Implementation of substance use screening and brief intervention model at primary healthcare level of Uttarakhand

As per the Magnitude of Substance Use in India report (2019),[1] 14.6% of the Indian population uses alcohol, followed by opioids (2.1%), and cannabis (2%). The burden of drug use in the state of Uttarakhand (UK) is on the higher side. The prevalence was found to be the highest (18.8%) for alcohol use, followed by 3.38% for cannabis and 2.58% for opioids. There is a huge treatment gap for substance use disorders in India.[2] This gap can potentially be bridged by capacity building of mid-level healthcare providers (MHLPs) who are trained in screening and management based on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework.[3] This model framework is evidence-based, scalable, and applicable across varied settings like hospitals, schools, and the community. As per recommendations of the National Health Policy (2017), there has been an initiative to establish Health and Wellness Centers (HWCs) to deliver Comprehensive Primary Health Care.[4] A 6-month certificate program in community health has been developed for qualified Nurses or Ayurveda practitioners to work as Community Health Officers (CHOs).[4] Uttarakhand has expanded its workforce successfully through this bridge initiative. CHOs conduct risk assessments of non-communicable diseases (NCDs) but use only two items on current use of alcohol and tobacco for such an assessment. As part of the National Mental Health Program and with financial support from the Nation Health Mission (NHM) Uttarakhand, we have initiated a Cascade Training Technique or Training-the-Trainer model to instill the SBIRT skills to CHOs. It consisted of Phase-I: Development of modules/study material by the investigators based on available World Health Organization (WHO) material and screening for substance use using Alcohol Smoking and Substance Involvement Screening Test (ASSIST),[5] followed by 2-days Short-term onsite practical (STOP) training for State-nominated Block Medical officers (BMOs) as Master Trainers (on SBIRT framework) conducted at a tertiary-care teaching hospital (with pre-post knowledge assessment being done); Phase-II: the Master Trainers conduct a 1-day workshop for CHOs in their respective districts (We provided soft-copy training material to the master trainers so that they could use and get it printed as per their needs.); and Phase-III of Continuity of Care, where continued support for those selected BMOs/CHOs at their workplace at regular intervals is provided through the virtual platform. STOP training for 03 batches for BMOs from 09 districts has been completed. The master trainers in many districts have also completed Phase-II workshops for CHOs. The intended locus is the clinical setting where NCDs assessment is done, including in the community and outpatient clinical setting. Online monitoring and handholding are to be done subsequently and will include field visits. The SBI/SBIRT model implementation in the State of Uttarakhand, supported by NHM, is a modest start in developing a stepped-care approach to strengthen universal primary health care and may be replicated elsewhere. The recent Tilak Venkoba Rao Oration Award paper also advocates the adoption of SBI as a public health tool in India to bridge the mental healthcare gap.[6] We acknowledge that our SBIRT approach has yet to be evaluated for on-the-ground ‘take-up’ and inculcation into the routine practice by CHOs, but it shows promise as an implementable model. Financial support and sponsorship National Health Mission, Uttarakhand. Conflicts of interest There are no conflicts of interest.