Q&A with Hazelden’s Dr. Marvin Seppala on Medication-Assisted Treatment

Traditionally many addiction treatment programs have focused only on 12-step programs and avoided medication-assisted treatment, which is the use of medication, along with therapy and other supports, to help address issues related to opioid dependence. Join Together spoke with Marvin D. Seppala, MD, Chief Medical Officer of the Hazelden Betty Ford Foundation, about how some treatment programs are starting to change their view of medication-assisted treatment for opioid dependence.

Why have many treatment programs traditionally focused solely on 12-step programs and avoided medication-assisted treatment?

Dr. Seppala: The treatment of addiction in the U.S. developed outside of the medical system at a time when most doctors wanted nothing to do with addicts and alcoholics. This limited significant medical involvement in the treatment of addiction until recently. There have also been numerous incidents of medications deemed safe and non-addictive by medical literature, only to be later recognized as addictive. Trust in the medical system, especially big pharma, and its research has been part of this issue.

Twelve-step programs are effective and recent research has supported their use, but this is neglected by some academics. Many people working in the addiction treatment field are in 12-step recovery and some see the 12 steps as the only way to treat this illness. Some treatment programs are basing decisions on philosophy and opinion rather than science. To be fair, the science is not definitive in regard to addiction treatment.

The primary controversy is about the use of maintenance medications for opioid use disorders. Strong evidence supports the use of these medications. However, there are legitimate concerns about maintenance medications that some people use to negate their benefits. They are sometimes misused, and we have little research defining who they are most appropriate for, and for how long; so all-or-nothing arguments ensue. One also has to wonder, from a neurobiological perspective, if the maintenance medications provide healing of underlying pathology or just limit some of the disease manifestations while underlying pathology is unchanged. At the extremes of the argument, some people would only prescribe medication and others only 12-step meetings.

The lack of consensus is unfortunate. Addiction is a complex, chronic brain disease and we should be using the best, evidence-based methods to treat it. This is especially true for moderate to severe opioid use disorders, which one can compare to aggressive cancers that quickly become severe and threaten life. With cancer we would seek out the best programs in the country, and use the best means of treatment available, but with addiction, outcome data for most programs does not exist so we don’t know the best programs, nor do we have adequate research to fully define the best treatments. The lack of definitive research and the lack of standardized outcome data allow addiction treatment providers to do whatever they believe in. These limitations undermine the ability to improve upon our treatment outcomes. The field needs to come together and demand that these two inadequacies be amended to provide the knowledge base necessary for continuous improvement of the quality of care and the outcomes for our patients.

Are you seeing a change in this treatment strategy? Is there still a lot of resistance to using medication?

Dr. Seppala: There is still a great deal of resistance, but it is rapidly changing. I have been contacted by multiple medical colleagues around the country who work in settings that don’t offer medication-assisted treatments. They are asking about our program and how we combine strong 12-step, abstinence-based treatment with medications. I spoke at the NAATP (National Association of Addiction Treatment Providers) annual conference several weeks ago and experienced tremendous support for what we are doing. That was not the case the first time I described our program two years prior. We have been criticized for using medications and this continues, but to a lesser degree.

How has Hazelden’s approach changed, and why?

Dr. Seppala: We recognized the opioid crisis as well as our inability to attract and engage patients with opioid use disorders long enough for them to enter into solid recovery. When people are dying in record numbers, it further motivates any group interested in healing. We altered our programs to provide group therapy sessions specific to opioid use disorders and added the use of buprenorphine/naloxone and extended-release naltrexone. We still provide a robust 12-step orientation and use multiple psychotherapies, including MET (motivational enhancement therapy) and CBT (cognitive behavioral therapy). Basically we have combined multiple evidence-based practices. We also inform every patient of the risk of opioid relapse and death. We have learned that long-term outpatient involvement is necessary for this population. We have a program, COR-12 (Comprehensive Opioid Response with the 12 steps), that provides long-term care, the option of these medications, and specific programming for opioid use disorders.

What results are you seeing from blending the two approaches in your patients?

Dr. Seppala: We have had a marked improvement in patient engagement, with atypical (early) residential treatment discharges for those with opioid use disorders improving from over 22 percent to 2.5 percent.

We are also keeping these people in outpatient treatment much longer, and witnessing tremendous success in recovery, with those on medications as well as those who don’t take medications. We are in the midst of a research project which we hope to publish within a year; this will detail our experience and our outcomes. People are staying in treatment longer and becoming engaged in recovery-based behaviors, which does result in better outcomes. We are seeing fewer people die upon relapse to opioid use, an essential outcome.