Addiction Treatment

Addiction is what happens when the brain’s reward wiring gets hijacked. There’s a circuit that’s supposed to push you toward food, sex, novelty, your kid’s face, the things that kept the species going. Drugs and alcohol short-circuit that wiring by flooding the dopamine pathway with a signal louder than anything food or a paycheck or your wife laughing at your joke could ever produce… the brain then quietly rewrites its priority list around getting that signal again, and after enough exposure that rewrite is real and structural, you can see it on imaging.

People are usually willing to hear “your brain got rewired.” The harder thing is that the rewiring doesn’t undo the next thing you do. Both are true at once, and getting comfortable with that contradiction is most of recovery.

The other thing nobody says out loud at the front desk: addiction almost never travels alone. The guy who walks in for help with drinking is usually also depressed, also anxious, also carrying some trauma he hasn’t named yet, sometimes ADHD that everybody missed at 14. Treat the substance and ignore the rest and you’ve written next quarter’s relapse into the chart.

The MAT landscape, drug by drug, in plain English

Medication-assisted treatment, or MAT, is the corner of addiction medicine that changed the most in the last twenty years and the part patients still walk in most confused about. Quick tour.

For opioid use disorder there are three real options. Buprenorphine, usually prescribed as Suboxone (which is buprenorphine plus naloxone, the naloxone is in there mainly to discourage injecting the pill), works by binding the opioid receptor partway. It takes withdrawal off the table, kills the craving, and the ceiling effect makes overdose much harder. Dosing usually lands between 8 and 24 mg a day. Methadone is the older, fuller-strength version, dispensed daily through a federally regulated clinic, and is still the right answer for some patients, especially anyone who’s been on high-dose fentanyl long enough that buprenorphine doesn’t quite cover them. Naltrexone, given as the monthly Vivitrol shot, works the opposite way… it blocks the receptor entirely, so if you use, nothing happens. The catch is you have to be fully detoxed before the first shot, which is the part that knocks a lot of guys out of the running.

For alcohol use disorder the menu is different. Naltrexone again, oral or injectable, and what it actually does is take the reward out of drinking for most people who respond to it… you can still drink on it, the drink just stops being satisfying in the way it used to be. Acamprosate (brand name Campral) is the other first-line option, three pills a day, works by quieting down the glutamate side of your brain (glutamate is the chemical that gets cranked up during withdrawal and keeps you miserable for weeks after the last drink), and it specifically helps with that grinding low-grade misery of the first month dry. Disulfiram (Antabuse) is the old-school one and it doesn’t reduce craving at all… it just makes you violently sick if you drink on it. Works for the narrow group of patients who want an external brake and who’ll actually take the pill every morning. Most patients won’t.

Stimulant use disorder, meaning cocaine and meth, still doesn’t have a good medication answer. Bupropion has a little signal. The thing that actually has the strongest evidence for stimulants is contingency management, which is the clinical name for paying people small amounts of money to test clean every week, and it works, and almost no insurance company will pay for it, because somehow handing patients twenty bucks a week to stay off meth offends sensibilities that handing them an antipsychotic doesn’t. That’s the state of the field.

The abstinence-versus-harm-reduction fight that wastes everybody’s time

There’s a long-running ideological brawl in addiction medicine. The abstinence camp says the goal is zero substance, period, anything less is enabling. The harm-reduction camp says the goal is fewer overdoses, fewer infections, fewer dead patients, and we’ll take whatever movement in that direction we can get. AA and most twelve-step programs sit firmly in camp one. Modern addiction psychiatry has mostly drifted toward something pragmatic in between, which is the correct place to be.

My take is the framing is a false choice for most of the people in the chair. The guy across from me wants to drink less, use less, or not die. Whether the goal he names is zero or way less than now is something I negotiate with him, it’s not a flag I plant on his first appointment. If a guy is drinking a bottle of wine a night and what he actually wants is to be down to two glasses on Friday, the cleanest play is naltrexone dosed an hour before he drinks, the Sinclair method version, and you check in a few months later and see where his liver enzymes landed. AA would call him a failure. I’d call him a guy whose life looks better, which is the whole job.

For opioids the calculus is different and I push harder. Fentanyl is in everything now and the cost of relapse is sometimes a body bag, so anything that involves “chipping” or trying to manage casual use is something I push back on hard. For alcohol, where the acute danger curve is gentler (the real exception being severe withdrawal, which can absolutely kill you and needs medical detox), there’s more room to negotiate.

What psychiatry does, what rehab does, and what neither one is

Patients show up confused about the levels of care, so here’s the map.

A psychiatrist managing the medication is one piece. A weekly therapist who actually knows addiction (not a generalist who took one workshop) is another. A group, AA or SMART Recovery or Refuge Recovery or whatever fits the patient’s politics, is a third. Most of the patients who actually stay in recovery have some version of all three running at once for the first year. The guys who try meds alone, or meetings alone, or willpower alone, are the ones who come back through the door at month nine.

What’s nice to hear, before we get to the comorbidity stuff

The thing nobody leads with about MAT, because the field is allergic to saying anything positive, is that this stuff works. Suboxone is one of the more impressive medications in psychiatry, full stop. The craving goes away, withdrawal stops being the bear it was, you can hold a job, you can be a parent, you can sit through a meeting without sweating through your shirt. People who’ve spent five or eight years cycling through detox and relapse and detox start saying some version of “I forgot what it was like to not be chasing this thing.” That’s the part the marketing material for sober living doesn’t run, because it doesn’t fit the moral-victory framing, but it’s the part patients actually live.

Same with naltrexone for alcohol. People describe the drink just being less satisfying, like flat seltzer, and the loop they’ve been stuck in for fifteen years loses its grip. Not a cure, just enough room to do everything else that needs doing.

The comorbidity reality, and why single-track treatment falls apart

Pull the chart on any hundred patients with substance use disorder and somewhere between half and three-quarters of them carry another psychiatric diagnosis… major depression, generalized anxiety, PTSD, bipolar, ADHD especially in the stimulant-use folks. The mood thing was usually there first, often since adolescence, and the substance was the patient’s way of medicating it before anyone called it anything.

Say you’ve got a guy who’d been on opioids for years before he got himself onto buprenorphine. The drug worked, he wasn’t craving, he wasn’t using, he just stayed deeply unhappy in a way more meetings weren’t going to fix. The piece nobody had asked about was a childhood that hadn’t gotten named as traumatic by anyone, and the opioids had been the thing keeping it quiet. Once we added an SSRI and got him in front of an EMDR therapist (more on EMDR in the PTSD post, it’s hokey, the research is solid, I refer for it anyway), recovery started feeling like recovery instead of sober suffering.

That’s the most common pattern. The substance was the lid. Take it off and whatever was under it is right there, often louder than before, because it’s been getting fed for years and nobody was paying attention. Anyone who treats addiction without also treating the depression, the anxiety, the trauma, the ADHD, the marriage that’s been quietly falling apart for a decade, is doing half the job and then acting confused when the relapse rate looks the way it does.

The substance was the lid.

Where I land on medication, and where you land is up to you

The patient-autonomy stuff still applies. If you want medication, you get medication, my job is the honest take on what’s likely to work and what the trade-offs are, your job is what you actually do with that information. I’m a provider, not a parent. I hardly ever say no. The most I’ll do is a disapproving yes where you walk out with the script and a clear understanding of what I’d watch for and why I wasn’t thrilled. That goes for the addiction medications and for everything I write underneath them too.

The field itself, as usual, is wrong in both directions. It overprescribes MAT in places where the patient hasn’t agreed to it and isn’t going to take it, and it underprescribes MAT in places where the patient is begging for it and the prescriber has decided they “haven’t tried hard enough” first. Both errors are routine and both have body counts attached.

What to do this week if any of this lands

One phone call. To a psychiatrist who does MAT, to a primary care doc who’s comfortable prescribing buprenorphine (more of them are now than five years ago, the X-waiver requirement went away in 2023), to an IOP intake line, to SAMHSA’s helpline (1-800-662-4357, free, around the clock). Pick the one that takes the least courage and start there. If you wait until you’re “ready” you’ll be waiting for years, ready isn’t going to show up before the call, ready shows up about a week into actually doing the thing.

The day before the first appointment is almost always the worst day.

The day before the first appointment is almost always the worst day. Most of the guys who’ve actually made the call can’t tell me, looking back, what they were so afraid of. They can tell me they almost didn’t show.

Sources

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2. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900. PMID 24825644.
3. Volkow ND, Koob GF, McLellan AT. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med. 2016;374(4):363-371. PMID 26816013.
4. Crotty K, Freedman KI, Kampman KM. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020;14(2S Suppl 1):1-91. PMID 32209915.
5. Rösner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867. PMID 21154349.