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Hazelden redefines its opioid addiction care, will use maintenance dosing

November 7, 2012
by Gary A. Enos, Editor
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Unacceptably high numbers of overdose deaths from prescription opioid use, in combination with chronic relapses with conventional opioid addiction treatments, are being cited as the impetus for dramatic changes in opioid addiction treatment protocols being unveiled this week by one of the nation’s most influential treatment facilities.

Hazelden chief medical officer Marvin D. Seppala, MD, confirmed in an interview with Addiction Professional that the new strategies now being implemented in the Minnesota-based organization revolutionize the 12-Step based center’s approach in numerous ways, from offering maintenance doses of the medication buprenorphine for the first time to breaking new ground in including opioid-specific counseling groups in the therapy schedule.

Tragic statistics related to increasingly widespread abuse of prescription painkillers in the population necessitate these dramatic moves, Seppala says, even as he acknowledges that his organization likely will absorb harsh criticism from some colleagues in the treatment field as a result of implementing these policies.

In fact, in an organization as large as Hazelden, “Not everyone even here in the organization agrees with what we’re doing,” Seppala points out. But he also emphasizes that in trainings of clinicians that already are under way at Hazelden, staff members are expressing overwhelming support for the changes because “all counselors have seen the devastation of opioid dependence.”

And Seppala adds that none of this alters a governing principle long held by Hazelden: “We’ll always be [a] 12-Step based [program]—that’s clear-cut.”

Balanced approach

Seppala says that the new protocols’ more widespread use of the buprenorphine-naloxone combination marketed as Suboxone, as well as the injectable formulation of naltrexone sold as Vivitrol, represents an extension of a longstanding move in the organization to expand integration of evidence-based medication treatments.

Hazelden for some time has employed use of several medications that treat alcohol dependence, and it also has been using Suboxone in opiate detox regimens. But the use of maintenance doses of Suboxone for the first time at Hazelden represents a dramatic shift for a 12-Step based program. Many of Hazelden’s 12-Step brethren in the treatment industry do not consider long-term buprenorphine maintenance as reflecting an abstinence- or recovery-based strategy.

“We see this as an opportunity to engage some individuals in treatment, to give them long-term care, to get them into a solid recovery, so they ultimately can get what they need,” Seppala says. Clients on maintenance doses of buprenorphine will be expected to pursue 12-Step based counseling and ultimately to taper off the medication, but Seppala says of this group, “They will be taking the medication for probably months.”

Seppala, who left Hazelden in 2007 and returned two years later, explains that in his second term of service in the organization he has advocated more use of medication-assisted treatment, citing experiences he gained with buprenorphine treatment after his departure.

“As the problem continued to worsen, we had to respond,” he says, referring to overdoses and poor outcomes from conventional treatment. He adds that in general, “The outcomes for addiction are not that good, so we need to do anything we can do,” tapping into all strategies that have a basis in the research literature.

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It is gratifying that an organization as large and respected as Hazelden is finally using evidence as a basis for treatment. Buprenorphine maintenance for various lengths of time is well established in peer reviewed literature as efficacious.
This article perpetuates a fallacy. 12 step based recovery and the use of Buprenorphine are NOT mutually exclusive despite many 12 step zealots claims. Nowhere in AA literature does it state that the use of medications prescribed by a physician with an understanding of the disease means one is not in recovery. AA literature published by the AA central office actually supports this statement (pamphlet "About Medications").
The supposition that the use of Buprenorphine by well intentioned but misled AA members ignores a real definition of recovery which includes acceptance and surrender. By this standard, the founder of AA, Bill Wilson, would not have been in recovery because he spent much of his life on various medications, including addictive ones, attempting to treat his depression. No one has suggested he was not in recovery.
According to AA published statistics, about 5% of those attending a 12 step meeting for the first time ever achieve long term recovery. If Buprenorphine improves this number, which evidence says it does, then kudos to Hazelden or anyone else for using it. In discussing this, it would be helpful for those involved in the treatment of addiction to educate rather than perpetuate misrepresentations of what 12 step programs are really about, and help close the divide that is completely erroneous that exists today between evidence based treatment and well meaning 12 step followers.

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