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

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. 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. 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. 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. 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. 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. 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. Organiza4onal
Change
Process
• Team
Established
• Literature
Review
• White
Paper
• Plan
for
Organiza=on
• Training
Forums
• Communica=on

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. 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. 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. 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. 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. 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. 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. Ini4al
Experience
• Acceptance
by
staff
• Support
from
Board
• Support
from
some
treatment
programs
and
professionals
• Bewilderment
from
others
• Pa=ents
seeking
care

17. COR-­‐12
Clinical
Implementa4on
Scoi
B.
Hessel=ne
M.A.,LADC
Tuesday,
April
2,
2013
3:30-­‐4:45
p.m.

18. Clinical
Perspec4ve
• Discuss
the
team
process
leading
to
implementa=on
• Clinical
Perspec=ve/Role
of
Counseling
Staff
• Role
of
Treatment
Services

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. 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. 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. 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. 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. 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. 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. 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. The
COR-­‐12
Program
Fred
Holmquist,
BA
Tuesday,
April
2,
2013
3:30-­‐4:45
p.m.

28. The
COR-­‐12
Program
An
Historical,
Philosophical
and
Anecdotal
Review
of
Hazelden’s
Ever-­‐Evolving
Twelve-­‐
Step/Abs=nence-­‐Based
Treatment
Model

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. 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. 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. 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. 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. 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. Ques4ons?