An interview with Zack Dumont, BSP, ACPR, MS, a clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a NaRCAD Training Facilitator
Overview: The Cannabis Act went into effect in Canada in October of 2018. The legalization of a drug with strong potential for a myriad of clinical uses was followed by many questions from patients and providers alike about its effectiveness, its safety, and lack of previous research. The RxFiles have carried out a cannabinoid academic detailing campaign to address the demand for truth in a time where research has just begun to shed light on previous myths, misconceptions, and clinical promises.
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.
Zack Dumont is an clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a new expert facilitator for NaRCAD's training courses. He has been involved with the RxFiles since 2008, with experience in both academic detailing and content development of RxFiles’ evidence-based drug therapy comparison tools. Zack maintains clinical practices for inpatient internal medicine, with more specialized experience in anticoagulation and heart failure. His professional interests include teaching evidence-based medicine, knowledge translation, development of clinical decision supports, collaboration, and leadership.
Zack graduated as a Pharmacist from the University of Saskatchewan in 2008. Following graduation, he completed a hospital pharmacy residency with the Regina Qu’Appelle Health Region, where he currently serves as a Clinical Support Pharmacist, with involvement in training new staff, precepting pharmacy residents and undergraduate students, and providing clinical support to various health region committees and working groups.
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.
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