A	  Comprehensive	  Response	  to	          the	  Opioid	  Crisis	                 Marvin	  Seppala,	  M.D.	  	     Chief	...
Learning	  Objec4ves	  1.  Iden=fy	  warning	  signs	  of	  misuse	  and	  abuse	      and	  how	  claim	  manager	  can	 ...
Disclosure	  Statement	  •  Marvin	  Seppala	  has	  no	  financial	  rela=onships	     with	  proprietary	  en==es	  that	...
Prescrip4on	  Opioid	  Dependence	  •  Fastest	  growing	  addic=on	  in	  the	  U.S.	  •  Four-­‐fold	  increase	  in	  t...
Hazelden’s	  Experience	  •  Increased	  admissions	  for	  opioid	  dependence	  •  Problems	  with	  ASA	  discharges,	 ...
Hazelden	  is	  Responsible	  •  To	  determine	  the	  best	  methods	  of	  treatment	     for	  our	  pa=ents	  •  To	 ...
Hazelden’s	  Response	  •  Alter	  the	  en=re	  treatment	  of	  opioid	     dependence	  within	  our	  system	  •  We	 ...
Organiza4onal	  Change	  Process	  •  Team	  Established	  •  Literature	  Review	  •  White	  Paper	  •  Plan	  for	  Org...
Extended	  Release	  Injectable	            Naltrexone:	  Vivitrol®	  •  Opioid	  receptor	  blocker	  (opioid	  antagonis...
Buprenorphine/Naloxone:	  Suboxone®	    •  A	  par=al	  opioid	  agonist,	  a	  maintenance	       treatment	    •  Admini...
Injectable	  Extended	  Release	                          Naltrexone	                                         Naltrexone	 ...
Buprenorphine	  /	  Naloxone	  Treatment	   for	  Prescrip4on	  Opioid	  Dependence	     •  2	  phase	  study:	  	        ...
Buprenorphine-­‐Naloxone	  Results	   Phase	  1:	  	  	  	     – Only	  6.6%	  were	  successful	     – No	  difference	  b...
Compa4bility	  with	  12-­‐Step	  	         Abs4nence-­‐based	  Model	  •  Extended	  release	  injectable	  naltrexone	  ...
Organiza4onal	  Response	  •  COR-­‐12:	  Comprehensive	  Opioid	  Response	  •  Completely	  altered	  treatment	  for	  ...
Ini4al	  Experience	  •  Acceptance	  by	  staff	  •  Support	  from	  Board	  •  Support	  from	  some	  treatment	  progr...
COR-­‐12	  Clinical	  Implementa4on	                                        Scoi	  B.	  Hessel=ne	  M.A.,LADC	  Tuesday,	 ...
Clinical	  Perspec4ve	  •  Discuss	  the	  team	  process	  leading	  to	     implementa=on	  •  Clinical	  Perspec=ve/Rol...
Clinical	  Implementa4on	  Medica4on	  Assisted	  Treatment	  Team	  	   •  Assembled	  to	  improve	  treatment	  of	  op...
Clinical	  Implementa4on	  Clinical	  Staff	     •  Experience	  increased	  complexity	  and	  acuity	     •  Increase	  i...
Clinical	  Implementa4on	  •  Large	  segment	  of	  opioid	  dependent	     popula=on	  were	  not	  effec=vely	  being	  ...
Clinical	  Implementa4on	  Clinical	  Concerns	     •  Crea=ng	  well	  defined	  and	  consistent	  ra=onale	        for	 ...
Clinical	  Implementa4on	  Program	  Development	     •  Clinical	  Prac=ce	  Protocols	     •  Addi=on	  of	  Educa=on	  ...
Clinical	  Implementa4on	  Recovery	  Management	    •  Use	  of	  MORE	  and	  full	  con=nuum	  of	  care	    •  Trea=ng...
Clinical	  Implementa4on	  Program	  Development	  Clinical	  Prac4ce	    Protocols	  (November	  15)	      –  Pre-­‐Entry...
Clinical	  Implementa4on	  Summary	    •  New	  clinical	  protocols	  have	  been	  developed	       and	  introduced	  i...
The	  COR-­‐12	  Program	                                                      Fred	  Holmquist,	  BA	  Tuesday,	  April	 ...
The	  COR-­‐12	  Program	  An	  Historical,	  Philosophical	  and	  Anecdotal	  Review	  of	  Hazelden’s	  Ever-­‐Evolving...
This	  Non-­‐Academic’s	  Previous	           Projects	  w/	  Dr.	  Seppala	  2006	  -­‐	  White-­‐Paper	  on	  Acuity/Com...
Historical	  and	  Philosophical	                          Review	  •  January	  10th,	  1949	  -­‐	  Hazelden	  founded	 ...
Historical	  and	  Philosophical	                   Review	  Con$nued…	  •  1956-­‐	  Developing	  a	  women’s	  stand-­‐a...
Risk	  and	  Resiliency	  Factors	  for	                      Ongoing	  Growth	  	                  Risk	  Factors	       ...
The	  Problem	  	  Heroin/et	  al.,	  generates	  a	  state-­‐of-­‐mind	  perhaps	      paralleled	  only	  by	  the	  hig...
The	  Solu4on	  •  Extended,	  adjunc=ve	  withdrawal	  protocols	     significantly	  long	  to	  allow	  more	  pa=ents	 ...
Ques4ons?	  
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Treatment opioids a_comprehensive_response_final

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Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. A Comprehensive Response to the Opioid Crisis presentation by Dr. Marvin Seppala, Scott Hesseltine and Fred Holmquist

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Treatment opioids a_comprehensive_response_final

  1. 1. 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    
  2. 2. 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.  
  3. 3. 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.  
  4. 4. 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  
  5. 5. 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  
  6. 6. 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  
  7. 7. 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  
  8. 8. Organiza4onal  Change  Process  •  Team  Established  •  Literature  Review  •  White  Paper  •  Plan  for  Organiza=on  •  Training  Forums  •  Communica=on  
  9. 9. 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  
  10. 10. 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    
  11. 11. 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  
  12. 12. 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  
  13. 13. 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  
  14. 14. 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  
  15. 15. 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  
  16. 16. Ini4al  Experience  •  Acceptance  by  staff  •  Support  from  Board  •  Support  from  some  treatment  programs   and  professionals  •  Bewilderment  from  others  •  Pa=ents  seeking  care  
  17. 17. COR-­‐12  Clinical  Implementa4on   Scoi  B.  Hessel=ne  M.A.,LADC  Tuesday,  April  2,  2013  3:30-­‐4:45  p.m.  
  18. 18. Clinical  Perspec4ve  •  Discuss  the  team  process  leading  to   implementa=on  •  Clinical  Perspec=ve/Role  of  Counseling  Staff  •  Role  of  Treatment  Services    
  19. 19. 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)  
  20. 20. 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  
  21. 21. 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.  
  22. 22. 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  
  23. 23. 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  
  24. 24. 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.  
  25. 25. 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)  
  26. 26. 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.  
  27. 27. The  COR-­‐12  Program   Fred  Holmquist,  BA  Tuesday,  April  2,  2013  3:30-­‐4:45  p.m.  
  28. 28. The  COR-­‐12  Program  An  Historical,  Philosophical  and  Anecdotal  Review  of  Hazelden’s  Ever-­‐Evolving  Twelve-­‐ Step/Abs=nence-­‐Based  Treatment  Model    
  29. 29. 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  
  30. 30. 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  
  31. 31. 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  
  32. 32. 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  
  33. 33. 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.  
  34. 34. 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.  
  35. 35. Ques4ons?  

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