Winnie: Hi Tara! It’s been a crazy year so far, hasn’t it? We want to check in with you and the University of Illinois, Chicago (UIC) team about your experiences in navigating the pandemic. Can you tell us a little more about yourself and your role in the ADVANCE academic detailing team?

Tara: I was hired about 7 months ago as the research coordinator, and it’s been one heck of a 7-month run. The majority of my work is focused on implementation, so I do all the scheduling and outreach to hospitals to talk to providers. I develop and establish relationships with office managers and providers, and I assign detailers to visits.

W: Our team at NaRCAD has been lucky to have worked with the UIC and ADVANCE team for a while through our trainings and your presentations at our conferences and our webinar series, and we’re excited about the research intervention that had been planned. Can you tell us a little bit more about the mission?
​
T: Our intervention is a CDC-sponsored, three pronged approach that’s built off a pilot program that we started in 2018 for Chicago-land providers. We have a team of about 30 detailers who are now trying to cover as much of the state as possible. We wanted to follow-up with providers to get a sense of whether or not the ‘dosage’ of AD made a difference, but we also wanted to expand the providers we worked with, and to introduce updated topics like the new features of the Illinois PMP or opioid alternatives. The third prong is creating a toolkit to give programs a blueprint and resources of what was effective for us. We would love to make the “how to” of AD more accessible to other groups.

W: Compared to other programs, you have quite a large and robust team at UIC. It must have been difficult for the pandemic to hit right in the middle getting your program launched.

T: It really impacted our recruitment as we had called providers from the end of January through early March 2020. There are a lot of things going on right now. Even a small ask, such as 15 minutes of their day, can feel like a big ask for providers.

W: Right, and interventions are very carefully laid out and planned ahead of time. COVID-19 has disrupted everything – especially those on the frontlines who are both detailing and being detailed. Can you tell us a little bit more about how else the impact on your original plans for the intervention?

T: We had been so focused on ramping up that by the time we hit mid-March, we had many people on deck reaching out to providers. We started hearing “No, we can’t do this right now” or “this is a really bad time” often.
​
Once the stay-at-home order came through, we stopped contacting offices for about 2 months. We had to sort out so many protocols and even our IRB to make amends for virtual visits. What we’ve found since we’ve resumed virtual visits in May is that there’s a lot of variability – some offices have capacity because they aren’t seeing many patients, while others have providers that have been transferred to hospitals and have no idea when they’ll be available. We’re also talking about layoffs and burn-out and low morale.

W: There are many of considerations on how best to proceed safely right now. One is looking at the impact on the critical work you’ve done on opioid safety. Unfortunately, the pandemic has only exacerbated the overdose epidemic. What progress has been made on your opioid initiative?

T: One of the ways our team has shifted has been moving to virtual visits. We knew that these would have its own difficulties, such as concerns about “no-shows”. But our team is relatively tech-savvy, and now my job is making sure they’re all familiar with how to troubleshoot the technological pieces of virtual visits. 

​There are a lot of tech issues that can interrupt a visit. So we do mock detailing and have the detailers practice with each other, where we introduce certain needs and obstacles, maybe even a tech problem for instance, we role play a provider not turning on the webcam, or not being able to see your screen. Practice to strengthen adaptability and resilience become important in ensuring the detailers are prepared.

W: There’s definitely no time like right now to test detailing skill and ability to think on your feet! As a research coordinator, what do you think you’ve learned in the past few months?

T: How to be flexible! There are all sorts of external pressures right now to keep our project on track, but the most important part is keeping the human aspect in check. Having some insight and empathy for providers is important to understand what they’re going through. We can get bogged down into the guide posts, the bench posts, or the numbers – but this era reminds us that it’s all about empathy.
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​W: At the end of the day, we want better for our patients, for our communities, and for health outcomes everywhere, right?

T: Absolutely!

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An interview with Ramona Shayegani, PharmD, Program Lead, Academic Detailing Service, Veterans Affairs Southern Nevada Healthcare System

by Kristina Stefanini, NaRCAD Project Manager

Tags: E-Detailing, International, Materials Development, Opioid Safety, Substance Use, Rural AD Programs

Kristina: Programs are transitioning their academic detailing (AD) efforts to e-Detailing or virtual detailing amid the COVID-19 pandemic. As part of your role at the Veterans Health Administration (VHA) Academic Detailing Service, you’ve completed e-Detailing visits, which you presented on at the NaRCAD 2019 conference. I wanted to interview you today, Ramona, to learn more about how you transitioned to e-Detailing. First, how did your program decide to do e-Detailing?
​
Ramona: Thanks for interviewing me! We heard about an e-Detailing pilot project from our national office and we were excited to participate as our region is spread out and rural, covering Nevada, northern California, Hawaii, and Manilla, Philippines. We felt this would be an excellent setting in which to incorporate video calls into our communication with clinicians. As a result, e-Detailing has allowed us to reach our full potential as a service.

Kristina: Amplifying a program’s impact and reach through e-Detailing is something many other programs want to experience. Have providers been receptive to e-Detailing visits given the current COVID-19 pandemic?

Ramona: I think it varies by site, but for the most part, providers are very eager to learn about the VHA’s telehealth program. Initially, when we started e-Detailing, we launched a campaign to encourage clinicians to complete telehealth visits with patients. Now providers remember our names, and they reach out about setting up telehealth meetings with their patients and figuring out how to conduct video calls. It’s very rare for providers to reach out to academic detailers for help. We usually have to initiate outreach requests.
​
Kristina: That’s terrific that clinicians are the ones reaching out for the service. When you’re getting ready for an e-Detailing visit, do you prepare the same way as you would for an in-person visit? What materials do you use, and how do you use them?

Ramona: The campaigns we’re working now are so fast-paced, so we’re sharing materials via PowerPoint presentations on a video conferencing platform; we also use electronic PDFs.

In addition to showing providers electronic materials, you can still model an approach as you would in person by holding up some of the materials on the camera. For example, with naloxone education, we have naloxone spray “dummy” versions that I show providers on video; I ask if they have ever seen what a naloxone spray looks like, and whether they would be interested if I sent a model version, which they usually say yes to.
​
Kristina: That’s something we try and tell detailers who are pivoting to e-Detailing, which is that much of the interactive approach of an in-person visit is still accessible via video! Many detailers who are trying this out for the first time are eager to find ways to build a meaningful, trusting relationship with clinicians--do you have any advice for strong relationship-building approaches during e-Detailing visits?

Ramona: Sometimes, especially if it’s a new provider, I try to remind myself that I might not get to talk about any of the key messages. It’s really important to take that time to introduce yourself and your service. I don’t feel like it’s anything different than meeting someone face-to-face for the first time. However, detailers need some time to try this with each other, their team, or providers that they have a good relationship with. Detailers need to build that confidence before they go out and try these video calls with people they’ve never spoken with. The more I do it, the more confident I feel, which is key in building these relationships.

Kristina: That makes sense—it’s about comfort and confidence as much as knowing the evidence. We’ve also encouraged detailers to know that it may take more time to build up to delivering the key messages than you’d like it to, and to be patient and focus on building the relationship when carrying out visits online. In your experience, have you seen any drawbacks to e-Detailing?
​
Ramona: One thing is that detailers don’t have the luxury of getting a feel of what the clinic is like, which would be easy to observe in person. A lot of times when I am in a clinic, I get a chance to talk to an auxiliary support team, or I could just walk to the other room and talk to the nurse. I’ve found ways to adapt to e-Detailing to try and have more of the team’s perspective; I’ll often ask providers if they think it would helpful for the nurse to be on the call so we can have a group discussion. 

Kristina: It’s really about thinking outside the box and adapting the in-person approach, while trying to maintain connection. Is there anything else you’d like to share from your experiences with implementing e-Detailing?
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Ramona: Detailers should acknowledge that this is a brand-new approach; you may not feel like this is your preferred way to talk to providers. Remember that it will take some time to get comfortable with it. There’s a learning curve. Now that I use this approach full-time, I just love it, and I don’t want to go back! It’s just as effective, a lot more efficient, and it allows you to be flexible.

Biography.
​Ramona Shayegani is the program lead for VHA’s Academic Detailing service in northern California, Nevada, Hawaii and Manila. She received her Doctor of Pharmacy degree from Oregon State University in 2014 and has clinical background in mental health and addiction medicine. She was one of the first detailers to pilot e-Detailing at the VA and has completed over 400 virtual detailing visits.

An interview with Nadejda Razi-Robertson, PhD, LCSW, Managing Director, Synergy Health Consulting and  Andrew Suchocki , MD, MPH, Medical Director, Clackamas Health Centers

by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

Tags: COVID-19, Detailing Visits, Opioid Safety, ​Rural AD Program, Stigma, Substance Use

Anna: Thank you Nadejda and Andrew for spending time with us today to discuss the impressive work being done in your leadership roles around practice transformation at Synergy Health Consulting.  Can you tell us a little bit about Synergy and its impact on opioid safety-related care improvement?

​Nadejda: Our team works with health systems across the state of Oregon.  Our first phase of work started several years ago when we were largely focused on helping systems implement the CDC guidelines around opioid safety. Our work has since evolved, and we’re now focused on helping clinicians develop medication-assisted treatment programs, integrate behavioral health into primary care, and address the opioid epidemic at the community level. 

We often use academic detailing as one of the many tools in our toolbox when we work with different health systems on opioid safety. We take the basic concepts, such as conducting a needs assessment and identifying clinician barriers, from the traditional model of a detailing visit, and implement them on a larger scale.  

​Andrew: Many members of our team are practicing healthcare professionals in the field, which roots a lot of our work at Synergy.  I take what I’m seeing on the ground as both an administrator and a provider at a busy clinical practice and incorporate those experiences into my work at Synergy.

Anna: It’s so important to build teams where members have varied expertise and professional training when working together on practice transformation.  How have you incorporated academic detailing strategies into the work being done at Synergy, and how has it been received?

​Andrew: Some of the academic detailing work I’ve done has been with providers who need extra support from a peer, or from someone else working in the field.  When it comes to opioids, chronic pain, and addictions in primary care, there’s a tremendous amount of stigma and information that was accurate at one time, but as we’ve shifted as a society, many primary care providers are yet to catch up. 

​Stigma isn’t something that folks are actively choosing, it’s more of what they’ve been taught.  Changing that culture of practice is much more difficult compared to asking prescribers to prescribe cholesterol-lowering therapy.  There’s very little societal baggage when it comes to improving cholesterol than there is when it comes to destigmatizing addictions or chronic pain.

Nadejda: We use the same fundamental approach when working with systems, clinics, or individuals.  We start with a needs assessment, provide a group training based on those needs, and follow that up with 1:1 academic detailing visits to address barriers, provide materials, and explore personal bias that may be getting in the way of providing treatment. 

I’m currently working to schedule a training for several providers in a rural county in Oregon.  A number of those providers are X waivered (allowing them to prescribe medication therapy for patients with opioid use disorder), but they aren’t using their X waivers to prescribe buprenorphine.  A needs assessment will provide me with a better understanding of what the challenges and barriers are, what is working well, and where there may be bias, stigma, or gaps in knowledge.  We also use the needs assessment as a “listening session” that creates a sense of safety, fosters an experience that participants are being heard, and serves to “normalize” experiences across settings and practitioners. This process is also strategic in that it helps us understand where to focus our educational outreach and academic detailing efforts.  

The more we are doing this work, the more we are finding that this approach is effective in getting care teams, medical providers, and service providers across many sectors into increased “philosophical alignment” which is critical to effectively foster culture change around issues of pain, addiction, and trauma. 

Anna: Bias, stigma, and gaps in knowledge around chronic pain and addiction are common, especially in primary care.  We’ve found that many detailers have been successful in helping providers “catch up” to society and overcome personal bias through their detailing visits.  Speaking of detailing visits, face-to-face visits have clearly been impacted by COVID-19.  Can you tell us more about other ways that COVID-19 has impacted the work at Synergy?

Nadejda: Again, we’ve gone back to the wisdom of the original academic detailing model.  The needs of each setting have changed significantly, and we’ve been pivoting our work to meet those needs.  Providers want to know how to best support their patients who are dealing with pain during this time.  One thing we were able to provide early in the pandemic was a list of recommendations and resources around pain management for both providers and patients. ​

Andrew: We saw the need to adapt to massive changes related to COVID-19, and to do so essentially overnight.  We’ve had questions about conducting urine drug screenings, initiating treatment over the phone, and maintaining the patient-clinician relationship. 

There’s also a shared vulnerability among providers and patients when visits are conducted virtually.  Our patients have had requests for increased medication use, which is understandable because they’re not able to do activities that they’ve typically been able to do to keep themselves resilient.  That conversation is a difficult one - in some ways it is easier because you don’t have to see someone in person, but it also makes for a very ineffective conversation because you’re not able to demonstrate your humanity through body language.  Our team is struggling to wrap our head around this as we try to provide leadership and guide clinicians who are looking to us, or our state, for collective ideas around this field and how we practice. 

Anna: COVID-19 has certainly impacted the way we think about responding to changing needs for those who are trying to manage their pain.  Can you tell us about some of the other major changes you’ve seen in pain management over the past few years?

Andrew: The biggest thing I’ve seen is insurance expansion.  We’ve known for years what you need to have effective pain management and how important it is to shift the idea of living with pain and accepting pain versus eliminating pain.  We’ve seen Medicaid expansion and expansion of benefits, especially in the Northwest, that has given patients access to modalities that are effective for safer pain management. 
​
Historically, things we knew that worked like, gym memberships, physical therapy, occupational therapy, mindfulness, and chronic pain groups, were never paid for or weren’t available.  As society has changed how it believes pain should be managed, we’ve started to see the insurance side supporting these modalities more.  There’s also been heavy reporting on the opioid crisis in the media that has led patients to understand that opioids have risks. 

Nadejda: We’ve continued to grow and learn as a team over the past several years.  Our entry point into communication around chronic pain and pain management has continued to be centered around assessing if patients and their care teams have an understanding about how pain works.  We want to make sure that clinicians have the proper training and are up-to-date on evidence and resources.

Andrew: We’ve known some of this information about pain management and how pain works for a while, but it takes many years to take what we know from as a research perspective and translate it into practice.  One of our roles at Synergy is to accelerate that.  We’re seeing our evolution as a group mimic and reflect the experience we’re having as a culture as we start to dial in to the most effective ways to manage pain. 

Anna: As Synergy continues to respond to changing societal needs around pain management, what insights can you share about the impact of academic detailing to date?

Andrew: One thing I’ve learned about academic detailing is that it’s only as effective as your intervention across an entire system. I’ve realized that any work that I’m doing is irrelevant unless I’m addressing the entire system and the culture.  If the front desk staff isn’t on board, if the medical assistant isn’t a believer, if the nurse doesn’t understand addiction, if the CEO doesn’t understand that the health system is already treating these patients, there will be challenges that will be harder to overcome. 
​
Nadejda: Because academic detailing has been an arm of a larger change approach we’re using, it’s hard to measure its effects.  We don’t have data to show that only detailing has moved the needle around these topics in these ways.  Sometimes I see academic detailing as the “cherry on top” after there’s a lot of work that’s been done in prepping a system. I’ve recently been doing practice facilitation work with providers and clinics just to understand the barriers in a system—there’s an art to the change process in the pain management space.  Academic detailing comes in after you’ve truly understood what the barriers are.  After you understand the barriers, you can bring in nuggets of evidence and information in a way that the system is ready to receive. 

Biography. 
Nadejda Razi-Robertson is the Managing Director of Synergy Health Consulting, as well as Synergy’s project lead for the Oregon Health Authority’s Prescription Drug Overdose Prevention Project. Nadejda is a practice facilitator within health systems around the State of Oregon and provides technical assistance to clinics that are focusing QI efforts around safe opiate prescribing, MAT program development, and behavioral health integration. Over the past twelve years, she has worked in private practice with a specialty in trauma treatment, as a behavioral health provider in two Federally Qualified Health Centers (FQHCs), and as a consultant with Oregon’s Coordinated Care Organizations (CCOs) and the Oregon Health Authority supporting efforts in addressing the opioid epidemic throughout the state of Oregon.

Biography.
Dr. Andrew Suchocki is a family physician with additional training in Preventive Medicine. He has worked in underserved medicine with a focus on chronic pain and addiction for ten years, and has been a medical director at an FQHC in the Portland, Oregon region for the past five. Andrew provides educational outreach and consultation in the areas of system change in primary care around opiate prescribing, MAT system design and capacity growth, coordinated specialty care, and reducing risk. Dr. Suchocki is an Oregon Opioid Prescribing Guidelines Task Force member and Oregon Medical Board consultant. He provides technical support and academic detailing for the Oregon Psychiatric Assistance Line (OPAL) which provides immediate referral sources for primary care. Dr. Suchocki also provides strategic planning, creation of innovative clinical decision support tools, physician mentoring, and health system process mapping for Yamhill County Health and Human Services, Community Corrections and Specialty Behavioral Health. He is a regular presenter at national and international pain related conferences.

An interview with Sarah Ball, PharmD, Research Assistant Professor, Division of General Internal Medicine, Medical University of South Carolina and Megan Pruitt, PharmD, Clinical Pharmacy Consultant, SCORxE Academic Detailing Service and Assistant Professor, Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina 
​
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: COVID-19, Opioid Safety, Stigma, Substance Use, Training

Anna: Hi Sarah and Megan- thanks for taking the time to chat!  Can you tell us a bit about your program, SCORxE, and how your AD work has concentrated on improving opioid safety?
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Sarah: SCORxE began in 2007 as an academic detailing service at the South Carolina College of Pharmacy and is now part of the Medical University of South Carolina (MUSC) College of Pharmacy. Our current efforts are around addressing the opioid epidemic. We’re fully funded by the South Carolina Department of Health and Human Services, and our agreement talks about  bringing together quality initiatives for safer opioid prescribing and expanding access to MAT.

We’ve been able to effectively bring together quality initiatives from different state agencies that span prevention and treatment. This braiding has been a unique experience for our academic detailing service. Regardless of the specific topic, our detailers promote opioid risk reduction strategies, help recruit and support MAT providers, and work to reduce stigma around MAT. We’re currently shifting our focus from chronic pain to acute pain. We’ll be detailing both primary care providers and surgeons on post-surgical pain.  

Anna: Detailing surgeons is a unique approach – we’d love to hear about the results of that process in the future. And you’re working on other topics outside of opioid safety, too – tell us more.

Sarah: Our providers always welcome new topics. While our focus is on the opioid epidemic, we try to expand our content reach when possible. We recently detailed on depression and anxiety screening, and touched on alcohol use disorder in our topic on naltrexone. We’ve always offered CME credits and our current strategy is shorter and more focused visits that offer a half hour of CME credit, as opposed to one or two hours of credit. This allows us to have multiple visits with each provider and to individualize next topic selection.
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Megan: As a detailer, it’s helpful to have a menu of shorter topics that providers can choose from – it makes our visits more flexible.  

Anna: Speaking of flexibility - how are you continuing to detail and run your program given the current COVID-19 pandemic?

Sarah: We haven’t previously engaged in virtual visits or e-detailing. We’re planning to reach out to our network of academic detailing colleagues who’ve had e-detailing visits in the past to see what their experience has been like. It’s times like these that show how valuable it is to have a network of academic detailing services. Being able to share ideas and find out what other folks have done will help us determine what will work best in our state.

Megan: We’ve been using the past few weeks to work on creating materials and scripts for upcoming topics. It’s been a good time to refresh on a lot of our content and update various internal documents. I’m going to begin reaching out to providers within the next few weeks and gauge their interest and comfort level in using a virtual platform. 
​
Sarah: We know this is a difficult time for primary care providers, so it’s important for us to be compassionate in how we go about scheduling visits. We want to be sensitive to our providers’ time and respect what they’re going through, while still offering our detailing service around topics related to the opioid epidemic.

Anna: You’re not alone in figuring out this balance! You also mentioned that peer learning is an important component to a successful intervention. Can you tell us about your own peers on your team, and how they enhance your overall detailing service?

Sarah: Our program is under the College of Pharmacy, so we’ve recruited all our detailers from there and they’ve all been clinical pharmacists. We’re fortunate to have pharmacists because they’re well-respected among providers we visit. We have two full-time detailers, which is a privilege, and they’re very passionate about their work. Being able to have two people fully commit to detailing is far greater than the number implies. Both of our detailers have different personalities and different experiences to share – I think they complement each other very well!
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Detailing can be lonely, though. When you have more detailers in your program that add up to two full time equivalents, what we have had in the past, you have more people sharing experiences during debriefs and more people to bounce ideas off; there are pros and cons to both scenarios.  

Megan: My colleague, Lauren, and I come from different clinical backgrounds. When we work on our content development and role playing, we’re able to help each other consider things differently. It’s been fun to work with somebody who differs so much from me!
​
Anna: It sounds like you balance each other out well. How are the detailers in your program trained?

Sarah: All of our detailers have gone through pretty intense academic detailing training on the marketing of evidence-informed clinical ideas. Our most recent hires have gone through NaRCAD training, but before there was a NaRCAD, our pharmacists went through a training developed by a group in Australia. That training gave us a step up on everything when we first started our program, as NaRCAD also does with programs just getting started. We garnered our baseline of how we develop content, how we develop our supporting materials, and essentially how we put together our whole intervention.

Anna:  It sounds like the detailers in your program are trained well and prepared for the field.  Do you have certain strategies for getting in the door? Are there key stakeholders who your program has connected with that have helped you to do this?

Megan:  Showing up at the office has repeatedly proven to work for us. We bring a letter to share with the first gatekeeper at the front desk, so that we can get face-to-face time with the providers for introductions. We’re usually able to schedule a meeting fairly easily after that. If we can’t meet with the provider face-to-face, we try to speak with the Office Manager. 
​
Recently, we’ve been leveraging our group presentations at clinics to get more 1:1 visits. We try to promote our detailing visits during our presentations and grab contact information from providers afterwards. We’ve also found that it’s been helpful to stay in the break room at an office after a visit - we might stay there all day and introduce ourselves to a number of providers who end up wanting to either schedule a visit that day or in the future. We’ve found great success in being present for providers when they’re ready. 

Sarah: When you can get face-to-face with the providers for a brief introduction, it’s a beautiful thing-it’s how we’ve gotten most of our visits over the years. When we first started, gaining access happened in different ways. We had champions in the area that supported what we were doing, and we could use that to get our detailers in the door. Our program was also previously part of a demonstration project where providers were required to have an academic detailing visit as part of the initiative. I would say that our cold calls became “warm calls” during that time because all the offices and providers knew we were coming.
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Anna: I’m sure having providers in the area know about your detailing service has helped to build your program. Can you tell us more about how your program is working towards sustainability?

Sarah: We’re more sustainable than we’ve been for a while. Part of that is due to the funding that we have for opioid-related topics, but it’s also been due to the effort our program has put into effectively bringing together different quality initiatives over the years. We’ve had funding come in from multiple sources in that process. 

One agency asked us to take on the topic of naloxone for pharmacists--our ability to respond to such requests helps up strengthen relationships, and may help us with future sustainability. It is also important that our interprofessional teams at MUSC see value in academic detailing.
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Additionally, our detailers help us with sustainability through their visit documentation and tracking. The data they collect is included in our reporting and helps illustrate the value of academic detailing. Our clinical pharmacists are amazing people, and they both bring so much to what we do in the academic detailing world– programs are only as sustainable as the strength of their individual detailers!

Biography.
Sarah Ball, PharmD is a Research Assistant Professor in the Division of General Internal Medicine at the Medical University of South Carolina (MUSC), with a focus on patient-centered care, patient safety, and educational outreach. She has had direct involvement with academic detailing for over twelve years, beginning with the development and implementation of the SCORxE Academic Service under the SC College of Pharmacy in 2007.  Current efforts include the integration of research and programmatic opportunities to identify interventions that change prescriber behavior to reduce the risk of opioid overuse, misuse, abuse, and overdose. Dr. Ball is currently leading the MUSC team partnering with the South Carolina Department of Health and Human Services for the provision of drug utilization review (DUR) services, which includes educational outreach to primary care providers and surgeons.  Dr. Ball has twenty plus years with a career focus on improving patient care through the application of technology and effective communication of clinical knowledge, information, and data-derived findings. She is a graduate of the Medical University of South Carolina, where she received both a B.S. in Pharmacy and Pharm.D.

​Biography. 
​Dr. Megan Pruitt is a South Carolina Offering Prescribing Excellence (SCORxE) clinical pharmacy consultant and assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the Medical University of South Carolina in Charleston, South Carolina. She received her bachelor of science in health science from Clemson University and her doctor of pharmacy from the South Carolina College of Pharmacy. She has published an Amazon ebook, Catalyst (pharmD): The Next Generation Pharmacy Student, and has previous experience as a community pharmacist at Federally Qualified Health Center in South Carolina. In her current role as a SCORxE clinical pharmacy consultant, she provides academic detailing visits to primary care providers on monitoring practices to promote safe opioid use and to reduce the risk of misuse and abuse in South Carolina. 

Winnie: We appreciate you taking the time to speak with us today about the work that MICIS (Maine Independent Clinical Information Service) has done supporting evidence-based prescribing since 2008, and safer opioid prescribing since 2016. Can you tell us a little bit more about MICIS?
 
Elisabeth: We’re a small program created by legislation in the state of Maine, housed within the Maine Medical Association. We serve over 8600 prescribers including physicians, pharmacists, nurse practitioners, and physician assistants across the entire state. Our two detailers are contracted to work about 5 hours a week each, which includes all of our administrative and detailing time.

​​​Winnie: That’s an amazing feat to be serving such a large population with a small team. How have you built and maintained all of those relationships?

Elisabeth: We have always used more of a general educational outreach approach than the traditional one-on-one academic detailing model. We have limited resources with our contract, and the only way to reach that number of prescribers is to do small groups or lectures.
 
Winnie: We understand that there are many programs who adapt the original model of detailing to allow for more than one provider at a time to participate. While it’s a common workaround solution to having limited resources and a long list of providers to detail, it can be more difficult to discuss challenging topics, especially something like opioids and related stigma. How have you been able to navigate those challenges?

Elisabeth: When we detail in our groups, we focus on small group discussions. One method I use involves flashcards with myths or biases about Opioid Use Disorder (OUD) and Medication-Assisted Treatment (MAT), and asking two or three of the attendees to discuss that amongst themselves. We have also used a language sheet that guides providers in what to say.
 
We have people talk about the language commonly used in practice, and how that can affect the care that’s provided. I think just like any other place, we encounter people who have all of the biases that you’ve heard of when it comes to opioid use disorder – that it’s not a disease, that buprenorphine and methadone are just trading one drug for another.
 
Winnie: There must be a lot to unpack when discussing the root of where these beliefs come from. It’s a core component of what we hope to achieve through academic detailing – an honest dialogue that leads to positive clinical practice outcomes.

Elisabeth: Exactly. I think it’s important to understand that, for example, with chronic pain prescribing, there are a lot of people who are reluctant to embrace evidence from the past five years that shows no benefit from opioids, and more significant evidence of harm. It’s been interesting to see how people have been stuck on what they learned twenty years ago, and to see them reject the newer information.
 
Winnie: It’s incredibly important that detailers remember in navigating tough conversations about stigma that there is a shared goal of promoting patient health. No provider undergoes training and hard work with the intention of harming patients.

Elisabeth: I think these tough conversations can produce some cognitive dissonance in people. Basically, if I, as a physician myself, agree with the premise that what I did fifteen years ago actually contributed to OUD in my patients, and if I admit that, then I also have to carry a burden that it was my fault. It’s a hard jump for people who made it their life’s work to care for people.
 
Winnie: It’s absolutely a human response. What have you found to be an effective way of addressing the problems caused by stigma, while also addressing the fact that providers are human?
 
Elisabeth: People don’t want to be overwhelmed by data, but repeated snippets of data over time can help you reinforce the message, which is what we do with academic detailing. I think of myself in my work as a physician – I started on opioid education projects more than half a decade ago. It wasn’t my top choice, but I became more and more educated about the crisis and heard the information in multiple ways. It really changed my way of thinking to the point of realizing I needed to be part of the solution. I received my X-Waiver back in 2016 and started prescribing buprenorphine.

Winnie: That’s a wonderful reflection on how repeated messaging helped change your mindset as a provider. It’s important to understand that people can change, no matter what holds them back.
 
Elisabeth: I think that as academic detailers, we might not always recognize the impact right away. We might not get the immediate positive feedback from a clinician after an interaction, but especially if you’re lucky enough to grow relationships with the people you detail over time, you can see the change. I think that’s the most effective and rewarding part of detailing.
 
I prescribe buprenorphine because I can teach about it, but I also do it because it’s important. This work gives us an opportunity to be leaders for people who don’t always have a voice, and because of stigma, aren’t being listened to. Most of our patients with OUD are on the margins and struggle even during stable economic times. Especially right now with the COVID-19 pandemic, the rest of the country may not be worrying about how we’re going to safely maintain our patients on buprenorphine, but we need to worry about it.

An interview with Tony de Melo, RPh, Director of Clinical Education Programs, Alosa Health
​by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Detailing Visits, Opioid Safety, Program Management, ​Training

NaRCAD: Tony, thanks for chatting with us today about your role at Alosa Health! What’s been the most exciting part of the work that Alosa has done this year? 
​
 
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.

NaRCAD: That collaboration does sound exciting!  Now, let’s talk a little about your role at Alosa.  You actively detail, you manage academic detailers in the field, and you lead trainings at Alosa. Which aspect of your role is your favorite, and why? 
 
​
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.  

NaRCAD:  As a coach, how do you know when your work has been impactful?

​
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.

NaRCAD:  With success comes challenges.  What are some of the major challenges you see academic detailers face in training and in the field?

​
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.  

In the field, the major challenge is access to providers. Many health systems have regulations and restrictions for those who want to meet with providers, because representatives in the pharma industry have bombarded and overloaded providers throughout the years.  As a result, we’re often seen as an outside influence or an outside visitor, so we aren’t always given the opportunity to meet with a provider. 

​
NaRCAD: With these challenges in mind, how do you instill confidence in academic detailers as a trainer and as a manager?

Tony: We spend a lot of time practicing and providing feedback during trainings.  We practice individually, with partners, and with outside folks who are playing the role of providers.  Practicing multiple situations, multiple times, over multiple days, builds confidence.  We also videotape the trainees so that they can see what they’re doing well and what they can improve upon. 

​
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.

NaRCAD:  Those are all great ways to build confidence among detailers. What’s one piece of advice that you would give to academic 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.  

NaRCAD:  That’s extremely helpful advice for detailers. What’s the best thing a program manager could do to maintain high levels of engagement among detailers?


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!

Biography.
​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.

​Director's Letter | Mike Fischer, MD, MS, Director of NaRCAD

​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.)

Although we have been conducting more trainings recently, we see the demand for them continuing to grow at an even faster pace. As we grow, so does our core team, and all of us are dedicated to amplifying the impact of the important work you do. We’re already starting to plan for NaRCAD2020, our 8th annual conference, and we invite you to consider submitting your ideas and innovations when we start accepting submissions on March 1, 2020. But you don’t need to wait until then—we’re here to offer you customized support to strengthen your program, as you plan for success in 2020 and beyond. ​
Happy New Year!
-Mike

​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.  

NaRCAD: Those are all familiar challenges across many of the programs we support. How did you maintain strong relationships with your detailers and support them in the work that they were doing in the field? 
​
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!

NaRCAD: These are all great reflections for AD program managers to learn from. Based on the successes and challenges of this pilot, where do you see your program in a year?

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. 

Biography.
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.

NaRCAD: Zack, thank you for taking the time to speaking with us today! RxFiles has been around for more than 20 years. What do you do you believe is driving the demand for the resources that academic detailing is providing?

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?”

​NaRCAD: Did RxFiles choose to launch its cannabinoid campaign with the passage of the Act, or has this been planned for a longer period of time?

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. 

​NaRCAD: Right now is a shifting and transformational time, especially with something like cannabinoids with a distinct history of stigma and legalization, even with all this new interest. As an academic detailer, how do you source your information knowing that there isn’t enough research out yet and a lot of gray area information? How do you begin to build a campaign around a topic like this?
​
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. 

NaRCAD: Is there any advice you would give any other academic detailing organizations considering this topic for a campaign?
 
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.

NaRCAD: Thanks so much for joining us to share how your detailing project has gone in Ware County, Georgia, Dr. Parks. Can you talk to us a bit about how the opioid crisis has presented itself in your community?

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. 

In public health, we’re facilitators, data people, and information sharers.  I really believed AD would work when I saw the statistics about Ware County during the 2-day training. Ware County is the highest prescribing county in the state, and the 12th highest prescribing county in the nation. Those statistics are eye-opening, and I believed that would make detailing successful in Ware County by raising awareness of how the opioid crisis is impacting our own community.

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. 

NaRCAD: That’s excellent—this is an example of how pre-existing relationships and a fusion of both experience in clinical care as well as public health can really merge to encourage change. What else was unique about your detailing experience?

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. 

After answering initial questions about where the data came from, clinicians were open to discussing things in more detail, and were consistent in enacting the CDC’s opioid stewardship recommendations, especially consistently using the PDMP. It also gave clinicians the opportunity to express concerns and challenges they face in their daily practices.

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.”  

NaRCAD: That’s a great way to handle that kind of situation, and academic detailers are indeed the connector to resources, and certainly don’t need to know all of the answers. Well-handled! And speaking of not knowing all the answers, what is something you wish you knew prior to joining the LOOPR Academic Detailing project?
 
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.

Via NaRCAD, NACCHO, & the CDC’s pilot project, “LOOPR”, we were able to connect with high-burden counties across the U.S. whose rates of high prescribing and high fatal and non-fatal overdoses identified them as a county in need of support. NaRCAD worked on the implementation of an academic detailing initiative over the course of 2017-2019 with Boone County, located in rural West Virginia.
 
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.

​One of the most unique approaches across all 5 sites of the LOOPR Project was carried out in Boone, with the team of 5 detailers being hand-selected from the nearby University of Charleston West Virginia’s School of Pharmacy. Four of these five recruited detailers were students in training to become pharmacists; one detailer works at the university as a professor of pharmacy. Selecting pharmacy students and faculty allowed for many positive approaches to the project, as well as creating unforeseen challenges.
 
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.

a reflections from Boone County’s Detailing Team, it’s clear that best practices in detailing should also consider the vast amounts of new information that students are absorbing early in their learning careers, and that learning clinical content may take longer to grasp. In addition, the comfort level with new clinical information may lead to less confidence in discussing best practices, especially with clinicians whose careers are much more established. Finding the right balance of tenacity, communications savvy, more time to ramp up to comfort in delivering and leading 1:1 sessions, an additional amount of technical assistance provided at more frequent intervals, and additional practice time or shadowing time with a mentor, can all benefit student detailers who are training to join a clinical outreach education team in a high burden area.
 
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.

​Other reflections from the Boone County AD Team included looking carefully at the social climate in which AD interventions of this nature may be implemented. While no county is free of potential clinician-level or community-level stigma, particularly around issues such as opioid use disorder, Boone’s AD team shared a particularly challenging setting within which the local community was not as supportive of evidence-based harm reduction initiatives as would be beneficial. One detailer’s suggestion to raise the visibility of and advocacy for harm reduction included considering a public health campaign prior to a detailing campaign, to ensure that subsequent roll-out of detailing is more sustainable and met with an openness from clinicians to consider behavior change.
 
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.

NaRCAD: Hi Lutricia, thanks so much for taking the time to speak with us about your work as an academic detailer for the opioid crisis in your community. Can you talk to us about how the opioid crisis has presented itself in Bell County, Kentucky?

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.

​NaRCAD: Thanks for sharing your perspective, Lutricia—it can be true that some clinicians don’t see the impact of their role in prescribing opioids, and many times may believe that people who develop an opioid use disorder do so because of a moral failing, rather than seeing it as a medical issue. Did you think 1:1 outreach, provided directly to prescribing clinicians, would lend itself to improving patient health in response to the opioid crisis in this community?

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.

NaRCAD: Thank you for sharing that Lutricia; the opioid crisis is personal to so many of us. What would you say has been the most impactful piece of this academic detailing intervention as you went into the field and spoke with clinicians?
​
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.

NaRCAD: Getting in the door is definitely a consistent challenge across many programs. We’ve heard from other detailers that practice makes perfect, and sometimes it’s easier to gain access when you actually show up and request a meeting in person. What else did you learn after being in the field?
 
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.

​NaRCAD: Thanks for joining us to talk about academic detailing in St. Francois, Amber. Let’s start the conversation with some background information about your county. How has the opioid crisis presented itself in your community?
​
​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.   

NaRCAD: Why did you think the strategy of academic detailing would lend itself to improving patient health in response to the opioid crisis in your community?
 
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. 

NaRCAD: So, it sounds like it’s been a success so far. What would you say has been the most impactful piece of this intervention?
 
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.  

NaRCAD: That does sound frustrating! During our 2-day training, we really emphasis the importance of asking open-ended questions to draw clinicians out. However, there will always be some clinicians who will not engage, no matter how great of a detailer you are. Victoria Adewumi from the original cohort of LOOPR detailers discussed that in a prior blog post. What is something you wish you knew prior to joining the LOOPR Academic Detailing project?
 
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.

NaRCAD: Can you tell us about your background? How did you become an addiction treatment specialist?
​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.

NaRCAD: How does Academic Detailing lend itself to the opioid crisis?
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. 
​

NaRCAD: There is a huge problem with stigma when it comes to opioid use disorder (OUD), as with any substance use disorder. How can we combat stigma?
​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.  
​

NaRCAD: We have heard from detailers that many clinicians ask "isn't medication-assisted treatment (MAT) just trading one drug for another?" What do you say to that?
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. 

NaRCAD: Based on all your research and knowledge, what can be done to stop the opioid crisis?
​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. 
​

An Interview with Johnathan Goree, MD
Director of Chronic Pain and Opioid Stewardship
University of Arkansas for Medical Sciences
NaRCAD Training Alumnus

​by Kristina Stefanini, Program Coordinator at NaRCAD

​Tags: Detailing Visits, Opioid Safety, Training 

​​NaRCAD: Thanks for talking with me today! Can you tell me a little bit about yourself and how you ended up in pain management?

​​Johnathan Goree: I’m from Arkansas originally. After completing college at Washington University in St. Louis, medical school and residency at Cornell, and a pain medicine fellowship at Emory, I was recruited to start the chronic pain division at the University of Arkansas for Medical Sciences – 2 miles away from where I went to high school. I’m proud to work in Arkansas; Arkansas is such a poor and rural state, so we don’t often have the resources that other states have. 

I went into anesthesiology because I wanted to be the best prepared doctor for an emergency, but I moved into pain medicine because I missed the 1-on-1 patient contact and longitudinal patient care. Here are some other things that lead me into pain medicine. After getting my wisdom teeth removed, I was given too much fentanyl during the procedure resulting in being given Narcan to wake up. 

​That was the first time in my life I experienced 10/10 pain.  It allowed me to understand how pain can completely dominate someone’s consciousness. I am also passionate about pain management in minority communities. Many in those communities feel that their pain is undertreated, and evidence backs that up. 

NaRCAD: As a physician, what are some of the barriers that detailers may have talking to clinicians about pain management? How can these be navigated?​

Johnathan Goree: Every physician will say the number one barrier is time. While most physicians are excited to learn about anything that will improve patient care, unfortunately, physicians are usually not in control of their schedule.

​NaRCAD: How can clinicians act as champions in an academic detailing campaign?
 
Johnathan Goree: One way physicians can help is with the crafting of educational materials. Physicians know how physicians think and can help by crafting a message that may better catch attention.   
 
Another is by dedicating time to answer follow-up questions from detailers and other clinicians.  In my field of chronic pain management, detailers that don't have a clinical background may not know how to answer questions on specific off-label situations or treatment of specific pains. A follow-up visit or call with a clinician can help with that. 
 
NaRCAD: Anything else you’d like to add for our readers?
 
Johnathan Goree: More praise for you guys – your course is excellent! Really understanding the science and method behind academic detailing made me excited to be a part of it. I hope more physicians engage both as detailers and as champions. I think it’s really important. 

Biography. 
Johnathan Goree, MD, Director of Chronic Pain and Opioid Stewardship
​University of Arkansas for Medical Sciences
​​Board certified in anesthesiology and pain medicine, Dr. Johnathan Goree received his Bachelor of Arts in biology from Washington University in St. Louis.  He then moved to New York City where he completed both his medical degree and a residency in anesthesiology at the Weill College of Medicine at Cornell University.  Following his time in Manhattan, he completed a fellowship in chronic pain medicine at Emory University Hospital in Atlanta, Georgia.  In 2014, Dr. Goree returned home to Little Rock, Arkansas to join the faculty at University of Arkansas for Medical Sciences where he serves as the Director of the Chronic Pain Division and an Assistant Professor in the Department of Anesthesiology. He primarily focuses on the treatment of chronic pain conditions using opiate sparing, minimally invasive techniques.  His specific research interests include complex regional pain syndrome, neuromodulation, and the effects of opioid education initiatives on patient outcomes.    

An Interview with Victoria Adewumi, MA, Community Liason, City of Manchester Health Department
NaRCAD Training Alumna
by Kayland Arrington, MPH, Program Manager at NaRCAD

Tags: Detailing Visits, Opioid Safety, Program Management, Training

​NaRCAD: What has your experience been as a detailer who does not have clinical experience but who does have public health expertise? Is someone able to be effective as an academic detailer without as much prior clinical training?
Victoria: My experience has been extremely positive! I care about community, and I thought this was a great opportunity to gain new expertise in this field. I’ve always felt that a community perspective is needed for us to be able to leverage our impact in this field.
​
​The NaRCAD Academic Detailing techniques training was fantastic in helping me build tools to be able to speak well and motivate clinicians around medication-assisted treatment (MAT). My goal as an individual detailer is always to present myself as being on the same team as clinicians. I really see detailing as having a solution for clinicians, rather than simply trying to sell them an idea. 

NaRCAD: You have mentioned the power of the team of detailers--can you tell us how the Manchester AD came to be so strong and effective?
Victoria: I didn’t know any of the other detailers before the project. The NaRCAD training was great as an introduction to the work and to each other. We all had a sense of hope that was immediately apparent. We have the privilege of doing work that helps save lives and because of this attitude, there was a sense of camaraderie right away. We’ve been effective because our AD team is strong, and it was strong because we were intentional about building bonds. During the implementation period, we never went more than a month without checking in with each other, and sharing successes and challenges.

​I don’t think I would have enjoyed the process as much if I didn’t have this amazing AD team of colleagues. We’ve had incredible success in building a team of detailers who are all committed to and excited about the work of connecting with frontline clinicians to improve patient care around opioid safety. ​

Tags: HIV/AIDS, Opioid Safety, LOOPR, Training

​​This New Year, NaRCAD has new staff, new partnership sites, and will be addressing critical topics in health. We’ve had a successful 2018, and we’re already working hard to improve patient health through clinician education in 2019. 

One of the main topics we provide support on is HIV prevention for high-risk patients. While it is true that rates of HIV are declining in some populations, other groups are still very much at risk for developing HIV. According to the Centers for Disease Control (CDC), half of all black men who have sex with men will contract HIV in their lifetime. These statistics are staggering, and NaRCAD is doing everything we can to help by engaging directly with frontline providers who can communicate best options for prevention directly to their patients. We do this by training academic detailers to meet with clinicians to offer tailored, evidence-based clinician recommendations. 

​In December, we traveled to Las Vegas to facilitate an AD training to increase prescriptions of Pre-exposure prophylaxis (PrEP). PrEP is a daily medication prescribed to people with a high risk of developing HIV. The CDC reports that PrEP reduces the risk of getting HIV from sex by more than 90%; it also reduces the risk of contracting HIV from injection drug use by more than 70%. NaRCAD is continuing our work in 2019 to train health educators to talk to frontline clinicians about the benefits of prescribing PrEP to their high-risk patients. Our first training of 2019 is in February at the PrEP Public Health Detailing Institute in San Francisco, hosted by our partners at the San Francisco Department of Public Health.                                       

​We’ve also added on 2 new sites to our county-level LOOPR Partnership! We will be traveling to St. Francois County, Missouri and Ware County, Georgia in March. The CDC has identified 220 counties (5% of counties in the nation) that are at highest risk of HIV and/or Hepatitis C as a result of the opioid crisis. St. Francois County, MO is ranked 69 out of those 220 counties. Ware County, GA is located in the southeast corner of the state and doesn’t have as much access to resources as counties more centrally located. NaRCAD is excited to join both of these high-burden counties in their efforts to reduce harm from the opioid crisis.

One element that is a common thread with both HIV and the opioid crisis is the fact that these are both highly stigmatized clinical topics. Along with community stigma, clinicians themselves may be inadvertently biased against patients with substance use disorder and/or those at high risk for developing HIV. As the result of a fear of stigma, it’s also common for patients to refrain from sharing high risk behavior with their providers.   To ensure that front line clinicians increase PrEP prescribing and work to treat pain in safer ways, the academic detailers we train this year will also explore ways to address clinician stigma.

​Along with our county-level support, we’ll also travel to Tennessee, Oregon, and Maryland this year. And as always, we’ll hold our usual Boston home trainings in May, July, and September before our year comes full circle at our 7th Annual International Conference on Academic Detailing in November. No matter how we connect in the year ahead, our entire team is looking forward to supporting you in 2019—let us know how we can help, and stay tuned for more updates here on the DETAILS Blog.

Biography
Kayland Arrington, MPH | Program Manager, NaRCAD
Kayland earned her Master’s Degree in Public Health from Boston University, with concentrations in Health Policy and Law and Maternal and Child Health. She has experience coordinating suicide prevention and awareness programs. She also has experience in health promotion and education on topics ranging from substance use disorder to sexual violence. Kayland is passionate about improving access to resources, supporting population health programming, and is an advocate for evidence-based medicine. Read More.

Tags: LOOPR, Opioid Safety, Stigma, Substance Use, Training

​EDITOR'S NOTE: Manchester, New Hampshire, was the third site of four selected for a 2018 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. Four sites experiencing significant public health problems related to opioids were selected 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, with Manchester’s team focusing primarily on access to Medication Assisted Treatment [MAT]. As year 1 comes to a close, we’re showcasing successes from the field.

Thanks for talking with us about your work in Manchester, New Hampshire. Can you tell us about your team? How were detailers chosen to represent the health department for this pilot project?
Carol: Tim Soucy, from the Manchester Department of Health, contacted representatives at each of our organizations and gave a little bit of information about the training. He asked if our organizations had particular people that might be interested, and my supervisor thought of me, since I was in the middle of developing a MAT program for my organization. I jumped at the chance to participate.
 
Jill: My organization received the same email, and as the primary care lead nurse practitioner, I was considered the most appropriate to participate.
 
Katie: The invitation came from the site that received the CDC grant (City Health Department). The invitation was disseminated among a number of local human service/health agencies who are part of a Network of agencies as a result of our 1115 Waiver partnership.

The NaRCAD team came to your site back in March, 2018, helping you get ready to be ‘in the field’ and talk to clinicians about the opioid crisis. Tell us how that went, and how you applied what you learned in training.
Carol: I’m a naturally shy person who dislikes being the center of attention, so I was incredibly nervous about the role plays during training. The turned out to be invaluable, since I use the skills I developed through practicing and receiving feedback during every visit. The role plays prepared me so well for meeting with providers, and I go into the conversations feeling confident and comfortable. When they ask questions, I feel that I know how to answer, or where to turn for more information, such as the wonderful handouts available on the NaRCAD website.
 
Jill: For me, learning how to hold a discussion as a detailer was the most important element of the training. I learned how to frame a conversation using open-ended questions, which allows the discussion to progress. Understanding how to simultaneously get a provider’s perspective, while also giving them the information they need, is a critical detailing skill.
 
Katie: We were able to role play, which has proven very helpful out in the field to stay focused, on topic, and empathetic to the position of each clinician that I speak to. The handouts that NaRCAD provided have easy to read information and great graphics, so they have also proved useful for staying on track with the key messages during detailing visits, along with providing supplemental information.

​The opioid epidemic has affected many communities in unique ways. How have local clinicians responded to your visits? What do clinicians in Manchester see as major barriers to improving health for their patients struggling with this issue?
Carol: Clinicians can be a little skeptical at first, since they’re often expecting that I’m going to try to “sell them” on something. When I focus on listening to their experiences and their concerns, I’m able to gently address those concerns and give resources or suggestions. Even just having a discussion can help clinicians to feel that you’re interested in how they feel, and that you genuinely want to help them – I would describe some clinicians as “dumbstruck” from our conversations, because they’re preparing to do battle with me, but they instead come to see me as a resource, and are more willing to meeting with me.
 
As for challenges, we deal with a fair amount of stigmatization of substance use. It’s a major barrier, and we’ve had to spend a lot of time addressing that in my organization. Another barrier for clinicians is a preconceived notion that providing MAT is an onerous process, and too time-consuming to add into their schedules. And these two barriers really complement each other in a bad way – I often get providers saying that MAT is too much work and that their MAT patients will just end up using opioids again and ending up back in the emergency room. Breaking down these misconceptions about MAT and getting to the root of the stigma against MAT is a big challenge.
 
However, we’re approaching these challenges with education and lots of conversations, since we’ve found that helping our staff to get a better sense of addiction as a disease is really invaluable to making them more open to MAT and treating people with opioid use disorder. The timing of the academic detailing initiative couldn’t have been better for my organization, because having conversations about addiction leads well into having conversations about MAT, and vice versa. Engaging in academic detailing has opened up a whole new avenue of clinician education for me.
 
Jill: Because of my role at my health system, I talk to providers about many different topics and they’re used to me approaching them, which has definitely helped give me and automatic “in” and bring up sensitive topics. My institutional knowledge helps too, since I can answer questions specific to my organization and our various programs or resources around opioids. 

A major challenge I face is that providers don’t think they have the time and resources to implement MAT into primary care, and they don’t feel they have the behavioral health support to do so successfully. However, I’ve found that this is often based around a lack of knowledge, since when I ask more probing questions about MAT, it’s often clear that they don’t really know much about it!

​Providers will come to conclusions without getting the right education, and I find that they often “change their tune” when I give them more information. Providers are also hesitant about writing a prescription for a MAT patient if there isn’t someone in their office who can talk to the patient about addiction itself. Right now, we’re working on integrating behavioral health clinicians into primary care, which I’m hopeful will help with this very real concern.

Katie: There has been some hesitation in sharing with detailers, in regards to professional experience, as I believe most clinicians are on edge in trying to do the best that they can to address patient needs, while also supporting alternatives to typical or historical use of prescribed opioids. With an empathetic and interested stance, I’ve found that most clinicians are open with their experience and struggles.

There are a number of themes among clinicians for challenges that I’ve noticed, including a limited behavioral health workforce to support what they view as an ideal MAT protocol, which would include individual and group counseling, regular urine toxicology screens, and wraparound services along the continuum of care. In addition, there is a concern among providers about the potential diversion of Buprenorphine by patients.

Lastly, what advice would you tell new detailers? What do you wish you knew when you started out?
Carol: I would tell new detailers to take a deep breath and know that you’re ready for this – NaRCAD does such a good job of training us as detailers, and you just feel ready. 
 
Jill: I would say to recognize that everyone has a natural process for adapting to new ideas. You’ll get some providers who are ready and energized, some who will want to watch others in action before they jump in, and some who simply may not be interested. It can be frustrating when providers aren’t interested in your topic or resources, but understand that this is natural, and don’t take it personally! Every visit will be different, and that’s okay.
 
Katie: My advice is to remember that success is not defined as “convincing” someone that the topic of your detailing visit is “the right answer”. In fact, trying to convince another person of anything is essentially walking against waves. Instead, be open to listening to that person and their experiences, and then value the experience that they have had. This is more likely to open the conversation to allow you to share your wealth of information and experiences. It’s all about planting seeds.

Featuring: Robin Tuttle, RN, ER Nurse, Academic Detailer, NaRCAD Training Alumnus
Interview by Kabaye Diriba, Senior Program Analyst, NACCHO, in partnership with NaRCAD

​Tags: Detailing Visits, LOOPR, Opioid Safety, Rural AD Programs 

EDITOR'S NOTE: Bell County, Kentucky, was the first site of four selected for a 2018 pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of City and County 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. Four sites experiencing significant public health problems related to opioids were selected 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 1 comes to a close, we’re showcasing successes from the field.
 
Thanks for talking with us about your on this pilot project with NACCHO, the CDC, and NaRCAD, working to support local efforts in your community.
Robin: What we’ve been doing has been a breath of fresh air! I'm proud to be a part of it, and happy to help in any way that I can.
 
Tell us how local detailers were selected for this project—what kinds of professional backgrounds make up your diverse team members?
Robin: ​I was asked by a co-worker, another detailer, who thought “I know this really outgoing, outspoken person that might fit the team.” Our team is made up of people that have hands-on knowledge about the opioid epidemic. I’ve been in healthcare since 1988 and I’ve been living here in Bell County for 30 years. I started working as a nurse aid at one of the local hospitals and then went on to college to get my RN.  Our detailing team all had a common interest when we got together. 

​What elements of the training do you apply most often during your visits when delivering your key messages?
Robin: What helped me the most was that last day of training when we were practicing academic detailing. Asking open-ended questions is the most important thing. You get so wrapped up in wanting to deliver your messages, but it’s not necessary that you get all of your messages in on that first visit. You may feel rushed to deliver all your messages if you’re afraid you’re not going to make it back in the door, but what I found is the more I met with doctors, and the more I said things like, “What have you seen in your practice?” or “Tell me about a patient…” or “Talk to me about the problems you’re having…”, the more I saw the conversation open up. That’s something I really picked up on the second day of training—learning to turn it back around and asking [needs assessment] questions. Let them get involved, and let me really listen to what they have to say; that way it'll help contribute to the conversation going forward.
 
The opioid epidemic can be a sensitive topic. When you approach clinicians to discuss their behaviors around the opioid epidemic, how are you generally received? What do clinicians in Bell County see as major challenges in your community?
Robin: ​Almost everyone I spoke to was very receptive about everything that we talked about, including all 5 of our campaign’s key messages. Because treatment in this area is slim to none, it all circled back to, “What if I find someone [a patient] that has opioid use disorder? How can you help me?” Doctors here are telling me that even people that have overdosed and come to the hospital are having a hard time [getting access to treatment]. There are places that are not in Bell County, but we would need some sort of transportation system that could get patients to those places. 

What challenges do Bell County clinicians face, along with being busy, when trying to support their patients who are prescribed opioids?
Robin: ​Clinicians are often challenged in identifying symptoms of someone with opioid use disorder. Also, sometimes patients are sent to a pain [management] clinic, but those don’t always work. In our community, we can send them to the local Suboxone clinic which is accessible and easy to get to.
 
When it comes to Suboxone, you cannot look at it as an “all-or-nothing” approach. That’s a challenge here in Bell County, trying to get the community to know that abstinence is not always the answer, and sometimes people might have to take some form of medication for life to get the wiring back together that they've already lost because of their disorder.
 
I also understand some of the doctors are adamant about their current patients that have been taking these medications for 25 years for this chronic pain, which they don’t think they can do much about, and they’re concerned about this newer generation [of patients] coming in.

What have been some of the more rewarding exchanges you’ve had with clinicians you’ve met with?
Robin: ​I've had a lot of good visits, but this one sticks out in my mind: there was one clinician where I felt immediately like I was going to get the “brush off”. But I ended up staying for an hour and a half! I sat there with this doctor, who I’ve had a challenging professional relationship with historically, and he ended up talking to me at length about patients he was seeing, and those he had inherited. I was so excited that I’d spoken with him for so long, and that I’d covered all 5 of our campaign’s key messages. I walked away from that visit with questions to follow up on that I wanted to be able to answer for him at a future visit, and I felt like I made a new friend. 

What do you want to tell new detailers who are just starting to form teams and try this kind of 1:1 outreach education model out with clinicians in their communities? What piece of advice would you have appreciated when you started your first detailing visits?
Robin: ​Try not to get discouraged! After we divided up all the physicians, we started making phone calls. That can be discouraging. I found out we actually had more luck stopping by. We called it the “drug representative look”: you dress up, put your badge on that says academic detailer, have the clipboard and all the paperwork, and you look professional. I really found out that I had more luck by just walking in and saying, “Do you have a minute?”
 
Don’t get discouraged if you're making calls all day long and they keep putting you off, because receptionists are making appointments all day long too and it’s hard to explain what you’re doing over the telephone. We definitely felt discouraged during the first couple of weeks of outreach. We were feeling like we hit a brick wall, and that’s when we coined the term "drive-by” detailing visits. We started driving around and just showing up at offices. So, get out and drive if you can’t get through over the phone. Go with a card and introduce yourself. They [clinicians] all want to talk about opioids. You'll be surprised when you get in the room with them and they start talking.

Tags: Director's Letter, LOOPR, Opioid Safety, Rural AD Programs, Training

​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.