In at least one respect, President Donald Trump’s replacement for Tom Price as Secretary of Health and Human Services is an improvement: Alex Azar believes in expanding medication-assisted treatment (MAT) for drug rehab. Let’s hope it’s because he accepts the science, not just because he was once a pharmaceutical company executive.
To be completely fair, Price did believe in one type of MAT: Vivitrol, a once-monthly injectable form of the opioid antagonist naltrexone. Price didn’t like the other two Food and Drug Administration-approved drugs for MAT, however: buprenorphine (Suboxone) and methadone.
Buprenorphine and methadone are opioid agonists, which causes some people to conclude they are as bad as heroin. These agonists attach to the opioid receptors in the brain like other opioids. Price and others say using them is just replacing one addictive drug with another.
(In his film Annie Hall, Woody Allen’s Alvy Singer imagines the fates of some of his elementary school classmates. One says, “I used to be a heroin addict. Now I’m a methadone addict.” That’s a funny line, but that doesn’t make it true, accurate or fair.)
The fact is buprenorphine and methadone work, just as insulin works for diabetes. Addiction journalist Maia Szalavitz says the data confirms, “if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.”
Yes, they can be abused. Addiction is possible, but it’s not likely unless you are taking far more than the prescribed dose, crushing or dissolving long-acting pills to get the full rush at once, or supplementing them with additional narcotics.
To minimize the risk of abuse, methadone is almost always administered in the doctor’s office or methadone clinic on a daily basis. Buprenorphine has abuse deterrents also: Suboxone is a formulation of bupe and naloxone, an opioid antagonist. If crushed or liquefied, the antagonist negates the effects of the opioid bringing on withdrawal.
Taken as prescribed and in the correct dosages, buprenorphine and methadone don’t cause highs. Instead, they take away the withdrawal cravings that compel users to continue using even after they’ve stopped enjoying it or recognize the harm that it’s doing to their lives, relationships, careers. They are maintenance drugs. That maintenance can take months, a year or more depending on various factors.
Why was Price wrong to say that Vivitrol is better? Because it’s not; it’s just different. Some treatments work better for some people. no one solution works for all.
Buprenorphine and methadone help you manage your addiction, but they do require concurrent counseling and therapy. MAT isn’t just drugs. It’s medication-assisted treatment, not medication-only treatment.
Vivitrol, by contrast, requires that you get straight first. Total abstinence is required, and to the point that you have already gone through withdrawal. That’s because Vivitrol doesn’t help you get clean. It helps you stay clean. If you are still using a drug and take naltrexone, you go through withdrawal almost instantly. If you are clean when you get a shot of naltrexone, nothing happens. If you take opioids after an injection of Vivitrol, nothing happens.
Addiction isn’t only physical, however. It also is psychological. You may try to get high anyway, and if you try hard enough, take a large enough dosage, you can overdose even without getting high. Again, a full MAT treatment plan is needed, not just a drug.
Vivitrol may help, but so may Suboxone and methadone. Some people may benefit from one more than another. All options need to be on the table, and it’s a happy situation that our current HHS secretary knows that.
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