State Continuing Education Requirements for Physicians and Dentists, Including Requirements Related to Pain Management and Controlled Substance Prescribing

Continuing education (CE) is widely recognized as playing an important role in many public health initiatives. States often require subject-specific CE as a condition of a physician's or dentist's licensure to promote professional competence, address matters of public health concern, and enhance patient protection.

In recent years, many stakeholders have promoted prescriber education programs as a means of combating the opioid epidemic in the United States. Overdoses from prescription opioids are a driving factor in a 15-year increase in opioid overdose deaths,1 and their sales quadrupled between 1999 and 2014.2 One study found that people at the highest risk of overdose most frequently obtained opioids through prescriptions from physicians (27%).3 A national survey showed that more than 40% of patients receiving treatment for substance use said that their physicians had missed diagnosing a substance use disorder.4 Meanwhile, many physicians who reported that their training in the management of opioid dependence was unsatisfactory believed that additional training programs could help address this knowledge deficiency.5 In addition, as pain is the most common complaint in the emergency department, researchers have also called for better opioid prescribing training and education for emergency physicians.6 Professional organizations, including the Federation of State Medical Boards, also recommend continuing education on the use of opioid analgesics and safe opioid prescribing.7 

The federal government has promoted CE as part of a concerted effort to address the opioid public health crisis. For example, the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration have collaboratively developed an online educational resource for providers, the “Substance Use Trainings” webpage, which includes both one-time and ongoing training events that could be counted as CE credits.8 The Office of Disease Prevention and Health Promotion also developed an online interactive learning tool titled Pathways to Safer Opioid Use.9 The tool trains providers on patient-centered chronic pain management, while modeling safe opioid prescribing and offering CE credits. In addition, the U.S. Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy for extended release/long-acting opioids requires that opioid manufacturers offer CE on opioid prescribing through accredited CE providers, using all the elements in an FDA Blueprint for Prescriber Education.10 

In addition to federal efforts, states also leverage the CE system to carry out important public health initiatives, most notably mandates for provider training on pain management and/or controlled substance prescribing. According to the Centers for Disease Control and Prevention, the rate of opioid prescribing varies by state. In 2012, health care providers in the nation's highest-prescribing state (Alabama) wrote nearly three times as many opioid prescriptions per patient as those in the lowest prescribing state (Hawaii).11 State-required CE that provides updated knowledge of safe prescribing and the diagnosis or management of opioid dependence has significant potential to improve prescribing practices.

A previous study exclusively focusing on physicians found that as of 2015, few states had required opioid-related CE for all or nearly all physicians, and fewer than half required any physicians to obtain such training.12 However, this study did not examine opioid-related CE requirements applicable to dentists, nor did it review other state subject-specific CE requirements. Furthermore, additional states have established subject-specific CE requirements in the past two years.

To enhance understanding of the scope and nature of state-level CE requirements and to support evaluation research, we describe the prevalence and characteristics of state-level, subject-specific CE requirements for both physicians and dentists, with a focus on CE for pain management and controlled substance prescribing.

We searched individual state medical board websites for information on CE requirements for Doctors of Medicine (MDs) and Doctors of Osteopathic Medicine (DOs) in the 50 states and the District of Columbia, and confirmed those assessments with additional data from the Federation of State Medical Boards, the American College of Physicians' website, and other publications on CE requirements.12–15 We also reviewed CE requirements for Doctors of Dental Surgery in these states by reviewing the CE information listed on websites for state boards of dentistry and additional data from the American Dental Association website.16 We reviewed all laws or regulations regarding CE requirements effective in the 50 states and the District of Columbia, as of April 30, 2017.

For each state, we collected data on the number and topics of subject-specific CE requirements and whether the CE requirement was one-time only or a part of license renewal. Not every state requires topic-specific CE for each renewal cycle; some states may permit CE in alternate renewal cycles, for example, but we still considered those to be renewal CE requirements for the purposes of this study. Providers are awarded a set number of CE credit hours for completing requirements; this paper defines duration as the number of hours awarded for completing trainings or courses. While used as the metric to award credit, CE hours may not represent the time providers actually take to complete requirements. States generally do not specify the content of CE but instead defer to CE providers. We considered pain management and controlled substance prescribing together in this analysis as both could potentially affect opioid prescribing. We recorded the average number of credit hours per subject required, normalized to the two-year period most commonly used as the basis for state CE renewal cycles. For states whose CE duration requirements varied by specialty, we selected the highest requirement. If a state CE requirement provided a choice among several topics, we counted each choice as a separate requirement. If a prescriber could choose among, for example, three subjects for six hours of an overall 50-hour requirement in a two-year period, we assumed for the purposes of this study that each subject was required for two hours.

For states with pain management/controlled substance CE requirements, we reported whether they applied to all physicians or dentists and identified states that limit these requirements to certain prescribers of controlled substances. States that exempted only limited numbers of practitioners from the CE requirement (e.g., California, where pathologists and radiologists are exempt from the pain management training) were still considered to have requirements applicable to all providers in this study. States with a CE requirement only applicable to opioid prescribing were considered to have CE requirements for controlled substance prescribing. We did not include certification in life support training, such as cardio-pulmonary resuscitation or cardiac life support, because some states permit such training to count toward CE hours, while other states do not.

Thirty-two of the 50 states and the District of Columbia (63%) have at least one subject-specific CE requirement for either MDs or DOs, with the highest number of subjects being seven in Connecticut and Massachusetts — although both of these states permit providers to select CE subjects from a list of seven topics (Figure 1). Seven states (14%) have a one-time CE requirement, three of which require CE in only one subject, while the other four require CE in two subjects. Thirty states (57%) have subject-specific requirements for license renewal, with nine having one subject-specific CE requirement and the remaining 21 requiring two or more subjects (maximum of seven). Five states (10%) have both one-time and renewal requirements.

Three states require one credit hour of CE, six require two hours, nine require three hours, and 12 require more than three hours. All of these CE requirements are part of, and not in addition to, the total number of CE hours required.^*

Pain management and controlled substance prescribing are the two most common subject-specific CE requirements, with 29 states (57%) having one or both requirements. All of these states, except Rhode Island and Wisconsin, established their requirements through statute. Twelve of the 29 states require only pain management CE, 10 require only controlled substance prescribing CE, and seven require both (Figure 2). Twenty-six of the 29 states have such requirements for both MDs and DOs. Two states (Oklahoma and Nevada) have requirements only for DOs, and one state (Vermont) has requirements applicable only to MDs. Twelve of the 29 states (California, Connecticut, Michigan, New Jersey, Nevada, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Virginia, and Vermont) require CE on pain management/controlled substance prescribing of all MDs or DOs, while the remaining 17 states' requirements apply only to a subset of physicians/osteopaths, such as controlled substance prescribers or certain providers based in pain clinics.

Of the 12 states with pain management/controlled substance prescribing CE requirements for all MDs and DOs, 10 (Connecticut, Michigan, New Jersey, Nevada, Oklahoma, Rhode Island, South Carolina, Tennessee, Virginia, and Vermont) have CE requirements for license renewal (four for pain management only, three for controlled substance prescribing only, and three for both) and two (California and Oregon) require one-time CE. No state with requirements related to renewals for all MDs and DOs requires more than two hours of pain management/controlled substance prescribing CE over a two-year period.

Of the 17 states limiting application of CE requirements for pain management/controlled substance prescribing to controlled substance prescribers or certain providers, eight require CE exclusively on pain management, seven do so for controlled substance prescribing, and two require both. The requirements in these 17 states all pertain to license renewal, and differ by provider specialty, practice setting, and other variables. For example, Texas requires the medical director or owner/operator of a pain management clinic to complete 10 hours of CE in pain management annually. The number of CE hours required for certain providers (e.g., pain management specialists) is generally equal to or greater than the requirements for all MDs and DOs (range, 1–30 hours over a two-year period, median=3 hours).

Thirty of the 50 states and the District of Columbia (59%) have at least one subject-specific CE requirement for dentists, with a maximum of 15 subjects in Arizona. Among these 30 states, 10 have one subject-specific requirement, seven have two requirements, eight have three requirements, and five have more than three requirements (Figure 3). The most common subject-specific requirement is infection control (16 states), followed by pain management (nine), ethics (nine), and controlled substance prescribing (eight).

Thirteen states (25%) require dentists to complete pain management and/or controlled substance prescribing CE; four require both (Figure 4). All but two states require the training every renewal cycle. Five of 13 states only require that a subset of dentists, such as those registered with the Drug Enforcement Administration or dentists considered dispensers, complete the requirements at each renewal cycle. Of the eight states requiring all dentists to complete CE in pain management/controlled substance prescribing, two have a onetime requirement with no more than three hours, and one requires dentists to complete CE at renewal but does not specify the minimum number of CE hours. The remaining five states specify the minimum hours required; four require less than three hours over a two-year period; and one requires three hours.

A summary of specific state CE requirements for physicians/osteopaths and dentists can be seen in Table 1.

This analysis demonstrates that 32 states (63%) have some subject-specific CE requirement for MDs or DOs, and 30 states (59%) have such requirements for dentists. The two most common subjects for MDs and DOs are pain management (19 states, 37%) and controlled substance prescribing (17 states, 33%). The most common subjects for dentists are infection control (16 states, 31%), pain management (nine states, 18%), and ethics (nine states, 18%). Those CE requirements related to all physicians at renewal never exceeded three hours for either physicians or dentists. However, only 10 states (20%) require CE on pain management and/or substance control prescribing at license renewal for all MDs or DOs at each license renewal, and only six states do so for dentists. These results imply that at least 32% of the U.S. population lives in states with no pain management/controlled substance prescribing CE requirement.17 While providers in states without required CE may seek additional education on pain management/controlled substance prescribing on their own, a large number of providers may not be reached. Some states may have established pain management CE requirements owing to a concern about palliative care rather than the opioid abuse and dependence.

All prescribers have a responsibility to prescribe opioids appropriately and to minimize their potential for harm. In 2012, dentists wrote only 6.4% of all prescriptions for opioids, even though opioid prescriptions constituted 29% of all prescriptions they wrote.18 Although the American Dental Association encourages continuing education on the appropriate use of opioid pain medications,16 only 13 states require dentists to complete some form of continuing education on either pain management/controlled substances. Two states (Arizona and Pennsylvania) have such requirements for dentists but not for physicians.

Our study did not track the actual hours individual physicians or dentists spent participating in an opioid-related CE, and states often allow physicians or dentists to select certain subjects among several options. Moreover, prescribers in states without CE requirements may seek out CE on their own or may take more hours than are required.

Previous studies of the impact of CE suggest positive impacts on physician performance and physician knowledge, but studies of patient health outcomes show mixed findings.19,20 A systematic review of the impact of CE concluded that CE can improve physician performance and patient health outcomes.19 A systematic review published in 2014 found that evaluations of CE on opioid prescribing indicate a gain in knowledge, but limited adoption of safe opioid prescribing practices.20 However, the studies reviewed usually evaluated few provider specialties and had small sample sizes.

Our research did not evaluate the effectiveness of the training states required of their providers, but rather sought to determine the extent to which states require pain management/controlled substance CE in light of the current opioid overdose problem. Evaluating the effectiveness of a training would depend on its particular objectives and the ability to measurably assess provider knowledge, provider behavior, or patient outcomes. Given that research on the effectiveness of CE is limited, providers and policy makers would benefit from additional studies evaluating the effectiveness of CE in the context of the wider social, political, and organizational factors affecting physician behaviors and patient outcomes.19 More research is needed to examine the availability and quality of state CE programs on pain management/controlled substance prescribing trainings and the long-term impact of such programs on prescribing behaviors.

We found that a majority of states have subject-specific CE requirements, and many states require CE to address pain management/controlled substance prescribing, but few do so for all professionals at every renewal. Because current requirements for CE in pain management/controlled substance prescribing are of limited duration and included in the overall state CE hour requirements, they are unlikely to impose significant additional burdens for licensure. Our analysis suggests steps that states without pain medication/controlled substance prescribing CE requirements might take to help address the opioid epidemic.

We would like to thank Marguerite Lee, Stella Kim (Intern), and Brady Mickelsen (Intern) of the FDA; Vincent Beswick-Escanlar (Preventive Medicine Resident) of Uniformed Services University, Canada; Mitra Ahadpour of the U.S. Substance Abuse and Mental Health Services Administration; and Christopher M. Jones of the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services for their valuable contributions to the manuscript.