AMA Opposes Use of Ketamine, ‘Excited Delirium’ for Law Enforcement Purposes

The AMA opposes the use of ketamine and other sedative/hypnotic agents as a pharmacological intervention for agitated individuals in out-of-hospital settings to chemically restrain an individual solely for law enforcement.

In addition, the AMA opposes use of the term “excited delirium” as a medical diagnosis until a clear set of diagnostic criteria for the term is validated.

With strong support from APA and the Section Council on Psychiatry, the AMA House of Delegates approved a report by the AMA’s Council on Science and Public Health (CSAPH) addressing concerns about recent deaths of people—predominantly young Black men labeled as experiencing “excited delirium”—after ketamine was administered to restrain them. In December 2020, the APA Board of Trustees approved a position statement asserting that “excited delirium” lacks any clear diagnostic criteria and calling for evidence-based protocols for administration of ketamine in emergency medical situations outside the hospital.

During the AMA’s Annual Meeting of the House of Delegates in June, Ken Certa, M.D., senior delegate for APA, told delegates that too many people—disproportionately people of color—have died after being administered ketamine by police or emergency medical technicians.

“As psychiatrists, we have experience dealing with people brought in by the police in agitated states,” Certa told the AMA delegates. “That doesn’t mean they have ‘excited delirium’—we don’t know what that is. We have tried to find a coherent body of literature to support that diagnosis, and it is simply not there. ... Out-of-hospital ketamine has the potential to kill people, especially people who have been marginalized.”

Section council member Sara Coffey, D.O., director of child and adolescent psychiatry at Oklahoma State University, also told delegates, “The public looks to us to make sure we are using accurate terms. Words matter. But ‘excited delirium’ is not in DSM; it is also not in the ICD-10.”

The new policy urges law enforcement and frontline emergency medical service (EMS) personnel to participate in training overseen by EMS medical directors that minimally includes de-escalation techniques and the appropriate use of pharmacological intervention for agitated individuals outside the hospital. The policy also urges medical and behavioral health specialists—instead of law enforce.ment—to serve as first responders and decision-makers in medical and mental health emergencies.

Laura Halpin, M.D., Ph.D., a member of the CSAPH and a child and adolescent psychiatry fellow at UCLA, said the recommendations can be protective. “Our recommendation that physicians and mental health specialists, and not law enforcement, should serve as the first responders and decision-makers on crisis intervention teams will help protect our vulnerable patients.”

One recommendation of the CSAPH report, calling for independent oversight of how agitated individuals detained by the police are handled by EMS personnel, was not approved but will be decided by the AMA Board of Trustees. Certa called independent oversight “the teeth of the report” and said that in other areas, medicine applies “community standards to make sure we are doing things right.”

AMA delegates also approved a CSAPH report on youth suicide that received passionate support across specialties. The report includes a range of recommendations for physicians, health systems, communities, schools, and lawmakers to address what many delegates called an urgent life-and-death crisis (see “Youth Suicide a ‘Dire’ Crisis” below).

The House also approved a resolution calling for equitable access to evidence-based addiction treatment as a standard of care for incarcerated people with opioid use disorder (OUD). This includes “naloxone or any other medication that is approved by the United States Food and Drug Administration for the treatment of an opioid overdose.”

The resolution also calls for access to a wide range of psychiatric services, including psychosocial services, for incarcerated individuals and those transitioning into the community. “Individuals who are incarcerated face not only a higher burden of mental illness but also multiple psychological and social barriers,” said section council member Dionne Hart, M.D. These individuals not only benefit from the implementation of a medical-based model but also psychosocial treatment to address the issues that contributed to their incarceration and increased risk for reentry.”

Name Change Said to Mislead Patients

In other business, the AMA House approved a resolution opposing the recent decision of the American Academy of Physician Assistants (AAPA) to change the professional title of “physician assistant” to “physician associate.” The AMA is advocating that the term “physician” be used only to refer to physicians of allopathic and osteopathic medicine, and “not be used in ways that have the potential to mislead patients about the level of training and credentials of nonphysician health care workers,” according to the resolution.

APA released a similar statement in June (see "APA Opposes “Physician Assistant’ Title Change” below).

Other Actions

Finally, the House approved two items relevant to physician health and well-being. These include the Council on Judicial and Ethical Affairs’ (CEJA) Report on Physician Responsibilities to Impaired Colleagues. CEJA Chair and psychiatrist Rebecca Brendel, M.D., J.D., told the House that the report “clarifies the distinction between disability or disabling conditions—for which accommodations may enable a physician to practice safely—and impairment, which compromises safe practice.”

Brendel added, “The report also provides guidance for individual physicians, health care institutions, and the profession to address physician impairment. This updated guidance emphasizes that in many instances physicians with disabling conditions can responsibly and safely practice with appropriate accommodations and care. In addition, interventions should strive to ensure that physicians receive appropriate evaluation and treatment for any impairing conditions.

“Finally, the report recognizes the importance of a supportive professional culture advocating for services and accommodations that will enable colleagues who require assistance to practice safely.”

In a similar vein, the House passed a resolution affirming that “no physician or medical student should be presumed impaired because they and their treating physician have chosen medication for opioid use disorder to address the substance use disorder, including methadone and buprenorphine.”

Addiction psychiatrist and Section Council Chair Jerry Halverson, M.D., said access to methadone can be crucial, but that a record or history of being treated with methadone for a substance use disorder can typically disqualify a physician from practicing.

“Certainly, there are risks and benefits to any medication that a patient and his or her doctor need to discuss,” he told delegates. “But methadone is extremely important in the medication-assisted treatment of addiction. It’s cheap, valid, and effective, and it saves lives.”

Halverson noted that the same prohibition against practicing medicine does not occur when a physician uses methadone for pain. “This is just discrimination against patients with addiction,” he said. ■

Youth Suicide a ‘Dire’ Crisis

The AMA House of Delegates approved a report from the Council on Science and Public Health on youth suicide, which delegates from multiple specialties called an urgent crisis.

“Young people can develop symptoms of psychiatric illness up to 10 years before they receive an accurate diagnosis and treatment,” said Sara Coffey, D.O., director of child and adolescent psychiatry at Oklahoma State University. “Prior to COVID-19, youth suicide was already a significant concern, but the pandemic has made it more so. We need the AMA’s support for increased investment [in child and adolescent mental health] to support our youth who are in dire need.”

The report outlines factors that increase the risk of youth suicide, including substance use disorder, adverse childhood experiences, increased use of digital devices, bullying and cyberbullying, and the impact of the COVID-19 pandemic. The report also identifies evidence-based interventions, protective factors, as well as resources to enhance resiliency aimed at mitigating youth suicide risk.

Under the new policy, the AMA will do the following:

• Encourage the development and dissemination of educational resources and tools for physicians, especially those more likely to encounter youth or young adult patients, that are effective at preventing suicide.

• Support collaboration with federal agencies, relevant state and specialty medical societies, schools, public health agencies, community organizations, and other stakeholders to enhance awareness of suicide among youth and young adults and support evidence-based prevention strategies and interventions.

• Support research to better understand suicide risk and effective interventions for implementation in middle and high schools.

• Promote novel technologies and treatments, along with improved utilization of existing medications, to address acute suicidality and underlying risk factors in youth and young adults.

• Advocate at the state and national levels for policies to prioritize children’s mental, emotional, and behavioral health and for a comprehensive system of care including prevention, management, and crisis care for children with mental and behavioral health problems.

• Support increased screening for adverse childhood experiences (ACEs) in medical settings, and the inclusion of information on ACEs and trauma-informed care in undergraduate and graduate medical education curricula.

APA Opposes ‘Physician Assistant’ Title Change

A recent decision by the American Academy of Physician Assistants (AAPA) to change the professional title of “physician assistant” to “physician associate” will confuse patients and obscure the distinction between physicians and nonphysicians, APA said in a statement in June.

The APA statement, issued in a June 8 press release, asserts: “The AAPA’s decision to rebrand their profession by changing the title of physician assistant (PA) to physician associate does not accurately convey PA responsibilities under the critical guidance of a physician-led team. In the name of medical care transparency, the American Psychiatric Association (APA) strongly opposes this name change as it will exacerbate the challenges patients already face when discerning the qualifications of those who are both providing and leading their care.

APA also joined a similar statement with other medical societies led by the American Academy of Dermatology: the American Academy of Child and Adolescent Psychiatry, American Academy of Ophthalmology, American Academy of Otolaryngology-Head and Neck Surgery, American Association of Orthopaedic Surgeons, American College of Radiology, American College of Surgeons, American Society of Anesthesiologists, American Society for Dermatologic Surgery Association, American Society of Plastic Surgeons, and the American Urological Association.

The joint ADA statement cited a survey by the AMA’s Scope of Practice Partnership that found that 88% of patients believe only medical doctors should be permitted to use the title “physician” and that 79% of patients support state legislation to require all health care advertising materials to clearly designate the level of education, skills, and training of all health care professionals promoting their services.