Ryan Crowley, BSJ; Neil Kirschner, PhD; Andrew S. Dunn, MD; Sue S. Bornstein, MD; for the Health and Public Policy Committee of the American College of Physicians (*)
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2953.
Requests for Single Reprints: Ryan A. Crowley, BSJ, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, RCrowley@mail.acponline.org.
Current Author Addresses: Mr. Crowley and Dr. Kirschner: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Dr. Dunn: Mount Sinai Medical Center, Box 1086, 1470 Madison Avenue, New York, NY 10029.
Dr. Bornstein: 3111 Beverly Drive, Dallas, TX 75205.
Author Contributions: Conception and design: S.S. Bornstein, R.A. Crowley, A. Dunn, G.C. Kane, J.D. Lenchus.
Analysis and interpretation of the data: J.F. Bush, R.A. Crowley, A. Dunn, N. Kirschner.
Drafting of the article: S. Ahmed, R.A. Crowley, A. Dunn, N. Kirschner.
Critical revision for important intellectual content: G.M. Abraham, S.S. Bornstein, R.A. Crowley, A. Dunn, T.L. Henry, J.D. Lenchus, D. Newman.
Final approval of the article: G.M. Abraham, S. Ahmed, S.S. Bornstein, J.F. Bush, S.G. Candler, R.A. Crowley, A. Dunn, H.E. Gantzer, T.L. Henry, G.C. Kane, N. Kirschner, J.D. Lenchus, J. Li, B. McCandless, D. Newman.
Statistical expertise: R.A. Crowley.
Administrative, technical, or logistic support: R.A. Crowley.
Collection and assembly of data: R.A. Crowley, N. Kirschner.
Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.
When scientists began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment. Today, thanks to science, our views and our responses to addiction and other substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem (18).
Appendix Table. Numbers of Illicit Drug Users Among Persons Aged ≥12 Years in the Past Month: 2014
Substance use disorders are treatable chronic medical conditions that should be addressed through expansion of evidence-based public and individual health initiatives to prevent, treat, and promote recovery. ACP supports appropriate and effective efforts to reduce all substance use, including educational, prevention, diagnostic, and treatment efforts. In addition, ACP supports medical research on substance use disorders, including causes and treatment. ACP emphasizes the importance of addressing the stigma surrounding substance use disorders among the health care community and the general public.
Treatment of substance use disorders should be made available in a timely manner, including making them available for those in the criminal justice system as an alternative to incarceration and other criminal penalties.
ACP calls for policymakers and researchers to carefully assess the arguments and evidence for amending criminal justice laws to remove or reduce criminal penalties (decriminalization, legalization, or offering treatment as an alternative to criminal justice penalties) for nonviolent users of drugs, including assessing the following:
a. The relative risk that such drugs pose for the individual health of the users, the potential for misuse, and the potential effect on the overall health of the population that might result from decriminalization or legalization
b. Whether criminalization acts as a barrier to preventing and treating substance use disorders and recurrence of such disorders
c. The consequences of criminalization on the person with a substance use disorder, including disproportionate adverse effects on persons based on racial, socioeconomic, and ethnic characteristics
d. Whether decriminalization or legalization leads to more or fewer substance use disorders and the health consequences associated with them
ACP also calls for research on the individual and public health effects in states that have legalized or decriminalized the use of marijuana and the effectiveness of regulatory structures in those states that may minimize any adverse health effects, especially on children and adolescents.
ACP believes that physicians should work with other stakeholders, including medical and behavioral health care professionals, public health officials, government programs, patient advocacy groups, insurance plans, and law enforcement to address the prescription drug use disorder epidemic.
To help address the prescription drug use epidemic, ACP makes the following recommendations:
a. Physicians are obligated by the standards of medical ethics and professionalism to practice evidence-based, conscientious pain management that prevents illness, reduces patient risk, and promotes health. ACP strongly believes that physicians must become familiar with, and follow as appropriate, clinical guidelines related to pain management and controlled substances, such as prescription opioids, as well as nonopioid pharmacologics and nonpharmacologic interventions.
b. Lift barriers that impede access to medications to treat opioid use disorder (methadone, buprenorphine, and naltrexone) and to medications for overdose prevention (naloxone). The federal government should consider lifting the cap on the number of patients who can receive buprenorphine if a physician has been trained in proper prescribing practices. Public and private insurers should remove onerous limits on medications for overdose prevention and medication-assisted treatment, including burdensome prior authorization rules or lifetime limits on buprenorphine that prevent medically necessary care. Oversight and enforcement efforts should be strengthened to protect against misuse, diversion, and illegal sale of buprenorphine and other opioid treatment drugs. Policymakers should evaluate and consider removing restrictions on office-based methadone treatment provided by trained physicians or other health care professionals.
c. Funding should be allocated to distribute naloxone to individuals with opioid use disorder to prevent overdose deaths and train law enforcement and emergency medical personnel in its use. Legal protections (that is, Good Samaritan laws) should be established to encourage use of naloxone and the reporting of opioid overdoses in instances where an individual's life is in danger. Physician standing orders to permit pharmacies to provide naloxone to eligible individuals without a prescription should be explored. Insurance and cost-related barriers that limit access to naloxone should be addressed.
d. Pre- and post-buprenorphine training support and education tools and resources should be made available and widely disseminated to assist physicians in their treatment efforts. Physician support initiatives, such as mentor programs, shadowing experienced providers, and telemedicine, can help improve education and support efforts around substance use treatment.
e. ACP reiterates its support for the establishment of a national PDMP. Until such a program is implemented, ACP supports efforts to standardize state PDMPs through the federal National All Schedules Prescription Electronic Reporting program. ACP strongly urges prescribers and dispensers to check PDMPs in their own and neighboring states (as permitted) before writing and filling prescriptions for medications containing controlled substances. All PDMPs should maintain strong protections to assure confidentiality and privacy. Efforts should be made to facilitate the use of PDMPs, such as by linking information with electronic medical records and permitting other members of the health care team to consult PDMPs.
ACP strongly supports parity of mental health and substance use disorders and the coverage of comprehensive evidence-based treatment of substance use disorders. Strong oversight must be applied to ensure adequate coverage of medication-assisted treatment components, counseling, and other items and services. Components of comprehensive drug addiction treatment should also be extended to those in need, including medical services, mental health services, educational services, HIV/AIDS services, legal services, family services, and vocational services.
ACP supports policies to increase the professional workforce engaged in treatment of substance use disorder. Loan forgiveness programs, mentoring initiatives, and increased payment may encourage more individuals to train and practice as behavioral health professionals.
Training in screening and treatment of substance use disorders should be embedded in the continuum of medical education. Continuing medical education providers should offer courses to train physicians in addiction medicine, medication-assisted therapy, evidence-based prescribing, and the identification and treatment of substance use disorders.
Public health–based interventions for substance use disorder, such as syringe exchange programs and safe injection sites, that connect the user with effective treatment programs should be explored and tested.
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Mark Antony LaPorta, MD FACP
Mark Antony LaPorta, MD FACP Private practice
April 4, 2017
Dimensions of addiction and recovery
I don't know what disturbs me worse about this "policy, " that academic and political orthodoxy miss entire personal, social, and societal dimensions, or that no one else has commented. Colleagues, be careful what you ask for while fretting the problems of the world. You know that axiom: you may get what you ask for.
Crowley R, Kirschner N, Dunn AS, Bornstein SS, for the Health and Public Policy Committee of the American College of Physicians. Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper. Ann Intern Med. [Epub ahead of print 28 March 2017]:. doi: 10.7326/M16-2953
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Published: Ann Intern Med. 2017.
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