Mandating reimbursement for non-FDA-regulated cannabis is bad public policy.

An influential cannabis lobby and its allies are engaged in an aggressive initiative to mandate health and worker's compensation insurance coverage for non-standardized, non-FDA-regulated cannabis products. If successful, mandated reimbursement would present a severe public health risk and force taxpayers to fund a risky and under-regulated industry. Leaders in psychiatry and other medical specialties have sounded the alarm about the marketing and sale of cannabis products for medical uses without prior review by the FDA. We echo their strong opposition to bills requiring workers' compensation carriers and health insurance plans to cover the cost of dispensary-purchased "medical" cannabis. Mandated insurance reimbursement of dispensary products is "a recipe for a public health disaster, as lowering or eliminating out-of-pocket costs will encourage more consumers to become certified under a state's medical cannabis program, and result in more frequent use of higher-potency cannabinoids (e.g., THC and CBD) that are associated with serious adverse events." Until there are thorough studies into these products, including adverse events, side effects and long-term concerns, these products should not be considered appropriate alternatives to FDA-approved medications. Their use should not be encouraged nor paid for through mandated reimbursement by public or private third-party payers.

Screening, Brief Intervention, and Referral to Treatment in a Retail Pharmacy Setting: The Pharmacist's Role in Identifying and Addressing Risk of Substance Use Disorder.

OBJECTIVE: This study determined the feasibility of interviewing and screening patients presenting to a retail pharmacy using Screening, Brief Intervention, and Referral to Treatment (SBIRT) interview protocols, and to compare SBIRT results to a risk score calculated from Prescription Drug Monitoring Program (PDMP) data. METHODS: Using the NIDA Quick Screen and NIDA Modified-ASSIST (NM-ASSIST) and the Alcohol Use Disorder Identification Test (AUDIT), retail pharmacy customers were screened for substance and alcohol use disorder and tobacco use. PDMP reports were collected on subjects and a PDMP-risk score was calculated based on the numbers of Schedule II-V prescriptions and prescribers over the previous 12 months. RESULTS: A total of 24 patients were included in this study (67% response rate). SBIRT screening revealed that 20.8% were at-risk for substance use disorder (SUD), 16.7% for alcohol use disorder, and 37.5% used tobacco. Overall, 33.3% of subjects were at-risk for SUD or alcohol use disorder. Fifty percent of subjects required education and/or brief intervention based on their responses, 37.5% of all subjects were deemed at-risk based on their PDMP-risk score, and 60% of patients who were risk-positive by SBIRT screening were also PDMP-risk positive. CONCLUSIONS: This study demonstrates the feasibility of performing SBIRT-based screenings in a retail pharmacy setting and combining these with PDMP-risk analysis to screen patients for prescription and illicit drug misuse. Findings from this study will inform the design of larger multisite studies, which should validate these findings and include follow-up analysis to assess the efficacy of intervention on this patient population.

Evaluation of an experiential curriculum for addiction education among medical students.

OBJECTIVES: Undergraduate medical education about addictive disease can take many forms, but it is unclear which educational methods are most effective at shaping medical students into physicians who are interested in and competent at addressing addiction. The purpose of this study was to evaluate the efficacy of the Betty Ford Institute's Summer Institute for Medical Students (SIMS), a week-long program aimed at educating medical students about addiction through a combination of traditional didactic and novel experiential sessions. METHODS: A written survey assessing beliefs, attitudes, and practices related to addictive disease was administered to physicians who previously participated in SIMS (n = 140) and to physicians matched for year of graduation from medical school who did not participate in SIMS (n = 105). RESULTS: Compared with their peers, and controlling for sex, age, year of graduation from medical school, specialty, personal experience with addiction, and training in talking to patients about substance use, physicians who participated in SIMS were more likely to believe that they could help addicted patients, find working with addicted patients satisfying, be confident in knowing available resources for addicted patients, believe that addiction is a disease, and be confident in speaking to patients about substance use. Physicians who participated in SIMS were not more likely to practice addiction medicine or to view talking to patients about substance use as clinically relevant. CONCLUSIONS: Undergraduate medical educational interventions combining traditional and experiential programming may render participants better equipped than peers receiving only traditional education to address addiction as physicians.

Maldynia: pathophysiology and management of neuropathic and maladaptive pain--a report of the AMA Council on Science and Public Health.

BACKGROUND: Because of disparate taxonomic arrays for classification, the American Academy of Pain Medicine has proposed categorizing pain on a neurobiologic basis as eudynia (nociceptive pain), Greek for "good pain," or maldynia (maladaptive pain), Greek for "bad pain." The latter has been viewed as maladaptive because it may occur in the absence of ongoing noxious stimuli and does not promote healing and repair. OBJECTIVE: To address recent findings on the pathogenesis of pain following neural injury and consider whether the development of maladaptive pain justifies its classification as a disease and to briefly discuss the scope of pharmacologic and non-pharmacologic approaches employed in patients with such pain. METHODS: English language reports on studies using human subjects were selected from a PubMed search of the literature from 1995 to August 2010 and from the Cochrane Library. Further information was obtained from Internet sites of medical specialty and other societies devoted to pain management. RESULTS: Neural damage to either the peripheral or central nervous system provokes multiple processes including peripheral and central sensitization, ectopic activity, neuronal cell death, disinhibition, altered gene expression, and abnormal sprouting and cellular connectivity. A series of neuro-immune interactions underlie many of these mechanisms. Imaging studies have shown that such damage is characterized by functional, structural, and chemical changes in the brain. Such pain is maladaptive in the sense that it occurs in the absence of ongoing noxious stimuli and does not promote healing and repair. CONCLUSION: As defined, maldynia is a multidimensional process that may warrant consideration as a chronic disease not only affecting sensory and emotional processing but also producing an altered brain state based on both functional imaging and macroscopic measurements. However, the absolute clinical value of this definition is not established.

The First National Pain Medicine Summit--final summary report.

Pain is ubiquitous. At some point in time it affects everyone. For many millions pain becomes chronic, a scourge that impacts every facet of life-work, hobbies, family relations, social fabric, finances, happiness, mood, and even the very essence of identity. According to the National Institutes of Health (NIH), pain is one of our most important national public health problems, a silent epidemic. In 1998, NIH reported that the annual amount spent on health care, compensation, and litigation related to pain had reached one hundred billion dollars ($100,000,000,000). Considering that health care costs have doubled since then, it is not unreasonable to assume that the costs related to pain care have doubled as well. Millions of patients suffer needlessly with acute pain, with cancer pain, and with chronic pain. The ineffective management of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the nervous system. This translates into progressive bio-psycho-social epiphenomena resulting in further pain and disability. It creates a vicious cycle transforming a functional human being into an invalid who becomes a burden to family, to society, and to oneself. In the face of adequate medical science, adequate technical skills, and adequate resources the reality of delayed and inadequate pain care is paradoxical. This dilemma deserves close scrutiny and effective remediation. The American Medical Association (AMA), long dedicated to the need to improve pain care in this country, has been faced with this reality. It was from this vision that the idea of holding a Pain Medicine Summit was conceived. Resolution 321 (A-08) set in motion a process that would bring together a diverse group of stakeholders for the purpose of discussing the present and future status of pain care; a process that culminated in a broad-based coalition of physicians and organizations dedicated to improving pain care, the first National Pain Medicine Summit. The process began with the adoption of Resolution 321 (A-08) at an AMA Annual House of Delegates meeting in June 2008. Resolution 321 (A-08) states, in part, that "...the AMA encourages relevant specialties to collaborate in studying: 1) the scope and practice and body of knowledge encompassed by the field of Pain Medicine; 2) the adequacy of undergraduate, graduate, and post graduate education in the principles and practices of the field of Pain Medicine, considering the current and anticipated medical need for the delivery of quality pain care; and 3) appropriate training and credentialing criteria for this multi-disciplinary field of medical practice." The next step was delegating the responsibility for implementing Resolution 321 (A-08) to the Pain and Palliative Medicine Specialty Section Council (PPMSSC). The PPMSSC, under the direction of its chairman, Philipp M. Lippe, MD, FACS, assumed responsibility in November 2008 for identifying a process that would achieve the goals established by Resolution 321 (A-08). The PPMSSC in turn established an Advisory Committee, charged with strategic planning, and an Implementation Committee, charged with tactical operations. The two groups began work immediately. The process included three distinct phases centered on a Pain Medicine Summit. Phase One involved a modified Delphi process identifying the five most pressing and relevant themes in pain care. Phase Two consisted of the Pain Medicine Summit itself, including a gathering of representatives from across the pain care spectrum to address the previously identified five most pressing themes. Phase Three was the preparation of this report, which describes the conclusions drawn and recommendations developed by the attendees at the Pain Medicine Summit. Based on a recommendation from the Advisory Committee, the PPMSSC decided to retain the services of a consulting firm to help the PPMSSC implement the Pain Medicine Summit process. In August 2009, PPMSSC selected Grey Matters, a New York-based advisory firm. The PPMSSC also appointed a Steering Committee to assist Grey Matters and to coordinate all activities. The Committee consisted of Charles Brock, MD; Ronald Crossno, MD; Jose David, MD; Michel Dubois, MD; Albert Ray, MD; and Philipp M. Lippe, MD, FACS (chair). The consulting firm, Grey Matters, proposed a multi-phasic process in order to facilitate the implementation of the Pain Medicine Summit and to ensure a coordinated, efficient, and productive outcome. This process consisting of three phases-pre-summit, summit, and post-summit-is described in detail in the following section. All aspects of the project were closely coordinated and supervised by the Steering Committee, which included the selection of the team leaders of the five Workgroups, based on specific criteria. The Pain Medicine Summit, adhering to the dictates of Resolution 321 (A-08), explored the body of knowledge and the scope of practice of Pain Medicine; the education and training in medical school, graduate, and postgraduate programs; and the credentialing and certification processes in the field of Pain Medicine. It addressed the barriers hampering delivery of high quality pain care. It recognized the need for clarification and consensus in many areas. Several points of consensus emerged: The continuum of medical education in the field of Pain Medicine is inadequate and fragmented. It needs to be fortified in scope, content, and duration. Credentialing and certification processes in Pain Medicine are variable, diverse, and deficient in many instances. Deficiencies in these areas lead to suboptimal and fragmented pain care having a negative impact on direct patient care and public health. Effective and prompt remediation is desirable and essential to achieving the goal of high quality pain care. Barriers exist inhibiting or retarding progress toward the common good. There are several viable avenues to achieving our stated goal, "excellence in the delivery of high quality, cost-effective pain care to the patients we serve," including the development of Pain Medicine as a distinct specialty with ACGME accredited residency programs and ABMS certification. The Pain Medicine Summit concluded with a number of recommendations, including the following: That the pain community remains engaged in addressing the issues raised and in mitigating the barriers. That the recommendations be referred to the AMA and the PPMSSC for support and implementation. That another national Pain Medicine Summit with enhanced participation be convened. That consideration be given to convening an International Pain Summit in conjunction with the IASP World Congress in Montreal. That the final report of the Pain Medicine Summit be widely disseminated.