Hazelden Betty Ford Foundation's decision nearly seven years ago to break from tradition among industry peers by implementing extended medication-assisted treatment (MAT) for opioid use disorder (OUD) within a 12-Step environment has received strong confirmation in initial research findings. Beyond the data on patient engagement and outcomes, the organization's experience also has served as a reminder of the value of multifaceted and targeted treatment for patients with OUD.
In a interview this week with Addiction Professional, Hazelden Betty Ford chief medical officer Marvin Seppala, MD, explained that an accompanying decision that outsiders might consider less dramatic also has proven pivotal to the success of the Comprehensive Opioid Response with the 12 Steps (COR-12) initiative. Hazelden Betty Ford decided that along with MAT, it would add opioid-specific groups to its treatment program, rather than keeping OUD patients scattered across groups and among patients with other primary substance issues.
“We found that people with OUD were originally bonding negatively when they were lumped together with others on the unit,” Seppala says. This played out in ways such as their conspiring on how to get out of treatment.
However, the collective energy turned positive when opioid-specific groups were organized, he says, as patients with common experiences started helping each other cope with withdrawal symptoms and encouraging fellow patients to try a medication treatment.
Seppala co-authored a prospective study published in the September 2019 issue of the Journal of Substance Abuse Treatment involving 253 residential or day treatment patients enrolled in COR-12 during the period between June 2013 and June 2017. The research was intended to determine if OUD patients in a 12-Step focused program would agree to initiate MAT (either buprenorphine plus naloxone or the oral or injectable formulation of naltrexone), and to evaluate their outcomes one and six months post-treatment.
The study found that among the predominantly male group with an average age of just over 30, 71% elected to take a medication, a percentage higher than what Hazelden Betty Ford leaders had initially expected. Buprenorphine and naltrexone were about equally popular. Among participants who left treatment taking one of the MAT options, medication compliance rates at one and six months post-treatment were 81% and 59%, respectively. Those who self-reported compliance were more likely to be abstinent from any substance use.
Seppala adds that since COR-12 has been implemented, the percentage of OUD patients leaving treatment early has declined sharply, and transition from residential to outpatient care within the Hazelden system has increased substantially.
“We want long-term engagement,” he says. “This is not something that goes away in a few weeks.”
Patient drives treatment
Based on the compelling evidence supporting the approved medication treatments for OUD, “We'll try to influence the patient to take a medication,” Seppala says. If the patient doesn't want medication as part of treatment, the subject may be brought up again later. “In the end, it's their decision,” he says.
Counseling staff can play a major role in engaging patients with OUD on the idea of taking medication, which is why Hazelden Betty Ford conducted comprehensive staff training events when it decided to implement COR-12.
“The person who's coming into treatment is often precontemplative at best,” says Seppala, so at first there will be resistance to medication. A counselor can be pivotal to convincing the patient at least to read material about medication and possibly to meet with medical staff again at a later time.
The study paper describes the challenges Hazelden Betty Ford faced internally in the yearlong planning process before COR-12 took effect. It states that “a small number of clinical staff left the organization,” but adds, “Public criticism from other 12-Step, abstinence-based treatment programs was much more negative than our internal experience.”
Seppala says that in one pre-implementation meeting attended by 100 staff, three-quarters of clinicians raised their hand when asked if they had experienced the death of a patient or someone close to them with OUD. The most common reaction Hazelden Betty Ford leaders received in these planning sessions was, “We've been wanting to do more about this,” he says.
Comparison between medications
The study compared outcomes for groups receiving 12-Step treatment with buprenorphine-naloxone, oral naltrexone, injectable naltrexone, or no medication (methadone was not offered as an option). Some patients who preferred the monthly injectable formulation of naltrexone (Vivitrol) had to settle for taking the oral medication because of cost/insurance barriers.
At one- and six-month follow-up, patients reporting compliance with the medication treatments generally were more likely than their non-compliant counterparts to be abstinent from illicit drugs and alcohol. Outcomes for patients who stayed on their regimen of injectable naltrexone were more encouraging than what previous studies have suggested, Seppala adds.
Notably, patients in the no-medication group also were more likely than patients noncompliant with oral naltrexone to have maintained abstinence. The researchers did not find an association between medication condition/compliance and patient craving, or patient 12-Step meeting attendance.
Researchers emphasized that this was a complex patient group, with nearly half having an alcohol use disorder and/or cannabis use disorder in addition to OUD, and 90% meeting criteria for a mental health disorder.
They found other interesting differences among patient groups, including that individuals with higher levels of craving and more severe withdrawal symptoms were more likely to choose buprenorphine-naloxone as their preferred MAT.
The paper states that the findings demonstrate the feasibility of including MAT in a 12-Step oriented program. It also points out, “The COR-12 program has evolved and is now an integral, essential aspect of Hazelden Betty Ford's treatment for OUD and clinical staff compete for open positions within this program.”