Joanna Katzman, MD
Neurologist Joanna Katzman, MD, is director of the UNM Pain Consultation and Treatment Center.

A University of New Mexico Health Sciences Center (UNM HSC) study published recently in the American Journal of Public Health shows that a state-mandated program of continuing medical education for health care professionals is reducing opioid abuse and overdose rates.

“We thought it important to build metrics into this program to measure its effectiveness,” explains Joanna Katzman, MD, a UNM neurologist and director of the UNM Pain Consultation and Treatment Center. She is lead author of The Public Health Crisis of Chronic Pain and Addiction – Rules and Values: A Coordinated Regulatory and Educational Approach to the Public Health Crises of Chronic Pain and Addiction.

More people suffer from chronic pain in the U.S. than from cancer, diabetes and vascular disease combined. Unfortunately, prescription opioid abuse has become a major public health issue, affecting approximately 35 million Americans who have used an opioid pain reliever non-medically at least once in their lifetime – an 18-percent increase over an eight-year period.

New Mexico has the highest rate of opioid drug overdose death in the U.S. Almost every county in New Mexico has a higher drug overdose death rate than the rate for the entire U.S., with Rio Arriba and Mora counties’ overdose death rates at five times the national rate.

Education approach

The good news is that New Mexico’s opioid overdose and abuse rates appear to be dropping, according to the paper. While many states imposed new regulations governing specific prescribing practices, New Mexico chose to adopt continuing medical education, or CME, requirements and develop chronic pain treatment and opioid addiction training. With support from New Mexico Gov. Susana Martinez and the New Mexico Legislature, a diverse coalition was developed in 2011 to update the Pain Relief Act of 1999 requiring CME training in the treatment of chronic pain.

This coalition is comprised of the University of New Mexico Health Sciences Center and UNM’s Project ECHO (Extension for Community Healthcare Outcomes); the state department of health, and medical, nursing and pharmacy boards; and the New Mexico Veterans Affairs Health Care System. The group developed a mandatory continuing medical education program requiring physicians and physician assistants to complete five hours of CME in pain and addiction between Nov. 1, 2012, and June 30, 2014.

“Primary care clinicians in New Mexico who manage the majority of patients with chronic non-cancer pain and addiction struggle with access to specialty care for these patients,” Katzman says. “They also often lack the resources – mostly time – to pursue evolving best practices in pain and addiction treatment. We needed an immediate response focused on practitioner education.”

The state adopted the program and further required that all physicians and physician assistants participate in the New Mexico Board of Pharmacy Prescription Monitoring Program to check each time a prescription for chronic opioids is written and every six months thereafter.

A half-day course was by designed by UNM HSC Pain Center faculty members, Project ECHO Pain, and the New Mexico Veterans Affairs Health Care System specifically to fulfill the CME requirements and address New Mexico’s public health crises of chronic pain and unintentional overdose.

A measure of success

The paper asserts New Mexico’s legislatively mandated CME program, designed to have a positive public health impact on prescribing patterns statewide, is succeeding. To assess educational intervention success in improving clinical practice, UNM HSC faculty conducted a research study to determine whether the CME course would result in improved knowledge, self-efficacy, and attitudes when treating patients with pain and addiction. Longer-term objectives were to determine whether education and regulation efforts were achieving a reduction in prescription opioid deaths in the state.

Nearly 1,100 New Mexico clinicians were surveyed before and after they took the course (offered in Albuquerque, Las Cruces and Santa Fe) to compare participants’ knowledge, perceived competence in chronic pain management, and attitudes toward caring for patients with pain and addiction.

Survey results demonstrate a significant positive change in knowledge, self-efficacy and attitudes – with respondents improving their knowledge scores alone by more than 17 percent. Equally promising are reductions in the total morphine milligram equivalents (MME) of opioids dispensed in New Mexico since its peak in December 2011.

Moreover, the amount of opioid MME per prescription has declined. This decline was accompanied by a shift in prescribing patterns with a significant reduction in high-dose opioid prescriptions. During 2012, there also was a decline in the total drug overdose death rate from 25.9 per 100,000 in 2011 to 24 per 100,000 in 2012, and a decrease in the number of deaths from 521 in 2011 to 485 in 2012.

Study results indicate that an innovative coalition of an academic medical center, the state department of health, the medical and pharmacy licensing boards, the Project ECHO Institute, and the state legislature can develop a mandated CME requirement that significantly impacts the knowledge, attitudes and self- efficacy of practitioners with regard to best practices in pain management and opioid prescribing.

Finally, New Mexico Board of Pharmacy data suggest that New Mexico clinicians are adopting the best practices of prescribing lower doses of opioids, because higher doses of opioids are associated with increased morbidity and overdose deaths, especially in chronic pain patients. New Mexico has attained these public health goals without the restriction of physician autonomy seen in other states. New Mexico prescribing data thus far suggest that clinicians are not refusing to prescribe opioids for chronic pain, but instead are prescribing them more safely and responsibly.

New Mexico innovation

The authors highlight five unique aspects of the New Mexico policy and educational initiative that account for these positive outcomes:

  1. The statutory requirement that pain CME include education on addiction. There is insufficient communication and coordination between the pain and addiction communities, and that failure to provide clear and consistent guidance on the management of the co-occurring disorders of pain and addiction leaves clinicians with mixed messages;
  2. Physicians are not the only practitioners who prescribe opioids that are misused and abused. New Mexico is the only state requiring CME training on chronic pain and safe opioid prescribing for all practitioners with DEA registration;
  3. Unlike several other states that target only primary care physicians, no medical or surgical specialty in New Mexico is exempt from the CME requirement;
  4. Only New Mexico requires pain CME with each license renewal;
  5. New Mexico mandates both CME and the patient PMP querying every six months.

“Our approach is intended to share best practices in managing pain with opioids without creating a chilling effect in treating legitimate chronic pain patients,” Katzman says. “Data suggest that New Mexico clinicians are not refusing to prescribe opioids for chronic pain, but instead are prescribing them more safely and responsibly.”

Opioid prescribing practices of health care professionals can be positively affected by mandated education without mandating prescription limits, which has translated into real-world, positive changes in practitioner prescribing.