This interview features Carla Foster, MPH, who leads the conceptualization, implementation, and evaluation of Public Health Detailing as an Epidemiologist within the Bureau of Alcohol and Drug Use Prevention, Care and Treatment (BADUPCT) at the New York City Department of Health and Mental Hygiene (NYC DOHMH). She is currently activated for the COVID-19 emergency response as Lead Analyst managing the Reporting Unit within the Integrated Data Team of DOHMH’s Incident Command System.
 
By Winnie Ho, Program Coordinator

Tags: Data, Detailing Visits, Evidence-Based Medicine, Health Disparities, Program Management, Stigma, Substance Use, Training

Winnie: Hi Carla! You’ve certainly had a lot on your plate with so many diverse campaigns. Can you walk us through the conceptualization process for your detailing campaigns, and how your team came to choose cocaine use as your current detailing topic?
 
Carla: We can start with some data on this. In 2018, more New Yorkers died from drug overdose than from homicide, suicide, and motor vehicle crashes combined. Cocaine – in both crack and powder forms – has played an increasingly prominent role in this crisis. The mortality rate from overdose deaths involving cocaine more than doubled between 2014 to 2018, amounting to 52% of all drug overdose deaths in NYC. Some of the associated risks are serious - increased exposure risk to fentanyl, cardiovascular disease events and death.

W: That’s stunning data. Especially in the midst of the opioid crisis, it’s important that we don’t lose sight of other substance use issues going on right now. I’d love to learn a little more about the challenges and lessons that your team has learned by detailing on cocaine use.
 
C: First, we have to be aware that fentanyl, a powerful opioid 50 to 100 times stronger than morphine may be found in many substances, including cocaine. We’re very concerned about fentanyl and cocaine because people who use cocaine do not have tolerance to opioids and are at even higher risk for overdose.

It’s also important to address the perception of who is most impacted by high mortality rates. There’s this idea that cocaine use is more prominent in younger populations, but our data show that it’s actually impacting an older population more than many might expect. In particular, residents age 55-84 in the Bronx Borough have experienced the largest increase in cocaine overdose death rates in New York City from 2014 to 2018.

That’s why it’s critical for us to raise awareness in an effort to mitigate misconceptions and stigma around risky use and those who may have a substance use disorder (SUD). In addition to shame, there are still very real potential socioeconomic and legal consequences from disclosing substance use, which can deter folks from even seeking help.
 
We take into account the unjust consequences of policies applied unevenly according to race, and how this impacts implicit biases in terms of which patients are thought to use substances, which types of substances they might use and even more critically, which type of treatment, if any, they are offered. Implicit biases combine with the effects of systemic racism to compound these consequences. It’s important to note that it’s not race that drives poor health outcomes, but racism.

​W: Challenging stigma is one of the most powerful ways that detailing campaigns can combat the damage done by the War on Drugs, because stigma can make the difference of whether or not people receive dignified care. With a campaign so focused on addressing stigma and with a topic this important, how do you prepare your detailers for this task?
 
C: We devote a significant amount of time towards training our detailing reps – a week-long training, 8 hours a day. We spend a large amount of that time talking in detail about stigma as related to cocaine use. It’s critical to us that our detailers are comfortable and knowledgeable when speaking about this topic, because it sets the tone for the providers who then set the tone for their patients.

We ensure that our representatives are prepared to respond to a wide range of questions or comments, because this builds the provider-detailer relationship and enhances the value of the detailing visit. We’ve found during our follow-up visits that this support has led to high provider engagement with the campaign and providers reporting incorporation of the key recommendations into their daily practice, which is the aim of our public health detailing campaigns.

W: How have providers responded when detailed on a topic that carries so much stigma?
 
C: The good news is that we’ve found NYC healthcare providers to not only be receptive to our work on substance use, but they’re eager to partner with us to support their patients once they learn about the severity of the issue.
 
Our team provides statistics that relate to the provider’s specific neighborhoods and specialty, giving them real-time pictures of what’s happening with the patients they see. We know that it’s still a difficult topic to bring up, so we help address this with our action kit resources on stigmatic language and counter-top brochures that signal to patients that the provider’s office is a safe place to discuss these issues.

W: It gives me tremendous hope to hear about that there’s been enthusiastic response from providers. It means that things are changing.
 
Let’s also talk a bit about program sustainability. Your team has worked extensively on campaigns across multiple topics. What have you learned from implementing past campaigns?
 
C: Each public health detailing campaign is different, but we’ve learned some key strategies that support the growth and success of subsequent campaigns:

• ​Sending an introductory letter, about 2 weeks in advance, signed from the Deputy Commissioner of our health department outlining the campaign and encouraging participation, helps gain interest.
• Using a standardized visit workflow that all of our detailing representatives follow to ensure that key components are covered is key. Ours is still flexible enough for the detailers to meet the specific needs of each provider, which really helps with the uptake of the action kit and clinical practice recommendations.
• We meet as a team and evaluate our program weekly, allowing us to continuously adapt and to implement any necessary adjustments.
• Incorporating promotional items inscribed with the campaign’s logo and NYC DOHMH logo. For the cocaine campaign we distributed hand sanitizer and pens to detailing targets. These items serve as highly visible reminders of the campaign mission and have the potential to be incorporated into daily usage by the targeted health care providers.

 
Our overall goal is to do everything we possibly can to improve the health of our fellow New Yorkers. I like to remind our detailers of this James Baldwin quote that informs our public health detailing mission: “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!

Carla Foster, MPH is an Epidemiologist at the New York City Department of Health and Mental Hygiene (NYC DOHMH). Her research focuses on the implementation and evaluation of public health detailing campaigns across New York City with the aim of reducing overdose mortality. Prior to joining the NYC DOHMH, she led development of clinical practice guidelines at the American Urological Association. She received dual Bachelor of Arts degrees in Africana Studies and Neuroscience from Wellesley College. Carla also obtained her Master of Public Health Degree in Epidemiology from Columbia University.

Winnie: Thank you both again for joining us today! In one of our past technical assistance discussions together, we’ve gone into depth about some common clinician stigma and barriers. In particular, you shared with us that because New Hampshire was a lower incidence state for HIV, you would encounter clinicians who felt that that particular issue didn’t really fall within their patient population. It’s a common barrier we hear from many detailing programs, whether they address opioid use disorder (OUD) or infectious diseases. Can you go into more depth about your experiences with this phenomenon, and how you’ve addressed it? 

Megan: Providers are extremely busy, and they’re often expected to be an expert on so many topics. Our program helps bring providers filter through new information so they can start to bring it up with their patients. By walking them through the best practices, the recommendations, and local and state-specific data, we can show them that it’s something that is impacting their patient population.

In addition, one of the things that stuck with me from the NaRCAD training we attended was that because there’s so much new information, providers would be expected to read up to 17 papers a day just to stay current. Something like HIV would be one of many things that providers are concerned with on a daily basis. Our job is to help bring the most relevant and evidence-based information to the surface for them and their patients.

Jess:  Megan is completely right on this!  I’m in provider offices a lot.  What I hear is that they often feel like they're just treading water and not able to keep up with new information.  What we try to do is bring that info to them in a way that doesn’t feel like just one more thing to squeeze into a day.  When we talk to them about stigma, we don’t want to start there.  We want to start with some easy and really useful information and tools that will make their job easier.  By doing that work first, they feel like the precious time they are giving to us is worth it.  After a couple visits, emails, or phone connections have happened, that's the time to bring up new approaches and topics.

Winnie: I really appreciate that your lens on this barrier embodies a ‘How do we best support you?’ attitude. The goal of academic detailing is to navigate and close knowledge gaps in hopes of changing clinician behavior. Sharing knowledge and having difficult conversations is our best tools to address clinician stigma and discomfort. It’s not a battle against them and certainly the goal isn’t to shame clinicians. This is a collaborative operation to improve health outcomes.

Megan: Right, in the end, our mission is to close health inequities altogether. If I were a clinician and wasn't comfortable or familiar with best practices for preventing HIV, then I might feel a high level of hesitation trying to broach something like taking a sexual history from my patient. But if it’s something that I get more comfortable with, I’m more likely to bring it up and ask the right questions.
 
Ultimately, we’re trying to build a relationship with the provider so they see us as a resource when a new practice, tool, or clinical guideline comes out. They can then use those tools and information to address stigma that a patient may be experiencing. Providers constantly have new information and guidelines thrown at them, and we would like to help make it easier for them to take that information and apply it in their daily work.

Jess: Whenever I address something uncomfortable with a provider, stigma or otherwise, I try to create an environment where we can work collaboratively on the issue and the provider feels as though I am a resource for them.  I will say something like, ‘the last we talked, you mentioned this to me and it really got me thinking….” Or “I was talking with a colleague the other day about….” Then I will find a way to circle back around to the original topic.  By approaching the topic in this manner allows them to feel we are a partner and have a shared goal.

​Winnie: I want to circle back to your team’s mission of addressing health inequities. Inequity is the core of why we discuss things like stigma and discomfort. We need to approach clinician stigma with a human approach, but we also need to address the very real impact that it can have on patient health outcomes.

Megan: In a mostly rural state like New Hampshire, healthcare access is limited to begin with, and clinician stigma could drive patients who need help to either forego care or have to travel very far to seek care that they are comfortable with. We know providers want the best outcomes for their patients, and through detailing, we want to help the providers achieve those outcomes. Looking at potential stigma is one of the keys to making sure we address health inequities.

​Winnie: A lot of these experiences about clinician stigma are anecdotal, but as you just outlined, they have a very real impact on health outcomes. From our previous call, we have discussed and imagined a tracking tool for these encounters with clinician stigma and barriers. What would you find useful about a tracking tool like this, and what would you hope to learn from the data?

Megan: A tracking tool would help us better understand and represent the stigmatic responses that are out there. It would help us focus our efforts to help a provider address stigma in their practice. Anecdotes are helpful, but it can be hard to grasp. We don’t want to make decisions by theorizing what patients are experiencing. As a small state program with limited resources, this would help us optimize our response and to make sure we’re heading in the right direction by seeing if stigmatic behaviors change.
 
Winnie: It would be extremely exciting to see a tool like this become available and specialized for the hundreds of detailers who do this work. 
​
Megan: Yes, it’s a theoretical tool at the moment, but we were in discussions prior to COVID-19 about how to develop it. It would be amazing to see programs collaborate on something like this. I can only imagine how much further we’ll go with that as a resource.

Biography. 
Megan DeNubila is the Provider Relations Manager for the Bureau of Infectious Disease Control, New Hampshire Division of Public Health Services. She has been leading the Public Health Education and Detailing team since August of 2018. Megan has over 8 years of public health experience in capacity building, coalition development, and community health. She earned her Master of Public Health degree from the Boston University School of Public Health with a concentration in Maternal and Child Health in 2016/2017 and her Bachelor of Arts degree in Health: Science, Society and Policy from Brandeis University in 2012.
​

Biography. 
Jessica Alward has been with the State of New Hampshire Division of Public Health Services for almost two years and recently earned her MS in Homeland Security and Emergency Management.  With a background in education and training, she works full time as an academic detailer all over the state.  In her spare time she enjoys directing community theatre productions, running and hiking. She is married to Scott and mom to two grown sons. 

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?
​
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.
​
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!
​
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.
​
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.
​
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 Brandon Mizroch, MD, MBBS, Provider Network Supervisor, Louisiana Department of Health 
​by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager

​Tags: Hepatitis C, HIV/AIDS, PrEP, Rural AD Programs, Sexual Health, Stigma, Training

​NaRCAD: Thanks for chatting with us today, Brandon! We’re excited to be catching up with you.  Can you tell us about your program at the Louisiana Department of Health and the work you’re currently doing?​
​
Brandon: Absolutely. I was hired to do work around PrEP and PEP, detailing providers across the state of Louisiana, in 2017.  Since then, my role has expanded and I promote education for providers about syphilis, congenital syphilis, and Hepatitis C.  Our department now has 3 detailers, including myself. 
​
Louisiana became the first state in the country to undergo an incredibly revolutionary Hepatitis C Elimination Plan, which has caused my detailing focus to shift.  There’s been huge advancements in the drugs that treat Hepatitis C, but they’ve been inaccessible to much of the population due to cost.  We negotiated a fixed rate price for Hepatitis C treatment and can now treat 100% of the population, compared to the 3% of the population we could treat previously.  There’s been a big push to identify and train providers who’ve never previously treated patients with Hepatitis C. I’ve been leading the charge by getting the word out, running symposiums, and working with the marketing team that’s creating our statewide campaign.  

NaRCAD: ​Wow, that sounds like innovative and exciting work. Can you explain your program’s approach  a bit more?

Brandon: I try to blend a few different approaches together.  I attended the NaRCAD training during my first year as a detailer.  NaRCAD built the foundation of detailing for me. I always use the NaRCAD methodology to get my foot in the door and identify providers who can be champions within their practices.  I find it much easier to follow up and do longer didactic sessions about complex clinical topics when I use the techniques of academic detailing during my first face-to-face visits with providers.
​
I connect with about 20 providers in this 1:1 model each month.  I also work with residency programs, hospital systems, and present at Grand Rounds to expand my reach.  There’ve even been instances where I’ve attended dinners for physicians that are hosted by pharmaceutical companies to network and identify new clinics that would benefit from detailing. 

​NaRCAD: ​We’re happy to see that you’re blending academic detailing with other approaches.  Do you provide follow-up to providers after your visits?
​
Brandon: Follow-up is incredibly important, no matter what approach is being used.  I like to send an email after each visit that includes digital resources for both providers and patients.  I also offer providers the ability to call, text, or email me because of the apprehension that exists around topics where the knowledge base is still growing.  Maintaining relationships with providers also ensures that we have a strong provider network that we can continue to educate on other clinical topics down the road.

NaRCAD: ​Building a connection with providers is imperative, especially as you move into different clinical topics.  Your program spans the entire state.  Do you find that there’s a difference when you provide clinical outreach education in rural vs. urban communities?
​
Brandon: Yes, there’s certainly a difference.  The providers in urban areas tend to have a higher knowledge base when it comes to PrEP and syphilis, perhaps due to marketing efforts or higher patient loads.  This makes starting the conversation a bit easier.  Additionally, urban communities have access to navigators, who help with non-medical aspects, like transportation issues, lack of health insurance, and long commute times that all prevent folks from getting the treatment they need.  Providers in urban areas are also busier and easily distracted during 1:1 visits, which can make detailing a bit difficult. 


On the other hand, rural communities are quite the opposite. Providers tend to have more time in their schedules and are excited to sit down with somebody from the state office.  They’re eager to learn, but there’s typically less of a knowledge base, making it slightly more difficult to start the conversation. 
​
​
I’ve also learned about patient barriers as well, which affect access and provider care. Patients in rural areas are often friends or family with those throughout the community, including those who work at clinics.  The notion that you would know the receptionist or provider at a clinic is enough to deter folks from seeking medical care around a topic like sexual health.  To encourage access, our state has created a TelePrEP program that offers PrEP services to anyone via telemedicine.  Consultations take place over the phone, labs are obtained at third party lab companies, and medications are mailed right to the front doors of patients.  It was originally created to help folks in rural communities who face stigma-related barriers, but we’ve expanded the program across the entire state of Louisiana.  It’s a great referral service that I can share with providers.

NaRCAD: ​It’s wonderful that you’re able to identify these challenges and have resources and tools to address them. What’s one piece of advice you’d give to folks who are detailing on a similar clinical topic or have a large geographical region to cover?

​Brandon: It’s important to have several different ways of presenting information to the providers you’re detailing and to use varied approaches depending on the barrier(s) they’re facing.  I typically focus on emotional connection, financial concerns, and the evidence and science behind the key messages I’m delivering.  I’m also ready for provider resistance, and am prepared to address it, which is something I learned from NaRCAD.
​
When it comes to detailing over a large and diverse geography, it’s always necessary to plan ahead.  My general rule of thumb is that however many hours it takes to drive to a location, that’s how many providers I want to meet with while I’m there.  I typically try to use larger educational events, like meetings with clinics over lunch, as my anchor point for longer trips.  After I have that scheduled, I search for smaller clinics around the area where I can meet with providers 1:1.  It’s all about maximizing your time.

Biography.
Brandon Mizroch received his MD/MBBS from the University of Queensland/Ochsner Clinical School Program in November of 2016. Since taking over as the PEP/PrEP Provider Outreach Specialist at the Louisiana Department of Health in August, 2017, he has worked with hundreds of doctors statewide on HIV prevention best practice. Since then he has expanded his educational base and now serves as the head of the academic detailing department at the Louisiana Department of Health, Office of Public Health, STD/HIV/Hepatitis program. As the Provider Network Supervisor he has helped lead the provider Outreach for the state’s first-in-the-nation Hepatitis C Elimination program. From grand rounds presentations at LSU-Shreveport Hospital and Baton Rouge General, to state-wide symposia and conferences, to one-on-one counseling encounters at dozens of clinics all over Louisiana, he has helped spread awareness and education on HIV prevention, syphilis screening and treatment, and HCV screening and treatment through evidence-based care.

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.

Tags: Detailing Visits, Stigma

​As we reflect on the two major public health topics we’ve been focusing on as we’ve traveled to public health departments across the United States, we’re learning that the public health detailers we’ve been training are discussing much more than just evidence with the clinicians they’re meeting. When we train new health educators on the methods of interactive, 1:1 education, we’re asked most often to customize our curriculum to cover two of the most highly stigmatized topics today: the opioid crisis, and HIV prevention. As the topic of stigma has come up at every straining we’ve implemented this year, our training team has added dedicated time to our trainings to discuss ways to address clinician stigma that arises during 1:1 detailing visits.

So, what, exactly, is stigma? It’s defined as “a mark of shame or discredit,” and appears in numerous ways, including through labeling, stereotyping, discrimination, and social inclusion. One of the biggest myths about stigma is that some people carry it, and some people don’t. However, stigma is not binary, and we all possess the ability to stigmatize another group that we perceive to be an ‘outsider’ group. Historically, stigma has appeared mainly in the form of social inclusion, with those identified as ‘others’ being treated as societal outcasts.

The interactive approach of AD is well-suited to address clinician stigma by creating a space in which the detailer can ask the kinds of needs assessment questions that can identify the source of these stigmatizing perspectives. When a 1:1 visit is facilitated by a skilled clinical outreach educator who is curious about clinicians’ experiences and genuinely wants to help implement sustainable change, many clinicians feel comfortable in sharing beliefs, identifying patterns, and building relationships based on trust and service. 

Our language and beliefs will continue to evolve as we continue to learn, encourage one another, and be empathic. We can do this by holding each other accountable in a non-punitive way, pairing our best intentions with education to use inclusive, supportive language, and committing to holding one another accountable by identifying moments when we witness stigma, in order to correct, reflect, and move forward. We’ve seen the potential for change; the medical community’s understanding of substance use disorder and HIV prevention has improved significantly over the past few decades. 

​Outside of our training settings, where else can we start? We’d very much like to hear from you, our community members, about how you’ve experienced or witnessed stigmatizing behavior as it has occurred within the healthcare setting. If you’re an outreach educator, tell us about a time you’ve seen stigma arise from a clinician’s perspective, and what you thought was behind it. If you’re a patient or a provider, talk to us about ways in which you’ve experienced or carried stigma. Keeping a dialogue open and encouraging sharing is one of many steps towards a connected medical community that embraces its patients, clinicians, educators, and supporters with compassion, clarity, and support.

Thanks for reading, and please share your thoughts and experiences in the comments section below!

The NaRCAD Team

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. 
​

Featuring: Mary Nagy, MPH, RN/BSN, Public Health Detailer, HIV Care & Prevention Unit, Michigan Department of Health and Human Services, NaRCAD Training Alumnus

​Tags: Detailing Visits, Health Disparities, HIV/AIDS, Sexual Health, Stigma

NaRCAD: Tell us what interested you about your current position and what a “day in the life” of a detailer looks like for you.

Mary Nagy: I saw the job posted and was immediately interested in it because I think detailing, especially on the topic of pre-exposure prophylaxis (PrEP), is a really effective way to strengthen prevention infrastructure and affect health outcomes. Clinicians are under a lot of pressure and I was drawn to the idea of being a source of relevant, high quality, trusted information. 

The detailing program here in Michigan is comparatively young and its development is ongoing. Fortunately for me, lots of folks have been willing to help! I've drawn from a broad range of sources has been really helpful during detailing visits, because the needs of providers are so diverse; folks are asking about billing and coding for PrEP visits, standing orders, HIV risk assessment, nuts and bolts of services offered by our state lab, STI screening and trends, and financial supports for PrEP, best practices with PrEP initiation and follow up, and more. I’ve been working hard to broaden my knowledge base, but also to identify resources for questions I don’t know the answers to and topics I’m weaker on. 

​NaRCAD: Why are you passionate about HIV prevention, and why is academic detailing for HIV prevention so important?

​Mary Nagy: Even though I’m very new to the field, I think it’s a very exciting time to be doing this work because I do believe it is possible to end the HIV epidemic in the US within the next few decades. Racial and ethnic minorities continue to be underrepresented in PrEP utilization and overrepresented in new HIV diagnoses, and I want my work to contribute to correcting this. I think PrEP can be a tool for health justice and being part of that is valuable to me.

NaRCAD: You’ve mentioned environment a couple of times. Can you tell us how environment is connected to HIV contraction and prevention, if at all?

Mary Nagy: I think that’s where my mind goes, because I’ve seen the powerful effect of environment on health, and this is certainly true on a population level. I never want to diminish the power and agency of individuals, but everyone operates under multiple layers of forces. Examples of this include policy, especially the persistent legacy of overtly racist housing policies; the “war on drugs” and resulting mass incarceration; or a justice system that data shows us doesn’t work in the same ways for everyone.

​These systemic forces, applied to millions of people over many decades, result in the disparities we see in HIV rates, overall health, wealth, and many other areas. Increasing access to PrEP means we can mitigate some risk for folks who might have more exposure due to the environmental context in which they live.
​
For Michigan, one of the ways detailing can help make PrEP easier to access is increasing geographic availability. A large portion of our state is rural, and many counties do not currently have a known PrEP provider. Another challenge is, of course, cost. The cost of PrEP and associated visits and screening tests is a policy issue, and while we hope and expect to see cost come down in the future, in the current landscape, it's important to prioritize educating providers and their staff on available financial supports and how to apply them, so cost doesn’t keep people who can benefit from PrEP from getting and maintaining access.

NaRCAD: In addition to geography and coverage, what are some other barriers you’ve encountered when doing academic detailing for HIV prevention?
​
Mary Nagy: Stigma around HIV and other STIs is a big issue. We know that when providers talk openly with patients about their sexual health, they’re better able to accurately assess risk for HIV and STIs and screen and treat appropriately, but those conversations are not happening with enough regularity. Rates of STIs like gonorrhea, chlamydia, and syphilis have been rising, and continue to increase, so there's a lot of opportunity there. 

NaRCAD: How has detailing been received overall? Are providers open to education on PrEP?
When I think about why detailing is important and why I’m doing it, the first thing that comes to mind is a recent survey of primary care providers MDHHS carried out in Southeast Michigan. Providers were asked which supports would best help them to incorporate PrEP into their practice, and "education" was by far the most frequent answer. In addition to the research I’ve seen indicating detailing is an effective intervention to change provider behavior, it's clear that the providers themselves agree that education is important.  If we can work with providers to make PrEP available and easy to initiate and maintain, the protection it offers from HIV can improve health outcomes for patients at high risk.

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.