Stories of Success and Tools to Help You Get There
Vermont Doctors and Pharmacists Partner to Address Opioid Misuse
For the Brattleboro Area Prevention Coalition’s Rx Abuse Prevention (RAP) Team, the first step in reducing high rates of opioid misuse is building channels of communication and fostering a culture of collaboration between doctors and pharmacists.
In 2012, in southeastern Vermont, the Brattleboro Area Prevention Coalition, a Partnerships for Success sub-recipient, hosted a daylong panel discussion with community leaders to discuss the growing problem of opioid misuse in the city and surrounding Windham County. From that initial meeting, Coalition Director Cassandra Holloway convened a small group of medical professionals and pharmacists who had expressed interest in continuing the conversation started at the panel.
In six years, the Rx Abuse Prevention (RAP) Team has grown to include hospital directors, heads of local pharmacies, and prevention professionals. Over 40 members work together to address gaps in communication between pharmacists and prescribers, learn firsthand from people who have overcome opioid addiction, and engage in dialogue about what a shared solution to over-prescribing of opioids should look like.
What can we learn from the work of the Brattleboro Area Prevention Coalition?
Holloway talks about the “random assortment” of people who came to her first meeting after the initial panel discussion in 2012. “We had a pharmacist, a social worker, a case manager at the hospital, an orthopedic nurse, and some prevention people.” Holloway saw that this small group was passionate and she encouraged them to envision how the group could grow and then let them sell the project to others. She remains amazed at their ability to bring their colleagues on board. “It was really the initial group who kept going back to people at their offices and saying, you need to get involved with this thing I’m doing. They just kept pushing it and now we have a medical director, the head of addiction services, the director of health for the county, heads of local pharmacy chains—we are full of people who can make stuff happen in their environment and the county and have some clout.”
Like many savvy coalition directors, Holloway wanted to keep her initial group of coalition members engaged. To that end, she encouraged them to pursue projects that could be accomplished relatively quickly. “We started with small projects,” she says. “We initially tried to figure out what pain management alternatives there are in the community to prescribing opioids. We also got drug disposal containers to the providers and pharmacists.” With these early successes, the coalition went on to bigger projects like staff training for nurses to encourage them to use the Vermont Prescription Monitoring System (VPMS)—now law in Vermont. The larger projects also allowed members to grow the coalition organically. Explains Holloway, “The doctors at that point weren’t invested in it because they weren’t required to be. But the nurses brought each other to the table.”
One of Holloway’s strengths is her willingness to let the group’s passions direct the coalition’s discussions. “The group was very supportive of each other’s ideas. One person would say, “I want to see X happen” and I would ask them who can best speak to how to get X off the ground. They would name people and then we would invite those people to the next meeting to educate and talk to us about what they do. The discussions were great!” she remembers. The strength of the discussions served as a selling point for the subject matter experts as well. Holloway laughs, “After the discussions, the subject matter expert would start coming to our meetings! It was totally organically driven, not one of our goals but something we welcomed.”
Holloway is always on the lookout for chances to give her coalition what they ask for. She recounts a discussion that led to prescribers on the coalition mentioning that they wanted to hear from someone in recovery from opioids. They specifically wanted to understand what exactly patients might say when seeking drugs or “doctor shopping.” Holloway seized on the opportunity to give the prescribers the educational experience they were seeking and found speakers in recovery and the field of recovery who spoke at length with the coalition. “The prescribers had all these questions about how to help people in pain and how they felt uncomfortable not helping patients because that was why they had gone into medicine. The speakers were so insightful and really helped the prescribers. They reassured them that they should feel comfortable saying “no” to drug seeking individuals and reiterated that it was more helpful to do so.”
The Brattleboro Area RAP Team comprises both prescribers and pharmacists, which can be a struggle. “We are still trying to help the providers and pharmacists see that they are partners,” Holloway explains. “Our pharmacists feel like they are viewed as subordinate by providers and that they shouldn’t question their providers or ask questions. And the providers want to hear from the pharmacists because they feel like the pharmacists have a bigger picture on to what’s happening with their patients.” To help address these issues, Holloway uses “neutral” case studies drawn from conversations with both prescribers and pharmacists during meetings to foster discussions on how both groups could work together. “So many of the issues are more shared than they both think. They are both dealing with the same challenges.”
In six short years, the Brattleboro Area RAP Team has set the stage for innovative collaboration between pharmacists and prescribers of opiates and controlled medication. To facilitate communication, the team worked together to create standardized fax and email templates that pharmacists could use to contact prescribers with concerns about patient prescriptions. Prescribers ensured that dedicated staff would monitor incoming messages from pharmacists. Holloway is currently creating an evaluation to assess level of adoption of the program and its efficacy in increasing communication between pharmacists and prescribers.
The team has also started working to develop locally based prescribing guidelines of opiates and controlled medication, and are working with surrounding communities on the effort. As part of their comprehensive approach, the group has created a pledge for patients who are prescribed opioids to sign off on using their medications responsibly and disposing of unused medications promptly at one of many medication drop boxes around Windham County. Drop boxes are now located in the hospital and local pharmacy (both part of the RAP Team).
Holloway is excited for the group to tackle more challenging issues and relishes her role as the steward of a ship full of passionate medical leaders. “I’m learning so much every day in my work with this group. The advice I’d offer to other prevention professionals is that we shouldn’t expect to steer because it’s not our world. It’s their world and we need to let them lead us.”