Current American Medication-Assisted Treatment Conventions Aren’t All Ideal

While medication-assisted treatment (MAT) programs across the country have reduced harm that enrollees otherwise would have experienced without enrolling, some feel that MAT hasn’t been expanded far enough throughout the United States. I can’t help but feel glad it’s legal here in Tennessee, though I also believe our current MAT system is far from ideal — I think we can all agree on that.

Refraining from future drug use would best serve my interests, as I’ve long proven myself to be an often-problematic drug user. Most people can moderate their drug use to avoid addiction and dependency, but I’m not one of those people. While I still use illicit drugs today, I’m in a much better spot now that I’ve reduced my overall intake and largely maintain myself with buprenorphine (Suboxone).

Medication for opioid use disorder (MOUD) prescribers — those are the physicians licensed to prescribe methadone or buprenorphine — are morally incentivized to not tolerate “dirty” urine drug screen results, as knowingly allowing program enrollees to continue illicit opioid use and be maintained using Suboxone could get prescribers in trouble. How would allowing a patient to “get by” with illicit opioid use reflect on a physician if the patient died of an opioid-involved overdose?

Wouldn’t be too cash money, would it?

On the other hand, I wish long-term, addicted/dependent — both in my case — opioid users could be maintained on Suboxone while still using illicit opioids. In my case, since I reduced my other-than-Suboxone opioid use big time, I’ve done myself a solid by seeking out MAT program enrollment. Before getting on Suboxone in September, I found myself in almost-entirely-mental opioid withdrawal every week for anywhere between two and four days.

This cycle got started because I’d have enough money to afford anywhere from three to five days’ worth of using opioids — I could never afford to use throughout the week without interruption — before regressing into a shell of myself until I got paid again. I lived each day during this cycle constantly tracking the time in anticipation for my next high. I wasn’t very psyched about living, either — I felt indifferent about the potential of experiencing overdose. In other words, I never once worried that life was whizzing by too quickly during the three or four years consisting entirely of my oh-so-depressing, constantly-repeating week-long cycle.

After starting Suboxone, I didn’t fiend for heroin — more like a fentanyl-heroin mixture knowing the modern American illicit opioid market — or other opioids as I used to. I also stopped contemplating an “accidental” suicide via opioid overdose. Life was better, in general.

I worry that medication-assisted treatment programs’ firing of patients who test positive for non-prescribed (often-illicit) drugs seems to stand in contradiction to the tenet of keeping patients on — or at least constantly offering them MOUD access — MOUD in favor of returning to the (often-illicit) opioid use they came from, which is typically more dangerous.

Here’s my issue: is it better for MAT programs to (1) allow enrollees to use other opioids and be maintained on Suboxone or methadone or (2) kick enrollees out after testing positive for other opioids an arbitrary one-too-many times?

I think number one is the better option. Here’s why.

What’s the Point of Medication-Assisted Treatment?

I don’t think there’s an objectively-true purpose of medication-assisted treatment. We must ask ourselves what we value most from MAT programs to formulate a worthwhile answer — only then can we hope to define the purpose of MOUD maintenance.

Here’s What I Value From MAT Programs

I think MAT program enrollees’ often-problematic opioid use should decrease as a result of their buprenorphine or methadone use — that’s one performance indicator we can use. Their exposure to risky or detrimental scenarios (i.e., visiting a high-crime area to source illicit drugs) should wane — the second metric we’ve got. And, most importantly, their quality of life should improve — albeit this third metric is considerably harder to quantify. These are the central values I want from medication-assisted treatment.

No, these are not the almighty three “values” I hope to get from MAT. You’re encouraged to pick and choose your own values — don’t just blindly follow mine!

Of course, I recognize MAT as a super-solid alternative to opioid use — and even alcohol use (naltrexone). Whether you have opioid use disorder per the DSM-5 or not, MAT can help you. Even though I didn’t have a physical dependency to opioids before I enrolled in an MAT program — I didn’t experience the same “flu-like,” for lack of a better word, opioid withdrawal symptoms that so many others do; dealing with the mental fallout of ceasing opioid use was the big issue for me, personally — Suboxone maintenance was still a good fit for me.

Again, I think medication-assisted treatment is great for dealing with opioid use disorder and otherwise-problematic opioid use.

What Does the Volunteer State Want From Medication-Assisted Treatment?

The Tennessee Department of Mental Health & Substance Abuse Services’ medication-assisted treatment page states, “The prescribed medication [Suboxone, methadone, or naltrexone] operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.”

While this definition outlines the physiological effects of suboxone, methadone, and naltrexone, it doesn’t address any higher-level, overall goals for people involved in medication-assisted treatment programs.

Many medication for opioid use disorder prescribers in Tennessee are weighed down by looming regulations. Some are more comfortable than others with regularly accepting “dirty” drug screens — a more-appropriate term might be “positive drug screen” — from patients without firing them. Others fear regulatory backlash if they don’t act in accordance with state guidelines, which encourage prescribers not to retain patients’ enrollment if they submit just four positive drug screens in a two-year period, among other stringent regulations.

What Does Tennessee Want From MAT Program Enrollees?

All MAT programs’ prescribers want to see patients exhibit abstinence from illicit drugs while taking their prescribed dose of buprenorphine, methadone, or naltrexone. Some programs are willing to let regular cannabis use slide, though not anything more than that. Programs also aren’t cool with alcohol use, either.

Due to pressure from the state, however, prescribers often are constrained to appease the state by doing things that aren’t conducive to successful treatment outcomes.

The state’s regulations state that any enrollees who test positive for illicit drugs four times — the text actually reads, “Upon a second/third/fourth positive drug test result within six months of the first/second/third positive drug test result,” which means four positive drug test results for illicit drugs could span a 24-month period at longest — are required to “address the on-going [sic] multi-drug use through increased group and individual counseling, intensive outpatient [sic] and residential clinical treatment.” Imagine getting kicked out of a MAT program because, after pissing dirty four times in two years, you refused to go to residential inpatient clinical treatment.

The aforementioned document is 44 pages long and is packed to the brim with strict guidelines that make it difficult for prescribers to best help MAT program enrollees.

Consider This Scenario

Assume Bob is a regular illicit opioid user who lives in Tennessee. Bob has proven himself to be an often-problematic drug user, having found himself in legal, financial, familial, relational, social, mental, and physical trouble from his opioid use.

Bob solicits a medication-assisted treatment program that prescribes buprenorphine and shortly after enrolls in the MAT program.

Bob’s frequency and intensity of illicit opioid use decreases thanks to his enrollment and regular dosing of Suboxone. However, he still continues to use — just not as often or as much at once. Bob also doesn’t go on binges like he used to.

While Bob will be allowed at least one slip-up, he faces inevitable termination from the program if he continues to submit urine for drug tests that test positive for opioids. Assume that Bob maintains this pattern of use, regularly taking both illicit opioids and the Suboxone he’s prescribed.

Ask yourself — what do you think will happen if Bob is dismissed from the program? Do you think he’ll be better off enrolled in the MAT program and allowed to continue his concurrent consumption of illicit opioids and the Suboxone he’s prescribed or better off dismissed from the MAT program?

Here’s What I Think

Often-problematic drug users continuing their illicit drug use is rarely a good idea. As a long-term, often-problematic illicit opioid user myself, I’ve faced all the problems Bob has and more — I know that continuing to use opioids is a bad idea, at least for me, personally.

The most ideal outcome for Bob is to ultimately cease his illicit opioid use, if not quit the use of all drugs, opioid or not.

Would it be better for Bob, assuming that he wants to continue using illicit opioids, (A) to remain on Suboxone and use other opioids less often or (B) to be dismissed from the MAT program and use illicit opioids on a daily basis?

I think, although not ideal, (A) is the better option.

People in Bob’s shoes could be fired from MAT enrollment if they tell their prescribers that they plan on continuing illicit opioid use. In order to hide evidence of illicit opioid use, they’d have to secure “clean” urine — that which only tests positive for buprenorphine and nothing else — and sneak it in the MAT program’s facility on a regular basis.

Responsibilities of MAT Program Professionals

How responsible is my Suboxone prescriber if he’s okay with me continuing my use of illicit opioids, even though I’d still be on Suboxone and I’d be using less than before beginning Suboxone maintenance?

I don’t think it’d be responsible of him at all. What if I overdosed or another negative outcome occurred?

Is it good enough to have an MAT program enrollee reduce illicit opioid use (i.e., Bob’s scenario above) or would a MAT program physician be settling for less by allowing a patient to do so?

Even the most forward-thinking harm reductionists can see the problems with drawing the proverbial line between these two situations.

The Effects of Buprenorphine on an Opioid-Dependent Patient’s Brain

Before I got on Suboxone, I used illicit opioids as often as I could afford them. I’d be able to spend anywhere from one to four days high in a row upon getting paid. The rest of the week, I’d lay in bed unable to concentrate, nothing short of depressed, and interested in nothing more than the next time I’d be able to get high.

This pattern of use went on for at least two years, if not three or four.

What a way to live, huh?

When I got on Suboxone, I was actually able to finish Youtube videos to the end — not to mention feel joy from watching them. I felt more stable; on Suboxone, I’ve never acted like I would when I was super duper high, and, similarly, I’ve never felt as low as I used to after my binges were over — and that happened consistently… every… single… week.

Suboxone has also deterred me from using illicit opioids on several occasions because I knew I’d end up wasting my money thanks to buprenorphine’s opioid-blocking effects.

Also, although this doesn’t have anything to do with my brain, I’ve been around criminal activity much less than when I was actively using. That makes me feel better and reduces the likelihood of me being sent to jail or otherwise dealing with the criminal justice system.

Where Should We Go From Here?

Personally, I want be able to still use heroin and other illicit opioids on occasion and take Suboxone regularly without facing termination from the MAT program I’m enrolled in.

Going forward, I think patients enrolled in MAT programs should be able to use illicit opioids if they so choose without the risk of being kicked out. It’s safer for me to take Suboxone six days of the week and illicit opioids one day rather than me not use Suboxone at all and only use illicit opioids; I also feel confident that my quality of life is higher this way.

I don’t feel confident in asserting that my idea is the way to go. I certainly think what I proposed above is a good idea, but medical professionals, addiction specialists, mental health practitioners, social services workers, criminal justice system members, long-term illicit opioid users, and others need to spark up a discussion about this before we do anything. None of us know with certainty what’s best — but many of us feel we need change, and change is where we need to start.