A new requirement that doctors prescribing controlled substances get training on substance abuse is being criticized by doctors as vague and by addiction specialists as not going far enough, amid the toll of more than a million U.S. drug overdose deaths since 2000.
The federal mandate, which went into effect on June 27, requires for the first time that doctors receive eight hours of training on opioids and substance abuse disorders.
But experts said medical professionals may never get educated on critical subjects, including safe prescribing of opioids, because of few specifics in the mandate. In addition, the one-and-done nature of the training means doctors aren't required to keep up with changes in the field.
“It is very confusing,” said Dr. Kevin Zacharoff, course director of pain and addiction and clinical assistant professor at Stony Brook University’s Renaissance School of Medicine.
WHAT TO KNOW
Effective June 27, doctors and others who prescribe controlled substances — which includes almost all prescribers — must undergo at least eight hours training on opioids and substance use disorder.
Experts say the requirement lacks specifics, leading to confusion among doctors and a concern that key material — including safe and appropriate prescribing of opioids — will not be part of many physicians’ training.
Some also criticize the lack of a requirement for continuing education on the subject. The training is only required once in a doctor’s career.
Zacharoff said he supports the new requirement, but “the lack of specificity means people aren’t going to really know what they should do.”
An appropriations bill Congress passed in December included the mandate that any doctor, nurse practitioner, physician assistant or anyone else who prescribes controlled substances receive the training when registering with the Drug Enforcement Administration or renewing their registration, which takes place every three years. Almost all prescribers have DEA registrations, Zacharoff said.
Yet there are few specifics as to what the training should entail. A letter the DEA sent to all DEA-registered prescribers only says the training is “on the treatment and management of patients with opioid or other substance use disorders.”
The DEA referred all questions about training content to another federal agency, the Substance Abuse and Mental Health Services Administration, which recommends — but does not require — that the training include material on identifying and treating patients with substance use disorders, as well as on pain management and misuse of prescribed opioids.
Neither agency approves nor reviews training content, SAMHSA says. The two agencies provide doctors with a list of organizations authorized to provide training.
SAMHSA spokesman Christopher Garrett said appropriate prescribing of opioids is among the options in the groups’ training courses, many of which are online.
Zacharoff said that doesn't mean doctors will receive the training they need. The DEA should standardize training, he said.
“Unless there’s absolute consistency in the education, how can you ever hope to assume that everybody has the same foundational education requirements met?” he said.
Most opioids are prescribed by primary care physicians, nurses and physician assistants, and some have never received training on opioid prescribing, he said.
Training on opioids is 'long overdue'
Training also should include recommendations that doctors discuss with patients the potential for addiction, said Steven Chassman, executive director of the Westbury-based Long Island Council on Alcoholism and Drug Dependence.
Chassman said educating doctors and nurses on appropriate and safe prescribing of opioids is "long overdue." One of the reasons for the million-plus opioid deaths is that “the pharmaceutical companies basically conned a whole nation of prescribers” that highly addictive prescription opioids like OxyContin had low risk of addiction, he said.
“Education of doctors of responsible prescribing of opioids could have potentially prevented opiate use disorder and loss of life," he said.
New York State has required since 2017 at least three hours of training every three years on pain management prescribing and addiction prevention and treatment. The state specifies the eight topics that must be in the courses, but Zacharoff said it’s “just not possible” to tackle all those subject matters in three hours.
Past training, including by organizations approved to conduct the new training, counts toward the eight hours, the DEA says.
At least one of the groups authorized to provide the federally mandated training is unclear what that training should include. A letter from the American Medical Association, the nation’s largest doctors’ group, says there is widespread "confusion" as to what type of training fulfills DEA requirements.
The AMA opposed the training requirement entirely, stating in a July 2022 letter that there is no evidence it “will have the result that we all want, which is improving patient outcomes and stopping patients from dying from a drug-related overdose.”
Dr. Paul Pipia, president of the Medical Society of the State of New York and deputy medical director of Nassau University Medical Center in East Meadow, said the state medical society doesn't have an official position on the requirements.
But Pipia supports keeping the mandate general and opposes listing what material doctors should learn.
“Let the physicians have some self-determination on how to do it,” he said.
Pipia said training should go beyond the eight hours and continue through a doctor's career.
“As things change, people should get updated,” although updates should be significantly shorter than eight hours, he said.
The new law prohibits requiring training more than once. But, Garrett said, “One time is a minimum that prescribers can choose to supersede.”
No proof of training required
The DEA does not require proof that medical prescribers complete the eight hours of training. They need only check a box on an online DEA registration or renewal form.
Chassman said he must submit certificates of completion of continuing education required for his state social work license and substance abuse counselor credentials, and sometimes pass tests on what he learned. He questioned why the DEA does not have similar requirements.
Zacharoff predicted that few doctors would risk the consequences of lying to the DEA. Anyone who lies on their registration form faces up to four years in prison, a fine of up to $250,000 or both, according to a DEA document.
The AMA had urged the DEA to not require proof of completion, saying it “would only add to the burden associated with this new requirement.”
The AMA repeatedly has asked the DEA for a one-year grace period for doctors to satisfy the mandate, in part because of the uncertainty in how to meet the requirement. Losing DEA registration would mean that “patients will lose access to care,” the AMA said.
Zacharoff backs a grace period. "Eight hours of education is a big ask for people busy in their clinical practices,” and many doctors may be unaware of the new requirement, he said.
“I think this is going to catch a lot of people by surprise,” he said.