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Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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CHAPTER 5
DISCUSSION

COLLECTIVE INSIGHTS FROM THE LITERATURE REVIEW

To advance education and training approaches to address the opioid crisis, the Workgroup reviewed 10 years of published, peer-reviewed literature categorizing the nature and magnitude of PPGs and the results of a survey of more than 60 organizations that comprise the regulatory, certifying, and accreditation oversight of the continuum of education and practice for the medicine, nursing, physician assistant, dentistry, and pharmacy professions. The literature review of PPGs elucidated both a quantitative and qualitative understanding of barriers that separate current practices from optimal practices, summarized in Table 19. Addressing these specific gaps can help to improve practice and patient, family, and system outcomes.

Health Care Providers

Health care providers as described in the literature review are struggling. They are managing multiple and competing priorities, complicated by high patient volumes and acuity. Many lack access to user-friendly tools and resources at the point of care and struggle to identify and/or implement evidence-based guidelines to support patient-care decisions. They lack sufficient numbers of interprofessional team members to effectively manage patients with OUD and SUDs. They need access to data that can be easily shared and accessed across multiple platforms. They need consistent policies that are uniformly implemented and reinforced. They also need to feel safe when managing patients, and not fear that their jobs are threatened when managing patients’ pain. Health care providers also need to develop effective communication strategies with other members of the health care team, and with patients and their families.

Page 36 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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TABLE 19 | Professional Practice Gaps Identified from Peer-Reviewed Literature

Individuals	Teams	Institution or Practice Setting
Challenges related to screening and assessment Challenges related to identification/diagnosis Challenges related to prescribing/tapering opioids Lack of knowledge, experience, or strategies for prescribing non-opioids Lack of knowledge, experience, or strategies for prescribing nonpharmacological approaches (e.g., physical therapy, counseling, etc.) Differences in prescribing practices by patient age, gender, race, socioeconomic status, geographic location, patient population, comorbidities, payor type Difference in prescribing practices by provider type and type of pain Inability to navigate or effectively use practice resources Difficulty monitoring across practices Availability of referral for pain management and SUD care Negative attitudes toward patients and families Fear of causing harm or added stigma for patients and families Lack of effective communication strategies for providers and patients Patient-reported undertreatment of pain, insufficient time with health care provider, lack of shared decision making Fear of litigation related to opioid diversion and fraud	Negative attitudes toward and by interprofessional teams Lack of interprofessional collaboration Lack of interest in prescribing opioids among members of team Lack of team trust of pain patients Lack of effective communication strategies for health care teams	Conflicting organizational goals and provider/patient goals Concern about impact of negative assessments (surveys) from patients of organization Insufficient resources (time, guidelines, etc.) Administrative burden in providing non-opioid care and tracking Presence of insurance and/or reimbursement barriers (e.g., mental health services, addiction counselors) Regulatory restrictions, including mandatory continuing education, such as in risk evaluation and mitigation strategies (REMS) and buprenorphine waiver training Data interoperability for Electronic Health Records (EHR), PDMP Lack of access to appropriate care or referral for pain management and SUD at institution, particularly for rural care Lack of institutional guidelines or standardized practices for opioid prescribing

Page 37 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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Attitudes and Biases

The review of the literature revealed a number of concerns related to attitudes and biases that appear to negatively impact patient outcomes or the patient experience. Articles reported that gaps in practice were associated with patients who had comorbid conditions that included chronic pain, SUD, addiction, mental illness, and depression. In addition, health care providers were concerned about the social stigma associated with prescribing methadone and the fear of causing harm to patients and/or their families by prescribing opioids. Lack of trust was a theme in some articles, which was related particularly to the subjectivity of pain and pain scales.

It is important to note that reviewed articles did not report race in relation to attitudes or biases held by health care providers, nor was there evidence that health care providers self-identify their own attitudes or biases in relation to race. Yet, there is abundant evidence that there are reported differences in treatment of patients as it relates to race (Santoro and Santoro, 2018; Singhal, Tien, and Hsia, 2016). This is a critical area of research and investigation, as it is well known and supported by the literature that self-reported pain from BIPOC patients is often taken less seriously than the self-reported pain of White patients (Meghani, Byun, and Gallagher, 2012).

Treatment and Resources

The literature review found that health care providers struggle more often with treating patients with chronic pain compared to patients with acute pain. They were also more comfortable treating pain with a known origin, such as a broken bone, compared to pain from a difficult-to-identify source. Pain was more often treated in the outpatient setting than the inpatient setting. Health care providers expressed a need for education, tools, and resources to support efficacious prescribing practices, particularly in the areas of tapering doses, converting different types of opioids (e.g., from short-acting to long-acting and vice versa, converting from opioids of different potency), and efficacious use of non-opioid strategies concurrently with or in lieu of opioids.

Practice Variation of Undetermined Origin

Differences in prescribing practices between groups were prevalent in the literature. There were differences in prescribing practices among members of different professions (physician, APRN, PA); between different specialties within a profession (primary care physician versus pain specialist physician); and between levels of experience within a profession (early career versus late career). These differences may reflect experience levels with specific types of pain treatment modalities or how health care professionals are trained and socialized within a profession. There was significant practice variation that reflected patient demographic variables (age, gender, race, socioeconomic status, geographic location, and insurance type) that were not attributed to a specific cause. While some practice varia-

Page 38 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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tion may be reasonable—for example, treating a 25-year-old with a broken bone versus an 80-year old with a broken bone would likely require different strategies—differences in prescribing for race or socioeconomic status raise concerns. Overall, although SUDs were included as a domain of practice, the literature on related PPGs was limited when compared to pain management. In addition, data regarding practice variation, or lack thereof, in dentistry was limited in this review of the literature and should be further investigated.

System Issues

The literature review identified a number of issues at the system level that negatively impacted the ability of health care providers to effectively treat patients’ pain. Insurance reimbursement issues were cited as one significant barrier, including lack of insurance and insurance coverage that did not cover recommended services. Health care providers also identified that inadequate numbers of health care professionals in critical areas, such as mental health, addiction or specialty pain management, resulted in failure to meet patients’ needs and/or inability to receive these critical services.

Health care providers described practice variations within organizations and across professions that reflected a lack of standardization in treating patients’ pain and cited this as a contributing factor to gaps in care. Finally, system-level issues included social determinants of health and their negative impact on patients’ ability to access treatment. Discriminatory policies impact social, political, and economic systems and perpetuate issues such as a lack of transportation to medical appointments or limited money to buy medications, ultimately hindering a patient’s ability to access or pay for needed services.

VARIATION IN REGULATORY REQUIREMENTS TO ADDRESS PAIN MANAGEMENT AND SUBSTANCE USE DISORDER

The data from the brief survey of regulatory agencies and organizations provided some insights, summarized in Table 20 into the current state of policies and standards. The majority of respondents to the regulatory survey reported not having any standards in place for both pain management and SUDs (see Table 15). While a separate review of state licensing policies found all states have some policies regarding the treatment of pain, there was substantial variability in policy and professional requirements. There is also substantial variability across regulatory organizations involved in accreditation, certification, and licensing addressing both acute and chronic pain management and SUDs.

Of note, licensing in the U.S. is a legislative regulatory activity mostly under control of the states. This differs from the professional self-regulatory activities of accreditation and certification entities where standards and policies are mostly under control of the profession and remain the same across state lines. Additionally, there are myriad challenges in obtaining timely and accurate data about regulatory activities. This results in layers of fragmentation that can impede development and adoption of new policies and practices.

Page 39 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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Acknowledging and addressing this fragmentation in the educational systems across the continuum could help to advance policy change in pain management and SUDs, but requires each entity’s willingness to recognize this challenge, especially across professions.

TABLE 20 | Summary of Requirements and Policies of Regulatory Agencies, Certifying Boards, and Accrediting Organizations

Type or Stage in Care Process	System
Type or Stage in Care Process	Private	Public
Identification / diagnosis	Low priority given to pain control education for providers Educational requirements focus on treating pain rather than preventing it Guidelines are not always based in best practice Insufficient training requirements and resources for learners Lack of standardization in professional organizations Minimal pain education in education requirements and guidance on appropriate pain treatment approaches for practitioners	Practice restrictions for non-clinicians Limited number of evidence informed policies Guidelines can be insufficient to establish a standard of care Unsatisfactory policies to address pain management Policies can include stigmatizing language Lack of “expert” input Inadequate understanding of clinical practice and practitioner training
Treatment: Prescribing / tapering opioids	Differences in prescribing policies across regulatory agencies Insufficient policies to address standardized opioid prescription practices Educational policies do not include mitigation strategies for prescribing Lack of institutional guidelines or resources Internal barriers such as opioid training Restrictive prescription privileges	Prescribing policies are often “one size fits all” Drug manufacturers are increasingly required to develop educational materials and initiatives to train practitioners (Becker and Fiellin, 2012) Requirements related to buprenorphine waivers Absence of planning at state level to address adequate prescribers Overly restrictive policies Policies contribute to institutional and personal biases

Page 40 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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Type or Stage in Care Process	System
Type or Stage in Care Process	Private	Public
Treatment: Prescribing non-opioid medications	Lack of educational policy regarding the clinical indication and effective use of non-opioid medications One-size-fits-all approach Variability in policies Failure to recognize options outside of area of regulation	Practice restrictions, such as regulations that permit nurses to administer injections only intramuscularly Guidelines shown to have actively harmed patients Prior authorization serves as a barrier Policies are often ‘fail first’
Treatment: Prescribing nonpharmacological treatment	Guidelines do not lead to adequate training of providers performing interventional procedures Restricted pre-clinical and clinical educational opportunities Policies favor urban health care settings	Conflicts in policy Policy is specifically targeted toward opioid usage Inadequate financial support Available treatments are not equally promoted Policies support clinical treatment
Monitoring opioid use	Difficulty implementing PDMPs into prescriber education and workflow Absence of standardized training policies Most training comes from state licensing organizations Data collection systems differ Availability of databases to learners	PDMP use varies greatly across the United States Variability in states’ health information technologies and PDMP designs Prescribers and dispensers are subject to state-specific reporting requirements Limited interoperability between state PDMP and Electronic Health Records (EHR) platforms Providers may not have access to PDMPS depending on state access requirements Many monitoring policies are suggestions not explicit law
Referral for care of SUDs	Small number of specialty groups Lack of standardization of referral procedures Insufficient resources available Strategies are underdeveloped for making outpatient referrals	Insurance constraints Inadequate number of specialized providers Lack of referral programs and resources Low reimbursement rates Policies are focused on restricting provider referral

Page 41 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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Type or Stage in Care Process	System
Type or Stage in Care Process	Private	Public
Other	Inconsistent medical education requirements to addiction assessment and ability to identify SUDs Inadequate education for providers regarding safe medication and disposal methods Policies are viewed as the standard of patient care CE differs between organizations Regulatory focus is on a particular stage of education and profession	Federal and state provided education programs and resources are underutilized or limited Policy is not always informed by clinical evidence or data Funding is limited for education and training Policy can be slow to enact Cumbersome regulatory requirements Competing policies Government supply chain restrictions Conflicting policy goals Provider education is not focus of most policies

LIMITATIONS

Limitations to this review include evaluating PPGs solely based on the published, peer-reviewed literature, which could reflect publication biases; studies that relied solely on self-reported data; and data that may reflect response biases, such as a tendency to attribute blame to a system issue rather than to oneself. A further limitation may stem from the retrospective nature of the literature review, amplifying more abundant dated perspectives over more recent studies.

The predominance of studies focused on physicians and nurses in this literature review highlights the limitations of this study to gain greater insight to other professions’—and interprofessional—practice gaps. Focusing only on five identified professions (medicine, nursing, physician assistant, pharmacy, and dentistry), excludes the practice perspectives of several key types of professionals (e.g., psychologists, social workers, and peer coaches) actively engaged in current approaches to addressing pain management and SUDs.

The educational requirements survey and policy review results used a combination of convenience (e.g., those organizations participating in the collaborative) and snowball (e.g. other organizations recommended by the initial participants in the survey) sampling techniques and may not be fully reflec-

Page 42 Cite

Suggested Citation:"5 Discussion." National Academy of Medicine. 2021. Educating Together, Improving Together: Harmonizing Interprofessional Approaches to Address the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27108.

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tive of the overall landscape of regulatory requirements and policies. Only information submitted by respondents was included in this analysis.

Additionally, the validation survey for PPGs was conducted through a combination of convenience and snowball sampling. The validation survey should be repeated and expanded to incorporate a larger sample size to improve the representativeness and validity across the survey results.