Substance use and addiction exact a dire toll in the USA with an estimated 480,000 tobacco deaths, 140,000 alcohol-related deaths, and more than 106,000 overdose deaths annually.1 Overdoses are a primary driver of lost life expectancy and opioids alone accounted for $1.5 trillion annual costs in 2020.2 To help expand access to treatment of opioid use disorder (OUD), Congress passed the Mainstreaming Addiction Treatment (MAT) Act in December 2022. This legislation removed the 8- to 24-h training requirement to prescribe buprenorphine for OUD and the attendant special Drug Enforcement Administration (DEA) registration or license—the so-called X waiver. Congress also passed the Medication Access and Training Expansion (MATE) Act to address the limited education that most health professionals receive on substance use and addiction. The ramifications of the MATE Act will be felt by almost all prescribing clinicians. Effective June 27, 2023, the MATE Act requires all prescribers of controlled substances to attest to completing training on substance use disorders when they apply for their initial DEA registration or seek renewal. This one-time, self-reported attestation allows clinicians to “check a box” verifying that they have completed the required training. Herein, we review the requirements of the MATE Act and the implications for health professions education on substance use and addiction.

On March 27, 2023, the DEA released information on how prescribers could meet the new training requirements under the MATE Act (Table 1), including 8 h of accredited training for those who graduated from health professions school more than 5 years ago, do not have an X waiver, or are not board-certified in addiction medicine or addiction psychiatry.3 Simultaneously, the Substance Abuse and Mental Health Services Administration (SAMHSA) released recommendations for the core curricular elements for substance use disorder training under the MATE Act. The SAMHSA recommendations are designed to “ensure that practitioners have the knowledge, skills, and competencies to diagnose and treat [substance use disorders]” and cover content related to substance use disorders, treatment planning, pain management, and complications of substance use.4

Table 1 Information from the DEA on MATE Act Requirements 3
Full size table

While the MATE Act allows flexibility in fulfilling the training requirement, there are core content areas that should be addressed that go beyond the fundamentals of screening, diagnosis, treatment, and prevention. We believe the MATE Act provides a starting point to standardize expectations of clinician competence in substance use and addiction, as one might expect for the assessment and treatment of conditions such as diabetes, mood disorders, or heart disease. It provides the opportunity to place substance use and addiction education on equal footing with training for other chronic health conditions that clinicians are expected to address in general medical settings. But to adequately train health professionals on substance use and addiction, we need more than a one-time training requirement. Checking a box is simply not enough.

Training is needed to address the pervasive stigma surrounding substance use that exists both in society and healthcare. In addition, training should include patient-centered care approaches that incorporate shared-decision making, motivational interviewing, and harm reduction. Content on marginalized populations and treatment of individuals across the age spectrum is also needed to ensure a comprehensive approach and relevance for clinicians practicing in various specialties. Moreover, this training must address the systemic inequities and criminalization associated with substance use that have disproportionately impacted minoritized communities. By acknowledging and actively working to counteract these disparities, health professions education can play a pivotal role in advancing social justice and health equity.

While the earlier X-waiver training requirements posed barriers to clinician prescribing, most clinicians who obtained an X-waiver still did not prescribe buprenorphine at the top of the imposed limits, indicating additional training needs.5 Furthermore, the dynamic nature of the overdose crisis and evolving substance use landscape necessitates continuous attention and education. In the past decade, we have witnessed the influx of fentanyl and xylazine, and increases in stimulant-related deaths. Substance use disorders treatment has rapidly evolved in recent years with new medication formulations (e.g., injectable buprenorphine to treat OUD), medication initiation strategies, harm reduction approaches, integrated care models, and inpatient addiction medicine consult services. To provide effective care, health professionals will need continuous education that reflects these and future advancements. Ongoing, on-demand, evidence-based education and support are essential and should be normalized for practicing clinicians.

At a systems level, ongoing education for clinicians in practice can be achieved by incorporating substance use and addiction content into specialty-specific core curricula, board and licensing exams, maintenance of certification, and continuing education programs. It is important to note, however, that there is limited evidence that mandated continuing education alone improves clinical practice. Therefore, these sources of ongoing education should be supplemented by programs designed to support translating education into clinical practice, such as Project ECHO and the Providers Clinical Support System. Furthermore, efforts to ensure clinician competence should be prioritized throughout the health professions education spectrum, including continuing education.

Within the medical education system, for example, competency-based education is foundational. Yet, accreditation bodies have been slow to issue requirements on the need for competency-based content focused on substance use. At the undergraduate level, the Liaison Committee on Medical Education (LCME) does not specifically require inclusion of curriculum content on addiction or opioid prescribing but does issue standards that the faculty of a medical school ensure that the curriculum includes instruction in the diagnosis, prevention, appropriate reporting, and treatment of the medical consequences of common societal problems, providing a platform to integrate substance use and addiction content into core curricula. At our institution, we have demonstrated that substance use and addiction training can be threaded throughout health professions curricula rather than provided through “one-off” brief lectures or elective clinical experiences.6 Skills-based training with direct observation and feedback, clinical experiences in diverse treatment settings, and integrating the perspectives of individuals with lived experience are effective educational strategies that should be included. In graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) has added new requirements to provide training in the “recognition of the signs of addiction” across all specialties and clinical experiences in addiction medicine for internal medicine residency programs.7 However, the wide heterogeneity in substance use disorders curricula across graduate medical education training programs calls for implementation of core curricular elements, such as those recommended by SAMHSA, and support for trained faculty who can teach it and model competent care delivery.

While the MATE Act represents progress, it should be viewed as an initial stage towards the comprehensive integration of substance use and addiction training throughout health professions education. Checking a box will affirm completion of the new training requirement, but it should also represent an ongoing commitment. By recognizing that substance use and addiction education requires lifelong learning, internists and all health professionals can stay abreast of emerging trends, treatment approaches, and public health strategies. We must also prepare the entire healthcare team, and not just prescribers, to be equipped with the necessary knowledge and skills to effectively address the dynamic nature of the impacts of substance use and addiction. Only then will we make a lasting impact on one of the most pressing public health issues of our time.