摘要：Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico’s 2012–2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths. Pain is a major public health issue. 1–3 Chronic pain affects an estimated 100 million Americans, which is more than the number of citizens suffering from cancer, diabetes, and all vascular diseases combined. 1 Chronic pain costs up to $635 billion per year in medical treatment and lost productivity. 1,4 Prescription opioid abuse is also a major public health issue. 5 The 2010 National Survey on Drug Use and Health estimated that 35 million Americans (13.7%) adults age 12 years and older had used a pain reliever nonmedically at least once in their lifetime. 6 This is an 18% increase since 2002. In November 2011, the national Morbidity and Mortality Weekly Report reported 36 450 deaths from drug overdoses in 2008. 7 New Mexico and West Virginia have had the highest rates of drug overdose death in the United States since 2008. Almost every county in New Mexico has a higher drug overdose death rate than the rate for the entire United States (12.1 per 100 000), with 2 counties (Rio Arriba and Mora) in New Mexico having overdose death rates (67.4 per 100 000 and 65.0 per 100 000) at 5 times the national rate 7,8 ( Figure 1 ). Open in a separate window FIGURE 1— Drug overdose death rates by County: New Mexico, 2008–2012, and US, 2010. During the 1990s, the undertreatment of pain, especially among disadvantaged groups, was first identified as a deficiency in medical practice and education. 9 In response, academic medical centers, state medical boards, and accrediting agencies stressed the need for pain to be routinely assessed and effectively treated, which led pharmaceutical companies to aggressively market opioids and other drugs for the treatment of chronic pain. 10 Over the past decade there has been a growing recognition that the pendulum may have swung too far, creating an unprecedented epidemic of nonmedical use of opioids, with deleterious effects and—most notably—overdose deaths. 5,11 Primary care clinicians who manage the majority of patients with chronic noncancer pain and addiction struggle with access to specialty care for these patients and often lack the knowledge and confidence of best practices in pain and addiction treatment. 12–18 State and federal legislators and public health officials faced with the exponential and unprecedented misuse of prescription drugs have sought to control the problem in large part through the passing of new statutes and regulations governing the prescribing practices of physicians and other health care professionals. Unfortunately, these and other rules-based approaches could frequently have the unintended consequence of interfering with the physician–patient relationship and undermining practitioners’ ability to follow the Hippocratic Oath to “treat patients according to my ability and judgment.” 19 While additional training and consultation is often a component of these new state laws, New Mexico realized that the number of specialists available to provide these services is insufficient to meet the need and thus chose to adopt continuing education as a cornerstone of its public health policy. A unique coalition of the University of New Mexico Health Sciences Center (UNMHSC; the only academic medical center in the state); the New Mexico Department of Health; the New Mexico Medical, Nursing, and Pharmacy Boards; Project ECHO (Extension for Community Healthcare Outcomes) Institute; and the New Mexico Veterans Affairs Health Care System adopted a values-based educational approach as a primary intervention utilized to improve practitioner management of both pain and addiction. During the 2012 New Mexico State Legislative Session, Senate Bill 215 was adopted, which revised the Pain Relief Act of April 5, 1999, and required all health care professional licensing boards to mandate continuing medical education (CME) training in the treatment of chronic pain. 20 The bill also mandated the development of a Governor’s Prescription Drug Misuse and Overdose Prevention and Pain Management Advisory Council. The Governor’s Council included representation from the major stakeholders in the coalition. The New Mexico Medical Board (NMMB) developed a working committee composed of New Mexico Medical Board members and UNMHSC pain specialists. With input from the public, the committee determined the optimal number of CME hours that physicians and physician assistants should receive. The committee recognized that the epidemic of unintentional opioid overdoses and prescription medication misuse represented a true public health emergency, and that emergency, like other public health crises such as infectious disease outbreaks, warranted an immediate response focused on practitioner education. 21 The New Mexico Medical Board committee developed a consensus on the CME topics to be covered in these trainings: • a basic awareness of the epidemic of chronic pain as well as opioid abuse, addiction, and diversion; • management of pain with nonopioid medications; • Safer opioid prescribing; • identification and management of patients at risk for addiction; and • current state and federal rules and regulations including rules regarding use of the prescription monitoring program (PMP). 22 On August 10, 2012, the NMMB developed Rule 16.10.14, requiring physicians and physician assistants to complete 5 hours of CME in pain and addiction between November 1, 2012, and June 30, 2014. Additionally, the NMMB mandated that all physicians and physician assistants sign up with the New Mexico Board of Pharmacy PMP and check the PMP each time a new prescription for chronic opioids is written and every 6 months thereafter. Through the collaboration of the Governor’s Prescription Drug Misuse and Overdose Prevention and Pain Management Advisory Council, a number of health care professional licensing boards—including the nursing, pharmacy, podiatry, and dentistry, as well as the New Mexico Department of Health (for certified nurse-midwives)—in New Mexico have now followed the NMMB in mandating emergent, time-sensitive pain and addiction CME as well as pain-and-addiction CME requirements as part of their individual board’s renewal cycle. Members of the faculty from the UNMHSC Pain Center, Project ECHO Pain, and the New Mexico Veterans Affairs Health Care System, all of whom are experienced pain practitioners and medical educators, developed a half-day course designed specifically to fulfill the requirements of the NMMB. These courses are a means of bringing academic expertise and specialist consultation to address the public health crises of unintentional overdose and chronic pain in New Mexico.
