The opioid crisis has been recognized as a major national public health problem, but it actually reflects a collection of many thousands of local crises playing out in individual cities and counties. Each region faces a distinctive set of challenges, driven by economic and social factors, local medical practice patterns, political environment and pressures, and many other considerations.

​Identifying and implementing effective solutions to address the opioid crisis requires developing an understanding of how these individual challenges interact, and what strategies are most effective in specific situations--one of which is academic detailing.

The NaRCAD team is partnering with the CDC (Centers for Disease Control and Prevention) and NACCHO (the National Association of City and County Health Officials) on an exciting pilot program working with local health officials to develop customized interventions to reduce opioid overdose and death. Four sites experiencing significant public health problems related to opioids were selected: Boone County, Kentucky; Bell County, West Virginia; Manchester, New Hampshire; and Dayton, Ohio.

Public health officials at each site identified a wide range of local stakeholders to participate in developing a community action plan and recruited trainees to complete NaRCAD’s academic detailing training course, which we customized to address the unique challenges that each community faces. ​ We also developed a specialized online toolkit for these sites, including discussion boards, local resources, and printable resources.

We traveled to each site in March and April of this year, facilitating hands-on trainings in the techniques of academic detailing in alignment with the CDC prescribing guidelines. Trainees came from diverse backgrounds, including pharmacists, nurses, public health officials, and students in the health professions, including pharmacy students, dental students, and medical school students.

​Plans for implementing AD varied by site depending on the local health care environment; some sites focused more heavily on appropriate prescribing of opioids by clinicians, while others prioritized increasing referral rates for patients with opioid use disorder (OUD), including access to medication-assisted treatment (MAT). 

As the AD trainees at each pilot site continue their work in the field, we’ll learn more about how these diverse strategies succeed, and how we can support adaptations to make academic detailing more impactful. This important collaboration has allowed us to form invaluable partnerships with CDC and NACCHO, leveraging national resources to improve local responses to this epidemic through plans that respond more precisely to local needs and priorities.

We’re excited for this pilot program to serve as a model for future opioid safety AD interventions, and we’ll be providing updates here on the blog. ​In the meantime, tell us: what's happening in your local community around the opioid crisis? Sound off in the comments section below, and let us know if you think clinician-facing education could be a strategy that would improve outcomes for your community. And join us for our next training and our terrific annual conference to learn more about this and other exciting AD  projects.

-Mike

Biography.
Michael Fischer, MD, MS | Director of NaRCAD
Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.

Jerry Avorn, MD, Co-Director, NaRCAD
​
​Of all the medication use issues facing the U.S., the most pressing is of course that of opioid mis-prescribing.  When the anatomy of that mis-use is dissected, it becomes clear that the principles and methods of academic detailing are especially well suited to addressing this crisis, for several reasons. 

First is the problem of information deficit:  before the mid- to late-1990s, practical issues of the assessment and management of pain were often poorly covered (or not at all) in most medical school or residency training programs – so there’s a lot of good that can be accomplished by simple personalized knowledge transfer, to start with.

​Second is dealing with the contamination of dis-information: the growing documentation of the fact that sales reps for OxyContin, for example, actually under-stated the drug’s risks and over-stated its potential indications when describing their product to prescribers – distortions for which the company had to pay $600 million in penalties.

Third is the fact that for this therapeutic category more than for most others, a prescriber’s attitudes and motivations play an especially important role.
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These can involve “non-scientific” issues such as:

• “This patient is hurting and I want to help them but am not sure how, so I’ll give them the strongest thing I can think of.”​
• “The patient is demanding narcotics and I don’t know if I’m being scammed or not.”
• “I keep getting memos from bureaucrats and managers telling me I’m using too much opioid, but these people don’t have a clue what it’s like trying to do my job.”
• “I can’t manage this patient’s diabetes, angina, hypertension, memory loss, and depression in my too-short visit – how am I supposed to deal with their pain and all these new opioid constraints at the same time?”

​​… and dozens of other issues.

There is ample evidence that simple “gotcha” letters accusing a prescriber of opioid over-use have no effect. Similarly, draconian restrictions imposed by governments or health care systems limiting the amount of opioid that can be prescribed to a given patient clearly run the risk of under-treating genuine pain – a grotesque example of health care rules that seem guaranteed to increase patients’ suffering.

​Evidence-based guidelines, such as those promulgated by the CDC, are fine as far as they go, but most doctors haven’t read them, and even fewer have integrated them into their practices. 

But a well-trained, skilled academic detailer can interact with a prescriber to understand just what issues lie behind the apparent misuse of opioids by that physician, and present a set of interactive messages tailored to those particular needs.

​This will involve constructing a personalized blend of new knowledge transfer, dis-information detoxification, practice facilitation (including help accessing Prescription Drug Monitoring Program data less burdensomely), accessing local resources for help in patients with opioid use disorder, and assistance with patient education. 

A similar approach could also be enormously helpful for encouraging naloxone prescribing and improving the care of patients with opioid use disorder, including medication-assisted treatment, where information deficits and attitudinal issues are even more prominent.
 
Together, this kind of individualized outreach education can accomplish far more than mailed guidelines, accusatory nastygrams, or legal restrictions – and in doing so, do more to improve patient care and reduce preventable misery than can be expected from more old-fashioned interventions.

We've been staying busy here at NaRCAD this spring! With public health challenges like the opioid crisis, and the continued need for HIV prevention, the team here at NaRCAD has been on the road for 5 trainings in 6 weeks, and we're not stopping yet!

On February 14th - 16th, 2018, NaRCAD joined the amazing teams at San Francisco Department of Public Health and the New York City Department of Health and Mental Hygiene for an exciting initiative: A Public Health Detailing Institute on HIV PrEP and RAPID.

​Hosted in San Francisco's South Market neighborhood, 31 trainees attended, representing diverse public health departments from Texas, Connecticut, Alaska, Louisiana, Florida, Tennessee, Los Angeles, San Francisco, Mississippi, Michigan, Oregon, Nevada, Virginia, and beyond. These trainees joined the institute for a customized, 3-day event focusing on learning the techniques of academic detailing, along with showcasing best practices and success stories via special presentations and expert panels.

Trainees at each site of these pilot sites work with us across two days to learn the structure of an academic detailing visit, practice role playing 1:1 visits with clinicians, and become experts at using educational materials (including a suite of materials constructed by the CDC based on their 2016 Opioid Prescribing Guidelines).

​Our pilot site trainees walk away from our trainings ready to actively engage with clinicians to assess individual needs and provide customized support, and encourage behavior change for the opioid crisis in their respective communities. 

NaRCAD's team will continue to focus on launching new academic detailing interventions across the U.S. well into 2018, with upcoming opioid-specific trainings being carried out in late May in Albuquerque, New Mexico, with the University of New Mexico's Health Sciences Center, and in late June in Lansing, Michigan, with the Michigan Public Health Institute.

Our next all-topic, AD techniques training in Boston will kick off at the end of this month, where we'll train 24 health professionals from across the U.S.--we'll report back after that training and share lessons learned, highlights, slide decks, and clinical topics from represented programs, and we look forward  to sharing those with our community.

Join our subscription list to receive alerts for upcoming training opportunities. Want to customize a clinical topic-specific training for 15 trainees or more, on site in your community? Reach out to us to schedule a training consultation call at narcad@partners.org.

We can't wait to work with you!
-The NaRCAD Team

Mike Fischer, MD, MS, NaRCAD Director
​Fall is the season for conferences, and the most exciting one for us is #NaRCAD2017: Combatting Threats to Optimal Care! 

This year’s conference is a great chance for everyone interested in AD to learn more, whether you’re part of a long-standing program or just beginning to learn about the versatility and effectiveness of implementing this strategy to improve health outcomes. Our agenda is up, so take a peek, and register if you haven’t yet!

The keynote presentations will provide critical insights for creating and sustaining AD programs in different settings. Dr. Zoe Edelstein will kick off Day 1’s programming, representing the New York Department of Health and Mental Hygiene. This keynote will teach us about their public health detailing intervention to increase use of HIV pre-exposure prophylaxis (PrEP).  The New York program was originally founded in 2002, so Dr. Edelstein’s presentation will help anyone from a public health background understand how to both develop and sustain AD, and to adapt it for new and pressing health challenges. ​

Dr. Carol Havens from Kaiser Permanente will provide a detailed overview of the longest-running AD program in the US, a program that was developed with input from Jerry Avorn soon after the original AD studies were published.
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​We look forward to being inspired by lessons learned from a leading integrated health care system’s ongoing commitment to improving the quality of care around opioid safety with clinical outreach education.

The rest of our conference agenda draws almost entirely from proposals submitted by members of our NaRCAD network – we received twice as many proposals this year!

We’re looking forward to our “Field Presentations” sessions, featuring empiric results from detailers on the ground; expert panelists from the CDC, state departments of public health, and clinical care sharing important impressions on clinician stigma on the critical issues of HIV prevention and opioid safety; and breakout sessions covering many of the practical issues and challenges that detailers face when bringing best evidence to clinicians. Of course, for many of us, the highlight of each conference is the annual update from Jerry Avorn on the state of AD--see his recent blog piece, “Who Do You Trust?” for a preview of what’s to come!

The NaRCAD team is excited by the knowledge that integral opportunities, connections, and partnerships will be created at our unique 2-day event.​ But as excited as our team and our extended community may be about the conference, it’s not the only terrific development underway at NaRCAD this fall. We’ve continued to provide training and support for groups from around the country and the globe, with 2 trainings in the techniques of AD this past September, and more planned this fall and winter! ​Keep your eyes on our Training Series page for the official announcement of our Spring 2018 AD techniques training, and contact us at any time about opportunities and resources to support your AD program.

See you soon,
-Mike

In 2015, the Department of Veterans Affairs (VA) invested in the National Academic Detailing Service to improve the health of our Veterans to address the call to action for the opioid crisis. Through the Opioid Overdose Education and Naloxone Distribution (OEND) Program, our goals were to reduce harm and risk of life-threatening opioid-related overdose and deaths among Veterans.

Key components of the OEND program include raising awareness about the epidemic, 1:1 academic detailing visits with clinicians to provide education and training regarding opioid overdose prevention, opioid overdose rescue response, and issuing naloxone products. We developed direct-to-consumer marketing and other e-resources, including a video, Introduction to Naloxone for People Taking Prescribed Opioids.

We also created implementation tools, including population management dashboards to aid staff in evaluating risk factors of their patient population and distributing naloxone accordingly. Academic Detailers demonstrated to VA providers these resources to help raise awareness of opioid overdose risk for their patient panel.  

Decision-makers believed that funding this program would yield a good return on investment. As part of the National Academic Detailing Service, it’s our responsibility to collect data and supply decision-makers with evidence on the value and success of our program. In other words, we’re accountable for answering the question, “Is academic detailing worth it?” 

To answer this question, we performed several program evaluations of the National Academic Detailing Service from 2015 to 2017, one of which we just published in the Journal of American Pharmacists Association (JAPhA) (Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.) 
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The evaluation found that our program improved naloxone distribution rates at a seven times greater increase for Veterans at risk for opioid overdose. These results provided key empirical evidence that VA’s strategy of academic detailing was working. Just as important, these findings also gave decision-makers what they needed—proof that their investment in an area of high risk to Veterans’ health paid off by improving care.

​Sharing program results with the clinicians in this intervention also encouraged these providers to share their own results, many of which were stories of patients returning to the clinic to relate their experiences of using naloxone to reverse an overdose. These stories, along with reversal reports from the field that tracked the outcomes of naloxone kit distribution and subsequent use, also created a tangible “return on investment” for everyone involved.

We encourage other academic detailing programs to prioritize program evaluation as we have at the VHA—no matter the size of your program, if you’re thinking, “we can’t afford to do program evaluations,“ we stress that you can’t afford not to do them.

Measuring program work builds a case not just for the success of one academic detailing intervention, but for the success of future programs—a case for sustainability. Evaluation measures the quality of a program, analyzing results to look at a program’s impact, and allowing for process improvement adjustments to be made to streamline efforts and strengthen that impact. Evaluation cannot be optional, especially when lives are at stake.

​We also recommend that the results from program evaluations are shared with other stakeholders, such as clinicians, in order to encourage and sustain their behavior changes. Leveraging results from well-designed evaluation is essential for academic detailing interventions to illustrate success, share value, and provide stakeholders and community members with a clear “Yes!” in answer to their overarching question: “Was the investment worth it?”

Director’s Letter: Fall 2016 | Mike Fischer, MD, MS, Director of NaRCAD

When the leaves start to turn here in Boston, we know it’s almost time for NaRCAD’s International Conference on Academic Detailing. This year’s 4th annual conference features several new and exciting sessions we’re excited to share with our community.

​#NaRCAD2016 highlights the work of innovators in academic detailing from many locations and organizations, ranging from large national health systems to small independent programs. 

​Diverse clinical topics will be featured at our interactive sessions, including pediatric developmental screening, smoking cessation in patients with serious mental illness, opioid misuse and overuse, screening for ADHD, and many others.

​Breakout sessions offer attendees a chance to work closely with leaders in the field, featuring in-depth and hands-on exploration of specific elements of academic detailing. Whether your focus is on training detailers, preparing clinical topic materials, or program evaluation, our dynamic breakout sessions offer a chance to network and acquire new skills.

Our conference is our largest event of the year, but our team has been busy this fall with other activities. At our Boston-based training in September we welcomed trainees from organizations across the country, all of whom concentrated on learning the techniques of academic detailing.

We also spent two days this fall in San Francisco, working with the city’s Department of Public Health on an intervention to increase the use of pre-exposure prophylaxis (PrEP) for patients at risk of contracting HIV. We’re excited to continue supporting our partners at the SFDPH as they move forward on this important initiative.

​Come join us at #NaRCAD2016! There’s only a month left to register, and space is limited. Check out our conference hub archival page to see what previous events were like, including on-demand video and program highlights. We’re excited that clinical outreach education has been such an effective strategy to address the pressing problems facing patients, clinicians, and health systems.

This year, we know that the opportunity to learn, share ideas, and connect with experts will continue to ignite inspiration for our community’s important work in improving quality of care and patient outcomes in 2017 and beyond.

Director's Letter | Mike Fischer, MD, MS
NaRCAD has jumped right into action in 2016! We’ve been getting out of Boston, working with colleagues across the country in a range of settings. As we’ve partnered with state and local public health agencies, long-term care providers, primary-care networks, and other organizations, we’ve seen how the principles of AD can be adapted to fit the needs of different clinicians and patients. The work of our colleagues teaches us how we can best support clinical outreach education, raise its visibility, and improve health outcomes together.

At NaRCAD, we’re always expanding the range of services we provide, including our core training series on the techniques of AD, specialized workshops and seminars, and consultation on materials development for AD interventions. Let us know what we can do to strengthen your program and highlight your program successes this year.

Kicking Day 1 off and setting the tone for the entire event, NaRCAD Director Dr. Mike Fischer warmly welcomed our packed room at Harvard Medical School’s Martin Center by encouraging collaboration, connection, and sharing. Our Day 1 Keynote Speaker Dr. Carolyn Clancy, the CMO of the Veteran’s Health Administration, described the VHA’s work to improve pain management in the veteran population while addressing the challenges of medication abuse and overdose. Dr. Clancy shared strategy and data behind the national effort and the critical role of academic detailing in it, connecting attendees to a big-picture view that can be adopted to look at other health epidemics and interventions.

Our first expert panel presented Practice Facilitation in Primary Care. Andy Ellner moderated the session, leading panelists Ann Lefebvre of North Carolina's AHEC Program, Lyndee Knox of LA Net, and Allyson Gottsman of HealthTeamWorks to discuss strategies, contextualize their work in relation to academic detailing and quality improvement, and share their personal approaches to challenges in primary care behavior change.  Allyson Gottsman’s much-appreciated analogy that practice facilitation is not unlike “leading a fisherman to a well-stocked pond” resonated with panelists and participants alike. Many attendees who were actively engaged in practice facilitation in their daily work shared that the panel helped them to think about their work in a new way.

The afternoon’s breakout sessions offered attendees multiple tracks with AD-related topics to explore: deconstructing and analyzing a 1:1 AD visit, exploring the skills needed to manage an effective AD program, and strategizing on ways to identify and harness stakeholder support when initiating a new program or strengthening an existing one.

The afternoon closed with two presentations; the first, by Terryn Naumann of the Canadian Academic Detailing Collaboration (CADC), offered participants a view of the power of synergy and teamwork, the historical context of the CADC’s creation and growth, and the future of the collaboration.

More examples of successful practice change were illustrated by the morning’s Themed Plenary on the Intersection of Public Health and AD. Dr. Phillip Coffin of the San Francisco Department of Public Health shared the success of an intervention focusing on co-prescribing of naloxone to reverse opioid overdose deaths in San Francisco. Another successful AD intervention was presented by Michael Kharfen of the Washington D.C. Department of Health, who highlighted the successful implementation of AD programs to increase HIV and Hepatitis C screening and treatment.

The afternoon featured our second Expert Panel, this time on the role of AD within integrated healthcare systems. Moderated by Dr. Mike Fischer of NaRCAD, panelists Joy Leotsakos of Atrius Health (MA), Sameer Awsare of Kaiser Permanente Medical Group (CA), and Valerie Royal of Greenville Health System (SC) shared their experiences using AD in systems at different stages of development. Attendees had the opportunity to discuss this topic further in the afternoon’s breakout sessions, which also included a session on practice facilitation, as well as third session to continue to explore AD and public health partnerships.

The conference’s closing discussion was led by Mike Fischer, who thanked not only the speakers, panelists, and session leaders, but the participants, whose willingness to share their experiences within an interactive setting was key in creating solutions to bring back to use in their daily work. The creative collaborations, exchange of resources, excitement in combating challenges in the field, and belief in the importance of AD for the future of healthcare transformation were felt by all at the closing of a very full and thought-provoking event.

Our Twitter feed tracks the event’s highlights through #NaRCAD2015, and you can catch our event photo album on our Facebook page. We invite you to explore these topics, learn about our speakers and attendees, and connect with us at the NaRCAD Conference Hub, where you can access on-demand video of all main sessions from the conference. Thank you again to all who attended, and to AHRQ for funding our series. Please stay in touch with us and each other, and continue the conversation and idea sharing below. ​
​We hope to see you in 2016!

Bevin K. Shagoury, Communications & Education Director
Our most recent 2-day Academic Detailing Techniques Training was held here in Boston on May 4th and 5th, 2015, and it was a successful and exciting convening of 18 trainees from all over the country.  Clinical pharmacists, nurses, and program specialists gathered in Boston’s downtown to learn and practice social marketing techniques to use when educating front line clinicians about new evidence and important interventions.

Our trainees will take these valuable skills back to a wide range of programs, with goals including improving health for veterans with PTSD, increasing referrals to smoking cessation programs, and strengthening chronic disease lifestyle management programs.

Many of us have attended trainings and conferences heavy on Powerpoint presentations and light on practicing tangible skills. At NaRCAD, we use a dynamic curriculum wherein we integrate role-play, interactive large and small-group discussion, live demonstrations of a successful academic detailing visit, reflection through videography, ongoing networking, and the chance to learn from experts, clinicians, and colleagues through practice and skills sharing.

After their training sessions are done, trainees move forward to establish new academic detailing programs, strengthen and develop existing ones, or use our techniques in other clinical education settings. And as their work continues, so does ours—we maintain contact with our trainees, providing critical resources and featuring their work on our website and DETAILS blog. This fall, we’ll be featuring partner profiles of many of our trainees’ academic detailing programs, so that our community can learn about the critical role these programs play in improving health outcomes.

Join us at our next training this September—a program one recent trainee describes as “an excellent program, with fabulous faculty, and a well-run, valuable service to the healthcare community.”  We keep improving our curriculum to ensure that each of our trainees gets personalized support to make their work easier. Their appreciation and feedback helps us to refine our training, encouraging us to think about ways we can continue to provide the best resources available.  As the field continues to grow, so do we—and our trainees tell us that we’re making an impact by leveraging their work, sharing best practices, and running “the best training I’ve ever been to—seriously!”

by Bevin K. Shagoury, Communications & Education Director
NaRCAD spent January 12th and 13th, 2015 with the enthusiastic and talented public health professionals of the San Francisco Department of Public Health(SFDPH), teaching them the principles and practice of AD.  As with our prior trainings, the main goal was to ensure that trainees can understand and effectively practice AD techniques. This collaboration with SFDPH served as our first “on the road” training, providing an opportunity for our staff and facilitators to look closely at how to customize AD training to meet the needs of public health workers.

The SFDPH participants are developing and implementing programs to address needs in several important areas, including immunization programs, viral hepatitis outreach, HIV screening, reducing the risk of opioid overdose, and perinatal care. Like many of our prior trainees, this group was eager to learn about how to adapt the innovative, service-delivery model of AD to improve health outcomes by communicating effectively with front-line clinicians.

Throughout the training, SFDPH trainees and NaRCAD staff joined in brainstorming ways to implement novel strategies and techniques in their respective clinical areas to strengthen program successes, expand impact, and achieve long-term practice changes in San Francisco.

With academic detailing in their arsenal of intervention tools to change clinician behavior for the better, we look forward to seeing the ways in which our partners at SFDPH will improve health outcomes for the people of San Francisco.

by Arielle Mather, MPH, Education & Training Manager
On November 13th and 14th, 2014 NaRCAD hosted the Second International Conference on Academic Detailing. The focus of this year’s conference was on educational outreach in an era of rapid health care reform, with perspectives from prominent figures in government, research, and business. The conference explored a pressing clinical theme on each day, including presentations of academic detailing programs currently addressing these topics in the field.

After Dr. Jerry Avorn, NaRCAD’s co-director, opened the conference with a review of the past, present, and future of academic detailing, Dr. Joshua Sharfstein, Maryland Secretary of the Department of Health and Mental Hygiene, discussed the challenges of improving health care and outcomes for the residents of his state. Jean Slutsky, Chief Engagement and Dissemination Officer of the Patient-Centered Outcomes Research Institute (PCORI) reviewed the key principles for effectively communicating research results that improve patient health outcomes.

The clinical theme for Day 1 was prescription opioid use and overuse. Dr. Harry Chen, Vermont Secretary of the Agency of Human Services set the stage by reviewing the origins of current problems with opioid use and sharing details of his state’s initiatives for prescribing pain medication. This talk was followed by an interactive panel session that highlighted two academic detailing programs (in South Carolina and New Mexico) seeking to reduce opioid overuse and abuse. Small group breakout sessions allowed for more detailed conversation about these programs and other specific topics.

Day 2 of the conference began with an overview of the business case for evidence based practice, presented by Dr. Troyen Brennan, Chief Medical Officer of CVS Health. Daniel Wolfson of the American Board of Internal Medicine Foundation, followed with a presentation on the Choosing Wisely campaign, which is designed to engage clinicians in the critical questions of how to make healthcare safer and more efficient. Dr. Alice Bonner of Northeastern University began the conversation of the day 2 clinical theme: antipsychotic medication use in long term care. After Dr. Bonner’s introduction, two ongoing academic detailing programs (in Massachusetts and Saskatchewan, Canada) aimed at addressing this problem shared their insights.

The challenge of sustaining academic detailing programs was addressed by Frank May, who has successfully implemented programs in multiple settings internationally. Dr. Madeleine Biondolillo, Associate Commissioner at the Massachusetts Department of Public Health, made the final presentation, reviewing how academic detailing fits in with the other approaches that the state uses to improve health. In addition to the formal sessions, conference attendees from 15 US states, Canada, Europe, and Australia had a chance to interact informally, share ideas about academic detailing, and develop connections that will help support increased collaboration in the future.

The third installment of this AHRQ funded conference series will be held next year in November 2015. Finalized dates and registration information will be announced in the coming months. If you would like specific slide sets from any of the conference presentations, please email us.