Part 2

In the conclusion I give my views not only on medication assisted treatment but also on treatment generally, the treatment of a condition that research and medicine do not seem to know how to accurately define or conceptualise so subsequently appear to grasp at methods to treat it, although the treatment outcomes are often unproven or relatively unsuccessful. I argue that this may be the case because we have yet to comprehensively conceptualise what addictive behaviour is, what drives it and how are these mechanisms best treated.

“Medication-assisted Treatment at Hazelden

Bill White: One of Hazelden’s most controversial decisions was the decision to integrate pharmacotherapy as an option within Hazelden’s traditional psychosocial treatment methods. How did Hazelden come to make this decision?

Dr. Marvin Seppala: When I was the Chief Medical Officer between 2002 and 2007, we made a decision to start using naltrexone and then acamprosate for treatment of alcohol dependence. When I left the organization between 2007 and 2009, I gained experience using Suboxone with an opioid-dependent population.

When Mark Mishek asked me to return to Hazelden, I told him about this experience and my sense that we needed to take Hazelden into a new realm by integrating the option of medication in the treatment of opioid addiction. I knew that there would be some controversy related to this, but I believed it would be of benefit to selected patients and that such benefit should always be our guiding rod. When framed that way, Mark was supportive from the very beginning. Our Board was also unanimously supportive of this direction, paving the way for such a significant change in programming.

Bill White: How would you describe the initial reactions to this decision from everyone from staff and alumni to the larger field?

Dr. Marvin Seppala: It was variable, with responses at both ends of the spectrum. Our staff was very curious, and some really questioned our decision. Externally, people were saying that we were ruining AA. They were asking how we could turn our backs on abstinence.

There were claims that we were destroying the legacy of the institution and undermining everything Hazelden’s ever done for the treatment of addictions. And on the other hand, there were folks congratulating us for integrating the latest scientific advancements into the treatment of addiction. Amidst the personal attacks, there were those simply saying, “Well, it’s about time!”

Bill White: How have those responses evolved since the initial announcement? And I think, not only the field, but also how the staff attitudes towards this has evolved?

Dr. Marvin Seppala: Our staff wasn’t sure what to think when we first started talking about moving in this direction. In fact, one of our counselors who’s now the Co-Chair with me of this whole project, was quite ambivalent about it and asked me if it was a good career decision to join a team using Suboxone and Vivitrol for the treatment of opioid dependence. Today, we have remarkable support for this move among the staff. When people witness the advantages of using these medications in patients we are treating, they readily get on board, especially when they see the long-term engagement and watch people blossom in recovery.

We have had a marked reduction in atypical discharges among our opioid use disorder patients—in fact, a lower rate than in our general population. We particularly emphasize the importance of long-term care for people with opioid dependence. Some of them take a medication and some of them don’t. We actually have three different possibilities: no medication, Vivitrol, and Suboxone.

All three are together in groups sharing their experience throughout treatment. If you sit in on these groups, you cannot tell if someone is on medication or not, nor which medication. We are doing a research project because we have to figure out in a predictive manner who needs what and for how long. There are people who recover from opioid addiction with and without medication support.

Many recovering physicians have recovered without maintenance medications and some were addicted to the most powerful opioids on the planet. I’ve known a lot of people who walked into Narcotics Anonymous on their own and achieved sustained recovery without medication. I don’t agree with my colleagues who say that everybody with an opioid use disorder needs to be on a maintenance medicine and be on it for life. And I don’t agree with those who would deny medication as an option for all patients. We need the science, not personal opinion or ideology, to guide decisions on who should be and who shouldn’t be treated with these medications.

As a physician, I would like to be able to tell this particular individual and his/her family that this is the best treatment because of these particular aspects of his/her disease and I can’t do that at present because we don’t have the research to guide such prescriptive, individualized decision making.

Bill White: Do you think it’s an embarrassment for us as a field that at this late stage of our development, we don’t have the kind of outcome data you earlier referenced to guide these decisions?

Dr. Marvin Seppala: I think it’s an embarrassment for the whole of medicine. Although there are certainly some pockets where this is occurring in medicine, cardiology’s doing it, orthopedics is doing it, but in general, that’s not the case. If we could do this in the addictions field, we could actually be in the forefront of the direction all of medicine needs to proceed.

Bill White: I know that Hazelden is in the process of formally evaluating the different options you have around medication-assisted treatment and that this data will be reported, but I’m very interested just in you sharing what your impressions are to date. Are you engaging patients today who would not have been engaged earlier? Are people sustaining recovery who previously would not have been able to? What are you learning?

Dr. Marvin Seppala: I think we’ve made a real contribution in both those areas. There are people coming into our treatment settings now who would not have come in without having access to these medications. Opioid dependence is very hard to treat and there’s a high dropout rate. We continue to lose some people early, but as a whole, we are engaging them longer and with longer engagement comes better recovery outcomes.

If we can keep people engaged for at least ninety days across levels of care, they do really well and start to blossom. This is a chronic illness with a substantial death rate. We need to use everything at our disposal to improve outcomes, and we’ve noted a reduction in overdose death secondary to relapse after treatment.

Unfortunately, this issue is not getting adequate attention, and I hope my colleagues continue to focus on preventing this tragedy. We’ve learned that in long-term care how and why people engage changes over time and we need to listen to our patients and provide services they consistently gain from, or they leave. We also thought that many people entering our system would seek Suboxone, and that diversion and excessive use would be significant problems. Neither has been an issue.

In our youth program, many patients refuse Suboxone due to a history of past abuse, or they say it was the first opioid they used for intoxication and can’t imagine using it as a treatment. This was a surprise.

Bill White: Will the work on medication-assisted treatment that started in Minnesota be extended to other Hazelden facilities, including the Betty Ford Center?

Dr. Marvin Seppala: Yes it will. Our plan is to eventually have all our facilities offering this expanded service menu…

Bill White: There was an impression I got listening to critics of Hazelden’s decision on pharmacotherapy that all opioid addicted patients would be expected to go on medication. But, in fact, what you’ve described is really using medication to enhance the potency of all the psychosocial and spiritual supports that were built in to the traditional model and, at the same time, using those psychosocial and spiritual supports to enhance the power and potency of the medication.

Dr. Marvin Seppala: I believe that’s a great way of describing it, Bill. From the beginning, we said that we’re using the medications adjunctively to the primary treatment for addiction. We are not replacing our other methods with medication; we are offering the option of medication for some patients in combination with those other methods.

We think the medications can improve outcomes for opioid use disorders when combined with our robust treatment model and that most people will be able to discontinue medications after getting into solid recovery…

Recovery Management

Bill White: One of the trends you noted within the field are efforts to shift or extend acute care models of intervention to what you described in terms of recovery management. Do you see the integration of medications and psychosocial supports as an integral part of recovery management?

Dr. Marvin Seppala: I hope this is going to be the case. Currently, I don’t think it’s adequately being done. There’s still such bias against the medications or against the use of psychosocial treatments—presented as either/or options. I’m reminded of depression, where a combination of psychotherapy and anti-depressant medication has been shown to outperform either treatment alone. And yet, as with attitudes in our field, people are told to do one or the other. I hope we will find a way to escape this dichotomy.

I’m hoping we can explore models of effective integration of what for too long have been viewed as incompatible treatments.

The Future of Addiction Treatment

Bill White: What would your predictions be about how addiction treatment will likely evolve in the coming decades?

Dr. Marvin Seppala: Well, this may be a pipe dream, but I hope we get medicines that can actually reduce or stop use of these substances while continuing to recognize the need for inner healing and the value of psychosocial and spiritual supports in long-term recovery. My colleagues who are primarily pharmacologists don’t recognize this latter side of things and the need for them based on all the shame and guilt that addiction brings to the table. Abstinence is not enough.

I hope we get genetic testing soon so that we have predictors of risk for our children and our youth. The use of this technology will be fraught with complex ethical issues, but it may open up whole new approaches to prevention and early intervention. I hope we continue to view addiction as a bio-psychosocial, spiritual illness. I think all four aspects of that description are necessary no matter how good our biologic treatments get. Addiction is a complex and unusual illness. It’s too easy to become reductionistic by defining it from one perspective that can be treated with one approach.

I hope we can become a more mature and unified field that utilizes everything available to us in the treatment of addiction. I am also excited about the new field of positive psychology. George Vaillant writes in “Spiritual Evolution” about how the positive emotions are a force for healing in 12 Step programs. I would like to see us harness the therapeutic healing aspects of love to improve addiction treatment outcomes.

Bill White: What are your thoughts about the past, present, and future role of psychiatry in the treatment of addictions?

Dr. Marvin Seppala: In the past, I would say that psychiatry was of little help in the treatment of addictions, except for certain practitioners that were able see beyond traditional psychiatric models of care. Presently, I think psychiatry plays an important role, especially in the treatment of co-morbid medical and psychiatric illness, but unfortunately, those potential contributions have not been fully integrated in most addiction treatment settings. In the future, I hope such integration takes place.

I think psychiatry can bring a great deal more than it has to the addiction field and improve our treatment outcomes. And I think there is much the addiction field has that can contribute positively to the field of psychiatry, such as a spiritual approach to chronic illness and consideration of healing via enhancing the positive emotions.”

This was a fascinating insight  interview and insight into why and how Hazelden are incorporating medication assisted treatment as a treatment adjunct at their treatment facilities.

I think the interview might have benefited from being a little more critical and there was little challenge or counterpoint to Dr Seppala’s views which is not that helpful. Even in this “friendly” type interview it is useful to offer opposing views to encourage deeper insight. As a result I felt this interview was a bit lopsided and did not really go into detail about these medications and counter arguments against their therapeutic use.

At one point  William White  interjects “”really using medication to enhance the potency of all the psychosocial and spiritual supports that were built in to the traditional model and, at the same time, using those psychosocial and spiritual supports to enhance the power and potency of the medication.” which is hardly critical and a bit overblown in it’s effusiveness.

I think we need to get some hard data back before making such wild claims about it’s utility.

Suboxone is reported as having numerous advantages over say methadone and naltrexone. As a medication-assisted treatment, it suppresses withdrawal symptoms and cravings for opioids, does not cause euphoria in the opioid-dependent patient, and it blocks the effects of the other (problem) opioids for at least 24 hours. Success rates, as measured by retention in treatment and one-year sobriety, have been reported as high as 40 to 60 percent in some studies (according to PsychCentral anyway).

Suboxone is used to complement the education, counseling and other support measures that focus on the behavioral aspects of opioid addiction. This medication can allow one to regain a normal state of mind – free of withdrawal, cravings and the drug-induced highs and lows of addiction.  is an opioid that produces less of an effect than a full opioid such as heroin  when it attaches to an opioid receptor in the brain.

Taking more Suboxone than prescribed does not result in a full opioid effect. Taking extra Suboxone will not get the patient high. This is a distinct advantage over methadone. Patients can get high on methadone because it is a full opioid

The only issue here is that Suboxone can become addictive. Addicted people can become addicted to it. Addicted people can get addicted to nearly anything so why not Suboxone?

In recovery,  I once got addicted to an energy drink called Lucozade Sport, properly addicted, hiding away from my wife drinking bottle after bottle, continuously, all day, every day, for weeks. I even had terrible three day withdrawal from it too.

If I can get physically dependent to an energy drink it would be naive to suggest that I would be okay taking Suboxone? A sniff of a potential chemical buzz however small is often enough to get an addict’s brain going? Our brains have become addicted, for me this reward dysregulaton in the addicted brain is permanent and progressive. We addicts are always searching out a buzz, whether via workaholism or other obsessive compulsive behaviours.

Why such unqualified support at it’s adoption in Halezden? Especially  as we have had not long term studies into it’s effects or effectiveness?

As someone who researches the neurobiology of addiction I have often thought maybe we could use anti craving medication to help stabilize the nervous systems of people early in recovery to help them through the first anxiety inducing hours, days and weeks.

I still think we should keep an open mind on medication assisted treatment but so far remain unconvinced by what I have heard thus far.

I am trying to say the problem is always greater than we appear to be defining 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?

Why just stop at Suboxone?

For me the real issue is that academic research of varying hues has not grasped what addictive behaviour is, what causes it, what are it’s fundamental underlying mechanisms? This interview highlights that for me too. What is the pathomechanism that drives it forward?

It has to be more that substance as I can get addicted to behaviours too so why is that?

They talk in this interview about treating a spiritual illness but what is that exactly?

Why do addicts have this spiritual malady?

Is this the same spiritual malady which comes straight out of a book written in the 1930s? Isn’t that a bit outdated by now? Even Bill Wilson warned against the Big Book being “frozen in time” but that is what has happened?

We rush to embrace science and it’s various tools when we have not updated our views of what addiction is? At is very heart what is it? What causes it? What is the best way to treat it? This is very urgent!? Is it not that treatment at Hazelden is trying to reconcile two completely opposing worlds – one that of of medication assisted treatment with a spiritual malady borne out of the “sin disease” of the Oxford group. That is where the spiritual malady comes from, good old fashioned sin disease.

Can’t we in 2015 actually do better than this in conceptualising what addiction is? Is this still the best we got?

It strikes me that these two worlds are so distant and difficult to reconcile because each is the product of not having properly reconciled what addiction is? What the underlying mechanisms are? Thus treatment falls between two stools.

For me, as written about numerous times, the spiritual malady would be  better conceptualised in addicted individuals as a emotional disease or in neuropsychological terms as an emotion processing and regulation deficit. This clear conceptualisation also suggests clearly how to treat it, in fact, the 12 steps do actually treat it.

Describing it this way allows it to be treated by the 12 steps without turning sufferers away because they cannot accept the term spiritual malady or the solution, God as you understand Him.

Also this emotion processing and regulation deficit causes a different type of craving as conceptualised by medical and neuroscientific researchers.

To these mainly neuro-biological accounts, craving is a state of physiological urge, to positive reinforcement models, it is pathological wanting, and to negative reinforcement models it is a withdrawal or aversive state based desire to alleviate  these negative emotional states. Both are part of the phenomenon of urges for sure but they do not fully explain what craving is in the recovering person in treatment. Only an awareness of the cognitive-affective mechanisms that prompt craving in this group can show why physiological urges is only a fraction of the problem.

Cravings are distinct but sequentially related to urges in some cases but not in other case. Let me explain.

It is important to realise that in the early days and weeks of recovery that urges and 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 be defining it. It is certainly more complex than physicians or medical researchers appear to countenance at times.

These researchers look at medication designed to treat the symptomatic manifestation of this condition, urges, but do not fully consider “craving” as I define it.

Seppela cites George Vaillant who writes in “Spiritual Evolution” about how the positive emotions are a force for healing in 12 Step programs. The best way to get to positive emotions that heal is by processing negative emotions that distress. It is distress that prompts craving, urges, memories of past use, physically responding to both external and internal cues.

And this is what Love as a treatment can alleviate too. This emotional distress.  We drank, used and engaged in maladaptive behaviours because distress signals in the brains prompt all our decisions, actions and behaviours.

We need to consider that this is the root of this condition, distress, caused by the undifferentiated negative emotions which haunt us in early recovery.

I suggest that we think of more urgent ways to treating and soothing this distress in early recovery more effectively. Love is one way among others such as the teaching of coping skills and emotion processing skills where addicted people learn how to locate, identify, label, verbalise (share) their  feelings and emotions because if they are like me they were not taught this is their childhoods.

As  Seppela cites in this interview “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”.  The majority (over 75%) of all disorders have emotion dysregulation at their core.

Trauma, abuse, mistreatment co-dependency and attachment disorders, negative self schemas as the result of childhood  mistreatment, neglect in chaotic dysfunctional families is the fertile ground where the majority of addiction grows. Treatment needs to help with this developmental disorder which is what addictive behaviour is.

It needs to treat it by helping addicted individuals learn to develop these essential life skills so that they can cope with life on life’s terms rather than habitually returning to substance abuse to cope instead.

Reference

http://www.williamwhitepapers.com/pr/2015%20Dr%20Marvin%20Seppala.pdf