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Prevention and Early Intervention for Mental and Substance Use Disorders: What's Working, What's Needed?

Wendy Greene

04 Prevention and Early Intervention

Ask the Expert:  Wendy R. Greene, M.D., F.A.C.S. is the Assistant Director of Trauma and Critical Care and the Chairman of the Quality Improvement and Management Committee for Howard University Hospital and is an Assistant Professor of Surgery for the Howard University College of Medicine.

1) Question: How can we get behavioral health organizations and practitioners to understand and use continuous quality improvement to achieve better results?

Answer: Behavioral health organizations and practitioners can be motivated to achieve better results by supporting the following initiatives. The health care organization needs to
1. Support quality improvement and make it an institutional priority.
2. Educate the organization and staff regarding best practices.
3.  Provide hospital and practitioner data on the quality variables that are measured nationally with benchmarks.
4. Support departmental quality champions .
5. Initiate multidisciplinary groups (include nurses and physicians) to address quality deficiencies.
6. Modify existing compensation strategies to ensure a portion of at risk salary is linked to compliance with evidence-based strategies.

2) Question: Where can we find the best examples of highest quality emergency department service for behavioral health consumers?

Answer: Emergency departments that have an inpatient unit for detoxification and medical stabilization would often provide the best example of highest quality care.  SAHMSA provides links to comprehensive emergency medicine psychiatric services. 

3) Question: What concepts would you recommend for dealing with consumers that have substance use issues and change from their substance of choice to prescription narcotics in an inpatient setting?

Answer: The inpatient setting is a time to address the immediate pain concerns.  Weaning from narcotics should not be attempted while acute pain needs are being addressed.  Strategies to reduce the effect of the rush of the intravenous medications can be achieved with longer acting medications; time released patches and extended infusion times of intravenous medication.

4) Question: What is the road to recovery for people with chronic illness or chronic pain? I work with a county Mental Health and Recovery Services Board, but we do not have any providers that include chronic health issues or chronic pain management. 

Answer: The road to recovery for chronic pain sufferers can be protracted.  A multidisciplinary pain center that includes pain relief with traditional medications combined with acupuncture, magnet therapy and psychological support is an option.

5) Question: Understanding trauma and providing targeted services appears to be gaining traction, especially in my field of addiction, mental health services, and public health. There is also enthusiasm regarding the possibilities with the effective adoption of SBIRT, but then feeling stymied with barriers and resistance in attempting to change current practicing doctor’s behavior. Implementing at the point of medical school certainly makes more sense and would lend to the potential of sustaining the practice when in residency and beyond. What is exactly meant or what truly defines “trauma”? And, are there psychological and environmental components that would overburden certain populations defined by SES, ethnicity, and/or race, and/or co-occurring illnesses such as substance use disorder and mental illness?

a. Trauma patients are those involved in intentional or unintentional injury.
b. Incorporation of SBIRT into medical education would be a great first step.
c. The Howard University College of Medicine students are exposed to SBIRT on the trauma service extensively.  The residents have been trained to provide culturally sensitive discussions with trauma patients and the medical students are involved in this learning process.  It also fulfills the core competencies set forth by the national residency review committees regarding medical education.  It has also given the residents and students an opportunity to utilize reflective listening strategies and improved patient care.
d. The American College of Surgeons has the SBIRT as a requirement of level one trauma centers.  Howard University not only provides this service but also utilizes not only physician extenders but also the physicians in training and medical staff.

6) Question: I am a Disease Management Specialist who also has the current role of discharge coordinator for our congestive heart failure (CHF) patients.  What suggestions would you have for how to assist our chemically inclined patients who frequently get readmitted for CHF due to them not abstaining from their use of substances? We do give referrals to the patients.

a. Referral for treatment should follow the discussion of what the patient likes and does not like regarding drug of choice.
b. Give data on appropriate use of alcohol for gender and age as well as information on illicit drugs and prescription drugs used for non prescribed purpose.
c. Have the patient provide insight into prior success in changing behavior.
d. Evaluate their readiness to change.
e. Then give prescription for change and referral for treatment.

7) Question: I have a friend who recently returned from a tour of duty overseas. He appears to be depressed, is isolating himself, and doesn’t socialize.  When I have seen him, he always has a beer in his hand. I’m concerned for him. What can I do to help? 

Answer: I first want to acknowledge the service and sacrifice your friend has provided to our country.  We also appreciate you for caring enough to ask the tough questions and letting him know he is not alone.  The drinking you see is a way to drown out the real concerns your friend has.  I would suggest he reaches out to his branch of service for an evaluation by a mental health professional that can also ascertain if he has posttraumatic stress disorder.


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