Commentary: Medication-Assisted Treatment for Opioid Dependence

Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.

The scientific evidence is incontrovertible: addiction is a brain disease – and can be especially severe when substance abuse starts early in life. Since the brain continues to grow and develop through the twenties, it’s very vulnerable to the effects of any exogenous substance. Early drug use makes almost permanent changes to both the structure and function of the brain, which has profound implications for the rest of a person’s life.

A parent bringing their child into treatment wants to maximize the chance that the child can abstain from the drug so the brain can heal and preclude the lifelong struggles of adult addiction. Scientific studies show that psychosocial treatments alone (i.e. without medication) show relatively poor results. Part of the reason has to do with cravings. Here’s why.

When a person takes a drug, the brain feels an enormous “high” in the reward system. It then implants a memory in the limbic system — the “lizard brain” — where memories of pleasures such as food and sex are stored. Anything having to do with procuring or using the drug becomes part of the memory and can produce a craving years later, even if a person hasn’t used the drug. The “trigger” could be a happy event, sadness, or seeing a syringe or some white powder or smelling an alcohol wipe. All of a sudden that memory flooding in generates an enormous craving to use the drug again.

One of the medications used in treatment, buprenorphine, is a partial agonist of the brain’s opiate receptors: when it “locks in”, it both eliminates cravings and blocks the “high” should someone inject heroin or take an opioid painkiller. As a partial agonist, buprenorphine has advantages over methadone, a full agonist, whose side-effects can include sleepiness, shallow breathing, or even death.

Studies suggest that over 60 percent of people on buprenorphine therapy have very positive outcomes. In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.

In my 30-plus years as a pediatrician, I’ve always believed that the best treatment occurs in the least restrictive environment. Therefore our clinical program is outpatient-based. These children are living at home, and their parents are an integral part of the treatment team. We empower parents to supervise the prescription-taking, and both adolescents and parents participate in a 13-week education and support group.

As far as stigma, it breaks my heart when kids hear that “You’re not really clean and sober. Buprenorphine is just a substitute addiction.” I tell them, “Listen, you’re on replacement therapy. It does not make you high. It stabilizes your brain cells until they can recover. Please give it a year. Then we can talk about tapering off. OK?”

My advice to parents and teens is: check out medication in a reputable program. It could make the big difference in helping your child turn the corner and find sobriety. Over time medication can be tapered down. Does it always work? No. Are there accounts of abuse and unscrupulous practices? Unfortunately yes, and they must be investigated. But these negatives don’t negate MAT’s lifesaving value in helping treat the disease of addiction.

If someone says, “Well your child isn’t really clean,” walk away because those people just don’t know. The folks disseminating this misinformation are really doing a disservice because if we dissuade families from using this life-saving therapy we’re going to lose kids. We have to remember the tragedies: when kids are taken off or deprived of this medication they can die. And we don’t have any teens to spare. Not one. I’m not willing to see any more needless deaths.

John R. Knight, MD with Melissa M. Weiksnar

John Knight, MD, is a leading pediatrician at Harvard Medical School, specializing in the diagnosis and treatment of adolescent substance abuse. He is the Director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston, and a nationally recognized advocate for families’ involvement in adolescent addiction treatment.

Melissa Weiksnar is a Program Coordinator at the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children’s Hospital. She is a also a writer, speaker, and advocate for substance abuse prevention and treatment. She earned an S.B. in Economics from MIT and an MBA from Harvard. 

PHOTO CREDIT: Courtesy of Anders Brun and colleagues, Neuroimaging Research Center, McLean Hospital, Belmont, MA. ©Copyright Anders Brun/McLean Hospital 2013. All rights reserved.

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