By Anna Morgan-Barsamian, MPH, RN, PMP, Senior Manager, Training & Education, NaRCAD
An interview with Trish Rawn, BScPhm, PharmD, Clinical Service Director and Academic Detailer, Centre for Effective Practice (CEP). CEP is a not-for-profit in Canada that aims to close the gap between evidence and practice for healthcare providers.
Tags: Stigma, Detailing Visits, Substance Use
Anna: Hi Trish! Thanks for joining us today. Your team has been working on a number of AD campaigns including, falls prevention, type 2 diabetes, benzodiazepine use in older adults, chronic non-cancer pain (CNCP), and opioid use disorder (OUD). Can you tell us about some of the other recent work you’ve been doing at CEP?
Trish: Our team’s academic detailing work is a big part of what we do, but CEP has other supports as well. We create clinical tools and resources on myriad clinical topics where practice gaps have been identified. Our most popular resource has been our COVID-19 Resource Centre to support primary care clinicians in adapting their practice during the pandemic. It’s become a massive resource that has had over 140,000 downloads.
Anna: Wow! That’s an impressive amount of downloads. One of the other priority areas where your team has identified practice gaps is OUD. This topic often has a lot of stigma associated with it. Is this something you’ve experienced with the opioid detailing campaigns?
Trish: When we first started detailing on CNCP, opioid tapering, and OUD, there was a lot of fear and stigma among clinicians. They didn’t want to be known as the doctor “prescribing all the opioids.” Some clinicians were concerned that they might get in trouble, and they’d say things like, “I don’t have any of those patients” or “They’re all inherited patients.”
Clinicians also sometimes felt like they didn’t want to say the wrong thing to patients, so they wouldn’t say anything at all. We’re all guilty of this and we’ve tried to encourage language like, “Hey, I might be saying the wrong thing here, but let's just start the conversation.”
Anna: Just starting the conversation with the right intentions is helpful, even if you don’t get the language completely correct. Have you seen any stigma at the patient level?
Trish: We found that patients themselves were experiencing stigma when seeking help and when trying to talk openly about opioids with their clinicians. Family doctors are in a vital position to help patients because they tend to have long-term, trusting relationships with them; they have sometimes taken care of them since they were children. Studies show that when opioid replacement therapy is prescribed by family doctors, there are improvements in patient uptake, patient satisfaction, and treatment success.
We wanted to get the clinicians to a place where they felt confident talking with patients about opioids and where their patients felt comfortable sharing their experiences. It may feel like a jump for a clinician to go from, “I'm here to measure your blood pressure and adjust your medications” to “Let's talk about opioid addiction and set goals around tapering.”
Anna: I can see how talking about OUD might make some clinicians feel uncomfortable. What types of resources has your team developed to support both clinicians and their patients to feel more comfortable having these conversations?
Trish: For our academic detailing visits on opioids and CNCP we developed a resource called Talking Points with Patients, which includes scripts for clinicians to handle different scenarios. For example, one of the scenarios is about a patient asking for a dose increase for an opioid, but the clinician not agreeing that a dose increase will help manage their pain. We also have a Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) Goals resource to help clinicians set goals with their patients by taking the focus off the pain number scale and focusing on actions like, “What activities would you like to do if you had less pain?”
Anna: It’s clear that your team works hard to develop and tailor resources to support clinicians and patients. What kinds of local resources from your community are available for detailers to share with clinicians?
Trish: We often help clinicians find local resources through a program called The Healthline, which is a website that connects patients with social supports, like counseling, food, and safety. We’re also lucky to have Rapid Access Addiction Medicine (RAAM) clinics in our community that are a one-stop shop for patients with OUD where they’re assessed, given support and a plan for tapering, and referred to other community services.
Anna: It’s so important for clinicians and patients to be linked to local resources and know that they have a community supporting them. Can you share some data about how clinicians reacted to the opioid-specific campaigns overall?
Trish: Absolutely! I can share some key findings from our opioid campaigns.
Opioid therapy for CNCP AD campaign (n=475):
After the detailing sessions, clinicians indicated they were confident in their ability to have a conversation about tapering when appropriate, even when the discussion was challenging (93.5%).
Non-pharmacological and non-opioid alternatives for CNCP AD campaign (n=323):
Clinicians indicated that after the detailing sessions they were confident in their ability to help patients:
OUD AD campaign (n=250):
Clinicians indicated that the detailing sessions enabled them to support patients with OUD by:
Anna: That’s incredible. It’s obvious that your campaigns have made a huge impact on clinicians. What advice would you give to other AD programs who are supporting clinicians in reducing stigma, especially as it relates to opioids?
Trish: I would recommend remembering three key points:
Examine your own biases: When developing detailing tools, you need to make sure that you’re aware of your own biases and that your tools include the lens of equity, diversity, and inclusion. This is something we are actively working on incorporating in all our work at CEP.
Make space for clinician experiences: It’s important to remember to be sensitive to the clinician perspective. There have been times, especially with opioids, where clinicians have had painful experiences with patients overdosing. Be aware of their perceptions and respectful of the trauma they may have experienced.
Know your patient population: Understand who the patients are, the trauma they’ve faced, and the stigma they may endure. Look at the experiences of your team, the clinicians, and the patients you’re working with and try to understand how these different perspectives all influence one another as you develop your resources.
Anna: That’s beautifully said, Trish. Thank you so much for sharing about your important work in reducing stigma around OUD.
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Biography. Trish Rawn is the Clinical Service Director for the Centre for Effective Practice Academic Detailing Service. She is a hospital pharmacist who has been detailing for 6 years on topics such as antipsychotics in the elderly, opioid tapering, chronic pain, diabetes, falls prevention, and benzodiazepine deprescribing.
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