AMERSA People & Passion, Episode 3: Barriers to treatment for opioid use disorder: Why aren’t pharmacists stocking buprenorphine?

Patients with opioid use disorder must be able to obtain prescribed buprenorphine from a pharmacy promptly to reduce risk for a recurrence of use and subsequent morbidity and mortality. However, phone-based secret shopper surveys indicate many pharmacies do not consistently maintain an adequate stock of buprenorphine and qualitative surveys show some pharmacists refuse to dispense it altogether. The underlying reasons for this problem are complex and will require innovative collaborations between pharmacists, buprenorphine prescribers, policymakers, and other healthcare team members.




Photo of Jeffrey Bratberg
Jeffrey P. Bratberg, PharmD, Clinical Professor at the University of Rhode Island, studies community pharmacists' roles play regarding opioid safety, opioid overdose, harm reduction and opioid use disorders. He is a consultant or co-investigator on two federal grants, a randomized controlled trial of pharmacists’ use of a CPA to manage medications for opioid use disorder and a multi-state, randomized control trial testing the effectiveness of a pharmacist and pharmacy focused intervention to improve naloxone provision, nonprescription syringe access and buprenorphine dispensing in community pharmacies.


Lucas G. Hill, PharmD, BCPS, BCACP
 serves as PhARM Director, The University of Texas at Austin. Dr. Hill graduated from the UMKC School of Pharmacy and completed a combined residency/fellowship in the UPMC Department of Family Medicine. He is now a clinical assistant professor at The University of Texas at Austin College of Pharmacy where he founded the PhARM Program and led implementation of Operation Naloxone. Dr. Hill is the principal investigator for a five-year, $25 million TTOR grant which seeks to address the opioid crisis in Texas by educating health professionals and the public while conducting pragmatic research.


Photo of Lindsey LoeraLindsey J. Loera, PharmD is a PhARM Fellow at The University of Texas at Austin. Dr. Loera graduated from The University of Texas at Austin College of Pharmacy and is currently completing a two-year fellowship with the PhARM Program. In this role, she will develop an innovative clinical pharmacy practice at an outpatient medical home for SUD and conducts statewide research exploring the pharmacist’s role in addiction treatment. She previously served as President of the Student Pharmacist Recovery Network and co-founded the Addiction Medicine Advanced Pharmacy Practice Experience.


Change Project 911: Help! How do we deal with change project interruptions? 



Mat Roosa, LCSW-R
NIATx Coach

Maintaining forward momentum on top priorities

Once your team has developed a change project and you have strong executive support, it might seem like things should be smooth sailing. But there are a number of ways that a strong project can be blown off course.

Competing priorities

Before the 1900s, the word “priority” was only used in the singular. The logic seems clear: there can only be one most important element. During the last 100 years, we have grown to accept the notion of multiple priorities and have then focused on strategies to juggle them. Most of us keep adding new elements until we experience failure. We keep adding balls to our juggling effort until we start dropping them. 

You’ve probably heard the adage, “If everything is a priority, then nothing is a priority.” It speaks to one of the most important roles of  executive sponsors, as they help the team to maintain a focus on the critical priority activity(ies). With leadership help, your change team can work proactively to limit elements that are not true priorities and to focus the team energy where it counts: on mission-critical work.  

Maintaining momentum

Even with effective prioritization, new challenges can emerge that threaten the team’s focus. COVID 19, and all of the related stressors that systems have experienced because of it, are powerful examples of challenges to even the best priority planning. 

So how can a team maintain forward momentum when new priorities or crises emerge that challenge the change effort? When we coach teams that encounter these challenges, we sometimes think about the simple act of riding a bicycle. Strong forward motion creates a high level of stability to the change project. While slowing the project down reduces some project stability, maintaining some motion will ensure project health. The change project, like a bike, falls over when it stops moving forward.

Coaches, executive sponsors, and change leaders can work to ensure that, regardless of emerging priorities and challenges to momentum, the change project continues to move forward. Circumstances may require that the project slow down to accommodate challenges, but steady motion will maintain change project stability and progress.  

Staying Focused

Try these four practical strategies to help a team stay focused on top priorities and maintain forward motion:

  1. Provide regular “focusing” messages from leadership. Executive sponsors can set the tone by regularly reminding staff about the critical functions and goals. Accountability to leadership regarding progress on these priorities will also ensure proper priority focus and forward momentum. 

  2. Meet regularly. This is a simple and often-neglected fix. One of the ways that teams can maintain focus and momentum is to maintain a disciplined meeting schedule to address next steps and sustain a change project. 

  3. Use a checklist and check in. Using a checklist can add structure to ensure that the team addresses the key priorities when they meet. A short list and a timed agenda will aid the team in moving each priority forward in each meeting and will avoid the stalling of momentum that occurs when items are neglected.

  4. Create a data dashboard. Each priority project should be managed with a simple graph or table that reflects the project’s key measures. Gathering these graphs together in a central and accessible location provides a highly useful dashboard for monitoring activities —and a motivating visual display of change team progress.  

About Change Project 911

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a snag that you’re not sure to tackle? Share your issue in the comments section below, or email Change Project 911 at matroosa@gmail.comWe’ll offer solutions from our team of change project experts!

About our Guest Blogger


Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.

AMERSA People & Passion, Episode 2: Stigma – The Not So Silent Killer

The use of alcohol and other drugs is rising in the United States in the setting of Covid-19. In the 12-month period ending in May 2020, more than 80,000 people in the U.S. lost their lives to a drug overdose, the highest number ever recorded in a single year. Substance use and addiction affect millions of people across the nation as healthcare systems work to create innovative solutions related to prevention, early identification, treatment and recovery. One major barrier to accomplishing this monumental goal is the stigma experienced by people with substance use disorders. Stigma creates feelings of shame, limits access to care, and ultimately contributes to challenging and life-threatening cycles of addiction. While we know how to define stigma and how it impacts individuals and families, how we eliminate stigma specifically in healthcare settings to improve care and outcomes is poorly understood. In this podcast, we will describe the many barriers stigma forces on people with substance use disorders and how healthcare can support people with substance use disorders.


Cheyenne Johnson
is Saulteaux (Ojibwe) and of mixed Settler ancestry and is a member of the Tootinaowaziibeeng Treaty 4 Reserve (Valley River) in western Manitoba. She is a Registered Nurse who works in addiction and substance use care in Vancouver. She is currently a member at large with AMERSA and the Co-Interim Executive Director at British Columbia Centre on Substance Use and an Adjunct Professor at the School of Nursing at University of British Columbia and actively collaborates with interdisciplinary clinicians, educators and researchers across Canada.



Dr. Deborah S. Finnell is a doctorally-prepared registered nurse, certified in addictions nursing and a Fellow in the American Academy of Nursing. She is currently AMERSA’s President Elect, an Associate Editor for AMERSA’s journal Substance Abuse, and led the publication of AMERSA’s substance use competencies for nursing.

Dr. Finnell has been a staunch advocate for vulnerable populations, seeking to address the bias, prejudice and discrimination that leads to stigma. She is a coauthor of the seminal publication , “Confronting inadvertent stigma and pejorative language in addiction scholarship,” has published her plenary address at the 2018 AMERSA conference on the neural basis of stigma, and has evaluated the impact of a substance use-related curriculum on students’ attitudes and perceptions.

Richard Bottner, DHA, PA-C is an Assistant Professor in the Department of Internal Medicine at Dell Medical School at The University of Texas at Austin and a physician assistant in the Division of Hospital medicine at Dell Seton Medical Center.

Bottner is also the Director of Support Hospital Opioid Use Treatment (SHOUT) Texas, a program seeking to increase access to opioid use disorder treatment in hospitals across the state and is the Co-PI on a grant from the Association of American Medical Colleges to develop and disseminate the Reducing Stigma Education Tools (ReSET) modules.

Introducing the "AMERSA People & Passion" Podcast, Sponsored by the ATTC Network

AMERSA is proud to announce a new podcast exploring the world of substance use education, research, care and policy! AMERSA People & Passion is a 10-episode series sponsored by the ATTC Network and hosted by executive director Doreen Baeder, featuring subject matter experts across a variety of topics, as well as special guests detailing their experiences as AMERSA members.

You can listen to new episodes of the podcast every week, beginning with today's episode, "Screening and Brief Intervention, AMERSA, and What You Should Do." Rich Saitz, former AMERSA president, is interviewed by his colleague, friend, and former mentee Nic Bertholet. We find out about whether screening and brief intervention are effective, and what the controversy is. We also learn about the evidence, what research should still be done, what we should teach, what we should do in practice, and how it has loomed large at AMERSA. Rich also shares how great it is to be very involved with AMERSA based on his experience with the organization, the value of colleagues met and friends made there, and by thinking about what other areas of research, education and care AMERSA plays big roles in.


Photo of Richard Saitz


Richard Saitz, MD, MPH
is professor and chair, Department of Community Health Sciences at Boston University School of Public Health, professor of medicine in the section of general internal medicine at Boston University School of Medicine, and a primary care physician and addiction medicine specialist at Boston Medical Center and the Grayken Center for Addiction. He is editor in chief of the journal of Addiction Medicine, associate editor of JAMA, and a past president of AMERSA.



Photo of Nicolas Bertholet



Nicolas Bertholet, MD, MSc
is an addiction psychiatry and prevention and public health specialist, he is senior lecturer at the University of Lausanne, Switzerland.

Change Project 911: When Your Rapid-cycle PDSA is not Working

Change Project 911 logo

Mat Roosa, LCSW-R
NIATx Coach

Rapid-Cycle Plan-Do-Study-ACT (PDSA) is a powerful tool for improvement that can enable a team or organization to achieve its short-term goals and move toward long-term success. But sometimes, PDSA change cycles do not yield the desired results.



Here are a few questions to consider when your change project does not achieve the goal.


What are the lessons learned from “failure”?

Rapid-Cycle PDSA has been called a “no-fail” method. The lessons learned from change that does not achieve the desired result can yield as much information as a highly successful change project. Finding out what does not work enables a team to avoid future investments in ineffective strategies and focus on efforts with a high return on investment.


Was the goal realistic?

We often recommend a “stretch goal” for a project that pushes the team toward a result that might seem unattainable. Stretch goals can energize a team toward greater achievement. However, sometimes a lack of information or an overabundance of enthusiasm can result in an unattainable goal. Recalibrating the goal toward a more realistic expectation can clarify the level of success the change achieved. 


What does the early data tell us?

Some change teams make the mistake of waiting until the “Study” phase of PDSA to look at the data collected. However, an initial review of the data during the “Do” phase may uncover the need to restructure the change or reconsider the data plan. These adjustments can rescue some change projects from heading too far in the wrong direction.


Are we experiencing unexpected variables?

Confounding variables can have a big impact on change project results. Teams should conduct some form of environmental scan to consider factors such as seasonal events, economic trends, political or social events, changes in staffing, or other variables affecting the people being served or the people providing the service.


Was our aim statement hypothesis correct?

Increase A from B to C by date D through strategy E.

Teams can consider a number of assumptions related to this equation when a change project is not yielding the desired results:

  • Is E actually a primary driver of A? Perhaps other strategies will have a better impact on the thing that we are trying to change.
  • Is C too high? See our discussion of realistic goals above.
  • Do we need more time? An adjustment to D may allow the change to unfold in a manner that creates better understanding of the impact of the change, or achieves greater results.
  • Is A the key indicator of success? Are we measuring the right thing? Maybe there are better ways to understand the impact of strategy E. Maybe we are having an effect on a different goal.
  • Is our data source valid and reliable? Is our chosen measure giving us accurate information about the thing that we are seeking to change? Are all participants following the measuring and reporting process consistently? Sometimes participants in the data collection process have a different interpretation of the data collection rules. (Oh, I thought we were only counting attendance for people who showed up on time…etc.)   

Rapid-cycle change projects should always yield valuable results, even when they do not achieve the desired goal. Taking some time to consider the questions above will result in more reliable results that can serve as a compass to guide your ongoing change project journey.  

 

About Change Project 911

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a snag that you’re not sure to tackle? Share your issue in the comments section below, or email Change Project 911 at matroosa@gmail.comWe’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.