Integrating Data into Action: Addressing Cocaine Use through Public Health Detailing

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.

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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.

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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.

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​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.

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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.

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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:

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• ​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!

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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.

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