Innovative projects answer NIDA’s challenge to implement substance use prevention in primary care

By Dr. Nora Volkow

With nearly 110,000 people dying from drug overdoses last year, the crisis has not abated. We have effective treatments for opioid and other drug use disorders, but growing numbers of people are dying from fentanyl even in the absence of a substance use disorder—for instance, young people overdosing on fentanyl-contaminated counterfeit pills. In such a diverse drug landscape, treatment, while crucial, is insufficient to address the overdose crisis.?Increased focus on prevention of drug experimentation and escalation of drug use to addiction are fundamental in order to avert these kinds of tragic outcomes.

Recent research has identified primary care practices as an underutilized setting for substance use prevention, where providers can deliver brief prevention interventions and referral to other prevention or treatment services as indicated. However, there can be challenges in these settings, including provider stigma, staff that may already be overworked and lack the knowledge to screen or intervene effectively, and the reality that most prevention interventions are not currently reimbursed by medical insurance.

This past February, NIDA issued a Primary Care Challenge to generate ideas for how primary care practices can more effectively identify people at risk for substance use or misuse and prevent substance use initiation and escalation of misuse to SUDs. We received 30 submissions, which were evaluated by a team of judges from our Institute and other agencies within the U.S. Department of Health and Human Services. Three winning teams will each receive $25,000 prizes to support the implementation of their innovative prevention solutions targeting underserved or high-risk populations. There were also four honorable mention winners, each receiving prizes of $5,000.

One of the winning submissions came from a team at the University of Arizona Colleges of Nursing and Social and Behavioral Sciences. Because people reentering the community after a period of incarceration are at increased risk of drug overdose, their proposed project will provide substance-use screening and prevention services (or referral to those services) for adults who have been incarcerated within the past three years or who are on probation and residing in Cochise County, a large rural community of 125,000 people in southeastern Arizona. Services will be delivered at five primary care clinics in this community. Health workers will reach out to recently incarcerated persons who don’t yet have primary care physicians to help with insurance enrollment and visit scheduling.

Since addiction risk is highest with earlier substance initiation, youth have long been a key focus of substance use prevention, but interventions are typically implemented in school and family settings, not in pediatricians’ offices. However, a precedent for extremely effective primary-care-based prevention in this age group—indeed, one of the greatest success stories in medicine—is routine vaccination. Building on their success delivering human papillomavirus vaccination to 9- to 12-year-olds during the COVID pandemic, a team of pediatricians affiliated with the Yale Schools of Medicine and Public Health and Fair Haven Community Health Care won a prize for a project aimed at making personalized substance use prevention interventions in their large pediatric clinic as “Easy as Vaccination!” Their project will harness the power of electronic health records, machine learning, team-based care, and the existing workflow in their practice to screen and connect primary care patients to evidence-based universal and selective substance use prevention interventions, depending on individual patients’ identified needs and risk factors.

Depression, anxiety, and ADHD are risk factors for substance use in adolescence. Another team of pediatricians associated with the University of Vermont and HealthCentric Advisors won a prize for a project that uses quarterly follow-up visits for management of these mental health diagnoses to screen for substance use and deliver brief prevention interventions. Based on evidence supporting drug-refusal skills training in this age group, as well as the value of peer-led intervention, the team’s prevention approach uses brief video modules on avoiding substance use, made by local peers.

Each of the winning submissions focused on an underserved population in need of prevention services and proposed delivering those services using community health workers, incorporated referrals to mobile and established web-based programs, and used screening and counseling recommendations that have been given an A or B rating by the U.S. Preventive Services Task Force, which evaluates screening and prevention interventions. These ratings enable services to be billed to insurance at no cost to the patient.

Sustainability was one of the themes that ran through most of the submissions. It is important to make screening and prevention reimbursable as well as easy to implement utilizing existing technology and workflows. However, while it was clear from the submissions that screening is relatively easy to implement using readily available tools, including tools from NIDAMED , a lack of existing prevention services and workforce capacity is a major challenge. This is a problem highlighted by my NIDA colleagues in a recent article in Prevention Services . If we are to make headway reducing the burden of substance use and its consequences, such as overdose, we must foster greater collaboration between prevention researchers and the healthcare providers.

I thank all the teams who entered this Challenge and am impressed by the diversity of innovative models for screening and prevention delivery in primary care. I am hopeful that some of these models will prove successful and can be more widely used in communities across this nation not only to reduce overdoses but also address other negative impacts on quality of life that accompany the progression of substance use to addiction.

View Nora's blog on NIDA's website.