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Academic Detailing Can Promote Safe Prescribing Practices for Veterans with Chronic Pain

Richard is 55 years old and has had chronic lower back pain for two years. He finally decides to seek care at his local VA medical center, but he is new to VA care and it lacks access to his complete medical history. His provider performs a physical exam, obtains an oral history, and decides to prescribe an opioid to treat the back pain. However, she is unaware that Richard has a prescription from his community provider for benzodiazepines, which can be extremely dangerous when taken with opioids, as well as a previous history of drug misuse. While fictional, this scenario is an all-too-common situation that can lead to potentially tragic, yet preventable consequences including overdose and death.

Academic detailing is a service-oriented, interactive outreach strategy used to improve healthcare across different disease states and settings. It relies on experts, known as academic detailers, to engage frontline clinicians in one-on-one sessions to improve clinical decision-making and prescribing practices. Academic detailing depends on collegial education and motivation. In the scenario above, if Richard's provider had met with an academic detailer, she may have handled her patient's condition differently. Academic detailing equips providers like Richard's with the knowledge, tools, and skills to assess patients for overdose risk and to prescribe opioids safely. Topics include:

  • How to query the state prescription drug monitoring database for contraindicated prescriptions their patients might have obtained from other sources;
  • How to educate patients about the risks and benefits of opioid use; and
  • Prompts to perform urine drug screening to prevent harmful drug interactions and addiction.

In 2010, the VISN 21 (Sierra Pacific) Pharmacy Benefits Management (PBM) program recognized the value of academic detailing as one lever for improving prescribing practices and implemented a pilot program for this purpose. In 2014, opioid prescribing received additional attention when the VA Under Secretary for Health issued guidance for the Opioid Safety Initiative, outlined in nine goals. Recognizing the success of VISN 21's program, the Interim Under Secretary for Health called for system-wide implementation of academic detailing in 2015.

Partnering with VISN 21 PBM and the National PBM Program Office, the Improving Pain-Related Outcomes for Veterans (IMPROVE) QUERI program embarked on a quality improvement project to identify aspects of the VISN 21 academic detailing program that may be of benefit to other VISNs implementing similar programs. The qualitative evaluation incorporated input from providers and academic detailers in VISN 21 to identify key strategies such as:

  • Assessing and understanding providers' needs and patient populations prior to outreach;
  • Gaining provider buy-in through the use of motivational interviewing, barrier resolution, and leadership support; and
  • Reinforcing the value of academic detailing by providing time for staff to participate in these sessions.

When implemented effectively, academic detailing can be a powerful tool to promote safe prescribing practices. Furthermore, multi-disciplinary partnerships such as the collaboration between pharmacists and providers in the academic detailing model are critical to providing safe and effective care throughout the VA healthcare system.

For more information about this project, please contact Amanda Midboe, PhD, at Amanda.Midboe@va.gov .

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