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: R. Crowley, A.S. Dunn, G.C. Kane, J.D. Lenchus.
Analysis and interpretation of the data: R. Crowley, N. Kirschner, A.S. Dunn, J.F. Bush.
Drafting of the article: R. Crowley, N. Kirschner, A.S. Dunn.
Critical revision of the article for important intellectual content: R. Crowley, A.S. Dunn, G. Abraham, T. Henry, J.D. Lenchus, D.A. Newman.
Final approval of the article: R. Crowley, N. Kirschner, A.S. Dunn, G. Abraham, H.E. Gantzer, T. Henry, G.C. Kane, J.D. Lenchus, J.M. Li, B.M. McCandless, D.A. Newman, S.G. Candler.
Statistical expertise: R. Crowley.
Collection and assembly of data: 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.
Treatment for substance use disorders should be made available in a timely manner, including for those in the criminal justice system as an alternative to incarceration and other criminal penalties.
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).
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 for those in the criminal justice system, as an alternative to incarceration and other criminal penalties.
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.
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 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.
Jan Klimas, PhD, MSc, Launette Rieb MD, MSc
University of British Columbia
April 27, 2017
Bring Audrey back
Crowley et al., provide a clear statement by the American College of Physicians, published online in AIM on March 28th (1), that advocates for more education on substance use disorders. Here, we describe our experience with effective teaching of addiction medicine curricula and our concern about its dismantling with “curriculum renewal”. For over 20 years at the University of British Columbia (UBC), the first year medical students have had 20 hours of teaching on the theme Addiction Medicine and Inter-collegial Responsibility (AMIR) which has been both highly rated by medical students and has improved their OSCE test scores for motivational interviewing. In the first session of the course, Audrey and other volunteer guest speakers with lived experience tell their stories.Last Friday, Audrey stood up in front of over 200 medical students to bravely recount a life history the students can identify with – middle class upbringing, working in bars overseas as a fun gap-year. Then she plunges into her journey and takes the students with her through running from abusive boyfriends, heroin initiation, culminating in being chained to a radiator for months while pregnant. Her positive encounters with health-care providers turn things around. She had been in recovery for years when she sought a paediatrician for her son’s care. In the first interview, the paediatrician revealed that she knew Audrey. She had attended the AMIR session nine years prior and upon hearing Audrey’s story had decided that day to become a paediatrician. The two women sobbed together in the office, each one’s journey affecting the other. No one left the room during Audrey’s talk; no one checked their phones, tablets or laptops. As she finished, everyone in the auditorium stood up to applaud her. Although medical schools and experts around the world call for more hours for teaching about addiction, curriculum reform at UBC has cut AMIR and moved to paper case-based learning, with few cases dedicated to addiction.Truly, the efforts to redesign curriculum according to the latest findings of educational theory should be applauded. Nevertheless, one cannot help but wonder whether we are not losing too much when we move to learning that spirals over key educational encounters and content. When we spoke to the students after last Friday’s lecture and told them about the upcoming curriculum reform they urged us to "make Audrey come back, please!"1. Crowley R, et al. http://annals.org/aim/article/2613555/health-public-policy-facilitate-effective-prevention-treatment-substance-use-disorders Annals of Internal Medicine. 2017. Acknowledgments:This article was written, in part, thanks to funding from the US National Institutes of Health (R25DA037756). ELEVATE: Irish Research Council International Career Development Fellowship – co-funded by Marie Cure Actions (ELEVATEPD/2014/6), and European Commission grant (701698) – supported Dr. Jan Klimas. I thank Drs Evan Wood, Christy Sutherland, Launette Rieb, Keith Ahamad, Christopher Fairgrieve, Annabel Mead and Walter Cullen for providing background information and colleagues from the Curriculum Renewal programme for all of their efforts.
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]166:733–736. doi: 10.7326/M16-2953
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Published: Ann Intern Med. 2017;166(10):733-736.
Published at www.annals.org on 28 March 2017
Tobacco, Alcohol, and Other Substance Abuse.
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