Literature

Academic detailing on opioids

In-person academic detailing

Saffore CD, Tilton ST, Crawford SY, et al. 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(697):e589.  

Saffore et al. identifies six potential barriers to safe opioid prescribing for providers “on the ground” through an academic detailing intervention in the Chicago area. The barriers were identified through a thematic analysis of academic detailers’ field notes recorded after detailing sessions with primary care providers. In the notes, detailers were asked to describe the academic detailing visit content as well as any questions and concerns expressed by the provider. Several barriers to safe opioid prescribing included lack of provider knowledge about opioid and non-opioid treatments, pressure to prescribe opioids--particularly from inherited patients--and uncertainty and time constraints regarding the health system’s pain management practices and policies. Reviewing these barriers can help detailers prepare for objections providers may pose during academic detailing visits on opioid stewardship.

 

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(5):1055-1064.

The U.S. Veterans Health Administration (VA) has one of the largest academic detailing programs in the nation and can perform robust academic detailing studies with large sample sizes. This study in particular demonstrates the association of implementation of academic detailing and naloxone prescriptions. Between 2014 and 2017, some, none, or all providers at 130 VA sites received academic detailing on naloxone prescribing. The number of naloxone prescriptions at each site was subsequently recorded and then compared over the same time period. Sites where all providers received academic detailing were associated with a five-fold increase in naloxone prescribing rates compared to sites where no providers received academic detailing, highlighting the potential impact academic detailing has on increasing naloxone prescribing within a health system.

 

Bounthavong M, Harvey MA, Kay CL, et al. 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. Journal of the American Pharmacists Association. Published online December 20, 2019.

Allocating sufficient work time for academic detailers to complete detailing tasks and activities can be an essential consideration for program staff recruiting and hiring detailers. Providers who interacted with academic detailers with high full-time equivalent employee (FTEE) allocation (0.4 FTEE or greater, meaning at least 40% of the employee’s time is dedicated to academic detailing) had a 65% greater increase in the number of average monthly naloxone prescriptions compared to providers who interacted with academic detailers with low FTEE (less than 0.4 FTEE). The increase in naloxone prescribing highlights the potential benefit of higher FTEE allocation for detailers.

 

Midboe AM, Wu J, Erhardt T, et al. Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation. Pain Med. 2018;19(suppl_1):S46-S53.  

This paper summarizes several key components of an academic detailing program through qualitative interviews with current and former academic detailers and providers with varying exposure to academic detailing. The common themes included the importance of tailoring one-on-one sessions to providers’ needs, the role leadership plays in encouraging providers’ participation in detailing programs, and tracking detailer and provider performance. Reviewing these conclusions can help academic detailing program staff and detailers better understand and identify critical components of an academic detailing intervention.

 

Behar E, Rowe C, Santos GM, Santos N, Coffin PO. Academic Detailing Pilot for Naloxone Prescribing Among Primary Care Providers in San Francisco. Fam Med. 2017 Feb;49(2):122-126.

In this academic detailing intervention, based in San Francisco, California, primary care providers were detailed on safe opioid prescribing and naloxone. The providers who received the intervention had an eleven-fold increase in naloxone prescribing compared to those who did not receive the intervention. This study shows that the traditional academic detailing model of one-on-one, in-person visits can be effective in increasing naloxone prescriptions in a primary care setting.                 

 

Yeh JS, Van Hoof TJ, Fischer MA. Key Features of Academic Detailing: Development of an Expert Consensus Using the Delphi Method. Am Health Drug Benefits. 2016;9(1):42-50.

Yeh et al. identifies key principles of academic detailing training, implementation, and evaluation through developing consensus from 20 experts with the Delphi method. Experts agreed the goal of academic detailing is to 1) improve clinical performance, 2) recommend practice changes, and 3) offer decision support to providers. Other major themes included the importance of focusing on clinician behavior change and tailoring content to provider needs during detailing sessions. Experts also noted the necessity for interpersonal and communication skills in detailers to overcome providers’ barriers to behavior change. These conclusions, as well as others listed in the paper, can help guide the planning and implementation of an effective academic detailing program.

                                                                                                                                      

Virtual detailing (e-Detailing)

Smart MH, Mandava MR, Lee TA, Pickard AS. Feasibility and acceptability of virtual academic detailing on opioid prescribing. Int J Med Inform. 2020 Dec 25;147:104365. Epub ahead of print.

As the first paper comparing the feasibility and acceptability of in-person academic detailing visits (conducted before the COVID-19 pandemic) to virtual visits (conducted during the COVID-19 pandemic), Smart et al. is a noteworthy addition to the virtual academic detailing (also known as eDetailing) literature. Virtual visits were either conducted via WebEx with video and screensharing or on the telephone. While providers ranked in-person visits slightly more favorable than virtual visits, provider feedback indicated that there was no significant difference in feasibility between in-person and virtual visits. There was also no significant difference in providers satisfaction between video and telephone visits, and provider satisfaction was not impacted by technical difficulties.

 

Brunette MF, Dzebisashvili N, Xie H, Akerman S, Ferron JC, Bartels S. Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers. Nicotine Tob Res. 2015;17(8):960-967.

This is one of the few studies to compare in-person and videoconferencing delivery of academic detailing (called educational outreach in the study). Providers within a state mental health program either received virtual academic detailing (25 providers) or in-person academic detailing (18 providers) on smoking cessation. There was no significant difference between the providers who received in-person versus virtual academic detailing in 1) increased smoking cessation pharmacology prescriptions, 2) satisfaction with the sessions, and 3) post-intervention knowledge and attitudes. These findings indicate videoconferencing may be a plausible delivery method for academic detailing, although further investigation is needed.

Hartung DM, Hamer A, Middleton L, Haxby D, Fagnan LJ. A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics. BMC Fam Pract. 2012;13:129.

Hartung et al.’s pilot project provided in-person and virtual academic detailing to 41 clinicians at 4 different rural family practice clinics in Oregon. Each clinic received multiple detailing sessions over eight months. Providers who received in-person academic detailing reported a higher likelihood of changing their behavior compared to providers who received virtual academic detailing; however, the impact of in-person versus virtual academic detailing on provider practices post-intervention was not measured. Additionally, many providers indicated interest in continued participation of the program, but the likelihood of participation declined slightly if only virtual academic detailing was offered. While virtual academic detailing may be satisfactory, this pilot project suggests in-person academic detailing remains more desirable if both options are available. However, survey response rates were low and may not be sufficient to adequately detect significant differences between the two groups.

Buprenorphine

Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. Published online December 30, 2020:ajad.13135.

Brar R, Fairbairn N, Sutherland C, Nolan S. Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing – a case series. Drug and Alcohol Review. 2020;39(5):588-594.

Brunet N, Moore DT, Lendvai Wischik D, Mattocks KM, Rosen MI. Increasing buprenorphine access for veterans with opioid use disorder in rural clinics using telemedicine. Subst Abus. Published online February 20, 2020:1-8.

Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, Sohler NL. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat. 2011;40(4):349-356. 

Daitch D, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr. Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients. Pain Medicine. 2014;15(12):2087-2094.

Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013;126(1):74.e11-17.

Ghosh SM, Klaire S, Tanguay R, Manek M, Azar P. A Review of Novel Methods To Support The Transition From Methadone and Other Full Agonist Opioids To Buprenorphine/Naloxone Sublingual In Both Community and Acute Care Settings. The Canadian Journal of Addiction. 2019;10(4):41-50.

 Hämmig R, Kemter A, Strasser J, et al. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. SAR. 2016;Volume 7:99-105.

Kimber J, Larney S, Hickman M, Randall D, Degenhardt L. Mortality risk of opioid substitution therapy with methadone versus buprenorphine: a retrospective cohort study. Lancet Psychiatry. 2015;2(10):901-908.

Mehtani NJ, Ristau JT, Snyder H, et al. COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management. Substance Abuse. 2021;0(0):1-8.

Pierce M, Bird SM, Hickman M, et al. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016;111(2):298-308.

Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016;375(4):357-368.  

Tofighi B, McNeely J, Walzer D, et al. A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System’s Initiative to Expand Treatment Access during the COVID-19 Pandemic. J Addict Med. Published online February 5, 2021.

Xu KY, Borodovsky JT, Presnall N, Mintz CM, Hartz SM, Bierut LJ, Grucza RA. Association Between Benzodiazepine or Z-Drug Prescriptions and Drug-Related Poisonings Among Patients Receiving Buprenorphine Maintenance: A Case-Crossover Analysis. Am J Psychiatry. 2021 Mar 3. Epub ahead of print. 

Opioid tapering

Ajay Manhapra MD, Albert J. Arias MD & Jane C. Ballantyne MD. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance Abuse. 2018;39(2):152-161.

 

Coffin PO, Rowe C, Oman N, et al. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. 2020;15(5):e0232538.

 

Covington EC, Argoff CE, Ballantyne JC, et al. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clin Proc. 2020;95(10):2155-2171.

 

Davis B, Archambault C, Davis K, et al. A patient-centered approach to tapering opioids. J Fam Pract. 2019;68(10):548-556.

 

Davis MP, Digwood G, Mehta Z, McPherson ML. Tapering opioids: a comprehensive qualitative review. Ann Palliat Med. 2020;9(2):586-610.

 

Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. Pain Med. 2019;20(11):2179-2197.

 

James JR, Scott JM, Klein JW, et al. Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study. J GEN INTERN MED. 2019;34(12):2749-2755.

 

Lai B, Witt D, Thacher T, Witt T. A Proposed Opioid Tapering Tool. J Am Board Fam Med. 2020;33(6):1020-1021.

 

Lembke A. Tapering Long-Term Opioid Therapy. Am Fam Physician. 2020;101(1):49-52.

 

Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. Journal of Substance Abuse Treatment. 2019;103:58-63.

 

Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368.

 

Sturgeon JA, Sullivan MD, Parker-Shames S, Tauben D, Coelho P. Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis. Pain Med. Published online March 12, 2020.

For additional monthly updates of literature related to opioid overdose, risks and contributing factors, and overdose prevention provided by Dr. Coffin, click here.