Pain and Addiction in Specialty and Primary Care: The Bookends of a Crisis

Abstract

Specialists and primary care physicians play an integral role in treating the twin epidemics of pain and addiction. But inadequate access to specialists causes much of the treatment burden to fall on primary physicians. This article chronicles the differences between treatment contexts for both pain and addiction — in the specialty and primary care contexts — and derives a series of reforms that would empower primary care physicians and better leverage specialists.

Get full access to this article

View all access options for this article.

References

D.W.

Baker

, “History of the Joint Commission’s Pain Standards: Lessons for Today’s Prescription Opioid Epidemic,” JAMA 317, no. 11 (2017): 1117-1118, at 1117.

Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Prescribing Data, August 30, 2017, available at <https://www.cdc.gov/drugoverdose/data/prescribing.html> (last visited February 14, 2018).

C.M.

Jones ,

Campopiano ,

Baldwin , and

McCance-Katz , “National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment,” American Journal of Public Health 105, No. 8 (2015): e55-e63.

American Board of Preventative Medicine, Press Release, Addiction Medicine Subspecialty Certification Examination to be Administered in 2017, available at <https://www.abam.net/wp-content/uploads/2015/01/ABPM-TAMF-Press-Release-Nov.-30-2016.pdf> (last visited February 14, 2018).

Turner ,

S.P.

Kruszewski , and

G.C.

Alexander , “Trends in the Use of Buprenorphine by Office-Based Physcians in the United States, 2003-2013,” American Journal on Addictions 24, no. 1 (2015): 24-29, at 24, 26.

Brener ,

von Hippel ,

Resnick , and

Treloar , “Perceptions of Discriminatory Treatment by Staff as Predictors of Drug Treatment Completion: Utility of a Mixed Methods Approach,” Drug and Alcohol Review 29 (2010): 491–497.

R.J.

Bonnie ,

A.S.

Kesselheim , and

D.J.

Clark , “Both Urgency and Balance Needed in Addressing the Opioid Epidemic: A Report From the National Academies of Sciences, Engineering, and Medicine,” JAMA 318, no. 5 (2017): 423-424.

American Society of Addiction Medicine, Opioid Addiction 2016 Facts & Figures, available at <https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf> (last visited April 2, 2018).

Center for Disease Control and Prevention, Morbidity and Mortality Weekly Report, “Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008,” available at <https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w#fig2; https://turnthetiderx.org/> (last visited May 31, 2018).

10.

National Institutes of Health, Fact Sheet, “Pain Management,” October 2010, available at <https://report.nih.gov/nihfact-sheets/ViewFactSheet.aspx?csid=57> (last visited February 14, 2018).

11.

D.J.

Gaskin and

Richard , “The Economic Costs of Pain in the United States,” The Journal of Pain 13, no. 8 (2012): 715-724.

12.

See American Society of Addiction Medicine, supra note 8.

13.

T.J.

De Vries and

T.S.

Shippenberg , “Neural Systems Underlying Opiate Addiction,” Journal of Neuroscience 22, no. 9 (2002): 3321-3325.

14.

G.A.

Brat

et al ., “Postsurgical Prescriptions for Opioid naïve Patients and Association with Overdose and Misuse: Retrospective Cohort Study,” BMJ 360 (2018).

15.

T.J.

Cicero ,

M.S.

Ellis ,

H.L.

Surratt , and

S.P.

Kurtz , “The changing face of heroin use in the United States: a retrospective analysis of the past 50 years,” JAMA Psychiatry 71, no. 7 (2014): 821-826.

16.

Breuer ,

Cruciani , and

R.K.

Portenoy , “Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: a National Survey,” Southern Medical Journal 103, no. 8 (2010): 738-747, at 742.

17.

M.S.

Matthias

et al ., “The Patient-Provider Relationship in Chronic Pain Care; Providers’ Perspectives,” Pain Medicine 11, no. 11 (2010): 1688-1697.

18.

C.C.

Upshur ,

R.S.

Luckmann , and

J.A.

Savageau , “Primary Care Provider Concerns about Management of Chronic Pain in Community Clinic Populations,” Journal of General Internal Medicine 21, no. 6 (2006): 652-655, at 652.

19.

R.N.

Lipari ,

Park-Lee , and

Van Horn , “America’s Need for and Receipt of Substance Use Treatment in 2015, Substance and Mental Health Services Administration (September 29, 2016), available at <https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.html> (last visited February 14, 2018).

20.

Judge

David L.

Bazelon Center for Mental Health Law , “Primary Care Providers’ Role in Mental Health,” available at <http://naapimha.org/wordpress/media/Primary-Care-Providers%E2%80%99-Role-in-Mental-Health.pdf> (last visited February 14, 2018).

21.

K.S.

Yarnall

et al ., “Primary Care: Is There Enough Time for Prevention?” American Journal of Public Health 93, no. 4 (2003): 635-641, at 635.

22.

Fishman ,

Ballantyne , and

J.P.

Rathmell , Bonica’s Management of Pain: Fourth Edition (Baltimore: Lippincott, Williams & Wilkins, 2010): at XIX.

23.

D.A.

Tompkins ,

J.G.

Hobelmann , and

Compton , “Providing Chronic Pain Management in the ‘Fifth Vital Sign’ Era: Historical and Treatment Perspectives on a Modern-Day Medical Dilemma,” Drug and Alcohol Dependence 173, no. 1 (2017): S11-21.

24.

Gudas

, “Raymond W. Houde M.D.,” New York Times, Obituaries (March 16, 2006), available at <http://www.legacy.com/obituaries/nytimes/obituary.aspx?n=raymond-w-houdemd&pid=17098184> (last visited April 3, 2018).

25.

Seymour

, “Pain and Palliative Care: The Emergence of New Specialties,” Journal of Pain and Symptom Management 29, no. 1 (2005): 2-13.

26.

“An Interview with Kathleen M. Foley,”

available at <https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/palliative-care/interview-kathleen-m-foley> (last visited February 21, 2018).

27.

J.C.

Buffer

, “A Message from the President,” The Phoenix: A Diplomates Newsletter (Winter 2014), available at <https://www.theabfm.org/news.aspx?year=2014#d635541984> (last visited February 21, 2018).

28.

M.B.

Max

, Perspective, “Improving Outcomes of Analgesic Treatment: Is Education Enough?,” Annals of Internal Medicine 113, no. 11 (1990): 885-889. 28. Id. at 886.

29.

See Department of Veterans Affairs, Pain as the 5th Vital Sign Toolkit, October 2000, available at <https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf> (last visited February 21, 2018): at 5.

30.

See Department of Veterans Affairs, supra note 29.

31.

See

Brennan

, “The U.S. Congressional ‘Decade on Pain Control and Research’ 2001-2011: A Review,” Journal of Pain & Palliative Care Pharmacotherapy 29, no. 3 (2015).

32.

Nelson

, “Decade of Pain Control and Research gets into Gear in USA,” Lancet 362 (October 4, 2003), available at <https://ac.els-cdn.com/S0140673603145059/1-s2.0-S0140673603145059-main.pdf?_tid=18e03d6e-014d-11e8-bb6d-00000aacb35e&acdnat=1516829308_46681b426a4fe3832276deef3e8b8662> (last visited February 21, 2018).

33.

Joint Commission on Accreditation of Healthcare Organizations, Pain Standards for 2001, available at <https://www.jointcommission.org/assets/1/6/2001_Pain_Standards.pdf> (last visited February 21, 2018): at 2.

34.

D.M.

Phillips , Medical News & Perspectives, “JCHO Pain Management Standards Are Unveiled,” JAMA 284, no. 4 (2000): 428-429.

35.

See Joint Commission on Accreditation of Healthcare Organizations, supra note 33 at 3.

36.

Zgierska ,

Rabago , and

M.M.

Miller , “Impact of Patient Satisfaction Ratings on Physicians and Clinical Care,” Patient Preference and Adherence 8 (2014): 437-446.

37.

See Hospital Consumer Assessment of Healthcare Providers and Systems, HCAHPS Survey, January 2018, available at <http://www.hcahpsonline.org/globalassets/hcahps/survey-instruments/mail/jan-1-2018-and-forward-discharges/click-here-to-view-or-download-the-updated-english-survey-materials.pdf> (last visited February 21, 2018).

38.

See

Asbury

, “Four Cities File Lawsuit against Joint Commission on Accreditation of Health Care Organizations,” West Virginia Record, November 2, 2017, available at <https://wvrecord.com/stories/511258712-four-cities-file-lawsuit-against-joint-commission-on-accreditation-of-health-care-organizations> (last visited February 21, 2018).

39.

“Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals,”

The Joint Commission Perspectives 37, no.7 (2017): 2-4.

40.

A.V.

Zee

, Tthe Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health 99, no. 2 (2009).

41.

See

P.R.

Keefe

, “The Family That Built An Empire of Pain,” The New Yorker, October 30, 2017, available at <https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain> (last visited February 21, 2018).

42.

Addy

, “Opioid Companies Sued by York County No Strangers to Lawsuits, Settlements,” York Dispatch, December 11, 2017, available at <https://www.yorkdispatch.com/story/news/2017/12/11/opioid-companies-sued-york-county-no-strangers-lawsuits-settlements/942431001/> (last visited February 21, 2018).

43.

See

S.G.

Kertesz ,

A.J.

Gordon , and

S.L.

Satel , “Opioid Prescription Control: When the Corrective Goes Too Far,” HealthAffairs, January 19, 2018, available at <https://www.healthaffairs.org/do/10.1377/hblog20180117.832392/full/> (last visited February 22, 2018).

44.

T.J.

Atkinson ,

M.E.

Schatman , and

Fudin , “The damage done by the war on opioids: the pendulum has swung too far,” editorial, Journal of Pain Research 7 (2014): 265-268.

45.

See Kertesz, supra note 43.

46.

Olsen ,

G.L.

Daumit , and

D.E.

Ford , “Opioid Prescriptions by U.S. Primary Care Physicians from 1992 to 2001,” The Journal of Pain 7, no. 4 (2006): 225-235, at 228.

47.

See

Levy ,

Paulozzi ,

K.A.

Mack , and

C.M.

Jones , “Trends in Opioid Analgesic–Prescribing Rates by Specialty, U.S., 2007–2012,” American Journal of Preventive Medicine 49, no. 3 (2015): 409-413, at 409.

48.

R.J.

Gatchel

, “Comorbidity of Chronic Pain and Mental Health Disorders: The Biopsychosocial Perspective,” American Psychologist 59, no. 8 (2004): 795-805.

49.

See

E.E.

Krebs ,

T.S.

Carey , and

Weinberger , “Accuracy of the Pain Numeric Rating Scale as a Screening Test in Primary Care,” Journal of General Internal Medicine 22, no. 10 (2007): 1453–1458.

50.

Mezei and

B.B.

Murinson , “Pain Education in North American Medical Schools,” Journal of Pain 12, no. 12 (2011): 1199-1208.

51.

Id .

52.

A.S.

Chiu

et al ., “Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents,” Journal of Surgical Education 75, no. 1 (2018): 65-71.

53.

L.M.

Yanni

et al ., “Preparation, Confidence, and Attitudes About Chronic Noncancer Pain in Graduate Medical Education,” Journal of Graduate Medical Education 2, no. 2 (2010): 260-268.

54.

J.L.

Starrels

et al ., “Low use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain,” Journal of General Internal Medicine 26, no. 9 (2011): 958–964, at 958, 961.

55.

Dowell ,

T.M

Haegerich , and

Chou , “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,” JAMA 315, no. 15 (2016): 1624-1645.

56.

Bronstein

et al ., “Can Clinicians Accurately Predict which Patients are Misusing Their Medications?,” The Journal of Pain 12, no. 4 (2011):P3.

57.

See

E.M.

Geraghty ,

Franks , and

R.L.

Kravitz , “Primary Care Visit Length, Quality, and Satisfaction for Standardized Patients with Depression,” Journal of General Internal Medicine 22, no. 12 (2007): 1641-1647; L. Hemel et al., The Kaiser Family Foundation and the Commonwealth Fund, Experiences and Attitudes of Primary Care Providers Under the First Year of ACA Coverage Expansion, June 18, 2015, available at <http://www.commonwealthfund.org/publications/issue-briefs/2015/jun/primary-care-providers-first-year-aca> (last visited February 22, 2018).

58.

See

D.C.

Dugdale ,

Epstein , and

S.Z.

Pantilat , “Time and the Patient-Physician Relationship,” Journal of General Internal Medicine 14, no. 1 (1999): S34-40; R.C. Rabin, “15-Minute Visits Take A Toll on The Doctor-Patient Pelationship,” Kaiser Health News, April 21, 2014, available at <https://khn.org/news/15-minute-doctor-visits/> (last visited at February 22, 2018).

59.

M.K.

Shaw ,

S.A.

Davis ,

A.B.

Fleischer , and

S.R.

Feldman , “The Duration of Office Visits in the United States, 1993 to 2010,” American Journal of Managed Care 20, no. 10 (2014): 820-826.

60.

J.W.

Beasley

et al ., “How Many Problems do Family Physicians Manage at Each Encounter? A WReN study,” Annals of Family Medicine 2, no. 5 (2004): 405–410.

61.

American Academy of Family Physicians, Letter to Andrew M. Slavitt, Acting Administrator, available at <https://www.aafp.org/dam/AAFP/documents/advocacy/payment/medicare/feesched/LT-CMS-MPFS-122216.pdf> (last visited at February 22, 2018).

62.

See, for example,

Gungor

, “Do You Need to See an Interventional Pain Specialist,” HSS The Playbook, available at <https://www.hss.edu/playbook/do-you-need-to-see-an-interventional-pain-specialist/> (last visited February 22, 2018).

63.

See

Meier and

Goodnough , “New Ways to Treat Pain Meet Resistance,” New York Times, June 22, 2016, available at <https://www.nytimes.com/2016/06/23/business/new-ways-to-treat-pain-without-opioids-meet-resistance.html?_r=0> (last visited February 22, 2018).

64.

See

Thomas and

Ornstein , “Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers,” New York Times, September 17, 2017, available at <https://www.nytimes.com/2017/09/17/health/opioid-painkillers-insurance-companies.html> (last visited February 23, 2018).

65.

National Association of Attorneys General, Letter to Marilyn Tavenner, President and CEO of America’s Health Insurance Plans, September 18, 2017, at <https://ag.ny.gov/sites/default/files/final_naag_opioid_letter_to_ahip.pdf> (last visited February 22, 2018).

66.

See Meier, supra note 63;

B.Y.

Lee

, “16 Insurance Companies Make Commitment To Address Opioid Crisis,” Forbes, November 9, 2017, <https://www.forbes.com/sites/brucelee/2017/11/09/16-insurance-companies-make-commitment-to-address-opioid-crisis/#617491aa79de> (last visited February 22, 2018).

67.

Patient Protection and Affordable Care Act. Public Law No: 111-148: H.R. 3590. March 23, 2010.

68.

See

Elder

et al ., “Provision of Recommended Chronic Pain Assessment and Management in Primary Care: Does Patient-Centered Medical Home (PCMH) Recognition Make a Difference?,” Journal of American Board of Family Medicine 29, no. 4 (2016): 474-481.

69.

The Commonwealth Fund, Brief, Affordable Care Act’s Payment Delivery System Reforms: A Progress Report at Five Years, May 2015, at <http://www.commonwealthfund.org/publications/issue-briefs/2015/may/aca-payment-and-delivery-system-reforms-at-5-years> (last visited February 22, 2018). But see: J.M. McWilliams et al., “Early Performance of Accountable Care Organizations in Medicare,” NEJM 374, no. 24 (2016): 2357-2366.

70.

M.J.

Brownstein

, “A Brief History of Opiates, Opioid Peptides, and Opioid Receptors,” Proceedings of the National Academy of Sciences of the United States of America 90, no. 12 (1993): 5391-5393; Drug Enforcement Administration Museum and Visitor’s Center, Cannabis, Coca, & Poppy: Nature’s Addictive Plants, available at <https://www.deamuseum.org/ccp/opium/history.html> (last visited February 22, 2018).

71.

See Brownstein, supra note 70.

72.

K.E.

Vowles

et al ., “Rates of Opioid Misuse, Abuse, and Addiction in Chronic Pain: a Systematic Review and Data Synthesis,” Pain 156, no. 4 (2015): 569-576.

73.

National Institute on Drug Abuse, The Science of Drug Abuse and Addiction: The Basics, Last Updated October 2016, available at <https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics> (last visited February 22, 2018).

74.

Armstrong

, “Once-a-month Shot for Opioid Addiction Works as Well as Daily Medication, Study Finds,” STAT, October 28, 2017, at <https://www.statnews.com/2017/10/18/opioid-addiction-vivitrol-suboxone/> (last visited February 22, 2018).

75.

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, “History of Medication-Assisted Treatment for Opioid Addiction,” in Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (Rockville, MD: 2005), available through <https://www.ncbi.nlm.nih.gov/books/NBK64157/> (last visited April 3, 2018).

76.

“Methadone Diversion Control,” in

R.A.

Rettig and

Yarmolinsky eds., Federal Regulation of Methadone Treatment (Washington: Academies Press, 1995), available at <https://www.ncbi.nlm.nih.gov/books/NBK232116//> (last visited May 31, 2018); see also: B. Mund and K. Stith, “Buprenorphine MAT as an Imperfect Fix,” Journal of Law, Medicine & Ethics 46, no. 2 (2018): 279-291.

77.

But see Id.

78.

Vestal

, “How Severe is the Shortage of Substance Abuse Specialists?,” STATELINE, Pew Charitable Trusts, April 01, 2015, available at <http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage-of-substance-abuse-specialists> (last visited February 22, 2018).

79.

C.H.

Andrilla ,

Coulthard , and

E.H.

Larson , “Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder,” Annals of Family Medicine 15, no. 4 (2017): 359-362, at 361; see also: E. Hutchinson et al., “Barriers to Primary Care Physicians Prescribing Buprenorphine,” Annals of Family Medicine 12, no. 2 (2014): 128-133.

80.

Id.; see also:

Suzuki

et al ., “Implementation of a Collaborative Care Management Program with Buprenorphine in Primary Care: A Comparison Between Opioid-Dependent Patients and Chronic Pain Patients using Opioids Non-medically,” Journal of Opioid Management 10, no. 3 (2014): 159-168.

81.

See American Society of Addiction Medicine, Nurse Practitioners and Physician Assistants Prescribing Buprenorphine, available at <https://asam.org/resources/practice-resources/nurse-practitioners-and-physician-assistants-prescribing-buprenorphine> (last visited April 3, 2018).

82.

T.L.

Quest

et al ., “Buprenorphine Therapy for Opioid Addiction in Rural Washington: The Experience of the Early Adopters,” Journal of Opioid Management 8, no. 1 (2012): 29-38.

83.

Sharma

et al ., “Update on Barriers to Pharmacotherapy for Opioid Use Disorders,” Current Psychiatry Reports 19, no. 35 (2017): 1-8.

84.

Substance Abuse and Mental Health Services Administration, Apply to Increase Patient Limits, Last Updated February 9, 2017, available at <https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management/increase-patient-limits> (last visited February 22, 2018).

85.

See American Society of Addiction Medicine, supra note 81.

86.

Klasa

et al ., “Primary Care Models for Treating Opioid use Disorders: What Actually Works? A Systematic Review,” PLOS ONE 12, no. 10 (2017): 1-40. See also: Andrilla, supra note 79.

87.

Hudgins ,

Rose ,

P.Y.

Fifield , and

Arnault , “Navigating the Legal and Ethical Foundations of Informed Consent and Confidentiality in Integrated Primary Care,” Families, Systems, & Health 31, no. 1 (2013): 9-19.

88.

S.L.

Hedden

et al ., Center for Behavioral Health Statistics and Quality, Substance and Mental Health Services Administration, Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health, September 2015, available at <https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf> (last visited February 22, 2018): at 33.

89.

See American Board of Preventative Medicine, Addiction Medicine Pathways, available at <https://www.theabpm.org/become-certified/subspecialties/addiction-medicine/addiction-medicine-pathways/> (last visited February 22, 2018).

90.

See Klasa, supra note 86.

91.

Lee

et al ., “A Comprehensive Review of Opioid-Induced Hyperalgesia,” Pain Physician 14, no. 2 (2011): 145-161.

92.

J.A.

Cunningham

et al ., “Barriers to Treatment – Why Alcohol and Drug-Abusers Delay or Never Seek Treatment,” Addictive Behaviors 18, no. 3 (1993): 347-353.

93.

J.B.

Louma

, “Stigma Predicts Residential Treatment Length for Substance use Disorder,” American Journal of Drug and Alcohol Abuse 40, no. 3 (2014): 206-212.

94.

M.P.

Botticelli and

H.K.

Koh , Viewpoint, “Changing the Language of Addiction,” JAMA 316, no. 13 (2016): 1361-1362; L.M. Broyles et al., “Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: a Recognition and Response,” editorial, Substance Abuse 35, no. 3 (2014): 217-221.

95.

R.P.

Schwartz

, Commentary, “When Added to Opioid Agonist Treatment, Psychosocial Interventions do not Further Reduce the Use of Illicit Opioids: A Comment on Dugosh et al.,” Journal of Addiction Medicine 10, no. 4 (2016): 283-285.

96.

J.D.

Livingston

et al ., “The Effectiveness of Interventions for Reducing Stigma Related to Substance use Disorders: a Systematic Review,” Addiction 107, no. 1 (2012): 39-50.

97.

D.G.

Tobin

, “A Rational Approach to Opioid use Disorder in Primary Care” Cleveland Clinic Journal of Medicine 84, no. 5 (2017):385-387.

98.

Katerndahl ,

Wood , and

C.R.

Jaen , “Complexity of Ambulatory Care across Disciplines,” Healthcare 3, no. 2 (2015): 89-96, at 93-94.

99.

R.A.

Berenson and

J.D.

Goodson

“Finding Value in Unexpected Places — Fixing the Medicare Physician Fee Schedule,” perspective, NEJM 374, no. 14 (2016): 1306-1309.

100.

See Thomas, supra note 64.

101.

See Andrilla et al., supra note 79; see also:

S.R.

Johnson

, “Proven Tool to Fight Opioid Abuse Underused by Providers,” Modern Healthcare, April 2, 2016, available at <http://www.modernhealthcare.com/article/20160402/MAGAZINE/304029964> (last visited February 23, 2018).

102.

See Hedden et al., supra note 88.

103.

See Hutchinson et al., supra note 79; Quest et al., supra note 82.

104.

R.L.

Haffajee ,

A.B.

Jena , and

S.G.

Weiner , “Mandatory Use of Prescription Drug Monitoring Programs,” viewpoint, JAMA 313, no.9 (2015): 891-892.

105.

Department of Health and Human Services, Prescription Drug Monitoring Program Interoperability Standards: A Report to Congress, September 2013, available at <https://www.healthit.gov/sites/default/files/fdasia1141report_final.pdf> (last visited February 23, 2018).

106.

See Rhode Island Department of Health, Rules and Regulations for Pain Management Opioid Use and the Registration of Distributors of Controlled Substances in Rhode Island, February 2017, available at <http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/8473.pdf> (last visited February 23, 2018): at 6-7.

107.

Breuer ,

Pappagallo ,

J.Y.

Tai , and

R.K.

Portenoy , “US Board Certified Pain Physician Practices: Uniformity and Census Data of their Locations,” Journal of Pain 8, no. 3 (2007): 244–250.

108.

42 C.F.R. § 2.13(d) (eff. March 21, 2017).

109.

See Federal Register, Confidentiality of Substance Use Disorder Patient Records, January 9, 2018, available at <https://www.federalregister.gov/documents/2018/01/09/2018-00150/confidentiality-of-substance-use-disorder-patient-records> (last visited February 23, 2018).

110.

A.Y.

Walley

et al ., “Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers,” Journal of General Internal Medicine 23, no. 9 (2008): 1393-1398.

111.

Substance Abuse and Mental Health Services Administration, Qualify for Nurse Practitioners (NPs) and Physician Assistants (Pas) Waiver, Last Updated January 18, 2018, available at <https://www.samhsa.gov/medication-assisted-treatment/qualify-nps-pas-waivers> (last visited February 23, 2018).

112.

See Breuer et al., supra note 107.

113.

See American Academy of Pain Medicine, For the Primary Care Provider; When to Refer to a Pain Specialist, December 1, 2016, available at <http://www.painmed.org/files/when-to-refer-a-pain-specialist.pdf> (last visited February 23, 2018).

114.

See

A.R.

Gluck ,

Hall , and

Curfman , “Civil Litigation and the Opioid Epidemic: The Role of Courts in a National Health Crisis,” Journal of Law, Medicine & Ethics 46, no. 2 (2018): 351-366

115.

See, for example, American Academy of Family Physicians, Consultations, Referrals, and Transfers of Care, available at <https://www.aafp.org/about/policies/all/consultations-transfers.html> (last visited February 23, 2018).

116.

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, “Policies and Procedures,” in Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction in (Rockville, MD, Substance Abuse and Mental Health Services Administration: 2005), available at <https://www.ncbi.nlm.nih.gov/books/NBK64234/> (last visited February 23, 2018).

117.

See State of Vermont, Hub and Spoke, available at <http://blueprintforhealth.vermont.gov/about-blueprint/hub-and-spoke> (last visited February 23, 2018).

118.

J.R.

Brooklyn and

S.C.

Sigmon , “Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder: Development, Implementation, and Impact,” Journal of Addiction Medicine 11, no. 4 (2017): 286-292.

119.

Id .

120.

Id .

121.

Doorenbos

et al .,“TelePain: Improving primary care pain management,” Journal of Pain 18, no. 4 (2017): S67-68.

122.

See Providers Clinical Support System, available at <https://pcssnow.org/> (last visited February 23, 2018).