The opioid epidemic has taken a significant toll on the nation's public health. The US Centers for Disease Control and Prevention estimates that more than 500 000 individuals have died from an overdose involving opioids since 1999. Many of these deaths resulted from the misuse of prescription opioids (28% in 2019).1 The COVID-19 pandemic only exacerbated this health crisis—overdose deaths from opioids rose 36% last year, from 50 963 in 2019 to 69 710 in 2020.2
Despite the pervasive nature of the opioid crisis, physicians still experience professional practice gaps associated with the management of pain and the recognition and treatment of substance use disorder (SUD), including opioid use disorder (OUD).3 These practice gaps can be linked to variation in educational settings and curricula. The need to educate physicians on pain management and the recognition and treatment of SUD is a shared responsibility of the undergraduate, graduate, and continuing medical education communities.
In 2018, the Accreditation Council for Graduate Medical Education (ACGME) revised its Common Program Requirements to require that all programs “provide instruction and experience in pain management if applicable for the specialty including recognition of the signs of addiction.”4 Still, research suggests that clinical training programs continue to struggle to provide effective training in pain management and SUD.3
While the ACGME does not require specific curricular elements, it does convene relevant stakeholders to discuss education-related issues. The GME Stakeholders Congress on Preparing Residents and Fellows to Manage Pain and Substance Use Disorder did just this, convening more than 130 physicians and ACGME leadership with the goals of identifying strategies to effectively prepare physicians to confront the challenges of the opioid epidemic and reach consensus on the curricular materials and experience needed for residents and fellows to acquire the skills and competencies necessary to effectively manage pain and recognize and treat SUD, including OUD.
The Congress brought together specialty societies that develop the standards of practice, specialty boards that assess physician competency, program directors who develop curriculum to meet the expectations of the societies and boards, and the ACGME Review Committees that oversee compliance with program requirements. Congress invitees consisted of representatives from 10 specialties that play a role in treating pain and SUD: anesthesia, emergency medicine, family medicine, internal medicine, obstetrics and gynecology, orthopaedics, pediatrics, physical medicine and rehabilitation, psychiatry, and surgery.
Held virtually in March 2021, the event consisted of pre-recorded panel discussions, live question and answer sessions with panelists and keynote speakers, and breakout group discussions. Keynote speakers highlighted the importance of a national curriculum for pain and SUD and provided powerful reflections on the lived experience with pain. Panelists discussed the educational resources and clinical experience necessary for residents and fellows to achieve the knowledge, skills, and attitudes to care for patients with pain and SUD and shared existing resources and evidence already developed that can help inform curricula in pain and SUD, including OUD. Particular attention was paid to bias and stigma, and how institutions' learning culture and language influence trainee attitudes toward SUDs and the patients who suffer from them.
Recommendations for Curricular and Educational Experiences for All Residents and Fellows in Pain and SUD
Congress discussions resulted in recommendations for curricular elements and educational experiences to consider including in the education and training of all residents and fellows (Box), as well as specific recommendations for each specialty represented during the Congress (Table).
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Multimodal approaches to pain
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Non-opioid and non-pharmacologic treatment of acute and chronic pain
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Pharmacology of both opioid and non-opioid pain medications
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Safe opioid prescribing and management of opioid analgesics, including opioid selection, dosage and duration, and tapering
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Proper assessment of pain
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Value of interprofessional and interdisciplinary approaches to pain management
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Communicating effectively with team members and how to manage handoffs
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Communicating with patients about use of opioids, potential risks and realistic benefits of opioids and non-opioid or non-pharmacologic treatment methods for pain, setting reasonable goals for pain, function, and quality of life, and communicating with the patient's care team
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How to listen and talk to patients about pain and pain management
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Motivational interviewing
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Identifying and eliminating stigma, stereotypes, and bias that foster discrimination against and interfere with appropriate treatment for those with substance use disorders (SUDs)
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Identifying and eliminating use of stigmatized language regarding pain and SUD
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Use of medication to treat opioid use disorder
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Assessment of individual patient risk for developing an SUD or substance use–related harms
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Understanding of SUDs as brain disorders and not moral failings
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Recognition of SUD and where to refer patients for treatment
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Exposure to patients undergoing successful treatment for SUD
Pain Management
Congress participants agreed that all residents and fellows should understand the pharmacology of opioid and non-opioid pain medications and should receive education and training in the safe prescribing and management of opioid analgesics, including selection, dosage and duration, and tapering. Trainees should receive instruction in multimodal approaches to pain, including non-opioid and non-pharmacologic treatment of acute and chronic pain. Trainees should learn to assess pain and risks for developing an SUD or substance use–related harms.
Communication
Residents and fellows should learn to effectively communicate with patients about the potential risks and realistic benefits of opioid analgesics, non-opioid and non-pharmacologic treatment methods for pain, and to help patients set reasonable goals for pain, function, and quality of life. They should understand the value of interprofessional and interdisciplinary approaches to pain management. They should also learn to communicate successfully with the patient's care team, including how to execute a successful handoff. Residents and fellows should learn that effective communication requires identifying and eliminating stigma, stereotypes, and bias that foster discrimination against patients with SUD, and as such, should be able to identify and eliminate stigmatized language regarding pain and SUD.
Treatment for Substance Use Disorder
Residents and fellows should learn how and when to use medications for opioid use disorder (MOUD) and how to assess individual patient risk for developing an SUD or substance use–related harms. Trainees should receive instruction in recognizing SUD and know where to refer patients for treatment. Trainees should also get exposure to patients undergoing successful treatment for SUD. Curricula in pain management and addiction should address the bias and stigma that characterize SUDs as moral failures, and instead actively affirm their accurate characterization as disease of the brain.
Specialty-Specific Recommendations for Curricular and Educational Experiences in Pain and SUD
Congress attendees gathered in breakout groups according to specialty to discuss their specialty's role in the recognition and treatment of pain and addiction and the unique experiences and curricular elements that would support resident and fellow competence in these areas. The discussions highlighted the context in which physicians in each specialty provide care and the unique challenges of each specialty's practice and training programs. Each group developed recommendations for curricular elements and educational experiences for trainees in the specialty on pain and SUD and discussed potential next steps, such as specialty society development of practice guidelines or educational materials. The Table outlines the recommendations by specialty.
Addressing the public health crisis of the opioid epidemic will require interdisciplinary collaboration across the medical continuum. Congress attendees expressed optimism that this event would spark continuing conversations and innovation resulting in long-term change. Videos and resources for the Congress will remain available at no cost on the ACGME's learning platform “Learn at ACGME” to anyone who registers for an account.5
