This document summarizes presentations on the evolution of diagnosis and treatment options for substance use disorders. It discusses how Hazelden integrated medication-assisted treatment with the Minnesota Model approach. Recent brain science breakthroughs allow for improved diagnosis of chronic pain and addiction through quantitative electroencephalography (qEEG) brain mapping. Combining evidence-based medical and behavioral treatments with neurorestorative brain treatments shows potential for improved outcomes.

1. Treatment Track:
Evolution of Diagnosis and
Treatment Options
Presenters:
• Marvin D. Seppala, MD, Chief Medical Officer,
Hazelden Betty Ford Foundation
• Judi Kosterman, PhD, Senior Vice President,
WestCare Foundation, Inc.
• Jonathan Warren, Psychologist, Brain Treatment
Center
Moderator: Michael C. Barnes, JD, Executive Director,
Center for Lawful Access and Abuse Deterrence, and
Member, Rx Summit National Advisory Board

2. Disclosures
• Marvin D. Seppala, MD; Judi Kosterman, PhD;
Jonathan Warren; and Michael C. Barnes, JD, have
disclosed no relevant, real or apparent personal or
professional financial relationships with proprietary
entities that produce health care goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Describe Hazelden’s experiment with linking the
Minnesota Model of addiction treatment and MAT.
2. Evaluate the effectiveness of Hazelden’s new
treatment model, which bridges the traditional
treatment model and MAT.
3. Explain recent brain science breakthroughs in
diagnosis and treatment of chronic pain and opiate
drug abuse.
4. Analyze the potential for combining evidence-based
traditional therapeutic drug treatment and
neurorestoration brain treatment.

5. Substance Abuse Treatment:
A New Look at an Old Battle
Presented by Marvin D. Seppala, MD
Prepared by Robert L. DuPont, MD,
President, Institute for Behavior and
Health, Inc.

6. Disclosure
• Marvin D. Seppala, MD, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.

7. How We Got Here
• In 1949, a new model of alcoholism treatment
was invented in Minnesota in a state mental
hospital where the prior standard of care for
alcoholism had been one year of involuntary
treatment

8. The Genius of this Treatment
• Integrating Alcoholics Anonymous (AA) with good
healthcare into a single program
• Adopting the AA goal of no use of alcohol or
other drugs
• Lifelong frequent attendance at 12-Step meetings
• Working on comorbid conditions and patient
problems

9. How This Treatment Worked
• Patients were educated about the disease
concept of addiction and learned the language of
recovery
• Patients and their families were taught what to
do about this family disease – go to meetings
• Many staff members themselves were in recovery
acting as inspiring role models

10. Minnesota Model Expansion
• Started with alcohol but quickly extended to
other drugs
• Close links to Alcoholics Anonymous, Narcotics
Anonymous, and Al Anon
• A global treatment model

11. Medication-Assisted Treatment
• Methadone maintenance, medication-assisted treatment now
including buprenorphine and naltrexone, started in the mid-1960s
• Vincent Dole, a distinguished obesity research physician, saw
addiction to opiates as a life-long “metabolic” imbalance, a disease
which is normalized by a single daily dose of methadone, freeing
heroin addicts from chemical slavery
• Analogy to diabetes: Just as diabetics need to change their
lifestyles, they also need insulin for their lifetimes
• There was no end to methadone maintenance treatment as there is
no end to insulin for diabetics

12. The Conflict
• For decades there have polarized – nearly
“religious” – views separating these two, often
warring, factions each with their distinctly
different disease concepts and goals for
treatment
• Both were “forever” – either forever 12-step
meetings or forever medication

13. What is New in this Old Conflict?
• Today’s heroin epidemic, fueled by the
prescription opiate epidemic, has produced a
new and very different cohort of heroin
addicts.
• This new cohort is stimulating new thinking
about how these two distinct treatments can
be brought together in the best interests of all
patients

14. What This Experiment Is and
What It Is Not
• It provides buprenorphine and naltrexone as
options for opiate dependent patients after
those patients have chosen an intense
specialized opiate addiction program within
the Minnesota Model
• All of these patients are committed to
abstinence from all use of alcohol and other
drugs and to participation in the 12-step
programs

15. This Was Revolutionary
• Hazelden’s adding buprenorphine and naltrexone led
to conflict within the Minnesota Model treatment
community; many called it heresy
• But note that these patients are quite different from
the typical MAT patients:
– They are already in an abstinence-oriented intensive
residential program before they are offered
buprenorphine or naltrexone
– They are expected to attend 12-step meetings from the
outset
– If they chose to use medications their end-goal is to not to
use opiate medication, not necessarily quickly but
eventually

16. • Before you hear how this happened and the
early lessons from this historic experiment, let
me show some data about use of the 12-steps
in a methadone program
• Another recent example of a bridge over the
old treatment conflict
Role of 12-Steps

17. Study on the Use of 12-Steps by
Methadone Patients
• Methadone Maintenance Treatment (MMT)
program – 322 patients
• 66% of patients were currently participating in
a 12-Step Program, i.e., AA/NA

18. Importance of 12-Step Program
• Of those 66% of 12-Step participants:
• 72% of AA participants felt the program was
helpful for abstaining from opiate and other
drug use
• 76% of NA participants felt the program was
helpful for abstaining
• The conclusion: the 12 step programs are
commonly used and found helpful by many
methadone maintained patients

19. My Mission Today
• To promote better ways to use the full range
of treatments for all patients, especially those
with opiate dependence
• To focus on the goal of long-term recovery to
judge all treatments. How successful are
treatments, with and without medicine, in
meeting a new treatment standard: Five-Year
Recovery

20. References & Recommended Sources
• Owen, P. (2015). Minnesota Model: Description of Counseling Approach. National
Institute for Drug Abuse. Available: http://archives.drugabuse.gov/ADAC/ADAC11.html.
• Roman, P. M., Abraham, A. J., & Knudsen, H. K. (2011). Using medication-assisted
treatment for substance use disorders: Evidence of barriers and facilitators of
implementation. Addictive behaviors, 36(6), 584-589.
• Spicer, J. (1993). The Minnesota Model: The evolution of the multidisciplinary approach
to addiction recovery. Hazelden Publishing.
• Spicer, J. (1993). The Minnesota Model: The evolution of the multidisciplinary approach
to addiction recovery. Hazelden Publishing.
• White, W. L., Campbell, M. D., Spencer, R. A., Hoffman, H. A., Crissman, B., & DuPont, R.
L. (2014). Participation in Narcotics Anonymous and Alcoholics Anonymous and
abstinence outcomes of 322 methadone maintenance patients. Journal of Groups in
Addiction & Recovery, 9(1), 14-30.
• White, W. (2003). Hazelden Foundation. In Blocker, J. and Tyrell, I., Eds. Alcohol and
Temperance in Modern History. Santa Barba, CA: ABC-CLIO, pp. 290-291.
• White, W. L. (1998). Slaying the dragon: The history of addiction treatment and
recovery in America. Bloomington, IL: Chestnut Health Systems/Lighthouse Institute.

21. Science & Spirituality:
COR-12, An Approach to
Opioid Use Disorders
Marvin D. Seppala, MD
Chief Medical Officer
Hazelden Betty Ford Foundation

22. Learning Objectives
• Learn how and why a treatment model for
opioid use disorders integrated 12 Steps and
medication assisted treatment
• Explore the major characteristics of this model
• Learn about the positive experience both staff
and patients have had with this integrated
model

23. Annual Numbers of New Nonmedical Users
of Psychotherapeutics: 1965-2000
2001 National Household Survey on Drug Abuse
http://www.oas.samhsa.gov/NHSDA/2k1NHSDA/vol1/toc.htm#v1

24. Prescription Opioid Crisis
• Four-fold increase in treatment admissions
(U.S. 1998-2008)
• Overdose deaths have increased dramatically
(U.S. 3,000 in 1999  16,500 in 2011)
• Over 125,000 opioid overdose deaths have
occurred in the U.S. in the past decade

25. Rates* of opioid pain reliever (OPR) overdose
death, OPR treatment admissions, and kilograms
of OPR sold: United States, 1999-2010
* Age-adjusted rates
per 100,000
population for OPR
deaths, crude rates
per 10,000
population for OPR
abuse treatment
admissions, and
crude rates per
10,000 population for
kilograms of OPR
sold.
www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

26. Readily Available

27. The Hazelden Betty Ford Experience
• 1. Increased admissions for opioid dependence
– Adults: 19% (2001)  30% (2011)
– Youth: 15% (2001)  41% (2011)
• Problems with treatment retention
– Significant rate of ASA discharge
– Risk to patient  Nearly all of these patients leave
treatment to relapse
• Unit milieu issues
• Use of opioids during treatment
• Increased incidence of death following treatment
– Ethical imperative to evaluate the treatment model.

28. The Hazelden Betty Ford Response
• Alter the entire treatment of opioid dependence
within our system:
– A Comprehensive Opioid Response with the 12-Steps:
COR-12.
• We added groups, education and individual sessions
for opioid dependence
• We incorporated two evidence-based medications into
treatment protocols for opioid dependence:
naltrexone and buprenorphine
• We are studying the results
• Our goal will be discontinuation of medication as
patients become established in long-term recovery

29. COR-12: A Comprehensive Opioid
Response with the 12-Steps.

30. Phase I-Residential: COR-12
Treatment Planning
1. Chemical use disorder history and severity
- Prior treatment history
- Prior MAT history
2. Complicating medical or mental health factors
3. Environmental factors
4. History of “relapsing through” Suboxone or
Vivitrol
- Must be seen in the context of prior treatment
-
Structure? Monitoring? Patient Centered?

31. COR-12 Clinical Perspective
• We are focused on patient engagement – for the
long term
• The clinical research supports the use of these
two medications
• We borrowed heavily from models of intensive
Twelve Step practice (OA, SAA/SLAA) in which
total abstinence is not an option.
• We emphasize life long recovery.

32. COR-12
Patient Participation
Admissions to Center City Primary
One Year: January 2013– December 2013
18 Months: January 2013 – June 2014
One
Year
18
Months
2270 3385
Total number with opioid dependence 424 566
COR-12: No Medication
38
9%
52
9%
COR-12: Buprenorphine/Naloxone
30
7%
43
8%
COR-12: Extended Release Naltrexone
46
11%
70
12%

33. COR-12 Results
• 20% of opioid dependent patients who were not
in COR-12 discharged atypically
• 7.5% of COR-12 patients discharged atypically
• 6 former patients with opioid dependence died
following treatment in 2013
• None were in COR-12

34. Our Experience
• Opioid support group
• Patient engagement
• Long term approach
• Abstinence
• Staff bias and passion
• Communication
• Unfounded fears
• Can't tell who is on
medication
• Getting off
medications

35. Summary
• The opioid crisis requires we use everything at
our disposal, independent of personal bias,
to help those with opioid use disorders
• We have successfully integrated 12 Steps and
MAT to improve outcomes

36. Treatment Track: Evolution of
Diagnosis and Treatment Options
Recent Brain Science Breakthroughs…

37. Disclosures
Judi Kosterman, PhD, Senior Vice President, WestCare
Foundation, Inc., has disclosed no relevant, real or apparent
personal or professional financial relationships with
proprietary entities that produce health care goods and
services.
Jonathan Warren, Psychologist, Brain Treatment Center, has
disclosed no relevant, real or apparent personal or
professional financial relationships with proprietary entities
that produce health care goods and services.

38. Learning Objectives
• Explain recent brain science breakthroughs in diagnosis and
treatment of chronic pain and opiate drug abuse.
• Analyze the potential for combining evidence-based
traditional therapeutic drug treatment and neurorestoration
brain treatment.

39. A Journey to Today . . .
• Knowing nothing!
• Experience + Schooling = Learning
• Policy
• Real World Application
• Science Continues
• Returning Warriors and Veterans
• Compelling Obligation
• Discovery: Autism to Addiction

40. Quantitative Electroencephalography (qEEG)

41. Frequencies
Delta 1-4hz
Theta 4-8hz
Alpha 8-13hz
Beta 13-30hz

42. Brain States and Psychometric Parameters
Correlate with EEG Frequencies
• Predominant frequencies correlate with a particular brain
state (level of alertness, level of consciousness)
• Subtle changes in EEG frequency can correlate to an observed
phenotype, depending on the location and amplitude

43. Neurotypical qEEG Example:
Synchronous - Low Energy - High Efficiency
Stopped
Recording
mind task of motion
0 5 10 15 20 25 30
9.85 Hz
Amp
0.921
1.231
2.682
0.728
0.728
0.785
0.836
0.479
0.525
0.705
0.981
0.246
0.356
1.906
2.986
2.208
2.294
4.241
5.170
16.074
9.85 Hz Amp
4.02
0.0295
FZ-A1A2
CZ-A1A2
PZ-A1A2
FP1-A1A2
FP2-A1A2
F3-A1A2
F4-A1A2
F7-A1A2
F8-A1A2
C3-A1A2
C4-A1A2
T3-A1A2
T4-A1A2
P3-A1A2
P4-A1A2
T5-A1A2
T6-A1A2
O1-A1A2
O2-A1A2
1A-A1A2
Comment
-5.47 uV
0.519 uV
6.24 uV
-2.31 uV
-2.31 uV
-2.14 uV
-4.27 uV
0.592 uV
3.24 uV
0.924 uV
-2.23 uV
5.03 uV
2.31 uV
3.47 uV
5.65 uV
-0.0425 uV
5.52 uV
3.47 uV
6.8 uV
-3.71 uV
9.85

44. Addiction qEEG Example:
Chaotic - High Energy - Low Efficiency

46. Pre-Treatment
14:33:02.000 14:33:05.000 14:33:08.000 14:33:11.000 14:33:14.000 14:33:17.000 14:33:20.000 0 5 10 15 20 25 30
2.32-6.20 Hz 8.12-11.31 Hz
AmpSum AmpSum
27.136 5.334
25.099 6.366
44.274 2.862
18.725 3.895
13.912 4.838
13.411 4.273
19.721 3.942
6.282 1.681
7.039 8.827
6.610 7.177
4.395 7.887
2.332 1.717
3.135 3.440
4.624 8.774
4.735 13.233
3.376 10.317
1.219 3.914
2.607 3.220
1.862 5.681
497.578 324.917
2.32-6.20 Hz AmpSum
8.12-11.31 Hz AmpSum
16.7
1.09
FP1-A1A2
FP2-A1A2
F7-A1A2
F3-A1A2
FZ-A1A2
F4-A1A2
F8-A1A2
T3-A1A2
C3-A1A2
CZ-A1A2
C4-A1A2
T4-A1A2
T5-A1A2
P3-A1A2
PZ-A1A2
P4-A1A2
T6-A1A2
O1-A1A2
O2-A1A2
1A-A1A2
Time
2.32 6.20 8.12 11.31

48. Post Treatment
14:02:25.000 14:02:28.000 14:02:31.000 14:02:34.000 14:02:37.000 14:02:40.000 14:02:43.0000 5 10 15 20 25 30
2.32-6.20 Hz 8.12-11.31 Hz
AmpSum AmpSum
3.104 4.531
1.938 3.954
2.551 3.132
3.940 6.725
5.372 8.758
4.570 7.526
3.733 3.822
3.128 3.153
4.493 13.090
5.887 19.021
3.676 14.533
1.279 4.125
2.410 16.598
3.796 38.634
4.470 58.163
3.536 39.825
1.834 20.169
2.726 30.645
2.563 25.795
576.937 684.087
2.32-6.20 Hz AmpSum
8.12-11.31 Hz AmpSum
16.7
1.09
FP1-A1A2
FP2-A1A2
F7-A1A2
F3-A1A2
FZ-A1A2
F4-A1A2
F8-A1A2
T3-A1A2
C3-A1A2
CZ-A1A2
C4-A1A2
T4-A1A2
T5-A1A2
P3-A1A2
PZ-A1A2
P4-A1A2
T6-A1A2
O1-A1A2
O2-A1A2
1A-A1A2
Time
2.32 6.20 8.12 11.31

49. Magnetic Resonance Therapy
(MRT)

51. Addiction Outcomes
by the numbers . . .
• 500 patient cohort
• 100% get a soft landing with minimal cravings
(without an inpatient detox experience)
• 75% response rate as measured by sobriety at
60 days
• 30% are sober at a median follow up of 9
months

52. Most-Studied Clinical Uses for MRT
(Magnetic Resonance Therapy)
• Schizophrenia
• Substance Abuse
• Major Depressive Disorder
• Acute Anxiety Disorder
• ASD (Autism Spectrum Disorder)
• PTS (Post Traumatic Stress)
• TBI (Traumatic Brain Injury)
• Tinnitus (ringing of the ear)
• Opioid Abuse
• Pain Management
• Chemobrain
• Migraine Headaches
• Alzheimer’s Disease & Dementia
• Stroke

53. Questions?

54. Treatment Track:
Evolution of Diagnosis and
Treatment Options
Presenters:
• Marvin D. Seppala, MD, Chief Medical Officer,
Hazelden Betty Ford Foundation
• Judi Kosterman, PhD, Senior Vice President,
WestCare Foundation, Inc.
• Jonathan Warren, Psychologist, Brain Treatment
Center
Moderator: Michael C. Barnes, JD, Executive Director,
Center for Lawful Access and Abuse Deterrence, and
Member, Rx Summit National Advisory Board