Advances in Medication Assisted Therapy for Substance Use Disorders: Nicotine, Alcohol, Opioids, and Methamphetamine

This podcast episode delves into recent advances in Medication Assisted Therapy (MAT) for various substance use disorders, building upon previous discussions. It emphasizes MAT's role as a crucial stop-gap measure, particularly during the initial two years of brain recovery, rather than a permanent replacement for illicit drug use. The presentation highlights MAT's broad efficacy, including improved treatment retention, reduced relapse rates, lower incidence of suicide and overdose, decreased transmission of infectious diseases, and better overall health outcomes. Notably, the discussion extends MAT's application to methamphetamine use disorder, a growing concern, alongside established treatments for nicotine, alcohol, and opioids. The speaker underscores the significant public health impact of substance misuse, citing alcohol as the third leading preventable cause of death in the United States.

The episode makes key distinctions regarding MAT's mechanisms and applications. It clarifies that MAT, when appropriately administered, does not induce the same level of euphoria as the abused substance, offering relief instead. A significant innovation discussed is the FDA-approved Reset mobile medical application, which delivers cognitive behavioral therapy as a "therapist extender" to enhance abstinence and retention in outpatient programs, showing statistically significant increases in abstinence for alcohol, cocaine, marijuana, and stimulant use. The potential synergy of combining the Reset app with MAT is explored. Furthermore, the podcast introduces non-opioid treatments for opioid withdrawal, such as Lofexidine (Lucemyra), and discusses the benefits and challenges of long-acting buprenorphine injections and implants, acknowledging their potential for diversion.

A substantial portion of the discussion focuses on the evolving recommendations for opioid MAT during pregnancy. The speaker explains that fluctuating opioid levels are detrimental to fetal neurodevelopment, placental function, and can lead to prematurity. Contrary to older beliefs, evidence now suggests that medically supervised opioid withdrawal may be an option for a select group of women, though MAT remains the preferred choice. Buprenorphine is favored over methadone for pregnant women due to superior newborn outcomes, including increased birth weight and reduced need for neonatal intensive care. Naltrexone is also presented as an option, but concerns are raised about its potential impact on fetal neurodevelopment by blocking endogenous opioid signaling.

Finally, the episode explores the neurobiological underpinnings of addiction and the mechanisms of various MAT interventions. It details how alcohol alters neurotransmitters like GABA, glutamate, and serotonin (5-HT2, 5-HT3), leading to anxiety upon withdrawal, and how FDA-approved treatments like Acamprosate, Disulfiram, and Naltrexone address these imbalances. Off-label medications such as Zofran, Gabapentin, Topiramate, and Varenicline are also mentioned for their roles in modulating anxiety, dopamine, and nicotinic receptors. For methamphetamine, limited evidence supports the use of amphetamines (methylphenidate, dexmethylphenidate), buprenorphine, and modafinil, which primarily target norepinephrine and dopamine reuptake. The inherent challenge of personalizing treatment due to the inability to precisely measure individual neurotransmitter receptor activity in the brain is also highlighted.

medication-assisted therapy is not meant to be a forever thing it's meant to be a stop gap if you will during the first say two years while the brain is recovering

alcohol is the third leading preventable cause of death

people who are on medication-assisted therapy are less likely to commit suicide and less likely to overdose

almost 60 percent of people who also have medication-assisted therapy stay in treatment so you know let's look look at that that's double what you would get that is huge

once a week counseling or even intensive outpatient counseling where they're there for three four hours a day well then they're on their own for 20 20 21 hours a day and if they are struggling they are going to have significant difficulty staying clean and sober

evidence does not support detoxification as a recommended treatment intervention because of the result of low detoxification completion and high relapse rates

medication assisted treatment now favors buprenorphine use when compared to methadone because it results in an increased birth weight reduced need for newborn treatment and a shorter newborn length of stay in the neonatal intensive care unit

opioids adversely affect the human brain primarily the developing oligodendrocyte and the process of myelinization which is the white matter microstructure

there is no way to measure the receptor activity in the brain

monkeying with dopamine can be very challenging to get the right dose for people so they may start having other side effects that need to be add