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During the last few days of 2022, the Medication Access and Training Expansion (MATE) Act was included in the Omnibus Bill of 2023 (also known as §1262 of the Consolidated Appropriations Act, 2023), and it officially went into effect on June 27, 2023.1 This 4-year journey followed Massachusetts Congresswoman Lori Trahan's original introduction of the Bill in 2019, with the intention of standardizing substance use disorder training to "ensure that all prescribers of addictive medications possess baseline knowledge in evidence-based addiction prevention and treatments."2,3While the American Medical Association (AMA) circulated concerns that a decrease in licensed prescribers and increased barriers to care might result from the MATE Act, and about lack of evidence that a mandated one-time training would improve patient outcomes,4 the House of Representatives advanced bipartisan legislation projected to help address some of the causes and effects of the opioid addiction crisis, and thus the MATE Act was born.
When the Act became a law, all Drug Enforcement Administration (DEA) registered prescribers of Schedule II, III, IV, or V medications became required to complete a one-time, 8-hour educational program on managing and treating patients with opioid or other substance use disorders unless the practitioner was otherwise exempt as defined below.3 Meanwhile, a provision was made to standardize addiction medicine education throughout professional schools and phase out the requirement for future clinicians to take separate, federally mandated courses on the subject of addiction. With this provision, students in accredited dental schools, residency programs, medical schools, schools of advanced practice nursing, and physician assistant schools could fulfill the MATE training requirement through a comprehensive curriculum that meets the standards laid out in the statute and without additional education from an outside state licensing body or medical society required (Table 1).3,5 The MATE Act also authorized the federal government to appropriate grants to medical programs and schools to develop a comprehensive curriculum that would be used to train future clinicians on how to best identify and treat substance use disorders.
Practitioners who were already deemed to be qualified to provide evidence-based addiction prevention and treatments before the MATE Act went into effect and who are therefore exempt from the requirement include those who are board certified in addiction psychiatry or addiction medicine from the American Board of Addiction Medicine, the American Osteopathic Association, or the American Board of Medical Specialties.5 In addition, any prescriber who graduated in good standing from a dental, medical (osteopathic or allopathic), advanced practice nursing, or physician assistant school in the United States within 5 years of June 27, 2023, and who had successfully completed a comprehensive curriculum that met the standards laid out in the statute were also exempt from this new training requirement.
With the exception of veterinarians, all other eligible DEA-registered prescribers must satisfy this new training requirement prior to the date of their next scheduled DEA registration submission, regardless of whether it is an initial registration or a renewal registration (prescribers will be required to check a box on their online DEA registration form, attesting that they have completed the new training requirement).5 This one-time training requirement attestation will not be a part of future registration renewals. Dentists who are seeking information on accredited training opportunities can refer to the DEA website (www.deadiversion.usdoj.gov/pubs/docs/MATE_training.html) or other approved accredited professional organizations (Table 2).5 It is important to note that some dental and medical associations that were originally omitted from this list of approved accredited professional organizations, such as the American Academy of Family Physicians, the American Podiatric Medical Association, the American Optometric Association, the American Pharmacists Association, and the Academy of General Dentistry, are in the process of seeking legislative language to amend the MATE Act to be included.6
The Role of the MATE Act in Addressing an Unmet Need
While opioid prescribing, including the numbers of all prescriptions and high-dosage prescriptions, has been trending downward since 2012,7 high rates of opioid prescribing continue to be a significant public health concern and have been linked to the ongoing opioid abuse epidemic in the United States.8-11 In fact, according to the results of a recent survey, 34% of US adults reported misusing their prescribed opioid and 22% reported diverting their prescribed medication to others.12 In addition, the Centers for Disease Control and Prevention (CDC) reported that almost 85% of overdose deaths are caused by illicitly manufactured drugs, including the opioids heroin and fentanyl, among other illicit drugs.13Even more recently, the Stanford-Lancet Commission on the North American Opioid Crisis published that without urgent intervention, more than 1.2 million fatal opioid-related overdoses will occur in the United States during the next 10 years.14
Based on these findings, the passage of the MATE Act is an indication that lawmakers feel that they need to step in and help healthcare professionals in addressing the ongoing opioid epidemic to "ensure that all prescribers of addictive medications possess baseline knowledge in evidence-based addiction prevention and treatments." While the high rates of opioid prescribing are largely attributed to medical practitioners, regions of the nation with a higher number of dentists per capita are associated with increased opioid prescribing rates, as oral healthcare practitioners (OHCPs) are more likely to prescribe opioids than primary care physicians.15,16 Moreover, 2018 data suggested that the use of opioids following third molar extraction is associated with higher odds of persistent opioid use.17
The Importance of Dental Practitioners in Managing Opioid and Other Substance Use Disorders
Given the important role that dental practitioners play in the overall health of the population and in opioid prescribing rates, it is not surprising that dentists were included in the MATE Act. However, when the original Bill was introduced on March 18, 2021, to the House of Representatives, it excluded both veterinarians and dentists from the MATE training requirements.2 The Bill initially suggested that required training for prescribers on treating and managing patients with opioid and other substance use disorders (§303 of the Controlled Substances Act) be amended by adding, "with respect to any practitioner who is licensed under State law to prescribe controlled substances and is not a veterinarian or a dentist …." However, when the Bill was presented to the Senate on June 24, 2021, the applicability language was amended to read, "… with respect to any practitioner who is licensed under State law to prescribe controlled substances and is not a veterinarian …."18 The reason for this change is not publicly known, since minutes from committee meetings are not usually recorded, even though this Bill was reviewed by three different committees leading up to the Senate presentation (the Subcommittee on Health, the Committee on the Judiciary, and the Committee on Energy and Commerce).19 Regardless, the final verbiage to include dental practitioners was inserted in the Omnibus Bill of 2023 that became a law on December 29, 2022.1
DEA Registration
The ability to access and provide controlled substances for patients in the United States requires registration with the DEA through a new online process. For most dentists who are applying for a DEA license for the first time (form 224), the procedure is straightforward; this form is available at https://www.deadiversion.usdoj.gov/drugreg/. It should be noted that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.
Renewal applications (DEA form 224a) can be found at the same website address given above. If a renewal application is submitted in a timely manner prior to the expiration of the registration, the registrant may continue prescribing controlled substances, authorized by the registration, beyond the expiration date until final action is taken on the application by the DEA. The DEA allows the reinstatement of an expired registration for one calendar month after the expiration date. If the registration is not renewed within that calendar month, an application for a new DEA registration will be required. Regardless of whether a registration is reinstated within the calendar month after expiration, federal law prohibits the handling of controlled substances for any period of time under an expired registration.
Whether the registrant is applying for the first time or renewing his or her DEA license, the current 3-year fee is $888 USD. These fees were last increased in 2020 after 8 years without any fee increases.
The American Dental Association listed 202,536 professionally active dentists in the United States in 2022,20 and as of May 2023, the total number of professionally active physicians in the United States was 1,077,115.21Given the fact that DEA licensure must be renewed every 3 years, the MATE Act is requiring more than 1.2 million prescribers to complete the one-time, 8-hour educational training within this relatively narrow timeframe. While statistics related to the tracking of those who have successfully completed the training since June 27, 2023, are lacking, there will no doubt be a "rush to the finish line" for some prescribers, as not all are yet aware of this new requirement. The DEA is aware that prescribers and training providers may have difficulty complying with the new training requirement within the time that Congress has allowed. The agency is considering whether and how it can grant additional time within the scope of its statutory authority. Until a decision is announced, however, those subject to the requirement should be prepared to comply within the congressionally established timeline.
Additional Information on Fulfilling the MATE Training Requirement
Before prescribers register or take new courses, they should be aware that there is a grandfather clause in the MATE Act that notes that past trainings can be used to satisfy the training requirement. In other words, if prescribers completed a qualified training prior to the passage of the MATE Act on December 29, 2022, that training would count towards the 8-hour requirement.22 The DEA has confirmed that there is no statute of limitations for past coursework to qualify, and even a qualifying course (with a certificate of completion) taken 25 years ago would satisfy the requirement. It is important to remember that qualified coursework must satisfy the following three criteria22:
1. The course must be an approved topic and the subject matter broadly defined. It must cover some aspect of the safe pharmacologic management of dental pain and screening, brief intervention, and referral for appropriate treatment of patients with or at risk for developing opioid and/or other substance use disorders.
2. The course must be conducted through an approved medium, typically in the form of a classroom situation, seminar at a professional society meeting, electronic communications, or otherwise. The ADA is seeking clarification about whether reading a journal article for continuing education credit would count toward this requirement.
3. Finally, the course must be delivered by a designated training provider as described in Table 2.
It should also be noted that the training does not have to occur in one session; it can be cumulative across multiple sessions that equal 8 hours of training. Also, the same 8 hours of training can be recycled in situations where a prescriber holds multiple DEA registrations. Finally, this new federal requirement should be considered a floor, and not a ceiling. State Dental Boards may impose additional training requirements, and Section 1263 of the Act specifically states, "Nothing in this subsection shall be construed … to preempt any additional requirements by a State related to the dispensing of controlled substances under Schedule II, III, IV, or V."
The CDC Clinical Practice Guideline for Prescribing Opioids for Pain
The new MATE Act training requirements follow the release of the CDC Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022.23 Both the Act and the guideline are intended to improve the safety and effectiveness of pain management, decrease risks of morbidity and mortality from opioid use, and prevent substance misuse. The CDC guideline can be a clinical tool for primary care physicians and other clinicians such as OHCPs, who provide pain management for adult patients. The guideline offers treatment recommendations based on the duration of a patient's pain: less than 1 month (acute pain); 1 to 3 months (subacute pain); and more than 3 months (chronic pain). According to the CDC, this guideline is not intended to be a replacement for clinical judgment or individualized patient-focused care, nor should it be considered to represent inflexible standards of care for healthcare professionals or a substitute for the US Food and Drug Administration (FDA)-approved labeling.23 The updated guideline includes 12 recommendations for prescribing opioids for outpatients with pain, the first two of which focus on whether to initiate use of these drugs at all. Clinical takeaways for both the CDC Clinical Practice Guidelines and the MATE Act for treating acute dental pain were recently published in the peer-reviewed literature.24
Conclusion
The MATE Act was passed into law on December 29, 2022, and went into effect on June 27, 2023. It necessitates completion of a one-time, 8-hour educational requirement for all DEA-registered prescribers of Schedule II, III, IV, or V medications, including dentists. The coursework must be an approved topic, conducted through an approved medium, and delivered by a designated training provider. All eligible DEA-registered prescribers, with the exception of veterinarians, must satisfy this new training requirement prior to the date of their next scheduled DEA registration submission, regardless of whether it is an initial registration or a renewal of registration (prescribers will be required to check a box on their online DEA registration form, attesting that they have completed the new training requirement).
About the Authors
Mark Donaldson, BSP, ACPR, PharmD, FASHP, FACHE
Associate Principal
Vizient Pharmacy Advisory Solutions
Irving, Texas
Clinical Professor
School of Pharmacy
University of Montana
Missoula, Montana
Clinical Assistant Professor
School of Dentistry
Oregon Health & Sciences University
Portland, Oregon
Adjunct Professor
Faculty of Dentistry
University of British Columbia
Vancouver, British Columbia, Canada
Jason H. Goodchild, DMD
Vice President, Clinical Affairs
Premier Dental Products Company
Plymouth Meeting, Pennsylvania
Associate Clinical Professor
Department of Oral and Maxillofacial Surgery
Creighton University School of Dentistry
Omaha, Nebraska
Adjunct Assistant Professor
Division of Oral Diagnosis
Department of Diagnostic Sciences
Rutgers School of Dental Medicine
Newark, New Jersey
References
1. Consolidated Appropriations Act, 2023, HR 2617, 117th Congress, 2nd Sess (2022). Available at: https://www.congress.gov/117/bills/hr2617/BILLS-117hr2617enr.pdf. Accessed October 1, 2023.
2. MATE Act of 2021, HR 2067, 117th Congress, 1st Sess (2021). Available at: https://www.congress.gov/117/bills/hr2067/BILLS-117hr2067ih.pdf. Accessed October 1, 2023.
3. Press Release: Trahan's Bipartisan MATE Act Passes House, Moves to Senate. Available at: https://trahan.house.gov/news/documentsingle.aspx?DocumentID=2517#:~:text=First%20introduced%20by%20Trahan%20in,based%20addiction%20prevention%20and%20treatments. June 22, 2022. Accessed October 1, 2023.
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19. All Actions: H.R.2067 - MATE Act of 2021. 117th Congress (2021-2022). Available at: https://www.congress.gov/bill/117th-congress/house-bill/2067/all-actions?q=%7B%22search%22%3A%5B%22MATE+Act+2021%22%2C%22MATE%22%2C%22Act%22%2C%222021%22%5D%7D&s=1&r=1. Accessed October 1, 2023.
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24. Donaldson M, Goodchild JH. Know your MATE: Medication Access and Training Expansion Act. Gen Dent. 2023;71(5):7-10.