The problem of undetected substance use issues in primary care populations can ring obvious when comparing documented prevalence data to what professionals know anecdotally about their patients. Solutions to the problem might seem intuitive as well, but even so, they can prove difficult to implement.
Healthcare community leaders in New Hampshire, a state that has ranked near the bottom nationally in available treatment services, are trying to call attention to the potential benefits of Screening, Brief Intervention and Referral to Treatment (SBIRT) strategies to help narrow the treatment gap. This month, leaders gathered in Concord for a daylong summit to discuss SBIRT implementation, focusing largely on a $2 million Hilton Foundation-funded project that seeks to screen 10,000 adolescents and young adults by 2017.
A community health leader who attended the event points out that there will be numerous implementation challenges, not the least of which will involve securing viable treatment options for those identified with the most serious needs. In New Hampshire, “We don't even have a continuum of care yet,” says Melissa Silvey, director of public health at the Avis Goodwin Community Health Center, a federally qualified health center (FQHC) in the state.
Prevalence of illness
Silvey's own embrace of the SBIRT approach began around three years ago as she sought to identify low-cost options for behavioral health interventions for her FQHC's population. Conducting focus groups with Goodwin Center staff, she would hear the clinic's medical assistants estimate that at least half of the patients they see have a substance use problem. The prevalence of an actual diagnosed substance use disorder among clinic patients? Less than 1%. “We were missing so many opportunities,” Silvey says.
Mental health issues were being identified in the clinic population routinely, but substance abuse remained the proverbial elephant in the room. “No one was asking the question unless the person 'looked the part,'” says Silvey, such as if the patient had a disheveled appearance or exhibited signs of needle use. “This is what had to change.”
SBIRT efforts at Goodwin started with $32,000 in initial funding from the New Hampshire Charitable Foundation, a co-sponsor of this month's SBIRT summit. “That was probably the best investment I've seen made in prevention in our state,” Silvey says. “We revamped an entire practice.”
The community health center committed to screening all patients at a first visit to the clinic and during annual physicals. A medical assistant starts the process by using the NIDA Quick Screen, in which a patient is asked about past-year frequency of heavy alcohol use (5 drinks a day for men and 4 for women), tobacco use, non-medical prescription drug use and illegal drug use. A second level of screening employs the Alcohol Use Disorders Identification Test (AUDIT) for alcohol and the Drug Abuse Screening Test (DAST) for illegal drugs.
Although there has been a cultural shift in staff's overall willingness to initiate these discussions with patients, Silvey says the clinic still sees spikes and dips in data collection rates. It is not consistently meeting goals of a 90% screening rate for adult patients and an 80% rate for adolescents, she says.
In the vast majority of cases where screening uncovers an issue, the SBIRT protocol at the clinic will flag a staff behavioral health provider for a brief intervention. The tone is one of, “How can I support you?” Silvey says, as the provider also tries to evaluate the patient's motivation to make life changes. “It is never about wagging a finger.”
Shortage of treatment options
The clinic also pursues external referrals for the small percentage of patients who meet dependence criteria, but treatment options in the region are limited. Silvey says there is one abstinence-based residential program in the area of the community health center, as well as one methadone and one buprenorphine clinic. Wait lists for services are common.
This likely will be the ongoing challenge with the grant-funded project to screen 10,000 young people as well. At present, seven grantees, including the Goodwin Center, are implementing the SBIRT protocol at 15 practice sites across the state. “The challenge with adolescents has been that professionals are scared to ask the questions because they have no place to send them,” says Silvey.