Letters to the Editor

To the Editor:

In March 2019, the National Academies of Sciences, Engineering, and Medicine released a consensus committee report entitled Medications for Opioid Use Disorder Save Lives.¹ The report found that “To stem the opioid crisis, it is critical for all FDA-approved options to be available for all people with opioid use disorder.” The 3 current approved medications (methadone, buprenorphine and naltrexone) are available in multiple formulations, including long-acting implants and injectables, and all except methadone are usually prescribed in a physician's office. The report found that a major barrier to medication use is “the lack of appropriate education and training among health care providers.”

The Accreditation Council for Graduate Medical Education (ACGME) plays an essential role in educating and training physicians. Currently, none of the ACGME's curriculum components require that physicians-in-training learn to treat opioid addiction. At present, fewer than 7% of American physicians have completed the necessary 8-hour DATA waiver training to allow them to prescribe buprenorphine for opioid use disorder, a medication associated with a 50% or greater reduction in the probability of overdose death.² An ACGME requirement for such training in the over 11,000 programs they accredit would dramatically improve the nation's capacity to address the opioid epidemic and begin to close enormous gaps in training with respect to addiction more generally.

In recent months, a group of medical students and faculty have asked the ACGME residency review committees to consider requiring training in addiction treatment for residents.³ None have agreed to date. A recent JAMA blog posting set out the case for ACGME leadership; the response has been a willingness to consider the question further.⁴ A bipartisan group of 31 members of the US Congress has also asked the ACGME to require that all physicians-in-training who care for patients with opioid use disorder learn to treat opioid addiction.⁵

We ask that the ACGME act promptly and establish a requirement that all residents and fellows who care for patients who use opioids, as well as their core faculty, receive specific training on the treatment of opioid use disorder. This is a defining moment for American medicine. It is our obligation to provide physicians with sufficient training to effectively treat patients with opioid use disorder.

We are writing to urge health care professionals to sign on to this letter at www.AddictionTrainingFor-Residents.org.

Signatories:

• Josiah D. Rich, MD, MPH

• Professor of Medicine and Epidemiology

• Brown University

• Eli Y. Adashi, MD, MS, CPE, FACOG

• Professor of Medical Science Former Dean of Medicine and Biological Sciences

• Brown University

• Jia Ahmad, MPH

• Medical Student Johns Hopkins School of Medicine

• Daniel P. Alford, MD, MPH

• Professor of Medicine Associate Dean, Continuing Medical Education

• Boston University School of Medicine/Boston Medical Center

• Scott A. Allen, MD, FACP

• Professor Emeritus, Clinical Medicine University of California, Riverside Medical Director

• The Access Clinic, Borrego Health

• Frederick L. Altice, MD, MA

• Professor of Medicine and Public Health

• Yale University

• Katrina Armstrong, MD

• Physician-in-Chief, Department of Medicine

• Massachusetts General Hospital

• Monica Bharel, MD, MPH

• Commissioner

• Massachusetts Department of Public Health

• John M. Carethers, MD, MACP

• C. Richard Boland Distinguished University Professor

• John G. Searle Professor and Chair, Department of Internal Medicine Professor, Human Genetics

• University of Michigan

• Chinazo Cunningham, MD, MS

• Professor, Departments of General Internal Medicine, Family and Social Medicine, and Psychiatry and Behavioral Sciences

• Associate Chief, Division of General Internal Medicine

• Albert Einstein College of Medicine

• Paul H. Earley, MD, DFASAM

• President, The American Society of Addiction Medicine

• Jack A. Elias, MD

• Senior Vice President for Health Affairs

• Dean of Medicine and Biological Sciences Frank L. Day Professor of Biology Professor of Medicine

• Brown University

• David Fiellin, MD

• Professor of Medicine, Emergency Medicine, and Public Health

• Professor of Investigative Medicine Director, Yale Program in Addiction Medicine

• Director, Health Services and Research Core, Center for Interdisciplinary Research on AIDS Yale School of Public Health

• Traci Green, PhD, MSc

• Associate Professor, Emergency Medicine

• Associate Director & Senior Scientist, Injury Prevention Research Center Boston University Medical Center, Emergency Medicine

• Shelly F. Greenfield, MD, MPH

• President, American Academy of Addiction Psychiatry Kristine M. Trustey Endowed Chair in Psychiatry

• Chief Academic Officer, McLean Hospital Chief, Division of Women's Mental Health

• Professor of Psychiatry, Harvard Medical School

• Director, Clinical and Health Services Research and Education

• Division of Alcohol and Drug Abuse McLean Hospital

• Keith Humphreys, PhD

• Esther Ting Memorial Professor of Psychiatry, Stanford University

• Former Senior Policy Advisor, White House Office of National Drug Control Policy

• Gerald T. Keusch, MD

• Professor, Medicine and International Health

• Associate Director, National Emerging Infectious Diseases Laboratories

• Director, Collaborative Research Core Boston University

• Alan I. Leshner, PhD

• Former Director, National Institute on Drug Abuse

• National Institutes of Health

• David C. Lewis, MD

• Professor Emeritus of Community Health and Medicine

• Founder of the Center for Alcohol and Addiction Studies

• Brown University

• Wei Sum Li, MD

• Chief Medical Resident Brown University, Warren Alpert Medical School

• Joseph Loscalzo, MD, PhD

• Senior Physician, Brigham and Women's Hospital

• Head of the Department of Medicine at Brigham & Women's Hospital Harvard Medical School

• Paula J. Lum, MD, MPH

• Professor of Medicine Program Director, UCSF Primary Care Addiction Medicine Fellowship University of California, San Francisco San Francisco General Hospital

• Yngvild Olsen, MD, MPH

• Medical Director, Institutes for Behavior Resources, Inc.

• Vice President of the American Society of Addiction Medicine

• Michael S. Parmaceck, MD

• Frank Wister Thomas Professor of Medicine

• Chair, Department of Medicine Raymond and Ruth Perelman School of Medicine

• University of Pennsylvania

• Richard Saitz, MD, MPH

• Chair, Department of Community Health Sciences (CHS) Professor of Community Health Sciences & Medicine

• Boston University School of Public Health

• Boston Medical Center

• Jeffrey H. Samet, MD, MA, MPH

• Chief, General Internal Medicine John Noble Professor in General Internal Medicine & Professor of Public Health

• Boston University Schools of Medicine & Public Health

• Boston Medical Center

• Dean Schillinger, MD

• UCSF Professor of Medicine Chief, UCSF Division of General Internal Medicine

• San Francisco General Hospital and Trauma Center

• Joshua M. Sharfstein, MD

• Vice Dean for Public Health Practice and Community Engagement and Professor of Practice in Health Policy and Management

• Johns Hopkins Bloomberg School of Public Health

• Emma Simmons, MD, MPH

• Salma Haider Endowed Chair Professor of Family Medicine Senior Associate Dean of Student Affairs

• University of California Riverside School of Medicine

• Jacqueline Tulsky, MD

• Professor of Medicine, Emeritus UCSF HIV, ID and Global Medicine at ZSFG Clinician's Consultation Center – Substance use Warmline

• Allan Tunkel, MD, PhD

• Associate Dean for Medical Education Brown University, Warren Alpert Medical School

• Sten H. Vermund, MD, PhD

• Dean and Anna M.R. Lauder Professor of Public Health Yale School of Public Health Professor of Pediatrics Yale School of Medicine

• Bob Wachter, MD

• Professor and Chair Department of Medicine, UCSF

• Sarah E. Wakeman, MD

• Medical Director, Massachusetts General Hospital Substance Use Disorder Initiative

• Program Director, Massachusetts General Hospital Addiction Medicine Fellowship Assistant Professor of Medicine, Harvard Medical School

• Chief Medical Officer, RIZE Massachusetts

• Alexander Walley, MD, MSc

• Associate Professor of Medicine Director, Grayken Addiction Medicine Fellowship, Clinical Addiction Research and Education Unit

• Boston Medical Center/Boston University School of Medicine

• Alysse G. Wurcel, MD, MS

• Assistant Professor, Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center

October 8, 2019

To the Editor:

To address the opioid epidemic in the US, the ACGME is taking a leadership role to create sustainable solutions for the appropriate use of pain medication and the recognition and treatment of patients with addiction. The medical profession must work together to provide the resources and training necessary for physicians caring for patients to most effectively treat Opioid Use Disorder.

As of July 2019, the ACGME requires that all residency and fellowship programs “provide instruction and experience in pain management if applicable for the specialty including recognition of the signs of addiction.” As this is a core requirement, all specialty and subspecialty programs must provide, and all residents and fellows will receive this training. The ACGME is also providing resources to the graduate medical education community for this training on opioid use and treatment, which can be found here.

It is imperative that the medical community collaborate to address this issue. The ACGME is organizing a Congress of Medical Education Stakeholders in April 2020 to discuss the optimal curriculum for the education and training of residents and fellows on issues related to the treatment of addiction and management of pain. These stakeholders will include specialty societies, their certifying boards, program directors of ACGME-accredited programs, and the ACGME Review Committees, as well as representatives of the continuum of medical education. While the ACGME provides an educational framework for residency and fellowship programs, the curricula are the purview of the individual programs and their Sponsoring Institutions, and the relevant specialty societies and certifying boards. It will take a coordinated effort by all of these groups to effectively define the education and training needs for the entire medical community. The ACGME is taking the leadership role of convening and coordinating these efforts.

The ACGME is also financially supporting, a member of the steering committee, and co-chairing the National Academy of Medicine's Action Collaborative on Countering the US Opioid Epidemic Education and Training Work Group. This group is also working towards a coordinated approach for the continuum of health professional education that addresses acute and chronic pain management and substance use disorders. This continuum, which includes non-physician providers, begins in medical school for physicians, is developed during residency and fellowship training, and is enhanced throughout a physician's career.

Measures to provide resources and training to today's practicing physicians will have the most immediate impact on this epidemic. The ACGME strongly supports the removal of barriers to the use of these resources by all practicing physicians through changes in regulatory and payment policies. Currently, there is proposed legislation in the US Congress to improve access to these lifesaving therapies, which would allow physicians and other clinicians to immediately incorporate them into their practice.

The ACGME looks forward to continuing to work with the extended medical community to equip physicians with the full range of solutions needed to confront this epidemic.”

Sincerely,

Thomas J. Nasca, M.D., MACP President and CEO ACGME