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.

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.

My patients in Massachusetts who are on Medicaid are unable to fill prescriptions for Suboxone Film. It simply isn't covered by MassHealth. And if I should write them a prescription for Suboxone that exceeds 16 mg per day, the patient is required to obtain a prior authorization. The prior authorization takes three business days to go through the system. So imagine the scenario:

Mr. Smith has been on 16 mg of Suboxone and his last prescription runs out today. He shows up in my office, and we agree that his dose should go up to 20 mg. He goes to the pharmacy, they tell him he needs a prior authorization, and he suddenly is out of Suboxone because the PA will take three days to go through. And this will happen each time the prior authorization needs to be renewed should his dose remain above 16 mg.

The problems I face in Massachusetts are, however, nothing compared to the problems patients may have soon in Maine. The Maine budget task force recently recommended that MaineCare have a two year limit on Suboxone treatment. Strangely, the budgetary task force did not recommend a two year limit on pharmacotherapy for diabetes or hypertension. It appears that they picked specifically on those with opioid dependence in this round.

Given the increasing volume of complaints about issues of this nature that we're receiving, and the fact that problems are being described in far more than two states, we have established an Access to Pharmacotherapies Task Force. The new group will help coordinate ASAM's response to the roadblocks preventing our patients from receiving necessary treatment. We will be performing a state-by-state survey of policies. The group will undoubtedly also reflect upon the parity and Affordable Care Act related implications. And eventually, we will develop a document demonstrating that the economic impact of NOT providing appropriate care exceeds the cost of providing the medication, although we will certainly recognize that the budgetary silo into which the expense falls differs from the silo which eventually reaps the gains from the expense.

Are you interested in participating in the Task Force? Send us a note to let us know.

Last week, I participated as a medical expert in eight social security disability hearings. Within these hearings, my role was to review the medical evidence consisting of physician notes and opinions, then to render a neutral opinion regarding medical condition and impairment levels of the claimant. Within each of the hearings, substance use was a relevant aspect of the case.

In the first hearing, the claimant had been seeing a psychiatrist for over one decade. The psychiatrist prescribed a combination of three different sedative-hypnotics to his patient, who was now, unsurprisingly, complaining of worsening anxiety and depression. The claimant was now impaired, though she had not been impaired at the start of treatment. I noted to the court that the claimant was impaired as a result of the treatment she had been receiving, and that while she was physiologically dependent upon her prescribed sedative-hypnotics, she did not have any evidence of addictive illness. The result: her case was paid, largely due to her having been impaired secondary to poor medical treatment.

In the second hearing, the claimant was complaining of pain of such severity as to impair his ability to focus and concentrate. The medical notes revealed that he was receiving increasing doses of narcotic agents, that these agents were prescribed despite his subjective perception of pain worsening in response to the medication, and that no efforts had been made to prescribe non-narcotic alternatives. The claimant had never seen a psychiatrist or addiction specialist, and had no reason to suspect such an evaluation would be useful. Ultimately, this case was also paid, again largely due to his being impaired secondary to poor medical treatment.

In the third hearing, the claimant had a long history of heavy substance use alongside symptoms consistent with addictive disease. The claimant had been evaluated by a physician board certified in psychiatry. That physician opined that the claimant had major depression and an anxiety disorder (no mention of a substance use disorder), and further opined that the claimant was impaired as a result of these disorders. The case would have been paid were it not for a well-informed judge asking for medical expertise and opinion at trial. I indicated that the psychiatrist's opinion was in error, noting DSM-IV's criteria requiring that symptoms of depression and anxiety not be secondary to psychoactive substance use before permitting a diagnosis of major depression and generalized anxiety disorder. This case was ultimately not paid, as impairments secondary to addictive disease are not covered by social security.

The remaining five cases each had similar stories in which poor assessment or care led to significant impairment and potential or actual societal cost. The first two claimants will now be receiving taxpayer dollars as a result of their poor treatment. They will not be productive members of society. The third claimant's misdiagnosis leaves him untreated for an easily treated illness. He too will remain unproductive, though not at taxpayer expense, unless he paid attention to my testimony and takes action accordingly.

These stories are repeated on a daily basis across the nation, bearing witness to the issues raised in our press release last week and the new ASAM Prescription Drug Policy. ASAM is now asking for a requirement that DEA certification be tied to mandated prescriber education. Although this request will make us no friends within the medical community, which has by and large opposed such a requirement, it is clear that definitive action must be taken to stem the tide of overprescribing of addictive medications. It is also clear that such action must take place not only within the prescriber community but within medical schools and residency programs. As those students and trainees become practicing physicians, it is my hope that the DEA certification/education tie-in could be phased out, though I recognize that adding restrictions is easy but taking them away is difficult. Close study of the entire process will be necessary to determine when and whether the educational requirements are both successful, and ultimately, no longer needed on a recurring basis.

As always, I welcome your comments and concerns here at the President's Blog.