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 firstname.lastname@example.org, or leave your thoughts in the discussion forum below.
Expert Trainer Insight Series, Part 2:
An Interview with Amanda Kennedy, PharmD, BCPS, Director of the Vermont Academic Detailing Program
NaRCAD: Hi, Amanda! We’re looking forward to chatting with you. You’ve been an academic detailer for about 13 or 14 years—tell us about the Vermont program.
Amanda: The Vermont Academic Detailing Program was started in 1999, by Amy Jaeger, PharmD. I trained with Dr. Jaeger as a pharmacy resident. When she left Vermont in the early 2000s, she wanted to leave the program to someone who would be passionate about evidence-based prescribing in primary care.
So the job was mine! Amy unfortunately passed away unexpectedly in 2005, but her mentoring and passion for patient care has stayed with me, and has forever shaped the way I think about pharmacy and academic detailing.
We’ve evolved over time into a more organized program, with a grassroots focus of serving our state’s primary care providers. This commitment to service is how we succeed in building strong relationships with providers over time, and we infuse the spirit of service into all of our sessions.
NaRCAD: What challenges do you face that are specific to being a rural program?
Amanda: Our program has been stable, but it's been low budget over time. Despite being a small state, we face many challenges balancing the feasibility of delivering sessions to providers with our rural geography.
The evidence-base for academic detailing clearly demonstrates the value of a 1:1 ratio of academic detailer to provider. However, it doesn’t make sense for us to travel 2 hours each way to see one provider only to repeat the process the next day for a second provider within the same practice.
So we mostly deliver small group academic detailing sessions, as a way to serve as many providers as possible within our budget. We‘re mindful that “small group” means about 3 prescribers, which matches the types of practices we serve.
NaRCAD: Along with being a seasoned academic detailer, you also help us here at NaRCAD to train groups of new detailers at our Boston-based techniques trainings. Can you share some highlights?
Amanda: The power of the NaRCAD trainings is in the power of the individuals who attend. Realizing that other people are struggling with the same issues, and trying to address these issues with academic detailing, is so powerful.
NaRCAD: What would you tell someone who’s thinking about coming to a future NaRCAD training?
Amanda: I'd tell them to have fun with it! This training is a special opportunity to focus on how to best communicate with people around behavior change. It allows one to put aside specific topics and come together in a group to think about how best to deliver complex information.
The model applies across topics, allowing people from all types of programs to work towards a common goal. The training is hard work, but so rewarding, and offers the chance to learn and network with other trainees. The best part is that it’s immediately applicable upon returning to your program.
NaRCAD: That’s good advice—we agree that learning opportunities should be both challenging and enjoyable. In other news, we heard you recently presented at a U.S. House of Representatives Congressional Briefing. Tell us about that.
Amanda: I was invited to present at the briefing entitled, “Getting the Medications Right”: An essential ingredient in achieving the goals of H.R. 4878 – the Medicare Better Care, Lower Cost Act. The briefing was presented by the American College of Clinical Pharmacy and the College of Psychiatric and Neurologic Pharmacists.
The purpose of the briefing was to highlight pharmacists as members of the primary care team. I specifically presented some of my Vermont research that involved partnering pharmacists within patient-centered medical homes.
It was the perfect opportunity to showcase the innovative work we are doing here in Vermont. I think there was a great response from those who attended and for me personally, it was an absolute honor to be there.
NaRCAD: Thanks so much for taking the time to connect with us, Amanda. We’re delighted to have you as part of our core team of training facilitators, and we’re excited to share what you’re doing in Vermont with our community.
Learn more about Amanda Kennedy, or visit our Team Page to learn more about NaRCAD staff.
Join Us: NaRCAD's next training is open for registration.
Ask the Expert: Questions for Amanda? Ideas for us? Thoughts on detailing? Share your response in the comment section below for community discussion!
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.