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Medication-Assisted Treatment for Opioid Use Disorder

Summary

The opioid overdose epidemic continues
to claim lives across the country with a
record 47,600 overdose deaths in 2017.
(This number represents 67.8% of the
70,237 overdose deaths from all drugs)
[CDC 2018a]. More Americans now die
every year from drug overdoses than in
motor vehicle crashes [CDC 2016]. The
crisis is taking an especially devastating
toll on certain parts of the U.S. workforce.
High rates of opioid overdose
deaths have occurred in industries with
high injury rates and physically demanding
working conditions such as construction,
mining, or fishing [Massachusetts
Department of Public Health 2018;
CDC 2018b]. Certain job factors such as
high job demands, job insecurity, and
lack of control over tasks have also been
linked to opioid use [Kowalski-McGraw
et al. 2017]. Medication-assisted treatment
(MAT) (also known as medication-
based treatment*) has been shown to be
effective for many people with opioid
use disorder [SAMHSA 2015b; National
Academies of Sciences, Engineering,
and Medicine 2019]. In addition to providing
general information about MAT,
this document provides information for
employers wishing to assist or support
workers with opioid use disorder.

Background

Challenges related to prescription drug
misuse, illicit drug use, and addiction

affect individual workers, their families,
and both large and small businesses.
In a 2017 National Safety Council
survey, 70% of employers reported suffering
the negative effects of prescription
drug misuse; noting positive drug
tests, absenteeism, injuries, accidents,
and overdoses [Hersman 2017]. In
2013, the total U.S. societal costs of prescription
opioid use disorder (OUD)
and overdoses were $78 billion. Of that,
about $2.8 billion was for treatment
[Florence et al. 2016].†

In 2016, individuals with insurance
coverage received $2.6 billion in services
for treatment of opioid addiction
and overdose, a dramatic increase from
$0.3 billion in 2004 (based on claims
data from large employers). Of that
$2.6 billion, $1.3 billion was for outpatient
treatment, $911 million was for
inpatient care, and $435 million was
for prescription drugs [Cox et al. 2018].

Employers may save up to $2,607 per
worker annually (based on 2012‒2014
data) by getting workers into treatment
[NSC et al. 2016; NORC].

Despite these findings, 80% of individuals
in need of treatment for a substance
use disorder in 2016 did not receive
treatment [CBHSQ 2017]. Making medication-
assisted treatment (MAT) more
readily available to people with OUD
can help diminish the opioid crisis in the
United States.

*Note that some experts recommend the term “medication-based treatment” or MBT instead
of MAT. This change in nomenclature aligns with the premise that OUD is a chronic disorder
for which medications are first-line treatments (often an integral part of a person’s long-term
treatment plan) rather than complementary or temporary aids on the path to recovery [National
Academies of Sciences, Engineering, and Medicine 2019].

†The White House Council of Economic Advisers [CEA 2017] estimated the economic cost of
these deaths related to opioids “using conventional economic estimates for valuing life routinely
used by U.S. Federal agencies.” The CEA report “also adjusts for underreporting of opioids
in overdose deaths, includes heroin-related fatalities, and incorporates nonfatal costs
of opioid misuse.” CEA estimates that in 2015, the economic cost of the opioid crisis was
$504.0 billion, or 2.8 percent of GDP that year.”

Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health logos
Centers for Disease Controland Prevention National Institute for Occupational
Safety and Health

Treatment

What is medication-assisted treatment (MAT)?

MAT uses medications approved by the
U.S. Food and Drug Administration
(FDA) in combination with counseling
and behavioral therapies to treat OUD
involving misuse of either prescription

or illicit opioids. The medications reduce the cravings for
and the euphoria (extreme pleasure) experienced with opioids
[SAMHSA 2015b]. Some medications may also reduce
the risk of subsequent overdose. Three drugs are commonly
used in MAT:

• Methadone is a full opioid agonist, which means that it
  works similarly to other opioids such as heroin, morphine,
  or fentanyl. Unlike other opioids, methadone acts much
  more slowly in the body. This slower action helps to reduce
  the euphoric highs and lows associated with other
  types of opioids while diminishing withdrawal symptoms.
  Methadone treatment is available only through a federally
  regulated opioid treatment program (OTP) and requires
  those in the program to report to the OTP daily or
  near daily to obtain the medication. Methadone itself can
  be addictive and misused, so it is important that it be used
  only as prescribed and under medical supervision.
• Buprenorphine is a partial opioid agonist, which means
  that it does not have the full effect of other semi-synthetic
  opioids in the same class, such as heroin or oxycodone.
  The drug is long-acting, works slowly, and, similar to
  methadone, helps prevent the intense cravings and withdrawal
  symptoms associated with opioid use. Buprenorphine
  is available by itself or in combination with naloxone,
  an opioid antagonist that reverses or prevents the
  effects of opioids. Adding naloxone discourages the misuse
  of buprenorphine. While naloxone has no effect when
  the combination (buprenorphine/naloxone) is used as directed
  by sublingual tablet or buccal film, the naloxone
  does work to block the effect of buprenorphine when the
  combination is injected or used nasally. MAT using buprenorphine
  is available in healthcare settings outside of
  an OTP under certain circumstances. The Drug Addiction
  Treat Act of 2000 allows physicians who meet certain
  qualifications to obtain a waiver to treat OUD with
  buprenorphine in primary care settings. Such waivers
  may make this treatment more accessible to those seeking
  treatment. Like methadone, it is possible for buprenorphine
  to be misused when not taken as prescribed.
• Naltrexone is an opioid antagonist that blocks the euphoric
  and sedative effects of opioids such as heroin or
  morphine. It also reduces cravings for opioids [SAMHSA
  2015b; NIH 2018a]. This medication may also be prescribed
  outside of an OTP.

Table 1 lists the formulations and possible side effects of each
of these medications.

In addition to the side effects, serious drug interactions between
MAT and other drugs (including alcohol) are also
possible.

Table 1. Formulations and side effects of medications used in medication-assisted treatment (MAT).
Drug

Formulations‡

Potential adverse side effects

Methadone

Tablet (Dolophine)

Oral concentrate (Methadose)

Respiratory depression, heart rhythm problems, low
blood pressure, upset stomach, vomiting, constipation,
dizziness, light-headedness, sedation, weakness

Buprenorphine

(Subutex)

Patch (Butrans)

Intradermal implant (Probuphine)

Injection (Sublocade, Buprenex)

Sublingual tablet

Constipation, nausea, vomiting, headache, drowsiness,
sedation, insomnia, lack of energy, weakness

Buprenorphine/
Naloxone

(in combination)

Buccal film (Belbuca, Bunavail)

Sublingual tablet (Subutex, Zubsolv)

Sublingual film (Cassipa, Suboxone)

Constipation, nausea, vomiting, headache, insomnia,
lack of energy

Naltrexone

Oral (Revia, Depade)

Injectable suspension for extended
release (Vivitrol)

Upset stomach, vomiting, diarrhea, stomach pain,
headache, anxiety, dizziness, drowsiness, lack of energy,
joint and muscle pain

Sources: NIH 2018a; IBM Micromedex DRUGDEX 2018; ASAM 2015; Leshner 2019

‡Some formulations have generic versions available.

What are the typical steps in medication- assisted treatment (MAT)?

Treatment for OUD begins with stabilization and opioid
withdrawal management followed by medication maintenance
combined with counseling or behavioral therapy. Underlying
health conditions that may be influencing opioid use should also be addressed. In later phases of treatment,
healthcare providers work with patients to determine when
the medication(s) can be tapered or stopped.

Image: pills of varying shapes, sizes, and colors. Prescription boxes are in the background; labels are not visible.

What is the typical length of treatment?

Length of treatment is highly variable with all three MAT
drugs and spans from months to years. Long-term treatment
is often needed to prevent relapses. A decision to taper off
medication depends on factors such as compliance, tolerance,
adverse effects, and a patient’s progress toward abstinence
from opioids. Tapering off often takes several months [ASAM
2015]. Removing someone from MAT abruptly or prematurely
may increase the risk of relapse and subsequent overdose.

What is an opioid treatment program (OTP)?

OTPs are housed in facilities that provide substance abuse
treatment including MAT for OUD. MAT patients treated in
OTPs must receive counseling, which can include different
forms of behavioral therapy. These facilities are accredited
by the Substance Abuse and Mental Health Services Administration
(SAMHSA), licensed to operate by the state where
located, and registered with the U.S. Drug Enforcement

Administration (DEA) [SAMHSA 2015a]. Some MAT medications
are only available through an OTP, while others can
be obtained in other healthcare settings.

Image: Side view of a female doctor talking to a female patient. The doctor is holding a clipboard and is seated on a stool; the patient is seated on the examining table.

Can drugs used as part of medication- assisted treatment (MAT) cause side effects that impair work activities?

Research has shown that, when provided at the proper dose,
medications used in MAT have no adverse effects on a person’s
intelligence, mental capability, physical functioning,
or employability [SAMHSA 2015b]. However, side effects
of the medication(s) may impair a person’s ability to drive,
operate heavy machinery, or perform other functions safely.
Side effects will vary depending on the specific medication,
dosage, and duration of treatment. Workers with safety-sensitive
jobs may be subject to restrictions or limits on the jobs
or duties they perform while using these medications. These
restrictions may include operating motor vehicles, forklifts,
cranes, and other types of heavy equipment, or making decisions
that can affect the safety and health of others (such
as dispatchers, operations managers, or other jobs requiring
high levels of cognitive function or judgement). Case-
by-case determinations by qualified occupational healthcare
providers may be necessary based on the potential for impairment
resulting from MAT. Reasonable accommodations
by the employer should be considered when appropriate.

When starting MAT, the worker should avoid driving and
hazardous work activities until dosages are stabilized, side effects
are managed, and impairment risks related to the work
to be performed are assessed. Side effects often diminish over
time [ASAM 2015; IBM Micromedex DRUGDEX 2018].

Gaining Access to Medication-Assisted Treatment (MAT)

Does employer health insurance cover medication-assisted treatment (MAT)?

The Affordable Care Act requires most insurers to cover
treatment for substance use disorder. In addition, the Mental
Health Parity and Addiction Equity Act (MHPAEA) of 2008
requires health insurers and group health plans to provide
benefits for behavioral health services at the same level as
primary care. However, insurers may not cover all types of
treatment for substance use disorder or may cover only certain
treatments [SAMHSA 2017]. In addition, employers
can often play an important role in influencing the level of
healthcare and pharmacy benefits included in employer-
sponsored plans for the treatment of substance use disorders.

How can workers find medication-assisted treatment (MAT) healthcare providers?

Workers should turn to their physician and healthcare insurance
provider for assistance. Insurers can provide information
about coverage and often have access to a network
of preferred MAT providers. Some employers provide Employee
Assistance Programs (EAP) offering counseling, support,
and referrals. EAP and other member assistance programs
(present in many labor organizations) give workers
a safe, confidential space to talk about personal issues (including
substance use disorder) and can provide referrals to
local treatment facilities [ASSP 2018]. These types of programs
can help foster a positive, supportive organizational
culture that reduces the fear of serious repercussions when
workers seek care.

Many states offer treatment programs for those without insurance
coverage. Once a provider is identified, the worker
should contact the provider for an appointment. Some
programs are also able to offer walk-in services. In times
of crisis, many people access services through hospital
emergency rooms.

Other resources and information about locating addiction
treatment centers can be found at https://findtreatment.samhsa.
gov/ or by calling the National Helpline at 1-800-662-4357.

Regulations, Rights, and Worker Protections

Are opioid treatment programs (OTP) regulated?

OTPs are required by law to be accredited to help monitor
the quality of care provided and the appropriate dispensing
of opioid treatment drugs [SAMHSA 2015a; The Joint Commission
2018]. For further information about these federal
regulations, please refer to The Substance Abuse and Mental
Health Services Administration’s (SAMHSA) Federal Guidelines
for Opioid Treatment Programs.

What rights and protections are available to workers who have opioid use disorder (OUD)?

Employers should protect the privacy and confidentiality of
all workers’ health-related information.

For employers subject to the Americans with Disability
Act (ADA), federal law safeguards people against job
discrimination if they are undergoing MAT. Both the ADA
and the Rehabilitation Act of 1973 forbid most employers
from firing, refusing to hire, or discriminating (in the terms
and conditions of employment) against any qualified job applicant
or worker on the basis of a disability [Legal Action
Center 2009]. In addition, the ADA, the Rehabilitation Act,
and the Family Medical Leave Act (FMLA) give workers the
right to take medical leave, which can include alcohol or drug
treatment.

These federal laws cover employers in different ways. The
ADA applies to all state and local government agencies and
to private employers with fifteen or more workers. The Rehabilitation
Act applies to federal agencies and to state and local
government agencies and private employers that receive federal
grants, contracts, or other federal aid. When federal law
covers employers, they are prohibited from denying a job to,
or firing, a worker based on a worker’s participation in MAT.
They also must offer reasonable accommodation as needed to
allow those with a disability to perform their job duties, unless
the accommodation would cause undue hardship to the
employer [American Addiction Centers 2018].

In addition to giving workers with OUD the right to take
leave to focus on treatment, the FMLA also offers employers
resources for managing that leave, and places other obligations
and restrictions on the rights of workers.

More information from SAMHSA can be found here:
Know Your Rights: Rights for Individual Medication-
Assisted Treatment.

How Employers Can Help

Employers can take the following steps to contribute to prevention
and treatment of OUD [NIOSH 2018; CDC 2017;
Massachusetts Department of Public Health 2018; National
Safety Council 2018; Kowalski-McGraw et al. 2017]:

Image: Front view of male doctor seated at a table talking to a male patient. The doctor is wearing a white lab coat and has a stethoscope around his neck. The view of the patient is of the back of his head and shoulders.

• Ensure that work is safe and working conditions do not
  lead to worker injury or illness, or contribute to painful
  chronic conditions.
• Identify clinics that provide evidence-based treatment forinjured workers, including the adherence to opioid prescribing
  guidelines.
• Provide adequate leave and other benefits after workplaceinjury including flexibility in scheduling and receivingmedical care, support during recovery, and return to work.
• Take steps to manage workplace stressors and job insecurity
  to the extent possible.
• Take steps to decrease the stigma associated with substance
  misuse through awareness building and supervisortraining.
• Educate workers about how drugs impair work activities,
  including driving, and encourage them to notifytheir employers if they are taking medications that mayaffect their ability to work safely so that a safe solutioncan be determined.
• Develop and communicate clear drug-related workplacepolicies that include an offer of assistance to workerswith OUD.
• Offer comprehensive treatment options to workers withOUD, including healthcare coverage that provides MAT.
• Work with health plan providers and pharmacy benefitmanagers to attend to inclusion of such coverage in employer
  health plans.

Employers should also consider the following steps when
arranging services for their workers, or when working with
others to select an MAT program or provider:

• Ensure that the MAT program is licensed or certified byyour state.
• Verify that the MAT program offers FDA-approved medications
  to treat OUD.
• Check if the provider can offer or refer for psychological,
  social, and family support in the treatment program.
• Look for independent evidence that the program offerseffective and proven treatment whenever possible[SAMHSA 2019].

Acknowledgments

This document was prepared by John Howard, MD, MPH;
Lauren Cimineri, PharmD MPH; Tamekia Evans, MPH; L.
Casey Chosewood, MD, MPH; Susan Afanuh, MA; National
Institute for Occupational Safety and Health.

Suggested Citation

NIOSH [2019]. Medication-assisted treatment for opioid
use disorder. By Howard J, Cimineri L, Evans T, Chosewood
LC, Afanuh S. Washington, DC: U.S. Department of Health
and Human Services, Centers for Disease Control and

Prevention, National Institute for Occupational Safety and
Health, DHHS (NIOSH) Publication No. 2019-133, https://
doi.org/10.26616/NIOSHPUB2019133

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For More Information

More information about opioids in the workplace can be found
at https://www.cdc.gov/niosh/topics/opioids/default.html

Additional Resources

Certification of Opioid Treatment Programs

https://www.govinfo.gov/app/details/CFR-2007-title42-vol1/
CFR-2007-title42-vol1-part8

http://dptbeta.samhsa.gov/pdf/FederalGuidelines2015_508.pdf

The Federal Guidelines for Opioid Treatment Programs – 2015

https://store.samhsa.gov/system/files/pep15-fedguideotp.pdf

Medication-Assisted Treatment

https://www.samhsa.gov/medication-assisted-treatment/
treatment#medications-used-in-mat

https://www.samhsa.gov/medication-assisted-treatment/treatment/
naltrexone

https://www.samhsa.gov/medication-assisted-treatment/opioid-
treatment-programs

Treatment and Costs

https://www.samhsa.gov/medication-assisted-treatment/treatment/
insurance-payments

https://www.rehabcenter.net/insurance-cover-methadone-clinics/

https://www.opioidtreatment.net/insurance-coverage/
methadone-clinics/

https://www.drugabuse.gov/publications/research-reports/medications-
to-treat-opioid-addiction/how-much-does-opioid-
treatment-cost

Using Naloxone to Reverse Opioid Overdose in the Workplace

https://www.cdc.gov/niosh/docs/2019-101/default.html

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DOI: https://doi.org/10.26616/NIOSHPUB2019133

DHHS (NIOSH) Publication No. 2019-133

May 2019