President's Blog

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.