President's Blog

The academic year has always represented a new beginning for me following what is supposed to be a calm and restful summer vacation that never seems to recur the way it did when I was 12, despite my eagerness for such relaxation.  In any case, I couldn't help watching Apple Computer's stock price rise yet another 100 points over the summer and wondering why it did so well over the course of the last decade and why it did not do well, comparatively, in the 1980s. In both cases, there was one man in charge, moving things forward precisely as he saw fit. There were no decisions made by committees, no design groups, no focus groups…there was a single guy making decisions as to what was right and what was wrong. In the 1980s, he chose a closed system architecture that cost Apple the lead that it had over IBM in the newborn PC marketplace. In the 2000s, he chose differently. The remarkable progress that Apple made as a company was due to the decision making that only one person can make. Any group thought process would have diluted the brilliance. You might still have a good company, but you wouldn't have a great company, even if the entire group were to have been made up of equally brilliant people. And as we know, just as one person can be brilliant, one person can also be less than brilliant. In which case you would want committees, focus groups, and design groups because the overall skill set can be improved.

If we look at physicians the same way, and imagine that we all fall on a bell curve, you might think you want guidelines and protocols and teamwork, at least for the bottom half of the curve. But by applying them to everyone, you end up with regression to the mean that rules out brilliance. You'd have no one with terrible outcomes, but you'd have no one with amazing outcomes either. All physicians would be following the recipe, producing equal products of certain and specific quality. Medical school, like culinary school, would teach technique so that we could all follow the recipes correctly. But then if we're going to use that analogy, we immediately recognize that the best chefs are the ones who design their own recipes, who sometimes don't follow the rules, and who dictate the precise manner in which dishes should come together in their kitchen. We could, of course, forbid such chefs through the implementation of guidelines and protocols, licensure restrictions, and regulations, thus ensuring that a hamburger from Restaurant A is identical to a hamburger from Restaurant B, or that Dr. Smith diagnoses hypertension at precisely the same point in the physical exam review as Dr. Johnson would, for any and all patients.

Frankly, I look at physicians differently. We arrive as physicians by first being the best in high school, then the best in college, then the best at our MCATs, and so forth. If we're choosing our medical students correctly, then we've already cut off the lower half of the bell curve, and reapplying the bell curve to the remainder is illogical as the standard deviation is so small. In fact, we have greater potential for brilliance than for the absence of brilliance. But only if we're left to our own devices. Dr. Johnson might therefore decide that his patient has hypertension even though blood pressure isn't quite high enough, even though Dr. Smith is following the protocol and does not make the diagnosis, making that decision based upon observation of the gradual change in pressure noted over the past ten years, and deciding to treat it early rather than wait for the inevitable and morbidity-inducing further elevation. So the question is: do we want our new physicians to be innovative, creative, intuitive, and observant scientists? If so, they need the freedom to be scientists. We recognize that advances that come with innovation come with associated costs - an expense which might represent morbidity and mortality. Is innovation worth that risk? Without it, we wouldn't be where we are now, with the advances of the centuries behind us. I'd like to see continued innovation rather than stagnation. Obtaining that goal requires trust in ourselves and trust in our physicians. I would much prefer to see a physician who is an innovative, thoughtful, and brilliant scientist rather than a team player who follows all the rules and guidelines.

We all still have that choice. Will our children have it as well?

There have been quite a few studies over the years demonstrating the difference between children who later display the behaviors associated with addiction and children who do not have addictive disease. One of my long-quoted favorites is the sociologic work of Shedler and Block at UC Berkeley, who demonstrated that substance use is a symptom of an underlying process, that of addictive disease itself. Sociology won't convince everyone, however, and with apologies to sociologists, we need a better construct if we are to prove, finally, that addictive disease is present prior to the addictive behavior.

If we look at diabetes, we know that the disease is in process long before symptoms are evident. The genetic code and environmental insult have added up to an autoimmune response attacking islet cells. If one has an autoimmune response where islet cells are rapidly dropping in number, one has diabetes whether or not blood sugar, thirst, or urinary frequency have increased. Similarly in addiction, if the brain abnormality is already present and the only thing missing is the marker of substance use (or the addictive behavior of your choice), the patient has addictive illness. Our problem has been in the identification of these patients. That's the holy grail of addiction treatment: finding the patients BEFORE they ever begin their addictive behaviors.

Squeglia, Pulido, and others have written an article published this week in the Journal of Studies on Alcohol and Drugs. The article, titled "Brain Response to Working Memory over Three Years of Adolescence: Influence of Initiating Heavy Drinking," examines a neuroimaging study in youth who were identified as being at risk for substance use disorders. Put plainly, kids were examined with an MRI prior to their ever drinking alcohol. Naturally, the researchers found evidence of brain alteration secondary to heavy alcohol use which followed. We've known that for some time now. What we didn't know, though have long suspected, is that the brains of those who would later drink heavily differed from those who would not drink in this manner.

Alcohol-naive children who showed less activation in certain areas of the brain were at greater risk for becoming heavy drinkers in the three years that followed than were children who did not have such findings.

The lead author of the study, Lindsay Squeglia, PhD, said in a press release, "It's interesting because it suggests there might be some pre-existing vulnerability." We have known and recognized that clinically for decades, but this represents a very clear neurophysiologic correlate that once again underscores that addiction is a brain disease for which addictive behavior is a mere marker. The press release, interestingly, noted that the study doesn't mean teens should all start having MRI scans to see which ones might have addiction, but it is certainly my hope that the study means such a pre-addictive-behavior test may well be forthcoming. Imagine if we could test all children and determine prior to the first sign of addictive behavior which ones have addictive disease.

Preventing addictive disease is not likely to be achieved in the short term, but preventing addictive behavior through early identification of addictive disease is a far more reasonable and likely achievement.

As Co-Chairs of the ASAM Writing Committee tasked with developing a response to state-level marijuana legalization proposals, we are proud of ASAM’s leadership and decision to educate its members about the dangers inherent in the policy proposals to legalize marijuana.

Many physicians have serious, legitimate concerns about how drug use and drug addiction is treated within the United States. Some look to marijuana legalization proposals as ways to separate the problem of addiction from the criminal justice system. Others look to legalization proposals as ways to increase funding of treatment. We recognize that the marijuana policy issues are complex and we may never achieve consensus in this policy arena. What is abundantly clear to us as a result of the writing process and our research is that such proposals, if passed, would directly impact our nation’s health. Specifically, rates of marijuana use and substance use disorders, including addiction, would increase.

The full extent of outcomes of marijuana legalization is truly unknown because nowhere in the world is the use, sales, and production of marijuana legal. But, based on what is known about the harmful effects of marijuana use and the relationship of marijuana use by youth to its availability and perception of harm, we know we cannot support marijuana legalization.

Availability and access to screening, diagnosis, and treatment for marijuana-related substance use disorders must be improved, but these changes are not tied solely to the illegal status of marijuana.

As physicians in the leading organization specializing in addiction medicine, we see daily examples in our practices that marijuana is a drug of abuse that has serious negative consequences for many users. While legal drugs of alcohol and tobacco currently cause the most serious damage, both in terms of costs and harm to public health and public safety, states with active “medical” marijuana industries have begun to see the costs of quasi-legal marijuana.

Proposals to make marijuana – or any other drug of abuse – more widely available and acceptable, cannot be supported by addiction specialists. The public health is not served by expanded availability, increased acceptability or commercial activities that promote and seek to extend marijuana use.

We thank ASAM for providing much-needed leadership on this relevant public health policy issue.

Dr. Norman Wetterau, President of NYSAM, has submitted this week's blog entry. Contributions from our Chapters, Committees and members are always welcome.

The New York Chapter of ASAM has been actively involved in trying to shape state legislation. Three years ago the Uniform Accident and Sickness Policy Provision Law (UPPL) was passed working closely with the state medical society. We also helped convince several state senators to vote for drug reform, which reduced some sentences and required that every county have a drug court. Last year we found legislation that would prohibit convicting anyone of a crime for possession of small quantities of drugs after a 911 call to report a drug overdose. We called this the Good Samaritan law. The law was going nowhere until we took this issue to the state medical society and together pushed it forward. We met the sponsors, made phone calls to get the committees to consider it and during the last week of the session made calls to get the assembly and senate bills aligned. The law passed and was signed by the governor in 2011.

Every year we work hard to help defeat medical marijuana. We work with Drug Free Schools. The other medical organizations do not want to actively oppose the law, since the sponsor is the head of the assembly health committee. We have met with senators every year, especially those on the health committee. We have passed out copies of the ASAM white paper on this subject. We have made it clear that the issue is not whether Marijuana helps people feel better, but how medications are approved. We support FDA approved, nonsmoked marijuana derivatives. We have pointed out that Sativex is such a product and is being field tested in our state. One of the Drug Policy Alliance positions is that the FDA does not allow research on medical marijuana. Clearly this product is being tested in our state, so we can refute this and other statements made by the Drug Policy Alliance. Unfortunately the pro medical marijuana people have a lot of money behind them, but we have so far been successful.

What are some of the secrets to our success?  Our leaders are also involved in the state medical society and academy of family practice. Both these organizations have lobbyists, whom we know and help. They in turn help us on the issues where we agree. Even on the issue of medical marijuana they will provide us with advice and information. I spend three to five days a year in Albany. Other people also help. After public policy committee conference calls, the members write letters and make phone calls. A chapter needs one or two leaders who will advise others as to whom to write and whom to call. Those chapter leaders need connections to advise them. In our case, we use the state medical society, academy of family physicians, legal action center and drug free schools. The bills are all on the state website. Once you visit a senator’s or assembly office you get to know the staff and can always call them for follow-up.

Find one or two people to provide leadership and then choose one issue. Begin by spending a day visiting legislators. You do not always win, but so far we have had great successes.

Norman Wetterau MD    President NYSAM

We had a very successful meeting of the American Medical Association (AMA) last week with respect to addiction medicine. New AMA policies are now in place as follows:

• The AMA supports permanent authorization of and adequate funding for all states to have an operational Prescription Drug Monitoring Program (PDMP).
• The AMA considers all PDMP data to be protected health information.
• The AMA recommends that PDMP's be designed so as to make data immediately available upon clinical inquiry.
• The AMA recommends that PDMP's have connectivity across state lines.
• The AMA will promote medical school and postgraduate training focusing on pain medicine, addiction medicine and related issues.
• The AMA opposes federal legislation that would require physicians to check a PDMP prior to prescribing controlled substances.
• The AMA believes correctional facilities should provide addiction care meeting prevailing community standards, including appropriate referrals upon release.
• The AMA urges development of community-based programs offering naloxone and other opioid overdose prevention services.

The AMA House of Delegates explored issues pertaining to stigmatization of mental health disorders in medical professionals. We advocated for the removal of language on application forms for licensure, credentials, and other certification which asks whether the applicant has a diagnosis or history of a substance use disorder. This entire matter was referred to the Board of Trustees for decision, and we will undoubtedly have additional opportunities for input.

We attempted but failed to garner support for mandatory education tied to DEA certification. There was initially compromise language that would have offered physician’s benefits such as a decreased DEA certification fee in return for obtaining CME on the appropriate subject matter, but even this ultimately failed to be approved by the AMA.  However, we will surely revisit this at the next meeting in November, and I'm optimistic that we will obtain an acceptable compromise eventually.

The AMA's House of Delegates meets twice each year. I had the pleasure of working in this year's AMA meeting in Chicago beside Ilse Levin, Todd Kammerzelt, Norm Wetterau, Brian Hurley, Mike Miller, and Penny Mills, all of whom presented on so many occasions that we fielded numerous comments about the size of ASAM's delegation. Please let me know if you would like additional information about any of the new AMA policies. We would welcome additional members joining us at future AMA meetings. To participate, you need to be an AMA member in addition to being an ASAM member.