Executive Orders: Leaders` Views on MAT Shape Decisions on Treatment Offerings

Seven years after it was launched, Hazelden Betty Ford’s Comprehensive Opioid Response with 12 Steps program (COR-12) has become a model for addiction treatment providers across the country looking to implement medication-assisted treatment as a modality.

But to hear Marvin Seppala, MD, Hazelden Betty Ford’s chief medical officer who spearheaded the effort to develop COR-12, the company’s MAT framework never would have gotten off the ground had it not received the backing of Hazelden’s C-suite.

“Without the executive buy-in, if I were on an island, it would not work,” he says. “Having executive level support put me and others on our team in position knowing we were doing the right thing, based on the literature and the evidence.”

Because the use of MAT is a fundamental organizational philosophy as much as it is a treatment modality, implementation requires support from all levels, up to and including executives. For Seppala, getting the necessary buy-in at Hazelden was a multi-year process of winning over internal skeptics, from one counselor who feared he was putting his career in jeopardy to board members in recovery who were wary of potential misuse, among other concerns.

Going to the MAT

After spending two years as the medical director for another facility, Seppala returned to his post as chief medical officer at Hazelden in 2009. In those intervening years, two critical developments unfolded: Seppala for the first time used buprenorphine to treat patients with opioid use disorder, and Hazelden welcomed a new CEO, Mark Mishek, in 2008.

Seppala says his experience treating patients with buprenorphine, combined with an extensive review of available literature and research at the time, convinced him that MAT was a concept worth exploring at Hazelden. He found a willing listener in the company’s new chief executive, a former administrator with the Allina Hospitals & Clinics system.

“(Mishek) was so surprised by the difficulty in the addiction treatment setting of using medications to treat a disorder,” Seppala says. “When I first came back, I told him of my experience and that I wanted to see what we could do with that. He supported it from the start and suggested that I spend some time with our board.”

Seppala says he found an ally in a board member who was a Catholic priest from Minneapolis who had experience working with low-income and uninsured individuals and had seen the benefits of using medication in other settings. In January 2012, Seppala pulled together a team of clinicians and other Hazelden employees from different sites across the country—physicians, nurses, counselors, admissions personnel and even public relations professionals.

“I didn’t pick people who were supportive of the project,” Seppala says. “I picked people I wanted on the project who could make a difference. I say that deliberately because my hope was—and it was hope initially—once we showed the data, they would support the project.”

Building consensus through communication has been critical for earning buy-in on MAT implementation at an increasing number of addiction treatment organizations, says Jeff Allgaier, MD, FASAM. Allgaier is the co-founder, president and chief medical officer of office-based opioid addiction treatment company Ideal Option, which operates more than 65 outpatient clinics in eight states.

“That has really been a key—the communication between us as practitioners and the executives,” says Allgaier. “One of the trickier and more emotional pieces of this has been the transition from a model where opioid use disorder treatment was driven by inpatient facilities and only by counseling to an understanding of the hardcore evidence that frowns on isolated inpatient [treatment] for opioid use disorder without medications. That transition at an executive level just requires the medical community and executive level folks to communicate with each other, and that has been taking place.”

Allgaier, who is presenting on the medicalization of addiction treatment at this month’s Treatment Center Investment & Valuation Retreat, says there is “no debate anymore in the medical community regarding the fact that (MAT) is considered the gold standard.”

“There is some resistance from the abstinence-based community, which is a philosophical belief that you shouldn’t be provided with any kind of substitution treatment for opioid use disorder,” Allgaier says. “That view now would be considered medical malpractice. You don’t really see too many rehabilitation or other facilities anymore that don’t provide buprenorphine or methadone, and if you do, they’re doing the wrong thing scientifically. The evidence does not support abstinence-based treatment at all.”

Resistance not just philosophical

Contrary to Allgaier’s assertions, the case for abstinence-based treatment is not strictly philosophical or entirely unsupported by evidence.

James Balmer is the president of Dawn Farm, a not-for-profit provider of residential, outpatient and detox programs with facilities in Ypsilanti and Ann Arbor, Michigan. Balmer, a 46-year veteran of the industry, came to Dawn Farm in 1983 after being peripherally involved with the program since its launch 10 years earlier.

Dawn Farm has had a history of breaking new ground and reshaping its offerings to meet its community’s needs. Today, it operates two residential programs, facilities for detox, outpatient treatment and adolescents, and a supportive house. Although it’s an abstinence-based program, the organization isn’t actually philosophically opposed to medication-assisted treatment, Balmer says, noting that Dawn Farm was the first in the region to use buprenorphine for detox, it continues to use Vivitrol as a protectant, and it gives naloxone kits to patients when they leave.

The buck stops, however, with long-term medication-assisted treatment.

“One of the things I find ironic about the whole debate is that abstinence-based folks get pinched as being ideological. … My experience is that the opposite has been true,” Balmer says.

“When I see it touted as the gold standard, I just don’t know what to say. People aren’t reading the science. The failure rate is high, and the compliance rate is low, which I find bizarre.

“If they came out with a medication that we thought was reasonably effective, we’d use it.”

Balmer expresses concerns that buprenorphine interferes with emotional aspects of recovery and impairs cognition compared to abstinent recovering patients.

As an alternative to MAT, Balmer instead points to the physician health recovery program outlined in the Journal of Substance Abuse Treatment. In a study of 904 physicians with substance use disorders participating in physician monitoring programs across 16 states in which just 40 used naltrexone, one used methadone and zero patients used buprenorphine, 78% completed five years of monitoring with no episodes of relapse and 72% returned to practicing medicine.

In its position paper on the use of buprenorphine, Dawn Farm states that “treatment decisions for health professionals are not based on an expectation of relapse and overdose—and their outcomes are measurably better. The disparity in outcomes between addicted doctors and ‘street addicts’ comes perilously close to raising potent questions about class prejudice in the treatment field.”

“If it’s good enough for doctors, why isn’t it good enough for a 19-year-old kid?” Balmer asks of the abstinence-based physicians recovery program. “It raises troubling issues of class, I think. I guarantee you a lot of these doctors, if you would ask them if they would put their own kid on buprenorphine, they’d say no.”

The COR argument

What, then, made the most compelling case for the implementation of MAT at Hazelden?

“One of our more conservative counselors stood up and had a question. I’m thinking, ‘Here it’s going to start,’” Seppala recalls. “She said, ‘My daughter has opioid use disorder. She’s had residential treatment three times. She relapsed after each one almost immediately. I’ve been taking care of her children as a result. She couldn’t take care of herself until the last two years. She’s been on buprenorphine for two years. She’s now an active member of our family. She works again. She takes care of her children. It has been a god send.’

“Nobody knew this. She hadn’t told anyone about this—her daughter or the use of the medication. We were blown away. It bore witness to the potential of this medication for our patient population, and it silenced critics in the room. Nobody said anything against it after that.”

The COR-12 model was implemented at Hazelden in 2012, and in September 2019, Hazelden Betty Ford released research showing the outcomes it has achieved over the past seven years. In the study:

• 253 adult patients were admitted to a residential facility in Center City, Minnesota, between June 2013 and June 2017
• “Almost all” of the patients tracked successfully completed residential treatment, and nearly 75% stepped down to another program
• Suboxone- and Vivitrol-compliant patients had abstinence rates over 90% at month.
• 82% of Vivitrol-compliant patients were abstinent at six months. (Such rates historically for Hazelden Betty Ford patients with opioid use disorder typically have been in the low-to-mid 60s.)

After opening in 1949 and creating a program based on the 12 Steps that established an addiction treatment model for providers across the country, Seppala says history in some ways is repeating itself with COR-12, as other providers are taking notice again.

“At first, they would sneak in,” Seppala says. “They’d call me up and ask if they could see what we were doing. I’d say sure, come on by and take a look. Now, we’re doing more training nationally in major healthcare systems and some state-level programs. We’ve seen a major uptick in interest in what we’re doing and in the number of trainings we’re doing for other programs.

“I see it as a natural progression in our history going from things that worked in 1949 to things that work in 2019. We have to continue to pursue the literature and research to continue to determine what’s new to do what’s best for our patients.”