Drug-Related Physician Continuing Medical Education Requirements, 2010–2020

1. Introduction

The crisis of drug-related harm in the United States (U.S.) continues to worsen. Nearly 107,000 people in the U.S. died of a drug overdose in 2021, the highest number ever recorded (National Center for Health Statistics, 2022). The crisis has evolved over the last two decades. Initially driven primarily by the overprescribing of opioid analgesic medications, approximately 70,000 of the fatal overdoses occurring in 2021 involved synthetic opioids other than methadone, primarily illicitly manufactured fentanyl. Although deaths related to prescription opioids have retreated from their peak, they remain significantly higher than pre-2010 levels (Hedegaard et al., 2020).

Many factors have contributed to the ongoing crisis of drug-related harm, including inadequate provision of evidence-based treatment to individuals with opioid and other substance use disorders by medical practitioners, as well as clinicians who continue to engage in nonevidence-based prescribing for pain (Chua et al., 2022; Davis & Carr, 2016; Lum et al., 2011; Schoenfeld et al., 2020; Tormohlen et al., 2023). These practices may be driven in part by the relatively limited education received by many physicians regarding the treatment of pain and substance use disorders, as well as training - some sponsored by industry - that mis-represented the safety and efficacy of opioid treatment for some pain conditions (Kolodny et al., 2015; Muchmore, 2016; Van Zee, 2009).

There have been some recent efforts to better educate new physicians about treating both pain and substance use disorders. These efforts, however, may often fall short (Harris et al., 2023). While medical schools have increasingly required relevant didactic sessions in clinical years, as of 2022 fewer than half required didactic training in treatment of substance use disorders and only around 55% required training regarding pain management (Association of American Medical Colleges, 2022). A 2022 survey found that only around 56% of specialty resident and fellow training programs provide training on the treatment of dependence and addiction, and only around one-in-five provide experiential training in the use of medications for opioid use disorder (Accreditation Council for Graduate Medical Education, 2022).

Increased training in pain management and substance use disorder prevention and treatment in medical school, residency, and fellowship, where it exists, does not contribute to the knowledge of physicians already in practice. To address this gap in physician knowledge, many states now mandate that some or all physicians receive relevant continuing medical education (CME) regarding the treatment of pain, the recognition and treatment of substance use disorders (SUD), or both, either as a condition of initial licensure or on an ongoing basis. By the end of 2015, 23 states had at least one such law, and 13 states required all or nearly all physicians who prescribe controlled substances to obtain such CME (Davis & Carr, 2016). The escalation of drug-related harms since that time, including an approximately 67% increase in fatal overdoses from 2016 to 2021, has prompted additional states to create such requirements (Scholl et al., 2018; Spencer et al., 2022). In addition, in early 2023, the federal government for the first time introduced a requirement that almost all controlled substance prescribers attest to training in treating and managing patients with opioid or other substance use disorders as a condition of obtaining or renewing their federal license to prescribe controlled substances (United States Code).

To better understand the evolution of these laws and to build a foundation for empirical studies examining any association between their requirements and changes in physician behavior and patient outcomes, we describe increases in state adoption of CME requirements related to opioid prescribing, pain management, and similar topics; document the key characteristics of these requirements; and describe their evolution over time.

2. Materials and Methods

To determine the presence, characteristics, and effective dates of relevant CME requirements, a research team member with legal training systematically collected, reviewed, and coded all statutes and regulations (hereafter referred to as “laws”) that require continuing medical education as a condition of obtaining or renewing a medical license. We searched the Westlaw legal database for laws in all 50 states and the District of Columbia that had been codified as of December 31, 2020, using search terms “medical education,” “continuing medical education,” “CME,” and “continuing education.” We also systematically searched laws for provisions that contain the terms “physician” or “medic*” in the same sentence as “training” or “education.” We reviewed the laws resulting from that search for relevance. As there is no relevant EQUATOR guideline for this type of empirical legal research, we followed accepted best practices in the field. (Burris et al., 2010; Wagenaar & Burris, 2013)

In states where this search strategy revealed no relevant results, one research team member reviewed state laws governing the practice of medicine generally and state medical board websites for any germane requirements, with a second research team member independently repeating the process for half the states, selected at random. Discrepancies were minor and resolved by consensus. We cross-referenced results with a publicly available collection of continuing medical education requirements maintained by the Federation of State Medical Boards (Federation of State Medical Boards, 2021).

We excluded laws that apply only in limited circumstances, such as in the context of pain management clinics. We also excluded laws that only require education on controlled substance laws generally. We reviewed all relevant laws, and coded the specific requirements of the laws identified through this process on pre-determined dimensions including the physicians to whom the requirements apply, the dates the requirement went into effect (which is not necessarily the date the statute or regulation was signed or approved), and whether the requirements cover 1) prescribing practices; 2) addiction, substance use disorder, and similar topics; and 3) pain, pain treatment, or pain management.

We also reviewed previous versions of each legal requirement to determine the date on which each became effective and to catalog changes in the laws and their requirements over time. If the specific requirements remained ambiguous after review of state law, we coded the requirements based on the applicable regulatory body’s interpretation of the law. This process was conducted independently and in whole by two legally-trained members of the research team, with discrepancies resolved by discussion.

3. Results

At the end of 2020, 42 states had enacted laws that required all or nearly all licensed physicians to complete either one-time or ongoing post-graduate medical education courses regarding controlled substance prescribing, substance use disorder, pain management, or closely related topics. There is a great deal of heterogeneity in these requirements across states and regions (Figure 1).

Figure 1:

States with any relevant physician CME requirements, December 2020

In ten states (AR, CA, CT, MI, NJ, NY, OR, PA, SC, and TX) these education requirements apply to all or nearly all physicians, while in 29 they apply only to physicians who are licensed to or who do prescribe controlled substances. Additionally, the Nevada requirements apply to all osteopathic (DO) physicians but only those allopathic (MD) physicians registered with the federal Drug Enforcement Administration (DEA) to prescribe controlled substances. Tennessee’s requirements apply to all osteopathic physicians but only to those allopathic physicians who prescribe controlled substances. Maine’s requirements apply to all allopathic physicians but only to those osteopathic physicians who prescribe opioids. Only one state, Vermont, had requirements for allopathic but not osteopathic physicians.

The frequency and duration of required education also varied substantially. Eight of the 42 states (CA, GA, LA, MD, MN, OR, RI, and WA) require physicians to receive the specified education only once, typically when first applying for licensure. The duration of these one-time requirements varies: California requires 12 hours, while Washington state requires only a single hour. All other states with relevant laws require ongoing training, averaging approximately one hour annually. No state requires more than an average of 2.5 hours per year of relevant CME; Connecticut requires only one hour every six years.

Thirty-five states require education related to opioid or controlled substance prescribing; 27 require education related to misuse, addiction, or substance use disorder; and 24 require training on pain or pain management; some states require training on more than one topic. In some states, different requirements apply to allopathic and osteopathic physicians (Table 1).

Table 1:

Opioid-related Physician Post-Graduate Education Requirements, December 2020

State	Relevant Req’t	MD/DO	Covered Physicians	Req’t start date	Req’t end date	Hours req’d	Frequency (Years)	Topic: Prescribing practices	Topic: SUD	Topic: Pain
AL	Yes	Both	CS	1/1/2018	N/A	2	2	Yes	Yes	Yes
AK	Yes	Both	CS	7/1/2018	NA	2	2	No	Yes	Yes
AZ	Yes	MD	All	3/10/2018	3/8/2019	1	2	Yes	No	No
AZ	Yes	Both	CS	4/26/2018	NA	3	2	No	Yes	No
AR	Yes	Both	All	7/1/2018	NA	1	1	Yes	No	No
CA	Yes	Both	All	1/1/2002	12/31/2018	12	One-time	No	No	Yes
CA	Yes	Both	All	1/1/2019	N/A	12	One-time	No	Yes	Yes
CA	Yes	Both	All	1/1/2019	N/A	12	One-time	No	Yes	No
CO	Yes	Both	CS	10/1/2019	N/A	2	2	Yes	Yes	No
CT	Yes	Both	All	10/1/2015	N/A	1	6	Yes	No	Yes
DC	No	-	-	-	-	-	-	-	-	-
DE	Yes	Both	CS	4/11/2014	N/A	2	2	Yes	No	Yes
FL	Yes	MD	CS	7/15/2018	N/A	2	2	Yes	Yes	No
FL	Yes	DO	All	4/10/2010	8/20/2016	1	2	Yes	No	No
FL	Yes	DO	All	8/21/2016	8/8/2018	1	2	Yes	Yes	No
FL	Yes	DO	CS	7/11/2018	N/A	2	2	Yes	Yes	No
GA	Yes	Both	CS	1/1/2018	N/A	3	One-time	Yes	Yes	Yes
HI	No	-	-	-	-	-	-	-	-	-
IA	Yes	Both	All	8/17/2011	7/1/18	2	5	No	No	Yes
IA	Yes	Both	CS	4/17/2019	N/A	2	5	Yes	Yes	Yes
ID	No	-	-	-	N/A	-	-	-	-	-
IL	Yes	Both	CS	1/1/2020	N/A	3	3	Yes	No	No
IN	Yes	Both	CS	7/1/2019	N/A	2	2	Yes	Yes	No
KS	No	-	-	-	N/A	-	-	-	-	-
KY	Yes	Both	CS	7/1/2012	N/A	4.5	3	No	Yes	Yes
LA	Yes	Both	CS	1/1/2018	N/A	3	One time	Yes	Yes	No
MA	Yes	Both	CS	2/1/2012	3/13/2016	3	2	No	Yes	Yes
MA	Yes	Both	CS	3/14/2016	N/A	3	2	Yes	Yes	Yes
MD	Yes	Both	CS	10/1/2018	N/A	2	One-time	Yes	No	No
ME	Yes	MD	All	7/29/2016	N/A	3	2	Yes	No	No
ME	Yes	DO	CS	7/29/2016	N/A	3	2	Yes	No	No
MI	Yes	Both	All	12/6/2017	N/A	3	3	No	No	Yes
MN	Yes	Both	CS	1/1/2020	12/31/2022	2	One-time	Yes	No	Yes
MO	No	-	-	-	-	-	-	-	-	-
MS	Yes	Both	All	12/20/2012	6/14/2013	5	2	Yes	No	No
MS	Yes	Both	CS	6/15/2013	N/A	5	2	Yes	No	No
MT	No	-	-	-	-	-	-	-	-	-
NC	Yes	Both	CS	7/1/2017	N/A	3	3	Yes	Yes	Yes
ND	No	N/A	-	-	N/A	-	-	-	-	-
NE	Yes	Both	CS	10/1/2018	N/A	3	2	Yes	Yes	No
NH	Yes	Both	CS	9/1/2016	N/A	3	2	No	Yes	Yes
NJ	Yes	Both	All	7/1/2017	N/A	1	2	Yes	Yes	Yes
NM	Yes	MD	CS	9/28/2012	N/A	5	Once, in 1st year	No	No	Yes
NM	Yes	MD	CS	11/1/2012	2/13/2013	5	3	No	Yes	No
NM	Yes	MD	CS	2/14/2013	6/30/2014	5	One-time	No	Yes	Yes
NM	Yes	MD	CS	7/1/2014	N/A	5	3	No	Yes	Yes
NM	Yes	DO	CS	3/16/2014	6/11/18	2	One-time	No	No	Yes
NM	Yes	DO	CS	3/16/2014	N/A	6	3	Yes	Yes	Yes
NV	Yes	MD	CS	8/30/2018	N/A	2	2	Yes	Yes	No
NV	Yes	DO	All	2/27/2018	N/A	2	1	Yes	Yes	No
NY	Yes	Both	All	6/22/2016	N/A	3	3	Yes	Yes	Yes
OH	No	-	-	-	-	-	-	-	-	-
OK	Yes	MD	CS	11/1/2018	N/A	1	1	No	Yes	Yes
OK	Yes	DO	CS	Prior to 1997	N/A	1	2	Yes	No	No
OR	Yes	Both	All	7/20/2005	N/A	7	One-time	No	No	Yes
PA	Yes	Both	All	1/1/2017	N/A	2	2	Yes	Yes	Yes
PA	Yes	Both	All	1/1/2017	N/A	4	One-time	Yes	Yes	Yes
RI	Yes	Both	CS	3/22/2017	N/A	8	One-time	Yes	Yes	Yes
SC	Yes	Both	All	6/6/2014	N/A	2	2	Yes	No	No
SD	No	-		-	-	-	-	-	-	-
TN	Yes	MD	CS	7/1/2014	N/A	2	2	Yes	Yes	No
TN	Yes	DO	All	7/1/2014	N/A	2	2	Yes	No	No
TX	Yes	Both	All	9/1/2020	N/A	2	2	Yes	No	Yes
UT	Yes	Both	CS	1/1/2014	N/A	3.5	2	Yes	No	No
VA	Yes	Both	CS	7/1/2016	N/A	2	2	Yes	Yes	Yes
VT	Yes	MD	CS	12/1/2012	10/14/2017	1	2	Yes	No	No
VT	Yes	MD	CS	10/15/2017	N/A	2	2	Yes	Yes	Yes
WA	Yes	Both	CS	1/1/2019	N/A	1	One-time	Yes	No	No
WI	Yes	Both	CS	1/1/2017	N/A	2	2	Yes	No	No
WV	Yes	Both	CS	5/1/2014	N/A	3	2	Yes	Yes	Yes
WY	Yes	Both	CS	7/1/2019	N/A	1	2	Yes	Yes	No

MD: allopathic physician; DO: osteopathic physician; CS: controlled substance; SUD: substance use disorder

3.1. Changes over time

The number of states with required relevant CME has grown quickly. At the end of 2010, only four states (CA, FL, OK, OR) had any relevant CME requirements. California and Oregon required only a one-time training, and the Florida and Oklahoma requirements applied only to osteopathic physicians. By the end of 2014, the number of states with relevant requirements had increased to 15; by the end of 2017, 26 states had relevant laws. A total of 16 additional states joined them during the next three years, bringing the total to 42.

Once initially adopted, the requirements in each state remained relatively stable. Of the 42 states with relevant laws at the end of 2020, only eight (AZ, CA, FL, IA, MA, MS, NM, VT) had modified their requirements over time, and all but one (MS) did so by expanding the required topics. Vermont also increased the number of required hours from one hour every two years to two hours every two years, and Arizona moved from requiring only allopathic physicians to complete one hour to requiring most physicians to complete three hours every two years. (Table 1).

3.2. Unique elements

In California, physicians may satisfy the CME requirement by completing either a 12-hour course on pain management and the treatment of terminally ill and dying patients or a 12-hour course on the “treatment and management of opiate-dependent patients, including eight hours of training in buprenorphine treatment, or other similar medicinal treatment, for opioid use disorders.” The state exempts pathologists and radiologists from the requirements. New Mexico requires allopathic physicians to complete a 5-hour course in pain management during their first year of licensure in addition to the ongoing requirement that they complete five hours every three years; a similar 2-hour first year requirement existed for osteopathic physicians between 2014 and 2018 before being repealed.

California exempted physicians with a federal waiver to prescribe buprenorphine for opioid use disorder treatment from the requirement; Utah exempted physicians who obtain such a waiver on or after July 1, 2017, for two consecutive licensing periods (4 years total). New Hampshire allows physicians to pass an online test in lieu of completing three hours of CME on pain management and addiction disorder. Finally, Iowa is unique in that, while relevant regulations existed from 2011 to 2018 and from 2019 to the end of 2020, no relevant requirements were in place from July 2018 to mid-April 2019. Additional information on state requirements is available in the online Supplement.

4. Discussion

The number of states that require all or most physicians to receive post-graduate education on controlled substances prescribing, pain management, opioid use disorder, and similar topics increased rapidly from 2010 to 2020; by the end of 2020, most states required some form of such education. These education requirements vary substantially across states on multiple dimensions, such as topics covered and frequency required. However, across all states, the hours dedicated to mandated trainings averaged only one per year, a small percentage of the total CME hours that physicians commonly must have for relicensure, which often averages 20 or more hours annually (Federation of State Medical Boards, 2021).

CME trainings are an opportunity to enhance the education physicians received during their clinical training. For many physicians, meeting these particular CME requirements may be the first time they receive training on evidence-based pain treatment and SUD recognition, prevention, and treatment. Many physicians practicing today trained during an era in which they were encouraged to consider pain as the “fifth vital sign,” and provided sometimes inaccurate information regarding the safety and efficacy of opioid therapy for some types of pain, factors likely contributing to the dramatic increase in prescribed opioids seen in the 1990s and 2000s (Guy et al., 2017; Kolodny et al., 2015; Morone & Weiner, 2013; Rummans et al., 2018). The fact that physicians generally receive very little training in recognizing and effectively treating substance use disorders contributes to the reluctance of many to treat such disorders (McGinty et al., 2020; Wood et al., 2013).

A recent Cochrane review of the impact of educational meetings and workshops generally found some evidence that that they likely have a positive but small effect (Forsetlund et al., 2021). Research on the impact of opioid-related continuing education specifically is relatively sparse, and mostly focuses on provider knowledge. However, the evolving literature suggests that CME can improve physician knowledge and behavior in these areas. Several studies suggest that CME increases understanding of these topics, and one recent study found that self-reported measures in pain management improve after CME on that topic (Cervero & Gaines, 2015; McCalmont et al., 2018). A study of over 2,000 health care providers identified continuing education as one of the most commonly listed sources of helpful information regarding safe and effective opioid prescribing (Price et al., 2021). Furthermore, state- mandated CME related to substance misuse and addiction has been associated with increased buprenorphine prescribing in the five years subsequent to the legislation.(Stein et al., 2023)

However, despite the rapid increase in state laws mandating opioid-related CME for physicians, there is a paucity of research examining whether and how such education affects provider behaviors or patient outcomes, and much of the existing evidence is mixed and of relatively low quality (Sud et al., 2021). Indeed, much of the existing research evaluating opioid-related education relies on participant self-report (Sud et al., 2021). We also note that most existing research examines the effect of CME obtained voluntarily by learners who had self-identified a need or desire for additional training in these topics, and it is possible that findings in that context may not apply to mandatory training.

The information regarding physician education mandates provides a sound empirical foundation for studies assessing the efficacy of these mandates, particularly the importance of their variations. Including such information in analyses of the effects of state policies on relevant outcomes can help to ensure that such analyses address a broader range of state policies that might potentially be influencing the outcome being examined (Griffin et al., 2023; Schuler et al., 2021).

4.1. Limitations

Our findings must be considered within the context of their limitations. Although we document the presence or absence of state requirements, we do not know the quality of the CME training provided, nor do we address how closely states track physician compliance with educational mandates (Duensing et al., 2020). Mandates also generally provide very broad guidance with respect to the content of CME trainings, often placing relatively little emphasis on education regarding treatment for opioid use disorder, particularly with the medications methadone and buprenorphine; none have requirements specific to stimulants. The content and quality of the training provided will likely strongly influence how such trainings affect clinician behavior and patient outcomes.

We also note that physicians may be subject to requirements other than those found in law, including employer-required trainings. Finally, this research was limited to educational requirements for physicians. Previous research has shown that many states have enacted continuing education requirements for non-physician providers, and that non-physician prescribers generally prescribe opioids in a pattern similar to physicians. (Duensing et al., 2020; Lozada et al., 2020) This research therefore may provide an incomplete picture of the relevant legal landscape.

5. Conclusions

Physicians are uniquely situated to help reduce drug-related harm by adopting evidence-based practices to treat pain and prevent and treat substance use disorders. Early continuing education requirements focused primarily on appropriate prescribing of opioids and other controlled substances, and many state CME requirements continue to focus heavily on opioid prescribing. Yet the country has entered a “fourth wave” of the crisis in which morbidity and mortality related to stimulants is increasing even as harm caused by illicit synthetic opioids, particularly fentanyl, continues (Ciccarone, 2021). Post-graduate education requirements should be modified to reflect this shifting landscape. Research is needed to determine whether and to what extent the training requirements displayed in Table 1 translate into reductions in opioid and other drug-related harm, as well as how modifications to those training requirements could improve their efficacy. Research is also needed on how continuing education affects the actions and associated patient outcomes of non-physician health professionals (Duensing et al., 2020; Wiener et al., 2019).

Highlights:

• The number of states with relevant CME requirements increased dramatically from 2010 to 2021

• The average number of hours of relevant training required is one per year

• Despite shifts in the substances driving overdose, most requirements remain focused on opioids

• These data can help determine how these requirements impact physician action and patient outcomes