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 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. Improving professional training on opioids and alternative pain management plays a key role in prevention.

Key Information

The current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems which they will come across. There is limited education time allocated to pain and pain management. Pain curricula in medical school education for MDs in the U.S. ranges from 1-31 hours, with a mean of 11.13 hours. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain. One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics. Fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology, psychiatry, physical medicine and rehabilitation, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies, including NPPC options. The expansion of these strategies within anesthesiology and acute pain practices to chronic pain care have had success in carefully selected patients.

• 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.

Doctor shopping is the act of going to many doctors with the goal of getting multiple prescriptions for painkillers. Although only 0.7 percent of patients actively attempted to scam providers into issuing duplicate prescriptions, their impact is high. 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. So, doctors still need education on the signs that someone is just looking for a prescription. Dr. John Zweifler recommends that clinicians "find objective evidence of severe disease through physical examination or diagnostic studies before prescribing long-term opioids.

CDC Guidelines for Prescribing Opioids for Chronic Pain

In 2019, The Center for Disease Control and Prevention issued 12 recommendations for primary care providers, who account for nearly half of opioid prescriptions. If doctors take up the recommendations on non-opioid pharmacologic and non-pharmacologic therapies, they could help stop one of the deadliest drug epidemics in US history. Three of the recommendations are listed below:

• Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
• When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
• Providers should always exercise caution when prescribing opioids and monitor all patients closely.

The idea is to encourage doctors to be more cautious about prescribing opioids, making them less likely to distribute the drugs to patients who are prone to addiction or don't really need the medication. The evidence on whether opioid painkillers can even treat chronic pain is weak at best. The general guidance by CDC is to “start low and go slow” and to regularly monitor patients. The CDC aims to help healthcare providers understand and apply their recommendations in a clinical setting through interactive patient scenarios, videos, knowledge checks, tips, and resources. Their trainings cover the risks and benefits of prescription opioids, non-opioid treatment options, patient communication, and risk mitigation. Content offered in CDC trainings includes:

• 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.
• 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.

Wolters Kluwer is a global provider of professional information, software solutions, and services for clinicians. Their medical research lists the following two conclusions:

• Opioid Naïve Patients -- Many patients just want relief from pain, and they may not be aware of the risks or alternatives. Doctors who prescribe opioids should take steps to ensure that patients are not "opioid naïve". Patients who are considered opioid naïve should receive education and screening for risk factors. Five cited studies reported an increased risk of new persistent opioid use after prescription of opioids for acute pain in opioid naïve patients. "Importantly, post-surgical opioid prescription in opioid naïve patients is also associated with an increase in overdose and misuse."

• Other Risk Factors -- A summary of two citations concludes: "Risk factors for persistent opioid use after surgery include preoperative pain; medical comorbidities; depression; a history of drug, alcohol, or tobacco abuse; lower socioeconomic status; and use of benzodiazepines or antidepressants."

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

SAFE Project:

• SAFE Veterans provides services to connect veterans, active-duty service members, and their families — all military-connected individuals — to the resources they need to address mental health challenges and substance use disorders.
• SAFE Workplaces provides employers and employees, alike, with the tools and resources necessary to address issues of behavioral health and achieve emotional wellbeing in the workplace.
• SAFE Campuses provides developmental assistance to support the needs of students in recovery and collegiate recovery communities. The program offers program-specific sessions tailored to various professional degree programs.
• See the wiki titled "Increase Access to Non-Pharma Therapies" for more detailed information on alternatives to using opioids as pain management.

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 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 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 self-paced online clinical modules. The modules enhance 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 are employed to counsel patients on ER/LA opioids and to achieve positive outcomes. This course provides clinical insights from the SAFE Opioid Prescribing Blueprint.

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

• 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 medical professionals, regulatory agencies, and professional associations. 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 representing various state departments and private organizations can most effectively promote those practices.

• Project ECHO (Extension for Community Healthcare Outcomes) is a remote training that focuses on treatment of substance use and behavioral health disorders. ECHO was developed by Sanjeev Arora, M.D., at the University of New Mexico Health Sciences Center and features a team of multidisciplinary addiction specialists. It is a collaborative model of medical education and care management that helps clinicians provide expert-level care to patients, and it is offered for free to care providers in the United States. ECHO serves federally-qualified health centers with videoconferencing technology and equips healthcare teams to connect with a community of learners.