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Last modified: Tuesday, September 13, 2011

'We ask Everyone': IPRC, health care coalition use $8.3 million grant to target early substance abuse

Sept. 13, 2011

BLOOMINGTON, Ind. -- The Indiana Prevention Resource Center at Indiana University Bloomington is leading an ambitious initiative -- funded recently by an $8.3 million federal grant -- targeting the failure by health care providers to routinely ask patients about their alcohol and drug use, an omission considered a weak link nationwide in efforts to address substance abuse.

The Substance Abuse and Mental Health Services Administration (SAMHSA) awarded the State of Indiana a five-year grant for the IPRC-led project, which will work to integrate drug and alcohol screening, brief intervention, and referral to treatment (SBIRT) services into the routine standard of care at community health centers (CHCs) and community mental health centers (CMHCs) throughout Indiana.

The complex effort involves a coalition of health, research and educational groups, including Wishard Health Services, Midtown Mental Health Services, and the IU School of Medicine in Indianapolis; the IPRC and Academic Edge, Inc. from Bloomington; and the Family and Social Services Administration (FSSA), Division of Mental Health and Addiction (DMHA).

"SBIRT is an evidence-based solution to this problem of failure to ask," said Ruth Gassman, director of the IPRC, which is part of IU's School of Health, Physical Education and Recreation. "By creating a standard of care in which all patients are asked about substance use, and which has clear protocols for helping those patients based on the results of the screen, SBIRT increases the likelihood people in need of help, receive that help."

Alcohol and substance abuse remain challenging problems nationwide and in Indiana in particular. Beyond obvious cases of substance abuse, many people may be engaged in risky substance use, or may be at risk for personal and social consequences of use, misuse or abuse.

"Studies have shown that although only a small percentage of individuals in the United States have been diagnosed with alcohol abuse, a far greater number, as high as 20 percent of individuals, are risky drinkers. These patients will not always identify their health problems with alcohol or other substance use, nor will such a connection always be obvious," said Gassman. "The earlier a problem is detected, the more effective prevention efforts may be. Unfortunately, health care providers infrequently address substance use with their patients."

The IPRC led the writing of the awarded application and has taken the lead on project management, while Rick Goldsworthy, director of research and development at Academic Edge Inc., will oversee project implementation and dissemination.

"Changing practice across the state is a complex endeavor involving patient and provider behavior change, organizational change, and, to be sustainable in the long run, the need for financial and outcome evaluation, among other tough challenges," Goldsworthy said. "We are looking at not only changing provider practices across the community health centers, but also helping providers more effectively change their patient's behavior. These kinds of systematic challenges involve getting people to not only initially try out SBIRT but to keep doing it. It has to be easy, it has to be effective, it has to be something people simply do and accept. In the end, the CHCs, the providers and the patients all have to be onboard with the notion that 'We ask everyone.'"

Because of the nature of the screening process, all adult patients being seen at Wishard CHCs will be asked about their substance use -- confidentially. CHCs are primary care facilities that provide a variety of health-related services.

"This is a major system change at these health centers, and we don't want patients to get the idea that they're being 'singled out' for an SBIRT intervention," said Goldsworthy. "We also want to make it feel like a ubiquitous thing for providers to do. That's why several of the partners worked together to generate and disseminate the 'We ask Everyone' tagline on posters, on training and on patient forms."

Developed as part of an SBIRT Medical Residency training program overseen by Dr. David Crabb, chair of the Department of Medicine at the IU School of Medicine, the SBIRT process, posters and other resources are already in place in one pilot location.

The project team coalition will work closely with the first three Indianapolis CHCs to roll out SBIRT by early January 2012. A total of seven additional CHCs in Indianapolis will implement SBIRT in the second and third years of the effort. Case studies of each site's experiences, along with resources for adoption and implementation, will be made available to other CHCs and organizations throughout Indiana through a Web-based Indiana SBIRT learning portal and via technical and training assistance from IPRC and AEI. For more information about the project or to participate, please contact Ruth Gassman at the IPRC.

More about the project

"A growing trend in modern healthcare -- both for prevention and treatment -- is the integration of mental health and primary care," Gassman said. "SBIRT is an ideal evidence-based means of examining patients' substance use and abuse, partly because it meets them 'where they already are,' that is, in a primary care health setting. The variety of different agencies involved in this project speaks to our commitment to integrating these different fields into a cohesive whole."

The proposed effort will improve patient substance abuse, misuse, and use-related outcomes by facilitating SBIRT integration within CHCs and other practice environments throughout the state. This state-wide SBIRT adoption and implementation will be supported by:

  • Aggressively supporting SBIRT rollout in pilot, model demonstration, and practice-leader sites
  • Rigorously developing and disseminating adoption and implementation training and support materials and resources
  • Actively pursuing policy and systems changes supportive of SBIRT adoption and ongoing implementation at both the local and state levels.

"When we designed this proposal, we focused not only on immediate patient outcomes, such as reductions in substance use; we also emphasized the development of infrastructure to sustain SBIRT initiatives well beyond the scope of the grant," said Gassman.

The grant funds not only the implementation of SBIRT services in the initially targeted Wishard CHCs in Indianapolis, but also the development of a training and implementation protocol that can be disseminated to any primary care or mental health center in Indiana.

"Substance use and abuse are difficult, challenging, problems. Changing organizational behavior is often equally hard. Both require thinking big picture about why people do the things they do and how we can change those things." said Goldsworthy, the project implementation and dissemination director. "Fortunately, we have an extremely strong group of highly motivated partners -- Wishard, Midtown and the IPRC have tremendous expertise in prevention and treatment, and this is a fantastic opportunity to learn from initial efforts in this area, to look at ways to improve and further disseminate these efforts, and to capture the resulting experiences and resources so that others throughout Indiana can more readily adopt and implement SBIRT -- earlier detection and intervention with patients at risk for substance misuse and abuse."


SBIRT is a process that seeks to identify a patient's substance use, even when it is not necessarily severe, and then works to negotiate an appropriate treatment, whether it be a brief intervention or a referral to treatment for more serious issues.

"We see brief interventions as the process of 'nipping the problem in the bud," said Gassman. "In other words, even if someone isn't an alcoholic, they may be harming themselves with the amount of alcohol that they drink. A brief conversation designed to prompt change has been shown to have positive patient outcomes and to reduce substance use."

About the IPRC

The IPRC is operated by the School of HPER and its Department of Applied Health Science. The IPRC is funded, in part, by the Indiana Family and Social Services Administration, Division of Mental Health and Addiction, and financially supported through the HHS /Substance Abuse Mental Health Services Administration, Center for Substance Abuse Prevention, Substance Abuse Prevention and Treatment Block Grant.

For more information, contact Gassman at 812-855-1237 or, or Jon Agley at 812-855-3123 and