Precision Treatment: Addiction Medicine Gets Personal

0:00:24 William Moyers
Hello and welcome to Let's Talk, a series of award-winning podcasts produced and delivered by the Hazelden Betty Ford Foundation. Each podcast focuses on a topic related to addiction. From prevention and research to treatment, current events, trends, advocacy, and of course, recovery from a substance use disorder. I'm your host, William Moyers, and today our topic is personalized care in addiction medicine. Nobody is better positioned to talk about this than our guest, Dr. Marvin Seppala, the Chief Medical Officer of Hazelden Betty Ford. Marv.

0:00:58 Dr. Marv Seppala
Hi William. Glad to be here.

0:00:59 William Moyers
Yeah, good to have you back with us again. You and I go way back.

0:01:02 Dr. Marv Seppala
We do, it's a treat. Always a treat to get together.

0:01:05 William Moyers
And yet you have a story that goes back even before your professional role at Hazelden?

0:01:11 Dr. Marv Seppala
I do. So, I went to Hazelden as a 17-year-old high school dropout.

0:01:16 William Moyers
Seventeen.

0:01:17 Dr. Marv Seppala
Yeah I got sober at 19. In Rochester, Minnesota. And a year later went off to college. And then medical school back in Rochester, at Mayo. And then during medical school realized I didn't wanna be a cardiac surgeon [Moyers laughs] I wanted to go into addiction and work in addiction and went and did a Psychiatry residency in an addiction fellowship at the University of Minnesota.

0:01:43 William Moyers
Wow. How many years have you been in recovery?

0:01:46 Dr. Marv Seppala
Forty-four.

0:01:47 William Moyers
Forty-four years! What's changed about treatment since the days when you were, you know, finding recovery and all these decades later?

0:01:58 Dr. Marv Seppala
Yeah I think the main changes have been the body of information available to make treatment decisions now is so much different. We actually know a lot about the neurobiology of addiction—

0:02:09 William Moyers
Yes.

0:02:09 Dr. Marv Seppala
And that hasn't yet resulted in the type of change we hope for but it's starting to.

0:02:15 William Moyers
What do you mean by that?

0:02:16 Dr. Marv Seppala
You know, there's certain medications that are helpful for addiction but they still have kind of low response rates in general like for alcohol use disorders.

0:02:25 William Moyers
Mmm-hmm.

0:02:27 Dr. Marv Seppala
The medications for opioid use disorders are better. The kind of understanding how the brain works in a way that we could set up a psychotherapy that would be better for this individual versus that one. Like personalized care, you know?

0:02:39 William Moyers
Right.

0:02:40 Dr. Marv Seppala
Just for that individual, customized. We're not there yet at all. So, someday we will be.

0:02:47 William Moyers
But hasn't treatment always been personalized? I mean when you were seeking treatment and when I was seeking treatment at Hazelden in 1989, they were paying attention to me, wasn't it personalized back then?

0:02:57 Dr. Marv Seppala
It was personalized based on the kind of main characteristics of the individual. So, in general, treatment—like when I went it was four weeks long.

0:03:08 William Moyers
That was it.

0:03:08 Dr. Marv Seppala
Whether you needed it or not.

0:03:09 William Moyers
"28 days," right? [uses air quotes]

0:03:11 Dr. Marv Seppala
[laughs] Yeah, it was four weeks for everybody.

0:03:13 William Moyers
Right.

0:03:13 Dr. Marv Seppala
And I was a 17-year-old high school dropout and four weeks was not enough. I went out and five days later, I was using again.

0:03:21 William Moyers
Mmm-hmm.

0:03:22 Dr. Marv Seppala
Back in Stewartville, Minnesota, with no resources for an adolescent. Except AA which I didn't go to.

0:03:28 William Moyers
Mmm-hmm.

0:03:29 Dr. Marv Seppala
So I didn't work to help myself. But so the personalized care is really customized for the individual, tailored treatments, you know, for that person. Ideally based on kinda analytic predictors or biomarkers. So for medications, getting specific kind of a blood test that checks a couple biomarkers and tells you, William, this is the medicine you should be on, versus this one, 'cause this one you'll get side effects from and this one will work way better. It's just right for you. Compared to me where I might have to take the opposite one—

0:04:06 William Moyers
Mmm-hmm.

0:04:07 Dr. Marv Seppala
—For it to work right. And for behavioral interventions, they get a little bit ignored in the general medical description of personalized care. But for us, working in addiction, it's such a complex illness, we can't limit our treatments to the biologic. It can't just be about, you know, finding a genetic biomarker for this particular medication. We have to have other means of choosing which psychotherapy to use—

0:04:34 William Moyers
Mmm.

0:04:35 Dr. Marv Seppala
—And which kinds of treatments to use. And, you know, would this be the—the better course for this individual with PTSD, you know? I mean the medicine, the therapy, all of that. And—and we aren't there, but we'll get there.

0:04:51 William Moyers
What's gonna get us there though, Marv? How do we personalize addiction treatment for each person?

0:04:56 Dr. Marv Seppala
You know, right now, there's things we can do. Project Match, an old research study about psychotherapies for alcohol use disorders, compared Twelve Step facilitation therapies—

0:05:07 William Moyers
Mmm-hmm.

0:05:08 Dr. Marv Seppala
So preparing people to go to Twelve Step meetings. To cognitive behavioral therapy to motivational enhancement therapy. And as it turns out, for people whose social circumstances support ongoing alcohol use, they're better off with Twelve Step facilitation, than the other two. But for an angry person, the motivational tools work better. So that's actually a personalization—you can pick the psychotherapy based on the patient characteristics. And that is available right now. And you could make those decisions based on that information. And we're actually doing research in partnership with Mayo looking to determine these genetic—

0:05:52 William Moyers
Hmm. Mmm-hmm.

0:05:52 Dr. Marv Seppala
—And metabolic biomarkers. So just a simple blood test of things that are normally floating around in our blood that will determine who responds to this medicine Acamprosate for alcohol use disorders. And this is gonna take four or five years to figure out 'cause it just takes a long time. Once we have this figured out, we'll be able to tell someone, 'You should take this medicine.' While, you know, this other person should not. In fact, it only works for about ten percent of alcoholics.

0:06:21 William Moyers
Wow.

0:06:22 Dr. Marv Seppala
So it's always been thought that it was a genetic subtype.

0:06:25 William Moyers
Yeah. Mmm.

0:06:25 Dr. Marv Seppala
So we're gonna try and define how to tell who should take it and who shouldn't.

0:06:31 William Moyers
But Marv, even in our system of care at Hazelden Betty Ford with facilities all over the country, residential facilities, IOP, outpatient, day treatment, how do you—how can we reasonably expect to personalize care when we're treating thousands of people?

0:06:49 Dr. Marv Seppala
Once we get it nailed down, [we] should be able to just like in the example of the medication, a simple blood test on admission—

0:06:56 William Moyers
Yeah.

0:06:56 Dr. Marv Seppala
—Makes that decision. So, very easy we're gonna be taking people's blood anyway for other purposes.

0:07:02 William Moyers
Mmm-hmm.

0:07:04 Dr. Marv Seppala
You know the information we gather on admission can be used 'cause it describes all kinds of patient characteristics. And we're also doing another project with the University of Minnesota. Using data analytics or artificial intelligence.

0:07:21 William Moyers
Hmm.

0:07:21 Dr. Marv Seppala
We're giving this group at the University hundreds, or thousands of old patient charts. They're de-identified, can't tell who they are. But it describes all these characteristics and then we have the follow-up data for how they did over the first year of sobriety. And so, what we're gonna do is develop like we don't know how many but let's say six or seven different patient risk profiles. Almost like cancer stage, you know?

0:07:45 William Moyers
Mmm-hmm. Mmm-hmm.

0:07:46 Dr. Marv Seppala
Cancer stage 1, it's there but it's not life-threatening. 5 is really serious and life-threatening. It'll be the same kinda thing that for people that might be likely to overdose, we should have a profile and then treatment planning associated with it.

0:08:02 William Moyers
Mmm-hmm.

0:08:02 Dr. Marv Seppala
But we can do that based on information they give us with their first phone call before they even come in the door. So that it doesn't even take time really—

0:08:10 William Moyers
Wow. Yeah. [nods]

0:08:11 Dr. Marv Seppala
—It's just part of our system electronically and we just plug and play basically for that individual.

0:08:17 William Moyers
What is the role that technology plays in all this?

0:08:19 Dr. Marv Seppala
A really major role. So both of those studies that medication study we're partnering with Mayo on requires artificial intelligence to really determine what those biomarkers are. 'Cause it's just too complex otherwise for the human mind to get a handle on. [chuckles] And it can identify those things that one wouldn't be able to even notice. So that's one area. The Electronic Health Record then—

0:08:46 William Moyers
Mmm-hmm.

0:08:47 Dr. Marv Seppala
—Maintains all this information, right from the first phone call, so that we can use those characteristics to determine who fits into those risk profiles from that project with the University of Minnesota. And it should automatically populate that person's chart—

0:09:03 William Moyers
Hmm. [nods]

0:09:05 Dr. Marv Seppala
—With a treatment plan specific to that risk. So let's say their major risk is leaving treatment early and relapsing. That's a—you know if we can reduce the number of people that leave treatment early and relapse based on a specific treatment plan that's for that kind of profile, that's a big deal.

0:09:24 William Moyers
Mmm-hmm.

0:09:24 Dr. Marv Seppala
And the electronic aspect of it just makes it quick and easy for our counselors and our docs.

0:09:31 William Moyers
And so this whole focus on innovation, this focus on personalized care in addiction medicine, obviously there's two goals there. One of 'em is to do a better job treating the patient—

0:09:42 Dr. Marv Seppala
Yeah.

0:09:42 William Moyers
But the second one is also to improve the prospects of a better outcome.

0:09:46 Dr. Marv Seppala
Sure is. Yeah. Always in the back of my mind it's always about better outcomes. And you know and in a way—

0:09:53 William Moyers
Hmm.

0:09:54 Dr. Marv Seppala
—It should be in the back of all our minds in addiction treatment is how can we get better outcomes. And to me personalizing care is one way of really doing that. We've always talked about in addiction individualized care—

0:10:07 William Moyers
Right.

0:10:07 Dr. Marv Seppala
But it was based on, you know, this person has you know a cocaine use disorder and PTSD, so we're gonna get 'em a counselor for their PTSD and we'll treat their cocaine use disorder, but we'll do it the same way we treat other—

0:10:21 William Moyers
Mmm-hmm. Mmm-hmm. [nods]

0:10:21 Dr. Marv Seppala
—Addictions anyway, really. I mean there's certain—you know, if they're from New York, we'll set 'em up to see somebody when they get back to New York. So they're basically kinda major aspects of the individual's character that we can easily identify. What we wanna get to is if possible underlying you know kind of biologic information that could drive our decision-making. Or, and/or these predictors of response—

0:10:49 William Moyers
Mmm.

0:10:50 Dr. Marv Seppala
—To treatments that we're doing exactly what would be right for that person. And we'll never get exact; we should be able to get close. You know? But it'll be much more specific, much more tailored to that individual.

0:11:03 William Moyers
But Marv I can hear some people out there saying why are you getting so medical or so complicated or so technical on us? [Marv chuckles] All you gotta do is hang those Twelve Steps up on the wall and let 'em follow that. What's your answer to that?

0:11:17 Dr. Marv Seppala
Even within Twelve Step programs, I would say that people have the luxury of choice. You know they get to choose how they work those Steps. They're suggested Steps, they're not required, they're not mandatory. And, so it becomes individualized. And they get to choose their sponsors, they get to choose what meeting they go to—

0:11:36 William Moyers
Mmm-hmm.

0:11:36 Dr. Marv Seppala
They get to choose who they surround themselves with. And what else they read about those Steps and how to work them. And then figure out for themselves over time what that means. And even spirituality is left up for the individual to define for themselves. In a way that works for them. So I see that as really personalized in a way that we can learn from actually. [Both chuckle.] It's kind of funny that way.

0:12:02 William Moyers
Well Marv, we really appreciate your being with us today to talk about personalized care in addiction medicine, to talk about the importance of a good outcome. And I think it's always remarkable when you and I get to sit down together on these Let's Talk podcasts. To realize that you and I were once people who were baffled by our use of substances.

0:12:22 Dr. Marv Seppala
[chuckles] We're lucky to be alive and doin' this.

0:12:23 William Moyers
All these decades later.

0:12:25 Dr. Marv Seppala
Yep.

0:12:25 William Moyers
Here we are at the Betty Ford Center, you know, talking about things that used to baffle us about the disease.

0:12:30 Dr. Marv Seppala
[laughs] That's right.

0:12:30 William Moyers
I really appreciate you being with us today.

0:12:33 Dr. Marv Seppala
Oh, thanks, William. I'm glad to be here.

0:12:35 William Moyers
Dr. Marvin Seppala, the Chief Medical Officer of the Hazelden Betty Ford Foundation. And this has been another podcast of the Let's Talk podcast series. We hope you've enjoyed our topic for today and ask that you spread the word and let your friends and fellow travelers, your colleagues, and your families, let everybody know that these Let's Talk podcasts are alive and well and current. In our new year here at the Hazelden Betty Ford Foundation. And we hope that you'll tune in again. Thank you very much.