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The incidence of opioid overdose, diversion, and addiction has continued to rise (SAMHSA, 2017; CDC, 2016), suggesting that physicians are not sufficiently following evidence-based guidelines for prescribing opioids to minimize these risks. The parallel rise of the rate of opioid addiction and the number of opioid prescriptions (SAMHSA, 2013; DAWN, 2013) suggests that physicians do not follow guidelines to limit opioid prescribing. Training physicians in the guidelines for safe opioid prescribing would decrease exposure of patients with chronic pain to unnecessary risks of opioids (Dowell, et al., 2016).

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Due to the widespread extent of the opioid epidemic and patients with chronic pain (Volkow et al., 2016), physicians are seeing a high rate of relatively more challenging problems, such as opioid addiction, drug-related aberrant behavior, and diversion (CDC, 2016; SAMHSA, 2016). After a review of the evidence, the FDA concluded that physicians need training in evidence-based opioid prescribing and provided an outline for the content of the training needed (FDA, 2017). Providing training in opioid prescribing that emphasized the more challenging aspects of opioid prescribing while following the recommended training outline, will help physicians improve patient outcomes (CASA, 2005).

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Based on an extensive review of evidence and expert consensus, the FDA determined that all health care providers involved in pain management need training in safe opioid prescribing (FDA, 2017). Patients having opioid addiction or misuse are frequently encountered in primary care due to the alarming extent of the opioid epidemic: 11.8 million people aged 12 or older misuse of pain relievers (SAMHSA, 2016). Rates of overdose, diversion, and addiction rose in parallel with prescribing rates, suggesting that opioid prescribing is a contributing factor. Provider training in the fundamental opioid prescribing skills will help patients who misuse opioids (CASA, 2005).

Professional practice gaps exist when there is a disparity between educational needs and the ideal or desired level of knowledge, competence, and performance. Only around 6% of U.S. physicians are waivered to prescribe buprenorphine for office-based treatment of opioid use disorder (SAMHSA, 2017). Physicians are likely to encounter patients having this disorder due to the size of the opioid epidemic: 11.8 million people aged 12 or older engage in misuse of pain relievers (SAMHSA, 2017). Many people who need treatment are still not receiving it (SAMHSA, 2016). Federal law requires physicians to complete an 8-hour training in order to prescribe buprenorphine (CARA, 2016; DATA, 2000). Providing physician this training will prepare them to treat the many patients having opioid use disorder.

Buprenorphine is a safe and effective treatment for opioid use disorder for which 8 hours of training by an approved organization is required by law in order to prescribe it (SAMHSA, 2004; SAMHSA, 2016). Providing information on all aspects of buprenorphine treatment will help address this knowledge need. Moreover, buprenorphine treatment has a complex protocol that must be followed for successful outcomes and to minimize risks of overdose, death, and diversion (FSMB, 2013), which validates the need for mandatory training in order to prescribe it. Understanding of clinical protocol and how to apply it will help address this competence need. Lastly, despite the demonstrated effectiveness of buprenorphine, a relatively small percentage (3%) of U.S. physicians are trained and credentialed to prescribe it (NAABT, 2017). Experience with interactive case scenarios helps address the performance need of translating competence in following the protocol into actual practice.

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University of Wisconsin Center for Tobacco Research & Intervention (UW-CTRI). International Classification of Diseases (ICD) – 10 Codes Tobacco/Nicotine Dependence, and Secondhand Smoke Exposure Effective October 1, 2015. . 2015. Available at: http://www.ctri.wisc.edu/documents/icd10.pdf Accessed on: 2015-10-05.

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van der Wouden JC, Rietmeijer C. Motivational Interviewing in the Medical Care Setting. Patient Education Counseling . 2014; 96(1): 142. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24856448 Accessed on: 2015-09-29.

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Wagner C, Conners W. Motivational interviewing principles. Motivational Interviewing Website. 2003b. Available at: http://www.ourdailybreadmissions.org/Philosophy%20of%20MI.htm Accessed on: 2005-08-22.

Waldron HB, Turner CW. Evidence-based psychosocial treatments for adolescent substance abuse. Journal of Clinical Child & Adolescent Psychology. 2008; 37: 238-261. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18444060 Accessed on: 2015-06-17.

Washington State Department of Health (WSDH). Substance abuse during pregnancy: guidelines for screening and management . Office of Healthy Communities . 2015. Available at: http://here.doh.wa.gov/materials/guidelines-substance-abuse-pregnancy Accessed on: 2015-07-24.

Weddle M, Kokotailo P. Adolescent substance abuse. Confidentiality and consent.. The Pediatric Clinics of North America. 2002; 49(2): 301-315. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11993284 Accessed on: 2013-10-24.

Weisleder P. The right of minors to confidentiality and informed consent. Journal of Child Neurology. 2004; 19(2): 145-148. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15072109 Accessed on: 2013-10-24.

Westar HA , Aviram A. Core Skills in Motivational Interviewing. Psychotherapy (Chic). 2013; 50(3): 273-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24000834 Accessed on: 2015-09-29.

Westra HA. Motivational interviewing in the treatment of anxiety . The Guilford Press. 2012. Available at: https://www.guilford.com/books/Motivational-Interviewing-in-the-Treatment-of-Anxiety/Henny-Westra/9781462525997 Accessed on: 2015-06-25.

WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002; 97: 1183-1194. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12199834 Accessed on: 2015-06-02.

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Yudko E, Lozhkina O, Fouts A, et al. A comprehensive review of the psychometric properties of the drug abuse screening test. Journal of Substance Abuse Treatment. 2007; 32(2): 189-198. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17306727

Approximately 20 to 25% of primary care patients are likely to have a current substance use problem or health problem related to tobacco, alcohol, or drug use (Madras et al., 2009; Pilowsky & Wu, 2012). Screening, brief interventions, and referral to treatment (SBIRT) provided to all patients is effective in reducing alcohol, drug, and tobacco use (Agerwala & McCance-Katz, 2012; Pilowsky & Wu, 2012). Brief intervention in primary care is an effective and cost-efficient approach to reduce patients’ alcohol use (Seale et al., 2010; Madras et al., 2009). SBIRT was originally designed for patients with alcohol and tobacco use, but there is growing evidence that brief interventions for illicit drug use also leads to positive patient outcomes (Compton, 2009). Motivational interviewing is a set of structured counseling skills that has been shown to be one of the most effective means of motivating patients to change addictive behavior (Miller and Rollnick, 2012) and has been used successfully in primary care settings as the brief intervention phase of addiction treatment (Rahm et al., 2014).

Unfortunately, PCPs screen less than half of their patients for tobacco use and less than a third for alcohol use (Roche & Freeman, 2004; Seale et al., 2010). Brief interventions happen even less often than screening (NDCP, 2008). In patients who screened positive for substance use, less than 75% received a brief intervention. A lack of adequate training is the most frequently reported barrier to screening and brief intervention (Le et al., 2015). Appropriate follow-up is also happening less often as well (D’Amico et al., 2005). Only 48% of people with excessive alcohol use reported receiving follow-up, with most simply being told to “stop drinking”. There is also a practice gap in referral to treatment. Less than one-fifth of PCPs make a referral after screening positively for substance abuse or risky substance use (Madras et al., 2009). Primary care physicians need to understand the different types of specialty treatment so that they can make appropriate referrals for their substance abuse patients (SAMHSA, 1997).

Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: A brief review. Journal of Psychoactive Drugs. 2012; 44: 307-317. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801194/ Accessed on: 2017-07-26.

Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville, MD. Center for Substance Abuse Treatment. 1997. Available at: https://www.ncbi.nlm.nih.gov/books/NBK64827/ Accessed on: 2010-06-15.

Compton P. Urine toxicology screening: a case study. Emerging Solutions in Pain. 2009.

D’Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Medical Care. 2005; 43(3): 229-236. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15725979 Accessed on: 2013-10-24.

Le KB, Johnson AJ, Seale JP, Woodall H, Clark DC, Parish DC, Miller DP. Primary care residents lack comfort and experience with alcohol screening and brief intervention: A multi-site survey. Journal of General Internal Medicine. 2015; 30: 790-796. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25666210 Accessed on: 2015-06-19.

Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites. Drug Alcohol Depend. 2009; 99: 280-295. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760304/ Accessed on: 2011-03-24.

Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. The Guilford Press. 2013. Available at: http://www.amazon.com/Motivational-Interviewing-Third-Edition-Applications/dp/1609182278 Accessed on: 2014-10-10.

Office of National Drug Control Policy. Screen & brief intervention. . 2008. Available at: https://www.ncjrs.gov/pdffiles1/ondcp/screen_brief_intv.pdf Accessed on: 2015-06-18.

Pilowsky DJ, Wu LT. Screening for alcohol and drug use disorders among adults in primary care: a review. Substance Abuse and Rehabilitation. 2012; 3: 25-34. Available at: https://www.dovepress.com/screening-for-alcohol-and-drug-use-disorders-among-adults-in-primary-c-peer-reviewed-article-SAR Accessed on: 2014-04-28.

Rahm AK, Boggs JM , Martin C, et al.. Facilitators and barriers to implementing SBIRT in primary care in integrated health care settings . Subst Abus. 2014. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25127073 Accessed on: 2015-05-27.

Roche AM, Freeman T. Brief interventions: good in theory but weak in practice. Drug and Alcohol Review. 2004; 23(1): 11-18. Available at: https://www.ncbi.nlm.nih.gov/pubmed/14965883 Accessed on: 2013-10-24.

Seale JP, Shellenberger S, Velzsquez MM, Boltri JM, Okosun I, Guyinn M, Vinson D, Cornelius M, Johnson JA. Impact of vital signs screening and clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison. BMC Fam Pract. 2010; 11:18: . Available at: https://www.ncbi.nlm.nih.gov/pubmed/20205740 Accessed on: 2014-07-28.

Chronic pain is common, affecting a substantial number of people. For example, the National Health Interview from 2016 found that approximately 18% of adults have pain most days or every day, as well as an estimated 42% of adults have pain some days, indicating a high need for pain management (CDC, 2017). Common musculoskeletal pain conditions, such as arthritis, back problems, or frequent and severe headaches, affect around 43% of U.S. adults (Tsang et al., 2008).

Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain to reduce risk of addiction, other substance misuse, and overdose were developed by the American Pain Society and the American Academy of Pain Medicine, based on an extensive review of the literature by a multidisciplinary panel (Chou et al., 2009). More recent evidence-based guidelines by the CDC on opioid prescribing were even stronger in a number of these recommendations, such as recommending urine drug testing at baseline and periodically during chronic opioid therapy as well as checking prescription drug monitoring data bases regularly (Dowell, et al., 2016).

An opioid misuse epidemic continues: 12.5 million Americans or 4.7% of the American population age twelve or older reported misuse of pain relievers in the past year, with misuse defined as meaning use other than as recommended by a doctor (Hughes et al., 2016). Of those people, only 63% said that their opioid misuse was to relieve pain. Another part of the problem is that the rate of overdose deaths is steadily increasing. In 2015, over 22,000 deaths involved prescription opioids, an increase from 19,000 in 2014, which is nearly a 16% increase (CDC, 2016).

Despite these problems and the guidelines which recommend only 3 day initial prescriptions when opioids are needed to manage pain, providers continue to prescribe opioids at a high rate, enough for a bottle for everyone in the U.S. per year (Dowell, et al., 2016). According to national surveys, physicians do not follow key elements of the plan recommended by evidence-based opioid prescribing guidelines including screening for risk of addiction/misuse, assessing substance misuse, communicating effectively about opioid use and risks, and reducing the risk of prescriptions drug overdose and persion (CASA, July 2005, p. 53, p. 54, p. 7; Adams, et al. 2001).

On the other hand, pain is not recognized or adequately treated in other instances, especially for members of racial and ethnic minority groups, women, elderly, people with cognitive impairment, cancer pain, and end of life pain (Dowell, et al., 2016). Chronic pain, especially when inadequately treated, diminishes the quality of life.

The need for education/skills training in order to be able to follow the guidelines in pain management and safe opioid prescribing is evident from national physician surveys (CASA, July 2005, pp. 6, 90-91; CASA, April 2000, p. ii; Morley-Forster, et al. 2003). Based on the overall results of their physician survey on the problem of drug persion, CASA concluded that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance misuse and addiction (CASA, July 2005, p. 100).

Adams NJ, Plane MB, Fleming MF, et al. Opioids and the Treatment of Chronic Pain in a Primary Care Sample. J Pain Symptom Manage. 2001; 22: 791-796. Accessed on: 2015-09-21.

Califano, JA et al. Under the Counter: The persion and Abuse of Controlled Prescription Drugs in the U.S. The National Center on Addiction and Substance Abuse at Columbia University. 2005. Available at: http://www.centeronaddiction.org/addiction-research/reports/under-the-counter-persion-abuse-controlled-perscription-drugs Accessed on: 2013-09-13.

CDC. Opioid Data Analysis. Centers for Disease Control and Prevention. 2016. Available at: https://www.cdc.gov/drugoverdose/data/analysis.html Accessed on: 2017-03-27.

Centers for Disease Control and Prevention. QuickStats: Age-Adjusted Percentage of Adults Aged ≥18 Years Who Were Never in Pain, in Pain Some Days, or in Pain Most Days or Every Day in the Past 6 Months, by Employment Status — National Health Interview Survey, United States, 2016. Morbidity and Mortality Weekly Report . 2017; 66: 796. Available at: https://www.cdc.gov/mmwr/volumes/66/wr/mm6629a8.htm?s_cid=mm6629a8_e Accessed on: 2017-08-01.

Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130. Available at: http://www.jpain.org/article/S1526-5900(08)00831-6/abstract

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; ePub: March 2016: DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1er. Available at: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm Accessed on: 2016-03-16.

Hughes A, Williams MR, Lipari RN, et al. Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. SAMHSA. 2016. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm Accessed on: 2016-09-13.

Morley-Forster PK, Clark AJ, Speechley M, et al. Attitudes Toward Opioid Use for Chronic Pain: A Canadian Physician Survey. Pain Res Manage. 2003; 8: 189-94. Accessed on: 2015-09-21.

Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015; 16(8): . Available at: https://www.ncbi.nlm.nih.gov/pubmed/26028573 Accessed on: 2017-03-27.

The National Center on Addiction and Substance Abuse (CASA). Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University, Survey Research Laboratory. Chicago, IL: University of Illinois at Chicago. 2000. Available at: http://www.centeronaddiction.org/addiction-research/reports/national-survey-primary-care-physicians-patients-substance-abuse Accessed on: 2014-04-28.

Tsang A, Von Korf M, Lee S, et al. Common chronic pain conditions in developed and developing. J Pain. 2008; 9(10): 883-91. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18602869 Accessed on: 2017-03-27.

Part 1:

Data from the 2013 National Survey on Drug Use and Health shows that a serious epidemic of opioid misuse continues at a rate similar to the previous 5 years, with 4.5 million people aged 12 or older engaging in misuse of pain relievers (SAMHSA, 2014). Data from the following year cannot be compared due to a refinement in the definition of misuse to mean any way not directed by a doctor, but shows that the epidemic continues at significantly high rate (Hughes et al., 2016). With the new definition of misuse, 12.5 million Americans or 4.7% of the American population age twelve or older had misuse of pain relievers in the past year. Of those people, approximately 63% said that their opioid misuse was to relieve pain. Past year use of heroin continued to rise and was reported by 828,000 people age twelve or older in 2015. The rate of overdose deaths is also steadily increasing. In 2015, over 22,000 deaths involved prescription opioids, which is an increase from 19,000 in 2014, which is nearly a 16% increase (CDC, 2016).

Although the number of people receiving treatment for opioid use disorder has increased, the number of people being treated is still only a small fraction of those needing treatment: Past year treatment for prescription pain reliever misuse was still only received by 746,000 individuals in 2013 (SAMHSA, 2014).

Buprenorphine is a safe and effective treatment for opioid use disorder that offers patients a more widely available, accessible, convenient treatment option as compared to traditional opioid treatment programs (OTP) (SAMHSA, 2004; SAMHSA, 2016). The Drug Addiction Treatment Act (DATA) of 2000—an amendment to the Controlled Substances Act — allowed physicians who are not part of an OTP to prescribe buprenorphine with additional training and a waiver to the Controlled Substances Act. The Comprehensive Addiction and Recovery Act of 2016 (CARA) added nurse practitioners and physician assistants to the list of providers who can train to prescribe buprenorphine and become waivered.

The law requires physicians to complete an 8-hour buprenorphine training conducted by an approved organization in order to prescribe it; the required training for nurse practitioners and physician assistants is 24 hours. While buprenorphine is relatively safe, there are risks of overdose and death due to buprenorphine and there is a risk of diversion (FSMB, 2013), which, in addition to skills needed to prescribe the medication effectively for each individual, are among the reasons for the mandatory training.

This buprenorphine training activity prepares providers to prescribe buprenorphine safely and effectively to address needs of the millions of Americans with opioid use problems. The activity has been developed to meet the DATA 2000 training guidelines as defined in Public Law 106-310-106th Congress as well as the Comprehensive Addiction and Recovery Act of 2016 (S 524, Title III, Section 303-114th Congress) and is endorsed by the American Society of Addiction Medicine, one of the approved training organizations named in DATA 2000. The activity content was initially based upon SAMHSA’s 2004 publication Treatment Improvement Protocol (TIP) #40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction and follow the Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office (FSMB, 2013). It has been edited to SAMHSA’s Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder – Review and Update (2016), ASAM’s National Practice Guideline For the Use of Medication in the Treatment of Addiction Involving Opioid Use (2015), and the CDC’s guidelines on opioid treatment (Dowell et al., 2015) as well as CARA 2016. The courses are regularly reviewed and updated by ASAM members who are experts in the field of addiction medicine and buprenorphine treatment.

Practice Gap References

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