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.
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
The National Academic Detailing Service’s
Opioid Overdose Education & Naloxone Distribution (OEND) Program
Guest Blog Authors: Melissa Christopher, PharmD, National Director
Mark Bounthavong, PharmD, MPH, National Clinical Program Manager
In 2015, the Department of Veterans Affairs (VA) invested in the National Academic Detailing Service to improve the health of our Veterans to address the call to action for the opioid crisis. Through the Opioid Overdose Education and Naloxone Distribution (OEND) Program, our goals were to reduce harm and risk of life-threatening opioid-related overdose and deaths among Veterans.
Key components of the OEND program include raising awareness about the epidemic, 1:1 academic detailing visits with clinicians to provide education and training regarding opioid overdose prevention, opioid overdose rescue response, and issuing naloxone products. We developed direct-to-consumer marketing and other e-resources, including a video, Introduction to Naloxone for People Taking Prescribed Opioids.
We also created implementation tools, including population management dashboards to aid staff in evaluating risk factors of their patient population and distributing naloxone accordingly. Academic Detailers demonstrated to VA providers these resources to help raise awareness of opioid overdose risk for their patient panel.
Decision-makers believed that funding this program would yield a good return on investment. As part of the National Academic Detailing Service, it’s our responsibility to collect data and supply decision-makers with evidence on the value and success of our program. In other words, we’re accountable for answering the question, “Is academic detailing worth it?”
To answer this question, we performed several program evaluations of the National Academic Detailing Service from 2015 to 2017, one of which we just published in the Journal of American Pharmacists Association (JAPhA) (Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.)
The evaluation found that our program improved naloxone distribution rates at a seven times greater increase for Veterans at risk for opioid overdose. These results provided key empirical evidence that VA’s strategy of academic detailing was working. Just as important, these findings also gave decision-makers what they needed—proof that their investment in an area of high risk to Veterans’ health paid off by improving care.
But we learned that another group of stakeholders was just as important as the decision-makers who funded the program—the clinicians that academic detailers visited to provide outreach education as a service. Academic detailers work with clinicians to help them change practice patterns, focusing on improving health outcomes in alignment with balanced, current evidence.
As clinicians commit to sustainable behavior change, these providers need to hear the feedback about how the time they’ve invested with their patients ultimately improves outcomes and, in this case, saves lives.
Sharing program results with the clinicians in this intervention also encouraged these providers to share their own results, many of which were stories of patients returning to the clinic to relate their experiences of using naloxone to reverse an overdose. These stories, along with reversal reports from the field that tracked the outcomes of naloxone kit distribution and subsequent use, also created a tangible “return on investment” for everyone involved.
We encourage other academic detailing programs to prioritize program evaluation as we have at the VHA—no matter the size of your program, if you’re thinking, “we can’t afford to do program evaluations,“ we stress that you can’t afford not to do them.
Measuring program work builds a case not just for the success of one academic detailing intervention, but for the success of future programs—a case for sustainability. Evaluation measures the quality of a program, analyzing results to look at a program’s impact, and allowing for process improvement adjustments to be made to streamline efforts and strengthen that impact. Evaluation cannot be optional, especially when lives are at stake.
We also recommend that the results from program evaluations are shared with other stakeholders, such as clinicians, in order to encourage and sustain their behavior changes. Leveraging results from well-designed evaluation is essential for academic detailing interventions to illustrate success, share value, and provide stakeholders and community members with a clear “Yes!” in answer to their overarching question: “Was the investment worth it?”
Melissa Christopher, PharmD
National Director, Academic Detailing, US Department of Veterans Affairs Central Office, Pharmacy Benefits Management (PBM) Academic Detailing Service
Dr. Christopher is the National Director of VA Academic Detailing Services, overseeing the implementation efforts for academic detailing expansion across all Veteran Integrated Service Networks since 2014. She received her Doctor of Pharmacy from Duquesne University, Pittsburgh Pennsylvania. She completed a Pharmacy Practice Residency and Post Graduate Year 2 in Pharmacoeconomics and Formulary Management at VA San Diego Healthcare System. Dr. Christopher conducted research in health outcomes and pharmacoeconomic analysis for several chronic disease management areas. In recent years, Dr. Christopher has embraced the mission to expand efforts for educational outreach by clinical pharmacists for improvement of evidence based care in Pain Management, Depression, Schizophrenia, and Posttraumatic Stress Disorder as well as other substance use disorders. Most of her program efforts focus on development of educational materials, outcome monitors, provider specific electronic audit and feedback tools to trend practice patterns with implementation efforts for the newly developed as well as fully implemented AD programs.
Mark Bounthavong, PharmD, MPH
National Clinical Program Manager, Academic Detailing Service, Veterans Affairs
Dr. Bounthavong graduated from the College of Pharmacy at Western University of Health Sciences. He completed a PGY-1 Pharmacy Practice Residency at the Veterans Affairs Loma Linda Healthcare System followed by a fellowship in Outcomes Research and Pharmacoeconomics at Western University of Health Sciences. He started his career at the Veterans Affairs San Diego Healthcare System as a pharmacoeconomics clinical specialist. During his tenure at the VA, Mark worked on identifying cost-effective strategies and formulary management; directed the PGY-1 Managed Care Pharmacy Residency; and completed a Master of Public Health from Emory University. Mark left the VA in order to pursue a PhD in the Pharmaceutical Outcomes Research and Policy Program at the University of Washington. He recently accepted a position at the VA as one of the National Clinical Pharmacy Data Program Managers in the Academic Detailing Service.
The exponential increase in computing power and data storage capacity, coupled with the sharp decrease in data processing costs, have made possible an era of ‘big data’ that is transforming many aspects of life and commerce. In health care, this evolution is enabling access to information that was impossible to imagine in the era when I first began this work when most prescriptions and test orders were still written on little scraps of paper. As applied to academic detailing, this growing capacity opens up a veritable armory of double-edged swords.
Knowing what doctors are ordering: This information has always been an important advantage of the pharmaceutical industry, which routinely buys the detailed prescribing records of specific physicians from intermediaries such as IMS, who in turn purchase these records from nearly every pharmacy in the nation. In the hands of an agile pharmaceutical representative, knowing a doctor’s drug preferences can be a powerful tool in shaping a promotional message tailored to that person.
Many of us in have had mixed views about the use of such data. On the one hand, it can make possible a more precisely focused discussion about optimal ordering of tests and treatments that is based on a given practitioner’s actual behavior. On the other hand, the approach comes with several risks. One is the concern that clinicians may feel “spied upon” – a problem that doesn’t seem to come up much in industry visits. This in turn can divert the conversation to discussion of “Why are you visiting me?” rather than a conversation about optimal patient care.
Data feedback to clinicians also degenerates frequently into he said-she said debates that often come down to “My patients are different!” We welcome feedback from academic detailing programs on how this use of data has worked (or hasn’t) in their own settings.
What patients are (or aren’t) doing: The computerization of dispensing records opened an era of hitherto-difficult research on patient adherence to their medication regimens, with generally depressing findings of low adherence. The full import of this rampant epidemic of non-compliance is still not well understood by most prescribers. The rapid growth in mobile and wearable technologies that capture physical activity and other lifestyle choices provides another potential source of data on patient behavior, but the best applications of this information are even less well understood.
In principle, academic detailing programs embedded in health care organizations can provide feedback to clinicians on how much or how little their patients are taking medications as directed or complying with other medical advice, and – more important – what to do about it. Is this a useful component of the educational encounter? Again, we would welcome hearing how this use of big data to provide feedback on adherence or patient behavior does or doesn’t fit into the work of ongoing academic detailing programs.
In the coming years, we will see even greater access to terabytes of data on who is ordering what, and what patients are doing with their prescriptions and other treatments. Used well, this technological revolution can provide added power to programs designed to improve that clinical decision making.
Bevin K. Shagoury, Communications & Education Director @ NaRCAD
We’ve just wrapped up our Spring Academic Detailing Training here in Boston, and we're excited to share a recap of an important event. With each new class of trainees, we see new ways that academic detailing can improve health outcomes for a variety of topics and populations.
This May 16th & 17th, the NaRCAD team hosted 18 trainees from across the U.S. and Europe. Our trainees represented programs looking to increase STD screening and sex education in Philadelphia, reduce overmedication of elderly long-term care residents across Indiana, teach safer opiate prescribing in Wisconsin, and implement other quality improvement initiatives in Ireland, Denmark, Georgia, Rhode Island, and North Dakota.
Everyone at NaRCAD would like to thank our fantastic, enthusiastic class of trainees for participating. We’ll be keeping in close touch as they go out into the field to implement important academic detailing interventions.
For other members of our community, we hope you’ll consider joining us this Fall at our next 2-day course on September 19th & 20th, 2016--it's the core of what we do. If it helps to convince you, 100% of our trainees from this week's course said they'd recommend our course to a colleague, so save the date, and be sure to register early as space is limited and seats fill quickly.
Registration opens on June 15th-we're looking forward to seeing you there!
Until then, remember: "Good information doesn't disseminate itself."
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.