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April 18, 2023

Interview: Medication Assisted Treatment for Substance Use Disorders with Dr. Reynolds “Tad” Clodfelter

Alcoholism and other substance use problems can take a toll on health, relationships, families and finances.

Fortunately, alcohol and substance use disorders are very treatable. With the right care, dependencies on alcohol, prescription medications and illegal drugs can be overcome. People can recover and do every day.

An important tool, which physicians have to help patients with addiction, is medications that minimize withdrawal symptoms and ease cravings. Known as medication assisted treatment, or MAT, research has shown that MAT increases the chances that an individual will be able to recover from an alcohol or other substance use disorder and avoid relapse over the long-term.

The stakes are high: an estimated 9.5 million people in the United States misused prescription pain killers such as morphine, codeine, oxycodone (OxyContin®), hydrocodone (Vicodin®, Lortab®) and meperidine (Demerol®) in 2020, according to the U.S. Substance Abuse and Mental Health Services Administration.

One in eight U.S. adults, or 12.7 percent of the population, meets the diagnostic criteria for an alcohol use disorder, according to a study in JAMA Psychiatry.

“The good news is, we have very effective treatments to address those issues,” says Dr. Tad Clodfelter, PsyD, Vice President of Psychiatry and Behavioral Health at Avance Care.

Dr. Clodfelter, a clinical psychologist who has over 20 years of experience in addiction treatment, discusses how the psychiatrists and behavioral health specialists at Avance Care use MAT to support patients’ recovery and enable them enjoy life free of the stranglehold of substance use.

What is medication assisted treatment (MAT)?

MAT is the use of FDA-approved medications, in combination with therapy or counseling, to treat substance use disorders. The medications that are used are specific to the substance being treated.

What substances can be treated with MAT and who is MAT most appropriate for?

It can be used for most substances, but the ones we treat most often using a MAT approach are alcohol and opioids. The next two are benzodiazepines (such as Xanax®) and stimulants.

MAT is appropriate for just about any patient who has longer-term substance use. MAT is especially effective for persons with longer-term use, who realize they need extra help to stop.

What kinds of medications are used for MAT?

There are two broad categories of medications used in MAT: agonists or partial agonists, and antagonists. Agonists activate receptors in the brain and produce a response that’s similar to the drug being replaced, while antagonists block the receptor from producing a response.

A common treatment for opioid addiction is a partial agonist or full agonist, which bind to the opioid receptors in the brain, block or dilute the effect of the abusable substance, ease cravings, and help people focus on making the lifestyle changes they need in recovery. One example is buprenorphine. Another is Suboxone, which combines buprenorphine and naloxone.

For alcohol dependence, you’d use an antagonist, such as Antabuse (disulfiram), which can discourage people from drinking because it causes an unpleasant reaction if you consume alcohol while taking it.

Vivitrol (injectable naltrexone) or oral naltrexone can be used for both opioid addiction and alcohol use disorder. It’s a monthly, injectable medication that blocks the effects of the alcohol or opioid in the brain.

MAT should be combined with ongoing outpatient therapy as well. A good MAT program includes both. MAT programs can be tailored to the individual’s treatment needs.

Are there any new MAT medications that you’re using?

We’re using Sublocade® for opioid dependence more and more. It’s a monthly injection just under the skin that doses out suboxone in a time-released fashion for one month.

That means the patient doesn’t have to make a decision each day to take it. If you use opioids with Sublocade in your system, it will be unpleasant. You’re not going to have the pleasant, euphoric effect, because there is naloxone in that mixture, which is an opioid antagonist.

If someone is on MAT, do 12-Step programs such as Alcoholics Anonymous or Narcotics Anonymous still play a role in supporting sobriety?

Yes. The 12-Step models and similar accountability groups work well because of two components. One is the camaraderie, the sort of daily support with others who are walking in those same shoes. The other is the daily intentionality; the focus on behavior change and sobriety every day.

The 12-Step model works well, in combination with professional treatment, for alcohol misuse, abuse, and dependence. By itself, AA works for about 40 percent of the population. Why is that? What we know is that alcohol use disorder, and substance use disorders in general, occur in deep subcortical parts of the brain. There, good intentions, good rational thought, good human motivations like positive relationships and job stability, at the end of the day, pale in comparison to what’s going on (eg thoughts and cravings about use) at that deep subcortical part of the brain where the pleasure center lies. The same parts of the brain that are reinforcing eating and sex are also where substance addiction happens. And that’s highly reinforcing. This is why medications and cognitive and behavioral therapies are so important in the treatment equation.

So, not only do many people need a good daily connection with others who can provide support, who can walk with us, who can pick us up when we’re feeling vulnerable, but we often also need medicines and other kinds of medical interventions, because we’re dealing with a brain disorder. That’s where MAT comes in. It can help deal with those parts of the brain and body that need the extra boost. At the end of the day, “going cold-turkey” with some allies may or may not be sufficient, and often the data shows it is not sufficient.

Once you’re on MAT, are you always on MAT?

No. Like other medical treatments, MAT is individualized. There’s no one size fits all. If someone does well on MAT for opioid use disorder, after about 6-12 months we’d start tapering down to a lower dose. We’d look at, things like, what’s the quality of their life and level of functioning outside of the care program? We use all those factors to determine when and how and at what pace to decrease therapeutic dosages. We anticipate that patients will discontinue MAT over time, and be stable and successful. We also know that support is helpful, if not imperative, even beyond the treatment program, which is where the 12-Step and other support groups come in as helpful adjuncts.

How often do substance use disorders and mental health disorders co-occur?

It’s a huge percentage. More than 50% of the time, and closer to two-thirds. We treat the whole person, not just the identified disorder that shows up at our office. We follow the science, which says treat both simultaneously. We jump in with both feet on whole-person approach to care.

A great example of that is stimulant abuse and ADHD. Stimulants are used to treat ADHD. But you have patients who come in and they’re abusing cocaine or crystal meth. When we ask them how cocaine makes them feel, they say, “Oh, my gosh. I feel great and can focus so well. I’ve got so much energy. I feel like I’m on top of my game.” It often turns out they have undiagnosed ADHD. Then we treat the ADHD and often the stimulant abuse quels.

Who is involved with the treatment of substance use disorders at Avance Psychiatry?

We have a cadre of specialists who are experts in MAT, both on the prescription side and on the psychotherapy and counseling side. In addition to our MDs and advanced practice providers, we have licensed therapists, both at doctoral level and master’s level who specialize in substance use disorder treatment.

Because substance use disorders often co-occur with mental health disorders, our psychiatrists and behavioral health specialists work in a collaborative partnership in the care of the patient. Primary care physicians and referring providers are also involved as warranted.

What effects have you seen MAT have on the lives of patients?

It’s revolutionized the treatment of substance use disorders. It’s phenomenal. It’s not perfect. We don’t have any magic bullets. But for people who have really experienced such pain and difficulty, so often related to substance use, it gives a new opportunity, a new approach, many times that they haven’t even heard of, or don’t even know about. Shifting from the old school, total abstinence from all substances, including meds, is the only way, to MAT as a strong, science-based option, has immeasurably bolstered the care of our patients and their outcomes.

They’re so thrilled when they get the medications that can speak to their brain and body – the physiology of addiction. It helps people start to feel like they’re not just failures. This wasn’t just their moral shortcoming, or they couldn’t pull themselves up by their bootstraps. It’s given people new optimism about their short- and long-term sobriety, and even more than sobriety, life and happiness.

Why is it important to you to make MAT available for more people with substance use disorders?

I’m a substance treatment specialist. I got into this field 25 years ago, because I saw lovely, earnest people who were struggling in ways that were hard for them and hard for us to understand. Addiction is a medical brain disorder.

For all other medical disorders, we provide medical treatments. We go above and beyond to provide care, and the patient is never blamed if improvement doesn’t occur rapidly. Historically, with a substance use disorder, the patient cannot get good care much of the time, and they’re often seen as the reason for their problem(s).

MAT acknowledges the stigma. It names the disorder. It provides medical care and treatment for the disorder. It takes a harm reduction approach, as opposed to an all or nothing approach. And these types of messages and the infusion of hope and optimism in the community are reasons we feel so strongly about MAT and believe that access should be everywhere.

If you or someone you love is struggling with a substance use disorder, Avance Psychiatry can help.

Learn more about Avance Psychiatry’s MAT here. If you have questions or want to know if MAT is right for you, send us an email to [email protected] or use our online form to request an appointment



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