Medication-Assisted Treatment (MAT) for Opioid Addiction: Introduction to the Special Issue

ABSTRACT

Several countries are experiencing public health crises as a result of opioid addiction. Fatal overdoses have reached record highs in many regions and Hepatitis C virus is the norm among people who inject drugs in several countries. Thus, providing for the global availability of medication-assisted treatment (MAT) for opioid addiction is more important than ever. In this article, we introduce readers to the collection of papers that appear in this special issue on MAT for opioid addiction. We describe the articles and commentaries thematically to include topics that address 1) the contemporary history of methadone maintenance, 2) the provision of and access and barriers to MAT, 3) compliance and outcomes of MAT, 4) health issues among MAT patients, 5) race, ethnicity, and social class backgrounds of MAT patients, 6) criminalization and stigma, and 7) challenges associated with the expansion of MAT.

KEYWORDS:

• Medication-assisted treatment
• methadone
• buprenorphine
• opioid addiction

Globally, opioid addiction continues to have significant impact on individual and public health. Opioids remain the primary substance that are implicated in fatal overdose (United Nations Office on Drugs and Crime, 2017) and opioid use is often characterized by the transition to injecting drug use which can increase the likelihood of bloodborne illnesses such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV). At this writing, the United States has recently grappled with twin opioid epidemics that reflect a rise in both nonmedical prescription opioid misuse and heroin use. A third and emerging epidemic in the United States involves intentional and nonintentional fentanyl misuse. Canada is experiencing its own opioid crisis (King, Fraser, Boikos, Richardson, & Harper, 2014) despite the widespread availability of free or reduced medical care for Canadian residents. Although the extent of opioid addiction in most European countries and in Australia has not reached epidemic proportions such as that observed in the United States, the nature of problematic opioid use in Europe, Asia, and elsewhere continues to significantly affect individual and public health (Global Commission on Drug Policy, 2017). Moreover, widespread prescription opioid misuse has plagued Australia and other countries for some time. Fatal overdoses have reached record highs in many regions of the world and HCV is common among people who inject drugs (Platt et al., 2017; Roy, Arruda, & Bourgois, 2011; Vilibic-Cavlek et al., 2015). Thus, providing for the global availability of medication-assisted treatment (MAT) for opioid addiction is more important than ever.

In this special issue, we have assembled a collection of articles and commentaries that focus on MAT from an interdisciplinary lens. Also, whenever relevant we asked authors to include a description of MAT provision in their respective countries. We have organized the articles thematically to include topics that address (1) the history of methadone maintenance, (2) the provision of, access to, and barriers to MAT, (3) compliance and outcomes of MAT, (4) health issues among MAT patients, (5) race, ethnicity, and social class backgrounds of MAT patients, (6) criminalization and stigma of opioid addiction and MAT, and (7) challenges associated with national and international expansion of MAT.

In the first article, Joseph and Woods (2018) describe important historical information about methadone maintenance in the United States and the developments that led to its creation. They outline the vision of Drs. Vincent Dole, Marie Nyswander, Mary Jeanne Kreek, and other colleagues, discuss the challenges that these physicians experienced as they strove to conduct their research, and highlight several early evaluations of the effectiveness of methadone for treating opioid addiction.

In the next section, we feature three articles that address provision of, and access and barriers to MAT. In Vietnam, efforts are underway to expand and decentralize methadone maintenance so that it is available through community healthcare services. Lin, Tuan, and Li (2018) found that community healthcare providers had insufficient knowledge about methadone maintenance. The authors suggest several ways to increase providers’ knowledge so that methadone expansion would be more effective. In the second paper in this section, Kovitwanichkanont and Day (2018) discuss three main public health strategies for addressing the rise in prescription opioid misuse in Australia: guidelines for appropriate opioid use, prescription monitoring programs, and MAT (much of which is government-subsidized). They also report data on treatment retention and transitions from buprenorphine to methadone, which enable interesting comparisons with other countries. In a third paper, Matusow, Benoit, Elliott, Dunlap, and Rosenblum (2018) analyze data collected from MAT patients as well as directors and staff to examine the extent of emergency preparations for an approaching hurricane, and the impact of this natural disaster on treatment provision. Although the authors found that most clinics had been well-prepared to address the treatment needs of patients, some had failed to implement proper protocols. The authors provide detailed recommendations for emergency preparations to assist patients during natural disasters.

The fourth section of the special issue includes articles that address compliance or outcomes associated with MAT. Blum et al. (2018) report findings from the Comprehensive Analysis of Reported Drugs (CARD), a system that has the potential for identifying substances or metabolites in 28 distinct drug categories. Using a large sample of buprenorphine/naloxone patients, the authors focus on compliance and abstinence over time; they found that patients reduced their use of nonprescribed opiates while in treatment.

In the next article, Adelson, Linzy, and Peles (2018) compared patients attending methadone maintenance clinics in Tel Aviv and Las Vegas. The authors report several important findings relating to men and women patients at both sites, nonopioid drug use during treatment, and retention. In particular, there were considerably higher attrition rates in Las Vegas compared to Tel Aviv. Given that retention is often an excellent predictor of successful outcomes, more research is needed to understand high retention in some countries and poor retention in others.

Two papers report on MAT in Malaysia. Ali et al. (2018) describe methadone maintenance provision and cultural barriers to it in Malaysia. The authors’ main focus is on several health and social outcomes between baseline and three-month follow-up for largely male patients enrolled in MAT. The research found reductions in HIV risk behaviors and crime, and improvements in social functioning and quality of life. Although high attrition characterized the sample and external validity is limited, the study suggests several short-term benefits of methadone maintenance.

The final article in this section begins by describing the Malaysian government's transition from compulsory drug detention centers (which have been criticized by human rights organizations) to treatment than incorporates methadone maintenance and other harm reduction techniques (Khan et al., 2018). The paper presents data from patients attending a voluntary treatment program that formerly served as a compulsory treatment center. Outcome data are reported broken down by patients’ criminal justice involvement, inpatient/outpatient status, and other factors. The authors found high levels of patient satisfaction and reduced drug misuse, results that support the government's transition to more humane treatment.

MAT patients often experience an array of physical problems that can precede or result from opioid addiction. We include four articles that address important issues that affect the physical health issues of MAT patients. Shrestha et al. (2018) explore dietary and nutritional intake among four groups of pregnant women: (1) utilization of MAT during pregnancy, (2) self-reported alcohol use or positive for alcohol biomarker during pregnancy, (3) utilization of MAT and alcohol use during pregnancy, and (4) controls. Their findings suggest the importance of including dietary interventions as part of MAT provision. Klimas, Wood, Nosova, Milloy, Kerr, and Hayashi (2018) address alcohol use among MAT patients following a change in methadone formulation. In the Canadian region where the study was conducted, previous research had shown concerns for patients’ health given a change in methadone formulation. However, the authors found that “heavy” alcohol use did not increase with a change from methadone to Methadose (the latter is more concentrated than other methadone formulations). This finding is important; polysubstance use that includes alcohol and opioids has the potential to impair respiratory function.

Yee, Hoong, Joyce, and Loh (2018) conduct a meta-analysis of the effectiveness of smoking cessation interventions among patients in methadone maintenance. This topic is important because patients have disproportionately high rates of cigarette smoking while in MAT. The authors found that nicotine replacement therapy (NRT) led to significant reductions in smoking by the end of MAT. Incorporating NRT into MAT may be an important addition, however, abstaining from cigarette smoking after patients leave MAT needs further study.

The last article in this section examines buprenorphine as a treatment for depression among people who experience opioid addiction (Ahmadi & Jahromi, 2018). This novel study suggests that a single high dose of buprenorphine can relieve depression symptoms—at least in the short-term—for patients who are opioid-dependent; further research on this topic is warranted.

This special issue includes two articles that focus on MAT in the context of patients’ race and/or ethnicity. Pouget, Fong, and Rosenblum (2018) provide the prevalence of MAT admissions over several years in the United States. The authors note the changing nature of the opioid epidemic in the United States and observe important differences in patterns of use across White, Black, and Latino/a patients who were admitted to MAT. The results remind us of the need for MAT programs that are culturally competent. Hatcher, Mendoza, and Hansen (2018) highlight the distinction between the lived experiences of people who receive MAT in office-based primary care and those who receive clinic-based MAT. The authors offer rich interview data that reveal stigma along racial and class lines and suggest that some treatment settings might further marginalize patients who are racial/ethnic minorities and/or from low income backgrounds.

Stigma associated with opioid addiction continues to affect access to and retention in MAT. Two articles and two commentaries offer different perspectives on the ways in which individual- and structural-level stigma impact negatively on individuals who experience opioid addiction and/or are in recovery. In the first article in this section, Frank (2018) begins with a discussion of the concept of “recovery”—its history and meaning. He then discusses the central focus of his article, i.e., to explore patients’ views about how the War on Drugs has shaped the experiences of people in treatment. Frank offers an insider status that contributes greatly to our understanding of how people in methadone maintenance view treatment in the wider social context. Some of the findings challenge the notion that methadone is utilized as part of a recovery process.

In the second article in this section, Woods and Joseph (2018) focus on methadone maintenance, describing the evaluation results for health and social outcomes when patients receive adequate dose levels, and summarizing the Metabolic Theory of Addiction. They address common misperceptions of MAT, including the widespread public belief that methadone is a substitute for misused opioids such as heroin. Terminology is important; these authors prefer the word MAT “patient” instead of “client” to emphasize the medical value of methadone.

In their commentary, Wakeman and Rich (2018) discuss additional misconceptions of methadone and buprenorphine maintenance and highlight the negative implications of failing to provide MAT in correctional settings. Moreover, they argue that stigma is exacerbated because MAT provision in the United States is physically and ideologically separate from other treatments for chronic illnesses. A second commentary by McElrath (2018) argues that MAT provision in the United States is characterized by a high threshold, low tolerance model that bears strong resemblance to the community corrections model. The danger of such a model is that it reinforces the “addict” identity which can negatively affect recovery.

The final section of the special issue features two articles that address some of the challenges associated with MAT provision. In some countries, primary care physicians have the potential to change the landscape of MAT by their willingness to prescribe and treat patients who misuse opioids. Livingston, Adams, Jordan, MacMillan, and Hering (2018) draw on interviews with primary care physicians in Canada who discussed their perceptions about prescribing methadone. The authors describe the physicians’ perceptions thematically, noting that physicians are influenced by physician-, patient-, practice-, and contextual-related concerns. The second manuscript in this section is a commentary by Mark W. Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), an organization that represents and advocates on behalf of Opioid Treatment Programs (OTPs) in the United States and Mexico. Parrino (2018) describes important progress but also highlights the major challenges for expanding OTPs in the United States and abroad.

As this special issue shows, research into MAT has greatly increased since the groundbreaking work of Drs. Dole, Nywsander, and Kreek. We need to continue their vision and focus our efforts to further shape the provision of MAT in meaningful and effective ways.

Karen McElrath

Herman Joseph

Co-editors, Special Issue on MAT for Opioid Addiction

NB: I am grateful for the opportunity to work with Dr. Herman Joseph, co-editor of this special issue on MAT. Although in his 80s, Dr. Joseph meticulously reviewed dozens of submitted articles, and discussed the strengths and limitations of each. Despite the manifest focus of a particular article, Dr. Joseph often recalled in detail numerous findings from previous studies that were pertinent to the article under review. Moreover, his knowledge and recollection of the work of Dr. Dole and colleagues is inspiring; I learned greatly from it. Thank you, Herman.

Karen McElrath

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.