Should CPD for opioid prescribing be mandatory?

Dear Colleagues,

By the time this issue of Canadian Family Physician is published, we will have celebrated Family Medicine Forum’s 15th year; those at the Annual Meeting of Members will have decided on whether to support a proposal for a smaller, skills-based board; and your Board of Directors will have considered the Federation of Medical Regulatory Authorities of Canada’s (FMRAC’s) request to make continuing professional development (CPD) on appropriate prescribing—opioids being a priority—mandatory. What are the pros and cons of moving in this direction?

Opioid abuse and misuse has become a serious societal problem: Canada ranks second highest in terms of level of opioid use globally. In Ontario, between 2005 and 2011, there was a 250% increase in narcotic-related emergency department visits. A recent review of opioid-related deaths in the same province showed that in 66.4% of cases, a physician had seen those individuals within a month of their passing.¹ As our profession is required to demonstrate commitment to lifelong learning, what should the CFPC’s role be in fostering (or perhaps ensuring) the acquisition and maintenance of required knowledge and skills in this area?

Here are the arguments that support the CFPC making CPD in opioid prescribing mandatory:

• As the body responsible for the standards of accreditation of postgraduate residency programs in family medicine, Certification, and Maintenance of Certification, the CFPC signals the importance of competence in an area by making specific CPD mandatory.

• Licensing authorities delegate the responsibility of monitoring participation in relevant CPD to the 2 certifying colleges (Royal College and CFPC); therefore, the colleges should assume responsibility for this action.

• If CPD in this area is made mandatory by the certifying colleges, it is more likely to be done.

• Engaging in this multifactorial, complex issue gives a powerful signal from the medical profession and might stimulate other stakeholders to request mandatory CPD in a variety of areas.

The arguments against the CFPC making CPD on opioid prescribing mandatory are as follows:

• An upcoming document on physician performance by the FMRAC (sent for consultation) suggests that the role of certifying colleges should be to support clinicians in their journey to improve their practice through commitment to lifelong learning.

• The CFPC supports principles of adult learning, which include physicians assessing their own learning needs, making informed decisions regarding appropriate CPD activities, and reflecting on the effects of CPD on their practices. Mandating specific CPD would violate this approach, which has been core to our mission since the very beginning.

• It is likely that CPD staff would require dedicated time and resources to police adherence to such requirements and to manage exceptions among members for whom such a policy might not apply.

• A potential unintended consequence might be the discontinuation of all opioid prescribing by some physicians to avoid being scrutinized, thereby negatively affecting those patients who genuinely need opioids to manage chronic pain. There is also the potential for an increase in orphan patients resulting from this.

• Given FPs’ broad scope of practice, there is potential for additional requests for mandatory CPD in other areas. The FMRAC assures us that this will not happen; however, it does highlight 2 other areas—communication and appropriate documentation in medical records—that licensing authorities wrestle with.

Opioid misuse is broader than opioid prescribing and is really about how we approach patients with chronic pain in our communities. This includes inadequate treatment of chronic pain and it involves everyone in the medical profession. Regardless of any decision made at the CFPC board level, your College will develop key messages and regularly communicate with you on related emerging issues and on the importance of maintaining competence in this area (we believe that the relational continuity that FPs have with their patients places them in a unique position to approach care holistically). We will identify which CPD programs in this area would be particularly worthwhile for you (eg, by allocating a higher credit value to a program if it meets defined criteria). Further, we will work with others to create meaningful CPD to support you in your everyday practice.

We welcome your thoughts at info{at}cfpc.ca.

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