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Williams EC, Frost MC, Bounthavong M, Edmonds AT, Lau MK, Edelman EJ, Harvey MA, Christopher MLD. Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241243309. [PMID: 38634339 DOI: 10.1177/29767342241243309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives. METHODS Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation. RESULTS Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed. CONCLUSIONS AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Bounthavong
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Mathematica, Seattle, WA, USA
| | - Marcos K Lau
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | | | - Michael A Harvey
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Melissa L D Christopher
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
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Knudsen HK, Freeman PR, Oyler DR, Oser CB, Walsh SL. Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model. Addict Sci Clin Pract 2023; 18:72. [PMID: 38031180 PMCID: PMC10688494 DOI: 10.1186/s13722-023-00426-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY). METHODS To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations. RESULTS Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program. CONCLUSIONS These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA.
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science and Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, and Center for Health Equity Transformation, University of Kentucky, Lexington, KY, 40536, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA
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Sachidanandan G, Sud A. From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023:00005141-990000000-00099. [PMID: 37782259 DOI: 10.1097/ceh.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
INTRODUCTION The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes. METHODS Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management. RESULTS Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent. DISCUSSION Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.
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Affiliation(s)
- Grahanya Sachidanandan
- Ms. Sachidanandan: Medical Student, Temerty Faculty of Medicine, University of Toronto. Dr. Sud: Research Chair, Primary Care & Population Health Systems, Humber River Hospital, and Assistant Professor, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto
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Rawal S, Osae SP, Cobran EK, Albert A, Young HN. Pharmacists' naloxone services beyond community pharmacy settings: A systematic review. Res Social Adm Pharm 2023; 19:243-265. [PMID: 36156267 DOI: 10.1016/j.sapharm.2022.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Pharmacists' provision of naloxone services in community pharmacy settings is well-recognized. Recently, studies describing pharmacists' naloxone services in settings other than community pharmacies have emerged in the literature. There is a need to synthesize evidence from these studies to evaluate the scope and impact of pharmacists' naloxone services beyond community pharmacy settings. OBJECTIVES The objectives of this systematic review were to a) identify pharmacists' naloxone services and their outcomes, and b) examine knowledge, attitudes, and barriers (KAB) related to naloxone service provision in non-community pharmacy settings. METHODS Eligible studies were identified using PubMed, Web of Science, and CINAHL. Inclusion criteria were as follows: peer-reviewed empirical research conducted in the U.S. from January 2010 through February 2022; published in English; and addressed a) pharmacists' naloxone services and/or b) KAB related to the implementation of naloxone services. PRISMA guidelines were used to report this study. RESULTS Seventy-six studies were identified. The majority were non-randomized and observational; only two used a randomized controlled (RCT) design. Most studies were conducted in veterans affairs (30%) and academic medical centers (21%). Sample sizes ranged from n = 10 to 217,469, and the majority reported sample sizes <100. Pharmacists' naloxone services involved clinical staff education, utilization of screening tools to identify at-risk patients, naloxone prescribing and overdose education and naloxone dispensing (OEND). Outcomes of implementing naloxone services included improved naloxone knowledge, positive attitudes, increased OEND, and overdose reversals. Pharmacists cited inadequate training, time constraints, reimbursement issues, and stigma as barriers that hindered naloxone service implementation. CONCLUSION This systematic review found robust evidence regarding pharmacist-based naloxone services beyond community pharmacy settings. Future programs should use targeted approaches to help pharmacists overcome barriers and enhance naloxone services. Additional research is needed to evaluate pharmacist naloxone services by using rigorous methodologies (e.g., larger sample sizes, RCT designs).
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Affiliation(s)
- Smita Rawal
- Clinical and Administrative Pharmacy, University of Georgia, Athens, GA, USA.
| | - Sharmon P Osae
- Clinical and Administrative Pharmacy, University of Georgia, Albany, GA, USA
| | - Ewan K Cobran
- Department of Quantitative Health Science, Mayo Clinic College of Medicine and Sciences, Scottsdale, AZ, USA
| | - Alexis Albert
- College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Henry N Young
- Clinical and Administrative Pharmacy, University of Georgia, Athens, GA, USA
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Irwin AN, Bratberg JP, Al-Jammali Z, Arnold J, Gray M, Floyd AS, Bolivar D, Hansen R, Hartung DM, Green TC. Implementation of an academic detailing intervention to increase naloxone distribution and foster engagement in harm reduction from the community clinician. J Am Pharm Assoc (2003) 2023; 63:284-294.e1. [PMID: 36567216 PMCID: PMC9933140 DOI: 10.1016/j.japh.2022.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/10/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Respond to Prevent (R2P) is a randomized clinical trial which sought to accelerate distribution of naloxone and other harm reduction materials from community pharmacies. R2P combined an online continuing education course with in-store materials, specifically designed for use in community pharmacies, and then supported implementation through the one-on-one educational technique of academic detailing. OBJECTIVE The objective of this paper is to describe and synthesize our experiences providing academic detailing as part of the R2P randomized trial. METHODS Closed-ended items from standardized post detailing questionnaires were analyzed with descriptive statistics. Open-ended items were content analyzed for key themes using immersion-crystallization qualitative methods. RESULTS A total of 176 pharmacies participated in R2P with 175 receiving their initial academic detailing visit between August 2019 and May 2021. Initial visits were in-person and lasted a median of 35 minutes (interquartile range, 20-45 minutes). The R2P naloxone guide was the most common topic covered (n = 162, 92.6%). Following a fidelity check to assess adequacy of the R2P program implementation, 80 pharmacies (45.7%) required secondary academic detailing. Secondary detailing was more targeted and most frequently focused on the sale of nonprescription syringes (n = 28; 35.2%) or disposal container distribution (n = 30; 37.5%). Analysis of the open-ended items identified factors that the detailers perceived to affect the quality of academic detailing sessions, including the pharmacy environment, participant knowledge of and attitudes toward the subject matter, and ability of the detailer to remain flexible yet consistent. CONCLUSION R2P provided a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across 4 states. Academic detailing was perceived to be well-received and effective at providing education and promoting distribution of naloxone and nonprescription syringes in community pharmacies. Additional research is needed to confirm these perceptions through evaluation post-intervention behavioral and attitude changes.
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Coffin PO, Martinez RS, Wylie B, Ryder B. Primary care management of Long-Term opioid therapy. Ann Med 2022; 54:2451-2469. [PMID: 36111417 PMCID: PMC9487960 DOI: 10.1080/07853890.2022.2121417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
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Affiliation(s)
- Phillip O Coffin
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Rebecca S Martinez
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Brian Wylie
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Bunny Ryder
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
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Buchanan A, Sun T, Wu J, Aroke H, Bratberg J, Rich J, Kogut S, Hogan J. Toward evaluation of disseminated effects of medications for opioid use disorder within provider-based clusters using routinely-collected health data. Stat Med 2022; 41:3449-3465. [PMID: 35673849 PMCID: PMC9288976 DOI: 10.1002/sim.9427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 08/17/2023]
Abstract
Routinely-collected health data can be employed to emulate a target trial when randomized trial data are not available. Patients within provider-based clusters likely exert and share influence on each other's treatment preferences and subsequent health outcomes and this is known as dissemination or spillover. Extending a framework to replicate an idealized two-stage randomized trial using routinely-collected health data, an evaluation of disseminated effects within provider-based clusters is possible. In this article, we propose a novel application of causal inference methods for dissemination to retrospective cohort studies in administrative claims data and evaluate the impact of the normality of the random effects distribution for the cluster-level propensity score on estimation of the causal parameters. An extensive simulation study was conducted to study the robustness of the methods under different distributions of the random effects. We applied these methods to evaluate baseline prescription for medications for opioid use disorder among a cohort of patients diagnosed with opioid use disorder and adjust for baseline confounders using information obtained from an administrative claims database. We discuss future research directions in this setting to better address unmeasured confounding in the presence of disseminated effects.
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Affiliation(s)
- Ashley Buchanan
- Department of Pharmacy Practice, University of Rhode Island, Rhode Island, USA
| | - Tianyu Sun
- Department of Pharmacy Practice, University of Rhode Island, Rhode Island, USA
| | - Jing Wu
- Department of Computer Science and Statistics, University of Rhode Island, Rhode Island, USA
| | - Hilary Aroke
- Department of Pharmacy Practice, University of Rhode Island, Rhode Island, USA
| | - Jeffrey Bratberg
- Department of Pharmacy Practice, University of Rhode Island, Rhode Island, USA
| | - Josiah Rich
- The Warren Alpert Medical School, Brown University, Rhode Island, USA
| | - Stephen Kogut
- Department of Pharmacy Practice, University of Rhode Island, Rhode Island, USA
| | - Joseph Hogan
- Department of Biostatistics, Brown University, Rhode Island, USA
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Torres EL, Evoy KE, Thomas LO. Outpatient Opioid and Naloxone Prescribing Practices at an Academic Medical Center during the COVID-19 Pandemic. J Pain Palliat Care Pharmacother 2022; 36:178-186. [PMID: 35916655 DOI: 10.1080/15360288.2022.2105471] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
While improving opioid safety has been a national priority, the coronavirus disease 2019 (COVID-19) pandemic has been associated with increased rates of opioid overdose. The present study characterized outpatient opioid and naloxone prescribing patterns during the COVID-19 pandemic. A retrospective chart review was conducted of adult patients receiving opioid therapy between August 2020 through October 2020 from outpatient clinics within a Texas health system. The primary outcome was naloxone co-prescription during the study period or within the year prior. During the study period, 1,368 patients received an opioid prescription, most of which were prescribed for chronic pain treatment (63.0%). Most opioid prescriptions (91.5%) were written for < 50 MME/day. For prescriptions written for acute pain, 78% were written for ≤ 10 days supply. While 31.1% of patients received gabapentinoid prescriptions, few (7.9%) received benzodiazepine or Z-hypnotic prescriptions. Twenty-two (1.6%) patients were co-prescribed naloxone. In this study, naloxone was rarely prescribed for outpatients receiving opioid prescriptions during the COVID-19 pandemic. Health systems should continue to prioritize adherence to evidence-based clinical guidelines and increase access to naloxone.
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Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Harvey MA, Hoffman JD, Himstreet JE, Kay CL, Freeman BA, Grana A, LD Christopher M. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration regional networks. Int J Med Inform 2022; 161:104712. [DOI: 10.1016/j.ijmedinf.2022.104712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/08/2022] [Accepted: 01/28/2022] [Indexed: 12/29/2022]
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Sud A, Molska GR, Salamanca-Buentello F. Evaluations of Continuing Health Provider Education Focused on Opioid Prescribing: A Scoping Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:286-299. [PMID: 34074902 PMCID: PMC8781229 DOI: 10.1097/acm.0000000000004186] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE Continuing health provider education (HPE) is an important intervention supported by health policy to counter the opioid epidemic; knowledge regarding appropriate program design and evaluation is lacking. The authors aim to provide a comprehensive understanding of evaluations of opioid-related continuing HPE programs and their appropriateness as interventions to improve population health. METHOD In January 2020, the authors conducted a systematic search of 7 databases, seeking studies of HPE programs on opioid analgesic prescribing and overdose prevention. Reviewers independently screened the titles and abstracts of all studies and then assessed the full texts of all studies potentially eligible for inclusion. The authors extracted a range of data using categories for evaluating complex programs: the use of theory, program purpose, inputs, activities, outputs, outcomes, and industry involvement. Results were reported in a narrative synthesis. RESULTS Thirty-nine reports on 32 distinct HPE programs met inclusion criteria. Of these 32, 31 (97%) were U.S./Canadian programs and 28 (88%) were reported after 2010. Measurements of changes in knowledge and confidence were common. Performance outcomes were less common and typically self-reported. Most studies (n = 27 [84%]) used concerns of opioid-related harms at the population health level to justify the educational intervention, but only 5 (16%) measured patient- or population-level outcomes directly related to the educational programs. Six programs (19%) had direct or indirect opioid manufacturer involvement. CONCLUSIONS Continuing HPE has been promoted as an important means of addressing population-level opioid-related harms by policymakers and educators, yet published evaluations of HPE programs focusing on opioid analgesics inadequately evaluate patient- or population-level outcomes. Instead, they primarily focus on self-reported performance outcomes. Conceptual models are needed to guide the development and evaluation of continuing HPE programs intended to have population health benefits.
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Affiliation(s)
- Abhimanyu Sud
- A. Sud is assistant professor, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0001-8354-6153
| | - Graziella R. Molska
- G.R. Molska was research coordinator, Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada at the time this work was completed
| | - Fabio Salamanca-Buentello
- F. Salamanca-Buentello is a postdoctoral fellow, Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-3666-7785
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Himstreet JE, Shayegani R, Spoutz P, Hoffman JD, Midboe AM, Hillman A, Marin J, Chen A, Smith JP, Manning J, Grana A, Gray C, Erhardt T, Garcia C, Freeman B, Christopher MLD, Bounthavong M. Implementation of a pharmacy-led virtual academic detailing program at the US Veterans Health Administration. Am J Health Syst Pharm 2022; 79:909-917. [PMID: 35084487 DOI: 10.1093/ajhp/zxac024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To provide a summary of the implementation of a virtual academic detailing pilot program at the US Department of Veterans Affairs (VA). SUMMARY In September 2018, VA Pharmacy Benefits Management implemented a virtual academic detailing ("e-Detailing") pilot program across three regional networks. Academic detailing involves multifaceted collaborative outreach delivered by trained healthcare clinicians to other clinicians using targeted educational interventions that improve clinical decision-making. Across VA, academic detailing programs are primarily staffed by specially trained clinical pharmacist specialists. Implementation began with an in-person meeting to train academic detailers on using the virtual academic detailing platform (VA Video Connect) and virtual soft skills, which was followed by regular facilitation meetings to address issues and share experiences. During e-Detailing program implementation, the coronavirus disease 2019 (COVID-19) emerged, prompting the US Department of Health and Human Services to declare a public health emergency. VA followed with restrictions on nonessential travel for all employees, thus hampering in-person academic detailing activities. Fortunately, e-Detailing provided an alternative channel for academic detailers across VA to continue delivering critical outreach to providers during the pandemic. Qualitative assessment of academic detailers' and providers' perceptions on e-Detailing highlighted the need for local leadership support for e-Detailing and telehealth, the efficiency of virtual compared to in-person visits, and potential time savings resulting from avoidance of long commutes. CONCLUSION The timing of e-Detailing implementation during the COVID-19 pandemic illustrates the need and potential for a virtual platform to deliver timely provider outreach.
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Affiliation(s)
| | - Ramona Shayegani
- VISN Program Manager, Academic Detailing Service, VA Sierra Pacific Network (VISN 21), Pleasant Hill, CA, USA
| | - Patrick Spoutz
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Jonathan D Hoffman
- VA Rocky Mountain Network (VISN 19), Pharmacy Benefits Management, Glendale, CO, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, and Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ashley Hillman
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Jennifer Marin
- VA Sierra Pacific Network (VISN 21), Pharmacy Benefits Management, Pleasant Hill, CA, USA
| | - Andrea Chen
- Academic Detailing Service; VA Heartland Network (VISN 15), Kansas City, MO, USA
| | - Jason P Smith
- VA Rocky Mountain Network (VISN 19), Pharmacy Benefits Management, Glendale, CO, USA
| | - Jane Manning
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Andrea Grana
- Academic Detailing Service, VA Pharmacy Benefits Management, West Palm Beach, FL, USA
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Taryn Erhardt
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Carla Garcia
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Blake Freeman
- Academic Detailing Service, VA Pharmacy Benefits Management, New York, NY, USA
| | | | - Mark Bounthavong
- Academic Detailing Service, VA Pharmacy Benefits Management, San Diego, CA, and Division of Clinical Pharmacy, UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
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Kulbokas V, Hanson KA, Smart MH, Mandava MR, Lee TA, Pickard AS. Academic detailing interventions for opioid-related outcomes: a scoping review. Drugs Context 2021; 10:2021-7-7. [PMID: 34970320 PMCID: PMC8687092 DOI: 10.7573/dic.2021-7-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Academic detailing (AD) is a tailored, interactive educational outreach intervention that may improve patient outcomes. Insight into the design of AD interventions and the extent to which they are effective can help inform future AD-based programmes. The objective of this scoping review was to characterize opioid-focused AD interventions and describe their findings. METHODS A scoping review focused on AD interventions for opioids was conducted in PubMed, EMBASE and CINAHL databases through July 1, 2021. Studies were eligible for inclusion if written in English, included interactive opioid-focused educational interventions, and were conducted either in person, virtually or via telephone. Four independent reviewers reviewed titles and abstracts. Data extraction from full-text publications was completed using a standardized form. RESULTS Of 6086 articles initially identified, 22 articles met the inclusion criteria and 20 unique interventions were identified. The AD intervention was either delivered one-on-one (n=16) or in a small, interactive group setting (n=4). AD interventions varied in design. Effectiveness was evaluated in terms of opioid and naloxone prescribing rates, provider knowledge gaps, provider adherence to guidelines, and intervention feasibility. Sixteen (80%) interventions resulted in statistically significant improvement in one or more outcomes. CONCLUSION Generally, opioid-related AD was effective and programmes were primarily conducted one-on-one between pharmacists and primary care providers for 16-30 minutes. A variety of metrics and outcomes were used to assess the success/effectiveness of AD interventions, which is an important consideration in future studies as no single metric captures the effectiveness of an educational outreach-based intervention for pain management.
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Affiliation(s)
- Victoria Kulbokas
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Kent A Hanson
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Mary H Smart
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Monika Rao Mandava
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
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13
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Bounthavong M, Christopher MLD, Veenstra DL, Basu A, Devine EB. Exploring Providers' Perception to Naloxone Education for Opioid Overdose After Receiving Academic Detailing at the U.S. Department of Veterans Affairs. J Pharm Pract 2021; 36:514-522. [PMID: 34766510 DOI: 10.1177/08971900211053282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The U.S. Department of Veterans Affairs (VA), in partnership with the Opioid Overdose Education and Naloxone Distribution (OEND) Program, implemented the National Academic Detailing Service to deliver naloxone education to providers with patients at-risk for opioid-related overdose. METHODS We administered a 26-item online survey to VA providers to explore their perceptions about prescribing naloxone for opioid overdose emergencies and their experience with academic detailing between August 2017 and April 2018. Responses were analyzed using descriptive statistics to (1) explore their current perceptions of naloxone prescribing and their experience with academic detailing, (2) identify differences across provider types [primary care providers (PCP), specialists, and others], and (3) assess perceived naloxone prescribing behavior change after an academic detailing visit. RESULTS Providers (N = 137) indicated that they were practicing at a level that was consistent with VA goals to promote take-home naloxone to reverse opioid-related overdose events. Average domain scores were similar across PCP, specialist, and other provider types. Specialists reported a higher average attitude domain score (+.56, P = .011) and perceived barriers domain score (+.82, P = .009) than PCPs. Most providers agreed that they prescribed naloxone more frequently due to academic detailing (53%) and indicated that they synthesized information from the academic detailer to change their naloxone prescribing practice (60%). DISCUSSION VA providers' perceptions of take-home naloxone were aligned with current evidence-based practice. Moreover, providers reported increasing their naloxone prescribing and synthesizing OEND-related information after an academic detailing interaction. Understanding providers' perceptions can be used to improve and enhance the academic detailing program's effectiveness.
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Affiliation(s)
- Mark Bounthavong
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, 15532University of Washington, Seattle, WA, USA.,National Academic Detailing Service, Pharmacy Benefits Management, 8267U.S. Department of Veterans Affairs, Washington, DC, USA.,UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, Veterans Affairs (VA) Health Economics Resource Center (HERC), Menlo Park, CA, USA.,Veterans Affairs (VA) Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Melissa L D Christopher
- National Academic Detailing Service, Pharmacy Benefits Management, 8267U.S. Department of Veterans Affairs, Washington, DC, USA
| | - David L Veenstra
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, 15532University of Washington, Seattle, WA, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, 15532University of Washington, Seattle, WA, USA.,Department of Health Services, School of Public Health, 15532University of Washington, Seattle, WA, USA
| | - Emily Beth Devine
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, 15532University of Washington, Seattle, WA, USA.,Department of Health Services, School of Public Health, 15532University of Washington, Seattle, WA, USA
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14
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McQuillan A. Clinical pharmacist involvement in expanding naloxone distribution in a veteran population. Am J Health Syst Pharm 2021; 79:472-476. [PMID: 34755851 DOI: 10.1093/ajhp/zxab424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the process used in a clinical pharmacist specialist (CPS)-led Opioid Overdose Education and Naloxone Distribution (OEND) program initiative to increase naloxone distribution to veterans at high risk for overdose via provider education and identification of barriers to naloxone distribution. SUMMARY Drug overdose is the leading cause of accidental death in the United States. One step toward counteracting the epidemic includes expanding access to and use of naloxone. The Veterans Health Administration has developed initiatives to target veterans at risk for opioid overdose, such as the Veterans Affairs (VA) OEND program. Pharmacists can play a unique role in OEND by both prescribing naloxone and educating patients and providers on risk mitigation strategies. Through provider education, patient education, and facility-wide initiatives, naloxone prescribing was increased by 9-fold from August 2016 to August 2018. In addition, the number of new naloxone prescribers increased by almost 7-fold during the intervention period. Naloxone distribution to high-risk groups drastically increased across all target groups. CONCLUSION CPS involvement in promoting OEND at VAPHS drastically increased rates of prescribing of naloxone kits to veterans at risk for opioid overdose. This initiative showed that a CPS can play multiple roles in supporting OEND outreach at a large healthcare setting.
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15
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Stein BD, Smart R, Jones CM, Sheng F, Powell D, Sorbero M. Individual and Community Factors Associated with Naloxone Co-prescribing Among Long-term Opioid Patients: a Retrospective Analysis. J Gen Intern Med 2021; 36:2952-2957. [PMID: 33598891 PMCID: PMC8481397 DOI: 10.1007/s11606-020-06577-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Naloxone co-prescribing to individuals at increased opioid overdose risk is a key component of opioid overdose prevention efforts. OBJECTIVE Examine naloxone co-prescribing in the general population and assess how co-prescribing varies by individual and community characteristics. DESIGN Retrospective cross-sectional study. We conducted a multivariable logistic regression of 2017-2018 de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia. PATIENTS Individuals with opioid analgesic treatment episodes > 90 days MAIN MEASURES: Outcome was co-prescribed naloxone. Predictor variables included insurance type, primary prescriber specialty, receipt of concomitant benzodiazepines, high-dose opioid episode, county urbanicity, fatal overdose rates, poverty rates, and primary care health professional shortage areas. KEY RESULTS Naloxone co-prescribing occurred in 2.3% of long-term opioid therapy episodes. Medicaid (aOR 1.87, 95%CI 1.84 to 1.90) and Medicare (aOR 1.48, 95%CI 1.46 to 1.51) episodes had higher odds of naloxone co-prescribing than commercial insurance episodes, while cash pay (aOR 0.77, 95%CI 0.74 to 0.80) and other insurance episodes (aOR 0.81, 95%CI 0.79 to 0.83) had lower odds. Odds of naloxone co-prescribing were higher among high-dose opioid episodes (aOR 3.19, 95%CI 3.15 to 3.23), when concomitant benzodiazepines were prescribed (aOR 1.12, 95%CI 1.10 to 1.14), and in counties with higher fatal overdose rates. CONCLUSION Co-prescription of naloxone represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, we found that co-prescribing rates remain low overall. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.
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Affiliation(s)
- Bradley D Stein
- RAND Corporation, Pittsburgh, PA, USA.
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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16
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Vadiei N, Eldridge LA, Meyerson BE, Agley J. "The gatekeepers in prevention": Community pharmacist perceptions of their role in the opioid epidemic. Subst Abus 2021; 43:319-327. [PMID: 34214407 DOI: 10.1080/08897077.2021.1941516] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Community pharmacists are at the frontline of patient care, yet their role in the opioid epidemic remains unclear. This qualitative study examines the perception of community pharmacists about their role in the opioid epidemic and challenges to fulfilling this role. Methods: A secondary analysis of cross-sectional survey data from an Indiana census of community managing pharmacists was conducted. Qualitative data were coded using a priori and emergent themes. A priori categories included the perceived role of pharmacists in the opioid epidemic and perception of practice barriers. Results: A total of 215 Indiana community managing pharmacists participated in this study. Pharmacists understood themselves as gatekeepers in preventing opioid misuse and overdose. Reported pharmacy practices included providing patient education and communicating with prescribers. Challenges to fulfilling this role included pharmacy structure and operation, lack of patient and provider clarity about pharmacist scope of practice, and pharmacist perception that that there is no available discretionary time to support additional services. Conclusion: Pharmacists believe they have a vital role in combatting opioid misuse and overdose but are hampered by structural aspects of pharmacy practice and lack of recognition of their role. Pharmacy associations and policy partners are encouraged to identify opportunities to address these barriers.
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Affiliation(s)
- Nina Vadiei
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Lori Ann Eldridge
- Department of Applied Health Science, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA.,Prevention Insights, Institute for Research on Addictive Behavior, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA
| | - Beth E Meyerson
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, AZ, USA.,Family & Community Medicine, College of Medicine, The University of Arizona, Tucson, AZ, USA
| | - Jon Agley
- Department of Applied Health Science, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA.,Prevention Insights, Institute for Research on Addictive Behavior, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA
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17
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Ball SJ, McCauley JA, Pruitt M, Zhang J, Marsden J, Barth KS, Mauldin PD, Gebregziabher M, Moran WP. Academic detailing increases prescription drug monitoring program use among primary care practices. J Am Pharm Assoc (2003) 2021; 61:418-424.e2. [PMID: 33812783 PMCID: PMC8273068 DOI: 10.1016/j.japh.2021.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Clinical review of a prescription drug monitoring program (PDMP) is considered a valuable tool for opioid prescribing risk mitigation; however, PDMP use is often low, even in states with mandatory registration and use policies. The objective was to evaluate the impact of an academic detailing (AD) outreach intervention on PDMP use among primary care prescribers. METHODS AD intervention was delivered to primary care based controlled substance prescribers (N = 87) and their associated PDMP delegates (n = 42) by a clinical pharmacist as 1 component of a large-scale, statewide initiative to improve opioid prescribing safety. Prescriber PDMP use behavior was assessed by prescriber self-report and analysis of objective 2016-2018 PDMP data regarding the number of monthly report requests. We compared means between pre- and postintervention using a paired t test and plotted the monthly average reports over time to assess the trend of mean reports over time. Generalized linear mixed model with a negative binomial distribution was used to assess the difference in the trend and magnitude of the combined count of reports for the entire sample and prescriber subsets that were segmented on the basis of the adoption status of PDMP. RESULTS The monthly mean of reports by combined prescribers and delegates significantly increased after the AD intervention (mean 28.1 pre vs. 53.0 post; P < 0.001), with the increase in delegate reports (mean 17.1 pre vs. 60.0 post; P < 0.001) driving the overall increase. Reports were requested 40.4 times more often than in the preintervention period (P < 0.001). Patterns of pre- to postchanges in mean monthly report requests differed by baseline PDMP adoption status. CONCLUSION The AD intervention was transformative in facilitating practice change to use delegates to run reports. Visits with both prescribers and delegates, including hands-on PDMP training and registration assistance, can be viewed as beneficial for practice facilitation.
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Affiliation(s)
- Sarah J. Ball
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna A. McCauley
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Megan Pruitt
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly S. Barth
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, USA
| | - William P. Moran
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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18
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Bounthavong M, Lau MK, Kay CL, Wells DL, Popish SJ, Harvey MA, Himstreet JE, Grana A, Freeman BA, Morillo CM, Christopher MLD. Impact of Implementing an Academic Detailing Program on Opioid-Benzodiazepine Co-Prescribing Trends at the U.S. Department of Veterans Affairs. PAIN MEDICINE 2021; 22:1426-1434. [PMID: 33749779 DOI: 10.1093/pm/pnaa475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To assess the process and outcomes of academic detailing to enhance the Opioid Safety Initiative and the Psychotropic Drug Safety Initiative to reduce co-prescribing of opioid-benzodiazepine combinations in veterans. METHODS A retrospective cohort design was conducted to evaluate the impact of implementing an academic detailing program on opioid-benzodiazepine co-prescribing between October 2014 through March 2019 at the U.S. Department of Veterans Affairs (VA). The primary outcome was the monthly prevalence of veterans (number per 1,000 population) who were co-prescribed opioid-benzodiazepine combination. Process measure was evaluated using implementation reach (proportion of providers who received academic detailing). Station-level analysis was performed using a linear fixed effects regression model to evaluate the rate of change in the prevalence of veterans co-prescribed opioid-benzodiazepine. RESULTS Altogether 130 VA stations was included for analysis; 119 stations implemented opioid-related or benzodiazepine-related academic detailing, and 11 stations did not. Stations that had implemented academic detailing had a 33% greater monthly reduction on the opioid-benzodiazepine co-prescribing prevalence compared to stations that did not implement academic detailing (P = .036). In the linear fixed effects regression model, stations that were expected to have 100% of providers exposed to academic detailing were statistically associated with a greater decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine by 4.9 veterans per 1,000 population (P < .001) compared to stations with 0% of providers exposed to academic detailing. CONCLUSIONS Stations that implemented academic detailing and had a higher proportion of providers who were exposed to opioid- or benzodiazepine-related academic detailing had a significant decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine combinations.
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Affiliation(s)
- Mark Bounthavong
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA.,U.S. Department of Veterans Affairs (VA) Health Economics Resource Center, Menlo Park, California, USA.,U.S. Department of Veterans Affairs (VA) Center for Innovation to Implementation, Menlo Park, California, USA.,Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, California, USA
| | - Marcos K Lau
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Chad L Kay
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Daina L Wells
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Sarah J Popish
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Michael A Harvey
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Julianne E Himstreet
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Andrea Grana
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Blake A Freeman
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Christina M Morillo
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
| | - Melissa L D Christopher
- U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Academic Detailing Service, Washington, District of Columbia, USA
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19
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Opioid Prescribing and Opioid Risk Mitigation Strategies in the Veterans Health Administration. J Gen Intern Med 2020; 35:927-934. [PMID: 33196968 PMCID: PMC7728840 DOI: 10.1007/s11606-020-06258-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship. AIM To provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA. SETTING VHA is the largest integrated health care system in the United States. PROGRAM DESCRIPTION VHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019. PROGRAM EVALUATION VHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews. IMPLICATIONS VHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies. IMPACTS VHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.
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20
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Becker WC, Krebs EE, Edmond SN, Lin LA, Sullivan MD, Weiss RD, Gordon AJ. A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference. J Gen Intern Med 2020; 35:978-982. [PMID: 33145681 PMCID: PMC7728950 DOI: 10.1007/s11606-020-06260-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/21/2020] [Indexed: 11/27/2022]
Abstract
US military Veterans have been disproportionately impacted by the US opioid overdose crisis. In the fall of 2019, the Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of opioid safety, including both use of opioid analgesics and managing opioid use disorder. We present the methods and consensus recommendations from the SOTA. A core group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: managing opioid use disorder, long-term opioid therapy for pain including consideration for opioid tapering, and treatment of co-occurring pain and substance use disorders. The SOTA participants divided into three workgroups and identified key questions and seminal studies related to those three areas of focus. The strongest recommendations included testing implementation strategies in the VHA for expanding access to medication treatment for opioid use disorder, testing collaborative tapering programs for patients prescribed long-term opioids, and larger trials of behavioral and exercise/movement interventions for pain among patients with substance use disorders.
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Affiliation(s)
- William C Becker
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mark D Sullivan
- University of Washington School of Medicine, Seattle, WA, USA
| | - Roger D Weiss
- Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient Aligned Care Team Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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21
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Hoffman JD, Shayegani R, Spoutz PM, Hillman AD, Smith JP, Wells DL, Popish SJ, Himstreet JE, Manning JM, Bounthavong M, Christopher MLD. Virtual academic detailing (e-Detailing): A vital tool during the COVID-19 pandemic. J Am Pharm Assoc (2003) 2020; 60:e95-e99. [PMID: 32747164 PMCID: PMC7833607 DOI: 10.1016/j.japh.2020.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/19/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
Abstract
As the coronavirus disease (COVID-19) pandemic continues its course in 2020, telehealth technology provides opportunities to connect patients and providers. Health policies have been amended to allow easy access to virtual health care, highlighting the field's dynamic ability to adapt to a public health crisis. Academic detailing, a peer-to-peer collaborative outreach designed to improve clinical decision-making, has traditionally relied on in-person encounters for effectiveness. A growth in the adoption of telehealth technology translates to increases in academic detailing reach for providers unable to meet with academic detailers in person. The U.S. Department of Veterans Affairs (VA) has used academic detailing to promote and reinforce evidence-based practices and has encouraged more virtual academic detailing (e-Detailing). Moreover, VA academic detailers are primarily clinical pharmacy specialists who provide clinical services and education and have made meaningful contributions to improving health care at VA. Amid the COVID-19 pandemic and physical isolation orders, VA academic detailers have continued to meet with providers to disseminate critical health care information in a timely fashion by using video-based telehealth. When working through the adoption of virtual technology for the delivery of medical care, providers may need time and nontraditional delivery of "evidence" before eliciting signals for change. Academic detailers are well suited for this role and can develop plans to help address provider discomfort surrounding the use of telehealth technology. By using e-Detailing as a method for both familiarizing and normalizing health professionals with video-based telehealth technology, pharmacists are uniquely poised to deliver consultation and direct-care services. Moreover, academic detailing pharmacists are ambassadors of change, serving an important role navigating the evolution of health care in response to emergent public health crises and helping define the norms of care delivery to follow.
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22
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Coon SA, Hill LG, Hutchison RW, Arnold LM, Jarrett JB, Ottney AR, Oung AB, Painter NA, Smith MA, Stranges PM, Tran TH, McFee Winans AR, Bratberg JP. Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Scott A. Coon
- Department of Pharmacotherapeutics & Clinical Research University of South Florida, Taneja College of Pharmacy, Morsani College of Medicine Tampa Florida USA
| | - Lucas G. Hill
- Division of Pharmacy Practice The University of Texas at Austin College of Pharmacy Austin Texas USA
| | - Robert W. Hutchison
- Department of Pharmacy Practice Texas A&M Irma Lerma Rangel College of Pharmacy Round Rock Texas USA
| | - Lindsay M. Arnold
- Department of Pharmacy Services St. Elizabeth's Medical Center Brighton Massachusetts USA
| | - Jennie B. Jarrett
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Anne R. Ottney
- Department of Pharmacy Practice Ferris State University, College of Pharmacy Big Rapids Michigan USA
| | - Alvin B. Oung
- Department of Pharmacy Practice University of Wyoming School of Pharmacy Laramie Wyoming USA
| | - Nathan A. Painter
- Division of Clinical Pharmacy University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego California USA
| | - Michael A. Smith
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Paul M. Stranges
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Tran H. Tran
- Department of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove Illinois USA
| | - Amanda R. McFee Winans
- Section of Clinical Pharmacy, Department of Pharmaceutical Care Services Bassett Medical Center Cooperstown New York USA
| | - Jeffrey P. Bratberg
- Department of Pharmacy Practice University of Rhode Island College of Pharmacy Kingston Rhode Island USA
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Opioid Use Disorders in People Living with HIV/AIDS: A Review of Implications for Patient Outcomes, Drug Interactions, and Neurocognitive Disorders. PHARMACY 2020; 8:pharmacy8030168. [PMID: 32932786 PMCID: PMC7559328 DOI: 10.3390/pharmacy8030168] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/03/2020] [Accepted: 09/05/2020] [Indexed: 01/05/2023] Open
Abstract
The opioid epidemic has had a significant, negative impact in the United States, and people living with HIV/AIDS (PLWHA) represent a vulnerable sub-population that is at risk for negative sequela from prolonged opioid use or opioid use disorder (OUD). PLWHA are known to suffer from HIV-related pain and are commonly treated with opioids, leading to subsequent addictive disorders. PLWHA and OUD are at an increased risk for attrition in the HIV care continuum, including suboptimal HIV laboratory testing, delayed entry into HIV care, and initiation or adherence to antiretroviral therapy. Barriers to OUD treatment, such as medication-assisted therapy, are also apparent for PLWHA with OUD, particularly those living in rural areas. Additionally, PLWHA and OUD are at a high risk for serious drug–drug interactions through antiretroviral-opioid metabolic pathway-related inhibition/induction, or via the human ether-a-go-go-related gene potassium ion channel pathways. HIV-associated neurocognitive disorders can also be potentiated by the off-target inflammatory effects of opioid use. PLWHA and OUD might require more intensive, individualized protocols to sustain treatment for the underlying opioid addiction, as well as to provide proactive social support to aid in improving patient outcomes. Advancements in the understanding and management of PLWHA and OUD are needed to improve patient care. This review describes the effects of prescription and non-prescription opioid use in PLWHA.
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Schuler MS, Heins SE, Smart R, Griffin BA, Powell D, Stuart EA, Pardo B, Smucker S, Patrick SW, Pacula RL, Stein BD. The state of the science in opioid policy research. Drug Alcohol Depend 2020; 214:108137. [PMID: 32652376 PMCID: PMC7423757 DOI: 10.1016/j.drugalcdep.2020.108137] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies. METHODS We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005-2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category). RESULTS In total, 145 studies were reviewed (79 % state-level policies, 21 % federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20 % of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017-2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies. CONCLUSIONS Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.
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Affiliation(s)
- Megan S Schuler
- RAND Corporation, 20 Park Plaza #920, Boston, MA, 02216, USA.
| | - Sara E Heins
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Rosanna Smart
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Beth Ann Griffin
- RAND Corporation, 1200 S Hayes Street, Arlington, VA, 22202, USA
| | - David Powell
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Bryce Pardo
- RAND Corporation, 1200 S Hayes Street, Arlington, VA, 22202, USA
| | - Sierra Smucker
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center 2200 Children's Way, 11111 Doctors' Office Tower, Nashville, TN, 37232, USA
| | - Rosalie Liccardo Pacula
- Schaeffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna and Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
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25
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Providers' perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment. Res Social Adm Pharm 2020; 16:1033-1040. [DOI: 10.1016/j.sapharm.2019.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 08/13/2019] [Accepted: 10/25/2019] [Indexed: 11/18/2022]
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26
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Dieujuste N, Johnson‐Koenke R, Christopher M, Gunzburger EC, Emmendorfer T, Kessler C, Haukoos J, Smith J, Sasson C. Feasibility Study of a Quasi-experimental Regional Opioid Safety Prescribing Program in Veterans Health Administration Emergency Departments. Acad Emerg Med 2020; 27:734-741. [PMID: 32239558 DOI: 10.1111/acem.13980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/03/2020] [Accepted: 03/27/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) was implemented in 2013 and was associated with a 25% relative decrease in the dispensing of opioids. Although emergency department (ED) providers play a role in the initiation and continuation of opioids, the incumbent OSI did not target EDs. OBJECTIVE The goal of this feasibility study was to leverage the existing VHA OSI and test a novel ED-based quality improvement (QI) program to decrease opioid prescribing in multiple ED settings. METHODS This was a quasi-experimental study of phased-in implementation of a QI ED-based OSI. The general setting for this pilot were four VHA EDs across the Veterans Integrated Services Network (VISN) region 19: Denver, Oklahoma City, Muskogee, and Salt Lake City. We developed and disseminated a dashboard to assess ED-specific prescribing rates and an ED-tailored toolkit to implement the program. Academic detailing pharmacists provided focused audits and feedback with the highest prescribing providers. We measured change in ED-provider prescribing rate of opioids for patients discharged from the ED, by provider and aggregated up to facility level, pre- and postimplementation. RESULTS Interrupted time-series analysis of provider-level data from the program implementation sites indicated a significant decrease in the trend for proportion of opioid prescriptions relative to the preintervention trend. The results of the analysis suggest that the intervention was associated with accelerating the rate at which ED provider prescribing rates decreased. CONCLUSION Due to the high volume of patients and the vital role the ED plays in patient treatment and hospital admissions, it is evident that the ED is an important site for QI programs as well as the implementation of opioid safety measures. Given the findings of this pilot, we believe that implementation of a national Veterans Affairs ED OSI implementation is feasible practice.
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Affiliation(s)
- Nathalie Dieujuste
- From the VA Eastern Colorado Health Care System, Veterans Health Administration Aurora CO
| | - Rachel Johnson‐Koenke
- From the VA Eastern Colorado Health Care System, Veterans Health Administration Aurora CO
| | - Melissa Christopher
- National Academic Detailing Services, Veterans Health Administration San Diego CA
| | - Elise C. Gunzburger
- From the VA Eastern Colorado Health Care System, Veterans Health Administration Aurora CO
| | - Thomas Emmendorfer
- National Pharmacy Benefits Management, Veterans Health Administration Washington DC
| | - Chad Kessler
- Durham VA Medical Center National Emergency Medicine Program Office, Veterans Health Administration Durham NC
| | - Jason Haukoos
- and the Denver Health and Hospital Authority Denver CO
- and the Colorado School of Public Health Aurora CO
- the University of Colorado School of Medicine Aurora CO
| | - Jason Smith
- and VA Eastern Colorado Health Care System, Veterans Health Administration Denver CO
| | - Comilla Sasson
- From the VA Eastern Colorado Health Care System, Veterans Health Administration Aurora CO
- and the Colorado School of Public Health Aurora CO
- the University of Colorado School of Medicine Aurora CO
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27
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Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing. Br J Gen Pract 2020; 70:e589-e597. [PMID: 32540873 DOI: 10.3399/bjgp20x711737] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/17/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Understanding barriers to safe opioid prescribing in primary care is critical amid the epidemic of prescription opioid abuse, misuse, and overdose in the US. Educational outreach strategies, such as academic detailing (AD), provide a forum for identification of barriers to, and strategies to facilitate, safe opioid prescribing in primary care. AIM To identify barriers to safe opioid prescribing among primary care providers (PCPs) through AD. DESIGN AND SETTING Qualitative analysis of data was collected through an existing AD intervention to improve safe opioid prescribing in primary care. The AD intervention was delivered from June 2018 to August 2018 to licensed PCPs with prescriptive authority within a large independent health system in the metropolitan Chicagoland area. METHOD The AD intervention involved visits by trained detailers to PCPs who contemporaneously documented details from each visit via field notes. Using qualitative analysis, field notes were analysed to identify recurring themes related to opioid prescribing barriers. RESULTS Detailer-entered field notes from 186 AD visits with PCPs were analysed. Barriers to safe opioid prescribing were organised into six themes: 1) gaps in knowledge; 2) lack of prescription monitoring programme (PMP) utilisation; 3) patient pressures to prescribe opioids; 4) insurance coverage policies; 5) provider beliefs; and 6) health system pain management practices. CONCLUSION Barriers to safe opioid prescribing in primary care, identified through AD visits among this large group of PCPs, support the need for continued efforts to enhance pain-management education, maximise PMP utilisation, and increase access to, and affordability of, non-opioid treatments.
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28
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Bounthavong M, Harvey MA, Kay CL, Lau MK, Wells DL, Himstreet JE, Popish SJ, Oliva EM, Christopher ML. Comparison of naloxone prescribing patterns due to educational outreach conducted by full-time and part-time academic detailers at the U.S. Veterans Health Administration. J Am Pharm Assoc (2003) 2020; 60:639-646. [DOI: 10.1016/j.japh.2019.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/07/2019] [Accepted: 11/08/2019] [Indexed: 01/25/2023]
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Smart R, Kase CA, Taylor EA, Lumsden S, Smith SR, Stein BD. Strengths and weaknesses of existing data sources to support research to address the opioids crisis. Prev Med Rep 2020; 17:101015. [PMID: 31993300 PMCID: PMC6971390 DOI: 10.1016/j.pmedr.2019.101015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 12/18/2022] Open
Abstract
Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.
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Affiliation(s)
| | | | | | - Susan Lumsden
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Scott R. Smith
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Bradley D. Stein
- RAND Corporation, Pittsburgh, PA, United States
- University of Pittsburgh School of Medicine, Pittsburgh PA, United States
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Platt L, Savage TA, Rajagopal N. An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic. J Psychosoc Nurs Ment Health Serv 2020; 58:39-45. [DOI: 10.3928/02793695-20191218-08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/23/2019] [Indexed: 11/20/2022]
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31
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Evoy KE, Groff L, Hill LG, Godinez W, Gandhi R, Reveles KR. Impact of student pharmacist–led naloxone academic detailing at community pharmacies in Texas. J Am Pharm Assoc (2003) 2020; 60:81-86. [DOI: 10.1016/j.japh.2019.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/15/2022]
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32
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Evaluation of a pharmacist-led naloxone coprescribing program in primary care. J Am Pharm Assoc (2003) 2019; 59:867-871. [DOI: 10.1016/j.japh.2019.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 01/23/2023]
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33
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Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Evidence for state, community and systems-level prevention strategies to address the opioid crisis. Drug Alcohol Depend 2019; 204:107563. [PMID: 31585357 PMCID: PMC9286294 DOI: 10.1016/j.drugalcdep.2019.107563] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States. METHODS We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations. RESULTS The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting. CONCLUSIONS Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.
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Affiliation(s)
- Tamara M. Haegerich
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA,Corresponding author: (T.M. Haegerich)
| | - Christopher M. Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Pierre-Olivier Cote
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
| | - Amber Robinson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
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34
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Ragan AP, Aikens GB, Bounthavong M, Brittain K, Mirk A. Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans. J Pharm Pract 2019; 34:287-294. [PMID: 31446823 DOI: 10.1177/0897190019870949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs. OBJECTIVE To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans. METHODS A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre-post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans. RESULTS A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre-post analysis with sustained effects in the postintervention period. CONCLUSIONS Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.
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Affiliation(s)
- Addison P Ragan
- Department of Veterans Affairs, Atlanta Network, Duluth, GA, USA
| | - Garrett B Aikens
- US Department of Veterans Affairs, 19960Central Alabama Veterans Healthcare System, Montgomery, AL, USA
| | - Mark Bounthavong
- Department of Veterans Affairs, Pharmacy Benefits Management, National Academic Detailing Service, San Diego, CA, USA
| | - Kevin Brittain
- Department of Veterans Affairs, Columbia VA Health Care System, Columbia, SC, USA
| | - Anna Mirk
- Department of Veterans Affairs, Birmingham/Atlanta Geriatrics Research Education and Clinical Center (GRECC), Atlanta VA Medical Center, Decatur, GA, USA
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35
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Bratberg JP, Smothers ZPW, Collins K, Erstad B, Ruiz Veve J, Muzyk AJ. Pharmacists and the opioid crisis: A narrative review of pharmacists' practice roles. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1171] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jeffrey P. Bratberg
- Department of Pharmacy Practice; University of Rhode Island College of Pharmacy; Kingston Rhode Island
| | | | - Kathryn Collins
- Doctor of Pharmacy Program; Campbell University College of Pharmacy and Health Sciences; Buies Creek North Carolina
| | - Brian Erstad
- Department of Pharmacy Practice and Science; University of Arizona College of Pharmacy; Tucson Arizona
| | - Jennifer Ruiz Veve
- Doctor of Pharmacy Program; Campbell University College of Pharmacy and Health Sciences; Buies Creek North Carolina
| | - Andrew J. Muzyk
- Department of Pharmacy Practice; Campbell University College of Pharmacy and Health Sciences; Buies Creek North Carolina
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36
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Midboe AM, Wu J, Erhardt T, Carmichael JM, Bounthavong M, Christopher MLD, Gale RC. Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation. PAIN MEDICINE 2019; 19:S46-S53. [PMID: 30203010 DOI: 10.1093/pm/pny085] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA). Design Qualitative process evaluation using semistructured interviews. Setting Seven VA health care systems in the Sierra Pacific region. Subjects Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20). Methods Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research. Results Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources. Conclusions Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.
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Affiliation(s)
- Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University
| | - Justina Wu
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University
| | - Taryn Erhardt
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University
| | | | - Mark Bounthavong
- Veterans Health Administration, Pharmacy Benefits Management, Academic Detailing Service
| | | | - Randall C Gale
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University
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37
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Bounthavong M, Devine EB, Christopher MLD, Harvey MA, Veenstra DL, Basu A. Implementation evaluation of academic detailing on naloxone prescribing trends at the United States Veterans Health Administration. Health Serv Res 2019; 54:1055-1064. [PMID: 31313839 DOI: 10.1111/1475-6773.13194] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Academic detailing in partnership with the Opioid Overdose Education and Naloxone Distribution (OEND) program was implemented to increase naloxone access for the prevention of opioid overdose mortality in veterans at the U.S. Department of Veterans Affairs (VA). However, implementation was not uniform leading to varying levels of intervention exposure potentially impacting naloxone prescribing. We examined the impact of implementation strength (proportion of providers exposed to academic detailing) at each station on naloxone prescribing from September 2014 to December 2017. STUDY DESIGN AND SETTING Retrospective cohort design with fixed effects models at the VA. DATA COLLECTION/EXTRACTION METHODS We used VA Corporate Data Warehouse for data on pharmacy dispensing, station-, provider- and patient-level characteristics. OEND-specific academic detailing activities came from data recorded by academic detailers using Salesforce.com. PRINCIPAL FINDINGS VA stations wherein 100 percent of providers exposed to an OEND-related academic detailing educational outreach visit experienced an increased incident rate of naloxone prescribing that was 5.52 times the incident rate of stations where no providers were exposed; alternatively, this is equivalent to an average monthly increase of 2.60 naloxone prescriptions per 1000 population at risk for opioid overdose. CONCLUSIONS Our findings highlight the importance of academic detailing's implementation strength on naloxone prescribing. Decision makers must carefully consider the implementation process to achieve the greatest effectiveness from the intervention.
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Affiliation(s)
- Mark Bounthavong
- Pharmacy Benefits Management (PBM), National Academic Detailing Service, U.S. Department of Veterans Affairs, Washington, DC.,The Comparative Health Outcomes, Policy, & Economics (CHOICE) Institute, University of Washington, Seattle, Washington.,Veterans Affairs (VA) Health Economics Resource Center (HERC), Menlo Park, California.,Veterans Affairs (VA) Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - Emily Beth Devine
- The Comparative Health Outcomes, Policy, & Economics (CHOICE) Institute, University of Washington, Seattle, Washington.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Melissa L D Christopher
- Pharmacy Benefits Management (PBM), National Academic Detailing Service, U.S. Department of Veterans Affairs, Washington, DC
| | - Michael A Harvey
- Pharmacy Benefits Management (PBM), National Academic Detailing Service, U.S. Department of Veterans Affairs, Washington, DC
| | - David L Veenstra
- The Comparative Health Outcomes, Policy, & Economics (CHOICE) Institute, University of Washington, Seattle, Washington
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, & Economics (CHOICE) Institute, University of Washington, Seattle, Washington.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
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38
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Olsen A, Lawton B, Dwyer R, Taing MW, Chun KLJ, Hollingworth S, Nielsen S. Why aren't Australian pharmacists supplying naloxone? Findings from a qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 69:46-52. [PMID: 31078908 DOI: 10.1016/j.drugpo.2019.03.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists' perspectives or experiences of this change. METHODS Thirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016-2017 to investigate pharmacists' attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply. RESULTS Around half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges. CONCLUSION Pharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists' knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).
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Affiliation(s)
- Anna Olsen
- National Centre for Epidemiology and Population Health, Australian National University, Acton ACT, 0200, Australia.
| | - Belinda Lawton
- Crawford School of Public Policy, Australian National University, Acton ACT, 0200, Australia
| | - Robyn Dwyer
- Centre for Alcohol Policy Research, LaTrobe University, Bundoora Vic, 3086, Australia
| | - Meng-Wong Taing
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia; Centre for Optimising Pharmacy Practice-based Excellence in Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Ka Lai Joyce Chun
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia
| | - Samantha Hollingworth
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick New South Wales, 2031, Australia; Monash Addiction Research Centre, Monash University, Frankston, Victoria, 31699, Australia
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Bounthavong M, Lau MK, Popish SJ, Kay CL, Wells DL, Himstreet JE, Harvey MA, Christopher MLD. Impact of academic detailing on benzodiazepine use among veterans with posttraumatic stress disorder. Subst Abus 2019; 41:101-109. [PMID: 30870137 DOI: 10.1080/08897077.2019.1573777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Benzodiazepine use in the US Veterans Administration (VA) has been decreasing; however, a small number of veterans with posttraumatic stress disorder (PTSD) continue to receive benzodiazepine. Academic detailing, a targeted-educational outreach intervention, was implemented at VA to help reduce the disparity between existing and evidence-based practices, including the reduction in benzodiazepine use in veterans with PTSD. Since evidence to support the national implementation of academic detailing in this clinical scenario was scarce, we performed a quality improvement evaluation on academic detailing's impact on benzodiazepine use in veterans with PTSD. Methods: A retrospective cohort design was used to evaluate the impact of academic detailing on benzodiazepine prescribing in veterans with PTSD from January 1, 2016, to December 31, 2016. Providers exposed to academic detailing (AD-exposed) were compared with providers unexposed to academic detailing (AD-unexposed) using generalized estimating equations (GEEs) controlling for baseline covariates. Secondary aims evaluated academic detailing's impact on average lorazepam equivalent daily dose (LEDD), total LEDD, and benzodiazepine day supply. Results: Overall, there was a decrease in the prevalence in benzodiazepine use in veterans with PTSD from 115.5 to 103.3 per 1000 population (P < .001). However, the decrease was greater in AD-exposed providers (18.37%; P < .001) compared with AD-unexposed providers (8.74%; P < .001). In the GEE models, AD-exposed providers had greater reduction in the monthly prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers, by -1.30 veterans per 1000 population (95% confidence interval [CI]: -2.14, -0.46). Similar findings were reported for the benzodiazepine day supply; however, no significant differences were reported for total and average LEDD. Conclusions: Although benzodiazepine use has been decreasing in veterans with PTSD, opportunities to improve prescribing continue to exist at the VA. In this quality improvement evaluation, AD-exposed providers were associated with a greater reduction in the prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers.
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Affiliation(s)
- Mark Bounthavong
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA.,The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Marcos K Lau
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Sarah J Popish
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Chad L Kay
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Daina L Wells
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Julianne E Himstreet
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Michael A Harvey
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
| | - Melissa L D Christopher
- Academic Detailing Service, Pharmacy Benefits Management Services, US Department of Veterans Affairs, San Diego, California, USA
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Dyrkorn R, Langaas HC, Giverhaug T, Espnes KA, Rowett D, Spigset O. Academic detailing as a method of continuing medical education. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2019; 10:717-725. [PMID: 31507335 PMCID: PMC6719842 DOI: 10.2147/amep.s206073] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/18/2019] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Academic detailing is an interactive educational outreach to prescribers to present unbiased, non-commercial, evidence-based information, mostly about medications, with the goal of improving patient care. Academic detailing in Norway is an approach for providing continuing medical education to general practitioners (GPs). The basis of academic detailing is a one-to-one discussion between a trained health professional (the academic detailer) and the GP at the GP's workplace. METHOD Our first campaign was named "Better use of non-steroidal anti-inflammatory drugs (NSAIDs)", which aim was to reduce the use of diclofenac due to the risk of serious cardiovascular adverse events. At the same time we advised the GPs to use naproxen as the drug of choice if an NSAID was needed. We did a one-to-one intervention in two cities, where a trained academic detailer met the GP during office hours. A total of 247 GPs were invited to participate and 213 visits (86%) were completed. This article reviews the theoretical framework underlying the method and describes the development and implementation of academic detailing to GPs in Norway. RESULTS More than 90% the participating GPs considered academic detailing a suitable method for providing up-to-date evidence-based, manufacturer-independent information, and nearly all would most likely or probably welcome another visit. After the intervention there was a reduction of diclofenac prescribing of 16% and 18%, respectively, in the two cities. CONCLUSION We consider that academic detailing is a suitable method to bring the best available evidence to the point at which care is delivered, to achieve the best for the patients. According to the Norwegian GPs' evaluation, it is a key supplement to other methods of continuing medical education. To have maximum impact, it is important that academic detailing is practiced according to the consensus that has evolved in the USA and Australia.
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Affiliation(s)
- Roar Dyrkorn
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Correspondence: Roar DyrkornDepartment of Clinical Pharmacology, St. Olav University Hospital, 7006Trondheim, NorwayEmail
| | - Harald Christian Langaas
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Trude Giverhaug
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), University Hospital of North-norway, Tromsoe, North-Norway
| | - Ketil Arne Espnes
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Debra Rowett
- Repatriation General Hospital, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Sasson C, Smith J, Kessler C, Haukoos J, Himstreet J, Christopher M, Emmendorfer T. Variability in opioid prescribing in veterans affairs emergency departments and urgent cares. Am J Emerg Med 2018; 37:1044-1047. [PMID: 30146399 DOI: 10.1016/j.ajem.2018.08.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The Veterans Health Administration (VHA) is the largest integrated health care system in the U.S., serving approximately 2.5 million Veterans in the Emergency Department/Urgent Care Centers (ED/UCC) each year. Variation in opioid prescribing by ED/UCC providers in the VHA is described. METHODS This is an observational study using administrative data from the VHA Pharmacy Benefits Management Services database to assess ED/UCC providers' opioid prescribing rates between October 1st, 2014 to June 30th, 2017 in 121 U.S. facilities. The opioid prescribing rate was defined as the number of opioid prescriptions written by the provider divided by the number of patients discharged from the ED/UCC by that provider, by quarter. A regression analysis was performed to estimate the association between time and prescribing rates by provider. RESULTS Overall, the national trend in median prescribing rates decreased by 25.5% (p value = 0.00) from 9.1% ([range 1.5%-25.6%] to 6.4% [range 0.8%-21.8%]). The greatest rates of decline occurred between January 1st, 2016 to June 30th, 2017. The rate of provider opioid prescribing demonstrated wide variability between facilities (range: 0.5% to 39.1%). The prescribing rate for ED/UCC providers ranged from 0.2% to 100%. Between June 2016 and May 2017, 24 VHA ED/UCC providers were the highest opioid prescribers nationally in at least two of the four quarters (22%-70%), with rates two- to three-fold higher than their peers. CONCLUSION ED/UCC providers in the VHA system nationally vary considerably in rates of opioid prescribing. A focused initiative tailored for ED/UCC providers is needed to decrease opioid prescribing variability.
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Affiliation(s)
- Comilla Sasson
- Eastern Colorado Healthcare System, Veterans Health Administration, University of Colorado School of Medicine, Colorado School of Public Health, Aurora, CO, United States of America.
| | - Jason Smith
- National Academic Detailing Services, Veterans Health Administration, United States of America.
| | - Chad Kessler
- National Office of Emergency Medicine, Veterans Health Administration, United States of America.
| | - Jason Haukoos
- Department of Emergency Medicine, Denver Health, Department of Emergency Medicine, University of Colorado School of Medicine, Department of Epidemiology, Colorado School of Public Health, Denver, CO, United States of America.
| | - Julianne Himstreet
- National Academic Detailing Services, Veterans Health Administration, United States of America.
| | - Melissa Christopher
- Pharmacy Benefits Management National Academic Detailing Services, Veterans Health Administration, United States of America.
| | - Thomas Emmendorfer
- National Pharmacy Benefits Management, Veterans Health Administration, United States of America.
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Abd-Elsayed A, Albert CA, Fischer M, Anderson B. Naloxone Academic Detailing: Role of Community Outreach Teaching. Curr Pain Headache Rep 2018; 22:72. [PMID: 30151695 DOI: 10.1007/s11916-018-0730-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Testing the efficacy of academic detailing in improving the practice of prescribing naloxone for patients on high-dose opioids. RECENT FINDINGS Academic detailing has been identified as an effective method for improving health care practices through focused community education. We found that academic detailing is an effective method in improving health care providers' knowledge about the importance of prescribing naloxone for patients on high-dose opioids. We also found that prescribers prescribed more naloxone after our education program. This study reflects the importance of education and academic detailing in resolving health problems. Academic detailing can provide effective preventive tools that can reduce the incidence of health problems we encounter.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA.
| | - Christi Ann Albert
- Pharmacy Department, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Matt Fischer
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Brooke Anderson
- Henry Predolin School of Nursing, Edgewood College, Madison, WI, USA
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Abstract
To provide an update on prescription of naloxone as a harm-reduction strategy, PubMed was searched to identify publications relevant to naloxone prescribing for reversal of opioid overdose. Opportunities now exist to expand naloxone use, although evidence suggests these are often missed or underexploited. The US FDA has approved an intranasal naloxone spray and an autoinjector naloxone formulation for community use. Effective use of naloxone in community settings requires screening to identify patients at risk of opioid overdose, discussing naloxone use with patients and their relatives, and providing appropriate training. The tools exist to expand the use of naloxone more widely into the community, thereby creating an opportunity to reduce opioid overdose fatalities.
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Affiliation(s)
- Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48202, USA
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Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:172-179. [PMID: 28687187 PMCID: PMC5783633 DOI: 10.1016/j.drugpo.2017.06.005] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/28/2017] [Accepted: 06/12/2017] [Indexed: 01/12/2023]
Abstract
Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.
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Affiliation(s)
- Nadia Fairbairn
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada; Department of Medicine, University of British Columbia, Canada.
| | - Phillip O Coffin
- San Francisco Department of Public Health, United States; University of California, San Francisco, United States
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston Medical Center, United States
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