CHAPTER 2
INTRODUCTION

ADDRESSING THE EPIDEMIC WITHIN A PANDEMIC

Between 1999 and 2019, nearly 500,000 individuals living in the U.S. died from an overdose involving an opioid (CDC, 2021b). The devastation of this crisis persists, as the number of individuals living in the U.S. who died from a drug overdose reached an all-time-high of 100,000 recorded in the 12 month period ending in April 2021—surpassing the 2019 figures by more than 21,000 deaths (NCHS, 2021). Of these deaths, nearly 75 percent involved an opioid (Ahmad et al., 2021). Among the most significant barriers to combating the overdose epidemic in the United States is ensuring patients have access to affordable and evidence-based substance use disorder treatment. Of the 21.6 million people aged 12 or older with an SUD, only 12.2 percent received treatment in an appropriate facility in 2019 (SAMHSA, 2020).

The global spread of SARS-CoV-2 and the resulting coronavirus (COVID-19) pandemic have exacerbated the overdose epidemic. Based on provisional data from the Centers for Disease Control and Prevention (CDC), reported drug overdose deaths in the U.S. increased by 29.4 percent in 2020—the largest single-year increase since 1999 (Ahmad et al., 2021). Already disproportionately burdened by the worst effects of the COVID-19 pandemic, including the rising rates of morbidity and mortality, food insecurity, and unemployment, these overdose-related deaths have largely been shouldered by the economically disadvantaged as well as Black, Indigenous, and people of color (BIPOC), further widening existing health disparities (CBPP, 2021; CDC, 2020a; Haley and Saitz, 2020; Khatri et al., 2021; Patel et al., 2021).

Over a year since the onset of the COVID-19 pandemic, the U.S. health care system continues to grapple with fundamental challenges in training and educating its health care workforce amid a pandemic, ensuring health care providers can practice safely and with appropriate personal protective equipment, that care can be delivered both in-person and virtually, that health care professional students have access to clinical training sites, and that organizations can manage enormous financial strain. The impact of COVID-19 has exacerbated health care inequity for at-risk populations and has created

a perfect storm—a “crashing of crises”—for those already reeling from the existing opioid crisis (Alexander et al., 2020; Becker and Fiellin, 2020; Khatri and Perrone, 2020). National and local efforts to “flatten the curve” and reduce mortality for COVID-19 simultaneously and dramatically interrupted the care delivery system for those impacted by the opioid crisis.

While addressing a global pandemic is critical, health care providers and educators also cannot lose sight of the urgency of the opioid crisis and the adverse impacts of the COVID-19 pandemic, which will exacerbate drug overdose, death by suicide, and substance use-related morbidity and mortality in significant ways for, potentially, years to come (Volkow, 2020).

The Role of Health Care Professionals

For more than 20 years, the etiology of the opioid crisis has included the intersection of industry misconduct (Hoffman and Benner, 2021), harmful regulatory missteps (Bonnie et al., 2019), discriminatory and stigmatizing drug policies (Jordan, Mathis, and Isom, 2020), and health care and public health lapses that continue to this day (Jones et al., 2018). Sparked by overprescribing in its first decade and accelerated by illicit opioids, the crisis has raged on with immeasurable costs.

Addressing health professional practice has been at the center of the U.S. response to the opioid crisis, though largely through a regulatory approach and with a much smaller effort toward establishing specific competencies for health care professionals and incorporating relevant education across the continuum of health professions education. Concerted efforts to reduce opioid prescribing by clinicians have yielded steady declines—including a 20 percent reduction from 2012 to 2015 in annual prescribing rates for opioid prescriptions of <30 days’ supply—but may have unintended consequences in that patients experiencing addiction who have been denied opioids may seek illicit sources with dire consequences (Guy et al., 2017).

Even though synthetic opioids (i.e., fentanyl) are currently contributing more than any single drug to mortality, overdose deaths that include prescription opioids—among other drugs—continue at staggering levels and accounted for more than 100,000 overdose deaths recorded in the 12 month period ending in April 2021, the greatest yearly toll of any year (CDC, 2021c). The majority of overdose deaths that involved prescription opioids also included non-opioids (cocaine, methamphetamine, and benzodiazepines). A significant contributor to opioid misuse is individuals who obtain opioids from friends and family, which creates a more complicated environment that extends beyond simply addressing responsible prescribing (Gladden et al., 2019). Far from a post-opioid phase of the crisis, psychostimulants and benzodiazepines are filling the gap left by concomitant decreases in prescription opioids, indicating that polypharmacy is emerging in the complex environment of substance use as a growing cause of mortality (CDC, 2020b; Gladden et al., 2019; Tori, Larochelle, and Naimi, 2020).

Safer opioid prescribing is important but not sufficient to curtail the crisis. The enormity of challenges faced by the health care workforce cannot be overstated. Most clinicians are receiving insufficient or inadequate training to manage pain and substance use for their patients (IOM, 2011; Office of National

Drug Control Policy, 2004). Beyond individual competence, care teams struggle to implement evidence-based approaches that require interprofessional care coordination. System-based challenges, such as the use of data and technology systems and barriers in payment and reimbursement, compound the complex web of factors that must be addressed (Englander et al., 2017; Mackey et al., 2019; Makris et al., 2014). As research efforts, such as the National Institutes of Health (NIH)-funded Acute to Chronic Pain Signatures, continue to elucidate new approaches for managing pain and SUDs, the need for education to inform and re-shape health professional practice and care delivery is ongoing (NIH Office of Strategic Coordination - The Common Fund, n.d.). When considering the unique needs of individual health care professionals and teams—specific to practice setting—the difficulty of evolving practices, in competition with numerous other practice-based priorities, is apparent. To achieve and sustain the efforts to address the substance abuse epidemic in the midst of COVID-19 leaves health care professionals with the impossible imperative of “we must do better with less.”

THE NATIONAL ACADEMY OF MEDICINE’S ACTION COLLABORATIVE ON COUNTERING THE U.S. OPIOID EPIDEMIC

The National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic (the Collaborative) is a public-private partnership committed to sharing knowledge, aligning ongoing initiatives, and addressing complex challenges that require a collective response from public and private actors. It is comprised of over 60 member organizations from health care systems, federal agencies, state and local governments, community organizations, patient organizations, provider groups, payors, industry, academia, nonprofits, and persons with lived experience.

The Collaborative endeavors to identify unmet needs and develop and disseminate evidence-based, multi-sector solutions designed to reduce rates of opioid misuse and improve outcomes for individuals, families, and communities affected by the crisis. The Education and Training Workgroup of the Collaborative includes members across academia, federal agencies, health education and accreditation organizations, health professional associations, health systems, nonprofit institutions, the private sector, as well as practicing clinicians and persons with lived experience. The interprofessional Workgroup is helping its members to recognize the biases and limitations of professional silos, and by doing so, creating opportunities for creative problem-solving.

GOALS FOR THIS PUBLICATION

The Education and Training Workgroup has considered the complex ecosystem of current efforts to address the opioid crisis across health professions. All stakeholders, including people with lived experience, educators, regulators, certifying agencies, and accreditors, are actively engaged in this work. The organizing principle for this work became optimization and harmonization by providing support and guidance to this community.

The Workgroup asked:

• How do we determine if the solutions being developed are accurately matched to problems in practice?
• Where are additional resources and efforts warranted, and where are they contributing to inefficiency?
• How can we improve the acuity and impact of supportive efforts while eliminating unproductive variation and redundancy?

The Workgroup determined that it must begin with understanding the current environment for health care professionals in practice through an educational lens with the following objectives:

• Identify and highlight professional practice gaps for health care professionals that currently exist in relation to acute and chronic pain management and SUDs; and
• Analyze current accreditation, certification, and regulatory requirements for health professions education that foster competency in acute and chronic pain management and SUDs.

Professional practice gaps were identified as critical to understanding the current environment as they reflect the difference between health care processes or outcomes observed in practice, and those potentially achievable on the basis of current professional knowledge. Identifying a PPG does not presuppose the reason why it exists, but rather identifies a gap that requires further analysis or research to better understand. Education providers use PPGs as the basis for conducting needs assessments to identify possible contributors to those gaps, and to design and evaluate education to close the gaps.

Analysis of current accreditation, certification, and regulatory requirements were identified as critical to understanding the current environment as they set standards for professions across the continuum, from undergraduate to postgraduate and, ultimately, clinical practice. Examining what requirements and policies do and do not exist can help regulatory organizations identify areas for improvement of standards and programs to promote more effective education and practice in pain management and SUD care. Regulators can also use the results of the analysis to not only identify intra-organizational gaps and needs, but also identify opportunities for harmonization across professions and organizations.

By describing these insights from the environment of educational requirements and current practice gaps, the Workgroup was able to identify strategies to help health professions educators and stakeholders optimize their ongoing responses to the opioid crisis and model collaborative methods that can be used to address education and training needs for other complex public health imperatives.

To address these objectives, the Workgroup conducted a literature review to identify PPGs across five health professions: medicine (allopathic (MD) and osteopathic (DO)), nursing (registered nurse (RN) and advanced practice registered nurse (APRN)), physician assistant, dentistry (doctor of dental surgery (DDS) and doctor of medicine in dentistry (DMD)), and pharmacy (pharmacists and pharmacy techni-

cians). Field experts then validated these gaps. Concurrently, the group also disseminated an educational requirements survey to accreditation, certification, and licensure organizations to collate current regulatory policies or requirements for acute and chronic pain management and SUD care training.

It is important to note that the five professions selected for this analysis were not meant to imply that there are not very well-qualified experts from other health professions caring for patients with pain and SUDs. These professions were chosen because they represent a large number of prescribers or health care professionals in the current workforce.