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The American Medical Association (AMA) voted to support eliminating criminal penalties for drug possession for personal use at the annual House of Delegates meeting in Chicago on Wednesday.

"The war on drugs is quite reminiscent of the phrase, 'The beatings will continue until morale improves,'" said Ryan Englander, an MD/PhD candidate who is a delegate from Hartford, Connecticut, speaking on behalf of the New England delegation. "We have tried for decades to criminalize our way out of a substance use crisis in this country, and it has not worked ... We need to move to something different and better, something that actually works."

Oregon Versus Portugal

Englander noted that the state of Oregon's recent backtracking of its efforts to decriminalize drug use was "instructive, but so is the [experience of] Portugal, where that country decriminalized or removed penalties for personal possession of drugs for personal use, and they were actually able to get people into treatment, and mortality did drop. So there are models that we can use that can work."

The delegates voted 345-171 to adopt the new policy, which superseded language in an AMA Board of Trustees report (found on p. 94 of the ) calling for the association to "continue to monitor the legal and public health effects of state and federal policies to reclassify criminal offenses for drug possession for personal use."

The revised language from the AMA's reference committee took a much stronger stance, calling for "elimination of criminal penalties for drug possession for personal use as part of a larger set of related public health and legal reforms designed to improve carefully selected outcomes."

Stephen Taylor, MD, MPH, of Atlanta, Georgia, who spoke for the American Society of Addiction Medicine (ASAM), said ASAM suggested the new language to the reference committee because "there is, in fact, evidence that decriminalization can have public health benefits if it is done correctly. We would suggest that we have yet to see it done correctly" in the U.S.

Not everyone agreed, however. "Our policy must reflect the evidence, and currently, the evidence does not support broad decriminalization," said AMA president-elect Bobby Mukkamala, MD, who spoke on behalf of the Board of Trustees. "We just have to look at the Oregon experience. In 2020, Oregon decriminalized the possession of just small amounts of illicit drugs with the goal of getting people into treatment, but unfortunately, the outcome was quite different. There was no reduction in mortality and there was no increase in access to treatment ... The board doesn't believe it's wise to have the AMA support policies that do not have more robust evidence behind them."

Marianne Parshley, MD, a delegate for the American College of Physicians who was speaking for herself, said that there were "several things wrong" with how people looked at the Oregon experiment. Although the situation had begun to improve after decriminalization was passed in 2020, "in the same time period, fentanyl entered the market, and therefore the deaths rose," said Parshley, who is from Portland. And the "walking back" of the Oregon law was actually a way to get bipartisan support in the legislature for more funding and program support for drug treatment efforts.

"So, it's complex," she said. "We need to pay attention to the fact that [the situation] doesn't instantaneously change if you pass decriminalization and support for treatment."

Staffing Issues in the Emergency Department

The delegates also weighed in on the issue of emergency department (ED) staffing, softening a resolution from the Florida delegation urging that EDs be required to be staffed by physicians 24 hours a day, 7 days a week. The new language -- approved by a vote of 426-97 -- says the association supports such staffing.

"We think that this is an aspirational and clear policy that is not overly restrictive for our colleagues, who are struggling in many different ways to staff hospitals with physicians," said Hilary Fairbrother, MD, MPH, of Houston, who was speaking for the American College of Emergency Physicians. "But we think that this is the policy that will allow the full support of the AMA for advocacy efforts."

She added that Missouri and Ohio currently have legislation on the issue, while Mississippi, Vermont, New York, South Carolina, Texas, Utah, Oregon, and Pennsylvania all have possible legislation, "so it is critical that we claw back on this scope-of-practice topic."

Arthur Apolinario, MD, MPH, a delegate from Clinton, North Carolina, who was speaking for himself, spoke against the revision "because it's very vague. If I'm a lawyer and my client who's a patient that went to a rural hospital needed a neurosurgeon, and it was not staffed by a qualified neurosurgeon, this is vague enough to make [it sound like] we're actually against ourselves," he said. "It doesn't say 'staffed by an emergency physician.' If a general surgeon is not available, we could get into trouble if they need a general surgeon."

Cindy Firkins Smith, MD, of Spicer, Minnesota, spoke on behalf of the Minnesota delegation against the resolution. "I'd love for a physician and a qualified physician and an ER doc to be in all of our rural hospitals, but simply, that's not going to happen," she said. "If a patient shows up in one of our ERs and there's no one there, it's not a difference between not getting care and giving care -- it's a difference between dying and not dying. If this is misinterpreted ... If somebody feels that this means that we have to have a physician 24/7/365 in our rural hospitals, rural hospitals will close."

On the other hand, Jordan Warchol, MD, MPH, of Omaha, Nebraska, spoke for the Nebraska delegation in support of the revised resolution, in particular for working with Nebraska delegates on "getting something accomplished that maybe isn't what everyone wants, but it's something that everyone can live with."

A Split on Refugee Caps

Delegates were split on a resolution from the Medical Student Section that called for the AMA to "support increases and oppose decreases to the annual refugee admissions cap in the United States." The AMA's Reference Committee B suggested that the resolution not be adopted, citing comments during the reference committee hearing suggesting that "engaging with immigration policy at this time could be politically turbulent and could endanger our AMA's advocacy on other issues."

But Sham Manoranjithan of Columbia, Missouri, speaking for the Medical Student Section, urged delegates to pass it. "Earlier this year, HHS which showed that over a 15-year period, there was a net $124 billion positive fiscal impact" from refugees, she said. "This is echoed in analyses from states including Ohio, Michigan, and Minnesota, which demonstrate that refugees can contribute to economic activity, including payment into Social Security and Medicare, thereby offsetting costs for our aging population."

"My parents and sister were refugees over 25 years ago, escaping a genocide where civilians were systematically targeted," she said. "They spent days hiding in bunkers, listening to the sounds of bombings overhead ... I am positive that a number of us seated here in the House are also here as a result of these policies that allowed our families a chance to resettle and rebuild."

Deepak Kumar, MD, of Dayton, Ohio, speaking for the Ohio delegation, took an opposing view. "I am also sort of an immigrant, but came through a legal route, and also I was a refugee at one time, going from Pakistan to India," he said. "I understand the concerns ... but at this point, it is not in our purview, and we will oppose it."

In the end, the House of Delegates voted 195-284 not to adopt the resolution.

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