Addressing the SUD training gap: Two pilot feasibility studies in the Department of Veteran’s Affairs Health Care System

Abstract

Introduction:

Substance use disorders (SUDs) are an ongoing public health crisis in the United States. A large body of research indicates an urgent need for increased training in SUD research and treatment for trainees in mental health service disciplines. The VA Health Care System is well positioned, as the largest trainer and employer of health service psychologists and other mental health professionals, to address the SUD training gap and serve as a leader in training the upcoming health care workforce.

Method:

To this end, we conducted two pilot studies to (1) examine the feasibility of implementing supplemental SUD training for VA health service trainees, among current VA mental health service providers in psychology, social work, and medical care (N = 37) and (2) the efficacy of a single 2-hour interdisciplinary SUD training seminar for VA health service trainees in mental health (N = 13). The training seminar consisted of several components including lecture, facilitated discussion, and role play, aimed at increasing trainee self-efficacy in assessing and diagnosing SUDs.

Results:

Findings suggest that current providers are supportive of supplemental SUD training for VA trainees and believe that such training is beneficial for those wishing to pursue a career within the VA Health Care System. Additionally, results suggest that a single session didactic seminar improved trainees’ self-reported efficacy in the assessment and referral of veterans diagnosed with SUDs.

Conclusions:

Overall, the above studies support additional feasibility investigations that would pave the way for successful implementation of widespread SUD training programs across the VA Health Care System and beyond. Successful implementation would then serve to reduce the increasingly critical SUD provider shortage, thus leading to significant public health gains.

Substance Use Disorders (SUDs) are a significant public health challenge facing the United States. At the individual level, SUDs are associated with a number of comorbid psychiatric disorders including anxiety, depression, and PTSD (NIDA, 2020) and new SUD diagnoses and drug-involved overdose deaths continue to rise each year (NIDA, 2021). At the systems-level, SUDs present significant financial costs to the health care system and individuals with SUD are significantly more likely to be admitted to the hospital and intensive care units, compared to those without SUD (Peterson et al., 2021). There are several models for conceptualizing and treating SUDs, all of which involve varying levels of care (e.g., inpatient, outpatient, etc.) and health care professionals across multiple disciplines. To illustrate this, consider an example of treatment for severe opioid use disorder (OUD): An individual with severe OUD is likely to begin treatment in an inpatient setting for medically monitored withdrawal. Once this patient is stabilized, they may move to partial hospitalization or intensive outpatient programs (attending 10 to 30 hours of treatment per week). After completing more intensive stages of treatment, they may continue with individual therapy and/or peer support groups such as Narcotics Anonymous (NA). In an interdisciplinary setting, each stage of treatment should, ideally, include regular monitoring of physical health and management of medications used to help treat OUD (such naltrexone, buprenorphine, or methadone; SAHMSA, 2023).

As illustrated above, a complete course of treatment for SUD is likely to involve many different health care professionals across a variety settings. Alarmingly, in 2021, only 6% of individuals with SUD received addiction-related treatment of any kind (SAMHSA, 2023). This is, in part, a result of significant systemic barriers to treatment, one of which is a lack of qualified health-service professionals who are able and willing to treat SUDs (Farhoudian et al., 2022). Given the increasingly critical need for SUD-related medical services, a crucial line of research involves the creation and dissemination of training programs aimed at addressing the ongoing provider shortage.

In recent years, a growing body of literature has aimed to address the need for providers competent in treating SUDs. For example, in 2020, Training and Education in Professional Psychology published a special issue: “Moving the Needle to Promote Education and Training in Substance Use Disorders and Addictions.” The special issue presents a plea from prolific experts in psychology education and substance use disorder (SUD) research for enhanced training in the research and treatment of SUDs at the psychology graduate level and beyond (Bell and McCutcheon, 2020; Burrow-Sanchez, et al., 2020), and provides a “roadmap” for possibilities in training advancement (Pedersen and Sayette, 2020; Davis, 2020). The collection outlines current working models of graduate training in SUD (MacKain and Noel, 2020; McCrady et al., 2020; McCarty et al, 2020; Schumacher et al., 2020) and examples of disseminating SUD treatment models into the health care workforce (Breuninger et al., 2020; Martin et al., 2020; Scott et al., 2020). The current article proposes using the largest health care system in the United States, the Department of Veteran’s Affairs Health Care System, to address the SUD training gap in clinical psychology and collaborating health-service disciplines (e.g., social work, psychiatry, pharmacy).

There are undoubtably existing exemplars of graduate-level SUD training for health-service providers, such as the Department of Veteran’s Affairs Centers of Excellence in Substance Addiction in Treatment, graduate training programs at The University of New Mexico and The University of Missouri (McCarty et al., 2020), and the Yale Addiction Mini-Residency (Garcia Vassallo, et al., 2019) but such programs are exceptions to the pronounced training gap in SUD research and treatment.

Though efforts to improve SUD training for health-service professionals are ongoing, the dissemination of these models appears lacking; for example, as of 2017 less than 40% of clinical psychology PhD programs had one or more faculty specializing in SUD research and less than 30% offered specialized clinical training in addiction (Dimoff et al., 2017). The long-standing call for improved SUD training in psychology appears almost unanswered, at least according to the state of the current empirical literature.

Psychology, however, is only one component of an interdisciplinary SUD treatment team. Other health-service disciplines such as social work, pharmacy, nursing, and psychiatry play a critical role in the successful treatment of SUDs and, in many cases, also experience a significant lack of SUD training opportunities (Klimas, 2015; Lembke, 2018; Pederson and Sayette, 2020; Wylie and Zacharoff, 2020; Wilkey et al., 2013). Medical schools, for example, typically require only a few hours of SUD training over students’ entire education (Lembke & Humphreys, 2018) and only 2% of psychiatry residency (i.e., 1 month out of 4 years) is required to be spent learning about SUD treatment (Dejong et al., 2022). As a function of this dearth of training, students and professionals in mental health disciplines often express hesitancy and low self-efficacy to treat individuals with SUD (Chasek et al., 2017).

As detailed below, we believe that the VA health care system is perfectly positioned to be a leader in SUD training for the upcoming health care workforce in mental health disciplines. The VA trains and employs more psychologists than any other entity in the United States, as a well as many social workers, pharmacists, and physicians. Specific to clinical psychology, in the 2021 academic training year, the VA supported 129 accredited internship programs and 120 post-doctoral fellowship programs (U.S. Department of Veterans Affairs, 2022). Further, the VA houses the largest multi-level system of SUD treatment programs and trains providers in Cognitive Behavioral Therapy for SUD, Motivational Interviewing, Motivational Enhancement Therapy, Contingency Management, and medication for SUD. However, despite the availability of above resources, there are no policies which require VA trainees and health-service professionals to become and remain proficient at recognizing and treating SUDs. This is of particular concern for the VA health care system, given that veterans experience problems with substance use at a higher rate than the general population (Teeters et al., 2017). Given the availability of resources and access to both mental health-service professionals and trainees, the VA health care system appears to be an excellent, yet somewhat untapped, resource for filling the growing SUD training gap.

A limited body of research supports the effectiveness of multidisciplinary mental health SUD training programs, within existing health care systems (Finnell et al., 2022; Garcia Vassallo et al., 2019). For example, Garcia Vassallo and colleagues (2019) introduced an “addiction mini-residency” which was found to be effective at increasing VA and non-VA health-service provider’s self-efficacy in assessing, diagnosing, and treating OUD. The program consisted of a two-day interdisciplinary staff development workshop which utilized a variety of educational strategies including patient panels, lectures, facilitated discussion, and role play. Results supporting the effectiveness of supplemental training programs are promising, in part, because they suggest that comprehensive OUD training can be disseminated to a diverse group of providers in a short period of time (Garcia Vassallo et al., 2019).

However, no studies to date have examined the possibility of implementing multidisciplinary SUD training for students in mental health disciplines in the VA health care system. Thus, while the VA is perfectly positioned to advance SUD training for health care disciplines, the feasibility of implementing such training is unknown. Feasibility studies are necessary to assess whether implementing a multidisciplinary SUD training program is suitable and appropriate and the extent to which such a program is desired and likely to be used. Overall, feasibility studies provide critical information meant to increase the likelihood of successful implementation by providing the opportunity to identify possible programmatic changes that may be needed prior to further study (Bowen et al., 2009). To this end, we aimed to assess the feasibility of implementing a brief SUD training program for student trainees based in or rotating through mental health services within the local VA Health Care System via two pilot studies:

Pilot Study 1 aimed to assess (a) provider perceived competency in working with SUDs and (b) provider interest, willingness, and commitment to supporting students receiving SUD training, in a single VA health care system. Along with the above stated aims, results from Study 1 will serve as the basis for larger-scale investigations of VA health care provider willingness and competency to treat, and supervise the treatment of, SUDs. Specifically, they will inform whether adjustments to the current method for assessing providers are needed and the inclusion/exclusion of specific measurement items.

Pilot Study 2 implemented a 2-hour, multidisciplinary training seminar for students in psychology, pharmacy, and social work on the biopsychosocial-spiritual assessment and conceptualization of SUDs in veterans and examined (a) changes in student perceived ability to assess and treat veterans diagnosed with substance use disorders, and (b) acceptability of substance use training. Specifically, the seminar aimed to address screening and assessment competencies outlined by the Substance Abuse and Mental Health Services Administration (SAHMSA). Results from study 2 will aid in determining adjustments needed for future didactic seminars and will inform the creation and implementation of additional measures of trainee self-efficacy to diagnose and treat SUDs.

Pilot Study 1

Method

Participants

Participants consisted of 22 psychologists, 11 social workers, 2 psychiatrists, and 1 pharmacist currently employed at a VA Health Care System in the southeastern United States. The study invited a total of 91 health service providers to participate, resulting in a total response rate of 40%.

Measures

Providers stationed in mental health services were asked to rate a series of statements about their own competency in treating veterans diagnosed with SUDs, competency in supervising trainees treating veterans with SUDs, the relative importance of increasing SUD training within the VA health care system, and willingness to allow trainees protected time to engage in interdisciplinary SUD training activities on a scale from (1) strongly disagree to (4) strongly agree. To date, there are no existing measures aimed at assessing provider willingness to treat SUDs, provider willingness to supervise trainee’s SUD cases, and provider opinions of increased SUD training for students. As such, the authors created 22 items which were specific to treating and supervising SUD cases in a VA health care system. For the purpose of our analyses, disciplines were divided into three categories: psychology, social work, and medical providers (pharmacy and psychiatry).

Procedure

The study collected data as part of a quality improvement (QI) project aimed at increasing provider and trainee self-efficacy to assess and treat SUDs to ultimately improve outcomes for veterans. Providers stationed in mental health services received an email requesting their participation in an anonymous survey assessing the feasibility of implementing supplemental SUD training for VA trainees stationed in or rotating through mental health services. Given that data were collected as part of a QI project, the study did not collect demographic data such as gender and race. The study administered questionnaire items via REDCap and used IBM SPSS 27 to generate item frequencies and conduct omnibus chi-square tests of invariance to examine differences in item scores by provider discipline.

Results

Descriptives

On average, respondents reported spending 34% of their clinical time treating veterans diagnosed with SUDs (range: 0 – 88%). Additionally, providers reported supervising approximately 3 trainees over the past two years (range: 0 – 10) and 11% of those surveyed reported holding a leadership position within the VA Health Care System.

Competency, Demand, and Willingness to Participate

Overall, providers responded positively to items assessing their confidence in supervising trainees treating veterans with SUDs and the need for additional comprehensive SUD training for VA trainees. Response frequencies for specific relevant items, by discipline, are shown in Table 1 and mean scores for each item are shown in Table 2.

Table 1.

Frequencies of Questionnaire Item Responses by Provider Discipline (N = 37).

	Students at the VA have expressed confidence in working with veterans with SUD			I am comfortable supervising students working with veterans with SUD			I would like to see the VA implement additional SUD training for students			Students at the VA receive integrated and comprehensive training in SUD treatment			Students interested in a VA career would benefit from training in treating SUD
	Psych N=22	SW N=11	Med N=3	Psych N=22	SW N=12	Med N=3	Psych N=22	SW N=12	Med N=3	Psych N=22	SW N=12	Med N=3	Psych N=22	SW N=11	Med N=3
Strongly Agree	9%	-	-	90%	92%	67%	81%	75%	100%	32%	8%	33%	95%	82%	100%
Slightly Agree	50%	55%	33%	5%	8%	33%	14%	25%	-	36%	50%	33%	5%	18%	-
Slightly Disagree	32%	45%	67%	-	-	-	5%	-	-	27%	42%	34%	-	-	-
Strongly Disagree	9%	-	-	5%	-	-	-	-	-	5%	-	-	-	-	-

Note: Psych = clinical psychologists, SW = social workers, Med = pharmacists and psychiatrists; “-“ indicates options that were not endorsed by any provider.

Table 2.

Average Questionnaire Item Responses by Provider Discipline (N = 37).

	Psychology M (SD)	Social Work M (SD)	Medical M (SD)
Students at the VA have expressed confidence in working with veterans with SUD	2.6 (.8)	2.5 (.5)	2.3 (.4)
I am comfortable supervising students working with veterans with SUD	3.4 (.9)	3.6 (.9)	3.7 (.4)
I would like to see the VA implement additional SUD training for students	3.8 (.5)	3.7 (.4)	4.0 (0)
Students at the VA receive integrated and comprehensive training in SUD treatment	2.9 (.9)	2.6 (.6)	3.0 (.6)
Students interested in a VA career would benefit from training in treating SUD	3.9 (.2)	3.8 (.4)	4.0 (0)

Note: Psych = clinical psychologists, SW = social workers, Med = pharmacists and psychiatrists

Additionally, respondents reported that, on average, they would allow their trainees to participate in a maximum of about 2 hours of supplemental SUD training per week (range = 0 – 6 hours). Only 6% of respondents reported that they would not support their trainee’s participation in any weekly supplemental SUD training. Omnibus chi-square tests of independence revealed non-significant differences in average individual item responses, between groups of providers (χ² = 3.7 – 9.2, p = .07 – 0.3).

Pilot Study 2

Participants

Participants consisted 13 health-service trainees currently providing care at a large VA health care system in the southeastern United States. Invitations to participate were extended to all social work interns, pre-doctoral clinical psychology interns, and mental health pharmacy students (n = 16), resulting in a total response rate of 81%.

Measures

The study asked student trainees to rate a series of statements related to their own competency in treating veterans diagnosed with SUDs, ability to complete a biopsychosocial-spiritual assessment of SUD, and ability to make appropriate referrals for veterans with SUDs on a scale from (1) strongly disagree to (4) strongly agree. Example items included: “I am comfortable working with Veterans diagnosed with substance use disorders” and “The VA provides comprehensive training in treating substance use disorders.” Items were examined independently from each other.

Procedure

As in Study 1, Study 2 collected data as part of a quality improvement project in the local VA Health Care System. Student trainees were invited to attend a 2-hour didactic seminar on integrated care approaches for the assessment and treatment of veterans diagnosed SUDs. Seminar content aimed to address components of the substance use disorder counseling competency framework put forth by SAHMSA. Specifically, the seminar aimed to teach trainees how to systematically assess and diagnose SUDs and create case formulations based on information gathered. The seminar included several components including lecture, facilitated discussion, and role play of effective SUD screening and assessment. A licensed clinical psychologist and clinical pharmacist with expertise in SUD facilitated learning. Objectives for the training were to (a) increase trainees’ self-efficacy to treat and conduct a psychosocial-spiritual assessment for SUD and (b) increase trainees’ awareness of the role played by other disciplines within an integrated care team. A brief overview of the topics covered in the training is shown in Table 3.

Table 3.

Outline for a Single Two-Hour Multidisciplinary Didactic Seminar on Biopsychosocial-spiritual Assessment of Veterans with SUD

Modules	Content Covered
The (multidisciplinary) MH Clinician and SUD care	Clinical Beliefs about SUD care
	• Helpful vs. harmful beliefs
	• Impact of clinician beliefs
	• How to be mindful of beliefs about SUD care
	Exercise: Notice and write down judgements about SUD care
Clinical assessment of SUD: Basics	DSM-5 SUD criteria
	• Review of symptoms and criteria for mild, moderate, and severe diagnoses
	Measurement- Based Care of SUD
	• VA-based measured care of veterans with SUD
	• Brief Addiction Monitor (BAM-R; Cacciola, 2013)
	• Alcohol use disorder identification test (AUDIT; Saunders et al., 1993)
	Clinical Interview Basics for SUD
	• SCID-5-CV (First, et al, 2016)
	Exercise: Watch mock clinical interview for SUD between training leaders and provide feedback
A Conceptual Model of SUD: The Biopsychosocial-spiritual model	Define Conceptual Models
	• Definition:
	- Starts with the health care problem, identifies factors related to the problem, attempts to explain how the factors interact to initiate, maintain, or worsen the problem
	• Go over examples of different conceptual models
	Examine the Biopsychosocial-Spiritual Model for SUD
	• BIO: traditional medical factors
	• PSYCHO: psychological factors
	• SOCIAL: societal and system factors
	• SPIRITUAL: understanding and meaning making of non-physical aspects of life
	Exercise: Use case examples to practice using the biopsychosocial-spiritual model of SUD
Putting it all together: Comprehensive intake, treatment planning, and referral	The biopsychosocial-spiritual intake for SUD
	• Discussion:
	- What barriers do you see to doing a comprehensive intake?
	- How can you prioritize with limited time?
	- What areas do you foresee being most difficult for you?
	- What areas has your training prepared you best to assess?
	Points for referral and consultation
	• Discussion:
	- What barriers do you see to referral and consultation?
	- What past experience do you have with referral and consultation?
	Potential Interventions and Approaches
	• Motivational Interviewing
	• Motivational Enhancement Therapy
	• Medication Assisted Therapy or Psychiatric Med Management
	• Contingency Management (abstinence AND attendance) -
	- Abstinence: Marijuana, Cocaine/Crack, Amphetamines
	- Attendance: Anyone taking vivitrol (Alcohol, Opioids)
	• Cognitive Behavioral Therapy for SUD
	• Acceptance and Commitment Therapy
	• Behavioral activation

Trainees completed the above self-report measure twice: once, in person, immediately prior to the training and once, via Qualtrics, two weeks following the training, to examine changes in self-efficacy. Given that the study collected data as part of a QI project, and to preserve student anonymity, the study assessed pre- and post-training data between subjects. Paired samples t-tests were conducted, using IBM SPSS 27, to investigate changes in average self-report item scores pre- and post-training.

Results

Analyses revealed significant post-training increases in self-efficacy to treat, assess, and make referrals for veterans diagnosed with SUDs. Specifically, respondents reported increased self-efficacy in completing a biopsychosocial-spiritual assessment of SUD (t = 2.47, p < .05 ) and an increased understanding of the roles of other professionals within an interdisciplinary SUD treatment team (t = 2.14, p < .05 ). Results from all paired samples t-tests examining pre- and post-intervention responses are detailed in Table 4.

Table 4.

Dependent Samples t-tests: Comparing Pre- and Post-Training Scores for VA Trainees (N=13).

Item	Pre-Training	Post-Training	t(22)	p
	M (SD)	M (SD)
I am confident in treating SUDs	1.9 (0.9)	2.5 (1.0)	1.34	.10
I am confident in my ability to conduct a basic assessment of SUDs	2.2 (0.9)	3.0 (1.0)	1.58	.07
I have a good understanding of the role of other health disciplines in treating SUDs	2.3 (0.8)	3.2 (0.8)	2.47	.017 *
I know how to conduct a biopsychosocial-spiritual assessment for SUDs	2.0 (1.0)	3.2 (1.2)	2.14	.03 *
I can confidently make referrals for Veterans diagnosed with substance use disorders.	2.4 (0.9)	2.8 (0.9)	0.71	0.25

^*p<.05

Discussion

SUDs are an ongoing public health crisis in the U.S. and a large body of research indicates a critical need for increased training in SUD treatment and research for trainees in health-service disciplines. Though significant efforts have been made in recent years, SUD training remains lacking. The present manuscript proposed that the VA health care system is in an excellent position, as the largest trainer and employer of psychologists, and a major employer of other heal-service disciplines, in the U.S. to help fill this gap in training for student trainees. Additionally, we argue that large-scale feasibility studies are a necessary next step toward widespread implementation of such training programs across the VA health care system. To this end, we conducted two pilot studies aimed at examining the feasibility of implementing supplementary SUD training for health service trainees at a local VA Health Care System.

In pilot study 1, current health-service providers in psychology, social work, pharmacy, and psychiatry provided self-report data on the feasibility of, and demand for, a supplemental training program in SUD assessment and treatment for VA student trainees. Overall, results suggested that providers were supportive of efforts to implement weekly or monthly supplemental SUD training and believed such training is needed, particularly for trainees interested in a VA career. Results also showed no difference in average provider responses, between disciplines, to items assessing self-efficacy to treat and supervise SUD cases, demand for additional SUD training, and willingness to allow trainees to participate in such training. However, these non-significant findings may be a function of the small number of providers sampled.

Pilot study 2 examined the feasibility of a single two-hour interdisciplinary training in integrated care for veterans diagnosed with SUDs. When the study compared scores on a self-report assessment taken pre- and post-training, results suggested that the aims of the training were achieved: trainees reported significant increases in their self-efficacy to complete a biopsychosocial-spiritual assessment of SUD and understanding of the role complimentary disciplines play in the treatment of SUD. This finding, paired with results from pilot study 1, suggest that implementing regular didactic seminars on different aspects of integrated care for SUDs may be a feasible approach to training health service professionals within the VA health care system. Future studies should aim to determine the number and frequency of seminars necessary to provide adequate training in evidence-based care for SUDs.

The results from the above pilot studies should be considered in light of several limitations. First, results from both studies represent a small sampling of providers and trainees from a single VA health care system. Self-efficacy to treat SUDs, supervise trainees with SUD cases, and demand for additional training are likely to differ between VA health care systems. Second, our examination of the feasibility of the single 2-hour didactic training relied only on self-report measures from trainees. Relatedly, the study only included one group who received the didactic training and did not include a comparison group who received no training, thus limiting our ability to make confident inferences about its effectiveness. Third, our analyses included only single items. Though this is generally well accepted in feasibility studies, analyses of homogeneous scales containing at least three items may provide more reliable indicators of feasibility and efficacy. Last, our sample included a very small sample of medical providers such as psychiatrists and pharmacists. This is, in part, because there are proportionally fewer mental health medical providers in the VA Health Care System, when compared to psychologists and social workers.

With these limitations in mind, the present manuscript highlights the unique ability of the VA health care system to implement SUD training programs for trainees in psychology and related disciplines. The above pilot studies open the door for a multitude of possible future studies aimed at increasing access to SUD training for trainees within, and even outside of, the VA health care system. Specifically, related to Study 1, future studies should seek to survey a much larger number of VA providers across different geographic regions. As mentioned above, it is quite possible that provider responses, and attitudes toward supplemental SUD training, may differ between health care systems. Further, studies sampling a larger number of providers should continue to assess differences in attitudes toward SUD treatment and acceptability of an SUD training program across provider type (psychiatrists, pharmacists, social workers, etc.) Future studies may also include incentives for participation, in order to increase response rates.

Additionally, both Study 2 and the existing body of literature suggest that short-term supplemental training is effective at increasing both trainee and provider confidence in assessing and treating individuals diagnosed with SUDs. Future studies assessing the feasibility and effectiveness of such training programs should assess (1) participants self-reported increases in self-efficacy to treat individuals diagnosed with SUD and (2) objective reports of trainees’ ability to assess and treat individuals with SUD, over an extended period of time. Though it is outside of the scope of the current manuscript, a standardized training curriculum or a set of competencies on which trainees are to be evaluated is necessary in order to assess the success of supplemental SUD training programs.

Overall, the above results support the creation of additional feasibility, implementation, and efficacy studies of supplemental SUD training programs for VA health service trainees. Successful implementation of such programs has the potential to deliver comprehensive SUD training to a large number of trainees, across disciplines, thus helping to alleviate the increasingly critical SUD provider shortage for both veterans and civilians.

Highlights.

• The VA Healthcare System is well positioned to address the SUD training gap

• VA healthcare providers are generally in favor of SUD training for VA trainees

• Supplemental multidisciplinary SUD trainings may be effective for VA trainees

• Large scale feasibility studies of supplemental SUD training are necessary