Improve Professional Training on Opioids and Alternative Pain Management Approaches

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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)[1] 50 million U.S. adults have chronic pain. Approximately 19.6 million American adults have high-impact chronic pain that limits at least one major life activity. One-third of people with high-impact chronic pain have difficulty with self-care activities like getting dressed.

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.

The importance of engaging prescribers in efforts to prevent prescription drug misuse is critical to provide credibility, reach target audiences, and provide their perspective.

Key Information

Current Status

  • 72% of doctors in one study indicated their knowledge of opioid dependence was low.[2]
  • Many doctors in one study rated their training "unsatisfactory."[3]
  • Only 5 states require all physicians to receive opioid-related CME.[4]
  • Physicians who studied at lower-ranked medical schools prescribe nearly three times as many opioids per year as those who attended top-tier institutions [5]
    • On average, the researchers found, 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.[6]

 

Medical Education

The Forum, in collaboration with the Chris Cornell Foundation, will enhance the education of healthcare providers about the identification and treatment of substance use disorder (SUD). 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.[7]
The Department of Drug and Alcohol Programs (DDAP) and Department of Health (DOH) in Pennsylvania are co-chairing the Prescribing Practices 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.[8]
  TheVeterans 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 anOpioid 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.[9]
  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.[10] 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
  This infographic describes how state-by-state laws such as supply limits, PDMP, and assessment requirements vary in relation to prescription pain management and opioid use.

Best Practices

  • CDC Prescribing Guidelines
  • Non-pharmacologic therapies
  • Non-opioid pharmacologic therapies
  • “Start low and go slow”
  • Regularly monitor patients


Screening Before Prescribing

Dr. John Zweifler recommends that clinicians "find objective evidence of severe disease through physical examination or diagnostic studies before prescribing long-term opioids.[11]
 

DIRE Scoring System

Diagnosis, intractability, reliability with 4 measures, and efficacy [12]

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

Training Curriculum & Programs

Project ECHO

Project ECHO (Extension for Community Healthcare Outcomes) 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 an a team of multidisciplinary addiction specialists and is offered for free to care providers in the U.S.
  This 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, with a special focus on those that received the Substance Abuse Service Expansion awards using simple videoconferencing technology, healthcare teams connect to a community of learners. This free program ends in August of 2018.
 

Applying CDC's Guidelines for Prescribing Opioids

This[13] aims to help healthcare providers apply CDC’s recommendations in a clinical setting through interactive patient scenarios, videos, knowledge checks, tips, and resources. You will gain a better understanding of the recommendations, the risks and benefits of prescription opioids, non-opioid treatment options, patient communication, and risk mitigation.

Two training courses are already provided on their website:

  • Addressing the Opioid Epidemic: Recommendations from CDC[14]
  • Treating Chronic Pain Without Opioids[15]
  • 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.

 

COCA Call Webinar Series

CDC’s National Center for Injury Prevention and Control (NCIPC) partnered with CDC’s Clinician Outreach and Communication Activity (COCA) and the University of Washington to present a webinar series about the CDC Guideline for Prescribing Opioids for Chronic Pain.
  This seven-part series is intended to use a data-driven approach to help providers choose the most effective pain treatment options and improve the safety of opioid prescribing 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.
 

Providers' Clinical Support System For Opioid Therapies

[16]The Providers' Clinical Support System for Opioid Therapies is a national training and mentoring project developed in response to the prescription opioid overdose epidemic. The consortium of major stakeholders and constituency groups with interests in safe and effective use of opioid medications 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.

Core Curriculum
PCSS-O clinical experts have created 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 will provide 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. The result is the most comprehensive and up to date curriculum developed thus far for the treatment of chronic pain.

Clinical Online Modules
PCSS-O offers a large library of online 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 and are noted on the page.

These online modules are designed to increase your:

  • understanding of the current state of opioid use disorder
  • understanding of treatment issues for special populations
  • ability to assess and treat patients

CO*RE/ASAM Opioid Prescribing

The CO*RE/ASAM Opioid Prescribing: Safe Practice, Changing Lives course addresses this public health crisis. This comprehensive course was developed by renowned experts from Collaborative for REMS Education (CO*RE) and incorporates all six units outlined in FDA blueprint for safe opioid prescribing. The updated 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.[17]
 

Relevant Research

Pain Management- The Veteran Affairs Office of Research & Development[18]

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use[19] Evidence of Strategies to address the Opioid epidemic including training.

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.

Available Tools & Resources

Pain Management Best Practices- Interagency Task Force[20]A report by the Pain Management Best Practices Inter-Agency Task Force (Task Force) to guide the public at large, federal agencies, and private stakeholders.

Providers Clinical Support System PCSS is a national training and clinical mentoring project developed in response to the opioid use disorder crisis. The organization provides training resources for primary care providers.[21]

Interactive Training Series for Healthcare Providers Applying CDC Guideline for Prescribing Opioids for Chronic Pain[22]

Opioid and Pain Management CME: Guidelines, Research and Treatments Trainings from the AMA ED Hub focusing on alternatives to Opioids and Pain Management.[23]

SCOPE of Pain[24]SCOPE of Pain offers a wider series of CME training modules designed to promote safe and effective acute and chronic pain management

Guide to Free Course & CEs on Opioid Use[25] Guide provided by the Medical Society of Virginia

Promising Practices

SAFE Opioid Course [26] SAFE Opioid Course by the American College of Physician 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 - Dentists[27]Best Prescribing Practices in Dentistry Course- Cost is only $25. This 1-hour online, self-paced course will provide 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.

Sources

  1. ↑ https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm
  2. ↑ [1]Davis, C. S., & Carr, D. (2016). Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements. Drug and Alcohol Dependence, 163, 100–107. https://doi.org/10.1016/j.drugalcdep.2016.04.002
  3. ↑ [2]Davis, C. S., & Carr, D. (2016). Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements. Drug and Alcohol Dependence, 163, 100–107. https://doi.org/10.1016/j.drugalcdep.2016.04.002
  4. ↑ [3]Davis, C. S., & Carr, D. (2016). Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements. Drug and Alcohol Dependence, 163, 100–107. https://doi.org/10.1016/j.drugalcdep.2016.04.002
  5. ↑ [4]Doctors who attend lower-tier medical schools prescribe far more opioids. (2017, August 7). Retrieved November 24, 2019, from STAT website: https://www.statnews.com/2017/08/07/doctors-opioid-prescriptions/
  6. ↑ [5]Doctors who attend lower-tier medical schools prescribe far more opioids. (2017, August 7). Retrieved November 24, 2019, from STAT website: https://www.statnews.com/2017/08/07/doctors-opioid-prescriptions/
  7. ↑ [6]Forum, A. P. (n.d.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944301/ Retrieved April 7, 2022, from
  8. ↑ [7]https://www.hhs.gov/sites/default/files/pain-mgmt-best-practices-draft-final-report-05062019.pdf
  9. ↑ [8]HealthITSecurity. (2016, November 2). Addressing Opioid Abuse with Analytics, Population Health Strategies. Retrieved November 24, 2019, from HealthITAnalytics website: https://healthitanalytics.com/features/addressing-opioid-abuse-with-analytics-population-health-strategies
  10. ↑ https://healthitanalytics.com/features/addressing-opioid-abuse-with-analytics-population-health-strategies
  11. ↑ https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.1030.7742&rep=rep1&type=pdf
  12. ↑ https://pubmed.ncbi.nlm.nih.gov/16942953/
  13. ↑ https://www.cdc.gov/opioids/providers/prescribing/guideline.html
  14. ↑ https://www.cdc.gov/drugoverdose/training/overview/index.html
  15. ↑ https://www.cdc.gov/drugoverdose/training/nonopioid/index.html
  16. ↑ http://pcss-o.org/ PCSS-O
  17. ↑ [12]HealthI Security. (2016, November 2). Addressing Opioid Abuse with Analytics, Population Health Strategies. Retrieved November 24, 2019, from HealthITAnalytics website: https://healthitanalytics.com/features/addressing-opioid-abuse-with-analytics-population-health-strategies
  18. ↑ https://www.research.va.gov/topics/pain.cfm
  19. ↑ https://www.ncbi.nlm.nih.gov/books/NBK458653/
  20. ↑ https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
  21. ↑ https://pcssnow.org/education-training/
  22. ↑ https://www.cdc.gov/opioids/providers/training/interactive.html
  23. ↑ https://edhub.ama-assn.org/course/277
  24. ↑ 'https://www.scopeofpain.org/core-curriculum/online-training/
  25. ↑ https://www.msv.org/wp-content/uploads/2017/02/opioid_ce_list.final_.pdf
  26. ↑ https://www.pri-med.com/online-education>
  27. ↑ http://maperc.mycrowdwisdom.com/diweb/catalog/item/id/722523/q/q=dentistry&c=61
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