Substance Use Support: When Medication-Assisted Treatment May Help

Written by Dr. Oswaldo Romero, PMHNP-BC

Substance use disorders are among the most misunderstood conditions in medicine. They are not a matter of willpower, moral failure, or personal weakness. They are chronic, relapsing medical conditions rooted in changes to brain chemistry; and like other chronic conditions, they respond to evidence-based treatment. One of the most powerful tools available is medication-assisted treatment, or MAT.

Yet despite decades of research proving its effectiveness, MAT remains underutilized. Stigma, misinformation, and a lingering belief that recovery should be achieved through abstinence alone have kept many people from accessing treatments that could save their lives.

What Is Medication-Assisted Treatment?

Medication-assisted treatment combines FDA-approved medications with counseling and behavioral therapies to treat substance use disorders. It is not "replacing one drug with another," which is a myth that persists despite being contradicted by every major medical organization. MAT works by stabilizing brain chemistry, reducing cravings, blocking the euphoric effects of substances, and normalizing body functions — all of which allow a person to focus on the behavioral and psychological work of recovery.

The three substance use disorders with the strongest evidence for medication-based treatment are opioid use disorder, alcohol use disorder, and tobacco use disorder. Each has FDA-approved medications that have been shown in rigorous clinical trials to improve outcomes.

Opioid Use Disorder: Where MAT Saves Lives

The opioid crisis has claimed hundreds of thousands of lives. In 2024 alone, over 53,000 deaths in the United States were attributed to opioid overdose. Yet only about 25% of people with opioid use disorder receive medication treatment. That gap between evidence and practice is one of the most significant failures in modern healthcare.

Three medications are FDA-approved for opioid use disorder:

- Buprenorphine is a partial opioid agonist that reduces cravings and withdrawal symptoms while blocking the stronger effects of illicit opioids like fentanyl. It can be prescribed in office-based settings and taken at home as a sublingual tablet or film, or administered as a weekly or monthly injection. Research shows buprenorphine reduces the risk of all-cause mortality by approximately 60%.

- Methadone is a full opioid agonist that reduces cravings and withdrawal symptoms. It has the longest track record of any medication for opioid use disorder, with over four decades of evidence supporting its effectiveness. In the United States, methadone for opioid use disorder can currently only be obtained in person at federally regulated clinics.

- Naltrexone is an opioid antagonist that completely blocks the effects of opioids. It is available as a daily oral tablet or a monthly intramuscular injection. Naltrexone requires a period of opioid abstinence (7 to 10 days) before it can be started to avoid precipitating withdrawal.

Both buprenorphine and methadone are considered first-line treatments. The Department of Veterans Affairs and Department of Defense clinical practice guidelines recommend opioid agonist treatment (buprenorphine or methadone) over psychosocial treatment alone, based on high-quality evidence for treatment retention and opioid abstinence, and moderate-quality evidence for reduced mortality. Extended-release naltrexone is a suggested second-line option, though it is associated with lower treatment retention and does not appear to reduce overdose or all-cause mortality to the same degree as buprenorphine or methadone.

An important development: the elimination of the X-waiver requirement means that any clinician with a DEA license can now prescribe buprenorphine, removing a significant barrier to access.

Alcohol Use Disorder: More Options Than Most People Realize

Alcohol use disorder affects millions of Americans, yet pharmacotherapy for this condition is dramatically underutilized. Three medications are FDA-approved:

- Naltrexone (oral, 50 mg daily) reduces craving and heavy drinking. A systematic review and meta-analysis published in JAMA found that naltrexone reduced return to heavy drinking with a number needed to treat of 11. It is taken once daily, making it a convenient first-line option.

- Acamprosate modulates glutamate neurotransmission and helps maintain abstinence. It has a favorable safety profile and is safe for use in patients with liver disease — an important consideration in this population. However, it requires three-times-daily dosing and is contraindicated in severe kidney impairment.

- Disulfiram works through an aversive mechanism: if alcohol is consumed while taking disulfiram, it triggers an unpleasant reaction including flushing, nausea, tachycardia, and hypotension. It may be most effective in motivated patients whose medication administration is supervised. Liver function should be monitored, and it is contraindicated in advanced liver disease.

The American Psychiatric Association endorses naltrexone and acamprosate as first-line treatments, with gabapentin, topiramate, and disulfiram as second-line options. Topiramate, though not FDA-approved for alcohol use disorder, has moderate evidence supporting its effectiveness and was at least as effective as naltrexone in a comparative trial.

Medications for alcohol use disorder are typically continued for at least 6 to 12 months after a patient has stopped drinking, and treatment can be extended for those with ongoing cravings who are not experiencing adverse effects.

Tobacco Use Disorder: The Most Common — and Most Treatable

Tobacco use disorder is the leading preventable cause of death, and it has the most robust pharmacotherapy toolkit of any substance use disorder. The FDA has approved seven medications for smoking cessation:

- Varenicline, a partial nicotine receptor agonist, is considered the most effective single agent. It more than doubles the likelihood of sustained quitting compared to placebo, with continuous abstinence rates of approximately 22% at 24 weeks versus 9% with placebo.

- Combination nicotine replacement therapy — a long-acting patch plus a short-acting formulation like gum or lozenge — is considered equally effective to varenicline and is the other first-line recommendation.

- Bupropion sustained-release increases quit rates by 52% to 71% and may be particularly helpful for patients with co-occurring depression.

All forms of nicotine replacement therapy (patch, gum, lozenge, inhaler, nasal spray) increase the likelihood of sustained quitting by 50% to 60% compared to placebo. The initial treatment duration is typically 12 weeks but can be extended to 6 months or longer. Adding behavioral counseling to pharmacotherapy further improves outcomes.

The Dual Diagnosis Reality

Substance use disorders rarely exist in isolation. Approximately 30% to 50% of people with serious mental illness also have a co-occurring substance use disorder. Depression, anxiety, PTSD, bipolar disorder, and ADHD frequently co-exist with problematic substance use, and each condition can worsen the other.

This is why integrated treatment matters. Research consistently shows that addressing mental health and substance use simultaneously, rather than treating them in separate silos, leads to better outcomes. In a psychiatric practice, this means that medication management for a mood or anxiety disorder should account for any co-occurring substance use, and vice versa.

Addressing the Stigma

One of the biggest barriers to MAT is stigma — from society, from healthcare providers, and even from within recovery communities. Research has identified stigma as the most common barrier among patients seeking medication treatment for opioid use disorder. This stigma takes many forms: the belief that using medication is "trading one addiction for another," reluctance to be identified as someone on MAT, and even discrimination from healthcare professionals who hold abstinence-only views.

The evidence is unambiguous: MAT is not a crutch. It is a medical treatment for a medical condition. Methadone and buprenorphine reduce all-cause mortality by 50% to 60% in patients with opioid use disorder. Naltrexone and acamprosate help people with alcohol use disorder maintain sobriety and reduce heavy drinking. Varenicline and nicotine replacement therapy help people quit smoking. These are not shortcuts — they are lifelines.

What MAT Is — and What It Is Not

It is worth being clear about what medication-assisted treatment involves in a psychiatric practice:

- It is an evidence-based approach that combines medication with ongoing clinical assessment and, when appropriate, behavioral interventions

- It requires regular follow-up visits with symptom monitoring, medication adjustments, and collaborative decision-making — just like any other medication management

- It is not a quick fix or a guarantee of recovery. Recovery is a process, and medication is one tool within a broader treatment plan

- It is not available for every substance use disorder. Currently, there are no FDA-approved medications for cannabis, stimulant, or hallucinogen use disorders, though research is ongoing

- It is not an emergency or crisis service. R&K Wellness Group is not an emergency or crisis service. Patients experiencing a substance use crisis should call 988 (the Suicide and Crisis Lifeline), go to the nearest emergency room, or call 911

When Should Someone Consider MAT?

Medication-assisted treatment may be appropriate when:

- A person has been diagnosed with opioid use disorder, alcohol use disorder, or tobacco use disorder

- Previous attempts at recovery without medication have been unsuccessful

- Cravings or withdrawal symptoms are a significant barrier to maintaining sobriety

- There is a co-occurring mental health condition that complicates recovery

- The individual is motivated to engage in treatment and willing to participate in regular follow-up

The decision to start MAT is always made collaboratively, through shared decision-making between the patient and provider. It takes into account the patient's preferences, goals, prior treatment experiences, and clinical needs.

The Bottom Line

Substance use disorders are treatable medical conditions, and medication-assisted treatment is one of the most effective tools available. Whether the challenge is opioids, alcohol, or tobacco, FDA-approved medications exist that reduce cravings, prevent relapse, and — in the case of opioid use disorder — save lives.

The hardest step is often the first one: reaching out. But understanding that effective, evidence-based treatment exists — and that it is available without judgment — can make that step a little easier.

Recovery is not about perfection. It is about progress. And medication-assisted treatment can help make that progress possible.

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