Regulatory Framework for Cannabis: A Position Paper From the American College of Physicians.

Cannabis, also known as marijuana, is the dried flowers, stems, seeds, and leaves of the Cannabis sativa plant. It contains more than 100 compounds, including tetrahydrocannabinol, which has psychoactive effects. Federal law prohibits the possession, distribution, and use of cannabis outside limited research activities, but most states have legalized cannabis for medical or recreational use. However, research into the potential therapeutic and adverse health effects of cannabis has been limited, in part because of the drug's federal legal status. In this position paper, the American College of Physicians (ACP) calls for the decriminalization of possession of small amounts of cannabis for personal use and outlines a public health approach to controlling cannabis in jurisdictions where it is legal. ACP recommends the rigorous evaluation of the health effects and potential therapeutic uses of cannabis and cannabinoids as well as research into the effects of legalization on cannabis use. It also calls for evidence-based medical education related to cannabis and increased resources for treatment of cannabis use disorder.

Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Health Disparities: A Position Paper From the American College of Physicians.

Lesbian, gay, bisexual, transgender, queer, or other sexual and gender minorities (LGBTQ+) populations in the United States continue to experience disparities in health and health care. Discrimination in both health care and society at large negatively affects LGBTQ+ health. Although progress has been made in addressing health disparities and reducing social inequality for these populations, new challenges have emerged. There is a pressing need for physicians and other health professionals to take a stance against discriminatory policies as renewed federal and state public policy efforts increasingly impose medically unnecessary restrictions on the provision of gender-affirming care. In this position paper, the American College of Physicians (ACP) reaffirms and updates much of its long-standing policy on LGBTQ+ health to strongly support access to evidence-based, clinically indicated gender-affirming care and oppose political efforts to interfere in the patient-physician relationship. Furthermore, ACP opposes institutional and legal restrictions on undergraduate, graduate, and continuing medical education and training on gender-affirming care and LGBTQ+ health issues. This paper also offers policy recommendations to protect the right of all people to participate in public life free from discrimination on the basis of their gender identity or sexual orientation and encourages the deployment of inclusive, nondiscriminatory, and evidence-based blood donation policies for members of LGBTQ+ communities. Underlying these beliefs is a reaffirmed commitment to promoting equitable access to quality care for all people regardless of their sexual orientation and gender identity.

Excessive Alcohol Use and Alcohol Use Disorders: A Policy Brief of the American College of Physicians.

Alcohol is used by more people in the United States than tobacco, electronic nicotine delivery systems, or illicit drugs. Several health conditions, including cancer, cardiovascular disease, and liver disease, are associated with excessive alcohol use and alcohol use disorder. Nearly 30 million people aged 12 years or older in the United States reported past-year alcohol use disorder in 2022, but-despite its prevalence-alcohol use disorder is undertreated. In this policy brief, the American College of Physicians outlines the health effects of excessive alcohol use and alcohol use disorder, calls for policy changes to increase the availability of treatment of alcohol use disorder and excessive alcohol use, and recommends alcohol-related public health interventions.

Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations: A Position Paper From the American College of Physicians.

Access to safe and stable housing has both a direct and indirect effect on health. Experiencing homelessness and housing instability can induce stress and trauma, worsening behavioral health and substance use. The absence of safe and stable living conditions can make it challenging to rest, recuperate, and recover from health ailments and can pose barriers to treatment adherence. Homelessness and housing instability is associated with high rates of numerous diseases and chronic conditions. Its cyclical relationship with other social drivers of health can exacerbate health disparities. As a result, unhoused persons experience unique health challenges and require a health care system and professionals designed to meet their distinct needs. Physicians and other health professionals have a role in educating themselves about the needs of unhoused patients as well as making themselves aware of community and government resources available to these populations. Policymakers must support health professionals in these efforts by supporting the data infrastructure needed to facilitate these referrals to resources, supporting research into best practices for caring for these populations, and investing in community-based organization capacity. Policy action is needed to address the underlying drivers of homelessness, including a dearth of affordable housing, while also addressing the short-term need for safe shelter now. In this position paper, the American College of Physicians (ACP) recognizes the need to address universal access to housing to fulfill one's right to health. ACP offers several recommendations to prevent homelessness and promote the necessary health care and social needs of unhoused populations.

Ensuring Equitable Access to Participation in the Electoral Process: A Policy Brief From the American College of Physicians.

During the past 2 decades, voter turnout in U.S. presidential elections has ranged from 51.7% to 66.9% of the eligible population. Low voter turnout rates and inequitable electoral institutions, such as gerrymandered districts, can skew policy decisions toward the preferences of a smaller group and further exclude individuals and communities who have been historically marginalized and excluded from decision-making processes. Voting and health are directly connected through the institution of policies by ballot initiative and the election of officials who incorporate health into their platforms. They are also indirectly connected, as civic participation connects persons to their community and empowers them with agency in decision making. In this position paper, the American College of Physicians seeks to inform physicians, medical students, and other health care professionals on the links between electoral processes and health; encourage civic participation; and offer policy recommendations to support safe and equitable access to electoral participation to advance health equity for both patients and health care professionals.

Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care: A Position Paper From the American College of Physicians.

Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams.

Modernizing the United States' Public Health Infrastructure: A Position Paper From the American College of Physicians.

The United States' public health sector plays a crucial role in preventing illness and promoting health. Public health drove massive gains in life expectancy during the 20th century by supporting vaccination campaigns, promoting motor vehicle safety, and preventing and treating tobacco use. However, public health is underfunded and underappreciated, forcing the field to do more with fewer resources. In this position paper, the American College of Physicians (ACP) updates its 2012 policy recommendations on strengthening the nation's public health infrastructure. ACP calls for effective coordination of public health activities, robust and stable year-to-year funding of public health services, a renewed and well-supported public health workforce, action to address health-related dis- and misinformation, modernized public health data systems, and greater coordination between public health and medical sectors.

Preparing for Future Pandemics and Public Health Emergencies: An American College of Physicians Policy Position Paper.

The onset of the COVID-19 pandemic revealed significant gaps in the United States' pandemic and public health emergency response system. At the federal level, government responses were undercut by a lack of centralized coordination, inadequately defined responsibilities, and an under-resourced national stockpile. Contradictory and unclear guidance throughout the early months of the pandemic, along with inconsistent funding to public health agencies, also created notable variance in state and local responses. The lack of a coordinated response added pressure to an already overwhelmed health care system, which was forced to resort to rationing care and personal protective equipment, creating moral distress and trauma for health care workers and their patients. Despite these severe shortcomings, the COVID-19 pandemic also highlighted successful policies and approaches, such as Operation Warp Speed, which led to the fastest development and distribution of a vaccine in history. In this position paper, the American College of Physicians (ACP) offers several policy recommendations for enhancing federal, state, and local preparedness for future pandemic and public health emergencies. This policy paper builds on various statements produced by ACP throughout the COVID-19 pandemic, including on the ethical distribution of vaccinations and resources, conditions to resume economic and social activity, and efforts to protect the health and well-being of medical professionals, among others.

Reproductive Health Policy in the United States: An American College of Physicians Policy Brief.

The legal landscape around access to reproductive health care services was substantially altered after the Supreme Court decision in Dobbs v Jackson Women's Health Organization. In the aftermath of the decision, some state governments have begun to impose stringent restrictions and complete bans on the provision of abortion, whereas others have sought to protect and expand access. Some have gone as far as imposing criminal and civil penalties on physicians and other clinicians who provide evidence-based, clinically indicated reproductive health care services and information that is guided by biomedical ethics and provided in the best interest of the patient's health and well-being. In several states, lawmakers have attempted and successfully used new approaches to enforcing and achieving these prohibitions, including prohibitions on crossing state lines to obtain abortion care, prohibitions on the mailing of medication abortion, and the authorization of third-party civil lawsuits. In this policy brief, the American College of Physicians (ACP) updates and expands on its previous public policy positions on abortion from its 2018 policy paper, "Women's Health Policy in the United States," to reflect this new reality. The College also offers policymakers and payers recommendations to promote equitable access to reproductive health care services and safeguard maternal health. ACP reaffirms its opposition to undue and unnecessary governmental interference in the patient-physician relationship that criminalizes the provision of health care made in the physician's clinical judgment and based on clinical evidence and the standard of care.

Health Care During Incarceration: A Policy Position Paper From the American College of Physicians.

The American College of Physicians (ACP) has a long-standing commitment to improving the health of all Americans and opposes any form of discrimination in the delivery of health care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to policymakers and administrators to improve the health and well-being of persons incarcerated in adult correctional facilities.

Environmental Health: A Position Paper From the American College of Physicians.

Environmental health refers to the health effects associated with environmental factors, such as air pollution, water contamination, and climate change. Environmental hazards are associated with poor outcomes in common diseases, including diabetes and heart disease. In this position paper, the American College of Physicians (ACP) seeks to inform physicians about environmental health and offers policymakers recommendations to reduce the adverse health consequences of climate change, improve air and water quality, reduce exposure to toxic substances, and address environmental injustice. ACP affirms that all communities, including people of color, people with low income, and marginalized populations, deserve to live in a healthy environment.

Supporting the Health and Well-Being of Indigenous Communities: A Position Paper From the American College of Physicians.

Indigenous peoples in the United States experience many health disparities and barriers to accessing health care services. In addition, Indigenous communities experience poor social drivers of health, including disproportionately high rates of food insecurity, violence, and poverty, among others. These challenges are unsurprising, given historical societal discrimination toward Indigenous peoples and government policies of violence, forced relocation with loss of ancestral home, and erasure of cultures and traditions. Indigenous peoples have displayed resilience that has sustained their communities through these hardships. Through treaties between the federal government and Indigenous nations, the federal government has assumed a trust responsibility to provide for the health and well-being of Indigenous populations through the direct provision of health care services and financial support of tribally operated health systems. However, despite serving a population that has endured substantial historical trauma and subsequent health issues, federal programs serving Indigenous peoples receive inadequate federal funding and substantially fewer resources compared with other federal health care programs. Access to care is further challenged by geographic isolation and health care workforce vacancies. Given the history of Indigenous peoples in the United States and their treatment by the federal government and society, the American College of Physicians (ACP) asserts the federal government must faithfully execute its trust responsibility through increased funding and resources directed toward Indigenous communities and the undertaking of concerted policy efforts to support the health and well-being of Indigenous people. ACP believes that these efforts must be community-driven, Indigenous-led, and culturally appropriate and accepted, and center values of respect and self-determination.

Long-Term Services and Supports for Older Adults: A Position Paper From the American College of Physicians.

The number of Americans aged 65 years or older is expected to increase in the coming decades. Because the risk for disability increases with age, more persons will need long-term services and supports (LTSS) to help with bathing, eating, dressing, and other everyday tasks. Long-term services and supports are delivered in nursing homes, assisted living facilities, the person's home, and other settings. However, the LTSS sector faces several challenges, including keeping patients and staff safe during the COVID-19 pandemic, workforce shortages, quality problems, and fragmented coverage options. In this position paper, the American College of Physicians offers policy recommendations on LTSS coverage, financing, workforce, safety and quality, and emergency preparedness and calls on policymakers and other stakeholders to reform and improve the LTSS sector so that care is high quality, accessible, equitable, and affordable.

Strengthening Food and Nutrition Security to Promote Public Health in the United States: A Position Paper From the American College of Physicians.

Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.

Health Care for Our Nation's Veterans: A Policy Paper From the American College of Physicians.

The Veterans Health Administration (VHA) is the United States' largest integrated health care delivery system, serving over 9 million enrollees at nearly 1300 health care facilities. In addition to providing health care to the nation's military veterans, the VHA has a research and development program, trains thousands of medical residents and other health care professionals, and conducts emergency preparedness and response activities. The VHA has been celebrated for delivering high-quality care to veterans, early adoption of electronic medical records, and high patient satisfaction. However, the system faces challenges, including implementation of an expanded community care program, modernization of its electronic medical records system, and providing care to a population with complex needs. The position paper offers policy recommendations on VHA funding, the community care program, medical and health care professions training, and research and development.

Financial Profit in Medicine: A Position Paper From the American College of Physicians.

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care: A Policy Paper From the American College of Physicians.

Racial and ethnic minority populations in the United States experience disparities in their health and health care that arise from a combination of interacting factors, including racism and discrimination, social drivers of health, health care access and quality, individual behavior, and biology. To ameliorate these disparities, the American College of Physicians (ACP) proposes a comprehensive policy framework that recognizes and confronts the many elements of U.S. society, some of which are intertwined and compounding, that contribute to poorer health outcomes. In addition to this framework, which includes high-level principles and discusses how disparities are interconnected, ACP offers specific policy recommendations on disparities and discrimination in education and the workforce, those affecting specific populations, and those in criminal justice practices and policies in its 3 companion policy papers. ACP believes that a cross-cutting approach that identifies and offers solutions to the various aspects of society contributing to poor health is essential to achieving its goal of good health care for all, poor health care for none.

Racism and Health in the United States: A Policy Statement From the American College of Physicians.

Racial minorities in the United States have reported experiencing widespread racism throughout all aspects of life, from housing to education to employment. Existing research has examined the role of racism, discrimination, and violence in one's interaction with the health care system and their association with poorer mental and physical health. Systemic racism that underlies the fabric of society often manifests itself in prominent institutions, such as law enforcement agencies, regardless of individual intent. Overt and covert racist laws and policies, personal implicit biases, and other factors result in Black individuals and other people of color being the subject of law enforcement violence and criminal justice system interactions at disproportionately high rates. The demonstrated association between discriminatory law enforcement practices and violence and personal and community health necessitates treating these issues as public health issues worthy of a public policy intervention. Addressing some of the sources of institutional racism and harm through transparency and accountability measures is the first of many steps required to begin correcting historical racial injustices.

Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries.

BACKGROUND: Hospitalized patients are frequently treated with opioids for pain control, and receipt of opioids at hospital discharge may increase the risk of future chronic opioid use. OBJECTIVE: To compare inpatient analgesic prescribing patterns and patients' perception of pain control in the United States and non-US hospitals. DESIGN: Cross-sectional observational study. SETTING: Four hospitals in the US and seven in seven other countries. PARTICIPANTS: Medical inpatients reporting pain. MEASUREMENTS: Opioid analgesics dispensed during the first 24-36 hours of hospitalization and at discharge; assessments and beliefs about pain. RESULTS: We acquired completed surveys for 981 patients, 503 of 719 patients in the US and 478 of 590 patients in other countries. After adjusting for confounding factors, we found that more US patients were given opioids during their hospitalization compared with patients in other countries, regardless of whether they did or did not report taking opioids prior to admission (92% vs 70% and 71% vs 41%, respectively; P < .05), and similar trends were seen for opioids prescribed at discharge. Patient satisfaction, beliefs, and expectations about pain control differed between patients in the US and other sites. LIMITATIONS: Limited number of sites and patients/country. CONCLUSIONS: In the hospitals we sampled, our data suggest that physicians in the US may prescribe opioids more frequently during patients' hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control. Efforts to curb the opioid epidemic likely need to include addressing inpatient analgesic prescribing practices and patients' expectations regarding pain control.