President's Blog

Twice each year, your ASAM Board of Directors conducts business of the organization in person. This is in addition to several teleconferences each year. One of the live meetings takes place in the two days before our annual meeting. We opened our meeting two weeks ago with a strategic planning session focused on the potential directions our organization can take in the coming years. Two choices rose to the top:

The first deals specifically with membership and our current eligibility requirements that only physicians can join. The Board discussed at great length the pros and cons of opening membership up to those other than physicians, and there are clearly arguments that can be made for both sides. Ultimately, the Board asked that our staff prepare information that explores in greater depth the mechanisms that might be utilized to accomplish this task. The simplest approach, that of removing the eligibility criterion and changing nothing else, would leave ASAM a very different organization ultimately.

To present an analogy, let's say that 500 of us are members of a tennis club. We decide to add a golf course so that we can attract additional members. 1000 golfers join the club. They decide the tennis courts are in the way of a planned driving range and putting green. The 500 original members, finding that the club no longer meets their needs, leave to start a new tennis club. Now you could say that this is a terrible analogy, that so long as the other healthcare professionals who join ASAM have the needs of all our patients at heart, we'd all have the same goals. But I think that while we'd largely have the same goals, it's critical to ensure that our current members' needs remain met even within an organization where they could be a minority. This will likely require some creative approaches to the membership model as well as our overall business strategy.

This is in the planning stages, so now is the time for you to provide input to your Board representatives.

The second strategic issue that we asked to have addressed is the possibility of ASAM certification for practices. Facilities currently can seek generic certification from a variety of sources, such as the Joint Commission. But there is no certification specific for addiction practices. A variety of reasons were considered as background for exploring this issue further. Among them was the issue of how one can distinguish a "pill-mill" from a vibrant and busy addiction practice. In a "pill-mill," a physician might issue a large number of prescriptions for controlled substances. In a busy addiction practice, the same is true. A glance at the volume of prescriptions will not differentiate between the tapering or appropriate maintenance of the addiction practice and the inappropriate prescribing of the "pill-mill." If ASAM developed a set of criteria by which practices could be certified, the certified practices would have some degree of protection as a result of their following reasonable peer guidelines. Here too, there are pros and cons that were quickly recognized and discussed, but ultimately the Board felt that this should be investigated as a potential organizational activity.

Here too, if you have ideas and thoughts, please bring them to your Board representatives so that we can discuss them.  

    
Our Board meetings are open. Any member can attend the entire meeting but for the rare occasion in which we go into executive session. If you're interested in attending, please let us know in advance so that we can send you a copy of the agenda and provide you with the date and time of the session.

It was a pleasure visiting with so many of you at our meeting in Atlanta!

There are some things that computers handle particularly well. Back in the 1970s, I used to help my father prepare his books for the accountant each tax season. We would sit up late into the evening adding columns of numbers and going through piles of canceled checks and receipts. After what seemed like a few weeks of this, everything was ready for the CPA. Now I simply set up Quicken to generate a report of the previous year. Weeks of potential work are boiled down into a punch of the OK button. There are those who would have us believe that online education and conferencing is an equivalent improvement over live conferences. The live conference involves a worsened carbon footprint, we're told, not to mention days away from the office and home.

And yet when I'm in the exam room with a patient, my treatment approach depends as much upon what I learn in the halls of medicine as in the classroom of medicine. I have no doubt that our Program Committee has put together their usual brilliant collection of presentations at our annual Med-Sci Conference later this month. It is for this reason that ASAM will capture every session from the conference to post on its e-Live Learning Center to provide all with the opportunity to learn from the leading addiction specialists and fulfill education requirements from the comfort of their home or office.

What I look forward to, however, are not only the sessions listed in the program but the unscheduled moments spent with friends, colleagues, and mentors as we discuss treatment, policy, and research approaches. These moments are impossible to recreate with a computer, no matter how inventive and imaginative we construct a website. The live meeting represents our chance to share, in person, with our fellow addiction specialists.

One of my pet peeves of some organizations is leadership-by-good-ol'-boy-network. I've worked hard with our Officers and Staff to ensure that we have new and diverse blood in our committee structure and our leadership moving forward. I hope those of you who have been coming to our annual meeting for years will enjoy the new faces of our organizational committees. And if you're interested in being involved, whether it’s your first Med-Sci or your twentieth, please introduce yourself and let me know what your interests are. For if it weren't for the efforts of our members over the years, and if it weren't for those same members speaking out before anyone recognized them, we wouldn't be able to do a fraction of the activities in which we're now involved.

So...come to Atlanta, enjoy the sessions, and don't forget to say hello. I'm looking forward to seeing you there.

Marijuana is a plant that contains, among other things, cannabinoids. The potential medical application of cannabinoids has been explored for many years and, based on the evidence so far, is deserving of continued study with respect to risks, benefits, and potential applications. This was the conclusion of both the American Medical Association and ASAM when the two groups, separately, composed white papers addressing the issue.

We left many questions unanswered.  These questions largely deal with legal issues which many of our state legislatures are now addressing. Should marijuana be a legal regulated drug akin to alcohol and tobacco products?  What actions should be taken with respect to those who possess, use, and sell marijuana? What should be done about physicians who write recommendations or who otherwise approve patient applications for “medical marijuana?”

The California Society of Addiction Medicine (CSAM) composed a paper titled “Youth First” over the last year. The paper was circulated among CSAM members and has gained significant traction within the group. Essentially, CSAM is distressed about physicians being utilized as middlemen between the marijuana industry and consumers, and the harm to young people that will likely arise from increased availability of marijuana if legalized.  CSAM believes that marijuana legalization is likely to pass within the near future and constructed their paper within that context.  Their recommendation is to restrict sales to adults only, and to use tax revenues to prevent child and adolescent marijuana use, and provide early intervention treatment to youth with marijuana-induced problems.

CSAM’s paper was circulated outside of the organization and ASAM was asked by the media its position regarding the issues raised by “Youth First.” Although we have older policies that allowed us to say that we are opposed to legalization of marijuana, we do not have more extensive policy that would permit the questions such as those asked above to be fully addressed. Further pressure upon us to elaborate on our earlier policy comes with ASAM’s bylaws, which state that a state chapter cannot have policy at odds with ASAM’s own policies.

I therefore asked Drs. Teitelbaum and Kraus, our Public Policy Committee chairs, to set up a writing committee specifically tasked with writing what will be a second marijuana-focused white paper. They in turn have asked Drs. DuPont and Barthwell to chair the committee, which will specifically include two CSAM representatives. In my initial discussion with the group, I noted the importance of our paper being based upon available evidence rather than opinion. I also noted, given our national status and the wide range of opinions present on these issues, the importance of developing consensus. To that end, if there are topics on which we cannot reach consensus, I believe we should continue to have no policy.

There are parallels within other medical organizations on other issues. For example, the American Medical Association has never taken a stand with respect to abortion. The AMA recognizes that this is a divisive issue with opinions driven by multiple domains, many of which lie outside the scientific purview. It may be that the ultimate question as to legalization of marijuana will face similar conflict. On the other hand, if ASAM cannot reach consensus as to whether a plant with known addictive and other health-related risks should be legalized, that alone will send a message.

Your input, comments, and suggestions are welcome. Feel free to post your thoughts here or to send an email. While we may not respond to each message, you can be certain your comments will be considered as the writing committee goes about its work.

For many years, it has been clear that there are insufficient physician specialists to meet the medical needs of the population with addiction. Making matters worse are the physicians prescribing excessive quantities of controlled substances and/or recommending marijuana use. Such behaviors serve only to increase the demand for our services. While the existence of the American Board of Addiction Medicine will likely lead to an increased supply of addiction specialists, such growth will require education of medical students as to the existence of this new pathway to specialization and practice. That will take time, and growth will be slow at first. Within our practice lifetimes, the demand for addiction diagnosis and treatment will continue to far exceed the supply of addiction specialist physicians. 

In the midst of the public and governmental recognition of the addiction epidemic, another source of pressure exists. I'm referring here to the increased attention paid to the rising cost of healthcare and to the federal response to this attention in the form of the Affordable Care Act (ACA). Through both ACA and various state legislative processes, we will continue to see an increased supply of nurses, including nurses specializing in various aspects of medical care. Nurse training is far less costly than medical training and in part as a result of that nursing care is less costly than medical care. 

Physicians to date have a variety of policies and guidelines with respect to when patients should be referred to specialty medical care for evaluation, diagnosis, and treatment. These guidelines refer not only to when patients should be referred by primary care physicians but to when referral from other clinicians should take place as well. Such guidelines are widely ignored with respect to addiction. There are many reasons for this, but even if clinicians wanted to make the referral, and even if third parties were willing to pay for the added expense of specialist physician care, there are still insufficient addiction specialist physicians to meet the demand. 

This leads to a question:  What should be done to more rapidly meet the national need to better diagnose and treat addictive illness? And the question is asked within the context of a nation well on the way toward primary and specialty nursing care as a method of cost reduction. 

How should ASAM respond to this situation? 

A) Not at all - ASAM should continue to focus on physicians, making sure that addiction specialists are the best they can be and further ensuring that non specialist physicians can diagnose and refer as appropriate.

B) Form a parallel organization for nurses, one which would ensure that addiction nurse specialists would attain the highest possible skill set given a nursing, rather than a medical, education. Such an organization would work closely with ASAM, with overlapping educational meetings, trainings, and cooperative ventures. Within this context, ASAM would still set policy for the broad field through its medical membership and board, but the nursing subsidiary would have a separate board focusing on nursing-specific issues within the overall field. 

C) Ignore the differences between the baseline education and simply admit nurses into the organization as members. Restrict board membership and committee leadership to physicians. 

D) Admit nurses into the organization as full members with such members having rights to attain any position within the organization through existing procedures. 

E) And what about psychologists, PA's, and other clinicians? Should each have a separate organization, or should we lump rather than split? 

F) Finally, there are existing organizations for addiction clinicians? Should we affiliate or otherwise interact with those organizations rather than starting our own?

I'd ask that you think about this from several perspectives, the most important being what would be best for patients with addiction. Next month, the ASAM Board of Directors will meet to discuss strategic plans for the future of our organization. Please share your thoughts on this matter with our Board, and as always, I welcome discussion at any time.

The nurse-anesthetist is starting a patient on anesthesia for an imminent surgical procedure. As the patient starts to fade, he sees a figure walking in the room in surgical scrubs. He thinks this person is the surgeon but then realizes that it's the bachelor’s level therapist who screened him for psychiatric issues prior to surgery. "Wait," he cries out, "you're a therapist, not a surgeon. There's no research to demonstrate that you can perform surgery!" The therapist lowers his mask and smiles. "That's true, but there's no research to say that I can't either."

This scenario is the basis of a nightmare with many specialties of medicine, but for some reason, addiction is treated by many who have no significant healthcare qualifications. And there has been no research demonstrating that these non-physicians have the necessary skills to treat a chronic medical illness. Even our research often utilizes a comparison group in which patients receive "treatment" from non-physicians. If Drug A is superior to Treatment as provided by midlevel clinicians, then Drug A is approved. No one bothers to demonstrate that Drug A is better than Treatment as provided by physicians. Is it because they cannot? Or is it because the perception is that there is no difference?

But of course as our nightmare therapist points out, there is no research to say that physician-provided treatment is any more effective than midlevel clinician treatment. Or that there isn't a wide range of quality among physicians themselves. Much depends on what question is asked, and how the question is worded. Let's say I ask, "Do anesthesiologists and nurse-anesthetists have equivalent rates of negative outcomes?" The answer is that, in fact, they do. So at first glance one might say there's no difference. But then let's ask a different question: "Given an emergent situation during a surgery, do anesthesiologists and nurse-anesthetists have the same rate of negative outcomes?" That comparison provides a very different outcome.

As we say in the airplane, nearly all pilots can get you from Point A to Point B safely. But throw in bad weather, an in-flight mechanical failure, and a bird strike and only the best pilot will successfully land the plane. The problem in life is that we never know if any one patient has these problems. From a population standpoint, we know most do not, but from an individual standpoint - as seen by any one patient - you want to be in the best hands at all times. I want the best pilot, the best physician, in any circumstance because I don't know if on this particular day, my patient will come up with a losing hand.

So who is the best? Lou Baxter, Penny Mills, and I met with NIAAA today. We'll share more about that meeting in future blogs, but I was particularly interested to hear of research funding being made available for comparative efficacy trials. We can finally begin to address the question as to which set of initials should be carrying out which role within addiction treatment. If in fact we're all the same, then we need to markedly reduce the educational burden on physicians entering this field - we would be shown to be overeducated for the given job. And if we're not the same, then we could speak out for our patients to ensure that they receive appropriate care for their illness just as we would expect given any other chronic medical condition.