Datica Podcast

May 28, 2019

America's Opioid Crisis - Origins, Diagnosis, and Treatment

We begin our series on opioid abuse in America with an overview of the origins of the crisis and current approaches to diagnosis and treatment with Dr. Marvin Seppala. Dr. Seppala is Chief Medical Officer at the world-renowned Hazelden Betty Ford Foundation and has over 30 years of experience developing programs and treating addiction. This is a do-not-miss episode for patients, clinicians, policy makers and anyone else touched by this crisis.

About the Series

America is in the midst of an Opioid abuse crisis. In 2017, more than 28,000 Deaths were attributed to overdosing on synthetic opioids. The steady rise in the number of people misusing opioids and the migration of some patients to street drugs like heroin and fentanyl when they can no longer get legitimate prescriptions has resulted in a genuine public health crisis and an “all-hands on deck” moment for healthcare. In this special series of 4x4 Health our guests share their views on this crisis as we look at the current state of diagnosis and treatment as well as the role technology can play in enabling better care.


Dr. Dave Levin: Welcome to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I’m your host Dr. Dave Levin. America is in the midst of an Opioid Abuse Crisis. Consider some of these statistics reported by the US Department of Health and Human Services or HHS. It’s estimated that in 2017, more than 28,000 deaths were attributed to overdosing on synthetic opioids which translates to more than a 130 deaths every day. Us of great concern is to study rise in the number of people misusing opioids for the first-time. In 2016, two million people misused prescription opioids for the first-time and reflecting the fact that patients often move on to street drugs when they can no longer get legitimate prescriptions, 81,000 people used Heroin for the first time. This is a genuine crisis and an all hands-on-deck moment for healthcare. In response HHS has proposed a five-point plan that’s designed to lead to better prevention, treatment and recovery services, enhance data collection and research, improve pain management and increased targeting of overdose reversing drugs like Naloxone. In this special series of 4 x 4 Health, our guests share their views on the crisis as we look at the current state of diagnosis and treatment as well as the role technology can play in enabling better care. Today I am talking with Dr. Marvin Seppala, Chief Medical Officer at the Hazelton Betty Ford Foundation where his responsibilities include overseeing all interdisciplinary clinical practices, maintaining and improving quality of care and supporting growth strategies for residential and non-residential addiction treatment programs. Marv is an adjunct assistant professor of Psychiatry at the Mayo Clinic College of Medicine and Science. He’s also the author of the Clinician’s Guide to the 12-Step Principles and co-author of several other books including Pain Free Living for Drug Free People, When Painkillers Becomes Dangerous and Prescription Painkillers. As you’ll hear today, Marv is a wealth of knowledge when it comes to the science and practice of addiction medicine. Welcome to 4 x 4 Health, Marv.

Dr. Seppala: Thanks a lot Dave, proud to be here.

Dr. Dave Levin: Before we get into the opioid discussion, let’s start with our usual opening question. Take a few minutes and tell us about yourself and your organization.

Dr. Seppala: Well, I’m a physician, I trained in Psychiatry and then specialized in addiction back in the 80s. And when I first, you know, told someone at Mayo Medical School where I attended that I was going to do that, this interest that I was thrown away a good career in medicine. Ha, ha [Laugh].

Dr. Dave Levin: Okay.

Dr. Seppala: You know, because in the 80s, who was interested in addiction. Basically, that was the question and yet it was what I wanted to do and I carried that out and when I first got out of training, I had to kind of, you know, cobble together four, five or six jobs a week to get a full time thing because no one wanted a full time psychiatrist working at addiction. And that’s changed so much since then. Even before this opioid crisis, there’s been an increased emphasis on addiction training in medical school, I’m treating addiction in healthcare systems but the opioid crisis itself is really focused at and I actually have a great job. I mean, I helped run one of the best organizations in the addiction field worldwide and I’ve been able to do some research, I do training, I do teaching. It’s really a wonderful opportunity for me to fully use my medical training and experience.

Dr. Dave Levin: Well, I’m really glad that you did not take that clinician’s advice.

Dr. Seppala: Ha, ha [Laugh].

Dr. Dave Levin: I think we can all see in retrospect you’ve had a terrific career. And there’s a little bit of irony there too Marv because I think we’ll probably get into this a little later but my understanding is we have a real shortage of knowledgeable and well-trained specialists in this area. So, in fact, he had it completely wrong that I’m glad you, so I’m glad you didn’t listen to him.

Dr. Seppala: Ha, ha…, [Unclear].

Dr. Dave Levin: Tell us a little bit more about Hazelton Betty Ford Foundation.

Dr. Seppala: So, Hazelton Betty Ford was founded in 1949. Headquarters is in Center City, Minnesota, rural area of Northeast of Twin Cities. And founded because there was very little in the way of any kind of treatment for alcoholics back in the 40s and all of a sudden AA had come along in the 30s and people recognized that some folks were actually getting sober which had never really happened before and it all occurred outside of, you know, the house of medicine basically, separate because no one in medical systems had wanted anything to do with alcoholics and drug addicts. As a result, the separate sort of system developed and that’s what happened with ours. So, we were completely separate from any other healthcare system. There was no treatment, even, there wasn’t even recognition that alcohol withdrawal existed in the late 40s. You know that, they hadn’t really put that together, certainly didn’t have medications to treat it. So, there’s some pretty funny stories about tongue depressors, you know, put in the people’s mouths to try and protect their teeth and they had seizers and stuff, that’s really unfortunate. This whole field is so new. Hazelton really developed based on a couple of people who recognized the need to use both the science and a kind of 12-step orientation what they’d seen working in the communities to address addiction. And that’s how we’ve grown since then. So, we helped get the Betty Ford Center off the ground in the 80s and then we merged with them five years ago. We had seventeen clinical sites around the country now, mostly outpatient but four major residential facilities. We have a graduate school in Addiction Studies which I teach at. We have the biggest publishing company in the addiction field. We have a prevention arm that does a great deal of work in schools around the country and actually around the world trying to help school systems address addiction and prevent its use. We also have an advocacy group that works in states where we have facilities but also a great deal in Washington DC trying to in an alter legislation and improve legislation. Especially now associated with the opioid crisis but it also related to other addiction issues like, you know, legalizing cannabis and that sort of thing.

Dr. Dave Levin: Well, I want to go just a little bit deeper on this and then we’ll turn to our main topic. The, your description of, if you will the bad old days, I think is really interesting and there’s an important thing buried in there that I think relates to the current situation as well. You know, my view of this is that for a long time, people in the medical profession viewed addiction basically as a character flaw.

Dr. Seppala: Oh yeah!

DDr. Dave Levin: Not as a disease. And that this very fundamental change in philosophy driven by, you know, evidence-based science is, has been a real important driver in this and I think this also plays out in how people look at the current opioid crisis as well. Before you answer Marv, one of the ground rules on 4 x 4 health is guests are encouraged to call BS on Dave. So, if you disagree, uh, please disagree and correct me. But if not, you know, amplify what I, with my observations.

Dr. Seppala: Well, you’re absolutely right about that Dave. Because, you know, when we got off the ground of 40s there was no recognition that this was a disease. It was considered a moral or ethical failing on the parts of those individuals, so real character flaw. And actually, when they have done surveys around the United States, that’s still the prevailing sort of understanding of addiction. That’s changing dramatically with this opioid crisis because it’s gotten so much PR in regard to this is a disease and it’s been defined that way and we have really solid research that the biggest change is been a recognition of, you know, what parts of the brain are involved with addiction and how it actually alters brain function and those that have this disease and primarily two parts of the brain. Now, the reward center where its primary function is survival itself. So, reinforcing those things that keep us alive like, sexual activity is really enjoyable for that reason, survival of the species itself. If food, most people really enjoy, liquids are a requirement, human interaction, love, that sort of thing. All those things that keep us alive and keep us, our whole species moving forward are centered in that reward center and the drugs and abuse actually play their biggest role right there and in a way they reprioritize drive states so that survival itself goes down a priority list and the continued use of the drug becomes the top priority. And it does that, addiction does that by increasing dopamine release, the primary but not the only neurotransmitter associated with addiction and it’s super physiologic levels of  dopamine way more than usual levels of that particular neurotransmitter and the only thing that dopamine can really tell the parts of the brain that it’s influencing is the importance of the stimulus, the salience of the stimulus. So, the higher the amount, the more important it is and the drugs, the intoxicants that we use and get addicted to, they cause release of way more dopamine than any natural reinforcers and thus become more important, seen as more important than those that cross a line into addiction. And so, and that’s all subconscious. It’s not a conscious area of the brain. That’s just happening subcortically. It’s connected to the prefrontal cortex where we usually will kind of recognize a problem and figure out a solution and kind of make a plan and carry that out and unfortunately in the course of addiction, that part of the brain is also dysfunctional. Not entirely, it’s not just shut down but the people with addiction, you know, we used to say, they deny that they have denial, you know. They deny they have the addiction; they deny the have these problems. So, it’s way more than that. They can’t even really fully recognize it and that drive is so powerful from that survival-based reward center that in the mind of the person of addiction, they’re doing the right thing and they can’t recognize just how bad it is or plan things out. So, truly brain function is altered in a diseased state of addiction and that recognition has been tremendously beneficial both for examining treatment for the potential medications to address addiction and for establishing better research about how to go about this treatment and care for those folks that have addiction.

Dr. Dave Levin: That’s a, that was a really beautiful suffering of about 30 years of science and research and the, I want to repeat the two things and I want to ask you a little further about one of them. So, there are these physiologic changes in the pleasure center and this very powerful neurotransmitter dopamine that essentially tells us that whatever you just did is good, do more of that.

Dr. Seppala: Yeah.

Dr. Dave Levin: And then there’s this alteration in the prefrontal cortex which is, you know, I think of as a, is sort of higher reasoning and judgment, that’s affected as well. You said something in that part that I think is really interesting and insightful which is it, the people’s judgement is impaired to the point where they don’t recognize the disease and themselves but what I’ve learned from talking to people who run 12-step programs and group therapy in general is, we’re still actually quite good at seeing it in other people.

Dr. Seppala: Yes, we are.

Dr. Dave Levin: And that this is part of the power of those approaches is that it begins with recognizing it in others rather than trying to recognize it in oneself. Again, please call BS on me if I’m not accurate in describing that well but…

Dr. Seppala: That’s extremely accurate David. And in fact it’s what, you know, we rely on in our treatment system and most treatment system in the US, we rely on group therapy for that reason that the new people just coming into treatment, they can’t see it in themselves, they can’t recognize it in the least, they know there’s some sort of problem there. They’ve got all kinds of ideas what that might be and it’s external to themselves, you know. So, it’s…

Dr. Dave Levin: Right.

Dr. Seppala: It’s that our political claim, it’s the economy, it’s, you know, it’s my spouse, whatever. But they see it in others and they can absolutely recognize addiction, it’s symptoms and even confront people, you know, that have those symptoms and talk to them about their illness and tell them, you know, you really should stop using in spite of the fact that they’re doing exactly the same thing and not recognizing it. And after a few weeks of abstinence where they’re in that kind of setting and have that recognition of others, all of a sudden it starts to kind of bleed through that, hey, I’m doing exactly the same thing and that recognition can develop about oneself and it’s really powerful.

Dr. Dave Levin: I, this is an idea I’ve been thinking about a lot in the last year so and I, as I’m want to do, I’ve begun to generalize it. I think it may be true about life in general.

Dr. Seppala: Ha, ha [Laugh]. There is truth in this, there is a bit.

Dr. Dave Levin: And I was thinking that I do some work with other startup companies and it hit me really hard recently when I realized, boy, I have no trouble looking at other startup companies and diagnosing their problems and offering them advice but it’s a completely different thing when it’s my own company. And so, I think there might, maybe I’m connecting dots that don’t connect but I think there may be something Universal in this. We’re just better at judging other people than ourselves.

Dr. Seppala: We are. For ourselves, for myself I’ve got all these reasons for what I’m doing.

Dr. Dave Levin: That’s why, that’s why.

Dr. Seppala: Harder to see in objective wise.

Dr. Dave Levin: Well, we’ve started to itch into this and so let’s really turn now to the opioid crisis specifically. And what I’d like you to do now is I’d like to hear a little bit of your personal history of involvement with this crisis and if you could use that to also tell us a little bit about in general, how this has progressed with in the United States? So, you know, what’s the story of this crisis generally and, what about you personally, what’s been your own personal kind of history and involvement?

Dr. Seppala: Okay. So, this isn’t the first opioid kind of wave in the United States. I’ll start there. So, back in the 1800s, there were no legal restrictions on importation of Opium itself and we had an opium crisis here. The primary people that were using opium were women and doctors. Ha, ha [Laughing]. And so, very odd sort of thing that, and there are all these patent medications back then, you know, these, that people could mix up themselves and most of them had opium in them. And that’s how I got started because it worked so well for so many things. Early in my career I worked in a Southeast Asian Clinic at the University of Minnesota and we were at that Lutheran Church after the Vietnam War, sponsored a lot of refugees that to come to Minnesota, the Twin Cities in particular. And so, there were a lot of Hmong that came from Southeast Asia and they were the ones primarily farming and growing opium. And they had just three medications back home. They were kind of hill tribes moved around a great deal. You know, basically just growing and cultivating opium. And the three medications were penicillin, aspirin and opium. And opium was, worked for anything that [Unclear] and back in the 1800s, it was the same year, it worked for anything that [Unclear] did. Both psychic pain and physical pain and, you know, diarrhea, that it worked for all the kinds of things. You just kind of forget you even had a problem when you take an opioid and that’s part of the issue. They’re fantastic medications for pain, both psychic and physical and yet so dangerous because of the highly addictive nature of them. And it was back in the early 1900s when the Government got involved and initially, they couldn’t pass was distinctly limiting importation. So, they started with interstate commerce and they put a tax on it and they did all these other things before they finally just outlawed opioids outside of medical situations which was really a big change.

Dr. Dave Levin: You know, there’s a, I’m listening you talk about this and I’m a huge fan of Sherlock Holmes.

Dr. Seppala: Oh man!

Dr. Dave Levin: And if they had just, you know, by coincidence I was recently watching an episode and it dawned on me. Pretty much the only thing that Dr. Watson ever prescribes is brandy or laudanum which as I understand it, laudanum was a, basically a mix of alcohol and opium and other things as well. So, your story rings true for me and I think it’s also interesting that you talk about this in waves because my understanding is, if you look at the last 10, 15 years in the United States, it hasn’t been one crisis. There’s been a series of waves. Can you talk about that part a little bit?

Dr. Seppala: I sure can. You know the, in the 80s we had a heroin crisis throughout the United States is mostly inner-city and mostly African-American and that’s an issue that’s come up related to this, opioid crisis because there wasn’t much a response back in the 80s to that particular heroin crisis. And the suggestion is, it’s because it was primarily inner-city and African-American folks involved that we ignored and now with this current crisis, the major difference is that it is not just inner-city, it’s basically everywhere, to rural areas, it’s throughout the United States and its involving primarily a Caucasian and fairly middle-class US folks and as a result, the controversy is that now that is affecting White people, we’re paying attention to it. And I think there’s absolute truth to that. However, it’s so much bigger now that we have to pay attention as well, you know. So, and the other aspect of this is, just back in September of 18, a public health paper came out describing the changing dynamics of drug overdose of the drug overdose epidemic from the late 70s through about 2016 and they showed that overdoses even before this opioid crisis, we’re already on the rise in an exponential manner and this opioid crisis just helped maintain that same curve that it’s just been growing and growing really significantly throughout that period. In a way that was somewhat unpredictable.

Dr. Dave Levin: What’s behind this growth? I mean, I imagined there that it’s complex and multifactorial but what’s the current belief about the, you know, the top two or three things that are driving the growth here, the increasing numbers.

Dr. Seppala: Yeah. I think there’s a couple of things that really come to mind. The first is that we’re a society that is very accepting of intoxicants and of their use and we can see that and, you know, the legalization of cannabis occurring in states across the country and now even Denver, the city itself suggesting in legalization of magic mushrooms and intoxicating, you know, hallucinogenic mushrooms. So, overall, we’re a society that’s gotten used to the drugs and medications. You know, especially the pharmaceutical industry and its growth since the 50s has somewhat convinced us that better living through chemistry sort of approach to life.

Dr. Dave Levin: Right.

Dr. Seppala: Whereas the rest of world, that’s not necessarily the case, you know, that 80% of the opioids prescribed in the world are prescribed in the United States. We only have, you know, but a little over four and a half percent of population of the world but we use 80% of the opioids.

Dr. Dave Levin: Wow!

Dr. Seppala: So, how we don’t tolerate pain as well or we use them for a whole lot more reasons, you know, than just pain and I suspect that’s what it’s really about. The other thing I guess, you know, you and I maybe close to the same age. So, growing up in the 60s and 70s, there really was this altered sort of recognition of use of these intoxicants and especially the illicit drugs and the like and that’s allowed. I think now that we’re at this age a change in and around the country in regard to the voting population and an acceptance of the use of these substances. The other thing related I would say that in medicine, when I went through medical school and training in the 80s, we were well versed in the fact that opioids were really dangerous. You had to be really careful with them. They were highly addictive, you only use them if you had to and if you did for acute pain, not chronic pain and only for short periods of time. And we changed our minds about that. Medicine itself all of a sudden, you know, started to say, hey, you should be using these really regularly, really long-term, no problem, don’t worry about it. When people need them, they need them, they won’t get addicted. And it was completely fabricated. It wasn’t accurate at all. The information that we had, long-standing information was accurate and we got, you know, fooled by this new information. Primarily, you know, people who were in a situation to make a lot of money or convincing us to do that you know, the pharmaceutical industry itself.

Dr. Dave Levin: I think this is one of the really interesting polarities or things we have to balance in this situation. You know, I was deeply involved in hospital-based work at the time when there was, we were putting much more emphasis on recognizing and treating pain and I think it’s fair to say, we weren’t doing a great job of that.

Dr. Seppala: Yeah.

Dr. Dave Levin: And, you know, for a period of time, you know, there were campaigns and things like, you know, pain is the next vital sign that we need to track and I think those things were all well-intended and necessary and, but are in balance with this, yeah, but some of these drugs are really powerful and there’s complications there. A very interesting discussion about this topic recently on this podcast with a colleague of mine who’s in palliative medicine. And, you know, there’s a place for this and it’s important but, how we do it, when we do it those things? You know, we’re clearly out of balance. I want to ask you specifically about fentanyl as well because from what I’ve read, this sort of super potent drug and the illegal synthetic forms that are coming into this country has played a major role in the dynamic as well. Have I got that right and if so, can you tell us a little bit about that aspect of it?

Dr. Seppala: You are absolutely right, Dave. So, fentanyl primarily manufactured in China in a powder form. Unlike the fentanyl used in a hospital situation or an operating room situation which is a liquid form, you know, developed by pharmaceutical companies here and elsewhere. It’s interesting in the late 80s when I got out of training, my best friend from medical school became an anesthesiologist and he started to tell me about and I knew of some people coming into the treatment program I was working at that wasn’t a part of our system at the time but now is out in Portland Oregon. And we were treating physicians with fentanyl addiction and I was talking to my friend Keith about this. He stayed at Mayo in the anesthesia and he recognized fentanyl deaths around the country being reported by anesthesia personnel, especially among residents. It more likely to, you know, experiment with a drug like that and there were deaths occurring across the country and it became a real issue in anesthesia and at that time late 80s, early 90s, Keith and I set up a program for the Mayo Anesthesia Department to try to prevent that from happening and he’s still really involved in that system and he was gone on to work on drug diversion throughout the Mayo system which has been a real model for any healthcare system in the country. Nonetheless, we talked with each other back then and I remember saying, thank God, this is not in the illicit drug supply because here we have anesthesiologists, absolute experts in the use of these types of medications dying on a regular basis by injecting themselves because they lose control and try and just get high again and take a little bit extra of this highly powerful opioid and they stop breathing and die. And now, it’s in the illicit drug supply and people are using it because when you use opioids on a regular basis and usually if you are addicted to and you have to use them daily usually multiple times per day, it’s just a grind if it’s work, you know. It’s more like maintenance than it is like getting high day and a day out. And, you know, when we think of people with addiction in general, in the US we often think it’s just, you know, they’re just doing it because they want to party all the time, they just want to have fun, you know, that sort of thing. That is not the case. Most people in the midst of addiction, it is just torture. Every day trying to come up with enough money, enough drug to fend off withdrawal and to kind of maintain this sort of intoxication that you can’t really get much high out of anymore because you’re so tolerant to the drug. And in that situation, if you’re tolerant to oxycodone which is commonplace prescription opioid or heroin and somebody actually gives you some fentanyl what you think that would be a great thing to try because, you know, you heard it’s so much more powerful. Now, you will do that because in that maintenance stage, you’re no longer getting high and if you’ve got something way more powerful, maybe you will. The old description from opium users is chasing the dragon. They’re chasing the high, they experienced the first few times, they used opioids before tolerance really set in. And when we had fentanyl first in the media, in the Twin Cities, Minneapolis and St. Paul, at that time in St. Paul on an outpatient program, we had about a hundred patients in our opioid program, trying to help them stay abstinent and get on in recovery. And when the, when it became apparent that thorough the media that fentanyl was in the illicit drug supply in the Twin Cities, about twelve of our people disappeared that first weekend. Thank God none of them died. Now, they went to try fentanyl because maybe they’d actually get high like they did when they first started opioids that chasing the dragon, that sort of man, it’s not just going to be the same sort of thing I’ve had for so long. I may actually get that feeling again. The craving is so long-lasting with opioid use disorders that people are really tripped up easily when that sort of thing happens. That triggers our subconsciously get back into that reward center and they had the ability to prevent following through it. That sort of thing requires a lot of effort and twelve people just suddenly went out and relapsed on a very dangerous drug. When most people hear those stories, they say, why would anyone use that? People die when they take it and people who use opioids, they hear that same story and they say, my God, I’ve got to try that.

Dr. Dave Levin: Right, right. And so, there’s so much in what you said. The things I’d like to highlight are that part of what we’re seeing in this crisis is that people who might start using some sort of opioid as a part of a legal prescription become addicted and at some point if they can no longer obtain a legal prescription, they will migrate to street drugs.

Dr. Seppala: Sure.

Dr. Dave Levin: And that might be heroin which is obviously bad. Fentanyl is like, super, super heroin and that’s part of what has made this all so much worse and to your point, it’s a drug that’s available legally in this country but we’re also seeing apparently a flood of illegally produced from outside the country. It’s super potent, meaning it’s also super concentrated. And so, from a drug smuggling perspective, it’s very attractive.

Dr. Seppala: Really.

Dr. Dave Levin: Though the, and then of course this other thing is just about the potency of this drug and that it just even experienced heroin users and others are being caught off guard but just how potent it is.

Dr. Seppala: Yeah. You know, when we looked at the death associated with this opioid crisis, the CDC published a really nice graph that showed, you know, increasing opioid prescribing in the United States starting in about ‘95 and then in the early 2000s, it really starts to escalate right along with that or treatment admissions for opioid addiction or opioid use disorders escalated in a similar fashion as did the death rate from prescription opioids. Well, then the folks who market heroin, you know, basically the black market for heroin, they saw an opportunity with all these prescription opioid addicted folks across the country, they could undercut the price of prescription opioids with heroin and they did. And so, a lot of people started to drift over to heroin which is more powerful than the prescription opioids in general. And made that easier to access. They actually turned it into a service industry to really make it easy to access it.

Dr. Dave Levin: Right, right.

Dr. Seppala: And then the death rate increases even more because heroin is more powerful. Usually people use it intravenously. And following that wave, we suddenly saw fentanyl come into the illicit drug supply just as you described it. It’s [Unclear] so powerful, 50 times more powerful than heroin. So, it’s really easy to package it in very small packages and get it into the country. It’s extremely easy to make a lot more money with fentanyl than with even heroin or prescription opioids. So, the people in the black market found this to be a lot better route to take. Even though it was killing a lot of their female subjects basically. So, the fentanyl then, the death rate escalates even more because of an even more powerful opioid being used frequently and then it started it to be, they started putting fentanyl into all kinds of other tablets and things. Maybe people were aware, maybe they weren’t. But it had fentanyl on it and that’s just a recipe for disaster.

Dr. Dave Levin: Well, one last comment on fentanyl and then I want to turn to diagnosis and treatment. I was talking last week to a friend who is in the United States National Security Apparatus and somehow, we got on this topic and he said something that completely shocked me. What he said was that, experts now are most concerned that a biological attack could come in the form of fentanyl.

Dr. Seppala: Wow!

Dr. Dave Levin: Which just floored me. And I, again, I just share that as a way of kind of putting the exclamation point on this part of the discussion. This is just something very different and it’s clearly had a big impact on the crisis.

Dr. Seppala: Sure, it had.

Dr. Dave Levin: Well, I’m pretty depressed and concerned at this point Marv. I’m really hoping that this next part of our discussion is going to give me some hope here. So, if you would talk for a few minutes about the keys to successful diagnosis and treatment.

Dr. Seppala: So, diagnosis of opioid use disorders is fairly straightforward. There’s a long list in the DSM-5 about, you know, eleven different symptoms but the truth is it comes down to three groups of symptoms. One, loss of control. People are using way more than they’ve planned or intended to. They’ve got this ongoing desire to keep using and spend a lot of time like with the opioids. Especially, you’ve got to spend a lot of time at it all day long and that, you want to be intoxicated up basically 24/7 or else you’re going to withdrawal which people cannot stand. It’s like the worst flu you’ve ever had. Only you know you can get rid of it immediately with an opioid. So, lots of control first. Increased consequences, primarily social consequences. You know, they no longer getting to work on time or at all. There’s family problems, you know, child problems, school problems. They keep using despite of all this, in spite of all this stuff and those, when that happens that exacerbates the addiction because you start getting this increased shame and guilt about your behavior and you don’t want to think of that, what’s happening in your life. So, all these different things start to add up psychically to undermine any attempts to get out of this addiction. People start risking their lives, you know. You overdose three or four times and you keep using without altering anything about it and then the third thing is craving. And the opioid craving is really, really nasty. It is, it drives continued use, so much so that the research scientists call the opioid withdrawal a motivational withdrawal syndrome. It motivates continued use because people cannot tolerate it and the craving associated opioids goes on for months if not years. So, real daily diligence to prevent that craving from overcoming a person’s attempts at abstinence as it is so necessary.

Dr. Dave Levin: So, that’s a pretty good summary of diagnosis and again, no pun intended, sobering in many ways. Well, let’s talk about treatment now. So, what are, let’s start generally with, you know, sort of general approach to treatment, the options that are out there and then I’m sure the audience would like to hear more specifically about the approach at Hazelton Betty Ford. But before you do that, listeners, if you’ve just joined us, you’re listening to 4 x 4 Health. We’re talking about the Opioid Abuse Crisis with Dr. Marv Seppala, Chief Medical Officer of Hazelton Betty Ford Foundation. So, Marv, tell us a little bit again in general about treatment and then specifically about the treatment options at Hazelton.

Dr. Seppala: So, main treatments for opioid use disorder are, you know, psychotherapies, mostly group psychotherapy as we discussed earlier. So, you can recognize the problem in others and then start to see it in yourself. Those psychotherapies are primarily like cognitive behavioral therapies, motivational enhancement therapies are really, there are evidence-based actually work well for addiction. We, and then medications, there’s three medications, FDA approved for opioid use disorders. That’s Methadone, Buprenorphine and Naltrexone. The Methadone and Buprenorphine work similarly. The Naltrexone completely different, it blocks opioid receptors so people can’t get intoxicated. So, in a way, it seems like an ideal sort of medication. You can’t get high on it. It blocks receptors. You can’t get high on opioids. It’s kind of makes so much sense that people just quit taking it unfortunately. The Methadone and the Buprenorphine are maintenance medications that you take on a regular basis. They are opioids but they’re really long-lasting and prevent continued use of other opioids as well as some of the antisocial behaviors, you know, illegal activities necessary to keep getting money to get your drug and stay high every day. And they prevent all three of these mediations, prevent the infections associated with intravenous drug use at Hepatitis and HIV in particular but also a lot of staph infections that can really undermine, end people’s lives. And then in addition to the psychotherapies and the medications, there’s peer support and peer support comes in a lot of ways. 12-step programs are considered peer support, smart recovery is a type of peer support. Some people join different religious groups to get their peer support. We tend to use a real trusted orientation in our system. But one other thing about addressing opioid use disorders is that for the most part at least in our system, we’ve done a study looking at the people that come into our system and how they responded to our treatments and 90% also had a mental health problem. So, depression, anxiety, PTSD, bipolar disorder and the like. So, we’ve got a lot of mental health issues in this population. So, you’ve got to have mental healthcare as well. The medical care for all those infections and the other issues that come up with addiction and the focus has to be on engaging people long-term because of the long-term craving. So, it may start in residential treatment, it may start an outpatient but the whole story is keep people involved in that outpatient setting for a long time. Keep them coming, keep them coming back, keep them involved.

Dr. Dave Levin: This is really interesting to me and one of the things that I’ve learned from the 12-step community is, and this was more in the setting of alcoholism but I assume it applies to substance abuse in general is, there’s a difference between not drinking and being sober and leading a sober life. And the way I understand that is, you know, stopping the use of the substances is one thing and obviously an important step in the right direction. But a lot of this is about learning to live differently and that’s the, that’s a critical piece of long-term sobriety and that very often, this is where people get stuck is, they stop using the substance which is good but they’re not on that journey to find a new way to live. And I think you described a lot of that in terms of how they engage with other people and finding it for purpose in life and spiritual connections and a lot of other things. So, if I got that right, what would you add to that?

Dr. Seppala: Yeah, I agree. That’s so important because during the course of addiction, people especially with opioid use disorders, a lot of illegal activities, lot of illegal behaviors. There’s a desperation about continuing the use of the drug. So, you’ve got women and men prostituting themselves and doing just about anything to get money, to get that drug. The shame and guilt is excessive when people come into treatment. It actually prevents people from seeking help. They just think that they’re worthless, they don’t even deserve the help and as a result, they don’t seek help and even when they do, that stuff has to be fully addressed. They really have to help people and I really appreciate a 12-step approach because it does provide a spiritual approach to living and gives people a way of addressing that shame and guilt really specifically. It’s like a blueprint for leading a completely different life, allowing those folks to move on from where they once were and to powerfully live with, you know, joy again with really good relationships with other people instead of just taking advantage of everyone they meet. And if you, there’s an old story around trust [Unclear], a silver horse thief is still a horse thief and…

Dr. Dave Levin: Ha, ha [Laughing].

Dr. Seppala: That’s it, you know, it fits. If you’re still doing the same old behaviors, those relationships aren’t going to grow. No one’s going to trust you, no one’s going to really want to be around you. And if you start to change your life building on a foundation which I think spirituality does provide but there’s other means of doing that as well. You can really not just remain abstinent but really develop a remarkably different and wonderful life.

Dr. Dave Levin: I think that’s just beautifully said. I want to talk a little bit more specifically about the programs at Hazelton. One of the things that jumped out at me in preparing the introduction was the use of the word, Interdisciplinary Clinical Practices. Tell us a little bit, what does that word mean and how does that play out in your setting? What is Interdisciplinary Marv?

Dr. Seppala: You know, it’s actually just a new term for a multidisciplinary. I think which is used for decades and it’s basically, we have physicians, psychologists, other mental health personnel, you know, masters level folks, addiction counselors and even spiritual counselors involved on our treatment teams, whether in an inpatient or an outpatient setting and that allows us to have remarkably different perspectives on the individuals that we are treating. And as a result, you, we’re not just using a single sort of approach to their care. So, whereas the American Society of Addiction Medicine describes addiction as a biopsychosocial illness, biopsychosocial spiritual illness actually. In their definition they add spiritual and in that respect, you know, that doc may only want to focus on, you know, neurobiology and use of medications and that psychologists may want to look at, yeah, you know, lot of this shame and guilt stuff and maybe the traumas that occurred and the chemical dependency counselors addressing their use of a 12-step program or other means of getting into recovery and the spiritual person is looking at their life, you know, from that perspective. When all those folks are meeting me together and talking about individual, you’re going to get really good treatment planning. That covers a more holistic approach for that individual, providing not just a means to initial abstinence but those long-term changes that we were just talking about.

Dr. Dave Levin: Well, I trained in family medicine and was essentially grew up believing in the biopsychosocial model is the right way to practice medicine and deliver great healthcare. So, this makes perfect sense to me. I would argue pretty much any clinical condition, would benefit from that approach. But it’s, it, there’s a particular symmetry here because as we’ve spent most of the first part of this discussion around, this is a complex disease with many different factors. And so, it requires a team of experts in those different point of view and that all makes just perfect sense to me. The other thing that I’d like to ask you about is, we’ve alluded to this a little bit today. That their inpatient and their patient, the treatment options. Tell us a little bit about, how you make that decision, how you work with them to make that decision? And then my guess is my listeners are probably more familiar with the outpatient setting. So, then take us a little bit deeper on, if you can, what’s the typical inpatient experience?

Dr. Seppala: So, when we’re trying to make that decision between, you know, inpatient or residential stay or an outpatient program, we’re looking at the support they have at home or, you know, in the community to see if there’s enough there to help them to get through those first few weeks. We’re trying to help them get through those first few weeks of abstinence which are so hard for people with opioid use disorders. The cravings high, the withdrawal can get in the way. So, in the outpatient setting, some people can’t maintain abstinence very easily. They don’t have enough support, they don’t have their personal skills, they’re just so caught up in a lifestyle that they can’t escape sometimes, you know. For others, they’ve got family intact, they’ve got an intact job, they’ve got some friends around that really want them to get sober. And they’re going to be more likely to be successful in an outpatient setting but for a lot of folks that opioid use disorders, it’s nice to kind of get away from your usual day-to-day activities and all those triggers to return to use in a residential setting, even if it’s just a couple of weeks, two to three weeks to break that cycle and get on medication that gets started in recovery and then return to the outpatient setting and that’s kind of how we look at it. It could also involve, if they have a significant psychiatric illness that’s not being addressed, you know, they’ve got a really severe depression, they’re also suicidal or residential stays going to be a lot more appropriate for them than an outpatient stay because you run the risk of, you know, a suicide, you run the risk of the depression overwhelming them. They just go back to, you know, the opioid which could relieve that to a degree at least momentarily. So, all those things, medical illness also plays into this. So, if they have a significant enough medical problem, they aren’t going to get to outpatient programming on a daily basis. They just can’t do it and residential state could be better.

Dr. Dave Levin: Again, this all makes perfect sense to me and this we were talking about a moment ago. This is about much more than just not using whatever substance is causing the problem. It’s about breaking long-standing habits and establishing a new way of living. And as you’ve rightly pointed out, for some people, the best way to start that is essentially to remove themselves from their current environment. You have to get a fresh start and then I’ll also just point out the obvious as we talked about earlier in that group setting, I may not recognize it in myself but I see it in others and that’s the beginning of me eventually recognizing it myself. [Unclear]

Dr. Seppala: Sure, it is. One of the priorities we have is just engaging people. Meeting them where they are at, using whatever motivation they have to keep them involved because if so many people drop out of treatment, it’s a really high dropout rate for opioid use disorders and so many people stop their medications, don’t show back up. And so, our focus is to keep them around, keep them coming back, get their families involved. You know, anyway you can to keep them coming back, that’s the focus.

Dr. Dave Levin: I think you might have anticipated my last question with that answer which was, you know, your most sage advice when it comes to this crisis. So, why don’t you build on that.

Dr. Seppala: Okay. I’d say, you know, the biggest issue in the addiction treatment situation and in this crisis is that the vast majority of people with addiction don’t know they have it. They know something’s wrong; they don’t know what it is and they don’t recognize it as addiction. So, part of that is what we’re talking about with the neurobiology that eliminates the ability to fully see it. The part of it is that so many people still see addiction as not a disease, that is just a lifestyle and, you know, this ethical or moral problem and they don’t recognize just how life-threatening it may be. And a lot of the triggers because of that neurobiological reward center driving everything, a lot of those triggers are subconscious, you know. You just see your dealer and all of a sudden, you’re using without even any forethought, without a plan or anything. And so again, back to engagement, we try and keep our people engaged, get them involved with a new group of people that are staying sober. Help them to come up with, you know, sober activities instead of going back to, you know, even if they’re back in the same, you know, block that they used to be hang out with, with other people using, that might be just enough to trigger them and they find themselves in the same house with the same people or right around their own dealer. So, engagement is the biggest thing that we try to emphasize throughout our treatment.

Dr. Dave Levin: So, my last question to you would be, what’s your advice to our listeners if they are concerned that they might have a substance abuse problem or someone that they love or care about might, what’s a good first step or two?

Dr. Seppala: You know the, I think the best first step is to find someone that’s an expert in addiction and go get an evaluation and with that evaluation, you’ll get a diagnosis and you’ll get a plan specific to what’s going on and I would say the easiest way to go about that is to go to the American Society of Addiction Medicine website and look for a certified physician in your area that knows addiction well and go see that person and get a good evaluation. Just like you would if you had a prostate cancer, go to a neurologist or breast cancer to an oncologist that specializes there. Go to an addiction specialist, get an evaluation and from there, follow their recommendation.

Dr. Dave Levin: Well Marv, this has been really terrific. I appreciate you taking the time to speak with us today, to share what’s obviously a rich history and experience and of course, some of the best practices at one of the world’s leading organizations addressing this. So, thank you for all of that.

Dr. Seppala: I would glad to Dave. I appreciate having this opportunity.

Dr. Dave Levin: We’ve been discussing the Opioid Abuse Crisis with Dr. Marv Seppala, Chief Medical Officer at the Hazelton Betty Ford Foundation. Marv, thanks again for joining us.