Interview with Dr. Stephen Delisi of

The Hazelden Betty Ford Center

Hazelden Betty Ford Center Interview with Dr. Stephen Delisi

Edited by: John Purakal, MD (Duke University SOM)

Stephen M. Delisi, MD, completed medical school at Loyola Stritch School of Medicine in Chicago. He then went on to complete a fellowship in Neuroscience for 3 years with Loyola at Hines VA, followed by his residency in adult psychiatry. Dr. Delisi has been board certified for 20 years and has been with the Hazelden Betty Ford Center in Minnesota for 15 years. He currently serves as the Medical Director for Professional Education Solutions, and as an Assistant Professor with Hazelden Betty Ford Graduate School of Addiction Studies.

1. The Hazelden Betty Ford Center is certainly a world-renowned treatment center for many with substance use disorder. Can you tell me how the center got started?

If we go back, the origin of the Hazelden model began back in the 1940s. There was a psychologist, Dan Anderson, who was just finishing his doctorate program in psychology and was going to be doing a postdoc. As he was driving across the country to get to one clinical site, his car broke down in rural Minnesota and he got held up in a hotel with family while waiting to get car parts. The local state mental health center learns he is in town and goes to talk to him. One thing leads to another and they ask him to lead up an inpatient program there and he agreed and was made director of the ‘Unit for the Inebriate’. It was a locked unit and the individuals who were going through alcohol withdrawal were locked in with the severely and mentally ill. There was very little respect and understanding of the disease of addiction. Dan Anderson made changes to have them on their own unlocked unit and everyone thought he had lost his mind. He heard of a fellowship group out in the community that was helping people find sobriety (the early origins of Alcoholics Anonymous) and he started to invite people from this group into the hospital to share their stories and tell their pathway to recovery and invited them to be a part of the staff. It had significant impact and started the model of what would become the addiction counseling profession (the graduate school for addiction studies is now an accredited master’s degree).

Right about that time, Hazelden was starting in rural Minnesota and they heard of what Dan Anderson was doing and asked him to join them. That was the beginning of a peer-based model of treatment, the holistic approach, and treating those patients with respect.

The origins of the Betty Ford center came when Betty Ford (former first lady of the United States) went to the board of directors of Hazelden and said “I want to bring this model of care to California, can you help me do that.” That led to a number of the Hazelden executive team going out to Rancho Mirage and working to start the Betty Ford center and so from its very origins they were of the same system of care with the same political model.

2. The Betty Ford Center has exceptional remission rates:

· 89% of patients are alcohol-free one month after rehabilitation

· 85% to 95% of patients are abstinent from all other drugs nine months after rehab

· 80% of patients report improved quality of life and health after rehab

Can you differentiate what sets you apart from other treatment centers?

Any time you see remission rates like that from any treatment facility, you have to start asking what the selection biases are, what the confounders are, and how that is being measured. I actually reached out to our Butler Center for research that does the research for Betty Ford and they also had a cautionary note that they are working diligently to improve survey rates so data is not confounded by who responded. Many times that is the huge confounder when it comes to treatment-oriented outcomes. One can imagine that if someone is struggling with their disease, they may not respond. There is also selection bias for who ends up as a patient at Betty Ford and that impacts the remission rates as well. We do have good remission rates at 1, 3, and 6 months and I believe it is because of that broad approach and our strong emphasis on continuing care. At 1,3, and 6 months we have more patients engaged in treatment and the longer you have patients in treatment, the better their outcomes. My concise answer is to be cautious about the absolute numbers but that holistic care and keeping people engaged for a minimum of 6 months and preferably for 12-24 months is key.

3. One thing I loved in my visit to the Hazelden Betty Ford Center was the holistic approach you took with patients. What factors do you believe need to be addressed in a person’s remission journey?

It is our insistence that we treat addiction as a chronic medical illness. We subscribe to the bio-psycho-social-spiritual model and we are holistically trying to integrate all of those aspects of humanness. I think that our interdisciplinary integrated care model is also what sets us apart. We truly integrate medical, behavioral health, substance use disorder professionals and peer support specialists along with spiritual care and wellness to provide that more holistic approach. And we also are really intentional about it because we believe in the chronic disease model. Our clinical model is moving patients from clinical management (with physicians and counselors managing the patient) to then stepping them down into lower levels of care within the same continuum so they get to the place where they are doing more self-management. I think that self-management contributes to the more positive outcomes.

4. I know the Hazelden Betty Ford Center has a family program and many resources for family members. What resources or advice do you have to encourage emergency physicians to incorporate the family in the treatment plan?

For emergency medicine in particular it is difficult unless the family has brought the patient in. As a physician, you are never neutral in your interaction with patient and family in terms of engaging them further into treatment or moving them away from treatment. Irrespective of how long you spend with the patient, you are either going to result in more motivation and engagement or less. We can debate the amount but nothing is neutral. So, what can you do? You can start by fully embracing addiction as an illness. It is no different from the other illnesses that people are presenting to your emergency department with and you’re going to be addressing it in a similar fashion. The same can be done with family members. Treat family members with respect and talk to them in the language of a disease that is non-stigmatizing. “Your loved one is presenting to the emergency department with symptoms of an active illness and this is a disease that can be treated.” When someone comes in for their third heart attack, the patient is not typically blaming themselves and the family is not typically saying they failed on their bypass surgery. Instead they are saying what can you do and how can you help them. And we don’t necessarily say the same thing with addiction especially in the emergency room.

5. A growing number of emergency physicians are getting MAT waiver-trained. What are your thoughts on Buprenorphine treatment for patients with opioid use disorder and what tips do you have for best managing this type of treatment?

As an emergency physician you don’t have to be MAT waivered to initiate buprenorphine. You can do a 3-day buprenorphine induction for opioid use disorder and then utilize a bridge clinic. This is the exception to the waiver that has been made, recognizing that there are not enough emergency physicians that are data waivered. Buprenorphine in the early treatment of opioid use disorder can benefit almost everyone. It is both a partial agonist at the mu receptor (so it helps with the withdrawal symptoms and the cravings) but it also is a kappa opioid antagonist (kappa receptors are activated by dynorphin which is activated during withdrawal and this causes dysphoria, agitation, irritability, anxiety, and restlessness). Buprenorphine blocks the kappa receptor and you can see within the first few doses people really settling down and stabilizing. They can listen and engage better and it truly maintains people in treatment in those early phases.

Similar to patients with type 1 diabetes that need to be on insulin for life, there are individuals with opioid use disorder where the medication component is an ongoing maintenance to their overall treatment. I am a recovery-oriented physician so I am always trying to help each patient find their pathway to recovery, which is more than staying alive and not using, but that’s not everybody. I am also a patient-centered clinician and I am always trying to meet the patient where they are at. I don’t differentiate between the “absence only” group and the “harm reduction” group. I think it always starts with harm reduction and stabilization because if the person is actively using or overdoses and dies, we are not going to be able to treat them. As they stabilize, I want to continue to engage with them and see what their goals for life and recovery are and then that may bring in more of the mental health, counseling, spiritual consultation and such. It’s a process and I think medications are really important. I don’t subscribe to just putting them on medications and being done. I also don’t subscribe to “unless you’re willing to do all sorts of other things, I am not going to give you the medicine.” I am going to give the medication because I want them stable and I want them safe. And then I’m going to engage in other aspects of treatment.

6. Emergency medicine physicians have busy shifts and often do not have the chance to see a patient across multiple visits. What do you recommend as the best approach when presented to a patient with substance use disorder? What can we do better as emergency medicine physicians for these patients?

One of the ways emergency medicine can do better is by starting to build treatment algorithms into the standard of care. If someone shows up with chest pain that radiates to the left shoulder, you know exactly what you should be doing. There should be exactly the same thing when someone comes in acutely intoxicated or in florid withdrawal. Some of it is to address stabilizing medically, but the other part is treating them with respect and using language that they are presenting with symptoms of an illness rather than as users, junkies, or even addicts. If it’s acute alcohol intoxication, then “your acute alcohol intoxication coupled with your liver enzymes tell me that you have symptoms of an active alcohol use disorder. That is what I am concerned about and I would like to give you some information about that and have you talk with our (ideally) social worker, community care coordinator, and/or peer support specialist in the emergency department.” This goes back to the Dan Anderson model. People with the wisdom of the lived experience, with specialized training should be embedded in the emergency department. Then you can say “I would love for you to talk to a peer support specialist” and then they swoop in and start to do motivational interviewing work and talk about their story and instill hope. There are EDs that are doing some of the best addiction medicine work in the country. They are doing acute stabilization and then induction of treatment. They are starting treatment right in the emergency room and then referring to a community bridge clinic, and again, they also have the peer support specialists or community care coordinators.

7. Stigma of addiction is prevalent not only in the general population, but within medicine as well. How do you recommend we work towards reducing stigma?

As a medical student or resident, take care of what you can take care of: your interactions with patients, with their families, and with your students. You can control how you interface with patients and that will be noticed by others. You may get made fun of by others or people may say it takes too much time but you don’t need time. You just need to relay care, compassion, and empathy, and that doesn’t take any time whatsoever. Impart that knowledge to those below you. Also know you don’t have to solve all of the problems right away or all by yourself. Look for connecting the local community addiction centers so when you’re making a referral you know what you’re referring to. My shame as a fourth year resident in psychiatry was giving someone a piece of paper with referrals and not even half of the phone numbers on that paper were current any longer.

As an attending physician you have a platform and your voice and advocacy goes a long way. We all have to be active with public policy and advocacy. We have to speak into the space. People with addiction are not going to do it for themselves. It’s an isolating, stigmatized, shame-filled disease, and if we don’t speak on their behalf there is going to be no one speaking for them. Emergency medicine is a profession with some of the least knowledge about addiction and some of the highest level of stigma, bias, and unwillingness to do what we are talking about. I also just want you to be prepared that some of what your role is going to be is as an ambassador for your colleagues and helping them to understand and conceptualize addiction as a disease.

8. What resources do you recommend for people who want to create a better understanding of addiction?

Get connected with organizations like Hazelden Betty Ford, American Society of Addiction Medicine, American Academy of Addiction Psychiatry (you do not have to be a psychiatrist to have that connection). Gain additional training in addiction medicine with an addiction medicine fellowship. Hazelden Betty Ford has a partnership with Emory health systems and formed the Addiction Alliance of Georgia that will be expanding medical education on addiction and perhaps creating an addiction medicine fellowship there in the future. There is also PCSS.org that is a wonderful SAMSA-funded outgrowth of the American Academy of Addiction Psychiatry that do a majority of the MAT waiver training, but they also have a mentorship program where you can sign up and get mentored in your work of treating addiction. Also, stay connected to your local community treatment centers.

9. Is there anything else you would like to add?

Call to action: Emergency physicians should be a source of de-stigmatizing this disease and courageously starting treatment right out of the emergency department.