Treatment Track:Evolution of Diagnosis and

Treatment Options

Presenters:• Marvin D. Seppala, MD, Chief Medical Officer,

Hazelden Betty Ford Foundation• Judi Kosterman, PhD, Senior Vice President,

WestCare Foundation, Inc.• Jonathan Warren, Psychologist, Brain Treatment

Center

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx Summit National Advisory Board

Disclosures

• Marvin D. Seppala, MD; Judi Kosterman, PhD; Jonathan Warren; and Michael C. Barnes, JD, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

1. Describe Hazelden’s experiment with linking the Minnesota Model of addiction treatment and MAT.

2. Evaluate the effectiveness of Hazelden’s new treatment model, which bridges the traditional treatment model and MAT.

3. Explain recent brain science breakthroughs in diagnosis and treatment of chronic pain and opiate drug abuse.

4. Analyze the potential for combining evidence-based traditional therapeutic drug treatment and neurorestoration brain treatment.

Substance Abuse Treatment:A New Look at an Old Battle

Presented by Marvin D. Seppala, MD

Prepared by Robert L. DuPont, MD, President, Institute for Behavior and

Health, Inc.

Disclosure

• Marvin D. Seppala, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

How We Got Here

• In 1949, a new model of alcoholism treatment was invented in Minnesota in a state mental hospital where the prior standard of care for alcoholism had been one year of involuntary treatment

The Genius of this Treatment

• Integrating Alcoholics Anonymous (AA) with good healthcare into a single program

• Adopting the AA goal of no use of alcohol or other drugs

• Lifelong frequent attendance at 12-Step meetings

• Working on comorbid conditions and patient problems

How This Treatment Worked

• Patients were educated about the disease concept of addiction and learned the language of recovery

• Patients and their families were taught what to do about this family disease – go to meetings

• Many staff members themselves were in recovery acting as inspiring role models

Minnesota Model Expansion

• Started with alcohol but quickly extended to other drugs

• Close links to Alcoholics Anonymous, Narcotics Anonymous, and Al Anon

• A global treatment model

Medication-Assisted Treatment

• Methadone maintenance, medication-assisted treatment now including buprenorphine and naltrexone, started in the mid-1960s

• Vincent Dole, a distinguished obesity research physician, saw addiction to opiates as a life-long “metabolic” imbalance, a disease which is normalized by a single daily dose of methadone, freeing heroin addicts from chemical slavery

• Analogy to diabetes: Just as diabetics need to change their lifestyles, they also need insulin for their lifetimes

• There was no end to methadone maintenance treatment as there is no end to insulin for diabetics

The Conflict

• For decades there have polarized – nearly “religious” – views separating these two, often warring, factions each with their distinctly different disease concepts and goals for treatment

• Both were “forever” – either forever 12-step meetings or forever medication

What is New in this Old Conflict?

• Today’s heroin epidemic, fueled by the prescription opiate epidemic, has produced a new and very different cohort of heroin addicts.

• This new cohort is stimulating new thinking about how these two distinct treatments can be brought together in the best interests of all patients

What This Experiment Is and What It Is Not

• It provides buprenorphine and naltrexone as options for opiate dependent patients after those patients have chosen an intense specialized opiate addiction program within the Minnesota Model

• All of these patients are committed to abstinence from all use of alcohol and other drugs and to participation in the 12-step programs

This Was Revolutionary

• Hazelden’s adding buprenorphine and naltrexone led to conflict within the Minnesota Model treatment community; many called it heresy

• But note that these patients are quite different from the typical MAT patients:– They are already in an abstinence-oriented intensive

residential program before they are offered buprenorphine or naltrexone

– They are expected to attend 12-step meetings from the outset

– If they chose to use medications their end-goal is to not to use opiate medication, not necessarily quickly but eventually

• Before you hear how this happened and the early lessons from this historic experiment, let me show some data about use of the 12-steps in a methadone program

• Another recent example of a bridge over the old treatment conflict

Role of 12-Steps

Study on the Use of 12-Steps by Methadone Patients

• Methadone Maintenance Treatment (MMT) program – 322 patients

• 66% of patients were currently participating in a 12-Step Program, i.e., AA/NA

Importance of 12-Step Program

• Of those 66% of 12-Step participants:

• 72% of AA participants felt the program was helpful for abstaining from opiate and other drug use

• 76% of NA participants felt the program was helpful for abstaining

• The conclusion: the 12 step programs are commonly used and found helpful by many methadone maintained patients

My Mission Today

• To promote better ways to use the full range of treatments for all patients, especially those with opiate dependence

• To focus on the goal of long-term recovery to judge all treatments. How successful are treatments, with and without medicine, in meeting a new treatment standard: Five-Year Recovery

References & Recommended Sources• Owen, P. (2015). Minnesota Model: Description of Counseling Approach. National

Institute for Drug Abuse. Available: http://archives.drugabuse.gov/ADAC/ADAC11.html.

• Roman, P. M., Abraham, A. J., & Knudsen, H. K. (2011). Using medication-assisted treatment for substance use disorders: Evidence of barriers and facilitators of implementation. Addictive behaviors, 36(6), 584-589.

• Spicer, J. (1993). The Minnesota Model: The evolution of the multidisciplinary approach to addiction recovery. Hazelden Publishing.

• Spicer, J. (1993). The Minnesota Model: The evolution of the multidisciplinary approach to addiction recovery. Hazelden Publishing.

• White, W. L., Campbell, M. D., Spencer, R. A., Hoffman, H. A., Crissman, B., & DuPont, R. L. (2014). Participation in Narcotics Anonymous and Alcoholics Anonymous and abstinence outcomes of 322 methadone maintenance patients. Journal of Groups in Addiction & Recovery, 9(1), 14-30.

• White, W. (2003). Hazelden Foundation. In Blocker, J. and Tyrell, I., Eds. Alcohol and Temperance in Modern History. Santa Barba, CA: ABC-CLIO, pp. 290-291.

• White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems/Lighthouse Institute.

Science & Spirituality: COR-12, An Approach to

Opioid Use Disorders

Marvin D. Seppala, MDChief Medical Officer

Hazelden Betty Ford Foundation

Learning Objectives

• Learn how and why a treatment model for opioid use disorders integrated 12 Steps and medication assisted treatment

• Explore the major characteristics of this model

• Learn about the positive experience both staff and patients have had with this integrated model

Annual Numbers of New Nonmedical Users of Psychotherapeutics: 1965-2000

2001 National Household Survey on Drug Abuse

http://www.oas.samhsa.gov/NHSDA/2k1NHSDA/vol1/toc.htm#v1

Prescription Opioid Crisis

• Four-fold increase in treatment admissions(U.S. 1998-2008)

• Overdose deaths have increased dramatically(U.S. 3,000 in 1999 16,500 in 2011)

• Over 125,000 opioid overdose deaths have occurred in the U.S. in the past decade

Rates* of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms

of OPR sold: United States, 1999-2010

* Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms of OPR sold.

www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

Readily Available

The Hazelden Betty Ford Experience• 1. Increased admissions for opioid dependence

– Adults: 19% (2001) 30% (2011)

– Youth: 15% (2001) 41% (2011)

• Problems with treatment retention

– Significant rate of ASA discharge

– Risk to patient Nearly all of these patients leave treatment to relapse

• Unit milieu issues

• Use of opioids during treatment

• Increased incidence of death following treatment

– Ethical imperative to evaluate the treatment model.

The Hazelden Betty Ford Response• Alter the entire treatment of opioid dependence

within our system:

– A Comprehensive Opioid Response with the 12-Steps: COR-12.

• We added groups, education and individual sessions for opioid dependence

• We incorporated two evidence-based medications into treatment protocols for opioid dependence: naltrexone and buprenorphine

• We are studying the results

• Our goal will be discontinuation of medication as patients become established in long-term recovery

COR-12: A Comprehensive Opioid Response with the 12-Steps.

Phase I-Residential: COR-12 Treatment Planning

1. Chemical use disorder history and severity

- Prior treatment history

- Prior MAT history

2. Complicating medical or mental health factors

3. Environmental factors

4. History of “relapsing through” Suboxone or Vivitrol

- Must be seen in the context of prior treatment -

Structure? Monitoring? Patient Centered?

COR-12 Clinical Perspective

• We are focused on patient engagement – for the long term

• The clinical research supports the use of these two medications

• We borrowed heavily from models of intensive Twelve Step practice (OA, SAA/SLAA) in which total abstinence is not an option.

• We emphasize life long recovery.

COR-12 Patient Participation

Admissions to Center City Primary One Year: January 2013– December 201318 Months: January 2013 – June 2014

One Year

18 Months

2270 3385

Total number with opioid dependence 424 566

COR-12: No Medication38 9%

529%

COR-12: Buprenorphine/Naloxone30 7%

438%

COR-12: Extended Release Naltrexone4611%

7012%

COR-12 Results

• 20% of opioid dependent patients who were not in COR-12 discharged atypically

• 7.5% of COR-12 patients discharged atypically

• 6 former patients with opioid dependence died following treatment in 2013

• None were in COR-12

Our Experience

• Opioid support group

• Patient engagement

• Long term approach

• Abstinence

• Staff bias and passion

• Communication

• Unfounded fears

• Can't tell who is on medication

• Getting off medications

Summary

• The opioid crisis requires we use everything at our disposal, independent of personal bias, to help those with opioid use disorders

• We have successfully integrated 12 Steps and MAT to improve outcomes

Treatment Track: Evolution of Diagnosis and Treatment Options

Recent Brain Science Breakthroughs…

Disclosures

Judi Kosterman, PhD, Senior Vice President, WestCareFoundation, Inc., has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Jonathan Warren, Psychologist, Brain Treatment Center, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities

that produce health care goods and services.

Learning Objectives

• Explain recent brain science breakthroughs in diagnosis and treatment of chronic pain and opiate drug abuse.

• Analyze the potential for combining evidence-based traditional therapeutic drug treatment and neurorestorationbrain treatment.

A Journey to Today . . .

• Knowing nothing!

• Experience + Schooling = Learning

• Policy

• Real World Application

• Science Continues

• Returning Warriors and Veterans

• Compelling Obligation

• Discovery: Autism to Addiction

Quantitative Electroencephalography (qEEG)

Frequencies

Delta 1-4hz

Theta 4-8hz

Alpha 8-13hz

Beta 13-30hz

Brain States and Psychometric Parameters Correlate with EEG Frequencies

• Predominant frequencies correlate with a particular brain state (level of alertness, level of consciousness)

• Subtle changes in EEG frequency can correlate to an observed phenotype, depending on the location and amplitude

Neurotypical qEEG Example:Synchronous - Low Energy - High Efficiency

Stopped

Recording

mind task of motion

0 5 10 15 20 25 30

9.85 Hz

Amp

0.921

1.231

2.682

0.728

0.728

0.785

0.836

0.479

0.525

0.705

0.981

0.246

0.356

1.906

2.986

2.208

2.294

4.241

5.170

16.074

9.85 Hz Amp

4.02

0.0295

FZ-A1A2

CZ-A1A2

PZ-A1A2

FP1-A1A2

FP2-A1A2

F3-A1A2

F4-A1A2

F7-A1A2

F8-A1A2

C3-A1A2

C4-A1A2

T3-A1A2

T4-A1A2

P3-A1A2

P4-A1A2

T5-A1A2

T6-A1A2

O1-A1A2

O2-A1A2

1A-A1A2

Comment

-5.47 uV

0.519 uV

6.24 uV

-2.31 uV

-2.31 uV

-2.14 uV

-4.27 uV

0.592 uV

3.24 uV

0.924 uV

-2.23 uV

5.03 uV

2.31 uV

3.47 uV

5.65 uV

-0.0425 uV

5.52 uV

3.47 uV

6.8 uV

-3.71 uV

9.85

Addiction qEEG Example:Chaotic - High Energy - Low Efficiency

Pre-Treatment

14:33:02.000 14:33:05.000 14:33:08.000 14:33:11.000 14:33:14.000 14:33:17.000 14:33:20.0000 5 10 15 20 25 30

2.32-6.20 Hz 8.12-11.31 Hz

AmpSum AmpSum

27.136 5.334

25.099 6.366

44.274 2.862

18.725 3.895

13.912 4.838

13.411 4.273

19.721 3.942

6.282 1.681

7.039 8.827

6.610 7.177

4.395 7.887

2.332 1.717

3.135 3.440

4.624 8.774

4.735 13.233

3.376 10.317

1.219 3.914

2.607 3.220

1.862 5.681

497.578 324.917

2.32-6.20 Hz AmpSum

8.12-11.31 Hz AmpSum

16.7

1.09

FP1-A1A2

FP2-A1A2

F7-A1A2

F3-A1A2

FZ-A1A2

F4-A1A2

F8-A1A2

T3-A1A2

C3-A1A2

CZ-A1A2

C4-A1A2

T4-A1A2

T5-A1A2

P3-A1A2

PZ-A1A2

P4-A1A2

T6-A1A2

O1-A1A2

O2-A1A2

1A-A1A2

Time

2.32 6.20 8.12 11.31

Post Treatment

14:02:25.000 14:02:28.000 14:02:31.000 14:02:34.000 14:02:37.000 14:02:40.000 14:02:43.0000 5 10 15 20 25 30

2.32-6.20 Hz 8.12-11.31 Hz

AmpSum AmpSum

3.104 4.531

1.938 3.954

2.551 3.132

3.940 6.725

5.372 8.758

4.570 7.526

3.733 3.822

3.128 3.153

4.493 13.090

5.887 19.021

3.676 14.533

1.279 4.125

2.410 16.598

3.796 38.634

4.470 58.163

3.536 39.825

1.834 20.169

2.726 30.645

2.563 25.795

576.937 684.087

2.32-6.20 Hz AmpSum

8.12-11.31 Hz AmpSum

16.7

1.09

FP1-A1A2

FP2-A1A2

F7-A1A2

F3-A1A2

FZ-A1A2

F4-A1A2

F8-A1A2

T3-A1A2

C3-A1A2

CZ-A1A2

C4-A1A2

T4-A1A2

T5-A1A2

P3-A1A2

PZ-A1A2

P4-A1A2

T6-A1A2

O1-A1A2

O2-A1A2

1A-A1A2

Time

2.32 6.20 8.12 11.31

Magnetic Resonance Therapy(MRT)

Addiction Outcomesby the numbers . . .

• 500 patient cohort

• 100% get a soft landing with minimal cravings (without an inpatient detox experience)

• 75% response rate as measured by sobriety at 60 days

• 30% are sober at a median follow up of 9 months

Most-Studied Clinical Uses for MRT (Magnetic Resonance Therapy)

• Schizophrenia • Substance Abuse• Major Depressive Disorder• Acute Anxiety Disorder• ASD (Autism Spectrum Disorder)• PTS (Post Traumatic Stress)• TBI (Traumatic Brain Injury)• Tinnitus (ringing of the ear)• Opioid Abuse• Pain Management• Chemobrain• Migraine Headaches• Alzheimer’s Disease & Dementia• Stroke

Questions?

Treatment Track:Evolution of Diagnosis and

Treatment Options

Presenters:• Marvin D. Seppala, MD, Chief Medical Officer,

Hazelden Betty Ford Foundation• Judi Kosterman, PhD, Senior Vice President,

WestCare Foundation, Inc.• Jonathan Warren, Psychologist, Brain Treatment

Center

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx Summit National Advisory Board