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The two primary treatment options for opioid use disorder (OUD) are medication-assisted treatment (MAT) and abstinence-only programs. [6] MAT involves the use of medications like buprenorphine or methadone to reduce cravings, withdrawals, and the risks of relapse and overdose. [1] Abstinence-based recovery programs do not involve the use of medications; instead, they focus on behavioral and psychosocial treatment to support long-term abstinence. [2][5]
- Medication-assisted treatment for OUD involves the use of medications to help treat symptoms of opioid addiction, which is sometimes combined with psychosocial therapies.
- Abstinence-based treatment approaches focus on providing therapeutic support to help people establish long-term sobriety without the use of medications.
- MAT has been shown to be more effective than abstinence-based programs, although there are a number of factors to consider when selecting which treatment is right for you.
Understanding MAT
Medication-assisted treatment (MAT), which is now more commonly called medications for opioid use disorder (MOUD), is an evidence-based approach for treating opioid use disorder (OUD). MOUD uses FDA-approved medications to reduce opioid cravings, relieve withdrawal symptoms, and lower the risk of relapse and overdose. [1]
Research shows that treatment outcomes are significantly better when these medications are included, which is why MOUD is considered a frontline treatment for OUD. While some MAT programs incorporate individual or group therapy, medication is considered primary and may also be used as a standalone treatment option. [3]
FDA-approved MOUD
There are currently three FDA-approved medications for treating OUD: buprenorphine, methadone, and naltrexone. Of these, methadone and buprenorphine have demonstrated the highest rates of treatment retention and the strongest evidence for reducing opioid use and overdose. [3] Both medications work by binding to opioid receptors in the brain to relieve withdrawal symptoms and reduce cravings. Naltrexone works differently; it is an opioid antagonist that blocks opioid receptors, preventing euphoric effects if a person uses opioids. [1]
MOUD can be provided in inpatient, residential, and outpatient treatment settings, and some medications may be prescribed for at-home use.
- Methadone: Methadone is typically dispensed through federally certified opioid treatment programs (OTPs), where patients often receive supervised daily doses, although take-home doses may be permitted for stable patients who meet specific criteria. Methadone is a full opioid agonist and carries a greater risk of misuse, dependence, and overdose than the other two FDA-approved medications, so it is more tightly regulated. [1]
- Buprenorphine: Unlike methadone, buprenorphine is a partial opioid agonist, producing a ceiling effect that lowers the risk of respiratory depression, misuse, and overdose, while still effectively reducing withdrawal symptoms and cravings. Buprenorphine can be prescribed in inpatient or outpatient settings and is commonly prescribed for home use. In some instances, general practitioners will provide prescriptions for buprenorphine, meaning it may not be necessary to seek specialized care at an OTP clinic. [1]
- Naltrexone: Naltrexone is an opioid antagonist, meaning it blocks opioid receptors and prevents opioids from producing rewarding effects if they are used. Because naltrexone does not relieve withdrawal symptoms or cravings during detoxification, patients must complete opioid withdrawal before starting treatment, as this drug can cause precipitated withdrawal. While some people also report that naltrexone can help minimize cravings, it is primarily used to deter opioid use by preventing people from being able to get high if they use. [1]
Understanding abstinence-based recovery
Abstinence-based treatment is an approach to treating OUD that focuses on achieving and maintaining recovery without the long-term use of medications. [5] The goal is complete abstinence from opioids, including FDA-approved drugs that activate opioid receptors, like buprenorphine and methadone.
Instead of relying on medication to manage cravings and withdrawal, abstinence-based treatment emphasizes behavioral therapies, counseling, peer support, relapse prevention, and lifestyle changes to help individuals achieve long-term recovery. These treatments can be provided in a number of different settings, including inpatient, residential, and outpatient settings.
Treatment often begins with withdrawal management (detoxification), during which medications may be used temporarily to reduce withdrawal symptoms and safely manage the acute withdrawal process. However, unlike medications for opioid use disorder (MOUD), these medications are typically discontinued once withdrawal is complete. At this point, individual, group, and sometimes family therapies become the primary method of treatment.
Different types of therapeutic approaches can be utilized by addiction treatment programs, including cognitive-behavioral therapy (CBT), motivational interviewing, or family systems therapy. Overall, there is research to support that these therapies can be effective in treating OUD and helping some people achieve long-term recovery. However, research suggests that MOUD has significantly better efficacy than abstinence-based programs, especially for people with more moderate or severe OUD.
Without medications to reduce cravings and normalize brain function, relapse rates following detoxification are high for people in abstinence-based treatment for OUD, particularly during the first several months of recovery. In addition, because opioid tolerance declines rapidly after a period of abstinence, a relapse after a period of abstinence significantly increases the risk of overdose. Because of these risks, most providers recommend MOUD as a frontline treatment.
MAT vs. Non-MAT recovery
There are several different factors to consider when comparing MAT vs. abstinence-based treatment for opioid dependence. Understanding the differences in these two treatment approaches and their uses, benefits, and risks can help individuals make informed healthcare decisions. More information can be found in the table below. [1][2][3][4][5][6]
| Treatment Feature | MOUD (MAT) | Abstinence-Based Treatment |
|---|---|---|
| Medication use | Uses FDA-approved medications (methadone, buprenorphine, or naltrexone) as part of a comprehensive treatment plan. | Does not use long-term opioid medications. Medications may be used temporarily during withdrawal management but are discontinued after detoxification. |
| Withdrawal management/relief | Methadone and buprenorphine effectively relieve withdrawal symptoms and can be continued as long-term treatment. Naltrexone is started only after withdrawal is complete. | Withdrawal symptoms are managed during detoxification with short-term medications and supportive care, but no ongoing medication is used after withdrawal. |
| Craving reduction | Methadone and buprenorphine significantly reduce opioid cravings. Naltrexone blocks opioid effects and may help reduce the risk of relapse in motivated individuals. | Relies on behavioral therapies, counseling, and coping strategies to manage cravings without medication. |
| Overdose protection | Significantly lowers the risk of fatal overdose while patients remain in treatment. Buprenorphine and methadone are associated with the greatest reduction in overdose deaths. | Does not provide direct biological protection against overdose. Following detoxification, reduced opioid tolerance increases overdose risk if relapse occurs. |
| Mortality risk | Associated with substantially lower risks for overdose and mortality rates compared with no medication treatment. | Higher mortality risk than MOUD, particularly following detoxification if relapse occurs. |
| Relapse prevention | Reduces relapse risk by controlling cravings, relieving withdrawal, and stabilizing brain chemistry. | Focuses on relapse prevention through counseling, behavioral therapies, peer support, and lifestyle changes. Relapse rates are generally higher for moderate or severe OUD when medication is not used. |
| Treatment retention | Produces the highest rates of treatment retention, particularly with methadone and buprenorphine. Longer treatment duration is associated with better outcomes. | Retention varies by program and individual engagement but is generally lower than with MOUD. Early dropout following detoxification is common. |
| Recovery support | Typically combines medication with counseling, behavioral therapies, case management, peer support, and recovery services to address the psychological, social, and medical aspects of addiction. | Emphasizes counseling, behavioral therapies, peer support groups, relapse prevention planning, family involvement, and recovery-oriented lifestyle changes without ongoing medication. |
| Best supported for | Moderate-to-severe opioid use disorder; recommended as first-line treatment by major medical organizations because of its strong evidence for reducing relapse, overdose, and mortality. | May be appropriate for some individuals who prefer a medication-free approach, cannot take MOUD, or have successfully transitioned off medication, particularly when supported by comprehensive behavioral treatment and long-term recovery services. |
Advantages and challenges of MAT/MOUD
Medication for opioid use disorder (MOUD) can reduce cravings and withdrawal symptoms, improve treatment retention, and lower overdose risk. However, cost, access, and personal preferences can affect whether this approach is suitable for an individual. [1][3]
Advantages of MAT/MOUD
- Reduces cravings and withdrawal: Buprenorphine and methadone help manage symptoms that can contribute to relapse. [1][3]
- Improves treatment retention: Managing cravings and withdrawal can help people remain in treatment and avoid illicit opioid use. [1][3]
- Lowers overdose risk: MOUD is associated with a reduced risk of overdose while in treatment. [1][3]
- Can be combined with behavioral therapies: MAT/MOUD can be combined with counseling, cognitive behavioral therapy (CBT), and peer support to address the psychological and social aspects of recovery. These interventions may help improve treatment retention and support long-term recovery.
Challenges of MAT/MOUD
- Cost and accessibility: Treatment can be expensive or difficult to access, depending on location, provider availability, and treatment requirements. [1]
- Time commitment: Frequent clinic visits, particularly for methadone, can be difficult to balance with work, family, and other responsibilities. [1]
- Physical dependence: Stopping medication can cause withdrawal symptoms, so any changes to treatment should be planned with a healthcare provider. [1]
- Personal preferences: Some people prefer medication-free recovery or view medications such as methadone as replacing one drug with another. [2]
Advantages and challenges of abstinence-based models
Abstinence-based treatment focuses on recovery without ongoing medication for opioid use disorder. While it may align with some people's personal preferences and recovery goals, research indicates that it carries greater risks than MOUD for people with OUD. [2]
Advantages of abstinence-based treatment
- Aligns with personal values: May suit people whose recovery goals involve avoiding ongoing medication use.
- Supports behavioral change: Counseling, peer support, and relapse-prevention strategies can help people develop coping skills and maintain recovery. [2]
- Offers an alternative approach: May be preferred by people who decline MOUD or face barriers to accessing it.
Challenges of abstinence-based treatment
- Higher relapse and overdose risks: Compared with MOUD, abstinence-based approaches are associated with greater relapse, overdose, and mortality risks among people with OUD. [2]
- Difficult withdrawal symptoms: Detoxification can involve painful physical and psychological symptoms, while post-acute withdrawal symptoms may persist for weeks or months. [2]
- Lower treatment retention: Abstinence-based programs generally have lower treatment retention than MOUD, which may affect long-term recovery outcomes. [2]
- Need for ongoing support: Counseling, peer support, and relapse-prevention planning remain important for managing triggers and sustaining recovery.
Choosing the right option
Deciding which OUD treatment option is right for you is an important and highly personal decision that is best made in conjunction with a licensed provider or treatment team. Many people start this process by scheduling a substance use evaluation. After this evaluation, treatment options and recommendations are made based on your particular needs, recovery goals, and personal preferences. [6]
While MOUD is the preferred treatment recommendation for many people with OUD, it may not be suitable for everyone. For those who are not open to the use of medications, a substance use evaluation can also provide abstinence-based treatment options.
It’s important to understand that while MAT and abstinence-based treatment are sometimes presented as mutually exclusive options, many people use a combined approach. For example, a person may use MAT short-term for withdrawal management and stabilization before tapering off these medications and adopting an abstinence-based recovery approach
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