Among the recommendations of the President's Commission on Combating Drug Addiction and the Opioid Crisis (President's Commission) is to mandate "medical education and prescriber education initiatives in proper opioid prescribing and risks of developing an SUD [Substance Use Disorder]."

This Insight focuses on physician efforts because physicians can prescribe in every state but not all states permit advanced practice nurses or physician assistants to prescribe opioids. Many of the policy options discussed in this Insight could also be applied to other provider types (e.g., nonphysicians) who have prescriptive authority.

Efforts to increase training on opioid prescribing for physicians could occur at three points during training:

• 1. during medical school,
• 2. during medical residency (i.e., as part of graduate medical education), and
• 3. while in active practice (i.e., as part of the requirements to obtain or maintain a license).

Federal efforts to mandate such education may be limited at each of these levels. For example, the federal government does not have direct oversight over the content of medical school curricula, although it has some indirect influence because federal student loan funds are often available only to individuals who attend a school accredited by an approved body (the Liaison Committee on Medical Education or the Commission on Osteopathic College Accreditation). Attending an accredited medical school is also required to enter residency training. Medical schools determine their own curricula subject to standards set by the relevant accreditation body. Some medical schools have implemented opioid-prescribing curricula.

Prior to being licensed to practice independently, typically a physician must complete a residency. As with medical school curricula, the federal government does not have a direct role in setting the content of residency training, although it plays a large role in financing residency training.

Physician licensing occurs at the state level. As such, the federal government cannot mandate that certain training be required for state licensure or be required to maintain state licensure. State licensure, however, is required to enroll as a provider eligible for reimbursement from federal health programs (e.g., Medicare). States have made efforts to increase provider education about prescribing opioids, for example, by requiring continuing education courses in pain management for physicians licensed in that state.

The federal government does regulate the prescribing of controlled substances, including opioids, by requiring individuals who seek to prescribe controlled substances to register with the Drug Enforcement Administration (DEA). This registration generally requires the DEA to verify an individual's state license and does not require additional training.

What Levers Are Available to the Federal Government?

Although much of the authority to mandate prescriber education would occur through schools or through states, the federal government may have some leverage in encouraging or requiring this education. Examples of policy levers are discussed below. Specific examples are provided where options have been used.

• Developing the content of potential new prescribing-related curricula. For example, the Centers for Disease Control and Prevention (CDC) released opioid-prescribing guidelines that have been used in some medical schools. In addition, the National Institutes of Health (NIH) Centers of Excellence in Pain Education (COPEs) have also worked to develop and distribute pain-related curricula. This initiative involves 11 health professional schools.
• Providing funding to encourage medical schools and residency programs to provide training in opioid prescribing and substance abuse. The explanatory statement accompanying P.L. 115-31, which provided appropriations for the end of FY2017, included the following language: "The agreement supports efforts by the Health Resources and Services Administration (HRSA), through its Title VII health professions programs, to provide educational and training grants to medical schools and teaching hospitals to develop innovative educational materials related to substance use disorders and pain management."
• Providing grants or explicit funding to support education and training. For example, Public Health Service Act Title VII includes a grant program for education and training in pain care, which authorizes awarding funds to health professional schools, and hospices, among others, to develop and implement programs to provide pain care training to health care professionals. Appropriations for this program were authorized through FY2012, but funds have never been appropriated.
• Providing funding preferences in federal grant programs to states that implement prescriber requirements or to medical schools that implement opioid training requirements. For example, HRSA provides grants to medical schools to increase training in primary care. Grant funds could be awarded in ways that give preference to medical schools that implement opioid prescribing curricula.
• Requiring physicians who are employed by the federal government to have training on safe opioid prescribing. For example, a 2015 presidential memorandum requires federal agencies such as the Department of Veterans Affairs (VA) and the Indian Health Service (IHS) to provide training to their providers about safe prescribing. The presidential memorandum does not mandate set curricula.
• Providing funding for programs that provide opioid training (or withdrawing funding from those that do not). As mentioned, the federal government provides financial support to hospitals for medical residency training, though the majority of these funds flow from the Medicare trust fund by formula; other GME payments could be used to incentivize training programs to include opioid-related training.
• Amending the Controlled Substances Act to require that individuals seeking to register with the DEA to prescribe controlled substances have training on opioid prescribing. The President's Commission recommended that the law be amended to require that prescribers undertake continuing medical education on opioid prescribing prior to being relicensed with the DEA.

These examples are some of the policy options that could be employed for training on safe opioid prescribing. These options could target physicians or a larger group of providers. While the options discussed in this Insight focus on opioid training, similar policy options could also be considered for other content areas, such as nutrition or end-of-life care.