with effective medical supervision and who also receive effective psychosocial support have a good chance for success. This is due to suboxone’s stabilizing effect on addiction brain abnormalities, returning the person to normal homeostatic consciousness. It also blocks the effects of other opioids, reducing the risk of continued harmful substance use. Brain homeostasis promotes the likelihood the person will continue in treatment.
Long-acting naltrexone (Vivitrol) is also used as a medication to support addiction treatment and has a place in the MAT formulary. While it blocks the effects of any opioids that may be attempted while in treatment, it does nothing to ameliorate the brain’s abnormal consciousness. This condition may persist for months, even years, leaving the person potentially less functional, motivated to use other drugs, and more likely to move away from treatment. It works best when there is a strong external incentive for treatment or clinically well-defined internal motivation.
About Billy Barclay, MD
Dr. Barclay is a psychiatrist who has specialized in treating addictions for 40 years and who has been board certified as an addiction psychiatrist for 20 years. The focus of his career has been the treatment of opioid addictions and the development of systems for treating them. Most recently Dr. Barclay was the Medical Director of Addiction Medicine at The Ohio State University Wexner Medical Center where he implemented MAT systems at Talbot Hall, the addiction treatment facility at Wexner, and programs for specialty areas including consultation to hospital inpatients, palliative care patients and sickle cell patients. Prior, he was the Director of Addiction Treatment Services for the University of Louisville Psychiatric Group where he founded their MAT program. Before returning to academia, Dr. Barclay was founder, owner and Medical Director of Powder Basin Associates, a mental health and addiction treatment facility, with 6 locations in five northern Idaho counties. Powder Basin Associates was selected by the Idaho Council for Alcoholism and Drug Dependence in 2002 for the annual award as Idaho’s Outstanding Drug Treatment Program.