By Alison Knopf
The American Association for the Treatment of Opioid Dependence (AATOD) has released recommendations on siting opioid treatment programs (OTPs). The guidelines are meant to encourage OTP sponsors to work with neighborhoods, local treatment programs, and local and state officials. The recommendations include:
- Focus on underserved areas. Good locations include those with high rates of overdoses, emergency room admissions, and criminal justice involvement. If a town has other OTPs, determine if those facilities are meeting patients’ needs. If the existing OTPs lack sufficient capacity to treat all local patients who require it, clearly additional programs are needed. New OTPs must work with municipal, county, and state administrators to be sure that programs are being located in underserved areas.
- OTPs should follow any specific requirements set up by municipalities, counties, and states. This helps to create a smooth transition into the community.
- Operating hours of OTPs should be published, and OTPs should let communities know what to expect from the treatment process.
- OTPs should work with community leaders. This will involve a high level of community education during siting, and is essential for developing trust.
- Avoid competing for patients where other OTPs are already established. The goal is to ensure that the new programs meet the community’s needs. It’s also important to minimize dual enrollments, and to facilitate the safe transfer of patients between programs.
- Follow AATOD’s Canon of Ethics: potential patients or third-party recruiters cannot be offered financial enticements.
- When a program is sited, develop relationships with office-based providers, as in the Hub and Spoke model in Vermont. In that model, OTPs assess all new patients, treat some, and refer others to office-based providers.
Reaching the current opioid crisis has taken more than three decades; emerging from it will take years, AATOD president Mark Parrino, MPA, noted, in issuing the guidelines.
“It is our collective hope that these guidelines will provide useful recommendations as our treatment system expands over the course of the coming years,” said Mr. Parrino, speaking for himself and the AATOD board. He added that in the years ahead, as OTPs continue to grow, it will be important to follow siting guidelines.
The guidelines issued October 4 can be accessed at: http://www.aatod.org/news/recommendations-in-siting-new-otps-in-the-united-states/.
By Alison Knopf
Citing the harms of untreated opioid use disorders, the federal Food and Drug Administration (FDA) says that benzodiazepine use should not preclude the use of medication-assisted treatment (MAT) for opioid addiction with methadone or buprenorphine.
In a September 20 drug safety communication, the FDA states that “buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system (CNS).” While it is true that combining these drugs can cause serious side effects, “the harm caused by untreated opioid addiction can outweigh these risks.”
By using careful medication management, health care professionals can reduce the risks, the FDA said. Labeling changes will be required for buprenorphine and methadone.
“Buprenorphine and methadone help people reduce or stop their abuse of opioids, including prescription pain medications and heroin,” the FDA said. “These medications are often used in combination with counseling and behavioral therapies, and patients can be treated with them indefinitely.”
Benzodiazepine use can occur either under a health care professional’s prescription, or illicitly, the FDA said. In either case, excluding or discharging patients from MAT because of the use of benzodiazepines or other CNS depressants won’t stop patients from combining the drugs. On the contrary—the combined use would continue outside the treatment setting, which could have even worse outcomes, the FDA said.
‘Win for Individualized Care’
“This is definitely a win for individualized care,” said Zac Talbott, CADC II, ICADC, CMA, program director of Counseling Solutions Treatment Centers, opioid treatment programs (OTPs) based in Chatsworth, Georgia and Murphy, North Carolina, of the FDA guidance. “It is in line with what credible voices in the OTP world have been saying as well.”
Noting that the concept was also stated in the benzodiazepine guidelines from the American Association for the Treatment of Opioid Dependence, previewed at the conference in Baltimore last year, Mr. Talbott said that policies need to be geared towards individual patients. “While it is critical we utilize caution when dispensing methadone or buprenorphine to patients prescribed other CNS depressants, blanket no-benzodiazepine policies are the opposite of the individualized treatment mandated by the federal accreditation guidelines,” he told AT Forum.
Treatment professionals should develop a treatment plan when patients are using benzodiazepines or other CNS depressants in combination with methadone or buprenorphine, according to the FDA.
- Educating patients about the serious risks of combined use, including overdose and death, that can occur with CNS depressants
- Developing strategies to manage concurrent administration of benzodiazepines or other CNS depressants—used as prescribed, or illicitly—when starting MAT
- Tapering the benzodiazepine or CNS depressant to discontinuation, if possible
- Verifying the diagnosis, if a patient is receiving prescribed benzodiazepines or other CNS depressants for anxiety or insomnia, and considering other treatment options for these conditions
- Recognizing that patients may require MAT medications indefinitely, and their use should continue as long as patients are benefiting and their use contributes to the intended treatment goals
- Coordinating care, to ensure other prescribers are aware of the patient’s buprenorphine or methadone treatment
- Monitoring for illicit drug use, including urine or blood screening
The FDA’s announcement follows the August 2016 drug safety communication from the agency warning about combining opioid-containing pain or cough medicines with benzodiazepines or other CNS depressants. Continued review by the FDA, based on a study conducted in Sweden, led to the decision to add information to the existing boxed warning for methadone products about the risks of slowed or difficult breathing and death when benzodiazepines or other CNS depressants are combined with the medication.
For the Warnings and Precautions section, there will be expanded guidance on how to manage patients in methadone treatment in OTPs who are also taking CNS depressants. Buprenorphine products, on the other hand, will have only an expanded and revised statement in the warnings and precautions section on managing patients in buprenorphine treatment who are also taking CNS depressants.
By Barbara Goodheart, ELS
Many health professionals have suspected it for a while, and now it’s official: a study published in October in Health Affairs, and written up by HealthDay, reports that heroin has once again become more popular than prescription opioid painkillers as the opioid of first use.
This turnaround is reminiscent of the 1960s—but back then the percentage was much higher: more than 80% of people who were dependent on opioids said their opioid use had begun with heroin.
Heroin was cheaper in those days than prescription opioids, and easier to get; and the same is true today.
The chart directly below shows the percentages behind patients’ initial choices of an opioid in 2005, and 10 years later.
Patients’ Choice, Opioid of First Use (%)
*In the 1960s, patients selected
heroin more than 80% of the time.
If the trend continues, additional follow-up studies could show a further shift—but this time from heroin to synthetic opioids, such as fentanyl. That’s the prediction of Lindsey Vuolo, JD, MPH, associate director, health law and policy, The National Center on Addiction and Substance Abuse. Ms. Vuolo, who was not an author on the study, was interviewed by Dennis Thompson for the HealthDay article, along with Tina Hernandez-Boussard, PhD, associate professor and senior researcher at the Stanford University School of Medicine, and senior author on the Health Affairs study.
The research team behind the Health Affairs article analyzed national data on hospital and emergency department admissions for opioid overdoses. They found a marked change in the overdose situation in recent years. Between about 2010 and 2014, treatment rates for prescription opioid overdoses fell by about 5% each year. But at the same time, cases of heroin overdoses skyrocketed—up by more than 31% a year, according to HealthDay.
Who’s at Risk?
The profile of the person at risk of opioid overdose has changed as well, according to Dr. Hernandez-Boussard. Back in 1997, the person at risk of opioid overdose was a young white male living in the northeastern United States. Today, all groups are at roughly equal risk; women and men, the young and the old; people of all backgrounds, living in all parts of the country.
A Near-Tripling in Opioid-Related Deaths Leads to Controls on Rx Opioids—and Heroin Deaths Resurge
In 2010, President Barack Obama issued orders resulting in action against the prescription opioid epidemic. The result was a significant annual drop in prescription opioid overdose rates of 5% for hospitals and emergency departments. The drop continued to 2014.
But was there a price to pay?
It’s since been suggested that many people who become addicted to prescription opioids—and eventually can no longer get them—turn to heroin. And it’s been pointed out that the yearly 31% rise in treated cases of heroin overdose began at around the same time as the regulations came into effect, while the overdose rate for prescription opioids dropped.
Dr. Hernandez-Boussard offered a different explanation: perhaps the real problem is that America’s response to the opioid epidemic hasn’t included an adequate focus on treating addiction.
Ms. Vuolo agreed. “People who are already addicted to prescription opioids are not being connected to treatment, and therefore moving to other forms of opioids,” she told HealthDay.
Needed: Resources for Patients
According to both Dr. Hernandez-Boussard and Ms. Vuolo, there aren’t enough resources—treatment centers and facilities—to combat addiction and help people addicted to opioids. The two experts also said that the doctors caring for these patients are failing to connect their patients with treatment.
To back this up, Ms. Vuolo pointed to a recent study of a Pennsylvania Medicaid program. That study found that only 33% of patients treated for a heroin overdose, and 15% of those treated for a prescription opioid overdose, were dispensed buprenorphine, naltrexone, or methadone within six months of the overdose. The two experts agreed that the hospital staff, health professionals, and police need better training on steering patients into treatment.
Dr. Hernandez-Boussard told HealthDay that, now that some patients are living through a heroin or prescription opioid overdose, “we need to think about strategies regarding recovery programs and managing opioid dependence.”
In their concluding statement, the authors of the Health Affairs article expressed a similar sentiment, adding that “specific treatment programs need to be implemented for patients discharged with opioid misuse.”
# # #
Tedesco D, Asch SM, Curtin C, et al. Opioid abuse and poisoning: Trends in inpatient and emergency department discharges. Health Aff (Millwood). 2017;Oct 1;36(10):1748-1753. PMID:28971919. doi:10.1377/hlthaff.2017.0260.
Thompson D. Heroin taking bigger share of U.S. opioid ODs. HealthDay. https://consumer.healthday.com/mental-health-information-25/addiction-news-6/heroin-taking-bigger-share-of-u-s-opioid-ods-727030.html. Published October 2, 2017. Accessed October 25, 2017.
Cicero TJ, Ellis MS, Surratt HL, et al. The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.
By Barbara Goodheart, ELS
This was a study of specialty treatment for opioid use disorders (OUDs) in publicly funded programs in the U.S. Investigators at Johns Hopkins who turned up this unexpected finding published their study online July 11 and in the September 1 issue of Drug and Alcohol Dependence.
(The term “specialty treatment programs” includes publicly or privately state-funded facilities licensed or certified by the local U.S. Substance Abuse Agency to provide substance abuse treatment in that state. Facilities that report data generally are those that receive drug agency funds from the state for providing drug treatment services).
Opioid agonist treatment (OAT) is the standard of care in OUDs, yet most people in treatment—more than two-thirds of those whose data are included in this study—are not receiving it.
The authors wondered if racial or ethnic differences, or both, accounted for the differences in OAT receipt, or if other factors, such as differences in clinical need, were involved. They noted that several factors often interfere with the inclusion of medication into “traditional substance use care,” and patients’ access to treatment may be hindered by regulatory barriers and by medication-stigma. Moreover, methadone treatment often involves long waiting lists and extensive travel, and buprenorphine access tends to be limited, because certified providers are in short supply.
In this study of 94,202 patients, investigators used data from the 2014 Treatment Episode Dataset (TEDS-A).
- Are there racial or ethnic differences in the proportion of patients given OAT?
- If so, to what extent are they explained by differences in clinical need?
(The term clinical need refers to factors that help a clinician decide whether to treat a patient for a given condition. For example, a clinician might decide that a patient who frequently injects opioids should be given priority status for agonist treatment.)
- When differences aren’t due to clinical need, how important are treatment setting and other factors?
- Are racial/ethnic differences similar in the “heroin” and “other opioids” groups?
Characteristics of Clinical Need
|Heroin use||Heroin users may be more likely to use OTPs that offer agonist treatment|
|Older age||Agonist treatment may be a less likely choice for younger patients|
|More frequent use;
Route of use
|Those who inject or use substances more frequently, with apparent or actual higher severity of disorder, may be more likely to be given agonist treatment|
|Use of benzodiazepines or alcohol||Could be considered a contraindication for agonist treatment|
The following table summarizes key data from the study, including patients’ race and ethnicity, percentage of the study population, OAT receipt, primary opioid, and type of facility where patients received treatment.
Patients’ Characteristics, by Race and Ethnicity
|Total N =
All values are statistically significant. (See the published reference for the complete table.)
As the table shows, blacks and Hispanics had a much higher likelihood than whites of receiving the preferred (agonist) treatment: 43% and 39.8%, vs. 25% for whites. The differences were evident only for those who used primarily heroin rather than other opioids.
Clinical need factors—such as heroin use—accounted for about three-fourths of the difference in the number of blacks and whites receiving OAT. The clinical factors also accounted for about half the difference in Hispanic vs. white patients. Another important factor: characteristics of the setting. Patients in ambulatory detoxification and non-intensive outpatient treatment were far more likely to be given agonist treatment than those in other settings.
Yet heroin use and other clinical factors did not completely explain the surprising finding mentioned earlier—that white OTP patients who use heroin are less likely than other patients to receive OAT. This finding contrasts with other research results, and the authors point out that it was not foreseen, in that minorities often receive a lower standard of health care than white patients. Additional studies are needed to account for the remaining differences.
Noting that OAT is considered the standard of care for patients with OUD, the authors found its underuse concerning. They commented that agonist therapy is the treatment recommended by federal government agencies, the recent Surgeon General, and SAMHSA, making it “ever more pressing that programs receiving public funding be held to treatment standards and be given the tools to administer evidence-based treatment that can help mitigate the harms of the ongoing opioid epidemic.”
This study emphasizes the need for improving patient care by making OAT available to more patients, especially white patients whose primary substance of use is heroin.
# # #
Krawczyk N, Feder KA, Fingerhood MI, Saloner B. Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample [published online ahead of print July 11, 2017]. Drug Alcohol Depend. 2017;178:512-518. doi:10.1016/j.drugalcdep.2017.06.009.
By Barbara Goodheart, ELS
In September of last year, the American Academy of Pediatrics (AAP) issued a policy statement calling for making drug therapy available to adolescents with opioid use disorder (OUD).
The statement caused hardly a ripple. Those who treat adolescents reported that some families, clinicians, even some patients, consider the medications—methadone, buprenorphine/naloxone, naltrexone—a last resort.
Now, a year later, several articles have addressed this issue and offer recommendations. One article underscores the risks of waiting “until things get worse” (see “Recommendations” under “Commentary,” below). This AT Forum article summarizes the recent findings and the many recommendations from these articles.
Rise in Opioid-Related Deaths Follows a Two-Year Hiatus
In 1999, adolescent death rates from overdoses involving opioids began rising sharply. Rates have zigzagged downward since about 2007, but began rising again between 2014 and 2015 (see figure below). How many young people have died from overdoses involving opioids isn’t known, but following the trend of the line in the figure below gives a clue to the severity of the situation.
Drug Overdose Death Rates Involving Opioids;
Adolescents Aged 15–19, United States, 1999–2015
Adapted from NCHS, National Vital Statistics System, Mortality. Curtin SC, Tejada-Vera B, Warner M. Drug overdose deaths among adolescents aged 15–19 in the United States: 1999–2015. NCHS data brief No. 282, August 2017. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db282.pdf.
Timely, appropriate treatment would have saved some of these young lives. Especially tragic: in 2015, about 80% of adolescent deaths were unintentional. Attitudes are beginning to change, however: many clinicians now realize that the need for treating adolescents with OUDs has indeed become urgent.
The AAP Policy Statement—
American Academy of Pediatrics. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics, 2016.
The 2016 publication, the first official policy statement on treating OUDs from a professional pediatric organization, indicated an important shift in professional thinking. Starting out by briefly reviewing the history, consequences, and treatment of opioid misuse, it went on to note the availability but underuse of effective medications and counseling, and the impediments to treating young patients: federal regulations that block most methadone programs from enrolling patients younger than age 18, and restrictions limiting buprenorphine treatment in patients younger than age 16.
Recommendations. The Policy Statement called for offering available treatment to adolescents with OUDs, and developing new treatments “to save and improve lives of youth with opioid addiction.” (The term “youth” in this context refers to adolescents and young adults.)
The AAP group recommends improving access to medication-assisted treatment (MAT) in the young, both in primary care and through counseling in community centers; conducting further research on “primary and secondary prevention, behavioral interventions, and medication treatment. It also recommends that pediatricians consider offering MAT to patients, or discussing referrals.
Addressing Stigma in Medication Treatment of Adolescents With Opioid Use Disorder. Bagley et al. American Society of Addiction Medicine, 2017.
Regarding the AAP Policy Statement, the clinical experience of the Commentary’s authors indicated that some patients, families, even clinicians perceive using medications to treat OUDs in adolescents “a last resort;”—believing it’s necessary to wait to treat “until things get worse.”
The authors, who are addiction specialists with the American Society of Addiction Medicine (ASAM), strongly disagree. Stressing that their role requires them to identify and prevent risky use and use disorders, intervene early, “and offer timely, evidence-based treatment,” they see treating adolescents not as a last resort, but as an opportunity “to prevent the long term medical, psychiatric, and social consequences of ongoing substance use.”
And they note that caregivers and patients may incorrectly assume that young people may need to continue medication for life, a misconception the authors attribute to stigma, possibly explaining the resistance to treating OUDs with medication.
The authors stress that the medication course can in fact be limited in younger patients, and “it is possible that earlier treatment in adolescence may lead to sustained recovery in adulthood.”
They acknowledge, however, that more needs to be known about selecting the medication and the length of treatment.
Recommendations. To destigmatize medication treatment, the authors recommend launching a coordinated effort that begins with the federal government, uses evidence-based interventions, and targets all players—parents, behavioral health providers, and state agencies. They say that the treatment models used in younger patients may need to be adapted to include family in treatment, and to account for developmental differences. They also emphasize reducing the stigma associated with using medications in treating this group.
MAT for Adolescents in Specialty Treatment—
Medication-Assisted Treatment for Adolescents in Specialty Treatment for Opioid Use Disorder. Feder et al. Journal of Adolescent Health, 2017.
This study, covering 139,092 patients, found that only 2.4% of adolescents treated for heroin use received MAT, compared to 26.3% of adults treated. For treatment related to prescription opioids, the corresponding numbers were only 0.4% of adolescents and 12.0% of adults. The data were from publicly funded programs in specialty treatment programs.
The authors noted severe restrictions on methadone access for patients aged 16 and 17 years. Methadone clinics need special wavers to treat adolescents, and require proof of two failed attempts by the patient to discontinue drug use.
Recommendations: Regarding Medicaid and CHIP (Children’s Health Insurance Program): include MAT in the early periodic screening, detection, and treatment benefit of state Medicaid programs, and include adolescents in ongoing Medicaid demonstrations to expand MAT. In addition, “policy and practice changes are needed to expand access,” as recommended by the AAP.
Trends: An Original Investigation—
Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. Hadland et al. JAMA Pediatrics, 2017.
A large retrospective study looked at insurance and treatment data from 20,822 commercially insured OUD patients aged 13 to 25 years. Although medication dispensing fluctuated, only one out of every four commercially insured youth ever received medication (buprenorphine or naltrexone). Moreover, investigators observed “disparities based on sex, age, and race/ethnicity.”
Those less likely to receive medication were younger, or female, or nonwhite. The authors commented, “Intervening early in the development of OUD is critical for preventing premature death and lifelong harm.”
Both the AAP policy statement and the 2016 surgeon general’s report reiterate the need to intervene early; in fact, two-thirds of patients being treated first used opioids before age 25; one-third, before age 18.
The team criticized the AAP Committee for not releasing a policy statement until September of 2016—during a worsening youth opioid epidemic, “despite preexisting recommendations from the Substance Abuse and Mental Health Services Administration.” This, the Committee said, may have delayed pediatricians’ adoption of drug therapy for their young patients.
Recommendations. Include drug therapy in pediatric primary care, and improve access to evidence-based treatment for adolescents—for example, by adding pediatric addiction subspecialists. In addition, expand the use of pharmacotherapy for youth, and ensure equitable access for all affected youth.
Editorial: Closing the Gap—
Closing the Medication-Assisted Treatment Gap for Youth With Opioid Use Disorder. Saloner et al. JAMA Pediatrics, 2017.
An editorial in the same issue of JAMA Pediatrics as the Hadland article includes many recommendations. We list some of them below.
- Have pediatricians refer youth to a methadone clinic or other specialty treatment for MAT
- Build capacity in pediatric primary care, giving physicians knowledge and support to prescribe MAT
- Expand the office-based prescriber workforce; include pediatricians
- Integrate primary and specialty care (for example, adapt “hub-and-spoke”)
- Reduce stigma toward MAT
- Improve health insurance policy support of youth access to MAT
- Arrange for payment through insurance programs for counseling and recovery management;
- Close the gap in evidence-based care for youth through comprehensive policy changes and individual practice changes.(See the published articles for details of all studies.)
# # #
AAP Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893. doi:10.1542/peds.2016-1893.
Bagley SM, Hadland SE, Carney BL, Saitz R. Addressing stigma in medication treatment of adolescents with opioid use disorder. J Addict Med. 2017 [Epub ahead of print]. PMID: 28767537. ISSN: 1932-0620/16/0000-0001. doi:10.1097/ADM.0000000000000348.
Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder. Adolescent health brief. J Adolesc Health. 2017;60:747e750. PMID: 28258807. doi:10.1016/j.jadohealth.2016.12.023.
Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, Larochelle MR. Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001-2014. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8):747-755. PMID:28628701. doi:10.1001/jamapediatrics.2017.0745.
Saloner B, Feder KA, Krawczyk N. Closing the medication-assisted treatment gap for youth with opioid use disorder. Editorial. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8);729-731. PMID:28628699. doi:10.1001/jamapediatrics.2017.1269.
By Barbara Goodheart, ELS
This update from the Substance Abuse and Mental Health Services Administration (SAMHSA) reports trends in the use of methadone, buprenorphine, and extended-release, injectable naltrexone—an option for treating opioid use disorder. Not included in the report are data from private physicians who aren’t affiliated with a treatment facility or program.
Paralleling the recent increase in deaths from heroin and other opioids, the number of opioid treatment programs (OTPs) and other medication-assisted treatment options for preventing such tragedies has also risen. The figure below summarizes key information from the August 22 CBHSQ Report, a SAMHSA publication.
Trends in Treatment at Substance Abuse Treatment Facilities: 2003-2016
+ + +
Alderks CE. Trends in the Use of Methadone, Buprenorphine, and Extended-release Naltrexone at Substance Abuse Treatment Facilities: 2003-2015 (Update). The CBHSQ Report: August 22, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.pdf.
By Alison Knopf
Longtime methadone and opioid treatment program (OTP) advocate and professional Edward J. Higgins died peacefully at home in Toms River, New Jersey on October 8.
Mr. Higgins began working in methadone treatment in 1973. In 1984, as clinic director in charge of state methadone programs in Asbury Park and Toms River, he helped 13 methadone programs form a group of private non-profit entities called JSAS HealthCare Inc. The next year he helped found the Northeast Regional Methadone Treatment Association, which eventually became the American Association for the Treatment of Opioid Dependence (AATOD). Mr. Higgins represented New Jersey at AATOD.
Mr. Higgins was CEO/Executive Director of the non-profit JSAS HealthCare Inc., Neptune N.J., from July 1984 until his death.
“Ed was profoundly helpful in organizing the New Jersey providers during the early period, and he also worked with our northeastern colleagues to lay the groundwork for what would become the American Association for the Treatment of Opioid Dependence,” said AATOD president Mark Parrino, MPA. “Besides being an extremely knowledgeable administrator, Ed was always generous with his time and efforts in moving our association’s agenda forward.”
Mr. Higgins was chair of AATOD’s finance committee and a mentor to many program administrators and staff, Mr. Parrino said. “All of us will miss him dearly. His legacy is the treatment program he leaves behind, and many grateful patients.”
Mr. Higgins, 74, was a frequent source of information for AT Forum throughout the years. We will miss him.
National Association for Court Management (NACM) 2018 Midyear Conference
February 11-14, 2018
Orange County, California
American College of Psychiatrists (ACP) Annual Meeting
February 21-25, 2018
American Association for the Treatment of Opioid Dependence, Inc. (AATOD) 2018 Conference
March 10-14, 2018
New York City at the Marriott Marquis