For a quarter-century AT Forum has served as a source of support and encouragement for the opioid addiction community, as well as an advocate of medication-assisted treatment (MAT) and opioid treatment programs (OTPs). Much has changed during that time, and some things have come full circle.
Back in the early 1990s, methadone was the only medication for treating opioid use disorders (OUDs). The opioid of choice among users was heroin, and most heroin users were living in urban areas. The first issue of AT Forum noted that the typical upper daily limits of methadone at some OTPs were only 20 to 60 mg; many patients require higher doses.
OTPs often worked in isolation, and they felt it keenly. A treatment that had been a scientific breakthrough in the 1960s now had few supporters. Program staff members, their patients, policy makers, and the media sorely needed reliable information.
AT Forum stepped in to help meet that need.
The 1990s—The Beginning: Some Dark Days, Some Bright Spots
The first issue of the AT Forum newsletter offered a mix of patient advocacy, management guidance, news updates, and research articles—as the newsletter does today.
Susan Emerson—publisher of Addiction Treatment Forum (atforum.com) throughout its lifespan—recalls those early days.
In the early 1990s, the Internet was several years away from being widely available, so the public had limited resources for information or help about opioid addiction. “Patients and families called AT Forum with questions,” Ms. Emerson recalls; “questions about how to find methadone treatment programs, specific questions about treatment itself—questions they couldn’t find answers to anywhere else.”
Ms. Emerson remembers the stories that had an impact. Some involved persistent stigma and NIMBY (Not in My Back Yard); others showed progress being made in treating OUDs. But what stands out most in her memory is the difference the publication made in peoples’ lives.
“People thanked AT Forum, because patients and OTP staff members were seeing improvements in their patients. Effective methadone dosing levels, and comprehensive care—things that AT Forum played a role in bringing about—were helping patients get better.”
Dr. Dole’s Disappointments
In 1995, AT Forum featured an interview with Vincent Dole, MD, one of the developers of methadone maintenance treatment (MMT). It was now 30 years after Dr. Dole, Marie Nyswander, MD, and Mary Jeanne Kreek, MD, first published their research showing the effectiveness of methadone treatment.
But Dr. Dole was now less hopeful than he had been three years earlier, when AT Forum first talked with him. He was disappointed about the “endless moral and other types of objections” that have nothing to do with the scientific data, and surprised to find that “we still get the anti-methadone argument of substituting one addictive drug for another,” he said. “The fact that people, especially medical practitioners, would dismiss the data as unimportant simply staggers me!”
An Ominous Shift in Opioid of First Use: The Rise in Prescription Opioids
An important shift occurred in the mid-1990s: more heroin users chose a prescription product, instead of heroin, for their first opioid use. As the graph below shows, heroin use continued in a downtrend, and prescription opioids in an uptrend, until the 2000s, when a reversal began. Not shown in the figure: the lines crossed again in 2017, as heroin became once again the opioid of choice.
Adapted from Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. 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. Published online May 28, 2014.
From 1992 to 2017: A Recap
Much has changed since AT Forum was introduced 25 years ago. Today, opioid-related deaths are reaching new highs. News about the escalating opioid crisis dominates media outlets—from newspapers to consumer magazines to broadcast media.
The makeup of the people who use heroin has changed. Heroin is no longer “an inner-city, minority-centered problem.” (JAMA Psychiatry 2014) The recent sharp rise in heroin use has been “greater among white individuals, unmarried respondents, males,” those with less education, and those living in poverty. Interestingly, heroin use may have become more socially acceptable among suburban and rural white individuals because its effects resemble those of widely available prescription opioids. (JAMA Psychiatry 2017)
Signs of progress. Along with the troubling news of increased heroin use, signs of progress have appeared along the way. Among them: Providers, government officials, corporate partners, and patient advocates have joined together to form a stronger community. In the treatment area, a choice of three medications gives health care providers options for treating OUDs. A fourth medication, naloxone, for treating opioid overdose, is now available without a prescription in many states, and has saved countless lives.
Today’s AT Forum articles cover topics such as these, as well as offering advice on other key aspects of addiction treatment—siting new facilities, adjusting drug therapy to conform to individual patients’ requirements, and meeting adolescents’ urgent needs for treatment programs, to name a few.
What Lies Ahead
Speculation calls for yet another change ahead in the opioid addiction community—a shift from heroin to fentanyl, carfentanil, and an opioid known as U-47700—as the upcoming choices of opioids of first use. Indications are that it’s quite likely to happen.
And if it does, AT Forum will be there to cover the news.
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Funded by an unrestricted educational grant from Mallinckrodt Pharmaceuticals ever since its inception a quarter-century ago, AT Forum has published 300 news updates and nearly 100 newsletters.
It’s Official: Heroin Is Once Again More Popular Than Rx Opioids. AT Forum. October 24, 2017.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. 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. Published online May 28, 2014.
Madras BK. The surge of opioid use, addiction, and overdoses: Responsibility and response of the US health care system [editorial]. JAMA Psychiatry. 2017;74(5):441-442. doi:10.1001/jamapsychiatry.2017.0163. Published online March 29, 2017.
Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US lifetime heroin use and heroin use disorder prevalence from the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(5):445-455. doi:10.1001/jamapsychiatry.2017.0113. Published online March 29, 2017.
For Additional Reading
To browse archived issues on the AT Forum website, go to https://atforum.com/newsletter-archives/.