MAT versus ORT– what’s the difference and which approach is the right option for YOU?
The science of addiction recovery has changed in recent years. Now, addiction – properly called Substance Use Disorder – is NO LONGER considered to be a moral weakness or failing on the part of the alcohol-or-drug-dependent person.
Rather, science has identified addiction as a legitimate disorder – a disease of the brain. This recognition is good news, because when an SUD is treated as a medical condition rather than a personal failing, the chances of a successful and lasting return to sobriety are greatly magnified.
What is MAT?
MAT stands for Medication-Assisted Treatment, a strategy for combating alcohol or drug addiction that combines behavioral counseling with certain prescription medications. These drugs are given to:
- Ease symptoms of alcohol or drug withdrawal– anxiety, insomnia, depression, etc.
- Reduce cravings
- Deter further substance use
What Is ORT?
Opioid Replacement Therapy—ORT—is also known as opioid maintenance or opioid substitution therapy. ORT medications are ONLY given to patients who are dependent on or addicted to opioid drugs such as prescription painkillers or heroin. The drug of abuse is replaced with a longer- lasting, less-euphoric opioid medication, typically methadone, buprenorphine, or Suboxone.
Since medications are involved, ORT is a subtype of MAT, but it is distinct, because it uses potential substances of abuse to treat a substance abuse disorder.
ORT gives opioid addicts an opportunity to gradually wean from illicit drug use while avoiding the worst withdrawal symptoms. The goal is to reduce the harm associated with uncontrolled substance abuse. In other words, ORT is an attempt to “manage” the addiction, with the following benefits:
- Two-thirds of opioid addicts receiving ORT eventually abstain from illicit opioid misuse.
- 70%-95% significantly reduce their opioid use.
- IV drug users can stop sharing needles, limiting the spread of HIV, AIDS, and Hepatitis.
- Guaranteed quality and dosage.
- Patients are encouraged to seek comprehensive drug treatment services.
- Lower crime rates
- Personal stability – Employment, school, relationships, etc.
The Key Differences between MAT and ORT
ORT is the controlled dispensation of other less dangerous opioids as safer alternatives to what the person is taking illicitly. It is important to understand that the primary goal of ORT is NOT necessarily total abstinence from drugs.
“Many people with addiction may not completely abstain from using drugs, but they will have better stability on social and health level by reducing the drug use (albeit not stopping completely)…” says Zena Samaan, an Associate Professor of Psychiatry and Behavioral Neurosciences at the McMaster’s Michael G. DeGroote School of Medicine.
To be clear, ORT patients ARE connected to more comprehensive programs of recovery IF they desire to become completely drug-free. But because ORT is not abstinence-focused, many patients continue to abuse drugs, sometimes, for years.
MAT, on the other hand, is typically offered as part of a more comprehensive program of abstinence-based recovery. Whether residential or outpatient, alcohol and drug rehabs use a combination of behavioral counseling, MAT, and other supportive therapies to help patients achieve and maintain total and lasting sobriety from all addictive substances.
The biggest reason for the difference approaches lies in the nature of the medications themselves.
ORT medications are, by definition, opioids. This means that, even though they are safer than the drugs they are replacing (when used correctly), they are still habit-forming and therefore, present a significant risk of abuse, addiction, and even overdose.
MAT drugs are NOT opioids and do not carry the same risks.
To better understand these differences, let’s take a look at specific MAT and ORT medications currently use.
“It is important to emphasize that the chief value of Antabuse lies in the fact that it paves the way for psychotherapeutic procedures… Antabuse in conjunction with psychotherapy may prove superior to other methods of treatment of chronic alcoholism.”
~ Drs. Eugene Barrera, Eugene Davidoff, and Walter Osinski, speaking to the American Psychiatric Association
Antabuse is the brand name of the medication disulfiram. First introduced in 1948, Antabuse works by creating an immediate, violent, and extremely unpleasant reaction whenever the patient drinks ANY alcohol – severe nausea, copious vomiting, throbbing headache, etc. For over 50 years, Antabuse was the first-line medication for alcohol addiction.
On the positive side, Antabuse demands total abstinence from alcohol. Simply put, a person cannot take Antabuse and drink. For a person who is extremely motivated and committed, Antabuse is powerfully effective. Some experts are of the opinion that when it is used in combination with other treatment strategies, it is the most-successful treatment for chronic alcoholism.
In fact, when the supervised dispensation of Antabuse is incorporated into a comprehensive program of recovery, successful abstinence rates reach over 50%.
But on the negative side, it also creates an extreme sensitivity to even trace amounts of alcohol. For example, certain mouthwashes, deodorants, colognes, medications, foods, and literally, THOUSANDS of other products can trigger a disulfiram reaction.
The required lifestyle changes are too complicated and difficult for some people. This is an important consideration, because Antabuse is a take-home medication. Frustration and a lack of supervision are why up to 80% of patients are non-compliant.
Part of the reason for poor compliance is the fact that Antabuse does NOT reduce cravings for alcohol.
The abrupt discontinuation of alcohol after long-term, chronic abuse can result in potentially-fatal withdrawal symptoms, especially during the first few days. During that time, benzodiazepine tranquilizers have proven benefits.
- Librium (chlordiazepoxide)
- Valium (diazepam)
- Ativan (lorazepam)
- Serax (oxazepam)
Of special concern, benzodiazepines are themselves highly habit-forming, and withdrawal is just as dangerous as that from alcohol. If a benzodiazepine dependency does develop, the best treatment is to slowly taper the dosage.
First approved for use in the US in 1981, buprenorphine can be taken under the tongue, as a skin patch, through an implant, or via an injection for the treatment of opioid addiction. Beginning in early 2018, a once-a-month injection will also be available. Buprenorphine is sold under the brand names Subutex, Butrans, Belbuca, and Buprenex, among others.
Buprenorphine is a partial opioid antagonist, which means it activates the same areas of the brain as heroin or other abused opioids, but to a lesser degree. Because of this, it helps ease opioid withdrawal and drug cravings.
Subutex and other buprenorphine medications have two major drawbacks, however.
First, as opioids, they can also be abused recreationally.
Second, they are so tightly-controlled that only about 3% of doctors are legally allowed to prescribe them.
In use in Europe since 1989, acamprosate – sold under the brand name Campral – gained approval by the US FDA for the treatment of alcohol addiction in 2004. Acamprosate corrects the chemical imbalance in the brain that results from years of chronic alcohol abuse.
Primarily, the medication works by reducing the cravings and withdrawal symptoms felt when a person tries to give up drinking. Acamprosate is effective in maintaining abstinence from alcohol. Compared to patients given a placebo, twice as many acamprosate patients maintain their abstinence for at least one year.
However, it does not help a person BECOME abstinent. For this reason, acamprosate is recommended for people who have already achieved at least a few alcohol-free days.
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“A positive treatment outcome depends on the patient functioning well – both socially and intellectually. If methadone treatment also impairs intellectual functions in humans, it could have a negative effect on the treatment result.”
~ Jannike M. Andersen, the Norwegian Institute for Public Health’s Division of Forensic Toxicology and Drug Abuse
For years, methadone was the only option for people who were addicted to heroin or other opioids, first gaining approval in 1947. It is the most commonly-prescribed ORT medication.
But as new solutions are being developed, it is important to understand some of the many drawbacks of methadone:
- It is an extremely powerful opioid – up to 5 times more potent than morphine.
- It is highly addictive.
- Methadone is itself a potential drug of abuse.
- Overdose is a concern – in 2011, for example, greater than 1 in 4 opioid-related deaths involved methadone.
- Even the FDA has stated, “Methadone use for pain control may result in death.”
- Methadone maintenance is a long-term – sometimes lifelong – option. It is not uncommon for a person to be receiving ORT using methadone for years.
- Some patients feel that they have no control over, or input concerning their own recovery.
- Methadone shows up on employment drug screens.
- Daily trips to the methadone clinic are inconvenient at best and problematic at worst, especially if the patient doesn’t have a vehicle or a license.
- Overnight travel – vacations, business trips, family obligations – often become impossible.
- Dangerous drug interactions can occur if a methadone patient is prescribed certain medications, particularly with benzodiazepines or other opioid painkillers.
- Drinking alcohol while receiving methadone therapy can be fatal.
But methadone’s biggest shortcoming is this – patients can STILL continue to misuse opioids illicitly.
First approved in 1984, naltrexone is a medication that is used to treat both alcohol AND opioid dependence. Sold under the brand names ReVia (daily oral tablets) or Vivitrol (monthly injections), naltrexone totally blocks the effects of heroin, opioid painkillers, and alcohol.
This means that a person taking naltrexone cannot experience the pleasurable effects of any of these three substances. Significantly, naltrexone is an opioid antagonist, which means that it binds to the opioid receptors within the brain and blocks the effects of all other opioids. Through this action, it also reduces cravings.
But naltrexone is NOT an opioid, which means it has several advantages over methadone or buprenorphine medications:
- Use does not result in dependency or addiction.
- It has no abuse potential.
- Tablets are available as a take-home prescription.
- Physician-administered injections are only needed once a month.
- Can also be used to prevent cocaine relapse.
A recently-published study concluded that naltrexone is even better at preventing relapse than Suboxone. Other findings also support the effectiveness of naltrexone, particularly when combined with behavioral counseling.
In fact, compared to patients receiving counseling and a placebo, naltrexone/counseling patients:
- Many more achieved opioid-free weeks, 90% to 35%.
- More reported feeling less opioid cravings, 55% to 3%.
- Were 17 times less likely to relapse.
- Stayed in treatment longer, an average of 168 days to 96 days.
When MAT includes both naltrexone and clonidine, a blood pressure medication, 85% of patients successfully complete their prescribed rehab program.
Importantly, ANY physician can prescribe naltrexone – a major advantage over buprenorphine-containing medications.
There are only possibly-significant issues with naltrexone.
FIRST, patients must be detoxed and opioid-free for 7-14 days before commencing.
SECOND, while taking naltrexone, they may not use ANY opioid, not even legitimately-prescribed pain medications.
THIRD, monthly injections Vivitrol injections can be expensive if not covered by insurance.
Suboxone is a combination drug made up of buprenorphine and naloxone. The second medication – naloxone – is added as an abuse deterrent, since it completely blocks the recreational effects of all opioids. Because of this greatly-lowered (but NOT impossible) potential for abuse, Suboxone is increasingly used as a first-line option for the treatment of opioid addiction.
Unlike methadone, Suboxone is available as a take-home prescription.
The biggest drawback of Suboxone is its limited availability. Because it contains buprenorphine, only about 1 in 30 doctors are legally able to prescribe it, and federal law limits the number of patients in opioid recovery they are allowed to treat.
Also sold as Abstem, Temposil is the brand name for calcium carbamide. Very similar to disulfiram, Temposil causes the patient to be extremely sensitive to alcohol.
Because it blocks how alcohol is metabolized by the liver, patients were tempted to drink alcohol will experience a severely unpleasant reaction – nausea, uncontrollable vomiting, horrible headache, dizziness, etc. These effects occur within 15 minutes of taking a drink, and can last up to 24 hours, making Temposil a powerful behavioral deterrent.
The positives are identical to Antabuse –Temposil patients MUST remain alcohol-free to avoid the reaction. And, when the medication regimen is combined with comprehensive program of recovery, the rates of successful sobriety are high.
But the negatives are identical, as well. Alcohol sensitivity requires extreme lifestyle changes that go beyond merely avoiding drinking, and the medication does NOT reduce cravings for alcohol.
Other MAT Medications
As adjunctive therapies, other medications may be prescribed during MAT to treat any temporary withdrawal-related conditions from which the patient may be suffering – anxiety, depression, insomnia, hypertension, seizures, etc.
Benzodiazepine anxiolytics/sedatives, muscle relaxants, anticonvulsants, and blood pressure medications can be given to relieve symptoms common to most withdrawal syndromes.
What’s the Right Choice – MAT or ORT?
The choice between MAT and ORT depends entirely on two things – the drug of choice, and the patient’s goals in recovery.
The drug of choice matters, because addictions not involving opioids are not helped by ORT.
The patient’s goals matter, because if abstinence-based recovery is the desired outcome, MAT better supports that goal.
Likewise, if an opioid-dependent person is finding it difficult to remain completely drug-free, ORT may be the improvement that can at least give them the necessary clear-minded stability to take the next step –specialized treatment.