A Comprehensive Response to the Opioid Crisis Marvin Seppala, M.D. Chief Medical Oﬃcer, Hazelden Founda=on Sco1 Hessel4ne, MA, LADC Chemical Dependency Program Supervisor, Hazelden Founda=on Fred Holmquist Lodge Program Director, Hazelden Founda=on
Learning Objec4ves 1. Iden=fy warning signs of misuse and abuse and how claim manager can take ac=on. 2. Describe the treatment experience. 3. Outline how to employ a 12-‐step, abs=nence-‐ based treatment program.
Disclosure Statement • Marvin Seppala has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. • Sco1 Hessel4ne has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. • Fred Holmquist has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services.
Prescrip4on Opioid Dependence • Fastest growing addic=on in the U.S. • Four-‐fold increase in treatment admissions (U.S. 1998-‐2008) • Overdose deaths have increased drama=cally (3,000 in 1999 15,000 in 2008) • Drug overdose is the No. 1 cause of accidental deaths, fueled by the increase in opioid overdoses
Hazelden’s Experience • Increased admissions for opioid dependence • Problems with ASA discharges, treatment reten=on • Unit milieu issues • Use of opioids during treatment • Increased incidence of death following treatment
Hazelden is Responsible • To determine the best methods of treatment for our pa=ents • To use scien=ﬁc evidence to improve treatment • To be a leader in the Twelve Step addic=on treatment ﬁeld
Hazelden’s Response • Alter the en=re treatment of opioid dependence within our system • We incorporated two evidence-‐based medica=ons into treatment protocols for opioid dependence: naltrexone and buprenorphine • We will study the results • Our goal will be discon=nua=on of medica=on as pa=ents become established in long-‐term recovery
Organiza4onal Change Process • Team Established • Literature Review • White Paper • Plan for Organiza=on • Training Forums • Communica=on
Extended Release Injectable Naltrexone: Vivitrol® • Opioid receptor blocker (opioid antagonist) • Administered by intramuscular injec=on, once a month • Prevents binding of opioids to receptors, elimina=ng intoxica=on and reward • Has been shown to reduce craving and relapse • Has no abuse poten=al
Buprenorphine/Naloxone: Suboxone® • A par=al opioid agonist, a maintenance treatment • Administered sublingually on a daily basis • Binds to and ac=vates opioid receptors, but not to the same degree as true opioid agonists • Improves treatment reten=on, and reduces craving and relapse • Illicit use and diversion are likely
Injectable Extended Release Naltrexone Naltrexone Placebo 1. Weeks abs=nent 90% 35% 2. Opioid free days 99.2% 60.4% 3. Mean change in 10.1% 0.7% craving 4. Median reten=on 168 days 96 days Lancet 2011; 377:1506-‐13
Buprenorphine / Naloxone Treatment for Prescrip4on Opioid Dependence • 2 phase study: – 2 week Bup/Nal stabiliza=on, 2 week taper, 8 week follow up – 12 week Bup/Nal stabiliza=on, 4 week taper, 8 week follow up • 653 treatment seeking outpa=ents with opioid dependence • Randomized to: – Standard medica=on management (SMM) – SMM & opioid dependence counseling • All par=cipants were referred to self-‐help groups Arch. Gen. Psych. Vol 68(No.12), Dec 2011
Buprenorphine-‐Naloxone Results Phase 1: – Only 6.6% were successful – No diﬀerence between SMM & SMM with opioid counseling Phase 2: – 49.2% successful while using bup-‐nal – No diﬀerence between SMM & SMM with opioid counseling – Success rates ager comple=on: 8.6% Arch. Gen. Psych. Vol 68(No.12), Dec 2011
Compa4bility with 12-‐Step Abs4nence-‐based Model • Extended release injectable naltrexone is already used for alcohol dependence • Buprenorphine /naloxone can induce intoxica=on and is abused, but primarily for detox or to get by • Twelve Step models tend to avoid buprenorphine • Suboxone® protocols will blur the line of abs=nence-‐based programming, so our goal will always be discon=nua=on once long-‐term recovery is established • Pa=ents are coming in on it and asking for it
Organiza4onal Response • COR-‐12: Comprehensive Opioid Response • Completely altered treatment for those with opioid dependence • Integra=on of two evidence based medica=ons within our Twelve Step, abs=nence-‐based model • Implementa=on at two sites with plans for all sites
Ini4al Experience • Acceptance by staﬀ • Support from Board • Support from some treatment programs and professionals • Bewilderment from others • Pa=ents seeking care
COR-‐12 Clinical Implementa4on Scoi B. Hessel=ne M.A.,LADC Tuesday, April 2, 2013 3:30-‐4:45 p.m.
Clinical Perspec4ve • Discuss the team process leading to implementa=on • Clinical Perspec=ve/Role of Counseling Staﬀ • Role of Treatment Services
Clinical Implementa4on Medica4on Assisted Treatment Team • Assembled to improve treatment of opioid dependence • Quickly realized posi=ve outcome was more than just expanded use of medica=on • Expanded protocols needed to lead to engagement in Twelve Step recovery services • Led MAT to COR-‐12; (Comprehensive Opiate Response with the 12 Steps)
Clinical Implementa4on Clinical Staﬀ • Experience increased complexity and acuity • Increase in mortality rates • Milieu management issues • Atypical discharges • Behavioral issues • Revolving Door syndrome • Readiness to Change issues • Staﬀ intensive demographic
Clinical Implementa4on • Large segment of opioid dependent popula=on were not eﬀec=vely being reached. • New protocols needed to be introduced along with purposeful clinical prac=ces. • Opportunity to provide a means for this high risk popula=on to have a beier chance at engaging Twelve Step Recovery.
Clinical Implementa4on Clinical Concerns • Crea=ng well deﬁned and consistent ra=onale for par=cipa=on in extended medica=on assisted treatment pathway. • Developing purposeful means of discon=nua=on • Are we invi=ng further milieu management issues or will this reduce some of the associated dysfunc=on? ₋ En Masse Discharges ₋ Drugs on Campus ₋ Sen=nel Events
Clinical Implementa4on Program Development • Clinical Prac=ce Protocols • Addi=on of Educa=on and Support Groups • S=gma Management Ini=a=ves • Use of con=nuum of care to enhance engagement in Twelve Step Recovery • Will require consistent and accurate messaging along with engaged recovery support
Clinical Implementa4on Recovery Management • Use of MORE and full con=nuum of care • Trea=ng Chronic Disease over an extended period of =me. • Ability to u=lize Recovery Management tools to assist with discon=nua=on. • Increase treatment reten=on through addi=onal support over an extended period of =me.
Clinical Implementa4on Program Development Clinical Prac4ce Protocols (November 15) – Pre-‐Entry – Nursing/Medical – Clinical Staﬀ – Con=nuing Care • Clinical Trainings (December 15) • Go Live in Center City (December 31)
Clinical Implementa4on Summary • New clinical protocols have been developed and introduced in a limited scope. • Experienced beneﬁts to opioid dependent pa=ents. • Pa=ents are beginning to move through the con=nuum of care.
The COR-‐12 Program Fred Holmquist, BA Tuesday, April 2, 2013 3:30-‐4:45 p.m.
The COR-‐12 Program An Historical, Philosophical and Anecdotal Review of Hazelden’s Ever-‐Evolving Twelve-‐ Step/Abs=nence-‐Based Treatment Model
This Non-‐Academic’s Previous Projects w/ Dr. Seppala 2006 -‐ White-‐Paper on Acuity/Complexity • Acuity-‐ the pa=ent-‐issue side of treatment process challenges • Complexity-‐ the system-‐issue side of treatment process challenges 2009 -‐ Staﬀ Training Team for Implemen4ng the use of Naltrexone and Vivitrol as an4-‐craving agents for selected alcoholic pa4ents • Alcoholics Anonymous Co-‐Founder’s craving reference
Historical and Philosophical Review • January 10th, 1949 -‐ Hazelden founded as a “charitable hospital for func=oning alcoholics”. An unstructured, 12-‐Step rest-‐farm model for men with eﬀorts to follow-‐up with former pa=ents-‐ foreshadows sta=s=cal research and recovery management • 1951-‐ Purchasing one-‐inch, one-‐column ads in the Wall Street Journal-‐ “Alcoholic employee? There’s help. Hazelden Center City, Minnesota”-‐ foreshadows EAP, outreach and interven=on prac=ces • 1953/1954-‐ Opening of a men’s half-‐way-‐house, Fellowship Club in St Paul from which the “24 Hours a Day” medita=on book was published, foreshadowing step-‐down residen=al services and expanded bibliotherapy
Historical and Philosophical Review Con$nued… • 1956-‐ Developing a women’s stand-‐alone treatment unit, Dia Linn in Dellwood, Minnesota where. in response to the greater acuity of alcoholic women’s needs, a more comprehensive, mul=-‐disciplinary team model of treatment developed, foreshadowing special-‐popula=on sensi=vity and the “Minnesota Model“ • 1966-‐ Not only expanding men’s treatment capacity and moving the Dia Linn women’s unit to the Center City campus, but incorpora=ng it’s comprehensive treatment methodologies campus-‐wide, replacing the yet exis=ng “rest farm” tradi=on for trea=ng men
Risk and Resiliency Factors for Ongoing Growth Risk Factors Resiliency Factors Out-‐dated Innova4on-‐ “old ideas” Mission • 1966-‐ Center City expansions • Dignity and respect • 1970’s-‐ Use of Niacin/Vitamin B3 • Mul=-‐disciplinary team • 1980’s/90’s-‐ “Co-‐Dependency” • 12-‐step/abs=nence-‐based philosophy • 1990’s-‐ New Yorker “Caﬀeine Wars” • Con=nuum of care Program Complexity • Research and evalua=on Staﬀ Engaging Client Resistance Margin Polarized Aftudes • Publishing Business Unit • Wet/dry Early Adapters • Abs=nence/maintenance
The Problem Heroin/et al., generates a state-‐of-‐mind perhaps paralleled only by the highest of spiritual experiences while simultaneously disallowing any tolerance for even the slightest discomfort. This complicates many pa=ent’s ability to remain in treatment or to be available for developing new rela=onships and acquiring new informa=on.
The Solu4on • Extended, adjunc=ve withdrawal protocols signiﬁcantly long to allow more pa=ents to remain in treatment and to be available for new rela=onships and informa=on. And….. • Borrowing directly from the models of intensiﬁed Twelve Step prac=ces, structured in the fellowships like OA and SAA/SLAA in which members con=nue to use non-‐craving triggering forms of their drugs of no choice.