In 2012, Hazelden, the iconic exemplar of the Minnesota Model of chemical dependency treatment, announced its decision to begin using naltrexone and buprenorphine as optional adjuncts in the treatment of opioid addiction.
This shift in clinical philosophy at Hazelden garnered considerable professional and public attention. At the center of the ensuing debates was Dr. Marvin Seppala, Chief Medical Officer of Hazelden Betty Ford. This interview conducted with Dr. Seppala December 2015 explores his career as an addiction psychiatrist and discusses numerous issues related to the treatment of addiction, including the 2012 decision on medication-assisted treatment and how medications are being effectively integrated into 12-Step-oriented addiction treatment.
Here we use some excerpts from Dr Seppala’s interview with William White (1) to understand how his personal and professional history have led to this fairly controversial decision.
Hazelden, the most iconic of 12-Step-oriented treatment programs in the United States, announced in November 2012 its decision to begin using medications (naltrexone and buprenorphine/naloxone) as an optional adjunct in the treatment of patients seeking help for opioid addiction. That decision may well represent a tipping point in the history of medicationassisted treatment of addiction in the U.S. As might be expected, this decision stirred professional controversy and considerable media attention.
At the center of the decision and subsequent national discussions was Hazelden Betty Ford’s Chief Medical Officer, Dr. Marvin Seppala. In December 2015, I interviewed Dr. Seppala about his life’s work, his experience with the introduction of medication-assisted treatment at Hazelden Betty Ford, and the future of addiction treatment…
Bill White: When you made the decision to enter medical school, did you do so with the intention of specializing in psychiatry or addiction psychiatry?
Dr. Marvin Seppala: No, I was planning on becoming a cardiac surgeon just like this Brazilian cardiac surgeon in the lab who influenced me to go into medicine…During clinical rotations, I recognized alcoholism and addiction everywhere I did hospital rounds. I was attending a particular 12 Step meeting at the time that had a couple of physicians, and I regularly complained about the failure to identify and treat the addictions underlying the presenting medical disorders. After several weeks of this, the two physicians took me to the side one day and said, “Marv, you have got to quit bitching about this and do something about it.” It was then that the possibility of specializing in addiction first entered my mind. I started looking at options to specialize in addiction, and it just felt so right, and it interested me so much.
After talking with several people, I decided to pursue psychiatric training and to specialize in the treatment of addiction. Interestingly, when I told one of the attending physicians at Mayo that I was going to go into psychiatry and specialize in addiction, he said I was throwing away a good career in medicine.
Bill White: Was that kind of attitude pervasive within your medical and psychiatric training?
Dr. Marvin Seppala: It certainly was in my primary medical training. No one could believe I actually wanted to work with addicted patients. Psychiatry was not regarded as a true medical specialty, and addiction was not even thought of as a disease.
Bill White: When you did your psychiatric residency, was there much focus on the treatment of addiction?
Dr. Marvin Seppala: Yes, at that time at the University of Minnesota, there was a great deal of interest in addiction and its treatment. There was an addictions department with addictions treatment services (primarily outpatient), and at the Minneapolis VA, there were both residential and outpatient services. The University of Minnesota actually operated a Southeast Asian Opium Clinic. After the Vietnam War, the Lutheran Church sponsored a lot of Vietnamese people to come to Minneapolis….I had a broad experience of addiction treatment throughout my residency and then even more so during my addiction fellowship with Joe Westermeyer.
Mark Willenbring, who later went to NIAAA, was also there at the time doing addiction-related research. It was a great place to be during those years (1984-1988). I was exposed to all kinds of alternatives to the Twelve Steps that really stretched me and forced me to look at diverse ways that people get sober. The Natural History of Alcoholism had been published by Dr. George Vaillant, which gave me another way of looking at this disease and to recognize that the way that I got sober wasn’t necessarily the way everybody got sober…
Early Work in the Field
Bill White: When you finished your psychiatric residency, what were some of the early positions and consulting roles you held?
Dr. Marvin Seppala: I had to work multiple part-time consulting jobs per week because no one was really hiring addiction physicians full-time at that point. I worked part-time at an adolescent treatment center, a women’s treatment center, and a dual diagnosis inpatient hospital. I worked at a couple halfway houses providing psychiatric care…
Bill White: Were there lessons from that early period that informed your later work with Hazelden?
Dr. Marvin Seppala: Absolutely. All of this work opened my eyes to other ways of doing things than what I had experienced in my own treatment at Hazelden or my training at Mayo and the University of Minnesota and exposed me to the tremendous passion that so many people bring to their work in this field.
These roles also sharpened my understanding of the ways in which psychiatrists could contribute to addiction treatment. I was often the only mental health person in these settings so I would be sent people with all manner of trauma and a wide array of psychiatric illnesses. In the HMO system in which I worked, I was the only person doing dual diagnosis care in the whole system. The addiction counselors and psychiatrists both referred people to me with co-occurring disorders.
I learned a great deal and rapidly gained comfort and expertise working with such complex situations. I was able to figure out ways to enter into discussions within these diverse settings to get the best possible care for each patient. I found people very receptive to the help I could offer using knowledge of both recovery and psychiatry to individualize care. I also had the benefit of training and experience in cross cultural aspects of addiction and psychiatric illness; another way to individualize care. I learned a great deal about relapse and the limited outcomes associated with all types of addiction treatment, helping me to understand the true complexity of this disease.
The limited research in the field was often unhelpful in determining how to plan treatment for the patients I was working with. So at the time, we had poor outcomes and lacked established means to improve upon outcomes. These influences forced me to learn as much as I could from the literature and from those I worked with, to put into use in innovative, creative ways in hopes of helping those who needed more than they were being offered.
Bill White: I would suspect you also developed a vision of what an ideal integrated system of care would look like that addressed both issues.
Dr. Marvin Seppala: I did. I thought about that a lot over the years and looked forward to a time I could apply what I was learning. I was later able to do that at Hazelden Betty Ford.
Hazelden Times Three
Bill White: Tell the story of how you came to serve as the Chief Medical Officer at Hazelden Betty Ford Foundation.
Dr. Marvin Seppala: Well, I’ve done it three times, and strangely, I’m the only person that’s served in this role… They didn’t know how to use me as a Medical Director, and I wasn’t really integrated into the system well. It was very disappointing, but the organization was not ready for physician leadership. So I left and returned to Oregon. There, I consulted at Springbrook Northwest, which was a treatment center outside of Portland, Oregon, until it was sold to Hazelden. At that time, the President of Hazelden and I talked, and he hired me again as the Chief Medical Officer. I did that from 2002 through 2007, at which point I had a disagreement with the new CEO in regard to how treatment should be provided—the tension between quality of treatment versus revenue.
I left for a couple of years and started an outpatient treatment program in which I gained a lot of experience with the treatment of opioid dependence using buprenorphine/naloxone, commonly 6 known as Suboxone.
In 2009, I got a call from the assistant to Mark Mishek, the current CEO of Hazelden, who … offered me my old job back. So I became the Chief Medical Officer for the third time and have been there since. It is a tremendous job and I’m surrounded by really talented people.
I have the support of the CEO and the Board. I don’t believe there exists a better job for me.
Bill White: How would you describe just the experience of working with one of the most iconic addiction treatment institutions in the world?
Dr. Marvin Seppala: That’s a tough question. We have tremendous resources for the treatment of addiction, which is our primary focus. We are a very organized, large, and diverse system with treatment, publishing, public advocacy, prevention, and education programs. Our leadership team is outstanding. We live our values at Hazelden Betty Ford.
We were founded on treatment provided with dignity and respect. Integrity is essential to our ability to function. In many ways, my experience here is much like that at Mayo; the resources are exceptional, the staff is tremendous, you are expected to perform at the highest level, and the primary focus is on exemplary patient care. There are extremely high expectations for the quality of care that we provide, but in the past, we had become quite parochial.
Hazelden Betty Ford stood on its laurels without feeling the need for continued innovation. The attitude was, “We know what we’re doing and don’t need to change.” In recent years, at least the last five or six years, that has completely shifted. I think we are shaking things up again to provide the highest quality of care we can for people with addictions. Hazelden Betty Ford leadership is now singularly focused on providing the highest quality of care. If I had to summarize my job, it would be, “How can we improve the long-term recovery outcomes of every patient that comes to Hazelden Betty Ford?”
Bill White: Wow, what a job description. Could you elaborate a bit more on how you’ve seen the treatment philosophy and methods evolve since your initial work with Hazelden?
Dr. Marvin Seppala: When I look back at 1974 when I was in treatment, we’ve come from using the “hot seat” in groups to now offering the very latest treatment medications. We’ve gone from a sub-acute care model of four weeks of treatment and go to AA to a real examination of treating addiction as a chronic illness over the lifespan—a sustained recovery management orientation. We have full mental health services.
In our adult setting, over seventy-five percent of our patients have a psychiatric diagnosis before they arrive and in our youth setting, it’s over ninety-five percent. We’ve integrated full time psychologists and psychiatrists into our treatment teams, and we continue to have very well-trained addiction counselors. We’ve used multiple psychosocial therapies for decades, and have moved our focus primarily to CBT and MET. And we’re retained our Twelve-Step orientation and an emphasis on the role of spirituality in addiction recovery—all while remaining open to new evidence-based practices that come along.
Bill White: Critics of the Minnesota model suggest that the approach represents a “one size fits all” approach to addiction treatment. How would you respond to that criticism?
Dr. Marvin Seppala: In the past, I’d say that was a fairly accurate criticism. There was the Minnesota model and it worked well for a number of patients, perhaps even most, but didn’t work for others. It was primarily program-based—you walked into this black box, you came out the other side, and you were expected to be better. It provided a framework for recovery, but neglected the chronic nature of addiction.
That’s not an adequate way of addressing any disease, and certainly isn’t in keeping with our current recognition of addiction as a complex, chronic illness. As any field matures, things change, and Hazelden Betty Ford has advanced with the field, even leading some of these advancements. We may have stuck with that black box too long, but we’ve made great progress in individualizing the care we provide.
We currently offer treatment for those with addiction and other mental illness, chronic pain, trauma, and we provide LGBTQ programming. As a possibility in the near future, we are looking to contract with insurance companies to provide services for a whole year in a person’s life for a set fee, providing all the care needed by that person to sustain his or her recovery. This will require objective decision making based on data describing the care most likely to result in abstinence and recovery at the lowest cost.
Bill White: Which would create an extremely nuanced, highly individualized approach to treatment?
Dr. Marvin Seppala: It would and it’s very exciting. We have the opportunity to use predictive modeling to individualize care. We have done outcome studies for years on subsets of our patients, but our vision is that clinical and cost outcomes would be tracked long-term on every patient treated at Hazelden. This will provide a database that can help us to predict the best care for people based on the outcomes of others. We will actually be able to determine if the changes we make to treatment improve outcomes or not. Our whole model would drastically shift toward this longer term vision of personalized recovery management.
As a psychiatrist, I have worked for multiple organizations and have licensure in multiple states, but no one has ever asked me about my clinical outcomes. That has to change; we need to know if what we are doing is helping and contributing to better outcomes or not. Knowing our outcomes on everybody will allow us to alter the programming in a prescriptive manner to meet the needs of each patient and family
Part 2 tomorrow…
Very interesting. As a recovering addict I know a lot of people who have come off heroin using suboxone/subutex in the UK. It definitely works and has less potential for abuse than methadone. http://bit.ly/1ER5cLY
I think keeping an open mind on whether opioid antagonists is helpful with the provisio that we are aware of people in recovery not just stopping at the “not craving” stage anymore. As long as we remain aware of the temptation not to delve any deeper therapeutically in our condition after the craving subsides or is greatly educed. Equally it is important to realise that in the early days and weeks of recovery the craving (or sometimes the fear of drinking) can be enormous problems. It took me a long time to realise that I had not been craving but had actually been terrified of drinking to such an extent that the thought of drinking would automatically appear in my mind. So we need to be aware of how we conceptualise craving too. It is more than just an physiological urge to drink or use drugs it is a cognitive and affective mechanism whereby we try to suppress the automatically occurring thoughts about drugs or alcohol and they rebound into our mind even more prolifically. These attempts at misappraising these thoughts can lead to a worsening situation whereby we think we want use again because we are not aware these are automatic thoughts which we have not control over and thus misappraise them as being thoughts that prove we actually want to drink. I am not sure how antagonists or other medication can deal with this which is not simply neuro biological mechanism but a cognitive -affective of psychological mechanism? I am trying to say the problem is always greater than we appear to define it. It is certainly more complex than physicians or medical researchers appear to countenance at times. What do we also do with too much glutamate in the brain in early recovery – this probably continues to the brain hyperarousal which can prompt to “hell with it relapse” or the excess stress chemicals which prompt relapse via anxiety based or withdrawal based relapse. Should we also deal with the hyper stress of early recovery by opposing the effects of stress chemicals like noradrenaline or glucocorticoids by giving noradrenergic receptor antagonists or CRF antagonists to block alcohol withdrawal–induced anxiety or Administration of NPY into the cerebral ventricles of the brain etc etc etc where does one draw the line or should these all be offered as treatment adjuncts – do they all mix – are there knock on effects? This is a wide ranging area of debate. I remain open minded but not completely convinced thus far.