Hazelden is moving toward using buprenorphine and Vivitrol in the treatment of opioid dependence, although in the long term, abstinence is the goal, the Center City, Minnesota, treatment program announced last week. The move is in response to opioid overdoses, said Marvin D. Seppala, M.D., chief medical officer. “Deaths from drug overdose, driven by the increase in prescription painkiller abuse, now outnumber those caused by car accidents,” Seppala said in a November 5 press statement. “This is an unspeakably tragic public health crisis — one that demands up-to-date, evidence-based treatment protocols that offer the brightest promise of recovery.”

Last year, 41 percent of the young adults and adolescents in Hazelden’s Plymouth, Minnesota, facility were there for opioid addiction, compared to 15 percent in 2001. Among adults in the Center City program, 30 percent were there for opioid addiction last year, compared to 19 percent in 2001.

Before the end of this year, Hazelden will gradually begin to phase-in medication-assisted treatment with both Vivitrol and buprenorphine.

What makes the addition of buprenorphine novel for the program is the fact that it is an opioid — something that programs like Hazelden, steeped in abstinence-based treatment, have resisted. However, Hazelden in no way sees the use of buprenorphine as a long-term maintenance medication. Instead, it is “a means to assist people to a stable, 12 Step–based recovery lifestyle and ultimate abstinence from opioids,” according to Hazelden.

“Our aim is to provide improved treatment using any and all means for those with opioid dependence,” said Seppala. “We have examined the research literature and will use medications to engage our opioid dependent patients long enough to allow them to complete treatment and become established in solid Twelve Step recovery. Our goal will always be abstinence.”

The two drugs work very differently — Vivitrol blocks the effects of opioids, and buprenorphine reduces craving and relapse.

Before patients are started on buprenorphine, which is taken orally on a daily basis, or Vivitrol, which is injected once a month, Hazelden will make sure that they have access to continuing care, and that the 12-Step groups they are attending will be receptive to the medications. In addition, Hazelden will incorporate opioid-specific group therapy in its treatment programs.

Next year, Hazelden will start introducing the option of buprenorphine and Vivitrol in other programs.

Not just medications

Training for the program started in August, Seppala told ADAW, saying that plans began in early 2012. “Our goal is to fully reevaluate the treatment of those people with opioid dependence,” he said. Because Hazelden follows patients for months after they leave treatment, the program knew that some had relapsed and overdosed.

Using its Butler Center for Research, Hazelden will be looking at how these two medications work. “We’re going to be doing research right from the beginning,” said Seppala. “We believe that the literature is lacking in an umber of ways.” First of all, there’s no good literature looking at these medications when used in conjunction with 12-Step philosophy, as Hazelden will be doing. Secondly, the Vivitrol clinical trial data is all from a small-scale study in Russia. And finally, it’s unclear how long patients should be on either of these two medications; Hazelden’s ultimate goal will be complete abstinence for all patients.

Hazelden has gotten some flak, internally and externally, for its newfound embrace of medications, said Seppala. Many treatment programs still believe that there should be no use of medications – especially addictive ones like buprenorphine – in the treatment of addiction. “We don’t want to get into defining abstinence versus recovery except to say that we feel well-founded in our decision-making,” said Seppala. And he used the analogies of food addiction and sex addiction. “People with those addictions have to define abstinence and recovery for themselves,” he said. “Their change in behavior defines what recovery is. Someone in overeaters anonymous still has to eat breakfast, lunch, and dinner.”

The black-and-white thinking needs to change, said Seppala. “If someone is in recovery for 20 years and has to get opioids for a month because had open heart surgery and has pain, we don’t say they have to change their recovery date.”

Finally, Seppala stressed that the medicines will be an adjunct to the formal program Hazelden has always had. “The medicines won’t become the primary treatment, which unfortunately is the case for a lot of physicians, including ASAM physicians, nationwide,” he said. “We feel that is irresponsible – the other extreme of irresponsibility from the one that says no buprenorphine at all. We’re trying to take a middle ground.”