Treatment opioids a_comprehensive_response_final

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

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.

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.

•  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

Prescrip4on Opioid Dependence

•  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

Hazelden’s Experience

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

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

Organiza4onal Change Process

•  Team Established

•  Literature Review

•  White Paper

•  Plan for Organiza=on

•  Training Forums

•  Communica=on

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

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

Injectable Extended Release Naltrexone

Lancet 2011; 377:1506-‐13

Naltrexone Placebo

1.  Weeks abs=nent 90% 35%

2.  Opioid free days 99.2% 60.4%

3.  Mean change in craving

10.1% 0.7%

4.  Median reten=on 168 days 96 days

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

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

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

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

Ini4al Experience

•  Acceptance by staff

•  Support from Board

•  Support from some treatment programs and professionals

•  Bewilderment from others

•  Pa=ents seeking care

COR-‐12 Clinical Implementa4on

Scoi B. Hessel=ne M.A.,LADC

Tuesday, April 2, 2013 3:30-‐4:45 p.m.

Clinical Perspec4ve

•  Discuss the team process leading to implementa=on

•  Clinical Perspec=ve/Role of Counseling Staff

•  Role of Treatment Services

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)

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

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.

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


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


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.


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)


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.

The COR-‐12 Program

Fred Holmquist, BA

Tuesday, April 2, 2013 3:30-‐4:45 p.m.

An Historical, Philosophical and Anecdotal

Review of Hazelden’s Ever-‐Evolving Twelve-‐

Step/Abs=nence-‐Based Treatment Model

The COR-‐12 Program

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

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

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

Risk and Resiliency Factors for Ongoing Growth

Risk Factors Out-‐dated Innova4on-‐ “old ideas” •  1966-‐ Center City expansions •  1970’s-‐ Use of Niacin/Vitamin B3

•  1980’s/90’s-‐ “Co-‐Dependency” •  1990’s-‐ New Yorker “Caffeine Wars”

Program Complexity

Staff Engaging Client Resistance

Polarized Aftudes •  Wet/dry

•  Abs=nence/maintenance

Resiliency Factors Mission •  Dignity and respect •  Mul=-‐disciplinary team

•  12-‐step/abs=nence-‐based philosophy

•  Con=nuum of care •  Research and evalua=on

Margin

•  Publishing Business Unit Early Adapters

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.

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.

Ques4ons?

Documents

Treatment opioids a_comprehensive_response_final