Melissa Jones, a registered nurse, drives around Allegheny and Westmoreland counties visiting three to five medical practices a day.
“She’d come at lunch like the drug reps used to do,” said Francis Colangelo, a doctor of internal medicine at Premier Medical Associates in Monroeville and North Versailles.
But Mrs. Jones isn’t pushing various pharmaceuticals on doctors. She’s promoting evidence-based care and safe opioid prescribing practices to directly address the challenges that prescribers face.
Did the doctors know that 1 in 10 people who are prescribed opioids become addicted? Have they considered safer alternatives? Tai chi, physical therapy and acupuncture are often successful for pain treatment. If a patient does need opioids to address pain, could a lower dose be tried?
“We’re not out there to chastise them,” she said. “It’s a discussion. We’re a sounding board.”
Mrs. Jones works with Alosa Health, a Boston-based company that specializes in what’s called academic detailing — educational outreach to prescribers that co-opts pharmaceutical company tactics to advocate for evidence-based care. Alosa’s program came to the Pittsburgh area in 2005 under a partnership with PACE, a program that offers low-cost prescription medication to elderly individuals who need financial assistance.
Mrs. Jones has spoken with practitioners on topics ranging from chronic obstructive pulmonary disease to dementia, Alzheimer’s and elder abuse.
Although academic detailing can apply to any medical issue, the growth of the practice in Pennsylvania has coincided with the opioid epidemic.
According to a May 2016 special report in the Post-Gazette, 608 doctors in Pennsylvania, Ohio, West Virginia, Maryland, Virginia, Kentucky and Tennessee were disciplined for overprescribing narcotics in 2011-15. One of the disciplined doctors told the Post-Gazette that he felt pressure to prescribe from pharmaceutical representatives who promoted addictive pain medicines with free lunches and glib words.
To combat these trends, the Centers for Disease Control and Prevention has updated its guidelines on opioid prescriptions, recommending lower doses. Pennsylvania has passed laws to limit opioid prescribing. Community centers have educated citizens.
But changes are slow. A recent CDC report continues to show high rates of opioid prescribing in counties throughout Western Pennsylvania.
Academic detailing, which emerged in the U.S. in the 1980s, is another approach. Australia, Canada, the United Kingdom and the Netherlands all have nationwide programs. A patchwork of providers, including Kaiser Permanente in California, brings the practice to several U.S. states.
The VA Healthcare System, which launched a pilot program in 2010, is spreading academic detailing nationally. The Pittsburgh branch trained two detailers in March.
“What’s nice about the academic detailing the clinical pharmacists are doing — we work with them directly,” said Joanne Suffoletto, associate chief of staff for education for VA Pittsburgh Healthcare System. “Physicians are able to have a mirror held to their prescription habits.”
Dr. Suffoletto said that having academic detailers on staff has already lowered opioid prescribing.
The detailers, Amanda McQuillan and Laura Potoski, who both have doctorates in pharmacy, reach out to doctors prescribing at high levels with at-risk patients. The meetings are less than 30 minutes, efficient and nonconfrontational.
Ms. McQuillan said that VA doctors have begun to reach out to her asking for meetings. “Patients themselves often don’t want to stop the meds,” she said. “We understand the barriers. … We really focus the conversation on what the providers need.”
Ajay Wasan, vice chair for pain medicine at UPMC, echoed the importance of understanding provider needs: “You have to be a peer.”
When he emailed prescribers at UPMC, he emphasized that they were not in trouble — “We are not the police. You are not being called to the principal’s office.”
Dr. Wasan directs what’s known as the 90-90 program, one of UPMC’s most intensive academic detailing efforts on opioids. The aim is to reduce the number of “90-90 patients” — those who had been prescribed at least 90 milligrams of morphine per day (or equivalent) for 90 days or longer. Dr. Wasan and his co-workers reached out to the 20 doctors with the largest numbers of 90-90 patients. They sent half of those doctors written materials with information on opioid prescription and scheduled intensive one-on-one meetings with the other half to look at specific patient cases “under a microscope.”
After the meetings, many of those 10 doctors called Dr. Wasan with follow-up questions on safely prescribing opioids for different patients. “There was a serious intent to change,” he said.
Six months later, the targeted doctors all had fewer 90-90 patients, which created a projected $200,000 in savings.
Axial Healthcare has seen similarly positive results. The program brings education to doctors through an online database with detailed information on patient medical history and guidelines on pain care. The program is not called academic detailing but also involves direct physician outreach. Centered in Tennessee, Axial has partnered with Highmark in West Virginia and other organizations nationwide. In the future, the program may expand to those with Highmark insurance in Pennsylvania.
After one year, those participating in Axial’s Tennessee program reported lower daily doses of opioids, fewer patients with scripts, less multi-prescriber activity and a reduction in rates of overdose and death. The West Virgina program has been in place for less than a year, but results so far have also been positive.
“We use all available insight to identify patients who are exhibiting high opioid risk behaviors,” said Axial’s CEO, John Donahue. “We bring that right in front of physicians at the point of care.”
Axial also monitors physician behavior. For doctors who are consistently prescribing opioids at high rates, “It’s immediate reach out,” Mr. Donahue said. “That’s how we are able to safeguard.”
Despite publicity about rampant opioid abuse, many doctors don’t know the role that they play.
Carey Vinson, the chief network officer at Axial, said that many physicians with high opioid prescription rates were surprised to see how they compared to the national average. While some doctors made excuses at first, they were open to learning about alternative pain treatments.
“Habits don’t change overnight,” said Stacey Grant, a pharmacist who reaches out to doctors in West Virginia on behalf of Axial. “The vast majority of providers want the best for their patients.”
Mrs. Jones of Alosa Health said that many doctors she worked with did not know that the CDC had lowered the maximum safe dose of opioids. “There’s an overload of information out there. It is so hard to stay up to date.
“We’re the ambassadors of the evidence.”
When Mrs. Jones spoke about opioids and pain management at Premier Medical Associates, Dr. Colangelo was struck. “Boy, that hit home.”
He has always been cautious about prescribing opioids, and he’s lost patients to doctors who prescribed more liberally.
“It was almost a vindication that how I’d been prescribing — it was the right way.”
Source: http://www.post-gazette.com/news/health/2017/07/25/Pittsburgh-New-groups-reach-out-to-doctor-s-prescribing-opioids-to-educate-and-discuss-alternatives-in-pain-relief/stories/201707070143
