More than gun-related incidents, more than car accidents, deaths from drug overdoses in Virginia are at an all-time high—a staggering 1,420 of them last year alone. Synthetic opioid, heroin, and prescription fentanyl overdoses increased 38 percent in the state between 2015 and 2016, and alcohol abuse is even more prevalent, with more than 6 percent of Virginians needing, but not receiving, treatment for it.
Now, through an ambitious partnership with the commonwealth, Mason is working to reduce these numbers with an evidence-based practice that identifies and assists patients with substance use disorders, and those at risk of developing them.
The Screening, Brief Intervention, and Referral to Treatment (SBIRT) program has been implemented in 29 states, and more than two million patients have been screened to date. Mason and Virginia’s Department of Behavioral Health and Developmental Services (DBHDS) are using a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to integrate the program into the clinical practice and electronic health records of at least 11 large community health care practice sites in Virginia over five years.
A Better Q & A
SBIRT is a three-pronged public health approach to managing risky and problematic substance use. The screening portion involves a questioning process, which brings substance abuse issues to the forefront during routine or emergency appointments, where health care staff or providers ask patients specific lifestyle questions. The brief intervention part of the initiative uses a counseling model called “motivational interviewing.”
Mellie Randall, director of Substance Use Disorder Policy for DBHDS, which served as the applicant for the Virginia grant, explains that the earliest work using motivational interviewing was done with smoking. “Routinely when you see a doctor, they ask about your smoking behavior,” she says. “That’s where this whole model was developed, and it was very successful.”
But to conduct interviews correctly, staff must be properly trained—to ask the right questions, and ask them in the correct way.
“If a doctor says, ‘You don’t drink more than four drinks at a time, do you?’ you’re going to get one answer, versus asking, ‘If you drink, how many do you have at one time?’” says Randall.
If answers to these questions during a routine appointment uncover a serious substance-abuse problem, a patient will be referred to a specialty clinic—the “referral to treatment” part of the program. But if a problem seems to just be starting, the provider will do a more thorough assessment, then a brief—around 15 minutes—intervention, and schedule the patient for roughly six counseling sessions, if needed.
The point of SBIRT, says Randall, is “to have that person think in a more deliberate way about how they’re using alcohol, marijuana, or a pain medication, and if they’re starting to misuse it. To catch the situation before it gets too severe.”
It also serves as a learning tool for health care providers.
“The big payoff is that staff behaviors start to change,” Randall says. “They start to understand that substance-abuse disorders are an illness just like any other illness.”
Training Health Practitioners
The Virginia SBIRT project (VA-SBIRT) is being led by Lora Peppard, PhD Nursing ’17, an associate professor in Mason’s College of Health and Human Services. In 2015, Peppard’s team received a $920,000 grant from SAMHSA to train students, faculty, and community partners in SBIRT. These individuals then carry that skill set into practice, assessing patients for substance abuse, stratifying their risks, and offering the most appropriate treatment based on their risk level.
In 2016, Mason built on that established training expertise and partnered with the commonwealth to execute an $8.3 million implementation grant in the Northern Virginia and Shenandoah Valley regions. This grant, also provided by SAMHSA but funneled through the state of Virginia, will be used to “work with community health care organizations to determine where screening will occur and which roles will administer the screening, offer the brief interventions, and all of the micro and macro details of integrating SBIRT into the existing clinical workflow of these sites,” says Peppard.
Over the last year, the Mason team has worked with seven sites in the Northern Virginia and Shenandoah Valley regions—one emergency department, two federally qualified health centers, two free clinics, one health department, and one student health center—and assigned each a training coordinator, practice coordinator, and data specialist.
“Our team works intimately with an organization’s leadership, clinical administrators, frontline staff, and health providers to support comprehensive SBIRT integration, and we also offer funding to assist them in hiring the right providers to support this effort in their organization,” says Peppard. “We help them think through, from a systems perspective, how they can integrate the various steps of the SBIRT process—who will serve each function, how data will be collected, what training may be required, and how this service fits into their larger community health picture.”
Since VA-SBIRT is one of the key response strategies in Virginia to address the rise of substance use, leadership and health care providers at these sites have readily welcomed Mason’s help in implementing it.
“Many executive directors jumped on the opportunity when Mason offered to assist them in executing this project,” Peppard says. “They see it as extremely valuable and important to the care they are offering.”
Mason is also developing a central data depository so health care professionals can analyze trends and improve strategies for addressing substance abuse, and this repository has an opportunity to grow as the SBIRT process is disseminated in other practice sites and regions of the state.
Peppard, who has worked as a psychiatric nurse practitioner for 14 years and has a doctor of nursing practice degree from Columbia University, leads a university-wide team comprising experts from Mason’s School of Nursing and the Departments of Social Work, Psychology, Health Administration and Policy, Communication, and Global and Community Health. The VA-SBIRT program provides experiential learning, practice, and research opportunities for Mason doctoral students, giving them a chance to see the value of their efforts firsthand. Several doctoral projects have resulted from student participation in the grant.
Elizabeth Idris, who is completing her final year of Mason’s Doctor of Nursing Practice (DNP) Program, has been involved in many elements of VA-SBIRT, from developing training materials to assisting in coaching sessions for providers. She’s found that, while SBIRT’s method of promoting interaction with patients seems simple, in reality it’s anything but.
“It affects the workflow, how patients move through the clinic, timing of appointments, and documentation,” she says. “Students and providers need regular training. Buy-in from all levels of staff is incredibly important.”
Mason graduate student Sarah Alsgaard, DNP ’17, became involved with VA-SBIRT as part of her doctoral project. She believes the work has expanded her knowledge and interest in substance use and screening, and taught her just how critical early intervention is. Being part of a training methodologies team not only allowed her to present her findings at a national conference, it “increased my confidence to collaborate with others in the future,” she says. “This project has provided me with hands-on experience and growth through navigating research challenges and solving problems.”
With a goal of universally screening a minimum of 100,000 patients over the next five years, these nurses have plenty of work ahead of them.
But, as Idris puts it, that work couldn’t be more worthwhile.
“This is a major issue of our time,” she says, “and I’m proud to be a part of it.”