Andrew N. Wilner, MD
June 26, 2023
The Consolidated Appropriations Act of 2023 mandates that all Drug Enforcement Administration (DEA)–registered physicians and healthcare providers complete a one-time, 8-hour CME training on managing and treating opioid and other substance abuse disorders. This requirement goes into effect on June 27, 2023. New DEA registrants must also comply. Veterinarians are exempt.
A DEA registration is required to prescribe any controlled substance. The DEA categorizes these as Schedule I-V, with V being the least likely to be abused (Table 1). For example, opioids like fentanyl, oxycodone, and morphine are Schedule II. Medications without abuse potential are not scheduled.
| Table 1. DEA Schedule (Abbreviated) |
|---|
| Schedule I |
| Medications with no accepted medical use and subject to abuse (ie, heroin, lysergic acid diethylamide [LSD]) |
| Schedule II |
| Medications with acceptable medical use but high abuse potential (ie, fentanyl, morphine, oxycodone) |
| Schedule III |
| Medications with intermediate abuse potential (ie, anabolic steroids, ketamine, testosterone) |
| Schedule IV |
| Medications with abuse potential (ie, alprazolam, diazepam, tramadol) |
| Schedule V |
| Medications with the lowest abuse potential amongst controlled substances (ie, dextromethorphan, pregabalin) |
Will 16 Million Hours of Opioid Education Save Lives?
One should not underestimate the sweeping scope of this new federal requirement. DEA registrants include physicians and other healthcare providers such as nurse practitioners, physician assistants, and dentists. There are nearly 2 million DEA registrants, all of whom must now dedicate 8 hours to complete the DEA-mandated CME. That is 8 hours per provider × 2 million providers: 16 million hours of CME!
Many states already require 1 or more hours of opioid training and pain management as part of their re-licensure requirements (Table 2). To avoid redundancy, the DEA-mandated 8-hour training satisfies the various states’ requirements.
| Table 2. State CME Opioid and Pain CME Requirements for MDs* | |
|---|---|
| Alabama | Two credit hours every 2 years |
| Alaska | 2 hours every 2 years |
| Arizona | 3 hours every 2 years |
| California | 12 hours or units one time |
| Connecticut | 1 hour every 6 years |
| Delaware | 2 hours every 2 years |
| Washington, DC | One course every 2 years |
| Florida | 2 hours every 2 years |
| Georgia | 2 hours every 2 years |
| Illinois | 3 hours |
| Indiana | 2 hours |
| Iowa | 2 hours every 5 years |
| Kentucky | 4.5 hours every 3 years |
| Louisiana | 3 hours one time |
| Maine | 3 hours every 2 years |
| Maryland | 1 hour every 2 years |
| Massachusetts | Three credit hours each renewal cycle |
| Michigan | 3 hours every 3 years |
| Mississippi | 5 hours |
| Nebraska | 3 hours every 2 years |
| Nevada | 4 hours every 2 years |
| New Hampshire | 3 hours every 2 years |
| New Jersey | 1 hour every 2 years |
| New Mexico | 5 hours every 3 years |
| New York | 3 hours |
| North Carolina | 3 hours every 3 years |
| Ohio | 20 hours every 2 years |
| Oklahoma | 1 hour every 3 years |
| Oregon | 6 hours one time |
| Pennsylvania | 4 hours once for initial licensure; 2 hours every 2 years |
| Rhode Island | 4 hours every 2 years |
| South Carolina | 2 hours every 2 years |
| Tennessee | 2 hours every 2 years |
| Texas | 2 hours every 2 years |
| Utah | 3.5 hours |
| Vermont | 2 hours every 2 years |
| Virginia | 2 hours every 2 years |
| Washington | 1 hour one time |
| West Virginia | 3 hours every 2-year renewal cycle |
| Wisconsin | 2 hours every 2 years |
*For states not listed, check with local medical associations.
An Uncompensated Mandate
Physicians are no strangers to lifelong learning and most eagerly pursue educational opportunities. Though some physicians may have CME time and stipends allocated by their employers, many others, such as the approximately 50,000 locum tenens doctors, do not. However, as enthusiastic as these physicians may be about this new CME course, they will likely lose a day of seeing patients (and income) to comply with this new obligation.
Not Just Pain Doctors
The mandate’s broad brush includes many healthcare providers who hold DEA certificates but do not prescribe opioids. For example, as a general neurologist and epileptologist, I do not treat patients with chronic pain and cannot remember the last time I wrote an opioid prescription. However, I frequently prescribe lacosamide, a Schedule V drug. A surprisingly large number of antiseizure drugs are Schedule III, IV, or V drugs (Table 3).
| Table 3. DEA-Scheduled Antiseizure Drugs (Source: DEA Orange Book) | ||
|---|---|---|
| Antiseizure drug | Brand name | DEA Schedule |
| Brivaracetam | Briviact | V |
| Cenobamate | Xcopri | V |
| Clobazam | Onfi | IV |
| Clonazepam | Klonopin | IV |
| Diazepam | Valium | IV |
| Lacosamide | Vimpat | V |
| Lorazepam | Ativan | IV |
| Midazolam nasal | Versed | IV |
| Perampanel | Fycompa | III |
| Phenobarbital | Luminal | IV |
| Pregabalin | Lyrica | V |
Real-World Abuse?
How often scheduled antiseizure drugs are diverted or abused in an epilepsy population is unknown but appears to be infrequent. For example, perampanel abuse has not been reported despite its classification as a Schedule III drug. Anecdotally, in more than 40 years of clinical practice, I have never known a patient with epilepsy to abuse their antiseizure medications.
Take the Course
Many organizations are happy to charge for the new 8-hour course. For example, the Tennessee Medical Association offers the training for $299 online or $400 in person. Materials from Elite Learning satisfy the 8-hour requirement for $80. However, NEJM Knowledge+ provides a complimentary 10-hour DEA-compliant course.
I recently completed the NEJM course. The information was thorough and took the whole 10 hours to finish. As excellent as it was, the content was only tangentially relevant to my clinical practice.
Conclusions
To obtain or renew a DEA certificate, neurologists, epilepsy specialists, and many other healthcare providers must comply with the new 8-hour CME opioid training mandate. Because the course requires 1 day to complete, healthcare providers would be prudent to obtain their CME well before their DEA certificate expires.
Though efforts to control the morbidity and mortality of the opioid epidemic are laudatory, perhaps the training should be more targeted to physicians who actually prescribe opioids rather than every DEA registrant. In the meantime, whether 16 million CME hours will save lives remains to be seen.
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