By Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
An interview with Adrienne Butterwick, MPH, CHES, Senior Improvement Advisor and Academic Detailing Project Manager, Comagine Health. Comagine Health is a national, nonprofit, health care consulting firm that works collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.
Tags: Detailing Visits, Evidence Based, Substance Use, Opioid Safety
Anna: Hi Adrienne! We recently saw you present on a panel where you spoke about your academic detailing project with dentists on opioid safety. Can you tell us a little more about how your team got started with this work?
Adrienne: In 2018, the CDC released funds to states through the Overdose Data to Action (OD2A) grant and the state of Utah selected academic detailing as one of the interventions they wanted to use. AD is one of the many different modalities that we use within my organization to reach clinicians to educate them and have an impact on the kind of care they provide.
The state began looking at specific regions and populations to target after we received the funding. Utah is unique in that it has a high number of adolescents undergoing surgery for wisdom teeth removal, which is one of the most common instances where controlled substances are prescribed.
A first prescription can be a huge turning point to potentially becoming addicted to a substance, especially at a young age. That’s when we decided to put together a team of two detailers to detail dentists. I was lucky enough to attend each detailing visit and collect data through pre- and post-surveys and answer any administrative questions that came up.
Anna: It’s impressive that your organization was able to look at the data in your state and build a program to fill a specific care need. What makes dentists and their environments unique when it comes to detailing?
Adrienne: There’s a theory that providers who are prescribing controlled substances are working within systems and teams that are well-poised to understand the challenges of opioid prescribing.
Dentists fall into a different healthcare model that’s often siloed; they aren’t usually affiliated with an overarching health system or university like many primary care providers are. This results in isolation, making the interactive, 1:1 outreach model of detailing even more important – we knew we needed to bring the information and support directly to them in their dental offices.
Anna: Detailing seems like a critical need for isolated dentists, both in providing them with customized education, but also in building connections. Were there any special considerations that your team took into account as you worked with the dentists?
Adrienne: The language that’s used in the dental world is very different than language that’s used in primary care. We were fortunate enough to have a dental provider, who’s a champion of AD, work with us as a detailer on our project. He knew the language, understood the workflow, and could speak to the need for safe opioid prescribing.
He always started his detailing sessions with a personal story like, “When I took wisdom teeth out, I would always prescribe 40 Percocet pills. All I can think of today is, ‘what have I done?’” You could see the mood shift the moment he started talking about his personal experiences, allowing for a connection between himself and the dentists he met. The success of this program wouldn’t have gone even half as far without his support.
Anna: A detailer who can build empathy with clinicians and who has personal experience with a challenging topic is an important asset to have in a detailing program. What obstacles did you face as your team implemented this project?
Adrienne: Connecting with dental offices, in general, was tough. We first started by working with dental associations to get relationships in place. We submitted newsletter articles, attended meetings, presented at the regional conference, and sent our program’s information via their listservs.
We also Googled practices and found ones that had more than one dentist working in the office at a time. We’d cold call those offices and say, “It looks like you have a big operation – is there a way we could bring training in for your team for continuing education credits?”
Before leaving the visits, we’d ask the dentists for referrals to other clinicians and leave flyers behind. Relationships grew organically over time.
Anna: It sounds like the project began to build on itself fairly quickly. Did your team experience any barriers from the dentists during the detailing visits?
Adrienne: We had a lot of dentists who thought the opioid crisis wasn’t relevant to their practice and we knew that we had to find ways to tie it into their profession. Fortunately, dentists have historically been involved in public health movements because they hold a different type of relationship with patients that is closer than a typical relationship with a primary care provider. They see patients more frequently and can detect small changes in health quickly.
The dental profession was incredibly important in the tobacco cessation movement in the 1990s. They were instrumental in getting individuals to reduce or completely stop using tobacco. Dentists are also starting to be trained in domestic violence and human trafficking.
For the dentists who were hesitant about the relevance of our detailing visits, we would say, “You have this amazing relationship with patients that we don’t see in other parts of healthcare—here’s how you can make a huge difference!” or “I can understand how there would be a lot of fear to step out of your comfort zone; we have a lot of resources and materials to support you.”
Anna: Dentists truly have a unique relationship with patients that can be used to promote countless public health initiatives. Can you think of a time your team was able to empower a dentist to change behavior and encourage them to see their relevance in combatting the opioid crisis?
Adrienne: There was a dental group in a rural part of the state that had one dentist and a big support staff. We came in for a detailing visit and had a conversation with the entire office.
After the meeting, one of the dental assistants pulled me aside and told me that a patient who had recently completed substance use rehab had visited the office in need of a procedure that would warrant prescribing an opioid. No one in the office knew what to do for pain control and they were all unsure how to approach the patient given his history. She said that because we came, she felt like she now knew how to have a conversation with him about the procedure and his safer, alternative options for pain management.
The dentist also shared that prior to our visit, he often didn’t know how to handle conversations about pain management and opioids and wasn’t sure if it was his job to do so. After our visit, he said he felt comfortable and confident doing this, and shared an anecdote of being able to create a safe space for an ongoing conversation with a recent patient.
Anna: It seems like your team has had such an impact by using one of the core elements of detailing – building relationships through empathy, validation, and support. Can you share some encouragement for readers who are considering having these conversations with dentists?
Adrienne: Be flexible and don’t come in with your own agenda – be sure to let the dentists drive the conversation and let them teach you along the way. It can be a rewarding yet challenging experience – don’t forget to celebrate the small wins on your journey!
Anna: Thanks for sharing this innovative approach to detailing, Adrienne! We’re looking forward to hearing about your continued impact with the dental community and beyond.
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Biography. Ms. Butterwick is a Senior Improvement Advisor at Comagine Health. She is currently working on quality improvement efforts directed by the Centers for Medicare & Medicaid Services (CMS) to improve quality of care for residents living in post-acute and long term care as well as assisted living and home health. She's also working on an initiative to increase advance care practices in those settings.
In addition, through a subcontract with the Utah Department of Health, Ms. Butterwick currently provides educational support for opioid prescribing to family medicine and dental providers. Her work with this contract has earned national recognition and has been presented at the RX Drug and Heroin Abuse Summit in April 2020 and the American Public Health Association’s annual conference in October 2020. She is currently also collaborating with faculty from the University of Utah regarding telehealth and advance care planning initiatives through the Utah Geriatric Education Consortium and Geriatric Workforce Enhancement Programs.
She completed her Bachelors of Science degree in Behavioral Science and Health at the University of Utah in 2007 and her Master's in Public Health at Westminster College in 2014. She has also earned recognition as a Certified Healthcare Education Specialist (CHES).
In her 15 years of public health project management she has also worked in rural health research, provider education programs and care management. She has a strong passion for quality improvement and public health.
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