Introduction
Opioid misuse, abuse, and overdose remain prominent public health crises in the United States. National statistics indicate that nearly 47,000 Americans died of opioid overdoses in 2018, increasingly through the use of heroin and synthetic opioids like fentanyl and its analogues.1 Yet approximately two-thirds of opioid-related deaths are due to the misuse of prescription opioids.2 In addition, approximately 1.7 million Americans experience substance use disorders related to prescription opioids.2,3 The Centers for Disease Control and Prevention (CDC) estimate that the economic burden of prescription-opioid misuse alone costs the United States $78.5 billion annually, which is represented in healthcare expenses, lost productivity, addiction treatment, and criminal justice costs. The latest US overdose data, which extend into the beginning of the COVID-19 pandemic, reveal the highest number of drug-overdose deaths ever recorded during a 12-month period (81,000 from May 2019-May 2020). In that same time frame, 37 of 38 US jurisdictions reported increases in synthetic opioid-involved overdose deaths.4
The American opioid crisis is the unfortunate result of several converging factors, including the high prevalence of chronic pain, the development and aggressive marketing of a number of newly available prescription opioids in the 1990s, the underestimated risk of addiction with opioids, and the rapidly escalating prescription rate of these opioids over the ensuing years in an effort to manage chronic pain.2,5,6 At the beginning of the 21st century, concerted efforts were made specifically to raise awareness of the undertreatment of pain. These efforts included the establishment of pain-management standards by the Joint Commission on Accreditation of Healthcare Organizations and the designation of the 2000s as the “Decade of Pain Control and Research” by Congress.7,8 The unintended results of these efforts were the widespread misuse and diversion of prescription opioids, before it became abundantly clear that they had the potential to be extremely addictive. Primary care prescribers have been at the unfortunate forefront of the opioid crisis, owing to their traditional gatekeeping positions within the healthcare system. Physician groups accounting for the highest opioid prescriptions are family medicine (20.5%) and internal medicine (15.7%).9 Nurse practitioners and physician assistants account for approximately 10% and 9% of opioid prescriptions, respectively. Family medicine physicians and medical internists also make up a significant proportion of the top tenth percentile of high prescribers of opioids.10
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In July 2012, the Food and Drug Administration (FDA) approved the Extended-Release (ER) and Long-Acting (LA) Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) to ensure that the benefits of opioid analgesics used in the outpatient setting outweigh the risks. To further address the misuse and abuse of prescription opioids and to promote the judicious prescription of opioid analgesics, the FDA approved the FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics in 2016.11 This blueprint stipulated that all companies producing or selling ER or LA opioid analgesics financially support ongoing certified continuing education (CE) for all health care providers who manage pain. The blueprint also outlined core educational messages for industry-funded CE activities, including the assessment and counseling of patients, the initiation and management of opioid therapy, and information about opioid analgesics. The FDA blueprint was modified in 2018 to include the use of immediate-release (IR) prescription opioids. Specifically, the FDA drafted and published its Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain.12 The 2018 FDA blueprint identified a need for comprehensive pain education, in which all pain management options are considered. The blueprint further stipulated that health care practitioners should have information about the risks of opioid use and misuse and should be able to create opportunities for patient counseling and other methods to reduce risks. The blueprint then laid out the clinical core educational messages to be addressed in a comprehensive pain education program. These core messages addressed broad categories of instruction that encompass assessments of pain, the use of comprehensive and multimodal management, and the recognition of opioid misuse and addiction.
In an effort to identify educational gaps in pain management and the prescription and monitoring of opioids among primary care providers, Rockpointe, a continuing medical education (CME) company, conducted pretest polling questions before and during 2 of its certified CE programs that were designed to adhere to and address the core educational messages outlined by the 2016 or 2018 FDA blueprint.
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