The Journal of the Arkansas Medical Society Issue 6 Volume 115 | Page 6

by CASEY L. PENN
MAT (Medication-assisted Treatment):
Could it Work in Your Clinic?
Real Discussion from Treatment Providers in Arkansas
I
n recent issues of The Journal, we
shared work being done by AMS
physicians and others to curb
abuse and overdose deaths related
to opioids. Continuing on topic, we focus this
month on medication-assisted treatment for
patients with opioid use disorder. We’ll draw from
credible academia, impart insight from MAT provid-
ers here in Arkansas, and leave you with resources
for further study.
Evidence Supported, Underutilized
The Substance Abuse and Mental Health Ser-
vices Administration defines MAT as “the use of
FDA-approved medications, in combination with
counseling and behavioral therapies, to provide a
‘whole-patient’ approach to the treatment of sub-
stance use disorders.”
New medications for addiction continue to
surface (perhaps a topic for another month), but
commonly used FDA-approved medications include
methadone, naltrexone, and buprenorphine. Most
used among the physicians we spoke to is a bu-
prenorphine/naloxone combination, as in the drug
Suboxone ® . (Suboxone ® was the first and once the
only formulation of this drug combination, approved
by the FDA some 14 years ago. Today, this formula-
tion is marketed by multiple drug manufacturers.) “A
synthetic opioid, Suboxone ® has some characteris-
tics of opioid but doesn’t provide any euphoria,” ex-
plained Gene Shelby, MD, an expert in the treatment
of OUD. “The buprenorphine creates a strong bond
with opiate receptors in the brain. Once people tran-
sition to buprenorphine, they lose their craving for
opioids because those opiate receptors are covered,
which prevents their withdrawal from opioids.”
A former member of the Arkansas House of
Representatives and a past AMS president, Dr. Shel-
by practices in central Arkansas MedExpress clinics,
operates a monthly HIV Clinic in Hot Springs, rep-
resents AMS as a member of the AMA Opioid Task
Force and, with his wife Faridah Katkhordeh, oper-
ates an opioid addiction treatment clinic, The Shelby
Clinic. (Find detailed coverage of Dr. Shelby’s work,
including a first-hand patient account, in The Jour-
nal, August 2016.)
Prescribers must be certified to prescribe MAT.
Physicians take an eight-hour course on the medi-
cines and on opioid dependence and then receive
a DEA number to prescribe in an outpatient setting.
(APRNs and PAs can be certified, with longer re-
quired course hours.) Find information about online
training at SAMHSA.org.
Supporting evidence for using MAT is strong.
According to SAMHSA, this treatment approach has
been shown to “improve patient survival, increase
retention in treatment, decrease illicit opiate use and
other criminal activity among people with substance
use disorders, increase patients’ ability to gain and
maintain employment, and improve
birth outcomes among women who
have substance use disorders and
are pregnant.”
Cross Blue Shield plans no longer require them.
Those that do, it’s generally simple and you get au-
thorization for at least a year for the person who has
entered treatment.”
Medicaid is a different story. On one of our at-
tempts to reach Dr. Shelby about the question of bar-
riers to treatment, his late response helped illustrate
his point. “I’m sorry I didn’t get back to you sooner,”
said Dr. Shelby, who has been forthcoming about his
battles with Arkansas Medicaid. “I spent two hours
today with Medicaid getting a prior authorization for
a new patient. It’s easy to see why primary care may
not want to treat these patients – at least those on
Medicaid. Arkansas has put big hurdles in the way
of the Medicaid population. They make it so difficult
to get prior authorization for treatment. I’ve gone to
their review committee about it, and
they did change their prior authori-
zation process recently. They said
they were making it easier, but I just
saw the new prior-authorization-
request form, and they’ve made it
even harder than it was.”
The AMA Opioid Task Force
recently released a report, “The
AMA Urges Removing All Barriers
to Treatment for Substance Use
Disorder.” Citing the National Insti-
Administrable from
tutes of Health; the National Institute
Various Clinic Settings
on Drug Abuse, the U.S. Surgeon
The question of how – and
General, and other sources, they
where
– MAT is best administered
Gene Shelby, MD
described MAT as “Unequivocally
continues to evolve. For decades,
Established,” and associated it with fewer overdose people diagnosed with substance use disorders
deaths, reduced transmission of infectious diseases, typically received care from a dedicated treatment
reduced health care expenditures and utilization, and facility. Many such centers have expanded to include
other benefits.
opioid treatment and as such have become certified
Opioid Treatment Programs (OTP).
Despite increased awareness and supporting
evidence, they reported, MAT is underutilized – in
According to SAMHSA.org, legislation passed
part, due to extra burdens faced by those providing in 2000 (Drug Addiction Treatment Act of 2000) ex-
this treatment. Prior authorizations were among the panded the clinical context of medication-assisted
hurdles, as were misconceptions and myths related opioid dependency treatment. “DATA 2000 reduces
to this treatment.
the regulatory burden on physicians who choose to
practice opioid dependency treatment by permitting
Here in Arkansas, things are improving on the
qualified physicians to apply for and receive waivers
insurance front, according to Dr. Shelby. “There’s
of the special registration requirements defined in
been a trend to make it easier to get the medica-
the Controlled Substances Act.”
tion through different pharmacy programs,” he said.
“Four years ago, even private carriers required prior
In the nearly two decades since DATA, num-
authorizations every few months. Now, some Blue bers of certified physicians have increased, but
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VOLUME 115