CHAPTER 1
EXECUTIVE SUMMARY

The United States is in the midst of an urgent and complex opioid crisis. To address how education and training can more effectively respond to this crisis, we must have a better understanding of problems in practice—or professional practice gaps—for health professionals and teams in practice. A coordinated response requires identifying and addressing professional practice gaps (PPGs) related to pain management, opioid use disorder (OUD), and other substance use disorder (SUD) care, as well as integrating evidence-based best practices into health professional education and training curricula across the continuum from undergraduate training into post-graduate continuing education (ACCME, n.d.-c). In this publication, a PPG is the difference between health care processes or outcomes observed in practice, and those potentially achievable on the basis of current professional knowledge. As part of the National Academy of Medicine’s (NAM’s) Action Collaborative on Countering the U.S. Opioid Epidemic, the Health Professional Education and Training Workgroup, led by Kathy Chappell, Eric Holmboe, and Steve Singer, created this Special Publication to serve as a resource to assist multidisciplinary stakeholders in developing a more coordinated and comprehensive health education system that supports interprofessional practice and improves patient- and family-centered care. This Special Publication presents two major information gathering efforts to assess and better understand the current health professional education environment: the first is a comprehensive literature review, and the second is a survey of the regulatory landscape.

The literature review identified persisting PPGs across five health professions that are part of the pain management and SUD workforce: medicine, nursing, physician assistant, dentistry, and pharmacy. Of the 310 articles included in the literature review, 83% discussed physician practice (unspecified, medical doctor [MD], or doctor of osteopathic medicine [DO]), 40% focused on the primary care/outpatient care setting, and 66% concentrated on chronic pain management. Data sources used to identify or describe PPGs were predominantly descriptive and self-reported (63%) and the most common PPGs involved opioid prescribing or tapering (93%). Major causes for PPGs were gaps in clinical knowledge (40%), attitudes and biases (30%), or failure to use/lack of available evidence-informed tools and resources (26%). Key themes include unexplained differences in prescribing practices between

groups of clinicians, the presence of harmful negative attitudes or biases held by health care professionals toward patients or the interprofessional team, and reports of insufficient time or resources and health system constraints exacerbating PPGs. Validation surveys were also conducted with clinicians and health systems (n=44) to confirm the findings of the literature review and to identify any potential areas that were not captured in the published, peer-reviewed literature.

The survey of the regulatory landscape included responses from a total of 62 unique organizations (national, state, or other) responsible for requirements, standards, or policies. Responses were sorted by policy type, organizational focus, and requirement focus areas. Across the pain management and SUD domain, the majority of organizations did not have requirements; only 47% and 31% of organizations reported having requirements or standards for health care professionals that address acute or chronic pain management or SUD respectively. Visual breakdowns of respondents for both pain management and SUD surveys are available in the relevant chapters. The survey data are indicative of fragmentation across the regulatory environment, as the surveyed organizations focus on different aspects of regulation without substantial coordination. There is a need for regulatory entities to work together to develop requirements and standards that support the complex and variable needs of health care professionals and the diverse patient populations they serve.

The results of the literature review and requirements survey underscore the need to collaboratively develop a harmonized interprofessional, person- and family-centered approach for the continuum of health professions education to more effectively address the opioid crisis. The Health Professional Education and Training Workgroup identified five key action-oriented priorities to support the goal identified above. Key priorities include the following:

1. Establish minimum core competencies in pain management and SUDs for all health care professionals, and support evaluating and tracking of health care professionals’ competence;
2. Align accreditors’ expectations for interprofessional collaboration in education for pain management and SUDs;
3. Foster interprofessional collaboration among licensing and certifying bodies to optimize regulatory approaches and outcomes;
4. Unleash the capacity for continuing education to meet health professional learners where they are; and
5. Collaborate to harmonize practice improvement initiatives.

This work brings into focus the opportunity to meet the complex challenges of the opioid crisis by optimizing the environment for health professionals’ continuous learning and improvement. This education imperative requires greater interprofessional collaboration between regulators, certifying bodies, accreditors and health professions educators. Addressing the “epidemic within the pandemic” is the focus of this publication, but the authors recognize that key themes—system-wide engagement, learning leadership, harmonization and alignment, recognizing complex and individualized needs—can and should be applied to other complex and intractable health imperatives.