Improve Professional Training on Opioids and Alternative Pain Management Approaches

Introductory Paragraph

Pain is one of the most common reasons Americans consult a physician. Chronic pain is ongoing pain that usually lasts longer than six months. According to a 2018 report by the Centers for Disease Control and Prevention (CDC) 50 million U.S. adults have chronic pain. Chronic pain is often accompanied by co-existing mental health conditions as persistent chronic pain can contribute to depression, anxiety, poor sleep patterns, decreased quality of life, and substance use disorder. It is also a risk factor for suicide. The consequences of chronic pain include lost work productivity, disability, and increased health care costs. It is critically important to engage prescribers in efforts to prevent prescription drug misuse, and improving professional training on opioids and alternative pain management plays a key role in prevention.

Key Information

• 72% of doctors in one study indicated their knowledge of opioid dependence was low.
• Many doctors in one study rated their training "unsatisfactory."
• Physicians who studied at lower-ranked medical schools prescribe nearly three times as many opioids per year as those who attended top-tier institutions. For example, researchers found that physicians who attended Harvard wrote fewer than 100 opioid prescriptions per year, while physicians trained at the lowest-ranked schools wrote about 300 per year.

Although the act of going to multiple doctors with the goal of getting multiple prescriptions for painkillers, known as doctor shopping, is a pretty rare phenomenon (studies indicate that only 0.7 percent of patients actively attempted to scam providers into issuing duplicate prescriptions), doctors should still educate themselves on the signs that someone's just looking for a prescription. This one group is particularly good at getting multiple prescriptions, purchasing a total of 11.1 million grams of opioids from their average of 32 prescriptions from ten different prescribers in less than a year. Dr. John Zweifler recommends that clinicians "find objective evidence of severe disease through physical examination or diagnostic studies before prescribing long-term opioids.

The CDC provides prescribing guidelines on non-opioid pharmacologic therapies and non-pharmacologic therapies. The general guidance for prescribers is to “Start low and go slow” and to regularly monitor patients. The CDC aims to help healthcare providers apply CDC’s recommendations in a clinical setting through interactive patient scenarios, videos, knowledge checks, tips, and resources. Their trainings provide a better understanding of the CDC recommendations, the risks and benefits of prescription opioids, non-opioid treatment options, patient communication, and risk mitigation. Content offered in CDC trainings includes:

• Addressing the Opioid Epidemic: Recommendations from CDC
• Treating Chronic Pain Without Opioids

• Communicating With Patients: Providers will learn communication strategies they can use when treating chronic pain, including motivational interviewing.
• Deciding Whether to Prescribe: In this section of the training, providers learn mechanisms for deciding if opioids should be prescribed, and next steps for treatment – whether opioid or non-opioid treatments are selected.
• Dosing and Titration of Opioids: How Much, How Long, and How and When to Stop? When providers choose to prescribe opioids, they need to know how to properly dose and titrate opioids to reduce risk of opioid use disorder and overdose. This module explains methods of dosing and titration.
• Reducing the Risks of Opioids: Providers will learn best risk mitigation strategies and when to employ them after prescribing an opioid.
• Assessing and Addressing Opioid Use Disorder: This module describes methods available to a provider for assessing and addressing an opioid use disorder when it is suspected.
• Implementing the CDC Guideline: This module provides strategies and tools for implementing the CDC Guideline for Prescribing Opioids for Chronic Pain in a provider’s own practice, while outlining steps to overcome common barriers to implementation.

Relevant Research

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. This report by the National Academies of Sciences, Engineering, and Medicine is a comprehensive review of pain management research and strategies to address the opioid epidemic. It includes findings on professional training.

Pain Management Best Practices. This report by 29 members of the Pain Management Best Practices Inter-Agency Task Force is the culmination of work done by the U.S. Department of Health and Human Services in conjunction with the U.S. Department of Defense and the U.S. Department of Veterans Affairs and the Office of National Drug Control Policy. It is intended to guide the public at large, federal agencies, and private stakeholders on how to address acute and chronic pain in light of the ongoing opioid crisis..

The Veteran Affairs Office of Research & Development provides a website that offers a compendium of new, ongoing, and published research on pain management.

The Substance Abuse Research and Education Training Program (SARET) is funded by the National Institutes of Drug Abuse. This summary article on SARET indicates that only 8 percent of all U.S. medical schools have a distinct course on addiction built into the required coursework and only a handful of schools teach a robust, evidence-based curriculum on the diagnosis and treatment of SUDs. The report presents the initial integration of SARET in an MSW program, the components of the program, and the mixed-methods evaluation of its effect on student’s attitudes towards substance abuse research and treatment.

Impactful Federal, State, and Local Policies

Although there are no federal requirements for training, five states have taken the lead in requiring all physicians to receive opioid-related CME. Seven states have enacted provisions requiring some or all physicians to obtain training in pain management or controlled substance prescribing as a condition of obtaining or renewing their license to practice medicine or to specialize in pain management.

Available Tools & Resources

An Infographic that describes how state-by-state laws such as supply limits, PDMP, and assessment requirements vary in relation to prescription pain management and opioid use.

Guide to Free Course & CEs on Opioid Use provided by the Medical Society of Virginia.

COCA Call Webinar CDC’s Clinician Outreach and Communication Activity (COCA) provides regular webinars for health professionals. One webinar in their series focuses upon the CDC Guidelines for Prescribing Opioids for Chronic Pain. The primary objective is to provide informative, case-based content that will demonstrate and instruct participants on how the 12 recommendations of the CDC Guideline for Prescribing Opioids for Chronic Pain can be incorporated and applied in a primary care practice setting.

The Veterans Health Administration recognizes the clinical challenges to successfully managing pain and prescribing safely for Veterans. The National Pain Management Program office convened a national task force comprised of multidisciplinary pain exerts to create the Opioid Safety Toolkit that contains documents and presentations that can aid in your clinical decisions about starting, continuing, or tapering opioid therapy, and other challenges related to safe opioid prescribing.

Opioid and Pain Management CME: Guidelines, Research and Treatments Trainings from the AMA ED Hub focusing on alternatives to Opioids and Pain Management.

SCOPE of PainSCOPE of Pain offers a wider series of CME training modules designed to promote safe and effective acute and chronic pain management

DIRE Scoring System -- A validated measure used to predict patient suitability for long-term opioid analgesic treatment for non-cancer pain.

Promising Practices

• The Providers' Clinical Support System for Opioid Therapies (PCSS-O) is a national training and mentoring project developed in response to the prescription opioid overdose epidemic. The PCSS-O is a consortium of major stakeholders and constituency groups with interests in safe and effective use of opioid medications. It offers extensive experience in the treatment of substance use disorders and specifically, opioid use disorder treatment, as well as the interface of pain and opioid use disorder. PCSS-O makes available at no cost CME programs on the safe and effective use of opioids for treatment of chronic pain and safe and effective treatment of opioid use disorder. PCSS-O clinical experts have created Core Curriculum -- a comprehensive course on opioid prescribing for primary care providers in the essential evidence-based clinical practices in treating chronic pain—with or without medications. This course provides clinicians with a solid base when treating chronic pain. The curriculum was created in an effort to consolidate the vast amount of information available to clinicians into a course that provides clinicians with the information, resources, and knowledge they need to treat their patients who suffer from chronic pain, including non-pharmacological treatments. PCSS-O also offers a large library of online clinical modules that allow you to take trainings when you want and at your own pace. The modules enhance prescribers’ and other health professionals’ knowledge, skills, and attitudes regarding safe and effective use of medication assisted treatment of opioid use disorder. Most modules include CME credit. Details about obtaining credit are provided with each module description. These online modules are designed to increase understanding of the current state of opioid use disorder and treatment issues for special populations and to improve the ability of professionals to assess and treat patients

• The Collaborative for REMS Education (CO*RE) is a member-led healthcare professional organization representing 600,000 clinicians who work in a wide range of clinical settings including primary care, hospitals, emergency departments, pain clinics, birthing units, and hospice and palliative care centers. CO*RE offers a comprehensive course that was developed by renowned experts and that incorporates all six units outlined in the FDA blueprint for safe opioid prescribing. The course also provides necessary context for safe opioid prescribing by discussing biopsychosocial aspects of pain, the newest clinical guidelines on the treatment of chronic pain, and state policies about prescribing opioids. This is one of many courses offered on the e-learning site of ASAM (American Society of Addiction Medicine).

• SAFE Opioid Course is offered by the American College of Physician and provides guidance that is essential for safe and effective pain management when prescribing extended-release (ER) and long-acting (LA) opioids. It is critical to recognize best practices for how to start to therapy with ER/LA, how to provide therapy, how to end therapy, and what to do in between. Evidence-based tools are required for screening at-risk patients and for monitoring adherence to prescribed ER/LA opioids. Proven methods to counsel patients on ER/LA opioids and to achieve positive outcomes need to be employed. Comprehensive information is also essential on ER/LA-opioids as a drug class. This recorded course will provide clinical insights from the SAFE Opioid Prescribing Blueprint.

• Best Prescribing Practices in Dentistry Course This 1-hour online, self-paced course provides information to understand the significance of the opioid epidemic, understand the role of dentists, learn best practices and strategies for preventing prescription drug diversion and abuse, and identify tools and resources.

• Prescribing Practices initiative The Department of Drug and Alcohol Programs (DDAP) and Department of Health (DOH) in Pennsylvania are co-chairing this Initiative with the purpose of reducing prescription drug abuse and overdoses, while maintaining effective pain management. The group includes representation from all medical professionals, as well as their professional associations and regulatory agencies. The focus of this group is to identify and find consensus on best and safest prescribing and pain management practices, and to identify ways that the stakeholders at the table (representing various state departments and private organizations) can most effectively promote those practices.

• Project ECHO Extension for Community Healthcare Outcomes (ECHO) is a program offered through the University of New Mexico. The program is a remote training that focuses on treatment of substance use disorders (SUDs) and behavioral health disorders. It features a team of multidisciplinary addiction specialists and is offered for free to care providers in the U.S. ECHO provides training in opioid addiction treatment at no cost, delivered right to your clinic, with a variety of bi-weekly schedules to choose from. They serve federally-qualified health centers, using simple videoconferencing technology, equipping healthcare teams to connect to a community of learners.