A Guide to Medication-Assisted Treatment

Revised Third Edition

 This guide is dedicated to the individuals seeking to improve
their lives and overcome substance use disorder (SUD)
through a medication-assisted treatment program,
and the loved ones’ supporting them every step of the way.

© 2024 BayMark Health Services. 3rd Revision.

 Table of Contents

Introduction......................................................................... 1

Understanding Opioid Use Disorder.................................... 2

What is Medication-Assisted Treatment (MAT)?.................. 4

About Methadone............................................................... 6

About Buprenorphine.......................................................... 8

About Naltrexone...............................................................10

Medication-Assisted Treatment & Pregnancy..................... 12

Completing a MAT Program...............................................14

True or False: Getting the Facts on MAT.............................15

Guidelines & Interactions for MAT........................................18

a) Physician Notification
b) Drug Interactions
c) Safe Storage
d) Driving
e) Traveling With Methadone

Overdose FAQ’s ................................................................. 23

What To Do In Case of Overdose ....................................... 25

Resources...........................................................................27
Opioid addiction, also known as opioid use disorder (OUD), is a chronic and relapsing
disease that can affect anyone. As with most other chronic diseases, addiction is
treatable. If you or someone you know is struggling, treatment is available. While no
single treatment method is right for everyone, recovery is possible, and help is available
for opioid addiction.
Source: [Link]/overdose-prevention/about/[Link]
The Road to Recovery Introduction

The deadly epidemic of opioid use disorder, or opioid addiction, touches

us all in some way. Hopefully you are reading this booklet because you are
ready to begin a medication-assisted treatment (MAT) program or because
someone you care about is ready to change their life.

An individual’s opioid addiction can begin as innocently and easily as filling

a prescription for pain medication after a surgery, injury, dental procedure
or the birth of a child. Others may begin with the intention of using drugs
as a recreational activity. However, in all cases, the medication or drug
use escalates to an addiction that is neither planned nor anticipated, and
becomes out of control.

The opioid class of drugs includes all street drugs or medications which
come fully or partially from opium or as synthetic street drugs and
medications which produce similar effects. It is very common now for illicit
opioids to contain fentanyl, a powerful, synthetic opioid, often without the
user being aware. Fentanyl is extremely potent, and dramatically increases the
chance of overdose and death. The use of both prescription pain medication
and illicit opioids, such as heroin and fentanyl, have exploded nationwide.

Some prescription opioids, and commonly known brand names, include:

l Hydrocodone — Vicodin, Lortab, Norco, Zohydro ER, or Lorcet

l Oxycodone — OxyContin, Percocet, Percodan, or Roxicodone

l Tramadol — Ultram ER, or Ultracet

l Codeine — Codeine pills, Tylenol with Codeine 3 or 4

l Morphine — Avinza, Kadian, MSContin, or MSIR

l Fentanyl — Duragesic, Fentora

l Oxymorphone — Opana, Opana ER

l Hydromorphone — Dilaudid, Exalgo

1
 Understanding Opioid Use Disorder

Opioid use disorder is a type of addiction defined as being physically, mentally

and emotionally dependent on that particular substance. When struggling
with addiction, a person is unable to stop using that substance without
experiencing negative side effects. It is possible, and common, for individuals
to be addicted to any number of substances, activities or other things that
may have a negative impact on their lives, but almost none so difficult to
overcome as an addiction to opioids.

Opioids have been used for thousands of years and their harmful effects are
well-documented. When an opioid is used, it binds to receptors in the brain
that can produce a euphoric or “high” feeling. This causes a release of
dopamine which also makes people feel good, as other natural chemicals
such as endorphins do. Dopamine is the chemical in the brain that is released
when participating in healthy, pleasurable activities in moderation, such as
eating a good meal or having consensual sex. However, dopamine is also
released in response to unhealthy, excessive participation in those same
activities or consumption of drugs or alcohol.

Many different drugs can cause the release of dopamine. What makes opioids
particularly difficult to stop using is that as an individual takes more of them,
the brain adjusts to the surges in dopamine. This causes an increase in the
amount of drugs required to reach the same feeling of euphoria, or eventually
to simply not feel sick. When that person doesn’t take the opioids, the brain
and body go into a state of withdrawal, which can be painful, unpleasant or
incapacitating. With that being said, many people fail to recognize that use
for an extended period of time causes the brain to not only expect, but rely
upon the presence of the chemicals just to make them feel normal. Feeling
normal goes beyond feeling “high” or euphoric, and may simply mean feeling
well enough to perform even basic tasks and functions in everyday life.

2
Addiction is a chronic, relapsing disease of the brain affecting a person’s
behavior and biology. And as such, leads to the physical pain of withdrawal,
as well as psychological and emotional pain, all of which contribute to the
development of addiction and must be addressed in treatment.

Physical Withdrawal
Physical withdrawal symptoms can be painful, and often debilitating, making
them one of the primary triggers for relapse when an individual is working to
recover from an opioid use disorder. Symptoms can include:

l Watery eyes l Abdominal cramps

l Runny nose l Loss of appetite

l Nausea and vomiting l Muscle aches and pains

l Sweating and/or chills l Restlessness, agitation and/or anxiety

l Goosebumps l Sleep disturbances

Preexisting physical characteristics, as well as genetic and environmental

factors are thought to play a role in determining those who are most likely to
experience issues with addiction or dependency.

It is not fully understood to what extent these factors determine the likelihood
of addiction, but they are relevant when looking at treatment options and
addressing all possible areas of an individual’s life which may come into play
in the recovery process. Those who relapse are not weak-willed. They suffer
from a chronic, treatable disease like diabetes, asthma or heart disease.

3
 What is Medication-Assisted Treatment?

When an individual battling opioid addiction is ready to stop using, help is

available. Medication-assisted treatment (MAT) is the use of medications,
in combination with counseling and behavioral therapies, to provide a com-
prehensive approach to the treatment of substance use disorders. Research
suggests that when treating substance use disorders, including opioid use
disorder, a combination of medication and behavioral therapies is most
successful.1

MAT programs for opioid addiction combine the benefits of using medication
to control withdrawal and cravings, with the emotional and psychological
benefits of counseling, to create a comprehensive, fully individualized
treatment plan. Additionally, at an optimal dose, these medications can block
the euphoric effects of illicit opioids for some patients, preventing them from
getting “high” if they use opioids while in MAT.

When a patient is taking methadone for an opioid use disorder (OUD), this is
often called methadone maintenance therapy or MMT, and is provided in an
Opioid Treatment Program (OTP). The medical provider typically begins
patients at a dose between 30-50 mg which is then increased over the

4
first weeks of treatment, as needed, until a therapeutic dose is reached. A
therapeutic dose of medication controls withdrawals and cravings without
causing euphoria.

This initial process, as well as subsequent medication changes, are supervised

by a licensed medical provider. Buprenorphine and naltrexone doses vary by
patient and delivery method. The treatment provider or physician works with
each patient to meet their individual needs.

Counseling in MAT is focused on addressing issues that may have contributed

to drug use, learning new tools and coping strategies and reintegrating
with family, friends and other support systems that can positively impact
an individual’s recovery. All of this is done with trauma-informed care best
practices in mind. These treatment goals are addressed in both individual and
group counseling settings.

MAT with methadone or buprenorphine will not provide relief for those whose
primary issue is with substances other than opioids. Concurrent dependencies
may require additional or alternative treatment.

People who receive medication-assisted treatment are safer and healthier

than those who do not depend on street opioids. They no longer need to use
illicit substances, typically spend less time in hospitals or jail, and reduce the
risk of contracting or spreading HIV and hepatitis. These personal and societal
benefits are why MAT is referred to as a harm reduction treatment model.

1 SAMHSA: [Link]/medication-assisted-treatment

5
 About Methadone

Methadone is a long-acting, synthetic opioid medication first approved as

a pain reliever by the FDA in 1947. During the 1960’s, it was shown to be
effective in the treatment of opiate addiction, and after intensive research,
was approved for this use in 1972. For more than 50 years, methadone has
been helping those struggling with opioid addiction, and together with
counseling and other psychosocial services, is considered the gold standard
of treatment.

Methadone is a full agonist opioid meaning that it acts similarly to other

opioids by activating the receptors in the brain fully, allowing the effects
of the opioid to be completely felt. It has some opioid blocking properties,
however, if a patient uses other opioids while taking methadone, they have
an increased risk of overdose.

PROPER DOSAGE
A proper dose of methadone is unique to each patient, but is achieved
when that person no longer feels the physical effects of withdrawal and also
does not feel the euphoric effects experienced when misusing an opioid.
Methadone metabolizes differently than short-acting opioids like morphine
or heroin, and stays in the body much longer. A proper dose of methadone
lasts 24-36 hours, allowing a daily dose to be sufficient.

Methadone, like other medications, is offered by many manufacturers

in different forms, but the active ingredient in them all is methadone
hydrochloride. It can be administered in liquid, powder or wafer form,
though wafer and powder are typically both dissolved in water before being
dispensed in an Opioid Treatment Program (OTP) to prevent diversion.

ADVANTAGES OF METHADONE
l M
 ethadone is safe and effective. This treatment option is affordable
compared with other treatment modalities. Additionally, there are many
government grants and programs in place to assist patients with the
financial aspects of MAT.

6
l Methadone treatment initially involves daily visits to the treatment program.

This provides much needed structure for individuals in early recovery.

l As patients become more stable, federal and state laws provide guidelines
allowing them to be able to take home medication. This change means less
frequent trips to the program are required as patient’s progress in treatment.

l Methadone does not have a “ceiling effect” and can be effective in the
treatment of withdrawal, particularly when a patient has developed a high
tolerance from a long-term use or use of large amounts of opioids.

POSSIBLE SIDE EFFECTS

Most side effects are reported as mild, and if experienced, should be
discussed with your treatment provider as a dosage adjustment may help.
Possible side effects can include:

l C
 onstipation l Headache

l S
 weating l Sleep disturbances
l W
 eight gain l Nausea

l D
 ry mouth l Mood swings
l C
 old or flu-like symptoms l Decreased libido

7
 About Buprenorphine

Buprenorphine and buprenorphine compounds, which combine buprenorphine

with naloxone, were approved by the FDA for clinical use in 2002 for the
treatment of opioid addiction. Similarly to methadone treatment, counseling
and other supportive services are usually recommended with buprenorphine
treatment to help patients achieve long-term recovery.

Buprenorphine is a partial agonist, meaning that it activates the opioid

receptors in the brain, but to a lesser extent than a full agonist. This creates
a “ceiling effect” limiting its ability to be used to get “high” or feel euphoria.
Additionally, it acts as an antagonist, blocking other opioids while its effects
are still accessible to suppress withdrawal symptoms and cravings. Naloxone
is added to buprenorphine to increase its safety and reduce misuse. Naloxone
is an antagonist or opioid blocker and can be used in some cases to reverse
a heroin overdose. If injected, buprenorphine with naloxone will cause an
individual to go into an immediate acute withdrawal state which deters misuse
and can prevent overdose.

PROPER DOSAGE
Buprenorphine is somewhat different than methadone in regards to dosing.
Like methadone, a therapeutic dose is unique to each person, and can be
adjusted early in treatment to be sure the patient is not feeling any withdrawal
or cravings. However, buprenorphine is often prescribed more aggressively
from the start rather than titrated up. Most importantly, buprenorphine has
been shown to be more effective at lower doses, meaning that at a certain
point, increasing the dose will not provide additional benefit.

Buprenorphine is dispensed in a pill or film that is dissolved under the tongue

(sublingually) or in the gums (buccally). Brands of buprenorphine compounds
include:

l Buprenorphine Only: Subutex

l B
 uprenorphine with Naloxone: Suboxone and Zubsolv

SUBOXONE is a registered trademark of lndivior UK Limited.

ZUBSOLV is a licensed trademark of Orexo US, Inc.

8
ADVANTAGES OF BUPRENORPHINE
l B
 uprenorphine overdose is less likely if patients take it as prescribed.
l B
 uprenorphine is long acting. After an initial period, a medical provider may

recommend taking the medication once daily or every other day.

l Buprenorphine
 is available through two different types of treatment programs:

1) Buprenorphine is provided through opioid treatment programs (OTPs) as

an alternative to methadone. Supported by counseling and other recovery
services, buprenorphine administered in this environment combines the
structure often needed by individuals in recovery with flexibility regarding
the federal requirements for getting take home medication more quickly.

2) Buprenorphine can be prescribed in a doctor’s office, or office-based

opioid treatment program (OBOT), which is similar to a primary care physicians
office. Prescriptions for buprenorphine or a buprenorphine compound can
be filled at any pharmacy. OBOTs specialize in treatment with buprenorphine
and many offer counseling and other supportive services for recovery.

POSSIBLE SIDE EFFECTS

Most side effects are reported as mild, and if experienced, should be
discussed with your treatment provider as a dosage adjustment may help.
Possible side effects can include:

l Constipation l Sleep disturbances

l S
 weating l Upset stomach or vomiting
l C
 old or flu-like symptoms l Mood swings
l H
 eadache

9
 About Naltrexone

Naltrexone was first approved by the FDA in 2006 for the treatment of alcohol
dependence. In 2010, the FDA approved its use for the treatment of opioid
use disorder as well. Naltrexone is a non-narcotic antagonist medication that
blocks the opioid receptors in the brain.

Unlike methadone or buprenorphine, an opioid antagonist does not release

dopamine when it attaches to the receptors, but rather creates a barrier that
prevents other opioids from attaching. This prevents patients using naltrexone
from utilizing other prescription or illicit opioids to achieve a feeling of
euphoria or “high”. It is highly recommended that treatment with naltrexone
be supported by substance use counseling or another recovery support
program to develop healthy coping mechanisms which can prevent relapse
and improve quality of life. Like other forms of medication-assisted treatment,
naltrexone is shown to be most effective when the underlying causes of
addiction are also addressed.

It is critical that a patient be opioid-free for a period of 7-10 days before

beginning a naltrexone treatment regimen to prevent sudden opioid
withdrawal.

PROPER DOSAGE
Naltrexone can be administered orally, via extended-release monthly injection
or through a long-lasting implant. The dose for an individual is primarily
dependent on the delivery method which will be determined by consultation
with a medical provider.

Brands of naltrexone include:

l Vivitrol, the extended-release injectable is administered at 380mg once a

month.1
l D
 epade, a pill form can be administered at up to 50mg per day.2

1. [Link]/content/pdfs/[Link]
2. [Link]/books/NBK64042/

10
ADVANTAGES OF NALTREXONE
l N
 altrexone is non-narcotic and as an opioid antagonist is non-addictive.
l N
 altrexone administration is medically supervised in an outpatient setting.
l N
 altrexone, when administered as an implant or injection, is released
slowly offering weeks of support without requiring daily medication.
l N
 altrexone can also be used for the concurrent treatment of alcohol use
disorder.

POSSIBLE SIDE EFFECTS

Common, mild side effects may include:

l N
 ausea, dizziness, vomiting l Cold symptoms
l D
 ecreased appetite l Joint or muscle pain
l S
 leepiness or trouble sleeping l Injection
site problems such as
l H
 eadache swelling, pain and infection

There is also a significant risk of overdose for those who attempt to overcome
the blocking effect of naltrexone by taking large amounts of opioids. Contact
a health care provider immediately if you experience any of the following side
effects due to naltrexone:

l S
 evere site reaction when administered via injection
l L
 iver injury – seek medical attention for signs or symptoms of liver disease
l Allergic pneumonia
l D
 epression or suicidal thoughts

11
 Medication-Assisted Treatment & Pregnancy

Methadone is widely known as the treatment of choice for pregnant, post-

partum or breastfeeding women with an opioid addiction. The effects of
methadone on pregnancy have been widely studied and found to be
significantly safer than detoxing or continuing to use opioids illicitly.

Although buprenorphine has not been in use as long as methadone, or as

widely tested, there is growing evidence that it is safe to use during
pregnancy as well, and may have benefits for the baby post-partum.

There is minimal research regarding the effects of naltrexone on an unborn

child. Current guidelines recommend speaking to a doctor if you are
pregnant to determine the best treatment options, as naltrexone is not
recommended during pregnancy in most cases.

A medical provider should be consulted before using ANY

medication during pregnancy; care should be coordinated
between the treatment provider and obstetric care provider.

The benefits of participating in a medication-assisted treatment (MAT)

program while pregnant include:

l Reducing the risk of miscarriage

l Reducing the risk of later pregnancy complications
l Helping the mother stop illicit drug use which leads to a more stable
environment for optimal growth and development of the baby.
l Lowering the risk of infection or other complications caused by intravenous
drug use and other risky behaviors.

12
MAT with methadone or buprenorphine has not been shown to cause birth
defects, and most babies born to mothers in treatment do as well as other
babies. Pregnancy can cause changes in metabolism, so to prevent going
into withdrawal and putting stress on the baby, working closely with a
treatment provider is critical to be sure the medication dose is adequate.

While the benefits outweigh the risks, there is the possibility of newborns
experiencing some withdrawal symptoms after birth for up to 6 weeks. This
is an expected result of being exposed to MAT and does not mean the baby is
“addicted”. These common withdrawal symptoms are known as neonatal
opioid withdrawal syndrome (NOWS) or Neonatal Abstinence Syndrome
(NAS) and are very treatable under medical supervision.

Most NOWS/NAS symptoms are mild, and treatable, but may include:

l I rritability/restlessness/excessive crying l V
 omiting/diarrhea

l S
 leep issues l S
 weating/dehydration

l P
 oor feeding or sucking l T
 rembling

l F
 ever l S
 tuffy nose/sneezing

A doctor should be involved in treating infants experiencing withdrawal

symptoms of any kind. A quiet, comfortable environment may provide relief,
but if the symptoms are severe, a doctor may prescribe medicine or recommend
monitoring the symptoms in the hospital. Never give methadone, buprenorphine
or any other medication to a baby, for any reason, without a doctor’s approval.
Even a small amount can be enough to seriously harm or even kill an infant.

While it is not known for certain what long-term effects an infant’s exposure
to methadone or buprenorphine may have, we know that their health outcome
is significantly improved in a medically supervised MAT program than it is
when exposed to unregulated amounts of any drug or medication.

BREASTFEEDING
Most mothers taking methadone or buprenorphine can still breastfeed, and
are often encouraged to do so for the many health benefits it offers. The
pediatrician can help women decide the best way to feed their baby. Women
who are HIV-positive, have active TB or have Hepatitis C should consult their
medical providers for specific guidance on breastfeeding.

13
 Completing a MAT Program

Many patients, for a variety of reasons, will at some point decide that they
are ready to taper off and stop medication-assisted treatment. Medical
providers may or may not agree with the patient’s decision, but MAT is
voluntary treatment and patients can make decisions that are right for them.
Some patients feel they have had the benefits of MAT for a sufficient time and
successfully taper off their methadone or buprenorphine and continue their
recovery without MAT. Others grow weary of visiting a treatment program on
a regular basis. Still others decide to come off MAT in preparation for possible
incarceration, relocation or any number of reasons.

Other patients will successfully complete their treatment, and taper off of
their methadone or buprenorphine, moving into the next phases of their lives
in recovery. Determining if an individual is ready to stop MAT is a personal
decision that should be made with the input of the patient’s medical provider
and counselor. Some people will remain sober off MAT, while some may
continue MAT to support their sobriety for the rest of their lives. There is no
right or wrong approach, just individualized decisions made based on each
patient’s unique needs.

TAPERING
When a patient has decided to stop MAT, or reduce their dose of medication,
they should work with their treatment provider to reduce their dose at a rate
which is safe, comfortable and does not cause withdrawal symptoms. It is
not advised to suddenly stop or quickly taper off of a dose of methadone,
buprenorphine or naltrexone, but it does happen in certain situations such as
illness, incarceration or to be in compliance with the requirements of a family
or criminal court.

Doctors can assist in preparing for the physical changes that may occur during
the taper period. Counseling staff works to ensure that patients are given the
tools and resources needed to live happy, healthy and productive lives after
the taper is complete, as well as plan for ongoing treatment at a different level
of care if required.

14
True or False:
Getting the Facts on Methadone

False: Medication-assisted treatment (MAT) is just replacing one addiction

with another.

True:  ethadone and buprenorphine are medications used to ease the

M
effects of withdrawals and prevent cravings when an individual
is recovering from opioid use disorder. These medications are
prescribed or administered in a controlled environment, under
the supervision of a medical provider. At therapeutic doses, these
medications have opioid blocking properties for some patients,
preventing the use of illicit opioids to reach a feeling of euphoria
or “high”, and last much longer than heroin or fentanyl, helping to
stabilize patients on a maintenance dose. These differences make
them a critical part of breaking the cycle of opioid addiction.

False: If you are in a MAT program you aren’t really in recovery.
True:  Recovery can be defined in many different ways. The traditional
abstinence-based model of recovery may not acknowledge MAT as
a valid form of recovery, but that concept is changing and there’s
significant evidence for the role of medication in the recovery
process. As addiction is increasingly viewed as a disease, it
becomes more widely accepted to treat it as other diseases with
medication and other available resources.

False: Methadone and buprenorphine/Suboxone offer the same “high” as

heroin.

True:  M
 ethadone and heroin are both full agonist opioids which can be
dangerous in large amounts. Buprenorphine is a partial agonist,
but could still be used to achieve a “high”, particularly for those
who do not commonly use opioids. However, when used properly,
medications in a MAT program are administered in a controlled
environment where doses are adjusted as needed to make them
therapeutically useful in eliminating withdrawals and preventing
cravings, but do not create a “high”.

15
 False: MAT medications cause fatigue and sedation.
True:  hile working toward a stable dose, patients may experience
W
some side effects with any medication used in MAT. Those who are
prescribed a proper dose will not experience more fatigue than a
person not in an MAT program. In fact, many will likely feel better.
If a patient is experiencing fatigue or sedation, they should contact
their medical provider immediately to have this addressed.

False: MAT medications trigger cocaine use.

True:  M
 ost patients in a medication-assisted treatment program who
use cocaine, or other illicit substances, did so prior to their
enrollment in the program. There is no evidence that methadone or
buprenorphine/Suboxone will cause an individual to use cocaine.
However, while MAT is not specifically used for the treatment of
cocaine use, many patients discontinue use of all illicit substances
while in the program.

False: It is more difficult to stop methadone treatment than to stop using
heroin.

True:  ethadone withdrawal symptoms may last longer but are not as
M
acute as those experienced with heroin. Because they last longer,
some individuals feel it is more difficult to stop. However, tapering off
methadone in a controlled MAT program is typically better tolerated
and more successful than stopping heroin without MAT.

False: Methadone is harmful to your body.

True:  E xtensive research over more than 50 years indicates that the use of
methadone, even long-term use, does not cause any physical harm
to individuals. Like other medications, methadone may have some
side effects such as constipation or disrupted menstrual cycles,
but a dose adjustment may relieve some of these. If side effects
do occur, patients should be sure to rule out the possibility of other
causes, such as pregnancy, stress or other medical issues.

16
False: Methadone weakens your bones and destroys your liver.
True:  ethadone does not in any way “get in” or damage a patient’s bones
M
or bone structure. Minor aches and pains experienced during MAT
can be alleviated with a slight dose adjustment, but do not indicate
bone damage. Additionally, some medications cause methadone
to be metabolized (broken down) differently in the body, and may
require a dose adjustment to feel relief from minor withdrawal
symptoms. The liver is responsible for metabolizing methadone
which does not cause it any harm. Individuals with liver impacting
illnesses, such as Hepatitis C, are generally able to take methadone
safely with no adverse effects.

False: The immune system is compromised by MAT medications

True:  M
 ethadone and buprenorphine/Suboxone do not have any damaging
or adverse effects on the immune system. MAT patients with HIV,
which does compromise the immune system, are shown in various
studies to be healthier when in a MAT program than drug users who
are not.

False: Lower doses of methadone and buprenorphine/Suboxone are better.

True:  T he proper dose of medication in MAT is different for every patient.
Some will experience relief from withdrawal symptoms with low
doses, while many will require significantly higher doses. While
it is true that a low dose of methadone may alleviate withdrawal
symptoms, a higher dose is often required to block the effects of
other opioids. However, buprenorphine and Suboxone are more
effective at lower doses and have a ceiling effect which limits their
usefulness after a certain point. Patients should work with their
medical provider to determine the right dose for them.

17
 Guidelines & Interactions for MAT

While in a medication-assisted treatment (MAT) program it is important to be

aware of the safety precautions for the use and storage of your medication,
as well as other guidelines.

PHYSICIAN NOTIFICATION
To receive the best possible care, it’s critical that all
medical providers who are prescribing medications
to that patient be aware of their enrollment in a
MAT program. Many patients feel reluctant to share
this information for fear of judgement or discrimination. If this is the case, it
may be best to find a primary care provider who understands the goals of
recovery and will provide support.

If you are having surgery or delivering a baby, medications for anesthesia

may interact with methadone, buprenorphine or naltrexone. Even if the
medical provider is aware you are in an MAT program, you should be sure to
ask questions and educate yourself about what is safe in these situations.

It’s best for individuals to be treated collaboratively, with all medical providers
responsible for their care in order to communicate about medication doses
and drug interactions. However it is illegal for them to do so without a
patient’s express, written consent.

[Title 42 of the Code of Federal Regulations, Part 2]

DRUG INTERACTIONS
All medications have interactions which will affect the way they work in the
body. Although most medications won’t have any impact on a patient’s use of
treatment medications, it is important to learn about those that do.

Methadone
l Benzodiazepines (Xanax/Valium, etc.), barbiturates (SOMA, etc.) and
alcohol can cause sedation, respiratory depression and death when

18
 combined with methadone. Extreme caution should be exercised when
taking these medications.

l T
 hefollowing are opioid agonist/antagonists and can cause withdrawal
symptoms if taken with methadone.

1) Buprenorphine (Suboxone)
2) Butorphanol (Stadol)
3) Nalbuphine (Nubain)
4) Naltrexone (Revia/Depade/Vivitrol)
5) Pentazocine (Talwin)
6) Tramadol (Ultram)

l T
 he
following is a partial list of common medications and drugs that cause
methadone to metabolize more quickly which can make a patient feel like
their methadone dose is not as effective.

1) Abacavir (Ziagen)
2) Amprenavir
3) Carbamazepine (Tegretol)
4) Efavirenz (Sustiva)
5) Phenytoin (Dilantin)
6) Nevrapine (Viramune)
7) Rifampin (Rifadin)
8) Efavirenz (Sustiva)
9) Ritonavir (Norvir)
10) Cocaine use

l T
 he following is a partial list of medications that may cause patients to
feel tired or drowsy on their usual methadone dose. Reducing methadone
usually corrects the symptoms, but when these other medications
are stopped, patients may feel withdrawal symptoms and need their
methadone dose adjusted again.

1) Amitriptyline (Elavil)
2) Cimetidine (Tagamet)
3) Fluvoxamine (Luvox)
4) Ketoconazole (Nizoral)

19
 Buprenorphine/Suboxone
l B
 enzodiazepines (Xanax/Valium, etc.), barbiturates (SOMA, etc.) and alcohol

can cause sedation, respiratory depression and death. Extreme caution

should be exercised when taking them with buprenorphine or buprenorphine
compound medications such as Suboxone.

l The following are opioid agonists that are likely to be less effective when
taken with buprenorphine. It is recommended to always inform treating
providers if you are in buprenorphine treatment so they can adjust other
prescribed medications for improved effectiveness:

1) Morphine
2) Codeine
3) Hydrocodone
4) Oxycodone
5) Tramadol

l Naloxone is combined with buprenorphine commonly in sublingual tablets

and films, but must also be mentioned here in this list of negative medication
interactions. When naloxone is taken orally as directed, it will not typically
interact with the buprenorphine. Injecting or inhaling naloxone, however, will
cause withdrawal for patients being treatment with buprenorphine.

Naltrexone
l Opioid(narcotic) medications or street drugs (Codeine, Hydrocodone,
propoxyphene)
l Levomethadyl acetate (LAAM, OrLAAM)
l M
 ethadone

l Blood thinners (Warfarin, Enoxaparin)

l Certain medications for diarrhea (diphenoxylate) and cough
(dextromethorphan)
l D
 isulfiram (Antabuse)
l T
 hioridazine

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 It is potentially dangerous to take benzodiazepines or drink
alcohol while taking methadone, buprenorphine/suboxone or
naltrexone. In combination, benzodiazepines and MAT medications,
have a high risk of causing sedation and respiratory depression
which can lead to respiratory failure, overdose and death. Communicate with your
treatment provider and physician about the best way to manage your medications
in a safe and effective way.

SAFE STORAGE
If you have been given take-home methadone or buprenorphine doses at your
treatment program, you may be required to pick them up and keep them in
a locked box. Even if not required, it is safest to store opioid treatment
medications in a locked box or cabinet at all times, out of the reach of children
and pets. Methadone or buprenorphine in even the smallest doses, can be fatal
to children or adults with no tolerance or possible unknown drug interactions.

If anyone other than the patient ingests the medication,

call 911 immediately.

Be sure that methadone and buprenorphine are stored away from extreme heat
and cold and are always kept in the original prescription bottle. Buprenorphine
should be kept away from moisture. Naltrexone is administered in office at either
an opioid treatment program or physician’s office. It is illegal to possess, trade or
sell any MAT medications without a prescription.

DRIVING
Patients stabilized on an appropriate dose of methadone, buprenorphine or
naltrexone should not experience any negative effects on their ability to
think, drive or perform any task normally. Numerous studies of methadone in
particular have shown this to be true. They conclude that there is no reason
an individual in a MAT program can’t perform tasks successfully.

If you have combined methadone with any other substances, or if you feel tired
or unable to focus, you should not drive as this could be dangerous or lethal.
This may be a sign that your medication dose needs to be adjusted, or that
you have another medical issue which should be addressed.

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 TRAVELING WITH METHADONE
Traveling with methadone, or while in a MAT program, can be challenging
and stressful for patients. Proper planning and understanding of the rules
and regulations in the area where you are going can make all the difference.

l For travel within the United States:

1) Determine if you are eligible for travel take-homes. If you are, then
you will receive doses for each day that you are away from your home
clinic. If not, your home clinic will assist you in arranging “guest
medication” services at a local clinic.
2) It is best to make these arrangements as early as possible. Guest
medication will require authorization of the dose and specific days of
treatment.
3) Federal, state and clinic regulations may have limits on the amount
of methadone that an individual may have in their possession. It’s
important to understand the laws and regulations at the destination.

l For travel outside of the United States:

1) Most countries allow visitors to bring their prescribed medications in
without issue, but methadone is not available in some countries and is
highly regulated in others.
2) Some countries have laws prohibiting individuals with a criminal record
or history of substance use disorders from entering.
3) It can be difficult to determine the laws of each country, and further
to understand which laws are enforced and to what extent. https://
[Link]/en/methadone-worldwide-travel-guide provides
information, or a country’s consulate may be able to provide information
or resources to assist.
4) Like travel in the US, individuals need to determine if they will be traveling
with their methadone or looking to locate a treatment center for guest
medicating at the destination.
5) Always carry a letter from the prescribing treatment provider explaining
that you are being treated with methadone under the care of a physician.
The letter should also indicate your daily dose, what form of methadone
you are carrying, and how much of it you have. Your methadone should
be kept with you at all times in your carry-on bag in a locked container.

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Overdose FAQ’s

Medication-assisted treatment (MAT), when used properly, can greatly reduce

the risk of overdose for those using heroin or other opioids illicitly. However,
there are still risks for individuals who do not discontinue use of other opioids
while taking treatment medications or who resume using after a period of
time in treatment.

FAQ’s
Q: Is it possible to overdose on methadone, buprenorphine or naltrexone?
It is critical for those enrolling in a medication-assisted treatment program
to be honest about the type and amount of drugs they have been taking so
that a proper dose of the chosen medication can be administered. Too much
medication could cause an overdose, particularly if the patient is still using
illicit opioids, but not enough will not be effective in minimizing withdrawal.

Because methadone is a long-acting full opioid medication, and it is possible to

overdose on it. There are laws in place to limit the dose that can be given on the
first day of outpatient treatment, and providers work to understand each patient
and administer methadone doses carefully to minimize the risk of overdose.

Because buprenorphine is a partial opioid agonist with a ceiling effect, it is

unlikely that a patient would overdose on this medication if taken as prescribed.
However, people who are not opioid tolerant or who take more buprenorphine
than directed can overdose.

Overdose while on naltrexone can occur if opioids are injected directly into
the veins or is taken in much larger quantities than usually used. However,
because naltrexone is an opioid antagonist, it does not cause sedation,
respiratory depression and overdose death in the way that opioid agonists can.

Q: If I use heroin while in a MAT program, will I overdose?

Despite the opioid blocking capabilities of a therapeutic dose of methadone,
buprenorphine or naltrexone it is possible to overdose on heroin while taking

23
 these medications. This can be caused by a person trying to break through
this blockade by using a larger amount of drug than they used to use in order
to feel “high”. This attempt to get “high” can lead to overdose and death. Any
additional substance added to the mix, such as benzodiazepines or alcohol,
substantially increases the chances of an overdose.

Q: What happens if I take other drugs while in a MAT program?

Prescription drug interactions can increase the possibility of adverse side
effects or overdose. This is also true of any substance that causes respiratory
or central nervous system slowing such as alcohol.

Put simply, it is safe to say that in addition to certain prescription medications,

any illegal drug, alcohol or mood-altering medication may interact with
methadone, buprenorphine or naltrexone and increase the risk of overdose
and death. We encourage patients to report all of the prescribed and over-the-
counter medications, herbs, vitamins and illicit drugs that they are using so that
the treatment program can provide education on risks with MAT.

Q: What happens if I “walk off” the MAT program or have to stop suddenly?
When an individual is on MAT, their body develops tolerance to that medication.
In other words, the body becomes used to the medication’s presence at the
same dose daily. If a person abruptly stops taking that medication, their
tolerance will change. It is very hard for anyone to know exactly what their
tolerance is for heroin or other opioids when they have recently stopped MAT.
As a result, any opioid use increases the chance of overdose. People are often
surprised by how fast their tolerance changes. Seemingly small amounts of
illicit drugs can have unexpected and deadly effects.

Q: W
 hat happens if I want to start MAT again a few days or weeks after
stopping?

Similarly to the increased possibility of overdose when using heroin or other

opioids after having been in a MAT program, it may not be safe for a patient
who readmits to immediately resume their previous dose. It is important to
work with your physician to determine the best initial dose of the chosen
medication and create a treatment plan from there.

24
What To Do In Case of Overdose


If you suspect a person has overdosed, call 911 immediately
then roll the patient onto their side. If you have naloxone,
administer it while waiting for EMS to arrive.

Naloxone (also known as Narcan) is an opioid antagonist medication used

to counter the effects of opioid overdose. Narcan is used during an opioid
overdose to counteract life-threatening depression of the central nervous and
respiratory systems, allowing the victim to breathe normally.

Although it is traditionally administered by emergency response personnel,

naloxone can be administered by anyone with minimal training. In some
states it is available over the counter, or can be obtained from a physician or
other human service organization— in many cases, free of charge.

Emergency personnel should still be called even if naloxone has been

administered to an individual during an overdose. It is important to share any
information you have, including what drugs the person took, so emergency
personnel can provide proper care.

l Signs of overdose include:

1) Drowsiness

2) Unresponsiveness

3) Slowed heart rate or pulse

4) Cold, clammy hands

5) Reduced body temperature

6) Bluish skin tone

7) Slow or no breathing

25
 l If someone is suspected of an overdose:

1) Call 911 immediately

2) Gently roll the person to their side

3) If you have naloxone, use it, but do not give any other medications

4) Stay with them and speak to them

5) Repeat administration if the individual is not responsive— see Narcan

instructions for more information.

NOTES

26
Resources

There are countless resources available for individuals with opioid use disorder
and their families. This is not an exhaustive list, but these agencies and
organizations offer information, resources and tools which may be helpful.

BayMark Health Services and its treatment brands do not specifically endorse
any organization or opinion featured in this list. They are offered only as guides
and tools for our patients and their families.

To Find a BayMark Location, visit:

[Link]/treatment-locations

Substance Abuse and Mental Health Services Administration

[Link]

For more information about drug interactions, visit:

[Link]

National Alliance of Advocates for Buprenorphine Treatment

[Link]

National Alliance of Methadone Advocates

[Link]

Addiction Forum Treatment

[Link]

American Association for the Treatment of Opioid Dependence

[Link]

Faces and Voices of Recovery

[Link]

Shatterproof
[Link]

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