Academic Detailing in SC to Promote Safer Opioid Prescribing and Expand Treatment for Addiction
AIMS: Implement and evaluate a prevention-focused academic detailing (AD) intervention promoting safer opioid prescribing in primary care practice settings supported by DHEC/CDC that blends treatment-focused initiatives of DAODAS/SAMHSA and the SCDHHS/CMS initiative to address gaps in evidence-based care and detect abuse, overuse or inappropriate medication use. METHODS: Academic detailing (AD) visits were conducted in nine South Carolina (SC) counties deemed “high risk” to promote safer opioid prescribing in chronic, non-cancer pain and extend the reach of medication for addiction treatment. Each visit provided hands-on training (i.e., signing in and navigating the Prescription Drug Monitoring Program [PDMP]) to promote effective use of PDMP data. Visits were tailored to meet the needs of individual providers so that core clinical content (i.e., key messages) were covered, yet pace and content emphasis varied depending on the unique needs of each provider and barriers to address. Prevention-based key messages were captured by the S.O.S. acronym: Share a patient provider agreement (PPA) with clearly established boundaries and patient expectations prior to initiating a trial of opioids for chronic non-cancer pain; Optimize patient treatment (drug/non-drug) using a multi-dimensional rating scale to assess chronic pain, quality of life and progress toward functional goals; and Screen for appropriate opioid use and the continued need for opioid therapy, including effective use of PDMP reports. A fourth unwritten key message involved the “dots” between each letter in “S.O.S.”– a reminder to “document, document, document” to protect patient and provider. The clinical pharmacy consultant (academic detailer) addressed barriers to treatment for opioid use disorder (OUD), engaged providers in treatment-focused conversations, when appropriate, and connected those interested to services supported by DAODAS/SAMHSA, including MAT waiver trainings, Project ECHO [Extension for Community Healthcare Outcomes] MAT tele-mentoring, and the SC MAT Access website (www.mataccess.com). Additionally, the detailer delivered one or more tipSC (Timely Information for Providers in South Carolina) opioid-focused newsletters (e.g., Using Morphine Milligram Equivalents (MME) to Signal Opioid Risk, Tapering Opioids and/or Benzodiazepines to Reduce Risk of Overdose) supported by SCDHHS/CMS prior to, during, or following AD visits. Packets of balanced, concise print materials supported the interactive discussions and were left as a resource to be read, shared or referred to after the visit. Packets also included provider and patient tools to support the key messages that are useful and practical for implementation and documentation. Live continuing medical education (CME) credit was offered that counted toward the mandated CME related to controlled substances required for SC license renewal. Behavioral intent to run PDMP reports and use multi-dimensional rating scales to assess chronic pain patients were measurements in the post-visit CME assessment form completed immediately after a visit. The academic detailer delivered post-visit surveys and new print material in person to practice sites approximately 6 to 8 weeks after the AD visit, and engaged providers in brief follow-up visits whenever possible. The follow-up survey to assess self-reported changes in prescribing behavior included: 1) use of a patient provider agreement; 2) use of multi-dimensional rating scale; 3) setting clear treatment goals and realistic expectations about pain management with patients; 4) confidence in running PDMP reports; and 5) use of PDMP reports to help make clinical decisions. The contemporaneous visit records and productivity logs kept by the academic detailer, including closed- and open-ended items, captured valuable data about overall visit logistics and individual visit details (e.g., barriers identified, enablers to overcome barriers, questions asked by provider, provider interest in MAT services) that were useful for follow-up with each individual provider and identification of ongoing and future improvements to the intervention. RESULTS: One hundred forty-two initial provider visits occurred from July 1, 2017 – April 30, 2018. Ninety-seven PDMP delegates were also visited during this timeframe, and 84 PDMP registrations (29 providers and 55 delegates) were facilitated by the academic detailer. Average length of each provider visit was 53.6 minutes. One hundred twenty-nine of the 142 providers visited completed the CME assessment form and of the 115 delivered a post-visit survey, 33 were returned. Visited providers who completed the CME assessment self-identified as 62 physicians, 15 physician assistants, 44 nurse practitioners and 8 other providers. A majority reported post-visit intent to run PDMP reports (77; 60%) and to use a multi-dimensional scale to monitor treatment progress 115; 89%), whereas 50 (39%) and 7 (5%) providers, respectively, reported these behaviors as already implemented in their practice. Providers who returned the follow-up survey self-identified as 17 physicians, 6 physician assistants, 8 nurse practitioners and 2 other providers. Survey results qualitatively substantiated baseline intent: 29 (88%) of the providers reported an increase in use of PDMP data, a net increase of 49% over baseline; and (21) 64% reported an increase in use of a multi-dimensional rating scale, a 58% net increase over baseline. Providers also reported more frequent engagement in the 3 behaviors measured at follow-up and not quantified in baseline intent measurements: 19 (58%) share a patient provider agreement more often than pre-AD visit; 21 (64%) set clear treatment goals and realistic expectations about pain management with patients more often than pre-AD visit; and 27 (82%) are more confident in running PDMP reports. A quantitative analysis to substantiate self-report data will be conducted on accessing PDMP upon delivery of de-identified data required for the analysis. To date, 66 providers have expressed interest in learning more about MAT, including 11 providers that have attended a buprenorphine waiver training (4 registered for July 2018 training), 6 providers that have attended at least one ECHO tele-mentoring session, and 14 providers that have registered for an account on the SC MAT Access website supported by DAODAS funding as a direct result of their AD visit. Additionally, 308 tipSC newsletters were delivered and 44 follow-up visits have been completed. CONCLUSION: AD visits provide an effective strategy to connect opioid initiatives of multiple state agencies and multiple funding sources, in particular three state agencies SCDHEC, SC Department of Alcohol and other Drug Abuse Services [DAODAS], SCDHHS) and three federal funding sources (CDC, SAMHSA, CMS). Results indicate AD visits effectively blended prevention and treatment-focused initiatives, with a sizable adoption of recommended opioid practices for safer opioid prescribing and a considerable interest and even engagement in expanding access to medication for OUD.