Hazelden Betty Ford Foundation's comprehensive blending of science and spirituality to address opioid addiction is showing striking results in improving patient engagement—if patients can be convinced to receive the more tailored services that in some cases include buprenorphine or injectable naltrexone.
At this week's National Association of Addiction Treatment Providers (NAATP) annual conference in Carlsbad, Calif., chief medical officer Marvin D. Seppala, MD, revealed compelling numbers from Hazelden Betty Ford's Comprehensive Opioid Response with 12 Steps (COR-12) initiative. While the overall percentage of atypical discharges for all patients at the Center City, Minn., primary treatment facility hovered around 13 to 14% in 2013 and 2014, it was substantially higher for opioid-dependent patients not participating in the optional COR-12 program and significantly lower for opioid-dependent patients opting into COR-12 (as low as around 2.5% in 2014 in the latter group).
“Both of these medications really help keep people involved,” Seppala said.
Yet the majority of opioid-dependent patients at the Center City facility do not choose to participate in the more intensive COR-12, which involves tailored individual and group sessions and extensive group engagement post-discharge. Moreover, some patients who do enter COR-12 choose to make the attempt without medication-assisted treatment, although Hazelden Betty Ford generally recommends that COR-12 patients receive either the buprenorphine-naloxone combination Suboxone or the injectable naltrexone formulation Vivitrol.
Of the 360 opioid-dependent admissions in Center City in 2014, 49 participated in COR-12 without medication, 29 were in COR-12 with Suboxone, and 44 participated with Vivitrol, Seppala reported. That means only about one-third of patients with opioid dependence chose to receive the more tailored services.
Seppala, who attributed his own relapse shortly after receiving treatment at Hazelden during his teens to not following a recovery program, described what he considers the moment that turned Hazelden Betty Ford toward a new approach in opioid treatment that has been praised by some nationally and derided by others.
At a staff forum to discuss the topic, three-quarters of participants raised their hand when asked if a former patient of theirs had ever died of an overdose post-treatment. “The [opioid-related] death rate is unprecedented,” Seppala said. “It's unbelievably tragic.” (There were 20 such deaths of Center City patients in the 2013-2014 period, with four of those being patients who had participated in COR-12.)
During a one-year examination of the issue in 2012, well prior to the Betty Ford merger, Hazelden leaders discovered that “we were ignoring opioid dependence without recognition,” Seppala said. COR-12 represents a complete reversal of that. “At assessment, patients are told about the risk for relapse, overdose and death,” he said. “Because they don't think about loss of tolerance during treatment,” which in a relapse scenario can cause potentially deadly effects at doses commonly used before treatment.
Seppala said that one of the ongoing challenges to maintaining patients on medication for extended periods comes from other patients in 12-Step recovery who question continued medication use. He said this is especially the case in Narcotics Anonymous (NA), where Seppala said the national policy is to exclude individuals in medication-assisted treatment from service positions or from speaking in meetings.
Seppala does not buy into the either/or approach that often characterizes the discussion of medication-assisted treatment and 12-Step recovery in the field. “My bias is we have to blend the two,” he said. “I see this as a brain disease, but I also see it as a disease of the soul.”
Hazelden Betty Ford described its perspective on discontinuing extended medication use as being based on patients' becoming established in long-term recovery. The period from 12 to 18 months after achieving sobriety is a relatively safe time to consider discontinuation, but possibly not if other recovery-affirming activities aren't occurring as well.
A summary slide in Seppala's presentation read, “The opioid use crisis requires we use everything at our disposal, independent of personal bias, to help those with opioid use disorders.”
The two-year numbers shared at the NAATP conference do not carry the rigor of peer-reviewed research, and conclusive data from COR-12 probably are still at least a couple of years away.