The Life Process Program Approach to MAT and Harm Reduction
The Life Process Program’s “MAT Empowerment Model”
MAT stands for medication-assisted treatment. This is the use of medications to assist recovery from addiction.
Harm reduction as it relates to substance use means improvement, or recovery, while continuing to use substances. This may mean either less harmful use of the person’s problematic or addictive substance, or else use of other drugs to replace the original addictive drug. MAT falls into the latter category.
In theory, MAT and harm reduction are highly compatible. However, MAT is often implemented in ways that directly oppose harm reduction principles. It may then offer little benefit for recovery, or even have a negative impact.
LPP’s MAT Empowerment Program ensures an appropriate relationship between MAT and harm reduction, and between both of these and recovery.
MAT includes four types of medications:
- Opioid substitutes. The best-known addiction medicines are methadone and buprenorphine. These are opioids themselves (agonists) that are used to substitute for opioids used on the street, like heroin and illicit painkillers.
- Naltrexone (Vivitrol). Naltrexone is an opioid and alcohol antagonist, meaning it blocks the effects of these drugs. It is often used as a part of the Sinclair Method, through which users disconnect (unlearn) the effects of the blocked drug or alcohol and no longer desire it.
- Naloxone (Narcan). Naloxone is a quick acting antagonist, or opioid reversal drug. It is administered to drug users in extreme distress, perhaps in a coma, to undo the effects of a narcotic they have taken. It is not actually a medicine used for treating addiction. It is an emergency rescue drug.
- Suboxone. Suboxone combines buprenorphine and naloxone into a single medication. The addition of naloxone prevents injection, since doing so activates the naloxone and negates the opioid’s effects.
Medication-assisted treatments like Suboxone and methadone have been shown to prevent deaths relative to unregulated illicit drug use. The medicines may also serve as a psychological and practical bridge to improve drug users’ lives, so that users can regulate or desist problematic drug use. The drugs accomplish this because they impose order in a users’ life. They remove the dangerous patterns that result from chaotically obtaining and using unregulated, or likely contaminated street drugs.
Naltrexone has not demonstrated clear-cut benefits, especially with opioids, where it has sometimes produced more relapses. Nor has it worked reliably in treating alcoholism. In several controlled studies, those receiving placebos were just as likely as those receiving naltrexone to desist or cut back drinking. Nonetheless, naltrexone therapy is popularly touted with both alcohol and opioids, and has been heavily marketed to jails and prisons as a non-addictive treatment to effectively prevent opioid use. But the research indicates that naltrexone’s effects are based on expectations. That is, naltrexone works to reduce the urge to drink or use opioids because both the treatment personnel and addicted individuals expect that it will—a lucky rabbit’s foot.
MAT drawbacks with opioids
Despite the growing use of MAT in the form of Suboxone, buprenorphine, naltrexone, and Narcan around the United States, drug deaths have not decreased in recent years. Rather, both before and during the pandemic, drug deaths have increased precipitously. Since these drugs have been shown to be effective for reducing deaths in controlled studies for limited periods, why are drug deaths still peaking?
A chief concern of MAT therapy is users’ retention in the treatment. If users quit the medication, or combine it with other drugs, death rates rise, sometimes dramatically. Yet discontinuation of MAT is very common: one half of patients will usually quit methadone or buprenorphine treatment by the end of a year. A portion of these users may experience worse outcomes than they had without MAT.
There are a host of reasons that drug users desist their therapeutic drug. Sometimes practical or legal roadblocks to treatment arise. Sometimes users tire of the medicalized routines. And sometimes they simply wish to return to their drug of choice. That is, users decide that the therapeutic drug doesn’t match the effects of their originally preferred drug, which is what they seek.
Addicted MAT use
Substitute narcotics such as methadone, buprenorphine, and Suboxone are themselves opioids, thus there is always a possibility that they simply become new drugs of addiction (this is especially so if medication is offered with no additional services or life-enhancement strategies). Indeed, in a sense, that is what the treatment proposes to do — to have users rely on a less harmful drug than their old, dangerous one.
But some reject the idea of trading one addiction for another — they simply don’t want to be addicted to drugs of any sort. We at LPP identify with this perspective. We don’t think that some drugs are more addictive or “better” than others. Instead, the circumstances in which people use drugs (their reasons for doing so and the consequences) can be more or less chaotic and problematic.
MAT as a tool, rather than a permanent dependence
In the Life Process Program, we regard MAT as a tool for transitioning people to a more complete, non-addicted lifestyle. And, indeed, there are signs that many people use them this way. “On average, in my experience, MAT users taper themselves off the drugs in two years,” says LPP coach and MAT manager Aaron Ferguson. Of course, this leaves many who don’t do so.
Whether people can finally recover is a matter of intense debate. People who think of addiction or alcoholism as diseases — including 12-step advocates and people who believe that addiction is a brain disease — don’t believe that drug users can quit addiction permanently. LPP-MAT means to encourage a different perspective among users.
For disease proponents, either total abstinence or permanent reliance on MAT drugs such as methadone is necessary. But we at the Life Process Program don’t subscribe to either view. We instead regard MAT as a tool, like others that we teach, such as life skills and self-reliance, to enable people to progress beyond addiction. For LPP, MAT succeeds by offering people the opportunity to use a narcotic in a safe, well-regulated fashion. They can then harness this time and space MAT provides to transition out of their addiction altogether.
MAT, self-identity, and stigma
Something larger is going on in terms of how people see MAT. If they feel that they are permanently addicted — that they are lifelong “addicts” — then addiction is central to who they are, to their identity.
We at LPP don’t believe that anyone is doomed to perpetual addiction. People quit smoking all the time, for instance. Yet smoking is generally regarded as the hardest drug addiction to quit. Instead, we believe that it is typical for people to outgrow their addictions over time.
Some people are slower at doing so, however. They face being addicted for a shorter or longer period with all of the risky choices and dangers that this presents.
Helping people to remain safe while they transition, and helping them to make the transition, are the useful functions that MAT can serve. This role is the essential value of MAT in the Life Process Program.
Meanwhile, LPP coaches don’t shame or stigmatize people when they don’t quit altogether. We make no moral judgments about anyone’s continued drug use or addiction (other than its effects on other people). People’s pace of recovery, indeed whether they feel free to leave MAT behind at all, is their choice. Accepting this freedom is an essential ethical tenet for a professional helper. Our treatment goal is to encourage people to feel as good as possible about themselves, and to lead as satisfying a life as they find possible.
LPP thus doesn’t feel the need to destigmatize drug use and addiction by calling it a disease. We simply don’t stigmatize drug use of any kind in the first place.
LPP redefines the meaning of “harm reduction”
We said that some people believe that total abstinence is necessary for recovery (those who follow the 12 steps), while others believe that people must rely forever on medications like methadone (those who believe addiction is a chronic brain disease).
The latter group believes that they are practicing harm reduction by using MAT. Going back to our original definition, they feel harm reduction means improvement, or recovery, while they rely on a medication. But AA and NA members often object to reliance on any substance. Therein lies a basic split between the two groups of disease adherents.
We at LPP define harm reduction in a larger way, one that omits such a dichotomy in thinking:
Harm reduction means that people improve their overall lives while using any substance. This definition of harm reduction doesn’t involve use of a substance or not. Our definition of HR instead depends on how well people function overall in their lives, and how much they improve this functioning. This holds true whether or not they use drugs or which drugs they use.
LPP changes how addicted people see themselves
LPP’s redefinition has further implications for people’s identities — whether they believe that they are lifelong “addicts,” or whether they believe they control their lives.
Harm reduction succeeds when it allows people to learn that they can modify their use of drugs in beneficial ways. This includes using a substance in less harmful ways, by cutting back or using it under safe conditions. Our definition of HR also allows for use of MAT medications.
In this view, MAT succeeds because it allows people to control their drug use. They then see and they appreciate that they can better manage their lives. This process is called empowerment, or personal agency.
LPP thus uses MAT to empower people, and not to convince them that they are powerless. Why, indeed would therapists seek to disempower anyone, whether they use drugs or not? Doing so, we feel, is another example of stigmatizing, of minimizing, drug users. And we won’t do that.
In summary: LPP offers an empowerment approach that allows people to take the reins with their patterns of use, instead of offering lip service to stigma reduction by creating new lifelong labels, or the perfectionistic absolutism of the 12 steps.