CHAPTER 6
KEY PRIORITIES

Health care professionals, health professions educators, and policymakers share a common, elusive challenge—effecting change amidst the complexity of the opioid continuing crisis. The authors of this manuscript have observed this complexity in the highly variable educational needs that underlie individual, team, and system gaps between current and optimal care for pain management and SUDs. Our study of education-related regulatory requirements also reveals a complex and fragmented environment of governmental and professional self-regulation. Our analyses may add perspective, but these are not novel insights. Particularly as we emerge from a global pandemic, the Quadruple Aim—the right care at the right time at the right cost, supportive of the well-being of the health care workforce—remains elusive for the opioid crisis. This statement does not diminish those widespread and substantial efforts that are successfully addressing aspects of the crisis, including: legislative funding for behavioral health, telemedicine for medications for opioid use disorder (MOUD), eliminating the X-waiver requirements, and ongoing advocacy about coverage/payment for non-opioid management of chronic pain. Rather, the question before health care providers and educators is how the insights of this publication can be used to identify specific, global, and comprehensive strategies that build upon the efforts of others and provide helpful guidance to the community of regulators, educators, and those with lived experience who seek to close the gaps in care that elude us.

The PPGs described throughout this Special Publication highlight underlying educational needs across the spectrum of practice and are situational to setting, clinical practice, and patient population. Although these gaps have been well-articulated in numerous publications (Blevins, Rawat, and Stein, 2018; Muzyk et al., 2019), this publication endeavors to prioritize cross-cutting areas of concern for individuals and interprofessional teams that include addressing bias/attitudes toward treating pain and addiction (i.e., stigma); effective communication, motivational interviewing, and shared decision making with patients and families; and a critical need to address interprofessional collaborative practice for pain management and early detection and treatment of substance misuse and dependency.

Requirements of governmental (licensing) and professional self-regulatory bodies are generally consistent with identified PPGs as found in the literature review described earlier in this Special Publi-

cation, but understandably cannot address the varied and complex needs of individual patients and families, their clinicians, and teams. Even when aligned, these requirements cannot consistently provide sufficient depth or resolution to define competencies tied to patient acuity for individual health care professionals—let alone interprofessional teams—across practice settings.

The continuum of health professions education in the U.S. is a patchwork reflective of the historically siloed development of each profession and between specialties. The survey detailed earlier found that less than half of the responding professional accrediting, and certifying organizations have specific requirements regarding training for and competency in pain management and SUDs. This finding is, in part, due to the heterogeneity in the scope and targeting of those requirements to individual professionals (e.g., specialty certifying boards), requirements for undergraduate and graduate training programs, or institutional and practice-based expectations (e.g., post-graduate continuing education accreditors). Irrespective of these differences, educational systems and their stakeholders are exerting significant effort and resources to both prepare students and trainees, and support professionals in practice to respond to the opioid crisis (Brady, McCauley, and Back, 2016). Despite these efforts, the combined complexity of each facet of this “system”—practice, regulation, education—makes optimization a challenging task.

From this analysis, we have identified five key priorities as actionable steps to make substantive and lasting progress to address the opioid crisis. Harmonization is a common theme through these priorities: seeking to navigate substantial complexity by identifying unwarranted (or unproductive) variation, finding opportunities to innovate around shared goals, and working methodically to reduce redundancy and burden. A summary of the key priorities and actionable strategies to catalyze change are summarized in Table 21.

Each key priority addresses opportunities for leadership for many stakeholders that can affect change; they underscore that solutions will be found through interprofessional collaboration that includes patients with lived experience perspectives. The key priorities are not ranked in order of importance or urgency, for they are overlapping and supportive individually and collectively. Embracing both complexity and humility, they place continuous learning at the individual, team, institution, and system levels at the center of the way forward. The authors of this manuscript believe these key priorities may also provide opportunities to marshal analogous strategies and actions in a broader context to address other complex public health challenges.

KEY PRIORITIES

1. Establish Minimum Core Competencies in Pain Management and Substance Use Disorders for all Health Care Professionals, and Support Tracking of Health Care Professionals’ Competence

Interprofessional, cross-continuum core competencies for pain management and SUDs must be developed. To embrace the complexity of the PPGs described in the literature, competencies should

be defined. Minimum core competencies should address skills necessary for effective interprofessional collaboration and continuous learning and improvement. These would potentially include screening, brief-intervention and referral to treatment (SBIRT); teaming; shared decision making; and addressing stigma and communication. The competencies should describe the knowledge, skills, behaviors/performance, and attitudinal expectations across health professions and be disseminated to educational systems and their stakeholders for collaborative implementation using best educational methods. This priority area is not intended to detract from existing or emerging evidence-based, interprofessional competencies for pain management and SUDs (Bratberg, 2018; Fishman et al., 2013). Rather, a set of minimum core competencies is intended to ensure flexibility reflective of scope-of-practice and setting-specific needs. It is the hope of the Education and Training Workgroup that this action will also reveal critical PPGs across the health education continuum for faculty to address. Minimum competencies are a first step in re-calibrating the U.S. health care workforce toward adaptive interprofessional practice, better preparing practitioners for future complex public health crises, and may, as well, provide insight to those characteristics to seek holistically in future pre-professional admissions.

Continuing education accreditors, regulators, and educational leaders across the continuum should collaborate to enable national tracking of currently practicing health care professionals’ achievement of competencies for pain management and SUDs appropriate to profession, scope of practice, and setting. Evolving toward regulatory frameworks that value accountable interprofessional teams and can track competencies will facilitate approaches to assemble effective functional interprofessional teams with greater sensitivity to setting and patient population.

The current timeline between the identification of PPGs and their dissemination in the published literature is long. Educators need a more nimble and immediate system for identifying and sharing gaps that enables them to quickly deploy relevant educational programs to meet community needs.

The authors of this manuscript suggest that national continuing education accreditors maintain a community discussion website where educational providers can convene and share issues they are seeing in their communities. In particular, this would foster connections with community organizations and agencies that can identify more timely population- and setting-specific priority gaps and have them addressed with appropriate curricula and interventions across the continuum.

To advance the work of educators, journal editors should collaborate with educational leaders across the health professions education continuum to foster greater research and scholarship for identifying and disseminating PPGs. Acknowledging the limitations of the search strategies for this literature review (detailed below), the authors of this manuscript are concerned at the paucity of published information regarding practice gaps of other health care professionals beyond medicine and nursing. Accessibility of needs and gaps data could be improved by modifying medical subject headings and taxonomies to make it easier for educators and other stakeholders to more readily explore practice gaps for pain management and SUDs. Furthermore, a framework for evaluating and tracking implementation of competencies is needed. These approaches, taken together, should center on identifying gaps in, and prioritizing care for, those populations and settings most endangered by the opioid crisis and the COVID-19 pandemic (Blanco, 2020; Indian Health Service, n.d.).

2. Align Accreditors’ Expectations for Interprofessional Collaboration in Education for Pain Management and Substance Use Disorders

To resolve unwarranted variation, accreditors should collectively and collaboratively work across health professions and the educational continuum to examine current standards, policies, curricula, and guidelines for pain management and SUDs. To create a more supportive learning environment for practicing health care professionals, there is a need to convene national health professional accreditors in continuing education to ensure that:

• interprofessional curricula are developed in alignment with competency expectations;
• practical and effective education module(s) are developed for required learning, testing, and implementation in daily practice;
• expectations are shared with educators across the health professions;
• educational activities and resources are available and listed in a central repository for health care professionals, indexed by competency/gaps;
• a data monitoring system is developed for tracking engagement and completions and is maintained among relevant stakeholders;
• educational activities are inspected/audited to ensure compliance with accreditation requirements on a periodic basis; and
• educational activities and resources are evidence-based/informed and are not influenced or biased by industry.

Accrediting organizations can leverage existing collaborations, such as the Interprofessional Education Collaborative (www.ipecollaborative.org) for undergraduate education, and the National Collaborative for Improving the Clinical Learning Environment (www.ncicle.org) and Joint Accreditation for Interprofessional Continuing Education (www.jointaccreditation.org) for post-graduate continuing education. Data system approaches can build upon the existing collaboration between health professions continuing education accreditors supporting data collection for health care professionals’ participation in accredited CE across health professions (e.g., FDA REMS and CME for American Board of Medical Specialties (ABMS) Continuing Certification) (ACCME, n.d.-a; ACCME, n.d.-b; FDA, 2018). The education requirements survey detailed in this publication found some organizations have incorporated standards and guidelines around pain management and SUDs. The accreditation community can play an important role by building on these early efforts to strengthen and sustain interprofessional collaboration.

3. Foster Interprofessional Collaboration among Licensing and Certifying Bodies to Optimize Regulatory Approaches and Outcomes

Interprofessional care is essential in helping to manage both pain management and SUDs in patients. Licensing and certifying bodies should ensure that they recognize activities that meet the shared curricular, competency, and interprofessional expectations. They should harmonize the regulatory environment for their stakeholders by recognizing interprofessional continuing education (JAICE, 2017).

State licensing authorities for health care professionals involved in pain management and SUDs should convene a national task force to study existing variations in state-level regulations and seek opportunities to harmonize policies. An example effort was the creation and evolution of the Tri-Regulator Collaborative, which was originally led by and composed of representatives from the Federation of State Medical Boards (FSMB), along with the National Association of Boards of Pharmacy, and the National Council of State Boards of Nursing. The Tri-Regulator Collaborative was created in 2011 to promote an interprofessional approach to patient care and regulation between the three organizations.

Building on the model of the Tri-Regulator Collaborative, in November 2020, the National Academy of Medicine and FSMB co-hosted the first summit of the nation’s state and territorial licensing boards for medicine, nursing, pharmacy, and dentistry, and expanded the reach to allied professions that represent the state and territorial boards of psychology, physical therapy, occupational therapy, and social work. Many of these licensing boards have taken innovative steps over the last several years through statutes and guidelines for prescribers to address the opioid crisis. Participants detailed their learnings from ongoing initiatives during the summit, including successes and lessons learned, opportunities for improvement, and areas for alignment across organizational efforts. The summit underscored the need for continued collaboration, leading the boards of medicine, nursing, pharmacy, and dentistry to formally join forces and establish the Opioid Regulatory Collaborative (ORC) in 2021. The ORC shares resources and strategies to reduce opioid use disorder and aims to enhance regulatory alignment across professions, to focus ongoing initiatives and ultimately curb the addiction crisis. These types of models provide a structure for catalyzing interprofessional collaboration and harmonization efforts.

Overall, there is a need to establish requirements where there are none and harmonize existing state licensing policies. This will address fragmentation and encourage the development and/or adoption of regulation and requirements that are supportive of clinician needs and patient safety. Licensing bodies should seek to address unwarranted variation across the following policy categories, where possible:

• Policies addressing patient behavior
• Policies addressing patient health
• Continuing medical education requirements
• Pain management clinics
• Opioid prescribing guidelines
• Doctor shopping laws
• PDMPs and tracking controlled substances

• Naloxone access
• Opioid addiction treatment

Through collaboration, the authors of this manuscript encourage licensing bodies to pursue opportunities to evolve or reframe regulatory accountability for individual professions and interprofessional teams. Opportunities for harmonization may include:

• Harmonizing statutory requirements (e.g., Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System—or MIPS—requirements, Substance Abuse and Mental Health Services Administration (SAMHSA) Medication-Assisted Treatment (MAT) Waiver Training, FDA REMS Requirements) to optimize health professional engagement in clinical improvement while reducing the burden of redundant or overlapping expectations. Example: an internist’s completion of a quality improvement project to reduce opioid prescribing in her practice can be recognized to simultaneously meet expectations for her state licensing requirement for opioid REMS CME, MIPS Improvement Activity participation, and medical specialty board continuing certification.
• Promoting data interoperability between PDMPs
• Standardizing across boards for education, penalties, and violations
• Establishing standards for expected office-based policies and practices

Certifying bodies across the professions should advance interprofessional practice in pain management and SUDs by supporting programmatic activities in assessment, and where appropriate, curricula. Additionally, appropriate quality measures should be used and/or adapted to reinforce practice standards for interprofessional teams in pain management and SUD care. These standards and assessments should be appropriately targeted for the professional roles overseen by the certification entity, but it is also critical that collaborative dialogue occurs intra- and interprofessionally.

It is time to catalyze a healthy dialogue around scope of practice issues to better address OUD and SUDs. While most certification organizations focus on a particular stage and profession of the educational continuum, there is an opportunity for different professional certifying organizations to collaborate and advance the opportunity to develop appropriately skilled health care professionals in pain management and SUDs. Additionally, as a part of the priority to safeguard the public, their oversight should include providing educational remediation that supports education and training for health care professionals across professions.

4. Unleash the Capacity for Continuing Education to Meet Health Professions Learners Where They Are Through Investment and Leadership

The survey of educational requirements on which this manuscript is partially based demonstrates that regulatory bodies uniformly see participation in accredited continuing education (i.e., CE, CME) as the predominant educational delivery method for health care professionals learning to improve approaches to pain management and SUDs. Continuing education accreditors for the health professions—such as the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, the American Nurses Credentialing Center, the American Academy of Physician Assistants, the American Dental Association’s Continuing Education Recognition Program, and the Joint Accreditation for Interprofessional Continuing Education—oversee a large and diverse community of more than 4,000 health care organizations, or accredited CE providers, that deliver education predominantly as a service or benefit to their members or health professional staff. These providers—which include health systems and hospitals; medical education companies; medical schools, universities, and academic health centers; professional organizations and societies; and state and local health departments—routinely interface with physicians, nurses, physician assistants, pharmacists, and dentists across all 50 states. For this national network of education providers, those accredited organizations that operate in regional and/or local settings are uniquely positioned to address the specific practice-based needs of their health professional learners due to their proximity to the care setting and population. However, their capacity to assist in closing professional practice gaps is severely limited by a lack of resources and investment. Most professionals have very limited or no allowance and paid time for CE in this competency. Federal and/or state investment in this area in forms of grant or tax deduction is essential because the cost to society of not investing in CE is much higher than the necessary investment in this critical endeavor.

Importantly, mandatory continuing education requirements from regulatory bodies have the unintended consequence of reducing motivation and limiting effective practice change (NASEM, 2018). Mandates that limit educational flexibility and the local needs of communities are counterproductive. Instead, by adhering to accreditation requirements that are grounded in improvement science and adult learning best practices, CE providers can flexibly design the activities and the relevant assessment to individualize education that effectively creates and sustains behavior change (ACCME, 2021). To better address the complex and varied gaps in pain and substance use practice, regulators and certifying bodies should transition requirements away from knowledge acquisition and focus, instead, on setting expectations that health professions learners demonstrate changes in competence and performance as a result of their engagement with accredited CE. Accredited CE providers should be given the latitude and resources to apply innovative and creative approaches that facilitate application to practice setting, interprofessional learning and collaboration, and needed engagement of persons with lived experience in the development and delivery of CE activities.

To effectively change educational outcomes, public and private entities should pursue strategies to increase support of accredited CE providers. These approaches can include:

• Encouraging health system leaders to provide financial support and staff resources to fully leverage interprofessional CE as an organizational asset for workforce learning and change management to close gaps in addiction and pain management care (see Box 1);
• Funding of professional development opportunities for CE providers and their educational teams (e.g., leaders, administrators, faculty) to measurably improve capacity to meet local health care professional workforce needs;
• Provide grant funds to foster innovative approaches for CE related to interprofessional collaboration, identifying PPGs, enhancing pedagogical/instructional methods, improved assessment and outcome measurement;
• Funding to spur research and scholarship to study and disseminate evidence-informed findings of effective educational practices that achieve key outcomes related to SUDs and pain management;
• Funding and collaboration to engage patients, families, and the public as planners and teachers in accredited CE for SUDs and pain management;
• Connecting interprofessional competencies to nationally recognized quality metrics;
• Funding for community-based interprofessional (and multi-sector) collaboratives that bring together health care and non-health care stakeholders (e.g., law enforcement, criminal justice, community-based faith organizations, social services) around continuous learning to improve coordination of prevention, screening, care, and long-term recovery for those with SUDs; and
• Incorporating accredited CE as a tactic to address federally funded practice improvement initiatives (see Key Priority #5 below).

5. Collaborate to Harmonize Practice Improvement Initiatives

In response to the immense challenges to care delivery during COVID-19, federal agencies and regulators have moved quickly to adopt innovative approaches to help address patients’ needs. Exemplars include the SAMHSA, the DEA, and HHS piloting eHealth and telehealth interventions for MOUD and SUD care (Samuels et al., 2020; Brandt, 2020).- State licensing authorities have also responded by reducing or temporarily waiving licensure requirements and facilitating telehealth approaches (FSMB, n.d.-a).

To address the opioid crisis, these regulatory bodies have implemented numerous practice improvement initiatives for health care professionals in a range of practice settings—from small offices to large, integrated health systems. Historically, the CMS has funded initiatives such as the Hospital Improvement and Innovation Network—a “learning collaborative” of CMS-contracted health care organizations working to reduce patient harm for several priority areas, including harm reduction related to opioid overprescribing. Contract Quality Improvement Networks and Quality Improvement Organizations receive funding from CMS to provide technical assistance through regional hubs. Similarly, SAMHSA supports a regional network of Addiction Technology Transfer Centers that provide education

and training for behavioral health and primary care clinicians (Addiction Technology Transfer Center Network, n.d.). A number of these programs have grown substantially with support from the 2018 Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (H.R.6, 2017-2018).

Collectively, these statutory programs use a range of approaches from addressing opioid overprescribing through monitoring of prescription claims data to consulting to practices seeking to become accredited and certified Opioid Treatment Programs (CMS, n.d.; SAMHSA, n.d.). These initiatives include statutory requirements that limit broader partnership and flexibility in implementation of education and training. To the degree that the disruption of COVID-19 has created avenues for innovation, the authors of this manuscript encourage regulatory agencies, such as CMS and SAMHSA, to explore collaboration with health professions education accreditors to expand reach and impact for statutory initiatives (Sinsky and Linzer, 2020). There is a need to convene federal agencies together with CE accreditors to identify opportunities for harmonization and elaboration of practice improvement through approaches such as the following.

• Mainstreaming MOUD training with interprofessional continuing education (IPCE), allowing any accredited CE provider to deliver MOUD training that meets appropriately defined competencies.
• Ensuring that participation in practice improvement initiatives is synonymous with accredited CE (and awards CE/IPCE credit) to harmonize and simplify engagement by various health care professionals across states, specialties, and disciplines.
• Providing funding, as well as a conducive environment, for the development of competency-based educational modules on pain management and SUDs for all relevant professions in health care, criminal justice, and regulatory bodies.
• Developing mechanisms to measure, monitor, and modify the processes and quality of educating the workforce and implementing changes in practice.

CONCLUSIONS

These collective strategies share a common goal: to meet the complex challenges of the treating pain and substance use by optimizing the environment for continuous learning and improvement. System-based engagement is required from all of the different stakeholders whose mission is to support health professional practice and the health of the public. The opioid crisis is our immediate focus for this work, but we recognize that the tenets of these approaches—interprofessional learning, harmonization and alignment, recognizing complex and individualized needs—can and should be applied to other complex and intractable health imperatives.

The authors are grateful for the opportunity to continue a truly interprofessional approach to tackle these issues across the education continuum. With due effort and support, these approaches will amplify effective practices while harmonizing and improving the environment for health care professionals to best serve the needs of their patients and communities.

TABLE 21 | Taking Action on the Key Priorities - Who Can Affect Change and How?