By Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
An interview with Shuchin Shukla, MD, MPH, Faculty Physician, Mountain Area Health Education Center (MAHEC), NaRCAD Training Facilitator
Tags: Harm Reduction, Detailing Visits, Evidence-Based Medicine, Opioid Safety
Anna: Welcome to the DETAILS blog, Shuchin! You wear many hats - you’re an addiction medicine physician, an academic detailer, and an academic detailing trainer. Tell us how you got started with academic detailing.
Shuchin: I had an interest in marginalized populations and did my residency in the Bronx in New York City. I was a clinician in HIV care for several years before moving with my family to Western North Carolina. Soon after we moved, I began working at our Area Health Education Center (AHEC) and it was evident that addiction was the primary public health and clinical issue that was causing the most harm in my community.
Fast forward a few years and one of my colleagues received a Centers for Disease Control and Prevention (CDC) grant and asked if I could attend a NaRCAD training to learn more about AD. The medical board and one of our pharmacists at the Department of Public Health were very interested in using AD for overdose prevention. We started with a pilot where we detailed 10 clinicians and slowly built our program. We now have multiple AD grants we’re working on, including one on adverse childhood experiences (ACEs) and one on harm reduction.
Anna: We often tell programs to start with a small pilot before growing their programs so that they can identify what went well and where there are opportunities for improvement, especially on new detailing topics like ACEs (e.g., key message adoption, clinician response, etc.). You do a lot of education around substance use disorder and mentioned that your team received a harm reduction grant for AD – what does harm reduction mean to you?
Shuchin: The goal is, simply enough, to reduce the level of harm that a person may be facing. Harm reduction means having no expectation of a person's behavior and accepting the reality of what people live and do without judgement. It’s about being open with patients so that they’re more likely to come back for a visit where you can continue to have a conversation with them about getting a little bit healthier.
There’s evidence to support harm reduction. The research shows that providing harm reduction services, whether it's naloxone or syringe exchange, reduces harm, but also decreases substance use and helps people engage in substance use care and treatment.
Anna: Do you see harm reduction being used with other topics beyond substance use disorder?
Shuchin: There are tons of examples of harm reduction that are built into everything we do. Seatbelts, masks, fire escapes, smoke detectors, vaccines, and the FDA regulatory agency are all forms of harm reduction. As a society, we’ve never looked at substance use through this lens because using drugs is so stigmatized.
Anna: I imagine it’s difficult to have detailing visits with clinicians because of the type of stigma associated with it, such as thinking that it’s some sort of moral failing. How have clinicians responded to detailing visits on harm reduction?
Shuchin: Most of the teaching about harm reduction is unlearning all the inaccurate information we've been taught. We're taught if you use drugs, you're a bad person and you should be penalized. I remember watching the show Cops growing up and there was always a person of color laid out on a car resisting arrest. Law enforcement would pull out a bag of cocaine from the car and say they’ve saved the community.
None of this is right, but I saw that on TV as a middle school kid. It’s easy to generate a lot of negative energy about substance use disorder and substances in general from these shows, and clinicians are part of that thinking too.
Asking clinicians to talk to their patients about harm reduction is a lot different than asking them to check their Prescription Drug Monitoring Programs (PDMPs) to ensure that patients aren’t receiving multiple prescriptions for controlled substances. Having a conversation with a patient takes empathy and thoughtfulness, whereas checking a PDMP does not. We’ve found that clinicians who have been the most resistant to harm reduction are those who have family members with substance use disorders. They are often angry, and rightfully so.
Anna: It’s imperative to be empathetic during detailing visits, especially on a topic that affects so many people. Let’s explore harm reduction from a different angle. How do your patients respond when you bring up harm reduction during your clinic visits?
Shuchin: These are certainly challenging conversations to have, so you need to start off by letting patients know that they aren’t going to get in trouble for sharing this information and you need to acknowledge the trauma and stigma that surrounds substance use.
Patients seem grateful that I approach conversations in a straightforward way that doesn’t stigmatize their use of drugs. I’ve never had a patient be offended or confused about why I was talking to them about harm reduction. Their eyes usually widen when I ask them things like how they use their drugs, how they cook their drugs, or where they get their drugs from. They often say, “I’ve never had a doctor like you.”
Anna: You must spend a lot of time building trusting relationships with patients so that you can have these conversations.
Shuchin: I do. It also helps that the organization I work for, our county commissioners, and our sheriff are all on board with harm reduction. There’s a lot of focus on Naloxone distribution among members of our community, such as law enforcement, first responders, and other clinicians.
Our clinic prescribes a lot of medications for opioid use disorder, specifically buprenorphine, which is also a form of harm reduction. We have peer support specialists who meet patients where they’re at and start the conversation about harm reduction with them before they even have their first visit with me.
Anna: It’s definitely critical to have a community that supports the way you practice, as well your program’s AD messaging. Can you share a final tip for other detailers who are working on harm reduction?
Shuchin: Harm reduction is an emotional topic for a lot of people, especially folks who are in frequent contact with people who use drugs, like emergency room clinicians or people with lived experience in their families.
With this topic, paying attention to the emotions of the clinician you're detailing and acknowledging those emotions before jumping into your key messages is much more important than any other topic I’ve worked on. Be patient and empathetic – every visit counts toward making a change.
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Biography. Shuchin Shukla, MD, MPH, was born and raised in New Orleans, Louisiana. He completed medical school and public health school at Tulane University and completed a residency in family medicine at Montefiore Medical Center in the Bronx, New York. He worked in the South Bronx for 5 years following residency, providing primary care for adults and children, as well as for adults living with HIV. He also served as medical director for Montefiore Project INSPIRE, a primary care-based Hepatitis C treatment program. He then moved with his family to Asheville, North Carolina, where he currently serves at Mountain Area Health Education Center (MAHEC) as faculty physician and Clinical Director of Health Integration.
He is an associate clinical professor of medicine in the Department of Family Medicine at the School of Medicine, University of North Carolina in Chapel Hill, and is a Diplomate of the American Board of Preventive Medicine, Board-Certified in Addiction Medicine. Additionally, he is a Robert Wood Johnson Clinical Scholar. He leads on various initiatives and projects around addiction, HIV, Hepatitis C, homelessness, and the criminal justice system. His main experience as a detailer has been focused on improving evidence-based provider interventions related to opioids, pain, and addiction.
By Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
Tags: Primary Care, Opioid Safety, Evidence Based Medicine, Harm Reduction
Our team at NaRCAD has been working on an exciting new project developing harm reduction key messages for primary care clinicians in collaboration with the National Association of County and City Health Officials (NACCHO), Centers for Disease Control and Prevention (CDC), and consultants from Boston Medical Center.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines harm reduction as an approach that aims to prevent overdose and infectious disease transmission, improve physical and mental health, and offer options for accessing treatment and other health care services for people who use drugs. Various harm reduction approaches have been proven to prevent overdose and death, injury, infectious disease transmission, and substance misuse. For instance, there is nearly 30 years of research that has shown that syringe services programs decrease transmission of viral hepatitis, HIV, and other infections.
There are several other harm reduction approaches beyond syringe service programs, including:
It’s critical that academic detailers continue to encourage primary care clinicians to discuss harm reduction with their patients and link them to services within their community. Academic detailers have the ability to empower clinicians to have difficult conversations with patients to reduce infections, overdose, and death. Our team developed the following key messages to support primary care clinicians in caring for patients who would benefit from harm reduction. These key messages are currently being piloted across the United States in a project funded by NACCHO.
Harm Reduction: Key Messages to Improve Outcomes for People Who Use Drugs
1. Assess factors that may contribute to risk of Opioid Use Disorder (OUD) for patients who use opioids.
2. Identify opportunities to reduce risk of harm using a patient-centered approach.
3. Offer Medications for Opioid Use Disorder (MOUD) to patients identified as having OUD.
4. Connect patients with community harm reduction services and other services that meet identified needs.
These evidence-based key messages can help clinicians provide support to their patients and build strong and trusting relationships with those who need it most. Building trust between clinicians and patients allows patients to feel heard and be open to seeking additional treatment, ultimately leading to improved health outcomes.
Our team is looking forward to continuing to explore harm reduction and updating our key messages based on the results of the pilot through NACCHO.
If your program is interested in collaborating with our team on future harm reduction work, or any other clinical topic, please reach out to us at firstname.lastname@example.org.
Want to learn more?
Stay tuned to learn about the results of the pilot and how clinicians responded to these key messages in the field. You can also join our discussion forum to interact with peers who are working on harm reduction!
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