Changing Minds
Episode 4: Bridging the Gap: Creative Approaches to Harm Reduction
You're listening to Changing Minds, Transformative Chops for Healthcare Improvement. Grab a coffee or tea and join our team as we chat with leaders in the academic detailing space. For more information on academic detailing, visit us at narcad.org. Hello and welcome back to Changing Minds. I'm your host, Anna Morgan-Barcinian, the Senior Manager of Training and Education at Narcad. Today, I am joined by Emeline Pencil, the Director of Professional Affairs at Iowa Pharmacy Association. I've had the privilege of meeting Emeline this past year and have thoroughly enjoyed working with her and invited her to chat with all of you today. So, Emeline, thank you for joining us today. How are you? I'm doing well. Thank you so much for having me. It's a pleasure to be here. Of course. Can you tell our listeners about the academic detailing project you're working on and where I first got to meet you was through this project? So, I'd love if you could tell our listeners a little bit more about that project. Absolutely. So, this is an exciting project. So, as Anna mentioned, I am the Director of Professional Affairs for the Iowa Pharmacy Association. And in that role, I am a pharmacist who has worked in community pharmacies, hospitals. I've worked in solid organ transplant, and I've been able to pull in all of those experiences and combine them with my interests in education and advocacy and the work that we do at the Iowa Pharmacy Association. So, we are the only state society representing pharmacy in Iowa, and we represent pharmacists, student pharmacists, pharmacy technicians, and owners from a diverse set of practice settings. So, people commonly know retail, but we like to use the word "community" because it really is community pharmacy. And for our project, we have been engaged with the Iowa Department of Health and Human Services for the last five years, even longer, on other initiatives similar to harm reduction, really focused on HIV and HCV testing and screening, HCV surveillance, increasing distribution of naloxone, and then also in increasing the uptake and sale of over-the-counter syringes. And so, our work with NATO builds upon this work, and we have been focused on doing academic detailing, education, or sessions with community pharmacists based off of a survey that we did. And so, I think it was a year or two ago, we surveyed the entire state to ask about their attitudes and beliefs around syringe sales, naloxone, and understanding their policies and procedures. And then, the following year, we did a follow-up survey where we looked at the distribution across the state, and just the gaps in where there aren't these services being provided to their communities. And so, when we first came up with the project and our academic detailing focus, we looked at what those gaps are around the state and the northern or southern regions, and which pharmacists can we engage in. And so, we have been developing key messages with the input of people with lived and living experience, and I do have to shout them all out here. So, we've been working with the Drug Dependency Services of Southeast Iowa, the Dubuque Harm Reduction, North Iowa Mutual Aid, the Iowa Harm Reduction Coalition, Iowa HHS, we've had CG Health, UCS Healthcare in West Des Moines, Lynn County Public Health, and Crush of Iowa Recovery Community Center, all who have been providing amazing leaders to share and react to the messages that we've developed, and really just give us the understanding of what is happening out in our communities, what is the experience like, and how do we build better relationships between our pharmacy professionals and people who are seeking care. And so, for the last couple of months, we've been meeting with them in between our academic detailing visits. We've been linking up with the CPESM, the Community Pharmacy Enhanced Services Network to meet with some of their pharmacists and share this project as our first go of academic detailing, and then from there going into follow-up meetings with individual community pharmacists, on their turf to hear what their experiences are, to share some of our key messages, and to encourage and inspire the behavior change that we really want to see from the profession in the state. So, that's really the gist of the project. I think beyond that too, has been also providing follow-up resources after we have those academic detailing visits. So, resources that can be printed, patient materials, or educational materials to leave behind, or training videos to learn more about the laws, or how to utilize non-stigmatizing language. So, it's been really impactful work Anna. To give additional context to our listeners, the Nature Project, the National Association of County and City Health Officials, they funded this academic detailing project on harm reduction, and you can learn more about that in episode three of this podcast. My colleague, Bevan Amira, and I talk a bit more about that, but what's really cool about this project, there's two things. One is that you used the voices of folks in the community to inform your key messaging, and two, the project really focused on different audiences outside of primary care clinicians to receive detailing visits. So, for your particular project, as you mentioned, you're focused on detailing pharmacists, which is a pretty innovative audience for our NARCAD community. So, thank you so much for all the work that you're doing online and for sharing about that. In your own words, what is harm reduction, and why is it an important approach to public health? Yeah, this is such a great question. I know we were talking a little bit about it before we even started recording here, and it's interesting, because I think the word or the phrase "harm reduction" can be such a trigger for some people. One, it's really simply strategies and principles that help provide patients, or even just people in the community with the care that they need, specifically as it relates to substance use or drug use. And I think one thing that's been very clear especially in my training as a pharmacist and my work in public health through this role has really been that we all have a role within harm reduction, and that it is such a key measure of public health. It's present in our regulatory processes, in the clinical processes, the education, and harm reduction really is just all the strategies and the ways that we can tackle the epidemic that we're seeing. And so, some of those examples can be access to opioid reversal agents, so NARCAN or naloxone, or testing methods to identify substances of harm, language that we use. Sometimes we talk about the understanding the goals of the individual and meeting them where they're at. So, recognizing that cure or abstinence is not the goal, it's safe use, and reducing spread of infectious diseases. So, that can include HIV and HCV testing or STI and STD testing as it relates to injection drug use, which is something that IPA has been involved with over the last five, going on six years, has been HIV and HCV screening and testing and community pharmacies. It's so, so important because from the aspects of prevention to treatments and recovery, there's so much and there are so many really great groups that are focused in on this work, like the harm reduction coalition, NARCAD, NATO, everyone of SAMHSA. And so, I view harm reduction as meeting people where they are and centering and providing non-judgmental care and access to resources or education. And we all have a role, especially as pharmacy professionals in the success of harm reduction initiatives, because really, discrimination, stigma, lack of knowledge of how quickly this landscape is changing, should not impact a patient's access to harm reduction strategies. And the thing that makes me proud about being on staff at IPA is that our organization, our membership association, has a house of delegates that we hold every year where we vote and adopt policy to officially adopt into the association. And last year, we passed a policy on harm reduction that really focuses in on the role of the firm's profession and supporting and increasing access to the strategies and principles. And so, to have the voice and the official position of the association also be focused in on harm reduction and that commitment is really something truly special and it's good to be part of. It's incredible the work that IPA is doing. And you said that just so beautifully about what harm reduction was in your own words. And there was a piece that I really wanted to pull out that I loved that you said you said it's centering and providing non-judgmental care. I just really appreciate the word centering. So, thanks for sharing that. You talked a little bit about the role that pharmacists play in the success of harm reduction initiatives. Can you dive into that a little bit more? Absolutely and I'll definitely even hit on some of the key messages that we've been developing because that's it's a perfect way to really highlight it. And I think as pharmacists, pharmacy professionals, we really are pillars of our communities. Oftentimes that community pharmacy or sometimes even that inpatient pharmacist helps provide education or referrals and especially in the community are seen as that go-to place. Often people see their pharmacists or interact with their pharmacists more than they do their primary care provider on a yearly basis. And so, oftentimes the relationship that people can have with their pharmacist is deeper and there's a little bit more that's shared in those spaces. And so, especially when we look at populations, specifically people who use drugs, there's a lot of trust and respect to be had within those settings. And feedback that we received from the group that we engaged with that has experience and are working with this population is that it's so important to maintain that confidentiality and as I mentioned that nonjudgmental, unbiased care and focusing on the whole person and not just the disease. And so, as pharmacy professionals and I see that because it really does include the pharmacists, the technicians, the interns, the support persons. When somebody comes in, it's really building trust with your community and just being seen as a hub for connection or someone that they can come to with questions. And so, it's so important that patients feel safe to engage with pharmacists as a provider for when they're ready and have those harm reduction needs. And so, for what that looks like in practice, that's simply having materials present or marketing or promo, for example, displayed to say, ask me about Miloxone or just access to other tools. Oftentimes, due to a stigma and lack of awareness and disease of the disease, some people may only be reached through their peers. And so, if pharmacists initiate some of those conversations or have those conversations with somebody who frequents their pharmacy, that ripple effect can be so amazing and just being able to extend the knowledge or that trust with others who are part of the community. Other tangible things that we've been encouraging as part of some of our key messages have been also providing and promoting like wellness services and offering screenings and testing for infectious diseases, providing access to Miloxone syringes and sharps disposals. And just the rationale behind that has really been and that it's so essential to provide harm reduction tools and that there's a lot of evidence in it contributing to safety. And so, when the pharmacy's able to share those resources that we're already trained to provide or we're already providing, it really helps as an access point in the community for those who are in need and for individuals who may want services and resources but would otherwise not have access or are able to receive reliable care. I think I talked a little bit already about the syringes, that's a big thing. With that, I'll just say everyone should just know the regulations and the protections in their state. What the laws are around providing syringes without a prescription because that really does help reduce the spread of infectious diseases, it ensures safe use and also ensures that people who inject drugs are able to access clean syringes from pharmacies with less resistance from other professionals that they might have engage with in the communities. And then I guess lastly, just advocacy for the pharmacy profession's involvement is really the things that we're already doing. So, medication therapy management, doing medication reviews, having conversations about co-prescribing Miloxone or deep prescribing, or even if you're not ready to really be that person in your pharmacy, figure out what else is going on in your community or what partnerships you could be having with local public health. It could be something as simple as medication disposal or providing a hands-on training or education on the use of Miloxone. I really think that there is a way for everyone to get involved and to start somewhere and wherever is most comfortable. And the more that you learn, the more that you have the support of organizations such as the Iowa Pharmacy Association, hopefully that expands the confidence and the comfortability and being able to be an access point in the community. It sounds like, Elin, that you're really putting a harm reduction lens on the work that's already being done in pharmacies. Is that correct? Yes, absolutely. That's a perfect way to put it. I think one thing that I've realized in my role has been oftentimes when you share like an initiative or a project, there can be some resistance for many, many reasons. But I find that it's so valuable to say you're already doing this work. You just didn't realize that it was called harm reduction or whatever the case may be. And so don't think of it as something new. Realize where you're doing well and how you can expand and broaden the conversation. Or I guess I don't know if it would be broadening or narrowing in, but whichever direction honing in on harm reduction. Well said, can you share an anecdote from one of your detailing visits for this project? That's a good one. I totally have two, but the one that I all have to say is I recently myself and the other academic detailer, my fellow, but Kayla Tys Harris, we visited Parkersburg pharmacy and Ryan Beck pharmacy, I think a week or two weeks ago, and sat down and had conversations and started going through the key messages. I did ask, it's like, oh, what are you doing to promote? Or you said something about social media is a little bit challenging. So tell me more. And the pharmacist was a little bit like, you know, I've been trying to do some things. I'm just not really big or I'm not interested much in social media. I don't have the time. I mean, who has the time to be a social media manager and content creator and run a pharmacy right now? I mean, it's a lot, but notice that there was a TV screen like right in front of their their front desk where they had been just promoting a couple services. And I started asking and prompted and I said, you know, like, tell me more about this and what was the rationale behind it. And he said, well, you know, I put it there as something to catch people's attention when they're in line. It just helps them also just know what's going on. And so I began prompting and asked if they would be willing to start promoting, like, ask me about harm reduction or ask me about naloxone or have naloxone just in case. And the way that he lit up and said, you know, I never even thought to do that. Like, I saw the shift in his like acceptance or his ability to say like, oh, yeah, no, we can't do we can't do that. We don't have time to, oh, yeah, like we're doing it right now. We didn't even realize that like, yeah, let's let's add more up there and just let it scroll all day. So that was really cool. You never know what's going to happen in a detailing visit. And you were able to think on your feet. So thanks for sharing that. On the flip side, how can detailers advocate for implementation of harm reduction strategies in areas or communities that are resistant to change or a pharmacy that's resistant to change? Do you have any tips? That is a really good question. And I will say resistance is something that every academic detailer will probably come up against and our CAT team has been super helpful in just understanding the tips and approaches. And I think my greatest advice and my tip, even though I would say I'm not I wouldn't call myself an expert still learning it and there's always going to be learning within behavior change. But I really do think that meeting people where they are and listening for where there's that resistance and just prodding a little bit and saying tell me more or let's go a little bit deeper will help you to untangle and understand where those beliefs or where that resistance is originating from. And it opens the door for exploration for solutions or sometimes just a point of we can come back to this and educate a little bit more on it. I think especially as health care professionals who do academic detail and what we want to solve, we want there to be the nice complete resolution. But sometimes just being seen as a trusted person to ask questions to or answer questions for can go a long ways. And so even though like we might have this list of like messages or behavior or evidence, sometimes people just want to be heard. Sometimes they they have a personal experience that has really shaped their their views. And when you are able to just step out of just the focus of the work and really connect with that individual, it does open up the door to hopefully less resistance. Most people aren't like completely resistant. They're hesitant. And so if you're able to understand what that hesitancy is and go at their pace and meet their needs in the moment and just go by that that framework, it builds trust. And I think right now, there's just been so much within the health care landscape for providers, for physicians, for nurses, for pharmacists, for patients, and just the different levels of trust, especially within harm reduction substance use. At the end of the day, you're talking to another human. I really like what you said about most people aren't resistant, they're hesitant. That's really great to remember. And folks are going into detailing visits. Like we can change behavior. We just got to dig into why someone feels a certain way. I want to wrap up with a final question. What advancements or innovations do you see on the horizon for harm reduction? I mean, there's so much changing right now. There has been never a greater period of time where patients have access to so many resources, education materials. And it's important, but it's also important to have evidence-based, like proper information, not misinformation. But I see a greater trend in just access to those referral services. More, I would say support and more patient-centered resources. And by that, where I'm heading with or what I'm trying to explain is that in working on this project, I will say that as a pharmacist myself, it took me a while to realize, oh, it's not about me, it's about the patient, it's about the community, it's about them. And we may think that we know everything, but at the end of the day, it's not our experience, and I always say nothing for us without us. So I feel like we're in a period where we're going to start seeing even more resources, materials, and just behavior change, like habit tractors and things that are designed by the people with these experiences in collaboration with healthcare providers. And so I see greater collaboration. I see individual empowered resources and tools so that people in their comfort of their home or their community or access, depending on what resources they have access to, will be able to be more empowered is the direction that I hope that we're heading in. Well, I hope that's the direction we're headed into, Emily. We so appreciate you being on our podcast today. Thank you.