Director’s Letter: Mike Fischer, MD, MS
The opioid crisis has been recognized as a major national public health problem, but it actually reflects a collection of many thousands of local crises playing out in individual cities and counties. Each region faces a distinctive set of challenges, driven by economic and social factors, local medical practice patterns, political environment and pressures, and many other considerations.
Identifying and implementing effective solutions to address the opioid crisis requires developing an understanding of how these individual challenges interact, and what strategies are most effective in specific situations--one of which is academic detailing.
The NaRCAD team is partnering with the CDC (Centers for Disease Control and Prevention) and NACCHO (the National Association of City and County Health Officials) on an exciting pilot program working with local health officials to develop customized interventions to reduce opioid overdose and death. Four sites experiencing significant public health problems related to opioids were selected: Boone County, Kentucky; Bell County, West Virginia; Manchester, New Hampshire; and Dayton, Ohio.
Public health officials at each site identified a wide range of local stakeholders to participate in developing a community action plan and recruited trainees to complete NaRCAD’s academic detailing training course, which we customized to address the unique challenges that each community faces. We also developed a specialized online toolkit for these sites, including discussion boards, local resources, and printable resources.
We traveled to each site in March and April of this year, facilitating hands-on trainings in the techniques of academic detailing in alignment with the CDC prescribing guidelines. Trainees came from diverse backgrounds, including pharmacists, nurses, public health officials, and students in the health professions, including pharmacy students, dental students, and medical school students.
Plans for implementing AD varied by site depending on the local health care environment; some sites focused more heavily on appropriate prescribing of opioids by clinicians, while others prioritized increasing referral rates for patients with opioid use disorder (OUD), including access to medication-assisted treatment (MAT).
As the AD trainees at each pilot site continue their work in the field, we’ll learn more about how these diverse strategies succeed, and how we can support adaptations to make academic detailing more impactful. This important collaboration has allowed us to form invaluable partnerships with CDC and NACCHO, leveraging national resources to improve local responses to this epidemic through plans that respond more precisely to local needs and priorities.
We’re excited for this pilot program to serve as a model for future opioid safety AD interventions, and we’ll be providing updates here on the blog. In the meantime, tell us: what's happening in your local community around the opioid crisis? Sound off in the comments section below, and let us know if you think clinician-facing education could be a strategy that would improve outcomes for your community. And join us for our next training and our terrific annual conference to learn more about this and other exciting AD projects.
Michael Fischer, MD, MS | Director of NaRCAD
Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.
Jerry Avorn, MD, Co-Director, NaRCAD
Of all the medication use issues facing the U.S., the most pressing is of course that of opioid mis-prescribing. When the anatomy of that mis-use is dissected, it becomes clear that the principles and methods of academic detailing are especially well suited to addressing this crisis, for several reasons.
First is the problem of information deficit: before the mid- to late-1990s, practical issues of the assessment and management of pain were often poorly covered (or not at all) in most medical school or residency training programs – so there’s a lot of good that can be accomplished by simple personalized knowledge transfer, to start with.
Second is dealing with the contamination of dis-information: the growing documentation of the fact that sales reps for OxyContin, for example, actually under-stated the drug’s risks and over-stated its potential indications when describing their product to prescribers – distortions for which the company had to pay $600 million in penalties.
Third is the fact that for this therapeutic category more than for most others, a prescriber’s attitudes and motivations play an especially important role.
These can involve “non-scientific” issues such as:
There is ample evidence that simple “gotcha” letters accusing a prescriber of opioid over-use have no effect. Similarly, draconian restrictions imposed by governments or health care systems limiting the amount of opioid that can be prescribed to a given patient clearly run the risk of under-treating genuine pain – a grotesque example of health care rules that seem guaranteed to increase patients’ suffering.
Evidence-based guidelines, such as those promulgated by the CDC, are fine as far as they go, but most doctors haven’t read them, and even fewer have integrated them into their practices.
But a well-trained, skilled academic detailer can interact with a prescriber to understand just what issues lie behind the apparent misuse of opioids by that physician, and present a set of interactive messages tailored to those particular needs.
This will involve constructing a personalized blend of new knowledge transfer, dis-information detoxification, practice facilitation (including help accessing Prescription Drug Monitoring Program data less burdensomely), accessing local resources for help in patients with opioid use disorder, and assistance with patient education.
A similar approach could also be enormously helpful for encouraging naloxone prescribing and improving the care of patients with opioid use disorder, including medication-assisted treatment, where information deficits and attitudinal issues are even more prominent.
Together, this kind of individualized outreach education can accomplish far more than mailed guidelines, accusatory nastygrams, or legal restrictions – and in doing so, do more to improve patient care and reduce preventable misery than can be expected from more old-fashioned interventions.
Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more.
We've been staying busy here at NaRCAD this spring! With public health challenges like the opioid crisis, and the continued need for HIV prevention, the team here at NaRCAD has been on the road for 5 trainings in 6 weeks, and we're not stopping yet!
On February 14th - 16th, 2018, NaRCAD joined the amazing teams at San Francisco Department of Public Health and the New York City Department of Health and Mental Hygiene for an exciting initiative: A Public Health Detailing Institute on HIV PrEP and RAPID.
Hosted in San Francisco's South Market neighborhood, 31 trainees attended, representing diverse public health departments from Texas, Connecticut, Alaska, Louisiana, Florida, Tennessee, Los Angeles, San Francisco, Mississippi, Michigan, Oregon, Nevada, Virginia, and beyond. These trainees joined the institute for a customized, 3-day event focusing on learning the techniques of academic detailing, along with showcasing best practices and success stories via special presentations and expert panels.
This past month, from March 7th through April 4th, 2018, NaRCAD hit the road four more times, as part of an exciting 4-site pilot project in partnership with our terrific colleagues at the CDC (Center for Disease Control) and NACCHO (The National Association of County and City Health Officials).
Upon identifying counties and cities with the highest burden of fatal and non-fatal opioid overdose and high prescribing rates, the CDC selected Bell County, Kentucky; Boone County, West Virginia; Manchester, New Hampshire; and Dayton, Ohio as 4 pilot sites in which to convene with key community stakeholders and roll out community action plans, along with targeted academic detailing interventions.
Our work has involved launching on-location trainings at each of these pilot sites, focusing on providing front line clinicians with tools and support to improve outcomes for patients.
Messaging and support for these campaigns include lowering prescribing rates, referring patients to treatment for opioid use disorder (OUD) including Medication Assisted Training (MAT), and using their state's PDMP (Prescription Drug Monitoring Program) to identify troubling patterns of use, which may, in turn, help to identify those patients who need more support and care.
Trainees at each site of these pilot sites work with us across two days to learn the structure of an academic detailing visit, practice role playing 1:1 visits with clinicians, and become experts at using educational materials (including a suite of materials constructed by the CDC based on their 2016 Opioid Prescribing Guidelines).
Our pilot site trainees walk away from our trainings ready to actively engage with clinicians to assess individual needs and provide customized support, and encourage behavior change for the opioid crisis in their respective communities.
NaRCAD's team will continue to focus on launching new academic detailing interventions across the U.S. well into 2018, with upcoming opioid-specific trainings being carried out in late May in Albuquerque, New Mexico, with the University of New Mexico's Health Sciences Center, and in late June in Lansing, Michigan, with the Michigan Public Health Institute.
Our next all-topic, AD techniques training in Boston will kick off at the end of this month, where we'll train 24 health professionals from across the U.S.--we'll report back after that training and share lessons learned, highlights, slide decks, and clinical topics from represented programs, and we look forward to sharing those with our community.
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We can't wait to work with you!
-The NaRCAD Team
Guest Blog | Alyson Decker, NP, MPH | San Francisco Department of Public Health
Our AD program is part of a 3-year demonstration project (CDC Project PrIDE), and as part of our grant-funded work our overarching goal is increasing PrEP access and prescribing to MSM (men who have sex with men) of color and transgender persons who are at substantial risk of acquiring HIV. Our goals include improving sexual health in the primary care setting, refining sexual health history-taking, increasing screening and testing for those with risks, promoting best practices around PrEP prescribing, and helping to establish relationships between our health department and our community providers.
The added benefit of public health detailing is that it also increases awareness about the issues that affect our community. I have been inviting clinicians that I meet to join us in our city-wide Getting to Zero consortium, which helps providers feel that they are part of this important movement of preventing HIV transmissions, deaths, and stigma.
In San Francisco, there is a need for urgency around this issue, especially because it’s become evident that as HIV transmissions continue to decrease, the disparities among new HIV positive diagnoses become more apparent. Many of these disparities are among communities who still may not be aware of PrEP, or are facing barriers to access. Our academic detailing program strives to reach the providers who work with these vulnerable communities.
When kicking off an intervention such as this, identifying the clinicians who see this target population is the first step. To do this, we used STD surveillance data to determine which providers and clinics were diagnosing syphilis and rectal gonorrhea and chlamydia, which are associated with an increased risk for HIV. However, since many providers are not performing appropriate screenings, we also reached out to clinics known to serve our priority population and those located in neighborhoods with the highest HIV incidences.
The next step is how to “get in the door” with these clinicians, which means finding a way to secure a 1:1 visit. I’ve found that initial non-responsiveness isn’t the end of the world—persistence pays off, so keep trying to get in the door, or find an entry point through other community contacts. Sometimes, choosing a different access point can really work well to start a relationship. There are many places where 1:1 visits aren’t feasible due to clinic structure or culture. If I’m able to detail to a small group, it can be a way to meet with a few providers and gain insight about how PrEP might be incorporated or enhanced in their setting.
Being invited to an all-staff meeting is often an excellent way to kick off an introduction to this important intervention, and can result in follow-up conversations with individual clinicians. One benefit of meeting in small groups is that if a clinician hears a fellow clinician say that he or she is already prescribing PrEP, there may be more openness to discussing the topic; other providers might feel comforted in having a PrEP "ally", resulting in buy-in from the clinic overall.
Some clinicians may think that this type of intervention isn’t relevant to their patient population; as I detailer, I often hear responses such as, “I don’t see this population reflected in my practice,” or “My patients don’t have this risk,”, even if it’s been proven that these clinics do, indeed, serve priority populations. In order to talk about PrEP, you first have to talk about risks for HIV, which often means talking about sex. I think there can be discomfort on both the patient and provider side, and sex is often still a stigmatized topic. There are also overarching resource barriers, including the fact that clinicians are extremely busy and have to address competing health needs in the primary care setting.
While a small pool of clinicians have minimal understanding of PrEP, and require a basic overview about elements like identifying potential PrEP candidates, how to take a good sexual history, and how to bring up PrEP in an appointment, I’ve found that many clinicians are aware to some extent about PrEP already, and are interested in next-level details about how to implement it. This might include what kind of testing is recommended, how to increase number of basic screens, and increasing their knowledge about comprehensive health.
There are also providers who are very advanced in their knowledge of what options are available to populations with risks for HIV. This is where the academic detailing becomes more intricate; some providers are seeing lots of patients with risk factors, and may have been prescribing PrEP already. In a scenario such as this, my messaging focuses more on how to support clinicians in ensuring consistent follow-up with their patients, or in how to deal with multiple risk factors, such as when high-risk sexual behavior may overlap with instances of substance use or homelessness.
For those who are just getting started, it may help to know that even after meeting with 300 providers, I still get nervous each time I prepare to detail, especially if I’m unfamiliar with a practice. Regardless of the nature of my visits, I walk away feeling that I’ve accomplished something if I’ve answered only one question that’s helped the clinician with his or her practice. And I’ve found that in most cases, the people I meet with are very thankful for this service, and are appreciative of the health department. I always thank providers for the work they do and remind them what an important role they have in the community.
Biography. Alyson Decker, NP, MPH
Alyson Decker is a Clinical Prevention Consultant and nurse practitioner with Disease Prevention & Control at the San Francisco Department of Public Health. As the branch’s lead academic detailer, she helped develop San Francisco’s first HIV pre-exposure prophylaxis (PrEP) detailing program. Her role consists of detailing with community providers to increase PrEP prescribing in the primary care setting and promote best prescribing practices. In addition, she provides training assistance to healthcare providers and frontline staff around improving sexual healthcare and STD testing and treatment. She also sees patients at the municipal sexual health clinic, San Francisco City Clinic.
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