Building Accountable Relationships: Critical Conversations on Opioid Safety with Clinicians in Bell County
An Interview with Lutricia Woods, RN
OVERVIEW: Bell County, Kentucky was one of 4 original sites selected for years 1 + 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at 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. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
NaRCAD: Hi Lutricia, thanks so much for taking the time to speak with us about your work as an academic detailer for the opioid crisis in your community. Can you talk to us about how the opioid crisis has presented itself in Bell County, Kentucky?
Lutricia: There’s not a family in this community that hasn’t been touched by the opioid crisis in some way. Twenty years ago, I worked in hospitals as an RN discharging patients and providing them with their prescriptions as they prepared to go home. At the time, I was shocked at the rates of prescriptions of opioids with benzodiazepines, and patients thinking it was safe. From my perspective, in our community, the opioid crisis really began by doctors beginning to prescribe many opioids to their patients without education or an understanding of the dangers.
Three years ago, I was working on a project at a middle school, and was surprised by the number of grandparents that were raising their grandchildren because their children were either in jail, or otherwise affected by opioid use disorder [OUD]. In Bell County, we also have so many people unable to find a job because they cannot pass a drug test, and once that happens, they return to use because of the stressors of not being able to find a job and pay their bills, and it becomes a challenging cycle to overcome.
NaRCAD: Thanks for sharing your perspective, Lutricia—it can be true that some clinicians don’t see the impact of their role in prescribing opioids, and many times may believe that people who develop an opioid use disorder do so because of a moral failing, rather than seeing it as a medical issue. Did you think 1:1 outreach, provided directly to prescribing clinicians, would lend itself to improving patient health in response to the opioid crisis in this community?
Lutricia: I desperately hoped it would. The opioid crisis is very personal to me, as it is to many people in our community. Years ago, my mom had 2 surgeries within 6 months. She had complications from one of those surgeries, and as a result, she was in the hospital for 6 weeks, during which time her care providers did not wean her off of the opioids she took immediately after the surgery. She returned home with prescriptions for opioids at a high dosage, and she developed opioid use disorder.
My mother’s doctor, with whom I worked, reached out to have a conversation with me. He told me that I had to be the one to intervene with my mother because she continued requesting more opioids. I conveyed that I wanted her to discontinue taking them, and that he needed to assist us in finding a way to do this, as I felt his prescribing without discussing safety caused the initial issue. His response was that he wanted to “keep her happy.”
My mother struggled for the rest of her life; she was able to completely wean off and discontinue using them, but it required a lot of counseling. As a result of this experience, I became a drug education coordinator, as I really wanted to do my part to mend the opioid crisis by providing drug education for every student in the county. And then, of course, I became an academic detailer for this project over the course of the past 2 years, which involves clinician education about safety and risk of opioid prescribing.
NaRCAD: Thank you for sharing that Lutricia; the opioid crisis is personal to so many of us. What would you say has been the most impactful piece of this academic detailing intervention as you went into the field and spoke with clinicians?
Lutricia: The most impactful piece has been the ways in which we’re trying to hold clinicians accountable for their roles in the crisis, as well as leveraging their ability to improve things based on their relationships with their patients. For many of the doctors and nurses I met with, our conversations and educational resources have made them more thoughtful and intentional about their role. They seem to realize more that they have the power to decrease the number of prescriptions they write, the length of time for which they write them, and talk more with their patients about safety.
NaRCAD: That’s fantastic. What about the most challenging part of this project—what’s been hardest about meeting with clinicians to talk about the opioid crisis in Bell County?
Lutricia: Getting an appointment to go in and meet with these clinicians has been so frustrating and challenging. I always say that the receptionists in doctors’ offices are the most powerful people in the world. If you can’t get through them, you’re not going to get what you need, and it is the same with the patients. I couldn’t even get in to see my husband’s doctor, who we’ve known since we were kids. My husband had an appointment, so I resorted to going with him, and did a detailing visit on the spot with his doctor. This same doctor ended up changing practices, and it’s been a lot easier to get into that practice—all because of the office manager. Those relationships are important.
NaRCAD: Getting in the door is definitely a consistent challenge across many programs. We’ve heard from other detailers that practice makes perfect, and sometimes it’s easier to gain access when you actually show up and request a meeting in person. What else did you learn after being in the field?
Lutricia: When I was “volun-told” that I would be attending a training, and doing “academic detailing”, I didn’t truly understand what it was or what the impact would be. I’m a big picture person, and I couldn’t see the big picture at all; I went into that training not knowing what to expect. It wasn’t until I actually started making visits that I could start to see the seeds we were planting to begin to have an impact.
Share your thoughts on this piece in the comments section below, or learn more about the LOOPR project and other opioid safety academic detailing initiatives here and on our Detailing Directory.
An Interview with Johnathan Goree, MD
Director of Chronic Pain and Opioid Stewardship
University of Arkansas for Medical Sciences
NaRCAD Training Alumnus
by Kristina Stefanini, Program Coordinator at NaRCAD
NaRCAD: Thanks for talking with me today! Can you tell me a little bit about yourself and how you ended up in pain management?
Johnathan Goree: I’m from Arkansas originally. After completing college at Washington University in St. Louis, medical school and residency at Cornell, and a pain medicine fellowship at Emory, I was recruited to start the chronic pain division at the University of Arkansas for Medical Sciences – 2 miles away from where I went to high school. I’m proud to work in Arkansas; Arkansas is such a poor and rural state, so we don’t often have the resources that other states have.
I went into anesthesiology because I wanted to be the best prepared doctor for an emergency, but I moved into pain medicine because I missed the 1-on-1 patient contact and longitudinal patient care. Here are some other things that lead me into pain medicine. After getting my wisdom teeth removed, I was given too much fentanyl during the procedure resulting in being given Narcan to wake up.
That was the first time in my life I experienced 10/10 pain. It allowed me to understand how pain can completely dominate someone’s consciousness. I am also passionate about pain management in minority communities. Many in those communities feel that their pain is undertreated, and evidence backs that up.
NaRCAD: As a physician, what are some of the barriers that detailers may have talking to clinicians about pain management? How can these be navigated?
Johnathan Goree: Every physician will say the number one barrier is time. While most physicians are excited to learn about anything that will improve patient care, unfortunately, physicians are usually not in control of their schedule.
NaRCAD: How can clinicians act as champions in an academic detailing campaign?
Johnathan Goree: One way physicians can help is with the crafting of educational materials. Physicians know how physicians think and can help by crafting a message that may better catch attention.
Another is by dedicating time to answer follow-up questions from detailers and other clinicians. In my field of chronic pain management, detailers that don't have a clinical background may not know how to answer questions on specific off-label situations or treatment of specific pains. A follow-up visit or call with a clinician can help with that.
NaRCAD: Anything else you’d like to add for our readers?
Johnathan Goree: More praise for you guys – your course is excellent! Really understanding the science and method behind academic detailing made me excited to be a part of it. I hope more physicians engage both as detailers and as champions. I think it’s really important.
Johnathan Goree, MD, Director of Chronic Pain and Opioid Stewardship
University of Arkansas for Medical Sciences
Board certified in anesthesiology and pain medicine, Dr. Johnathan Goree received his Bachelor of Arts in biology from Washington University in St. Louis. He then moved to New York City where he completed both his medical degree and a residency in anesthesiology at the Weill College of Medicine at Cornell University. Following his time in Manhattan, he completed a fellowship in chronic pain medicine at Emory University Hospital in Atlanta, Georgia. In 2014, Dr. Goree returned home to Little Rock, Arkansas to join the faculty at University of Arkansas for Medical Sciences where he serves as the Director of the Chronic Pain Division and an Assistant Professor in the Department of Anesthesiology. He primarily focuses on the treatment of chronic pain conditions using opiate sparing, minimally invasive techniques. His specific research interests include complex regional pain syndrome, neuromodulation, and the effects of opioid education initiatives on patient outcomes.
An Interview with Victoria Adewumi, MA, Community Liason, City of Manchester Health Department
NaRCAD Training Alumna
by Kayland Arrington, MPH, Program Manager at NaRCAD
NaRCAD: How did you get into AD? How was the Manchester team formed?
Victoria: I was very interested in community outreach and improving the health and well-being of families! I had cursory experience with substance use disorder management and had to jump in with both feet. It really helped having other detailers on the team that NaRCAD trained that I could lean on. The other detailers constantly provided support, and one helped open the door for me at her health system to speak with clinicians. She even provided me talking points that previously worked for her so I could walk into my first appointment feeling confident.
NaRCAD: What has your experience been as a detailer who does not have clinical experience but who does have public health expertise? Is someone able to be effective as an academic detailer without as much prior clinical training?
Victoria: My experience has been extremely positive! I care about community, and I thought this was a great opportunity to gain new expertise in this field. I’ve always felt that a community perspective is needed for us to be able to leverage our impact in this field.
The NaRCAD Academic Detailing techniques training was fantastic in helping me build tools to be able to speak well and motivate clinicians around medication-assisted treatment (MAT). My goal as an individual detailer is always to present myself as being on the same team as clinicians. I really see detailing as having a solution for clinicians, rather than simply trying to sell them an idea.
NaRCAD: Was there a time when a clinician presented pushback or obstacles that made it difficult to get your message across?
Victoria: Some clinicians seemed to have already decided whether they were going to be on board or not before I even met with them. I had to feel strong and confident in the skills that I have. When I meet with a clinician, I always frame it as “I’m coming in as a representative of the community. There’s a crisis in our community, and you, as a provider, are a key part of the solution. How can we get you involved?” and “What kinds of things can you tell us that we haven’t even thought about before?” We need everyone’s participation if we’re going to change the tide of the city of Manchester, and clinicians are a vital part of that.
NaRCAD: You have mentioned the power of the team of detailers--can you tell us how the Manchester AD came to be so strong and effective?
Victoria: I didn’t know any of the other detailers before the project. The NaRCAD training was great as an introduction to the work and to each other. We all had a sense of hope that was immediately apparent. We have the privilege of doing work that helps save lives and because of this attitude, there was a sense of camaraderie right away. We’ve been effective because our AD team is strong, and it was strong because we were intentional about building bonds. During the implementation period, we never went more than a month without checking in with each other, and sharing successes and challenges.
I don’t think I would have enjoyed the process as much if I didn’t have this amazing AD team of colleagues. We’ve had incredible success in building a team of detailers who are all committed to and excited about the work of connecting with frontline clinicians to improve patient care around opioid safety.
NaRCAD: How would you recommend other programs go about recruiting those people that are equally committed and excited?
Victoria: That’s a great question! I didn’t necessarily have an opioid response background, but I’ve always cared about communities. That desire to help others makes a great detailer. The trainings can teach the clinical content, but that element of wanting to improve people’s lives is the anchor of a strong AD team, and will resonate with the providers you’ll be detailing. I would then advise new sites to do the important work of helping their detailers to build strong relationships and a sense of teamwork right from the beginning. Those relationships will support everything, from good communication with clinicians, to a renewed sense of purpose in doing the work, which shields against burn out moving forward. Consistent opportunities to check in and connect between AD team members can’t be overemphasized—it truly made me feel that I was never in this alone; I was always working as part of something bigger than myself.
Victoria Adewumi, MA
City of Manchester Health Department
Victoria Adewumi is a Community Liaison with the Manchester Public Health Department. Victoria primarily helps coordinate and staff programming of the Manchester Community School Project, a model that facilitates better health for Manchester residents through place-based interventions. Victoria serves Manchester residents by linking them to partners in the health, social service, business, non-profit, and faith communities and by engaging community members in resident leadership and equity activities. Victoria also participates in efforts to serve refugees and newcomers in New Hampshire through both direct service and community-building initiatives. Victoria holds Bachelor and Master of Arts Degrees in Political Science from the University of New Hampshire.
Featuring: Carol Furlong, LCMHC, MAC, MBA, Director of Substance Use Disorders, Elliot Hospital
Jill MacGregor, APRN, Catholic Medical Center, & Katie Sawyer, LICSW, MLADC, Director, Integrated Treatment of Co-Occurring Disorders, Network4Health/Mental Health Center of Greater Manchester
Interview by Isabel Evans, Fellow, NACCHO, in partnership with NaRCAD
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.
Katie: It has been rewarding to meet with each clinician for different reasons – I would view success as learning more about the clinicians that are already on board and excited to pursue getting a waiver, as it gets them talking and feeling a renewed energy to share with others. I view my conversations with clinicians who are not interested in pursuing a waiver as equally rewarding, since it allows for both of us to share and hear the other’s perspective. We can agree that the work is needed and challenging, no matter how we decide to go about addressing the needs of our 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.
Ideas? Comments? Questions? Sound off on this blog in the comments section below!
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.
Guest Blogger: Monica Mais, MSN, FNP
Family Nurse Practioner/Academic Detailer
California Opioid Safety Network, Fairchild Medical Clinic
NaRCAD Training Alumnus
In 2011, I went from 15 years as an Emergency Room nurse to a new role as a Family Nurse Practitioner in a rural healthcare setting. I couldn’t believe the amounts of prescribed opioids that were coming out of our little clinic—the average chronic pain patient was receiving 240 Morphine Equivalents/day (MEDs), and many of these patients had been receiving these medications for years without oversight. In 2013 I introduced an evidence-based protocol and policy for safe prescribing of Opiates for Chronic Non-Cancer Pain (CNCP).
However, patients who could not obtain opiates from our clinic quickly moved on to the clinic across town. This influx of opiate seeking patients was reason for concern from those receiving clinics. My colleagues and I opened our doors to neighboring clinics and providers and began sharing our policies and successes. Many other area clinics started adapting our policies to their own practice, reducing their opiate prescribing as well.
We formed a coalition called Siskiyou Against Rx Abuse (SARA), and based on our previous successes, we were all shocked to see data showing our county was among the highest opioid prescriptions per capita in California, and had a high overdose rate per capita, despite our efforts. Clearly, more needed to be done! Our coalition facilitator, Maggie Shepard, RN, along with our medical director, Dr. Sam Rabinowitz, and myself were all invited to attend training to become Academic Detailers in San Francisco with the San Francisco Department of Public Health, a partner with NaRCAD, the National Resource Center for Academic Detailing.
We did scripting and role-playing throughout the training, learning the important social marketing and communication skills needed to conduct a personalized visit with a provider where the goal would be to change behaviors to continue to promote safe opioid prescribing, Naloxone, and Buprenorphine out to providers in our area.
During the training, I was videotaped during a practice role-play, which was very helpful, as it reminded me to speak more slowly, and to organize my key messages and talking points. After the training, getting our detailing program into the field involved a step-by-step process.
Here are important things to consider that have worked well for my detailing process:
I plan to continue AD throughout 2018. I believe we have experiences that we can share to encourage our colleagues to make positive changes in in their prescribing habits. Academic Detailing works due to mutual respect of one another’s experiences, professionalism, and willingness to receive new information—it’s an excellent way to foster change within a system!
Monica Mais, MSN, FNP
Family Nurse Practioner/Academic Detailer, Fairchild Medical Clinic
Monica Mais is a Board Certified Family Nurse Practitioner working at an FQHC in Siskiyou County, located in far Northern California on the Oregon border. She is a founding member of Siskiyou Against Rx Abuse, member of the California Opioid Safety Network and an X-Waived prescriber, working with chronic pain and opioid dependent patients. As a former Emergency Room Nurse for 15 years, many of Monica’s shifts involved witnessing overdoses, drug-seeking behavior, violence, desperation, and healthcare worker burnout. It had been escalating every year to its current crisis level, and Monica wanted to be part of the solution to this heartbreaking epidemic. Questions on this piece for Monica Mais? Contact her at email@example.com, or leave your thoughts in the discussion forum below.
As the Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, California, Stacy Piper, CLEC, acts as a regional liaison with the medical community as well as coalition's and various community partners. Learn more about Stacy in the bio at the end of this piece.
NaRCAD: Hi, Stacy! Thanks for joining us. Tell us a little bit about your work—we understand you, like many folks in public health, wear multiple hats.
As the Butte County Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, I act as a liaison with the medical community. I collaborate with hospitals, health care providers, public health programs, and community organizations to improve public health and continuity of care.
NaRCAD: Talk to us about detailing for the opioid crisis—you do this 1/4th of your time. How did you get started?
After providing educational detailing for the WIC Program funded at 30 hours a week, I was asked to be an Opioid Academic Detailer for Butte County. In preparation, I attended the Academic Detailer Training in San Francisco. The training provided by the CA Health Department, San Francisco Public Health Department's Substance Use Research Unit, and NaRCAD was one of the finest training experiences - even after the countless hours of extremely comprehensive training I received in the Pharmaceutical Industry.
Regarding impact on a local level, it is indescribable how every interaction with a healthcare provider is beneficial. Academic Detailing (AD) is an equal exchange of information. I consider it a huge responsibility, and a privilege, to be an educator for doctors and medical professionals.
I prefer the word “educator” instead of “detailer” because I have concerns that a “detailer” may be initially viewed as a salesperson. I love and respect that AD is not driven by attempting to influence medical professionals for personal gain. It’s all about helping providers improve health outcomes in patients with the entire focus of the conversation about the real people in their practice that need help.
NaRCAD: Tell us a little about your background in pharma, and how this translates to your detailing work now.
I was a Senior Executive Pharmaceutical Sales Representative for 15 years in Northern California, advocating for immunizations and promoting various prescription drugs. This provided first-hand experience of the astonishing evolution in the Medical, Pharmacy, and Insurance industries. Understanding the basic dynamics of medical offices has helped me navigate and gain access at a quicker pace for AD. Also, understanding the business acumen component of running a medical practice has proven to be valuable in my recent interactions.
NaRCAD: You mentioned that you’re committed to providing value for clinicians and patients alike. Talk to us about how you share key messages with the clinicians you visit.
In my experience, to truly influence the behavior of a highly-educated and experienced individual, you must come to the table with the goal of learning. With attentive listening, you ‘hear’ the medical professional, and process what you have learned. Your intuition will guide you to ask the appropriate, insightful questions needed to evaluate his/her priorities and challenges. This is a beautiful thing, because trust starts to blossom and the partnership has begun.
You can then confidently tailor key messages, valuable resources and solutions that are closely tied to those needs and challenges you uncovered. You should begin to see the individual’s genuine desire to truly change behavior and habits.
NaRCAD: Talking about opioids is a sensitive topic. What’s some of the typical pushback you get from clinicians you detail about opioid safety?
The response to academic detailing really depends on the situation and the type of clinician and/or establishment I am working with. Sharing local opioid statistics compared to our state statistics is an eye opener! I try to paint real life pictures by telling true stories.
For example, I’m honest about my own family members who were innocently caught up in this crisis, including the true story about the day my sister’s husband accidentally took his prescribed opioid medication twice. My sister lost her husband that day.
NaRCAD: Along with telling true stories, how do you handle pushback and stay positive, encouraging clinicians to pivot?
Time, or lack of time, is the biggest culprit in keeping physicians from attempting to personally assist in ending the addiction cycle for patients. I passionately believe clinicians need more time with people on opioids.
It takes several visits with an office to start moving in the right direction. Working with the medical assistants, nurses, and/ office managers is a key component. They can often have influence, give advice or insight, and even advocate when you are not there.
Also, I review our county’s Safe Prescribing Guidelines. If clinicians cannot institute all items in the guidelines, I ask providers to choose what they can commit to doing and to think about some specific patients they can work with. I also ask them to consider prescribing Naloxone for patients on high doses of opioids (above 50 morphine milligram equivalents).
NaRCAD: What would you share with new detailers who are about to go into the field and use AD to tackle the opioid crisis?
I have a few reminders and tips for detailers:
Stacy M. Piper, CLEC, Public Health Educational Specialist
Butte County California Public Health Department
As a Public Health Education Specialist, Stacy was chosen to work with two CA State grant funded programs educating Medical Professionals, Hospitals and Community Organizations for the WIC Program and the Opioid Drug Abuse Prevention Program. She maintains an active involvement with the Butte County Opioid Task Force, as well as the Butte County Drug Addiction Prevention Coalition, ACE’s Coalition (Trauma Informed), Breastfeeding Roundtable Coalition, Butte County Breastfeeding Coalition, Mother Strong Coalition, and Perinatal Coalition. Stacy has had extensive training with the California Department of Public Health's Opioid Stewardship & Chronic Pain Detailing Program, ID Training, UCSD CLE (Certified Lactation Educator), Coalition & Equity Training, Advocacy Training and holds 14 years of ongoing training & certification in the Pharmaceutical Industry. She is a member of the team coordinating and orchestrating the 2018 Northern California Opioid Summit.
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.
Join our subscription list to receive alerts for upcoming training opportunities. Want to customize a clinical topic-specific training for 15 trainees or more, on site in your community? Reach out to us to schedule a training consultation call at firstname.lastname@example.org.
We can't wait to work with you!
-The NaRCAD Team
Highlighting Best Practices
We highlight what's working in clinical education through interviews, features, event recaps, and guest blogs, offering clinical educators the chance to share successes and lessons learned from around the country & beyond.