Systemwide Prescriber Education

Description

Systemwide prescriber education programs educate prescribers about the benefits and risks of prescribing opioids, including strategies to prevent abuse, while maintaining legitimate and appropriate access to opioids.

Objective(s)

To reduce unnecessary prescriptions for opioids through prescriber education

Typical Elements

  • Information is provided to prescribers on how to best use opioids to treat chronic non-cancer pain (see Systemwide Patient Education), how to identify patients who may be at risk for abuse, and how to deal with substance abuse screening, treatment, and referrals (U.S. Department of Health and Human Services [HHS], 2013).
  • Prescriber education may be available from many sources, including events sponsored by drug manufacturers, continuing medical education (CME) programs, educational materials developed by interested organizations, and state-mandated training events.
    • Note: See the FDA Blueprint for Prescriber Education for Extended Release and Long-Acting Opioid Analgesics.
  • The Centers for Disease Control and Prevention (CDC) highlight 12 recommendations for primary care clinicians who are treating patients (18 years and older) with chronic pain via outpatient settings. The voluntary recommendations based on emerging research evidence. provide guidance on (Dowell, Haegerich, & Chou, 2016):
    • Determining initiation or continuation of opioid therapy
    • Selecting type of opioid, proper dosage, duration, follow-up, and discontinuation
    • Assessing the risk and addressing harms of opioid use
  • Through its Risk Evaluation and Mitigation Strategy (REMS) for opioids, the U.S. Food and Drug Administration (FDA) requires prescription drug manufacturers to sponsor the following types of prescriber education (FDA, 2013, 2014a, 2014b):
    • A Communication Plan that informs healthcare providers (including prescribers, dispensers, state licensing authorities, professional associations, and all other U.S. Drug Enforcement Administration registrants) about new prescription drugs. The plan must be published within 60 days of drug approval and must include a "Dear Healthcare Provider Letter" that explains the drug's potential and known risks (FDA, 2014a).
    • A Medication Guide for each drug intended for patients that provides more detailed information about the drug's use and risks (FDA, 2014b).
    • Voluntary opioid training programs for healthcare providers, delivered by an accredited CME provider (FDA, 2013). These programs are financially supported by independent educational grants from extended-release and long-acting opioid analgesic companies.
  • Forty-five states and the District of Columbia require physicians to obtain a certain number of CME credits per year to maintain their licensure (American College of Emergency Physicians [ACEP], 2013):
    • CMEs cover a wide range of topics, although some states require credits in specific topics (such as pain management, geriatric care, cultural competence, domestic violence, and patient safety).
    • Accredited CME programs may offer credits related to appropriate prescribing practices, often adhering to the FDA guidelines for manufacturer-sponsored education requirements (Safe and Competent Opioid Prescribing Education, n.d.).
  • Interested community-based organizations and states can develop educational materials and programs for prescribers focusing on, for example, safe and effective pain management and prescribing practices, risk assessment, and potential patient education tools (Physicians for Responsible Opioid Prescribing, n.d.). Project Lazarus is an example of a community-based prevention model.
  • States can require prescribers to receive training related to effective pain management, patient risk assessment, etc. as a condition of their licensure renewal (Massachusetts Legislature, n.d.).
  • HHS and the federal agencies within this department have developed a number of initiatives to support prescriber education efforts (HHS, 2013):
    • The Substance Abuse and Mental Health Services Administration (SAMHSA) offers an in-person CME course on safe opioid prescribing practices, a clinical support system for opioid prescribers, and free online training courses and resources (SAMHSA, 2012). SAMHSA's courses focus on managing chronic non-cancer pain through collaborative care models.
    • The National Institutes of Health (NIH) developed curriculum resources on prescription opioid abuse and designated 12 professional schools as Centers of Excellence in Pain Education to serve as development hubs for additional resources.
    • NIH also developed two video-based CME modules on prescription drug abuse and pain management.
    • The Centers for Medicare and Medicaid Services created a Medicaid Education Toolkit for pharmacy staff, which discusses drug diversion and prevention.
    • The FDA created its REMS for opioids, which requires manufacturer-sponsored training.
    • The Centers for Disease Control and Prevention and the FDA each support ongoing evaluations of the impact of prescriber education.

Populations

Opioid prescribers

Outcomes

  • In Washington State, optional opioid prescriber educational guidelines were associated with a 27% decrease in the number of workers on disability compensation who received an opioid prescription, and a 50% decrease in overdose deaths among those individuals (Franklin et al., 2012).
  • In Utah, expanded prescriber education programs focusing on recommended practices and using the state's PDMP were associated with a 14% decrease in medication-related overdose deaths and a 60–80% reduction in inappropriate prescribing habits among prescribers (Cochella & Bateman, 2011).
  • CMEs focusing on buprenorphine use and best prescribing practices in two U.S. regions were associated with greater prescriber knowledge and improved clinical behavior (Lofwal, Wunsch, Nuzzo, & Walsh, 2011).
  • Though not specific to opioids, a meta-analysis of CMEs found that 79% of studied CMEs were effective at improving clinical knowledge, while 42% were effective at improving patient outcomes (Cervero & Gaines, 2014). In addition, interactive CMEs can be more effective than didactic CMEs, but the sample size was too small to draw any definitive conclusions.

Guidelines

Cautious, Evidence-Based Opioid Prescribing.

CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016

Introduction for the FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics.

Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: An Educational Aid to Improve Care and Safety with Opioid Therapy—2010 Update.

Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Noncancer Pain.

Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release and Long-Acting Opioids.

SAMHSA Opioid Overdose Toolkit: Information for Prescribers.

Safe and Effective Opioid Prescribing for Chronic Pain.

SAFE Opioid Prescribing: Strategies, Assessment, Fundamentals, Education.

Acknowledged by

National Alliance for Model State Drug Laws. Model Health Professionals Training Act.

National Conference of Insurance Legislators. Best Practices to Address Opioid Abuse, Misuse and Diversion.

Office of National Drug Control Policy. Epidemic: Responding to America's Prescription Drug Abuse Crisis.

U.S. Department of Health and Human Services, Behavioral Health Coordinating Committee. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities.

U.S. Food and Drug Administration. Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS).

References

Cervero, R., & Gaines, J. (2014). Effectiveness of continuing medical education: Updated synthesis of systematic reviews. Retrieved from http://www.accme.org/sites/default/files/2014_Effectiveness_of_Continuing_Medical_Education_Cervero_and_Gaines_0.pdf

Cochella, S., & Bateman, K. (2012). Provider detailing: an intervention to decrease prescription opioid deaths in Utah. Pain Medicine, 12(Suppl 2) S73–S76.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2503508.

Franklin, G. M., Mai, J., Turner, J., Sullivan, M., Wickizer, T., & Fulton-Kehoe, D. (2012). Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. American Journal of Industrial Medicine, 55(4), 325–331.

Lofwal, M. R., Wunsch, M. J., Nuzzo, P. A., & Walsh, S. L. (2011). Efficacy of continuing medical education to reduce the risk of buprenorphine diversion. Journal of Substance Abuse Treatment, 41(3), 321–329.

Massachusetts Legislature. (n.d.). General Laws, Part 1, Title XV, Chapter 94C, Section 18. Retrieved from https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter94C/Section18

Physicians for Responsible Opioid Prescribing. (n.d.). Cautious, evidence-based opioid prescribing. Retrieved from http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf

Safe and Competent Opioid Prescribing Education. (n.d.). What is the SCOPE of pain? Retrieved from https://www.scopeofpain.com/about-us/

Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). COPE: Collaborative opioid prescribing education. Rockville, MD: National Registry of Evidence-based Programs and Practices, SAMHSA.

U.S. Department of Health and Human Services. (2013). Addressing prescription drug abuse in the United States: Current activities and future opportunities. Retrieved from https://www.cdc.gov/drugoverdose/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf

U.S. Food and Drug Administration. (2013). Extended-release (ER) and long-acting (LA) opioid analgesics Risk Evaluation and Mitigation Strategy (REMS). Retrieved from https://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

U.S. Food and Drug Administration. (2014a). Guidance for industry and FDA Staff—Dear health care provider letters: Improving communication of important safety information. Retrieved from https://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm233769.pdf

U.S. Food and Drug Administration. (2014b). Introduction for the FDA blueprint for prescriber education for extended-release and long-acting opioid analgesics. Retrieved from http://www.fmda.org/2017/Blueprint%20Opioid%20LA.ER%20REMS%20as%20of%201.20.2017.pdf