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. Have thoughts on our DETAILS Blog posts? You can head on over to our Discussion Forum to continue the conversation! ![]() 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. Supporting Clinicians in Utah: Working Together to Utilize Safe Opioid Prescribing Guidelines3/25/2022
An interview with Parveen Ghani, MBBS, MPH, MS, Health Program Specialist III, Division of Professional Licensing, State of Utah. by Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD Tags: Opioid Safety, Evidence Based, Training ![]() Anna: Hi Parveen! You’re one of our training alumni who’s built a strong program over the past few years. We’re thrilled to be able to catch up with you! Can you tell us about yourself? Parveen: I’m trained as a physician and have always wanted to work in public health. It was important to me to be able to make a difference in people’s lives. I currently work in the Division of Professional Licensing at the Department of Commerce in Utah. I've been working as an academic detailer since my NaRCAD training a few years ago. Anna: It sounds like the rest is history! Are there other detailers on your team who are helping you meet your program goals? Parveen: I’m a full-time detailer for our AD program along with my colleague, Marie Frankos. We work with many of the same prescribers over multiple detailing visits and build strong connections with them. ![]() Anna: Can you talk to us about your detailing work in overdose prevention? Parveen: Opioid overdose in the State of Utah is exceptionally high. We’re currently working with prescribers on the safe prescribing of opioids. Our state’s prescription drug monitoring program is called the Controlled Substance Database Program (CSD). The CSD includes both a Patient Dashboard and Prescriber Dashboard. The Patient Dashboard is an electronic clinical decision-making tool that grants prescribers access to information regarding controlled substance prescriptions for individual patients. It contains records of a patient’s poisoning or overdose and any violations associated with a controlled substance. The Prescriber Dashboard, on the other hand, tracks each clinician's prescribing patterns and CSD utilization behavior. Anna: We’ve seen a lot of success with detailing programs who work with clinicians to navigate their state’s prescription drug monitoring program, like your CSD. Does your state require prescribers to look at this database? ![]() Parveen: Yes. According to the Utah Controlled Substances Act, (a) A prescriber shall check the database for information about a patient before the first time the prescriber gives a prescription to a patient for a Schedule II opioid or a Schedule III opioid. (b) If a prescriber is repeatedly prescribing a Schedule II opioid or Schedule III opioid to a patient, the prescriber shall periodically review information about the patient in: (i) the database; or (ii) other similar records of controlled substances the patient has filled. Anna: It’s so important to support prescribers in using a database like this, especially when there are mandates in place. What is the overall goal of your AD program? Parveen: The goal of our AD program is to provide recommendations to prescribers regarding best practices in the utilization of the CSD per the Controlled Substance Database Act. This includes identifying individual prescriber’s prescribing and dispensing patterns of controlled substances, identifying prescribers who are prescribing in an unprofessional or unlawful manner, and identifying polypharmacy, doctor shopping, poisoning, or overdoses. Anna: It sounds like your AD program is working hard to support clinicians in CSD utilization. What kind of resources have you developed for clinicians that work towards your program’s overall goal, and how do you make these materials accessible? ![]() Parveen: We’ve created a toolkit that acts as a guide to help clinicians utilize the database and different resources within the community. During our in-person visits, we provide hard copies of materials that include screenshots of how to create a CSD account, reset CSD account passwords, and navigate the dashboards within the CSD. During our virtual AD sessions, we send these materials electronically. Additionally, we provide our contact information for further technical assistance, including our personal phone number, work phone number, and email address. We've made our toolkit available on our website along with prescriber FAQs. We’re continuing to update our website with helpful materials for clinicians. Anna: Making resources like this so accessible is key. Can you share some reflections on visits where you felt like you made a difference or were able to offer technical assistance? Parveen: I love helping prescribers, even if it is something as simple as walking them through the log-in process or resetting a password. I’ve had clinicians bring their entire medical team in for a detailing visit so that I can show everyone in the office how to use the database. One prescriber even told me after a visit that they would be sharing my name with a colleague and that I should expect a call to schedule a detailing visit. It’s lovely to get these types of referrals from the clinicians. Anna: Prescribers feeling thankful and impressed with your 1:1 support enough to refer you to their colleagues is a huge success! Let’s wrap up with one more question - what’s one tip you’d give to another academic detailer? Parveen: Find ways to collaborate. We can’t do it alone! Start working together with other programs and share information, especially community resources. We can really make a difference if we work together. Anna: I couldn’t agree more. Making community connections and sharing information allows for great success in accomplishing goals for both small and large initiatives. Our AD community will be able to glean a lot from your program’s successes, and we look forward to sharing more of your team’s expertise in the future. Have thoughts on our DETAILS Blog posts? You can head on over to our Discussion Forum to continue the conversation! ![]() Biography. Parveen Ghani has over eight years of work experience in public health. She obtained her Master in Public Health degree (MPH) from Walden University (Minneapolis, Minnesota). Following this, she worked for four years with the Office of Minority Health for the Nebraska Department of Health and Human Service. Parveen relocated to Idaho Falls in 2015 with her husband and began to pursue her career in bioinformatics. She obtained her master’s degree in Biomedical Informatics from the University of Utah in May 2018. Shortly after graduation, she started working as an Academic Detailing Specialist with the Division of Professional Licensing (DOPL), Salt Lake City, Utah. Before moving to the United States, Parveen earned her medical degree (MBBS) from Dhaka Medical College, Bangladesh. While not licensed in the United States, Parveen has worked as a physician in Bangladesh, Ireland, and Australia. Parveen enjoys working with the prescribers on the safe prescribing of opioids. Parveen loves to exercise, walk, read, play the piano, and play with her pet kitty in her leisure time. An interview with Carolyn Wilson, a Senior Health Program Coordinator at Ledge Light Health District. Ledge Light Health District is located in New London, Connecticut and is the regional health district serving the southern part of New London County. by Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD Tags: Opioid Safety, Evidence Based Medicine, Substance Use ![]() Anna: Carolyn, we’re thrilled to feature you on our DETAILS blog! I know you wear many hats – can you tell us about your current job role? Carolyn: I’m a health educator working within primary prevention, an academic detailer, and the host of our health district’s television program called Healthwatch. Healthwatch covers topics like mental health, physical health, disaster preparedness, general public health, COVID-19, environmental health, and disease prevention. I’ve been with Ledge Light Health District for 11 years. Anna: It seems like improving patient and community health outcomes is a common thread across all your roles. What primary prevention work or related projects complement your AD work? Carolyn: Depending on what topic I'm detailing on, I lean into my primary prevention work or the harm reduction work that my colleagues are working on. One of the larger initiatives I often share with clinicians during detailing visits is the Naloxone and Overdose Response App (NORA) project. The Department of Public Health developed a web-based application that can be downloaded directly to your phone. It has information about preventing, treating, and reporting opioid overdose. The app can be used by both folks in the community and clinicians. I also speak to clinicians about proper medication storage and disposal while promoting our “Take it To The Box” Initiative. ![]() Anna: We love to see programs using AD to spread the word about broader, community-focused initiatives. Are there other ways that your opioid-related AD work overlaps with work being done within your department? Carolyn: Yes! I’m so lucky to be able to work in the office side-by-side a recovery navigator. She helps link folks in the community to addiction services. Every day we say things like, “hey, I overheard you talking to that pharmacist just now – do they know x clinician?” We often share resources and try to work together to ensure that community health goals are achieved, often by making sure that the work people are doing is connected rather than existing within silos. It all comes down to helping one another work towards a common goal. Anna: What better way to work towards a common goal than to share resources across colleagues and projects! Can you share a story from the field where there was an intersection among various projects? ![]() Carolyn: I detail a lot of advanced practice nurses (APRNs) and also work with them on some of my primary prevention projects. The overlap in projects helps me build strong relationships with these clinicians. I sometimes work with school-based health centers as part of my prevention work, and these health centers are typically run by APRNs. These centers act as an access point to care for many students and families. It’s essentially a primary care clinic right in the school. The Child and Family Agency oversees the school-based health centers in southeastern Connecticut and reached out to me after a horrific event in a Connecticut middle school. A few months ago, a 12-year-old got access to fentanyl and brought it to school. He overdosed and passed away a few days later at the hospital. We haven’t seen many overdoses in schools, but after this happened, a lot of schools started looking at their policies and school-based health centers wanted to have naloxone on hand. The medical director of the Child and Family Agency advocated for a policy that required all school-based health centers to have naloxone and to be trained in administering it. Anna: What a devastating story. Have the school-based health centers been able to put these types of new policies into place? Carolyn: When one of the clinicians from the Child and Family Agency reached out to me, she said, “Carolyn, I know you do this kind of work. You trained me in naloxone not too long ago during an academic detailing visit. I’d like to have a naloxone training for my nurse practitioners in the school-based health centers. I want naloxone available in all of our clinics.” This type of request would typically be delegated to somebody else in our department, but because of the relationships I had built through academic detailing, I was asked to provide the training, and I did. As a result, the school-based health centers now all have access to naloxone and the clinicians know how to administer it. ![]() Anna: It’s incredible that you’d built trusting relationships with clinicians enough to be asked to provide this training, contributing to changing a policy in a span of one or two months. Carolyn: It means a lot that they came to me because they trusted me and knew I could get it done for them. I truly don't think I would have been involved if it wasn’t for my academic detailing work. Anna: I agree. It’s been a pleasure learning about your work and your unique approach to academic detailing. We’re excited to follow along with you on your AD journey as you continue to promote health across your community. Have thoughts on our DETAILS Blog posts? You can head on over to our Discussion Forum to continue the conversation! ![]() Biography. Carolyn Wilson is a health educator and prevention specialist serving as a program coordinator at Ledge Light Health District in New London CT for 11 years. Carolyn studied public health and health education at New York Medical College. Keenly interested in health promotion and behavioral science, Carolyn enjoys bringing her passions and talents to both primary prevention and academic detailing work. Carolyn has been serving as an academic detailer for over 2 years and enjoys speaking with clinicians about strategies to prevent opioid related deaths. Carolyn also manages the Groton Alliance for Substance abuse Prevention @Groton_Prevents. In her spare time, Carolyn enjoys serving on the Board of Directors for the CT Association of Prevention Professionals and Fiddleheads Food Cooperative. To connect with Carolyn, find her on LinkedIn. Aanchal Gupta, NaRCAD Program Coordinator Tags: Conference, Detailing Visits, Stigma, E Detailing, Opioid Safety Take a peek at the NaRCAD2021 conference materials on our Conference Hub. ![]() Fresh from our move to Boston Medical Center, our team at NaRCAD hosted the 9th annual International Conference on Academic Detailing, a virtual event concentrating on “Cultivating Relationships for Community Resilience.” There were robust discussions on critical topics, useful tools shared, and connections built. With over 300 registrants from across the globe, the AD community continues to learn and grow thanks to your support and passion for this work. Check out some of the highlights from our 2021 conference below. Day 1 + 2 Welcome Addresses
Field Presentations
Breakout Sessions
Expert Panels
Special Presentation: “Detailer Training in Action: Ask the Experts”
Real-time Roundtable
![]() Our team at NaRCAD is immensely grateful for your continued feedback and insights during our conference. This community has a wealth of knowledge to share, and as we approach 2022, we plan to continue to facilitate opportunities to connect you with others in the field, create a space to have conversations about stigma, and support your needs in the field. We look forward to seeing you in 2022. -The NaRCAD Team A special thank you to all of our NaRCAD2021 presenters! |
Elisabeth Fowlie Mock, MD, MPH, FAAFP is a self-employed Family Physician consultant living in Holden, Maine. She attended Vanderbilt Medical School and obtained a Master’s in Public Health at UNC-Chapel Hill. She is a clinical educator for the Maine state Academic Detailing program (MICIS) and Alosa Health in Boston. She is Board Certified in both Family Medicine and Addiction Medicine. Her part-time clinical work includes evening shifts as a hospitalist and prescribing at a high-risk, low-barrier buprenorphine clinic. She is passionate about women’s and girls’ basketball, travel, learning chess and singing. |
Wearing Multiple Hats at Alosa Health: Detailing Clinicians, Managing Programs, and Training Staff
1/22/2020
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Tags: Detailing Visits, Opioid Safety, Program Management, Training

Tony: Our partnership with Aetna, a managed health care company and health care insurer. We’ve been working with them to provide educational outreach to providers on chronic pain, acute pain, and opioid use disorder (OUD); supporting them in managing pain using non-opioid drug options; appropriately dosing opioids when they need to be used; tapering down patients who are on existing high doses of opioids; and helping to identify patients that may have opioid use disorder. We’re now working in Pennsylvania, Virginia, West Virginia, Ohio, Illinois and Maine.
Tony: When I’m training and managing detailers, I see myself more as a coach than a trainer. I’ve always liked educating and teaching—I enjoy helping others develop their skills and seeing them improve. Training folks and coaching them in the field is rewarding to me because I feel that I’m impacting what they’re doing in their own communities. It brings me happiness to see others succeed.
Tony: When I work with detailers in the field, I can see firsthand that they are able to be impactful with the providers because they are bringing about behavior change with their message delivery and confidence. We can also measure how impactful our work is by reviewing our Salesforce data. I can see from the detailer’s visit notes when providers have agreed to a behavior change, and this is a true measure of our work being impactful.

Tony: The major challenge is teaching detailers to have a conversation with clinicians rather than a lecture. Making the visit more conversational doesn’t often come as naturally as presenting the information in a lecture format, but the conversation must be about understanding where the provider is now, what their needs might be, and how to deliver content to make behavior change.
NaRCAD: With these challenges in mind, how do you instill confidence in academic detailers as a trainer and as a manager?
As a manager in the field, it’s quite similar. I usually sit down with each detailer after a visit and discuss what worked well and what they could do differently in their next visit, so that each visit becomes a learning opportunity. Providing feedback and being a mirror for the detailers helps them to build confidence and skills as time goes on. I also offer the detailers my perspective; having spent time doing this myself and observing others, I can share the tricks, skills, and wording I’ve heard throughout my time with the detailers.

Tony: Don’t be afraid to ask for a specific behavior change, and remember to follow up to make sure that the behavior change occurs. One thing that I find to be hard for academic detailers is the “ask”, where detailers are asking for commitment or behavior change from a provider at the end of the visit. I always tell detailers to frame it as, “based on what you’ve heard today, what is one thing you’d do differently?” Follow-up then ensures that providers are committed to change and holds them accountable for what they said they would do.
Tony: As a manager who’s coaching or guiding others, it’s important to build trust between yourself and the folks you’re coaching or managing. It can be lonely when you’re in the field detailing by yourself, so managers need to have touchpoints with their detailers. Building trust and having your detailers know you’re all working together helps them stay self-motivated; it makes them want to go out into the field and do a good job because they know someone is backing them up.
NaRCAD: Thank you for taking the time to chat with us today. We value your unique perspective on detailing, managing, and training!

Tony de Melo manages field staff and leads academic detailer trainings at Alosa Health. He attended Massachusetts College of Pharmacy and Health Sciences in Boston, where he received a BS in Pharmacy with a minor in Business Administration. This business interest led him to work for several pharmaceutical companies as a sales representative, account manager, training manager, district/regional manager, associate director of managed markets training, head of sales training, and development & marketing product manager. He has also worked for smaller businesses that were looking to grow their sales and marketing programs. Throughout his career, Tony has successfully sold, marketed, trained, led, designed, developed and executed solutions to meet business objectives.

Tags: Director's Letter, HIV/AIDS, Opioid Safety, Training
As NaRCAD enters its 10th year as the only national resource center dedicated to clinical outreach education, we’re ready to take our collaborations with you to the next level. The strength and sustainability of NaRCAD has grown from the hard work we’ve done together with you, our community members in the field.
We’re committed to continuing to provide the technical assistance you need to make your programs innovative, efficient, and successful. As we kick off 2020, our entire team at NaRCAD invites you to join us in leading our field forward through strategic partnerships, resource-sharing, and peer learning, all to implement important initiatives that will have a significant impact on clinicians and their patients.
The nature of our role as a resource center has continued to grow in parallel with increased recognition of the importance of academic detailing as a strategy to address multiple clinical challenges. We’ve been especially excited to see the effectiveness of AD enhanced when aligned with other initiatives to improve the quality of care.
Responding to this growing demand, we’ve dramatically expanded our reach, conducting 20 trainings in 15 different states across the US in the past two years alone, and 2020 looks to be no different. With the increased demand for AD technical assistance, we have a busy year ahead of us, from capturing your successes and sharing them via our DETAILS Blog to training your detailers to be ready for field work (and troubleshooting challenges along the way.)

We’re equally excited to have launched a new CDC research grant in collaboration with the Oregon Health Authority to rigorously evaluate the impact of their OD2A intervention and to develop a model for pragmatic assessment of similar efforts in other states. If you’re also interested in evaluating the impact of your AD program, reach out and let us know—we’re eager to hear from you.

Happy New Year!
-Mike
Michael Fischer, MD, MS, Director, 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.

An interview with Rachel Lemons, Project Manager, ONE Tennessee
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Tags: Opioid Safety, Project Management
NaRCAD: Thank you for taking the time to speak with us today—we’re excited to hear about you and your team! Can you tell us a bit about ONE Tennessee and how your organization first became involved with academic detailing?
Rachel: ONE Tennessee is a state-wide nonprofit healthcare collaborative who is focused on fighting the opioid epidemic. We were founded as an outcome of a summit hosted by the Tennessee Department of Health called “Turning the Tide.” The summit joined together healthcare professionals and stakeholders to discuss best practices for tackling the epidemic. Academic detailing was highlighted as a best practice during the summit and it was collectively decided that it would become one of our initial projects. ONE Tennessee brought the academic detailing pilot program to life through the opioid crisis funding the Department of Health received from the Centers for Disease Control and Prevention.
NaRCAD: We’re glad to know that the strategy of AD was highlighted! You’re now managing a program of detailers focused on opioid safety across the state of Tennessee—tell us what that’s like.
Rachel: Exciting! Once our detailers were trained by your team, my role was very much supportive in nature. I helped our detailers to identify clinicians in their communities, and troubleshoot any issues. We were fortunate enough to be able to recruit a passionate group of pharmacists for our pilot, and that made my job easier from a clinical standpoint, since they’re the subject matter experts on opioid prescribing. They‘re on the front line of the epidemic, and they fit the perfect mold for engaging with clinicians to build a strong and trusting relationship.
NaRCAD: You recently completed the pilot stage of your program. What would you say are some of the biggest lessons you’ve learned so far about building an academic detailing program?
Rachel: Getting in the door was one of the biggest barriers our detailers faced. From a programmatic standpoint, I think ONE Tennessee could have done a little more foundational work for our detailers, like speaking with our stakeholders and educating them on academic detailing as it relates to the opioid initiative—that would have really helped our detailers gain access to clinicians.
We also learned that time was a barrier for our detailers. Our initial grant period was only one year, and things moved very quickly. We recruited full-time community pharmacists, so having the bandwidth to prepare and complete academic detailing visits was often difficult, especially if there was limited employer support.

Rachel: I always had an open line of communication with our detailers. We had standing monthly webinars, but it was difficult to find a time that worked for everyone because they were full-time pharmacists. Our detailers were scattered across the state and were mostly in rural areas, so I was not able to meet with them in person; however, I was available via email, phone call, and text message. I learned early on that I had to meet detailers where they were. Some detailers did not have time to check email, so it was easier to do a quick call at lunch or early in the morning before their day got started. It really depended on the needs of the detailer, but I always maintained an open line of communication.
NaRCAD: That’s a great model, and regular communication helps detailers feel a sense of community through a project. Other supports are often more concrete, like tools and resources. What are some that you've found to be critical to program success, and why?
Rachel: I think first and foremost, our partners, specifically NaRCAD, the Tennessee Pharmacists Association, the Tennessee Hospital Association, the Tennessee Nurses Association, the Tennessee Medical Association, and the Tennessee Department of Health, were a tremendous resource that made our program incredibly successful. Google’s platform (Google Drive, Google Sheets, and Google Docs) was also critical to our success, as it allowed us to share data and updates in real time. We did not have access to specific evaluation tools because we are a young organization and our grant period was only one year. Our shared space online helped me to stay organized and capture information from our detailers all in one place, and it was free!

Rachel: I see us continuing our current model with our inaugural group of academic detailing community pharmacists while working towards designing, developing, and implementing a “train -the -trainer” model in partnership with your team. I also see us having discussions with large and small hospital systems to customize plans to fit their unique needs related to opioid safety. Most importantly, we want to continue to support the state and our other healthcare stakeholders who are with us on this journey.
NaRCAD: We’re happy to help support that vision. Any other important advice/tip that you’d give to other young programs?
Rachel: Patience. You must have an understanding that there are going to be pitfalls, but if you have the support and the right people involved, your program is going to succeed. Also, don’t try to reinvent the wheel if you don’t have to. There are so many other programs out there — reach out to people and have conversations!
NaRCAD: Rachel, thank you so much for sharing your experiences with us. We're excited to see the impact of your program into the future.

Rachel Lemons found passion for public service early on in life. She is committed to assisting those with the greatest need in her community. She’s working to effect change socially and through public policy. She is a graduate of East Tennessee State University, where she received her Bachelor of Science in Public Health. Her involvement with Tennessee’s Opioid Epidemic began with the Department of Health, where she was exposed to the State’s rapid response in this fight which lead her to joining ONE Tennessee as a Project Manager. She continues to build her career with a practical and wide ranging set of experiences in order to gain a global perspective on health issues facing communities today. Rachel is an active member in the Junior League of Nashville, Tennessee Public Health Association and currently serves as the Board Intern at Cheekwood Estate & Gardens in Nashville.
by Winnie Ho, NaRCAD Program Coordinator
Overview: The Cannabis Act went into effect in Canada in October of 2018. The legalization of a drug with strong potential for a myriad of clinical uses was followed by many questions from patients and providers alike about its effectiveness, its safety, and lack of previous research. The RxFiles have carried out a cannabinoid academic detailing campaign to address the demand for truth in a time where research has just begun to shed light on previous myths, misconceptions, and clinical promises.
Tags: Health Policy, International, Materials Development, Opioid Safety, Stigma, Substance Use

Zack: There’s an element of doubt in the information out there, because people have experienced misinformation before. People are often interested in the truth and that’s one of the most amazing things about academic detailing. There is also a desire for practical information that can be used to actually treat patients, and there’s a ton of overlap there. These things are important to these very, very busy providers who want the best for their patients.
NaRCAD: We know that your team is working on a cannabinoid campaign, which can be a nebulous topic. Can you discuss a little more about cannabinoid policy and conceptions in Canada?
Zack: We’re coming up on the one-year anniversary of recreational marijuana legalization, but medicinal cannabis has been legal for about two decades. With the legalization of recreational cannabis though, we’re seeing fairly rapid change in perceptions of what the truth is. It’s tough to keep up with.
With academic detailing, it was challenging to decide how to tackle it – can we just talk about the medicinal cannabis side? Or do we have to dive deeper? When we dug into it, it became clear that we also had to talk about the recreational side. For example, the people we provided our services to also wanted to know, “if I decline my patient cannabis prescriptions, what will they be able to get on their own?”

Zack: It’s coinciding with our work on pain, following our work on pain and opioids. In addition, because legalization was approaching, the providers had more questions because their patients were asking about cannabis as an alternative to opioids.
NaRCAD: How have provider responses been to the cannabinoid campaign so far?
Zack: It’s welcomed. Our information is usually welcomed. There’s some frustration over how little information there is out there. While frustrating, I think it’s kind of comforting to know that we’re not that far behind. It’s kind of mixed, but at the same time, they’re still happy to get information from a trusted resource. There's a lot of gray area information right now because it's a newer field.

Zack: The evidence pyramid gives us the best approach for practical information, for people who are the interface of care. You want to find high quality, synthesized information. Whether its osteoporosis or COPD or pain or cannabis, you start with the guidelines and figure out what kind of information they are providing. We started with some recently published guidelines and it was a synthesis of systematic reviews, and made an attempt to summarize all the evidence of where cannabis was found to be of benefit. We also reviewed the bibliography with all the primary literature and metanalyses.
This process is pretty similar for any academic detailing topic. The other process is going to the people we provide services for, and asking what their patients are asking to treat with cannabis. They tend to ask about cannabis for pain, insomnia, or for things like tremors and that gives us some guidance in terms of what kind of literature we want to find. Of course, we are also looking into what the key messages are in the information we find and distribute. With cannabis, the interesting thing was the lack of information on the different conditions it could be used for. In some ways, it was easier, as weird as it sounds. We didn’t have as much reading to do on that topic.

Zack: One, you’re going to have your conversations about stigma. There isn’t a perfect picture of who uses cannabis and it could be absolutely anyone. You’ve got to have the conversation about stigma and get to know your own biases.
In the same vein, we thought about how important word choice and language is. We thought about whether or not we call it cannabis, marijuana, pot, or cannabinoids. Do we call it a medication or a product? All of those words and the considerations that we’ve given opioids - do we call them "addicts", or is it "dependence", and what are the differences between addiction and dependence? The third piece would be that you’ve got to talk to your providers in your local area and find out what their main questions are.
Your job is to provide a service, and if you can find out what their wants and needs are, you’ll provide a far more satisfying service for them and could establish strong relationships that you can build on. There will be a lot of information out there and you will need a lot of leads to help you sort through it all. This won’t be the last time we're addressing this.
NaRCAD: Thank you for taking the time to speak with us, and for leading the charge in bringing cannabinoids to the conversation about treatment for pain.

Zack Dumont is an clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a new expert facilitator for NaRCAD's training courses. He has been involved with the RxFiles since 2008, with experience in both academic detailing and content development of RxFiles’ evidence-based drug therapy comparison tools. Zack maintains clinical practices for inpatient internal medicine, with more specialized experience in anticoagulation and heart failure. His professional interests include teaching evidence-based medicine, knowledge translation, development of clinical decision supports, collaboration, and leadership.
Zack graduated as a Pharmacist from the University of Saskatchewan in 2008. Following graduation, he completed a hospital pharmacy residency with the Regina Qu’Appelle Health Region, where he currently serves as a Clinical Support Pharmacist, with involvement in training new staff, precepting pharmacy residents and undergraduate students, and providing clinical support to various health region committees and working groups.
OVERVIEW: Ware County, Georgia, was one of 2 sites selected for year 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
Tags: LOOPR, Opioid Safety, Rural AD Programs, Substance Use

Rosemarie: Our agency serves 16 counties in Southeast Georgia, and we have seen the same things across all of these counties. The opioid crisis affects the community across the board; in every sector. Law enforcement is seeking the effects of this crisis, so is healthcare, and people that work with children and families. They all acknowledge that they’re seeing it in their day-to-day work. So many public health topics only affect one sector, but this opioid crisis affects them all.
NaRCAD: With it affecting so many, did you think the strategy of academic detailing would lend itself to improving patient health in response to the opioid crisis in Ware County?
Rosemarie: Being a clinician myself, I did initially see how academic detailing would be a good public health intervention. I thought academic detailing would make the lives of providers better by providing them with evidence-based information and resources. As we discussed during the training with NaRCAD, there’s so much information out there, and it’s really difficult to sort through all of it.

NaRCAD: You mentioned being a clinician—you’re also the Public Health Director for your district. How does being both a clinician and the Public Health Director make it easier for you to be successful as a detailer?
Rosemarie: My position allowed me to easily make appointments, and I did not have difficulties getting in the door, like so many other detailers do. I often had visits that were a lot longer than the usual 15 minutes, because clinicians would set aside more time to talk to me. My clinical experience as a primary care physician in private practice for many years made is so that I could relate to the clinicians, and allowed for more honest sharing. I would tell other doctors what worked and didn’t work for my practice, and that made them more comfortable opening up about their own experiences.

Rosemarie: Another thing that was unique in Ware County is we did both 1:1 visits, as the original model suggests, as well as group visits. There were many occasions upon which multiple providers and key leadership from a health system were all together in one room. This allowed providers to hear from other providers, and I saw that as a critical dynamic. The conversations continued well after those visits ended, and still continue to this day. It was also important that key leadership was present because they heard exactly how the issue is impacting clinicians and patients, and they have the power to make decisions affecting opioids in their health system.
NaRCAD: It’s great to hear that a group education approach worked so well. What would you say has been the most impactful piece of this intervention?
Rosemarie: I think academic detailing for the opioid crisis worked so well in Ware County because public health is seen as a neutral entity, and because of that, we were able to effectively facilitate these discussions. We do a lot of work in the healthcare community but it is rare that the public health department takes the time to visit an individual practice or provider. During my visits, I witnessed clinicians take in the data about how Ware is one of the highest prescribing counties in the nation, and saw how it immediately encouraged them to want to make a change.

NaRCAD: We’re so glad academic detailing has been impactful in your community. What has the greatest challenge been with implementing a successful academic detailing intervention to improve opioid safety in Ware County?
Rosemarie: The overall experience has been fantastic. As we discussed, the providers were really open and honest. For me personally, as a detailer, it was difficult not to feel like I needed to be the one who had all the answers. I handled this by being a link to information, rather than having all of the information myself.
For instance, when a clinician asked a question, or requested a resource I didn’t know about, I’d say something along the lines of, “Let me do some research about that, and when I come back I’ll be sure to have that information.” It helped when I was able to give the disclaimer that “I’m by no means the expert, but I’ve learned a tremendous amount about opioids and the crisis, and I’m here to share some of that information with you. And if I don’t know the answer to something, I can find someone who does.”

Rosemarie: Personally, there were no big surprises. Everyone did a great job in explanting the process, executing the training, and providing resources. Like anything though, you don’t really get the hang of it until you get those first few visits under your belt and become more comfortable. Overall, this has been a great experience. It was so helpful having additional resources, learning from people that are highly knowledgeable and respected in this field, and being able to share experiences across all LOOPR sites with other detailers who are doing the same work.

Dr. Rosemarie D. Parks serves as the District Health Director for the Southeast Health District (District 9-2, Waycross, GA). She has overseen the 16 county health departments, 3 wellness clinics, and over 50 programs since moving to rural Georgia from Ohio in 2005. Dr. Parks holds a Master of Public Health degree from Youngstown State University, Ohio, and a Medical Doctorate from the Northeastern Ohio Universities College of Medicine. She is board certified in internal medicine. She is also a member of the National Association of County and City Health Officials.
As the District Health Director for the past 14 years, Dr. Parks has overseen telemedicine and teledentistry projects that have expanded new technology to meet the ever-growing needs of a rural population. She has also worked diligently with community partners in planning to combat the opioid epidemic and strategized for innovative solutions to meet the public health needs of the community.
Tags: Detailing Visits, LOOPR, Opioid Safety, Program Management, Rural AD Programs

Boone County ranks as the 22nd most vulnerable county across all counties in the United States, with the highest drug overdose mortality rate of all counties in West Virginia. Due to these and other data, Boone was identified as a key county in which to test the implementation of an academic detailing program, in which trained detailers would speak to clinicians and pharmacists about safer prescribing of opioids, checking the state’s prescription drug monitoring program to avoid dangerous co-prescribing of opioids and benzodiazepines, and to try and provide treatment, non-opioid therapy, and resources to patients in need.

Programs considering hiring student detailers can often rely on the flexibility of students’ schedules, as well as an enthusiasm and energy for learning that may exist in smaller quantities later in one’s career, when full-time roles in healthcare take priority. While many career-established clinicians may have little room in their schedules to squeeze in 1:1 sessions with fellow clinicians, students may have more of an ability to shift their schedules, especially if they are not yet carrying out residency.

With these elements in place, a student detailer may be poised for success—however, other considerations include the fact that students may have new projects, graduation pending, or life events which may end up limiting their ability to dedicate consistent time to a project rolled out over many months.

NaRCAD’s work with the public health department in Boone County, in partnership with the students and faculty of University of Charleston, West Virginia, provided the kinds of insights critical to learning from a pilot project of this nature. As with many pilot studies, any information gathered can illustrate a clearer picture of the landscape within which public health initiatives can be implemented, so that future projects may have a greater impact. With many thanks to the student and faculty team of Boone County’s Academic Detailing Project team, we and our partners are grateful to have learned so much over the past two years.
OVERVIEW: Bell County, Kentucky was one of 4 original sites selected for years 1 + 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
Tags: Detailing Visits, LOOPR, Opioid Safety, Rural AD Programs, Substance Use

Lutricia: There’s not a family in this community that hasn’t been touched by the opioid crisis in some way. Twenty years ago, I worked in hospitals as an RN discharging patients and providing them with their prescriptions as they prepared to go home. At the time, I was shocked at the rates of prescriptions of opioids with benzodiazepines, and patients thinking it was safe. From my perspective, in our community, the opioid crisis really began by doctors beginning to prescribe many opioids to their patients without education or an understanding of the dangers.
Three years ago, I was working on a project at a middle school, and was surprised by the number of grandparents that were raising their grandchildren because their children were either in jail, or otherwise affected by opioid use disorder [OUD]. In Bell County, we also have so many people unable to find a job because they cannot pass a drug test, and once that happens, they return to use because of the stressors of not being able to find a job and pay their bills, and it becomes a challenging cycle to overcome.

Lutricia: I desperately hoped it would. The opioid crisis is very personal to me, as it is to many people in our community. Years ago, my mom had 2 surgeries within 6 months. She had complications from one of those surgeries, and as a result, she was in the hospital for 6 weeks, during which time her care providers did not wean her off of the opioids she took immediately after the surgery. She returned home with prescriptions for opioids at a high dosage, and she developed opioid use disorder.
My mother’s doctor, with whom I worked, reached out to have a conversation with me. He told me that I had to be the one to intervene with my mother because she continued requesting more opioids. I conveyed that I wanted her to discontinue taking them, and that he needed to assist us in finding a way to do this, as I felt his prescribing without discussing safety caused the initial issue. His response was that he wanted to “keep her happy.”
My mother struggled for the rest of her life; she was able to completely wean off and discontinue using them, but it required a lot of counseling. As a result of this experience, I became a drug education coordinator, as I really wanted to do my part to mend the opioid crisis by providing drug education for every student in the county. And then, of course, I became an academic detailer for this project over the course of the past 2 years, which involves clinician education about safety and risk of opioid prescribing.

Lutricia: The most impactful piece has been the ways in which we’re trying to hold clinicians accountable for their roles in the crisis, as well as leveraging their ability to improve things based on their relationships with their patients. For many of the doctors and nurses I met with, our conversations and educational resources have made them more thoughtful and intentional about their role. They seem to realize more that they have the power to decrease the number of prescriptions they write, the length of time for which they write them, and talk more with their patients about safety.
NaRCAD: That’s fantastic. What about the most challenging part of this project—what’s been hardest about meeting with clinicians to talk about the opioid crisis in Bell County?
Lutricia: Getting an appointment to go in and meet with these clinicians has been so frustrating and challenging. I always say that the receptionists in doctors’ offices are the most powerful people in the world. If you can’t get through them, you’re not going to get what you need, and it is the same with the patients. I couldn’t even get in to see my husband’s doctor, who we’ve known since we were kids. My husband had an appointment, so I resorted to going with him, and did a detailing visit on the spot with his doctor. This same doctor ended up changing practices, and it’s been a lot easier to get into that practice—all because of the office manager. Those relationships are important.

Lutricia: When I was “volun-told” that I would be attending a training, and doing “academic detailing”, I didn’t truly understand what it was or what the impact would be. I’m a big picture person, and I couldn’t see the big picture at all; I went into that training not knowing what to expect. It wasn’t until I actually started making visits that I could start to see the seeds we were planting to begin to have an impact.
Share your thoughts on this piece in the comments section below, or learn more about the LOOPR project and other opioid safety academic detailing initiatives here and on our Detailing Directory.
Moving Beyond Skepticism: Partnerships to Improve Health Outcomes in St. Francois County, Missouri
7/24/2019
St. Francois County, Missouri was one of two sites selected for year 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
Tags: LOOPR, Opioid Safety, Program Management, Rural AD Programs

Amber: As with many other places, St. Francois County has certainly felt the impact from the opioid crisis. We have high rates of overdoses and over-prescribing. There have also been more children in foster homes because their parents have an opioid use disorder, as well as increasing drug arrest rates. Many aspects of our community have been affected in some way or another. I think this is the main reason why so many community agencies have come together to start working on this issue.

Amber: Academic detailing is a great strategy to reach out directly to clinicians in their offices in order to provide resources and supportive education without punitive actions. We really weren’t sure what to expect with having two nurse practitioners, two registered nurses, and a pharmacist carrying out the 1:1 detailing visits.
Health Center administration and detailers were skeptical of how physicians would react to other disciplines “telling them how to do their job”. However, academic detailing isn’t telling them what to do, it’s talking with them about what they can do to keep their patients safe. It is a partnership.
Missouri is the only state without a statewide PDMP. St. Francois County passed an ordinance to join the St. Louis County voluntary PDMP in 2017. The first report from the PDMP showed St. Francois County as the highest prescribing county in the state. This was a big concern for the Local Board of Health and, we learned from community partners, the citizens of St. Francois County. Health Center administration has presented opioid-related health data for the county at various meeting and kept hearing from partners that clinician outreach education and patient education were top priorities when it came to prescription opioids.

Amber: The greatest success of academic detailing in St. Francois County so far has been the willingness of most physicians to start the conversation about how they can improve prescribing patterns, and care of patients at risk for or experiencing opioid use disorder (OUD). Also, many physicians have started using the PDMP regularly as a result of our academic detailing visits.
NaRCAD: That’s excellent news and shows the impact that 1:1 education can have! Over the course of this pilot project these past 4 months, what has the greatest challenge been with implementing a successful academic detailing intervention to improve opioid safety in St. Francois?
Amber: The challenge are the providers who do not want to talk with the detailers, or the ones who flat out refuse to change their prescribing patterns. As a nurse, this is frustrating to me because I believe in quality, evidence-based healthcare for all. The refusal to learn, or seek to learn, new information about medications that are prescribed daily is poor patient care and our citizens deserve better than that.

Amber: I wish I’d known more about choosing detailers. Recruitment is important. When recruiting detailers, it is more important to make sure to recruit people who have the bandwidth to do the detailing, rather than making sure they have the perfect clinical background. It may be a good idea to create a formalized agreement to ensure they completed their required detailing visits.
NaRCAD: You are spot on, Amber. Recruitment is a complex process. Readers can learn more about this later in the summer when we release our new Implementation Guide to help sites like yours select and hire the right candidates. Readers can read other LOOPR blog interviews here, and stay plugged in for more LOOPR site highlights in the next couple of months.

Amber Elliot, BSN, RN
Assistant Director
St. Francois County Health Center
Amber Elliott is the Assistant Director for the St. Francois County Health Center in Park Hills, MO. She received her Associates Degree in Nursing in 2008 from Mineral Area College to become a Registered Nurse. She went on to obtain her Bachelor’s Degree in Nursing in 2011 from Central Methodist University. She has spent most of her nursing career working in acute settings, primarily hemodialysis. Amber started working in public health four years ago in hopes to make her own community a healthier, safer place to live. Amber has been working on opioid-related activities since 2017. She currently resides in Farmington, MO with her husband and two children.
Optimism for the Opioid Crisis: Addressing Stigma and Disseminating Evidence to Clinicians
4/30/2019
by Kayland Arrington, MPH, Program Manager at NaRCAD
Tags: Opioid Safety, Stigma

Don: I was trained as a primary care physician, and my wife, Martha, is a behavioral health specialist. The two of us had an integrated-care model, where we did a lot of addiction treatment. I wanted to address that more specifically. An important part of my practice has always been to help those who couldn’t otherwise get help. I did medical work in Honduras, and then I realized that we had a large population of migrant farm workers where I lived in North Carolina. Most of these farm workers didn’t speak English or have a way to receive healthcare. With the help of others, I then opened a free clinic.
As far as addiction, I realized that so many patients initially became addicted from my colleagues and me prescribing opioids. The opioid crisis is a public health issue, and medical school doesn’t train you for public health work. Medical thinking addresses what is going on right now, but public health is so much bigger than that. I decided to get a master of public health degree at the University of North Carolina, and I completed that in 2017.

Don: Academic detailing can help by having more people with lived-experience do the detailing. In Wisconsin, people with lived experience are either going out with a detailer as a team or doing the detailing themselves. There is also a shortage of people treating OUD. AD is a great program for sharing how to get waiver trained to prescribe buprenorphine for OUD. AD lends itself well to the opioid crisis because it’s an area where little changes can make a big impact.

Don: I hear a lot from other clinicians that they don’t want “those people in my waiting room.” They are picturing someone who is all strung out on heroin on the street corner. We don’t get any education on addiction in medical school and the whole concept is overwhelming to clinicians. The best way to overcome stigma is for clinicians to have interactions with more people with OUD. I think that can be done by clinicians prescribing buprenorphine. I had to deal with my own stigma. For example, I had patients on opioids for chronic pain. I then found out they got arrested or were getting drugs from somewhere else, and I would just fire them from my practice. I saw them as bad people. Once I got trained to prescribe buprenorphine, I listened to their stories. I had made the same choices as many of my patients, yet they became addicted because of their personal history, social history, and genetics.
There’s also the importance of language. A lot of the older language around OUD identifies with bad choices and bad people. For example, relapse is associated with a fault of the person. When we are talking about a person with OUD, we are talking about someone with a disease and relapse is a natural course of the disease. When a patient’s blood sugar goes up, we don’t call it a relapse. Just like people with diabetes, we will never cure a person with OUD, but we help them manage.

Don: There is so much data that shows the first and best treatment for OUD is MAT. There are 11 criteria for OUD, and they are all behavioral. Once people get on the medication, they meet zero of the criteria for OUD. We don’t have many medications for other diseases that can do that. France had a big problem with heroin, and by making buprenorphine more readily available, overdose rates dropped by 80% in 2 years.

Don: We need to prescribe fewer opioids. A lot of our medical education is still driven by pharmaceutical companies. AD can help by disseminating the evidence on the appropriate treatment of pain. It was only in 2016 that the CDC first came out with guidelines saying opioids should not be the first line of treatment for people with chronic pain. It typically takes 17 years for research to become routine care, and there has already been a lot of uptake with this. Next, we should have all clinicians prescribing buprenorphine, like what France did. We also need to change our criminal justice system to reduce penalties for being found with a controlled substance, including heroin. I am optimistic about each of these things, and think they are all likely to be done in our lifetime – hopefully in the near future.

Don Teater, MD, MPH
Founder
Teater Health Solutions
Don Teater is a family physician who has lived and worked in western North Carolina since 1988. His work in the southern Appalachian Mountains made him aware of the problems with opioid pain medications years ago. In 2004 he started a clinic to treat those addicted to opioids in his primary care practice. From 2013 to mid-2016, he worked as Medical Advisor at the National Safety Council addressing the national epidemic of opioid abuse, addiction, and overdose. Dr. Teater was lead facilitator for the expert panel discussion during the development of the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Dr. Teater has also served on the World Health Organization Committee addressing drugged driving that met in Mallorca Spain in December 2015. Since June 2016, Teater has worked for Teater Health Solutions to concentrate on educating prescribers and others on the science of opioids and how that should influence treatment and policy decisions. Currently he contracts with the Center for Disease Control on the academic detailing of prescribers to educate them on the appropriate use of opioids for the treatment of pain.He continues to work one day per week treating those afflicted by the disease of addiction at Meridian Behavioral Health Services in western North Carolina.
Highlighting Best Practices
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