The mixed message behind “Medication-Assisted Treatment” for substance use disorder

ABSTRACT

The gap between treatment utilization and treatment need for substance use disorders (SUDs) remains a significant concern in our field. While the growing call to bridge this gap often takes the form of more treatment services and/or better integration of existing services, this perspective proposes that more effective labels for and transparent descriptions of existing services would also have a meaningful impact. Adopting the perspective of a consumer-based health-care model (wherein treatments and services are products and patients are consumers) allows us to consider how labels like Addiction-focused Medical Management, Medication-Assisted Treatment, Medication-Assisted Therapy, and others may actually be contributing to the underutilization problem rather than alleviating it. In this perspective, “Medication-Assisted Therapy” for opioid-use disorder (OUD) is singled out and discussed as inherently confusing, providing the message that pharmacotherapy for this disorder is a secondary treatment to other services which are generally regarded, in practice, as ancillary. That this mixed message is occurring amidst a nationwide “opioid epidemic” is a potential cause for concern and may actually serve to reinforce the longstanding, documented stigma against OUD pharmacotherapy. We recommend that referring to pharmacotherapy for SUD as simply “medication,” as we do for other chronic medical disorders, will bring both clarity and precision to this effective treatment approach.

This article is referred to by:

Medications for addiction treatment (MAT)

Response to “Medication for addiction treatment (MAT)”

Given the gap in treatment utilization for substance use disorders (SUDs) that has been an ongoing issue in our field for some time, access to and promotion of effective treatments is a topic of priority for treatment providers and patients alike (1). As such, there is a growing call to bridge the patient–treatment utilization gap through more SUD treatment services and/or better integration of existing services (2). While such advocacy is a valuable endeavor, our field would likely benefit from examining how effectively we are promoting and describing those treatment/services that currently exist in order to maximize treatment initiation and engagement.

Indeed, our ability to accurately promote and effectively disseminate information about existing treatments may be questioned by national survey data which suggest that 7.1% of those who needed but did not receive illicit drug use treatment reported that they were not aware of a program having the “type of treatment” they were looking for (3). While such a finding may be reflective of the distinctive ambivalence toward treatment which is thought to characterize the population in question, if we instead adopt the perspective of a consumer-based health-care model (wherein treatments and services are products and patients are consumers), we may begin to wonder: Are our descriptions of and labels for SUD treatment services facilitating or impeding engagement by potential consumers?

From a purely pragmatic perspective, the potential for labels to confuse consumers is well established (i.e., the Food and Drug Administration’s extensive regulations for the labeling and marketing of food products). The observation that even small differences in how products are labeled can drive consumer behavior is also well known within the field of behavioral economics; as Nobel Prize-winning psychologist Daniel Kahnman points out, there is a substantial difference on consumer behavior when labeling a product “90% fat-free” vs. the same product labeled “10% fat” (4). Within SUD treatment, as well, stigmatizing language and labels has been found to act as a barrier to treatment, one that influences patients and providers alike (5–7). In labeling treatments for mental health disorders, however, few such considerations exist—and a multitude of treatment labels with overlapping components and confusing labels abound. Consider a sample of treatment labels for opioid-use disorder (OUD): psychosocial, pharmacological, medical, peer support, Methadone Maintenance, Heroin-Assisted Treatment, Opioid Substitution Treatment, Opioid Replacement Therapy, Addiction-focused Medical Management, Medication-Assisted Treatment, Medication-Assisted Therapy, and others. How well can consumers (nonetheless providers) tell them apart?

In light of the above considerations as well as the current opioid epidemic, we believe it is important to carefully consider the implications of using inconsistent terminology when describing and promoting SUD treatment in general, and OUD more specifically. In particular, the phrase “Medical- Assisted Treatment” has become an increasingly common label (as well as a somewhat inconsistent one, as we will point out) for the pharmacotherapeutic treatment of SUD. In this commentary, we discuss how this phrase simultaneously de-emphasizes and prioritizes pharmacotherapy, sending a mixed message to a consumer base in need of clear and concise treatment labels and recommendations.

The origins of “Medication-Assisted Treatment”

While the term “Medication-Assisted Treatment” (and small variants thereof) has become increasingly applied to a growing number of SUD treatments, it is worth noting that the term originated (and is still most commonly applied) to OUDs, specifically (8). And given the background provided by early publications which first used the phrase “Medication-Assisted Treatment” as well as historical/contextual writings, it is reasonable to assume that the pervasive stigma toward pharmacologic treatment of OUD—particularly the opioid receptor agonists methadone and buprenorphine—may have helped to cast medication as the “assisted” part of OUD therapy (9,10). Indeed, stigma toward the so-called addicts “…replacing one drug with another” has been identified among both patients and programs for well over a decade (8,10) and stigma surrounding the use of pharmacotherapeutic approaches is still often present in peer-support settings (11,12). Even local and worldwide Narcotics Anonymous services “find themselves facing questions about the participation of members on methadone, buprenorphine, and other medications” with regard to the Third and Tenth Traditions and their philosophy of abstinence (11). Many patients report “shame” from trying to “get off drugs” (e.g., heroin) “with drugs” (e.g., methadone), thereby violating their conceptualization of what it means to be “clean” (11). In addition to some peer-support groups inadvertently encouraging stigma associated with pharmacotherapy, well-meaning health-care providers may also be culpable (13,14).

The idea that stigma is one component impacting the underutilization of pharmacotherapy was also noted by Galanter et al. (2), published in this issue of the American Journal of Drug and Alcohol Abuse. Here, the authors advocate for “enhanced use of [biomedical and 12-step] approaches, singly and in combination” to improve access to care while offsetting the relative strengths and weaknesses of each approach. If stigma regarding pharmacological treatment of SUD remains in perceived conflict with 12-step principles of abstinence, however, then the continued use of the phrase “Medication-Assisted Treatment” may inadvertently undermine the use of pharmacotherapeutics in the first place by implicitly supporting the idea that they are secondary. After all, if they are not the treatment, why use them?

The paradoxical intent of “Medication-Assisted Treatment”

Quite literally, the phrase “Medication-Assisted Treatment” simultaneously communicates that (1) medication is not the primary treatment and (2) another (unnamed) treatment is. Thus, with the default use of “Medication-Assisted Treatment” in describing and communicating treatment for SUD in general (and OUD more specifically), the concept that pharmacotherapy is secondary to other forms of treatment (e.g., psychosocial interventions, and community support groups) is reinforced. The use of the phrase Medication-Assisted Treatment may also obfuscate the very compelling point Galanter et al. make that 12-step programs may be useful “as an adjunct to medical treatment [emphasis added].”

Stated in a more extreme form, the implicit message about the secondary role of pharmacotherapy embedded in the phrase “Medication-Assisted Treatment” amounts to something analogous to “medication is both a priority in the treatment of SUD” as well as “medication is a supplementary component.” Extending the analogy to the treatment of diabetes (an analogy often used in advancing the “addiction as a chronic disease”) might be akin to advocating for the prescribing of insulin to patients with Type-1 diabetes while simultaneously referring to insulin as “Medication-Assisted Treatment.” Such an approach would likely send a message so mixed that confusion, suboptimal usage, and avoidance would result.

In contrast to the literal meaning behind Medication-Assisted Treatment, a number of definitions and prominent uses of the phrase emphasize the pharmacotherapy aspect of treatment. The Center for Substance Abuse Treatment emphasizes the primary medical/pharmacotherapeutic aspect of treatment for OUD, defining Medication-Assisted Treatment as a

Type of addiction treatment, usually provided in a certified, licensed opioid treatment program or a physician’s office-based treatment setting, that provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication, which may be combined with other comprehensive treatment services, including medical and psychosocial services. (15)

Similarly, the American Society of Addiction Medicine’s National Practice Guidelines (16) place a notably stronger emphasis on the medication component in the treatment of OUD relative to other, nonmedical components. The relatively higher prioritization of pharmacological interventions is visible, for example, in their description of psychosocial treatments for those individuals undergoing methadone pharmacotherapy and methadone maintenance, where “it is unclear whether added psychosocial treatment improves patient outcomes” and psychosocial treatments are “sometimes minimally needed,” respectively (16). The status of psychosocial treatments as secondary to pharmacologic treatments is also apparent in that they are “recommended in conjunction with any/all pharmacological treatments for OUD” (16) and not vice versa. Such a view is also consistent with the emphasis for OUD pharmacotherapy in the Veterans Hospital Administration/Department of Defense Clinical Practice Guidelines for the Management of Substance Use Disorders (17).

There are also a number of prominent public uses of “Medication-Assisted Treatment” that place greater emphasis on the pharmacotherapy aspect of OUD treatment, while minimizing the use of other sources of treatment or referring to them in a more complementary capacity. In President Obama’s 2016 speech for Prescription Opioid and Heroin Epidemic Awareness Week, for example, he not only highlighted the importance of “raising awareness of this epidemic” and cited the need for prevention, treatment, and enforcement strategies but, more specifically, calls for “improving access to Medication-Assisted Treatment” (18). Notably, this was done in the immediate context of calling for increasing the number of patients that “practitioners prescribing buprenorphine” are permitted to treat, without a specific focus on other services. Similarly, when the director of the National Institute on Drug Abuse cited the benefits of Medication-Assisted Treatment, the construct was directly equated with opioid pharmacotherapy rather than the other treatment services:

Fortunately, clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexone…Yet these medications are markedly underutilized. Of the 2.5 million Americans 12 years of age or older who abused or were dependent on opioids in 2012…fewer than 1 million received MAT (19).

Thus, in practice, the “Medication-Assisted Treatment” construct takes on a decidedly pharmacocentric view.

Conclusions

While our field places a great deal of emphasis on SUD as a biological disorder requiring medical (e.g., pharmacotherapeutic) interventions (20), the simultaneous apparent endorsement of medication as a secondary approach implied by “Medication-Assisted Treatment” is both confusing and at odds with the medical community’s approach to other chronic, relapsing disorders. As the critical role of framing effects are well known to cognitive-psychology (2) and within media/communication theory (21), it is useful to examine the functional consequences of the particular frames we employ—i.e., what does a particular frame allow us to say, do, or think? In this regard, the discordance between the literal reading of the term Medication-Assisted Treatment versus its contextual use may be telling; for those individuals who do not see medication as the way to treat addiction, it may provide a mental foot in the door as a way to lessen the cognitive dissonance associated with medical treatment—and perhaps, thereby, encourage it. For others, however, it may be used as a catch-all phrase, representing some amalgamation of medical, psychosocial, and peer-support services, thereby avoiding the need to distinctly promote one treatment over another. Other treatment professionals still may simply choose to occupy the space between these extremes. Optimally, however, we believe patients are best served by providing them with the most accurate, concise, and transparent treatment recommendations and labels—whatever they may be. Ultimately, while it will likely remain unknown whether the inconsistency in the messaging of Medication-Assisted Treatment is a cause or effect of the status quo, changing these labels (along with our thinking) deserves serious consideration.

Disclaimer

The contents of this commentary do not represent the views of the U.S. Department of Veterans Affairs, the United States Government, or the University of Texas Southwestern Medical Center.

Disclosures

The authors report no disclosures of interest.

Acknowledgments

This work was supported by the Dallas Addiction Leadership Training (DALT) fellowship, Office of Academic Affiliations, Department of Veterans Affairs and resources and the use of facilities at the North Texas Veteran’s Affairs Healthcare System, Dallas, Texas.