Should students be allowed to carry naloxone (Narcan)? Is the height of the border wall a health issue? Can connecting formerly incarcerated persons with healthcare stop the revolving door into prisons and jails?
These and other questions were debated at the American Medical Association’s (AMA) annual House of Delegates meeting on Saturday. Final policy decisions are expected early this week.
Naloxone in Schools
Ken Certa, MD, a delegate for the American Psychiatric Association representing the Section Council on Psychiatry, introduced a resolution calling for the AMA to advocate that naloxone for opioid overdose reversal be available to school staff, teachers, and particularly to students, to prevent opioid overdose deaths.
He acknowledged that the idea of students carrying naloxone is controversial, but he argued students have been dying from overdose in high school bathrooms.
“The idea that a school nurse, perhaps in the 4 hours that they’re there … would be willing or able to get to a student before they die is just fanciful,” Certa said.
School districts in Los Angeles County and in Arlington County, Virginia, have already “courageously” chosen to allow students to carry naloxone, he said, arguing that the AMA needs to take a leadership role on this issue.
G. Ray Callas, MD, speaking on behalf of the Texas delegation, said he supported the resolution with one caveat: “removing students from the solution.”
“In no way do we condone or encourage use of drugs in our schools, but we do want protection with the use of Narcan,” Callas explained.
“What we’re recommending … is that all schools should have it in faculty [areas] and in their nursing offices, because it does save lives,” he said.
Similarly, Steven Orland, MD, an alternate delegate from New Jersey, called for keeping naloxone in the school nurse’s office or behind glass cases, similar to defibrillators.
“It should be as widely available as possible, but not with students carrying it around school,” he said.
Karen Pierce, MD, a delegate for the American Academy of Child and Adolescent Psychiatry, took a different view: Like it or not, young people are already carrying drugs, and currently they are often removed or suspended if they’re found to be carrying naloxone.
“I have too many dead kids, and I wish they would have had a Narcan on them to be able to at least … get the minutes they needed to get help,” she said.
Stephen Taylor, MD, a delegate from the American Society of Addiction Medicine, recommended broadening the language to include the growing number of FDA-approved overdose reversal medications, including those expected to be approved to reverse overdoses of drugs mixed with the veterinary sedative xylazine.
Certa said the Council wrestled with whether to include children in the resolution, mainly because of the trauma it might inflict for a young person to administer naloxone to a friend.
“On the other hand, it’s much worse to not administer naloxone to a friend,” he said.
Carlos Puig, DO, a delegate for the International Society of Hair Restoration Surgery, argued that if the AMA is going to recommend that children carry naloxone, it should also recommend that they be trained in how to use it.
“If we can teach them CPR, we can teach them how to use naloxone,” he said.
A board report from the Council on Legislation issued after the discussion recommended the House adopt a policy stating that the AMA supports access to overdose reversal medications among teachers and staff across all educational settings, excluding students.
The Border Wall: A Health Issue?
Another policy question for delegates at the meeting was how to reduce harm to undocumented immigrants.
Laurie Lapp, a regional delegate for the Medical Student Section, introduced a resolution calling for the AMA to “oppose efforts to increase the height or length of border walls and fences at the U.S.-Mexico border and other policies that deter people from crossing the border by increasing or creating risks to their health and safety.”
She acknowledged that “immigration is a complex issue” but argued that when government actions threaten the health and safety of individuals and exacerbate a humanitarian crisis, doctors must speak up. Lapp invited delegates to look at data the Medical Student Section had shared online on the impacts of these falls. (In August, MedPage Today reported on the difficulty of accessing such data.)
Sophia Spadafore, MD, a delegate for the American College of Emergency Physicians speaking on her own behalf, also supported the resolution “as someone that grew up in Arizona, then went to medical school at a level 1 trauma center that receives all the patients from the Arizona-Mexico border, seeing open femur fractures, tibia fractures, traumatic brain injuries.”
“All of that is unfunded care,” Spadafore said.
Abhishek Dharan, a delegate for the Medical Student Section, who trained at a level 1 trauma center near the Texas-Mexico border, argued that the issue is definitely a medical one. “We need to really consider the impact on the patients and our healthcare system.”
However, Orland, again speaking on behalf of the New Jersey delegation, strongly disagreed, saying the issue was outside AMA’s purview. “The AMA in no way, shape, or form should utilize political capital on Capitol Hill on this issue.”
Other delegates were perhaps more direct.
“They shouldn’t have been on the wall in the first place. They’re breaking the law. They’re coming in illegally. It’s their fault that they got injured,” said Puig.
Gary Floyd, MD, speaking for the Council on Legislation, recommended reaffirming prior AMA policy that has already declared “Immigration status is a public health issue” as well as other AMA policies focused on immigrants’ privacy and access to public services, in lieu of the current resolution.
“The size of the wall … is something that AMA has no expertise [about] and should not be involved in,” Floyd said.
A report from the Council also recommended that the House reaffirm prior AMA policies.
Tackling Recidivism
A third issue, among many explored at the meeting, was how to stop formerly incarcerated people from cycling through jails and prisons.
Charles Lee, MD, JD, president of the American College of Correctional Physicians, who spoke on the college’s behalf and on behalf of the Section Council on Preventive Medicine, introduced a policy idea to help curb recidivism, which according to the resolution has grown in recent years.
Emergency room colleagues know the routine, he said. Patients are cleaned up, treated, discharged, and then come right back to the hospital.
“The same thing happens in correctional facilities,” he said. “We clean them up. We get them in good condition. We have them on medication. They are released.”
Then, because there is no place for them in the community, they fall into bad habits or land on the street, and “they come right back to us.”
The American College of Correctional Physicians’ proposed resolution calls for the AMA to encourage lawmakers and other public officials to scale up community mental health facilities and drug rehabilitation facilities, including residential facilities, to help match the needs of the “indigent, homeless, and released previously incarcerated persons.”
It also calls on the AMA to advocate for ensuring that there are enough personnel in correctional facilities to help ensure that those being released can immediately access support and to encourage lawmakers to advocate for quickly reinstating public medical programs and health plans for anyone being released from jail or prison.
“The whole idea is great,” said Orland, speaking again for New Jersey. But when it comes to the “prompt reinstatement” of medical programs and insurance, he asked, “Who’s going to pay for it?”
Arlene Seid, MD, a delegate for the American Association of Public Health Physicians, said the political will is there but that the AMA needs to lead on the policy front.
A report from the AMA’s Council on Legislation recommended adopting the resolution with some supportive amendments, including advocating that correctional facilities have adequate resources to support “timely access to mental health, drug and residential rehabilitation facilities upon release.”
These resolutions may be debated on the House floor and could receive a vote early this week.
