Medication-assisted treatment (MAT) combines behavioral therapy and medications to treat substance use disorders. 1 Medications that can be used in MAT which are approved by the U.S. Food and Drug Administration (FDA) include buprenorphine, methadone, and naltrexone. 2
While both are synthetic opiates, unlike its counterpart, methadone, which must be administered in a highly structured clinic, buprenorphine (Bunavail, Suboxone, Zubslov) is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in a qualified physician’s office. Both methadone and buprenorphine reduce the effects of physical dependency to opioids, such as withdrawal symptoms and cravings. Buprenorphine is an opioid partial agonists, which means that, like opioids, it produces euphoric effects as well as respiratory depression, hallmarks of opioids. The effects, however, with buprenorphine are weaker than drugs like heroin and methadone. Buprenorphine does have a “ceiling effect,” which is said to reduce the risk of misuse; however, the potential still exists. 1
Naltrexone (Vivitrol, ReVia, Depade) blocks the euphoric and sedative effects of opiate drugs, suppressing cravings. Naltrexone is said to have no misuse potential and prevents the feeling of getting high. 1
According to 2013 Medicare data, there are 130 buprenorphine prescribers in Tennessee: there were 11 methadone clinics. In the same year, there were 141,073 claims filed to Medicare in Tennessee for buprenorphine prescriptions, the overwhelming favorite; 31,288 filed for methadone; and 887 filed for naltrexone. 3
In a clinical setting, MAT can be a powerful aid in overcoming addiction, but are all patients receiving the quality counseling and behavioral therapy the Substance Abuse and Mental Health Services Administration claims is essential to the combination therapy?
In 2015, President Obama called for an increase in access to MAT by doubling the number of physicians certified to prescribe buprenorphine. In Tennessee, however, we are seeing what could be construed as a negative association with MAT.
In 2014, the Tennessee General Assembly passed what is commonly referred to as the Fetal Assault Law (TCA §§ 39-13-107 & 39-13-214). Under this statute, a woman can be prosecuted for the illegal use of a narcotic/opiate while pregnant, if her child is born dependent on the narcotic/opiate drug. The bill allows women to be charged with aggravated assault if their child has complications classified as Neonatal Abstinence Syndrome, or drug withdrawal as a result of the mother’s narcotic/opiate use during pregnancy. 4 The bill was set to be heard on March 8 in the House Civil Justice Subcommittee, but was deferred to the week following. The bill is still pending.
The law makes it an affirmative defense that the woman actively enrolled in a long-term addiction recovery program before the child was born, remained in the program until after delivery, and successfully completed the program.
While this law had the best interest of the baby at its core, we now see a shift in maternal substance of misuse from prescription narcotics/opiates to medication-assisted treatment. While they remain highly touted and promoted, MAT therapies, including buprenorphine and methadone, still induce NAS, causing withdrawal among exposed newborns.
The purpose of this law was to reduce the number of babies born and subsequently diagnosed with Neonatal Abstinence Syndrome (NAS); however, between 2013 (before the law was passed) to the end of last year, we still witnessed a 15% increase in total NAS diagnoses (from 855 in 2013 to 986 in 2015). Strikingly, the shift to MAT increased from 46.4% of all diagnoses to 61.5%. By increasing access to MAT and offering it as a “long-term addiction recovery program,” we have not reduced NAS diagnoses; rather, we have shifted maternal substance of misuse. 5
While there is seemingly no clear answer, one must consider the risks and benefits of medication-assisted treatment, especially during times of pregnancy.