**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration**

**Center for Substance Abuse Treatment**

**Request for Applications (RFA) No. TI 03-009**

### Cooperative Agreements for 

**Screening, Brief Intervention, Referral and Treatment**

**Short Title: SBIRT**

# Part I- Programmatic Guidance

**Receipt Date: July 2, 2003**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Charles G. Curie, M.A.,
A.C.S.W.

Director, Center for Substance Abuse Treatment Administrator

Substance Abuse and Mental Health Substance Abuse and Mental Health

Services Administration Services Administration

Date of Issuance: May 2003

Catalog of Federal Domestic Assistance (CFDA) No. 93.243

Authority: Section: 509 of the Public Health Service Act, as amended and
subject to the availability of funds

**Table of Contents**

\[Note to Applicants: To prepare a complete application, "Part II --
General Policies and Procedures Applicable to all SAMHSA Applications
for Discretionary Grants and Cooperative Agreements," must be used in
conjunction with this document, "Part I - Programmatic Guidance."\]

Agency\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...........\...\...\...\...\...\...\...\...\.......\...\...\...\...\...
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Purpose of this
Announcement\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......\...\...\...\...\...\...\............\...
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Who Can
Apply\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............
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Application
Kit\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............
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How to Get an Application
Kit\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..............\...
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Where to Send the
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..............\...
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Application Due
Date\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..............\...
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How to Get
Help\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............
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Cooperative
Agreements\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............
6

Award
Criteria\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............\...
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Post Award
Requirements\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............
8

Program
Overview\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\............\...
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What to Include in Your
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..............
19

Face Page

Abstract

Table of Contents

Budget Form

Project Narrative and Supporting Documentation

Appendices

Assurances

Certifications

Disclosure of Lobbying Activities

Checklist

Project Narrative -- Sections A through
D\...\...............\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
21

Section A: Establishing Need

Section B: SBIRT Implementation and Systems Change

Section C: Project Organization, Management, and Staffing

Section D: Data Collection, Monitoring, and Reporting

Confidentiality and SAMHSA Participant Protection
(SPP)..................................... 26

Special Considerations and Requirements
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29

Appendices

Appendix A- Resources for Implementing Screening, Brief Intervention,
Referral and Brief

Treatment (SBIRT)
......................................................................................
30

Appendix B- CSAT's GPRA
Strategy..............................................................
54

Appendix C- CSAT's GPRA Core Client Outcomes
............................................ 60

Appendix D- References and
Resources............................................................ 70

[]{.mark}

**[Agency]{.underline}**

Department of Health and Human Services (DHHS), Substance Abuse and
Mental Health Services Administration

**[Purpose of this Announcement]{.underline}**

The Substance Abuse and Mental Health Services Administration (SAMHSA),
Center for Substance Abuse Treatment (CSAT) is accepting applications
for fiscal year (FY) 2003 cooperative agreements to expand and enhance
State substance abuse treatment service systems by:

-   expanding the State's continuum of care to include screening, brief
    intervention, referral, and brief treatment (SBIRT) in general
    medical and other community settings (e.g., community health
    centers, school-base health clinics and student assistance programs,
    occupational health clinics, hospitals, emergency departments);

-   supporting clinically appropriate treatment services for
    nondependent substance users (i.e., persons with a Substance Abuse
    Disorder diagnosis[^1]) as well as for dependent substance users
    (i.e., persons with a Substance Dependence Disorder diagnosis);

-   improving linkages among community agencies performing SBIRT and
    specialist substance abuse treatment agencies; and

-   identifying systems and policy changes to increase access to
    treatment in generalist and specialist settings.

It is expected that approximately \$22 million will be available for an
estimated 7 State awards in FY 2003. The average annual award will range
from \$2,500,000 to \$3,500,000 in total costs (direct and indirect).
The State can choose to implement the project in as many sub-recipient
communities[^2] as the State wishes. For each sub-recipient community
chosen, the State must demonstrate need and potential for systems change
to rapidly initiate the SBIRT approach. Each sub-recipient community
must receive sufficient funds to enable the State to document an impact
using the SBIRT performance targets.

Cost sharing is not required in this program.

Applications with proposed budgets that exceed \$3.5 million will be
returned without review.

Awards may be requested for up to 5 years.

Annual continuation awards will depend on the availability of funds,
progress achieved and compliance with the Government Performance and
Results Act (GPRA) requirements. Financial incentives and reductions
based on performance will be built into the program monitoring and
continuation application process. States that can meet or exceed targets
may be eligible to receive financial incentives to expand their effort
to other communities. States that cannot meet their targets or
demonstrate problems in implementation may receive no or reduced
continuation funding.

![](media/image1.wmf){width="9.305555555555556e-2in"
height="9.305555555555556e-2in"}**[Who Can Apply?]{.underline}**

All States, Territories, and Federally recognized Indian tribes are
eligible to apply but the applicant must be the immediate Office of the
Governor of States (for Territories and Indian tribes, the Office of the
Chief Executive Officer). The Governor must sign the application.
**Applications not signed by the Governor are not eligible and will not
be reviewed.** State-level agencies are not considered to be part of the
immediate Office of the Governor and are not eligible to apply. This
means, for example, that the State Substance Abuse Authority (SSA) or
other State-level agencies within the Executive Branch cannot apply
independently. SAMHSA has limited the eligibility to Governors of States
because the immediate Office of the Governor has the greatest potential
to provide the multi-agency leadership needed to develop the State's
treatment service systems to increase the State's capacity to provide
accessible, effective, screening, brief intervention, referral and brief
treatment services to persons with Substance Use Disorders. States that
have already begun to develop such integrated systems, stressing early
intervention for persons at risk of dependence, are especially
encouraged to apply.

The Governor will designate a lead official to be Program Director for
the cooperative agreement. That individual may be, but is not required
to be, part of the SSA. However, the services to be provided through
this cooperative agreement program are to be integrated into the current
system of care. Therefore, SAMHSA expects that the SSA will be involved
in the project.

All direct providers of treatment services involved in the proposed
system of care must be in compliance with all local, city, county and
State licensing and accreditation/certification requirements. Include
appropriate Licensure/Accreditation/Certification documentation (or
documentation supporting why the local/State government does not require
Licensure/Accreditation/Certification) in **Appendix 1** of your
application.

Any direct providers of services involved in the proposed continuum of
care must also have been providing services for a minimum of two years
prior to the date of this application. A list of the service providers
and two-year experience documentation must also be provided in
**Appendix 1** of your application. The list should provide a break out
for each sub-recipient community.

**[Application Kit]{.underline}**

SAMHSA application kits include the following:

**1. PHS 5161-1 -** *(revised July 2000) **-*** Includes the Face Page,
Budget forms, Assurances, Certifications and Checklist.

**2. PART I** - of the Program Announcement (PA) or Request for
Applications (RFA) includes instructions for the specific grant or
cooperative agreement application. This document is Part I.

**3. PART II** - of the Program Announcement (PA) or Request for
Applications (RFA)- provides general guidance and policies for SAMHSA
grant applications. The policies in Part II that apply to this program
are listed in this document under "Special Considerations and
Requirements."

**You must use all of the above documents of the kit in completing your
application.**

![](media/image1.wmf){width="9.305555555555556e-2in"
height="9.305555555555556e-2in"}**[How to Get an Application
Kit:]{.underline}**

-   Call: ***National Clearinghouse for Alcohol and Drug Information
    (NCADI) 1-800-729-6686***, or

-   Download **Part I, Part II and the PHS 5161-1** of the application
    kit from the SAMHSA web site at
    [www.samhsa.gov.](http://www.SAMHSA.gov./) Click on "Grant
    Opportunities" and then "Current Grant Funding Opportunities."

    **[Where to Send the Application]{.underline}**

    Send the original and 2 copies of your cooperative agreement
    application to:

    **SAMHSA Programs**

    Mr. Ray Lucero

    Review Branch/SAMHSA

    Parklawn Building/Room 17-89

    5600 Fishers lane

    Rockville MD 20857

    \*\*Change the zip code to 20852 if you use express mail or courier
    service.

**All applications MUST be sent via a recognized commercial or
governmental carrier. Hand carried applications will not be accepted.
Faxed or e-mailed applications will not be accepted. You will be
notified by letter that your application has been received.**

Be sure to type RFA No. TI 03-009, SBIRT in Item Number 10 on the face
page of the application form.

**[Application Due Date]{.underline}**

Your application must be [received]{.underline} by July 2, 2003.

Applications received after this date must have a proof-of-mailing date
from the carrier before

June 25, 2003 ***.***

Private metered postmarks [are not]{.underline} acceptable as proof of
timely mailing. Late applications will be returned without review.

**[How to Get Help]{.underline}**

**For questions on program issues, contact:**

Herman I. Diesenhaus, Ph.D.

SAMHSA/CSAT

5600 Fishers Lane/ Rockwall II, 7^th^ floor

Rockville, MD 20857

\(301\) 443***-***6575

E-Mail: hdiesenh@samhsa.gov

#### Or

Jean Donaldson, M.A.

SAMHSA/CSAT

5600 Fishers Lane/ Rockwall II, 7^th^ floor

Rockville, MD 20857

\(301\) 443***-***6259

E-Mail: jdonalds@samhsa.gov

For questions on grants management issues, contact:

Stephan Hudak

Division of Grants Management

SAMHSA/OPS

5600 Fishers Lane/ Rockwall II, 6^th^ floor

Rockville, MD 20857

\(301\) 443-9666

E-Mail: shudak@samhsa.gov

**[Cooperative Agreements]{.underline}**

Awards are being made as cooperative agreements because substantial
Federal staff involvement is required in the funded project.

**Grantees Must:**

-   Comply with the terms and conditions of the cooperative agreement
    award.

-   Agree to provide SAMHSA with data required for the Government
    Performance and Results Act (GPRA).

-   Collaborate with CSAT staff in project implementation and
    monitoring.

-   Organize and conduct regular meetings of the project's Policy
    Steering Committee (PSC).

-   Select 15 to 20 representatives from State and community resources
    to serve on the PSC.

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-   Implement and monitor activities of the cooperative agreement
    project, including accountability for sub-recipients' service
    delivery.

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-   Collect, evaluate, and report statewide treatment project and GPRA
    data.

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-   Respond to requests for program-related data.

-   Document intended and actual systemic changes resulting from the
    project's activities.

SAMHSA Staff will:

-   Collaborate in selection of PSC members, review and approve final
    membership.

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-   Work collaboratively with the Governor's office, project staff, and
    PSC members to finalize the plans for a comprehensive project
    management plan.

-   Provide best practice program information, resource materials, and
    technical assistance, (e.g., examples of model programs, financing
    strategies and benefit designs, screening and assessment tools and
    protocols) to help grantees identify, select, and replicate
    science-based practices for implementing SBIRT.

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-   Provide guidance on how to assess resource allocation strategies in
    order to re-direct treatment resources toward an emphasis on
    nondependent users.

-   Review and approve the comprehensive Project Implementation Plan to
    be submitted by the end of the third month for release of funds for
    Phase II and III implementation.

-   Review and approve sub-recipient contracts and awards.

-   Actively participate in PSC discussions.

-   Work cooperatively with the Governor's office to make the transition
    from the cooperative agreement to State and local control and to
    sustain the system changes achieved by the project.

    **The Policy Steering Committee will:**

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-   Provide strategic policy and operational advice on the SBIRT project
    to the Governor as well as advise on integrating SBIRT into the
    existing system of care and on policies, as appropriate.

-   Consist of 15 to 20 members and a chair, to be appointed by the
    Governor.

-   Represent the Office of the Governor and diverse stakeholders in the
    State, including, for example, representatives from:

    -   Relevant State executive branch agencies (including the SSA),
        legislative committees, and judicial branch agencies

    -   Community specialist treatment organizations

    -   General and specialist healthcare organizations (e.g., Federally
        Qualified Community Health Centers, hospitals, family practice
        clinics, emergency departments, ob-gyn clinics)

    -   Occupational Health Clinics and Employee Assistance Programs or
        Human Resources Departments

    -   Student Health Centers and Student Assistance Programs

    -   Unions and Member Assistance Programs

    -   Professional and trade associations

    -   Recovery community organizations

    -   Community coalitions

    -   Training agencies and universities

    -   Employers and business coalitions

    -   Insurers and Managed Care Organizations

-   Hold the initial meeting within 60 days of award and continue to
    meet once a month for the first year and quarterly in subsequent
    years.

-   Coordinate with other State agencies, commissions, and offices
    (including the SSA) as appropriate.

    **[Award Criteria]{.underline}**

    Decisions to fund a cooperative agreement are based on:

    1\. The strengths and weaknesses of the application as identified by
    the Peer Review Committee and approved by the Center for Substance
    Abuse Treatment National Advisory Council.

2\. Availability of funds.

3\. **Ability to move rapidly to award sub-recipient funds and to
initiate SBIRT:**

CSAT places considerable emphasis on rapid award of Federal funds by the
State and implementation of individual projects by the sub-recipients.
Preference will be given to States that demonstrate that they have the
ability to move quickly (i.e., within 4 months) to allocate
sub-recipient funds to initiate SBIRT and to States that have already
established mechanisms for carrying out screening and brief
interventions. Such screening and brief interventions may be offered
either as treatment activities (e.g., pre-treatment, outreach or early
intervention) or as indicated prevention efforts. Evidence that the
State meets these criteria (e.g., copies of existing contracts, requests
for proposals, memoranda of agreement) should be included in **Appendix
2** of the application.

4\. Funding preference will also be given to states whose past
performance demonstrates rapid award of CSAT grant funds. Documentation
of past performance demonstrating rapid deployment of CSAT grant funds
must be included in application **Appendix 2**.

5\. **Need.** When determining the funding priority among those States
with scored applications, additional consideration will be given to the
size of the difference between need for treatment and capacity to
provide treatment in the States and sub-recipient communities. The
National Household Survey on Drug Abuse (NHSDA)[^3] now is able to
generate statewide estimates. (Epstein, 2002; OAS, 2002; Wright, 2002)
Those estimates will be considered, along with other State determined
indices of the size of the difference between treatment need/capacity
Statewide and in local communities as provided in the narrative.

6\. **Program Costs.** Per person costs per treatment admission will be
taken into consideration. The following are acceptable ranges by
treatment modality:

-   Screening/Brief Intervention/Brief Treatment/Outreach/Pretreatment
    Services - \$200 to \$1,200

-   Outpatient (Non-Methadone) - \$1,000 to \$5,000

-   Outpatient (Methadone) - \$1,500 to \$8,000

-   Residential - \$3,000 to \$10,000

    The grantee will be expected to compute per person costs for
    treatment provided under this initiative. Per person treatment costs
    for each modality should be computed by dividing the number of
    persons served in each modality by the amount of the project budget
    used to fund that program component after subtracting out the costs
    of required data collection and submission. The State will report
    these costs as well as provide a detailed explanation of how they
    were computed in their quarterly reports.

7\. In its award decision-making process, SAMHSA will consider
collaboration with applicants for the National Institutes of Health
(NIH) program announcement, PA-02-168: Implementation Of Screening And
Brief Interventions For Alcohol-Related Problems, jointly issued by the
National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the
National Institute on Drug Abuse (NIDA). The PA can be accessed at
[http://grants.nih.gov/
grants/](http://grants.nih.gov/ grants/)[guide/pa-files/PA-02-168.html]{.underline}.
Documentation of the proposed collaboration should be included in
**Appendix 3** of the application.

**[Post Award Requirements]{.underline}**

1\. Grantees must submit quarterly and annual progress reports and
applications for continued funding near the end of each year. Specific
submission dates, instructions, and format will be provided by CSAT.
These reports will be one part of the SBIRT-specific evaluation.
Grantees will be held accountable for the information provided in the
application as it relates to the number of persons to be served with the
award funds. CSAT program officials will take into consideration a
grantee's progress in meeting goals and objectives, and the grantee's
failures and corresponding strategy for overcoming these problems when
making an annual recommendation as to continuation of the cooperative
agreement, and amount of any continuation award. A grantee's failure to
meet its goals and objectives may result in reduction or loss of an
award.

2\. Grantees are required to attend [and must budget]{.underline} for
two technical assistance meetings in the first year and one in each of
the remaining years. A minimum of four persons from each grantee is
expected to attend the technical assistance meetings. Individuals who
are required to attend technical assistance meetings are the project
director, the individual responsible for overseeing clinical services in
contracted providers participating in SBIRT, and the individual
responsible for project GPRA reporting; the GPO will identify the fourth
person once the award is finalized.

Additional meetings will be convened over the course of the project to
bring together project leadership from each State (e.g., the Policy
Steering Committee Chairs, Project Directors) to share experiences,
discuss implementation, policy change, financing, and reporting issues
and to compare models in order to bring this program to full scale
nationally, both in other States and other communities within the
participating States. The expenses for these meetings will be borne by
SAMHSA/CSAT. Grantee meetings will normally be held in the Washington,
DC, metropolitan area.

3\. Grantees must develop a systematic approach to carrying out and
paying for (1) screening for Substance Use Disorders (SUDs) and
providing brief interventions (1 to 5 sessions), and brief treatment (up
to 12 sessions) and appropriate follow up and monitoring for individuals
who use drugs but are not yet dependent in healthcare and other
appropriate community settings; and (2) referral, when indicated for
those who are dependent or nondependent and nonresponsive to an initial
brief intervention, for assessment, treatment and rehabilitation, and
appropriate follow up and monitoring in specialist substance abuse
treatment settings.

4\. Grantees must commit to and report performance against targets for
(1) reducing drug use by patients receiving treatment through the SBIRT
project; (2) increasing the number of persons with SUDs who receive
treatment in each sub-recipient community; (3) increasing the number of
community settings where SBIRT services are provided, and (4) providing
treatment services within approved cost parameters for a given treatment
modality.

> 5\. Community service sites doing SBIRT may not use cooperative
> agreement funds to provide other health or social services.

6\. Funds may not be used to provide services to incarcerated
populations (defined as those persons in jail, prison, detention
facilities or in custody where they are not free to move about in the
community).

7\. During the course of the project, grantees are responsible for
ensuring that all direct service providers participating in the project
continue to meet all local, city, county, and State licensing,
certification or accreditation requirements as well as project reporting
requirements (i.e., GPRA client monitoring).

8\. Grantees must inform the SAMHSA/CSAT Project Officer of any
publications based on the project.

9\. Grantees must provide information needed by SAMHSA to comply with
the Government Performance and Results Act (GPRA) reporting
requirements. GPRA mandates accountability and performance-based
management by Federal agencies, focusing on results or outcomes in
evaluating the effectiveness of Federal activities and on measuring
progress toward achieving national goals and objectives. In using up to
10% of their awards for the collection and reporting of GPRA data, the
grantee must ensure that all sub-recipients meet the GPRA requirements.
GPRA measures required, in addition to the targets specified in Number 4
above, are included in Appendix C of this document.

10\. Grantees must submit a final report. Specific submission dates,
instructions, and format will be provided by CSAT. The final report must
summarize information from the quarterly reports and describe the
accomplishments of the project and planned next steps for sustaining the
systems and service changes developed during the cooperative agreement
period.

**[Program Overview]{.underline}**

**[Background]{.underline}**

For demand reduction, the 2002 National Drug Control Strategy (NDCS)
emphasizes (1) preventing initiation of drug use for those who have not
initiated illegal drug use, (2) intervening early with those who have
initiated illegal drug use but are not yet dependent, and (3) improving
treatment for those who are dependent on drugs. (ONDCP, 2003)

Federal programs, including those operated by SAMHSA/CSAT, have tended
to emphasize either universal prevention strategies aimed at those who
have never initiated use (Haggerty and Mrazek, 1993) or specialist
treatment for those who are dependent (Gerstein and Harwood, 1990).
Little attention has been paid to the large group of individuals who use
drugs but are not, or not yet, dependent and who could successfully
reduce drug use through "early intervention." (Klitzner et al., 1992;
Fleming, 2002). There is an emerging body of research and clinical
experience that supports use of the SBIRT approach as providing
effective early intervention for those persons who are nondependent
users of illicit drugs (e.g., Barry 1999; Bernstein et. al, 1997; Zweben
and Fleming, 1999; Roffman, 1999; Broskowski and Smith, 2001; Heather,
2001; Dennis, et al., 2002; Babor, et al., 2002; Blow, 1998; Fleming
2002).

Because the specialist treatment system alone cannot address the needs
of all those persons diagnosed with either a Substance Abuse or
Dependence Disorder, new program efforts are needed to provide funding
to introduce or expand screening and brief intervention and brief
treatment for nondependent users (i.e., those persons diagnosed with a
Substance Abuse Disorder). These new program efforts should be initiated
in primary health care centers and other generalist community settings
(e.g., trauma centers/emergency rooms, ob-gyn clinics, occupational
medicine programs, schools with student assistance programs and student
health services, welfare offices, and worksites with occupational health
clinics and employee assistance programs).[^4]

The SBIRT initiative is intended to assist States in redesigning their
current continuum of care to implement a comprehensive system that
effectively identifies, treats, and provides continued management
support for persons with substance use problems in both community and
specialist settings as required by their clinical status.

For purposes of this announcement, CSAT will not require a specific
protocol for carrying out screening, assessment, brief intervention,
brief treatment, and referral or require a specific number of sessions
for either brief treatment or brief intervention. For this cooperative
agreement program, the applicant will be required to describe their
current protocol, identify which methods of screening, placement, brief
intervention, referral, assessment, and brief treatment they will be
using, and provide a justification for their procedures (including a
discussion of the evidence for effectiveness). To enable cost
determinations under this RFA, brief interventions are considered to be
1 to 5 sessions in length and brief treatment to be 6 to 12 sessions.

Building on prior research done under the auspices of the National
Institute on Drug Abuse (Roffman et al., 1988; Stephens et al., 1994;
Karroll, 1998; NIDA, 1999; Stephens et al., 2000), CSAT has recently
supported development and evaluation of manualized brief intervention
and brief treatment strategies for adolescents and adults with marijuana
use disorders that can be utilized. (Godley et al, 2001; Copeland et
al., 2001; Sample and Kadden, 2001; Clark et al., 2002; White and
Dennis, 2002; Diamond et. al., 2002; Stephens et al., 2002)

Additional background and references for protocols and methods for
carrying out activities required to implement the SBIRT program can be
found in Appendices A and D.

##### Program Requirements

States must utilize at least ninety percent (90%) of their proposed
budget for the sub-recipient communities to provide services and report
performance. Up to ten percent (10%) of the award will be available to
the State for activities needed to carry out (1) project administration,
(2) policy and systems change, (3) training and technical assistance,
(4) monitoring sub-recipients' service delivery and reporting, and (5)
reporting.

States will be required to devote the majority (75%) of their
cooperative agreement services funds to expand and enhance their systems
to carry out screening and brief intervention for drug use disorders in
community agencies and the referral linkages to specialist treatment
agencies.

While the focus of this initiative is on screening and brief
intervention for nondependent users in community settings, it is
critical to ensure that appropriate services are available to treat
persons who are screened and for whom brief interventions in community
settings are not appropriate. Accordingly, States may use a portion (up
to 15%) of the cooperative agreement services funds to expand services
in the other specialty modalities (brief treatment, outreach/
pretreatment services, outpatient (non-methadone), outpatient
(methadone), and residential) for dependent persons who require more
intensive and prolonged traditional treatments for a Substance Use
Disorder.

States that do not seek to utilize part of this funding to close
existing gaps in their treatment continuum will need to provide evidence
to SAMHSA/CSAT that the State's system of treatment in each
sub-recipient community already provides sufficient capacity and
services (modalities) for all nondependent and dependent persons who
will be identified through the new SBIRT programs initiated under this
award.

The State may choose to hold back 10% of the funds devoted to service
provision for reporting or require the sub-recipients to use 10% of
their allocations for reporting.

**[Systems Change Considerations.]{.underline}** To implement policies
that will successfully attract and effectively treat individuals with
Substance Use Disorders, the State will need to demonstrate that its
systems change plan reflects an understanding of the general reasons
that people do not seek services, as well as recognize how these general
barriers that prevent individuals from successfully accessing the
clinically appropriate level of care may apply to their State's system
of care.

A substantial body of research is related to barriers to access to
health care in general, and treatment for Substance Use Disorders, and
there are various approaches to identifying and classifying barriers
(IOM, 1990; Fiorentine, 1993; Schmidt and Weisner, 1999; PLNP, 2000).
Less is known about those enabling factors that increase help-seeking
and access (Grant, 1997; Weisner and Schmidt, 2001; Fortney and Booth,
2001).

Of major concern is the numerous studies documenting the failure of
primary care physicians to identify persons at risk of or already
experiencing a Substance Use Disorder and initiating the appropriate
referral for evaluation and treatment. (Saitz et al., 1997; Hack and
Adger, 2002; CASA, 2002) Such identification in mainstream medical care
settings is necessary because perceived illness severity and stigma also
may act as a barrier to treatment.

Addiction policy and service provision in States occur within the
context of both general health systems and financing arrangements and
carved out specialty prevention and treatment systems and financing
arrangements. (Denmeade and Rouse, 1991) The implications of these
arrangements in your State for the diffusion of SBIRT necessitate
consideration in project formulation and implementation. Financial
accessibility implies that the cost of the service is reasonable and
there is no disincentive to use needed services because of their costs
or the method of reimbursement. However, many studies identify barriers
due to the manner in which substance abuse treatment is financed, such
as a lack of parity with physical illness in commercial and public
insurance leading to high co-pays and restrictions of payment for
diagnostic assessments; lack of coverage for nontraditional specialist
treatment modalities (e.g., residential therapeutic communities) or
payment for screening services in emergency departments and primary care
settings (Reader and Sullivan, 1992; Buck and Umland, 1997; Sing et al.,
1998; Rivara et al., 2001).

Another often cited barrier is the multiple, separate, fragmenting
Federal, State, local, and private funding streams operated by
frequently uncoordinated agencies[^5] that have different coverage
policies, codes, and procedures for treatment modalities and ancillary
services, different eligibility criteria for providers and patients,
different reporting requirements, different placement criteria, and
inconsistent benefit designs (Gerstein and Harwood, 1990; Schlessinger
et al., 1991; Horgan and Larson. 1998; Moss, 1998; Johnson, 1999).

Eliminating these barriers through systems and policy change is a major
emphasis of this program (e.g., Pauly, 1991; Libertoff, 1999; Zarkin et
al., 1995). Integrating SBIRT in community settings will require the
State to conduct an analysis of the inhibiting and facilitating policies
and practices in order to remove the institutionalized barriers and
describe how the State will facilitate access to clinically appropriate
treatment in the expanded continuum of care, starting with screening for
Substance Use Disorders in community settings.

##### Program Design Considerations. Participating States will be expected to adopt and implement a treatment system that includes all of the following components: 

-   [Screening, Identification, Brief Intervention, Referral, and Brief
    Treatment.]{.underline} This involves implementation of a system
    within community and specialist settings that screens for and
    identifies individuals with substance use-related problems.
    Depending on the level of problems identified, the system either
    provides for a brief intervention within the generalist setting,
    when appropriate, or motivates and refers the individual with a high
    level of problems and probable diagnosis of Substance Dependence
    Disorder to the specialist setting for assessment and diagnosis and
    either brief or long-term treatment. This includes training in
    self-management and involvement in mutual help groups, as
    appropriate. (Workgroup on Substance Abuse Self-Help Organizations,
    2003)

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-   [Sequential Assessment and Diagnosis]{.underline}. This involves
    having a system in place that assures that individuals who screen
    positive for substance use-related problems are appropriately
    assessed for the presence of Substance Use Disorders and co-morbid
    physical and mental disorders so that a diagnosis is made, an
    initial treatment plan developed, and a referral is made to the
    clinically appropriate community or specialist treatment setting for
    implementation and revision as dictated by the person's clinical
    status.

-   [Treatment]{.underline}. This involves having a system in place that
    assures that individuals who are diagnosed with a Substance Use
    Disorder are provided an opportunity to undergo an integrated
    pharmacological and psychosocial treatment regimen in order to
    reduce or eliminate their harmful consumption and its adverse
    effects in the clinically appropriate community or specialist
    treatment setting. (NIDA, 2000) This includes training in
    self-management and involvement in mutual help groups, as
    appropriate.

-   [Continued Management Support]{.underline}. This involves having a
    system in place that assures that individuals who complete their
    formal treatment episode will receive long-term management support
    (care management) as appropriate for their level of disability and
    relapse potential in the clinically appropriate community or
    specialist treatment setting. This includes training in
    self-management and involvement in mutual help groups, as
    appropriate.[^6]

The focus of the SBIRT program is on that part of the continuum of care
that addresses treatment of Substance Use Disorders and not the
treatment of Substance Induced Disorders, namely Substance Intoxication
and Substance Withdrawal. The focus is on identifying the level of
substance use problems for stabilized individuals presenting in
community settings.

Patients manifesting signs of intoxication, withdrawal symptoms, and
other physical problems that require emergency care or urgent action
would be managed in other components of the generalist or specialist
treatment systems. While stabilization and detoxification may be
required for some persons presenting to community agencies, the
availability of treatment resources, financing mechanisms, and other
access barriers vary from those encountered in treating individuals who
do not require withdrawal and stabilization.

This variation is recognized in the differentiation of the levels and
settings of services for detoxification and rehabilitation in the latest
version of the American Society of Addiction Medicine (ASAM) Patient
Placement Criteria (ASAM PPC-2R, 2000; Gastfriend et al., 2000) and the
guidelines developed by the Evidence-Based Clinical Practice Guideline
Working Group for the Veterans Health Administration, and the Department
of Defense (2001).

##### Project Phases and Operations. There will be three phases to the project: project planning and start-up; operations; and phase-out.

***Phase I: Project Planning and Start-up***.

This phase is expected to last approximately six months, during which
CSAT will work collaboratively with the Governor's office, project
staff, and Policy Steering Committee members to finalize the plans for a
comprehensive project implementation and management plan spanning the
full project period (up to 5 years, as determined by progress made and
funding availability) and to initiate the activities. The start-up tasks
to be completed in this phase are, at a minimum:

-   selecting the members of the Policy Steering Committee (and
    subcommittees, if appropriate);

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-   developing a solid organizational structure that involves or enlists
    the participation of an appropriate array of service providers and
    funders required to serve the needs of alcohol and drug-involved
    individuals in the sub-recipient communities, representing the full
    spectrum of community and specialist services;

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-   refining the project management, reporting, quality improvement, and
    cost control mechanisms;

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-   refining the needs assessment and survey of existing system gaps and
    precisely identifying the target populations and communities to be
    served;

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-   refining the plan to provide training and technical assistance,
    including information about SBIRT methods, training for staff in the
    community and specialist settings in carrying out SBIRT, and
    technical assistance to the overall project and its sub-recipients;

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-   finalizing all necessary inter-agency agreements, contracts,
    sub-contracts, billing procedures and fiscal controls, reporting and
    monitoring procedures with the agency or agencies in the selected
    communities that will deliver services;

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-   introducing reporting instruments and obtaining baseline data
    covering existing levels of service, patient/client needs and
    program performance characteristics as well as training and
    technical assistance provided and received;

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-   developing a plan for garnering and sustaining necessary policy
    changes and resources required to continue the project following the
    period of Federal support;

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-   demonstrating that required resources not included in the Federal
    budget request are adequate and readily accessible;

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-   initiating service delivery in the expanded continuum of care in
    each sub-recipient target community, if required;

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-   establishing the mechanism for monitoring performance against
    targets for (1) reducing drug use by patients receiving treatment
    through the SBIRT project; (2) increasing the number of persons with
    SUDs who receive treatment in each sub-recipient community; (3)
    increasing the number of community settings where SBIRT services are
    provided; and (4) providing treatment services within approved cost
    parameters for each treatment modality; and

-   submitting an acceptable final Project Implementation Plan that
    includes specific objectives and milestones, implementation time
    frames and designation of staff responsible for accomplishing
    individual program objectives.

Release of funds for project implementation will be contingent on CSAT
approval of the Project Implementation Plan finalized during the initial
phase and submitted for approval by the end of the third month following
award. At the conclusion of Phase I, every component of the project
should be fully operational.

***Phase II: Operations***. This phase is expected to last approximately
four years and three months, during which period CSAT will work
collaboratively with the Governor's office, project staff, SSA, and
other relevant agencies, Policy Steering Committee members, and
sub-recipients to implement the project management, monitoring and
reporting, training, technical assistance to sub-recipients, and service
delivery activities. In Phase II, grantee will be responsible for these
activities:

-   Policy Steering Committee (and its subcommittees, if appropriate)
    operations, including regular meetings, monitoring project
    activities and achievements (viz., the specific objectives and
    milestones, implementation time frames and designation of staff in
    the Project Implementation Plan), and communications with the
    Governor;

-   determining the need for and providing the requisite training and
    technical assistance needed to achieve project goals;

-   project management, reporting, quality improvement, and cost
    control;

-   managing the continuation award process to the sub-recipients;

-   accomplishing and tracking systems change (i.e., overcoming funding
    and other resource barriers, policy changes, improving linkages
    among specialist and community agencies, providing training and
    technical assistance, carrying service delivery in the expanded
    continuum of care in each sub-recipient target community; and
    achieving the targets for (1) reducing drug use by patients
    receiving treatment through the SBIRT project; (2) increasing the
    number of persons with SUDs who receive treatment in each
    sub-recipient community; (3) increasing the number of community
    settings where SBIRT services are provided; and (4) providing
    treatment services within approved cost parameters for a given
    treatment modality; and

-   refining operations as barriers are encountered and lessons learned
    through feedback from the monitoring and reporting systems.

***Phase III: Phase-Out.*** During the final three months of the
cooperative agreement award, CSAT will work cooperatively with the
Governor's office, project staff, and Policy Steering Committee members,
and sub-recipients to make the transition from the cooperative agreement
to State and local control and to sustain the system changes achieved by
the project.

##### Data Collection, Monitoring, and Reporting. 

Grantees must provide information needed by SAMHSA to comply with the
Government Performance and Results Act (GPRA) reporting requirements.
GPRA mandates accountability and performance-based management by Federal
agencies, focusing on results or outcomes in assessing the effectiveness
of Federal activities and on measuring progress toward achieving
national goals and objectives. In allowing grantees to utilize a portion
of their awards for the collection and reporting of GPRA data, the
grantee must ensure that all sub-recipients meet the GPRA requirements.

Grantees must submit quarterly and annual progress reports and
applications for continued funding near the end of each year. Grantees
also must enter client level data as specified below on a continuous
basis[^7] throughout the life of the grant. Specific submission dates,
instructions, and format will be provided by CSAT. Grantees will be held
accountable for the target number to be served proposed in their grant
application and the number reported as having been served will be
compared to the target proposed in the application. When making an
annual recommendation as to continuation of the cooperative agreement,
and amount of any continuation award, CSAT program officials will take
into consideration a grantee's progress in meeting goals and objectives,
and the grantee's failures and corresponding strategy for overcoming
these problems. A grantee's failure to meet its goals and objectives may
result in reduction or loss of an award.

Applicants should carefully note that there are 4 categories of services
or combinations of services to be supported by these cooperative
agreement funds and each category has specific reporting requirements
with regards to GPRA. The following GPRA data collection methodology is
congruent with the existing outreach methodologies and other GPRA data
collection activities currently being employed by CSAT.

The four categories of services or combinations of services to be
provided to individuals include:

-   Screening Only

-   Screening and Brief Intervention

-   Screening and Brief Treatment

-   Screening and Other Treatment for Substance Use Disorders.

    The following are the reporting requirement for each category:

# [Screenings Only]{.underline}

**Aggregated Data**:

For clients who are screened and do not require any level of substance
abuse treatment services, the following will be required for each State
and/or each community, if applicable:

-   Aggregated counts (unduplicated) and demographic characteristics of
    persons screened for each quarter and to date;

-   Aggregated counts of the number and types of settings where SBIRT
    services are provided for each quarter and to date;

-   Aggregated counts (unduplicated) of the number of people with
    substance use disorders who receive treatment services for those
    disorders and the percentage of those in need of such treatment
    services for each quarter and to date;

This mandatory information is reported to CSAT via the grantees
quarterly report[^8].

**[Screening and Brief Intervention]{.underline}**:

For all clients that are screened and require brief intervention the
following must be collected and reported:

**Baseline Client Level Data**: Baseline (at screening) CSAT GPRA data
elements limited to the demographic, and substance use domains must be
collected on all clients in this category of service (see Appendix C,
items A1, B1, B2 and H)[^9]. This individual client level data will be
used to count unduplicated clients served. It is important that all
clients complete a tracking information sheet in the event they are
selected for follow-up.

This information must be reported via client level data entry on the
CSAT GPRA web-site at [www.csat-gpra.org](http://www.csat-gpra.org/), as
soon as OMB approves the data collection package. States will be able to
download data from this existing site for its own use.

**Follow-up Client Level Data**: For a **representative sample** of
clients in this category, who were screened and required brief
intervention, follow-up GPRA data limited to the substance use domain
(See Appendix C, items A1, B1, B2, H, I, and J) must be collected at 6
months after baseline and entered into the CSAT web based GPRA data
entry and reporting system. The sampling strategy will be designed by a
CSAT contractor with State and CSAT collaboration and the sample size
will be as small as possible, but sufficient so that the results can be
generalized to all of those who received brief intervention supported by
the cooperative agreement within the State. Grantees will be notified
which clients have been selected as part of the representative sample
and need to be located for follow-up via a web based notification
report. Grantees are expected to achieve a follow-up rate of at least
80% of those selected.

**Aggregated Data**: In the quarterly report, the State must also
provide data about the costs for the delivery of screening and brief
intervention, including the mean, median, and range of costs overall, by
facility type, and region and sub-recipient, if applicable. The State
must also discuss how such costs compare to the CSAT approved cost
parameters for screening and brief intervention and what efforts they
are undertaking to bring costs into line with those expected.

**[Screening and Brief Treatment or Screening and Other types of
Treatment for Substance Use Disorders:]{.underline}**

For all clients that are screened and require either brief treatment or
other treatment, the following must be collected and reported:

**Baseline Client Level Data:** Baseline (at screening) using all of the
CSAT GPRA data elements must be collected on all clients in this
category of service (see Appendix C, items A through J). This
information is reported into the CSAT GPRA web-site at
[www.csat-gpra.org](http://www.csat-gpra.org/). It is important that all
clients complete a tracking information sheet in the event they are
selected for follow-up.

**Follow-up Client Level Data:** For a **representative** sample of
clients in this category that were screened and required substance abuse
services beyond brief intervention, follow up data (all domains, see
Appendix C, Items A through J) will be to be collected at 6 months after
the initiation of substance abuse treatment services on a representative
sample. The sampling strategy will be designed by a CSAT contractor with
State and CSAT collaboration, and will be as small as possible, so that
the results can be generalized to all of those who received brief
intervention supported by the cooperative agreement within the State.
The system will determine which clients need to be follow-up via a web
notification report. These client level data are to be entered into the
CSAT GPRA data entry and reporting system.

**Aggregated Data:** In the quarterly report, the State must also
provide data about the costs for the delivery of screening and brief
treatment as well as all other treatment modalities supported by this
cooperative agreement including the mean, median, and range of costs
overall, by modality, facility type and region, and sub-recipient, if
applicable. The State must also discuss how such costs compare to the
CSAT approved cost parameters for screening and brief intervention and
what efforts they are undertaking to bring costs into line with those
expected.

Grantees must comply with GPRA data collection and reporting
requirements, including continuous reporting[^10] of progress in meeting
the targets proposed (in the application) for the number of persons to
be served and the collection of the specified CSAT GPRA Core Client
Outcomes at specified time points. Grantees are required to collect and
report client level data for the overall project and each sub-recipient
using the CSAT GPRA web based data reporting system. Appendix B contains
a detailed description of CSAT's GPRA strategy. Full baseline GPRA and
follow-up data are to be entered on line at
[www.csat-gpra.org](http://www.csat-gpra.org/). (CSAT will provide
Grantees with user names and passwords as well as data entry training).

CSAT GPRA requirements for this specific RFA include data collection and
real time reporting about cooperative agreement-supported service
recipients at baseline/intake, and 6 months after intake, as noted
above. Grantees are expected to collect individual level baseline GPRA
data on all persons served, (those who receive at least screening and
brief intervention), through the cooperative agreement on a minimum of
eighty percent (80%) of all clients in the representative sample.
Grantees also are required to submit specified aggregate data in
quarterly reports. Grantees should consider these requirements when
preparing the data collection, monitoring, and reporting budget section
of the application.

Funds may not be used to pay for incentives to induce clients to enter
treatment. However, a grantee or treatment provider may provide up to
\$20 or the equivalent (coupons, bus tokens, and vouchers) to clients as
an incentive to participate in the required GPRA data collection
Follow-up. This amount may be paid for participation in each required
interview.

CSAT's GPRA Core Client Outcome domains are:

Number of individuals served;

[Ages 18 and above]{.underline}: Percent of service recipients who: have
no past month substance abuse; have no or reduced alcohol or illegal
drug consequences; are permanently housed in the community; are
employed; have no or reduced involvement with the criminal justice
system; and, have good or improved health and mental health status.

[Ages 17 and under]{.underline}: Percent of service recipients who: have
no past month use of alcohol or illegal drugs; have no or reduced
alcohol or illegal drug consequences; are in stable living environments;
are attending school; have no or reduced involvement in the juvenile
justice system; and, have good or improved health and mental health
status.

Applicants must clearly state which GPRA service population(s) they
propose to address as target populations. For more information, as well
as the electronic versions of the CSAT GPRA materials, go to:
[www.csat-gpra.org](http://www.csat-gpra.org/).

**[Other Reporting Requirements]{.underline}**

While a formal local evaluation is not required, the grantee will be
expected to monitor implementation of the project and its fidelity to
their plan, and to document the State-level and the sub-recipient
community level and provider agency level activities, accomplishments,
and outcomes. The grantee will also be expected to provide regular
feedback to the project managers, staff, and Policy Steering Committee
to ensure fidelity and improve operations and services. This feedback
should include both process and outcome measures. Process components
must, at a minimum, address:

Baseline (at the initiation of SBIRT) aggregate (unduplicated) counts of
the number of individuals screened for substance use disorders in the
State and each community, if applicable;

Aggregated baseline (at the initiation of SBIRT) counts of settings
where SBIRT services are provided in the State and aggregated
characteristics of such settings;

Average and median per person cost of screenings, and if applicable,
average costs per community where SBIRT has been introduced into
multiple communities;

Aggregated baseline of the number of people (unduplicated count) within
the State with SUD's who receive treatment services for these disorders;
and the percentage of those in need of such treatment services that the
baseline represents; similar information for communities if SBIRT was
introduced into multiple communities.

Data collection for these data elements (and related information)
outlined above and reported in quarterly reports, will be discussed and
verified during an annual interview with a CSAT contractor, either
conducted in-person or by telephone, with appropriate, knowledgeable
project staff. This interview will require OMB approval[^11].

**[Target Populations and Sub-recipient Communities]{.underline}**

Because of legal, funding, and programmatic issues, most States have
developed different continuums of care for treatment of pre-adolescent
children, youth (ages 12-17 years), adults, and elderly persons. States
can apply for SBIRT cooperative agreements for one, a combination, or
all of these target populations.

The State can choose to implement the project in as many sub-recipient
communities as the State wishes. For each community selected, the
application will need to identify the lead agency selected (if any) and
all potential sub-recipient(s) who will be providing services or
training and technical assistance. For each community selected, the
application will need to document the community's need and potential for
systems change to rapidly initiate SBIRT.

While SBIRT can be carried out in all community generalist settings
(e.g., healthcare, welfare, worksite, criminal justice), the State may
choose to implement the project in one generalist system. If so,
starting with the general medical system is recommended.

The State may contract with a lead agency that routinely serves as the
local administrator of funds for identifying and treating persons with
Substance Use Disorders (such as a local health department or a county
substance abuse authority) or with multiple generalist and specialist
agencies that contractually agree to work together to provide a
continuum of care including SBIRT for any or all defined community
service areas. Sub-recipient agencies may be public and domestic private
non-profit entities, including faith-based organizations.

**[What to Include in Your]{.underline} [Application]{.underline}**

In order for your application to be complete, it must include the
following in the order listed. Check off areas as you complete them for
your application.

-   **[1. FACE PAGE]{.underline}**

    Use Standard Form 424, which is part of the PHS 5161-1. See Appendix
    A in Part II of the RFA for instructions. In signing the face page
    of the application, you are agreeing that the information is
    accurate and complete.

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-   **[2. ABSTRACT]{.underline}**

    Your total abstract should not be longer than 35 lines. In the
    [first 5 lines or less]{.underline} of your abstract, write a
    summary of your project that can be used, if your project is funded,
    in publications, reporting to Congress, or press releases.

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-   [**3. TABLE OF CONTENTS**]{.underline}

    Include page numbers for each of the major sections of your
    application [and]{.underline} for each appendix.

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-   **[4. BUDGET FORM]{.underline}**

    Standard Form (SF) 424A, which is part of the PHS 5161-1 is to be
    used for the budget. Fill out sections B, C, and E of the SF 424A.
    Follow instructions in Appendix B of Part II of the RFA.

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-   **[5. PROJECT NARRATIVE AND SUPPORTING DOCUMENTATION]{.underline}**

    **The Project Narrative describes your project. It consists of
    Sections A through D.** These sections may not be longer than 35
    pages. More detailed information about Sections A through D follows
    #10 of this checklist.

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-   **Section A --** Establishing Need

-   **Section B** -- SBIRT Implementation and Systems Change

-   **Section C** - Project Organization, Management, and Staffing

-   **Section D -** Data Collection, Monitoring, and Reporting

    **The Supporting Documentation section of your application provides
    additional information necessary for the review of your application.
    This Supporting Documentation should be provided immediately
    following your Project Narrative in Sections E through H.** There
    are no page limits for these sections, except for Section G, the
    Biographical Sketches/Job Descriptions.

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-   **Section E** **-** Literature Citations. This section must contain
    complete citations, including titles, dates, and all authors, for
    any literature you cite in your application.

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-   **Section F** **-** Budget Justification, Existing Resources, Other
    Support. You must provide a narrative justification of the items
    included in your proposed budget as well as a description of
    existing resources and other support you expect to receive for the
    proposed project. **(See Part II of the RFA, Example A,
    Justification).**

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-   **Section G** - Biographical Sketches and Job Descriptions

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-   Include a biographical sketch for the project director and for other
    key positions. Each sketch should not be longer than **2 pages**. If
    the person has not been hired, include a letter of commitment from
    the individual with a current biographical sketch.

-   Include job descriptions for key personnel. They should not be
    longer than **1 page**.

-   **Sample sketches and job descriptions are listed** **[on page
    22]{.underline}, Item 6 in the Program Narrative section of the PHS
    5161-1.**

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-   **Section H** **-** **SAMHSA's Participant Protection.** The
    elements you need to address in this section are outlined after the
    Project Narrative description in this document.

***[6. APPENDICES 1 THROUGH 5]{.underline}***

-   Use only the appendices listed below.

-   **Do not** use appendices to extend or replace any of the sections
    of the Project Narrative unless specifically required in this RFA.
    Reviewers will not consider them if you do.

-   **Do not** use more than **30 pages** (plus all instruments) for the
    appendices.

    **Appendix 1:** Provide a listing of all community and specialist
    service providers, including:

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-   documentation of Licensure/ Accreditation/Certification or a letter
    from the licensure/accreditation/ certification authority stating
    that it is not required;

-   documentation of at least two years of experience in delivering
    substance abuse treatment for specialist providers;

-   identification of the sub-recipient community within the State where
    the provider will deliver services;

-   a listing of modalities and services provided in the project; and

-   if the modalities that the State funds within its continuum of care
    do not match those for which CSAT tracks for GPRA and calculates
    program costs, provide a cross-walk that aligns your modalities and
    costs with those that CSAT tracks.

    **Appendix 2:** Letters of Commitment, Contracts, Agreements, Table
    of Organization, Performance Schedule, Task-Sequencing Chart,
    Documentation from the Governor certifying rapid obligation of
    funds, and Documentation of past performance demonstrating rapid
    deployment of CSAT grant funds.

    **Appendix 3:** Documentation of any proposed collaboration with
    applicants to the NIH PA-02-168 announcement.

    A plan, budget, budget justification and signed agreement for
    training and technical assistance.

    **Appendix 4:** Data Collection Instruments/ Interview Protocols

    **Appendix 5:** Sample Consent Forms

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-   **[7. ASSURANCES]{.underline}**

    Non-Construction Programs. Use Standard form 424B found in PHS
    5161-1.

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-   **[8*.* CERTIFICATIONS]{.underline}**

    Use the \"Certifications\" forms, which can be found in PHS
    5161-1*.* See Part II of the RFA for instructions.

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-   **[9. DISCLOSURE OF LOBBYING ACTIVITIES]{.underline} (See form in
    PHS 5161-1)**

    Appropriated funds, other than for normal and recognized
    executive-legislative relationships, may not be used for lobbying
    the Congress or State legislatures. Federal law prohibits the use of
    appropriated funds for publicity or propaganda purposes or for the
    preparation, distribution, or use of the information designed to
    support or defeat legislation pending before the Congress or State
    legislatures. This includes "grass roots" lobbying, which consists
    of appeals to members of the public suggesting that they contact
    their elected representatives to indicate their support for or
    opposition to pending legislation or to urge those representatives
    to vote in a particular way. (Please read **Part II** of the
    RFA***,*** General Policies and Procedures for all SAMHSA
    Applications for additional details.)

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-   **[10. CHECKLIST]{.underline}** (Found in the PHS 5161)

    You must complete the Checklist. See Part II Appendix C of the RFA
    for detailed instructions.

    [**Project** **Narrative **]{.underline}

    **Sections A through D**

    In developing your application, use the instructions below that have
    been tailored to this program. These are to be used in lieu of the
    "Program Narrative" instructions found in the PHS 5161 on page 21.

    **Sections A through D are the Project Narrative of your
    application.** These sections describe what you intend to do with
    your project**.** Below you will find detailed information on how to
    respond to Sections A through D***.*** Sections A through D [may
    not]{.underline} be longer than 35 pages.

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-   **Your application will be reviewed and scored against the
    requirements described below for sections A through D*.* These
    sections also function as review criteria.**

-   A peer review committee will assign a point value to your
    application based on how well you address **each** of these
    sections.

-   The number of points after each main heading shows the maximum
    number of points a review committee may assign to that category.

-   Bullet statements do not have points assigned to them; they are
    provided to invite attention to important areas within the
    criterion.

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-   Reviewers will also be looking for evidence of cultural competence
    **in each section** of the Project Narrative. Points will be
    assigned based on how well you address cultural competency aspects
    of the review criteria. SAMHSA's guidelines for cultural competence
    are included in Part II of the RFA, Appendix D.

    **Section A:** **[Establishing Need]{.underline} 20 points**

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-   Describe the need for treatment Statewide and for each community in
    which SBIRT will be implemented. Include as much documentation as
    possible, with the focus on differentiating clinically appropriate
    treatment for persons diagnosed with a Substance Abuse Disorder
    versus a Substance Dependence Disorder.

**Note:** Documentation of treatment need, demand, barriers to access,
and resource availability may come from a variety of qualitative and
quantitative sources. (Dewit and Rush, 1996; NIDA, 1998; Weisner, 2001;
McAuliffe, 2002) The quantitative data could come from locally generated
data or trend analyses, from State data such as that available through
State Treatment or Prevention Needs Assessments, social indicator
analyses, waiting list analyses, and/or through national data sets, such
as that available from SAMHSA's National Household Survey on Drug Abuse
(NHSDA), Drug Abuse Warning Network (DAWN), and Drug and Alcohol
Services Information System (DASIS), which includes the National Survey
of Substance Abuse Treatment Services (N-SSATS) and the Treatment
Episode Data Set (TEDS), and DOJ's Arrestee Drug Abuse Monitoring (ADAM)
program. The description and data will provide the baseline for
monitoring performance against the SBIRT targets.

-   Describe the State's current resources and continuum of care for
    persons with Substance Use Disorders including---the provider and
    practitioner resources and the funding streams available for
    intervention and treatment services in the generalist and specialist
    systems.

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-   Describe how the State currently plans for, funds, and provides
    intervention and treatment services within its continuum of care
    (including SBIRT if it is part of the current continuum of care) and
    how SBIRT (or SBIRT expansion) can be integrated into the financing
    and provider systems. Include a discussion of the use of patient
    placement criteria and standardized screening and sequential
    assessment protocols, if these are used, and the modalities in which
    persons are placed. If the modalities that the State funds do not
    match those for which CSAT calculates program costs, provide a
    crosswalk that aligns your modalities and costs for each with those
    that CSAT tracks for GPRA (screening, brief intervention, brief
    treatment, outreach/pretreatment services, outpatient
    (non-methadone), outpatient (methadone), and residential). Where
    necessary, include the crosswalk between CSAT program cost
    modalities and the State's continuum of care in **Appendix 1**.

-   Explain why the existing services are insufficient or inappropriate
    to respond to the demand for services and the treatment needs of the
    target population chosen for this application.

-   Provide a description and analysis of the three most important
    barriers existing that prevent persons who need and seek treatment
    from accessing the clinically appropriate type and level of
    treatment. Barriers to be addressed might include laws, regulations,
    eligibility requirements for service receipt, facility and provider
    eligibility requirements, varied funding streams, coverage
    limitations, lack of patient placement criteria or standardized
    screening and sequential assessment protocols, etc.

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-   [Target Communities]{.underline}. Describe your method for selecting
    the communities for which funding is to be directed to increase
    services. Document for each how the need for treatment significantly
    exceeds the capacity to provide services, the potential for systems
    change, and that strategies exist to rapidly initiate SBIRT. Provide
    the same information about need, resources, and barriers for each
    community in which the project will be implemented that has been
    provided for the State. Where policies are the same Statewide so
    indicate, and describe only local variations (e.g., a local tax used
    to fund prevention or treatment).

    **Section B[: SBIRT Implementation and Systems Change]{.underline}**
    **40 points**

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-   **Systems Change:** Provide a detailed Project Implementation Plan
    that explains how the Governor proposes to use project funds in
    conjunction with other available funding sources to provide SBIRT
    services. All funding sources that are or could be used to pay for
    screening and treatment of Substance Use Disorders (e.g., State
    General Fund, Medicaid, Preventive Health and Health Services Block
    Grant, Community Health Center grants, commercial insurance,
    Substance and Abuse Prevention and Treatment Block Grant, Temporary
    Assistance for Needy Families (TANF) Block Grant, Child Care and
    Development (CCDF) Block Grant, Maternal and Child Health Block
    Grant) should be addressed, but the focus should be on the three
    **major** funding streams that you will use to increase support and
    decrease barriers.

-   Describe how the State will increase the number of generalist
    settings that provide SBIRT in each sub-recipient community as a
    result of the award and redirection of other funding sources.

-   **Service Delivery:** Describe how the State will provide SBIRT
    within its continuum of care, within the geographic areas proposed,
    including a description of the modalities and services to be
    provided, the protocols that will be used for standardizing
    screening, assessment, determining the level of service required,
    referral,Number range CHAPTER brief intervention, brief treatment,
    and follow up. Provide a justification for the procedures to be
    used, including a discussion of the evidence for effectiveness. The
    modalities and services described should match those listed in
    **Appendix 1**.

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-   If the State chooses to expend funds for other treatment modalities
    within the continuum of care, describe how these services will be
    implemented. States that do seek to fund specific components of
    their continuum of care through the SBIRT cooperative agreement must
    provide evidence that there is a sufficient amount of services in
    those elements of the continuum (modalities) for each community to
    be included.

-   Describe how the State will overcome the barriers to accessing
    clinically appropriate care, using the SBIRT approach. Whenever
    possible, apply findings from recent literature and other
    information that demonstrates a thorough understanding of the issues
    faced in introducing SBIRT into the State's continuum of care.
    Include literature citations in Section E of your application.

-   Describe the linkages to be developed between the participating
    specialist and community agencies for referrals, cooperation in case
    management, and information sharing.

-   Provide a plan to make available training and technical assistance
    to sub-recipient communities, including information about SBIRT
    methods, training for staff in the community and specialist settings
    in carrying out SBIRT, and technical assistance to the overall
    project and its sub-recipients.[^12] Include the plan, budget,
    budget justification and signed agreement in Appendix 3 of the
    application.

-   Describe how the State will increase access and availability of
    services to a larger number of persons with Substance Use Disorders
    as a result of the award. State clearly the number of additional
    persons to be served for each year of the proposed cooperative
    agreement in each element of SBIRT (i.e., number of persons to be
    screened by each participating service provider, number of persons
    projected to receive Brief Intervention, number of persons expected
    to be referred for specialist assessment, number of persons to
    receive Brief Treatment) and the number of persons to receive
    clinically appropriate treatment in all other modalities within the
    system. Show that the targets are feasible and reasonable.

-   Describe the expected outcomes of treatment (e.g., decreased drug
    use in those patients receiving services through SBIRT) and the
    means by which you determined these targets. Show that the targets
    are feasible and reasonable.

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-   Provide proposed per person costs per treatment episode based on the
    applicant's actual costs and projected costs over the 5-year project
    period for each modality. State whether or not these costs are
    within the acceptable ranges by treatment modality provided in the
    "Award Criteria" section. Discuss the reasonableness of the per
    person costs. If proposed costs exceed acceptable ranges, a detailed
    justification must be provided.

**Section C: Project Organization, Management, and Staffing.** **20
points**

**Project Management Plan.** There will be three phases to the project:
project planning and start-up; operations; and phase-out. For each phase
of the project, provide a realistic management plan that describes the
organizations and staff that will be involved in the project; presents
their roles in the project; and addresses their relevant experience.

-   Describe the structure, roles, and individual tasks to be performed
    to carry out the administrative and service delivery activities
    required to carry out (1) project administration, (2) policy and
    systems change, (3) training and technical assistance,[^13] (4)
    monitoring sub-recipients' implementation of service delivery, data
    collection, and (5) reporting. Be sure to include a description of
    the role and involvements of the processes to be used to ensure
    significant involvement and oversight of the State's project by the
    Governor's Office, the Policy Steering Committee, the Project
    Director, the State Substance Abuse Authority (SSA), and other
    relevant agencies.

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-   Provide a staffing plan that includes the level of effort and
    qualifications of the Project Director and other key personnel, such
    as the administrative staff providing oversight in the Governor's
    office, the clinical personnel in the community and specialist
    treatment agencies, trainers, and support personnel, specifying the
    agency that will employ these persons.

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-   Provide a description of the project organization, Statewide and for
    each sub-recipient community system. Include a Table of Organization
    with description of roles and relations, letters of support and
    commitment, outlining roles, funding, staff, services to be provided
    (if any), and referral relationships from participating and
    coordinating organizations in **Appendix 2**.

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-   Provide evidence that the existing and proposed staff have or will
    receive training to develop requisite experience and cultural
    sensitivity to provide services to the target population. Show
    evidence of the appropriateness of the proposed staff to the
    language, age, gender, sexual orientation, disability, literacy, and
    ethnic, racial, and cultural factors of the target population.

-   Provide a performance schedule for task completion that includes a
    description of sequential relationships and approximate level of
    effort required per task (in person hours or full-time equivalents).
    Each task should be related to the project goals and objectives, as
    well as to management and staffing levels. Include a performance
    schedule and a task-sequencing chart in **Appendix 2**.

-   **Phase I: Project Planning and Start-up.** Describe how the State
    will complete each of the start-up tasks specified above under
    Program Overview, Phase I: Project Planning and Start-up, that are
    necessary to implement the project. Describe how the Governor and
    the Policy Steering Committee will ensure that every component of
    the project is fully operational at the conclusion of Phase I and
    will monitor task accomplishments.

-   **Phase II: Operations**. Describe the actions and timelines
    necessary for carrying out the systems change and service delivery
    activities described as part of the initial planning phase. Describe
    how the State will carry out the activities necessary to implement
    the project as identified above under Program Overview, Phase II:
    Operations.

-   **Phase III: Phase-Out**. Describe the activities planned to make
    the transition from the SBIRT cooperative agreement funding to State
    and local control and funding in order to sustain the system changes
    achieved by the project.

**Section D: Data Collection, Monitoring, and Reporting. 20 points**

-   Provide a plan for collecting, analyzing, interpreting, and
    reporting data on activities, costs, and outcomes, including the
    means by which the overall project and each sub-recipient will
    comply with GPRA requirements\-- the collection of CSAT's GPRA Core
    Client Outcomes, and tracking and follow-up procedures.

-   Although a formal local evaluation is not required, the applicant
    will be expected to monitor implementation of the project and its
    fidelity to their plan. Therefore, the plan should explain how the
    State intends to:

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-   document the State-level and the sub-recipient community level and
    provider agency level activities, accomplishments, and outcomes
    associated with the SBIRT project;

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-   collect data in addition to the GPRA items, if any, using both
    quantitative and qualitative approaches as needed;

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-   measure changes in these activities and accomplishments over the
    life of the project;

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-   document what was actually done, what was learned, what barriers
    inhibited implementation, how such barriers were resolved, and what
    should be done differently in future projects;

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-   provide for obtaining consistent and uniform information across
    programs and sub-recipient sites Statewide; and

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-   provide regular feedback to the project managers, staff, and Policy
    Steering Committee to help the project improve operations and
    services. This feedback should include both process and outcome
    measures.

    **NOTE:** Although the budget for the proposed project is not a
    review criterion, the Review Group will be asked to comment on the
    appropriateness of the budget after the merits of the application
    have been considered.

    **[SAMHSA's Participant Protection Requirements]{.underline}**

    Part II of the PA/RFA provides a description of SAMHSA's Participant
    Protection Requirements and the Protection of Human Subjects
    Regulations.

    The evaluation requirements as described in the "Project Narrative"
    section of this RFA are subject to the SAMHSA Participant Protection
    (SPP) provisions. However, applicants who propose to implement more
    in depth evaluation activities may be subject to the Federal
    provisions at 45 CFR Part 46 (Protection of Human Subjects). In
    accordance with these provisions, evaluation approaches designed to
    conduct the systematic collection of data on individual clients
    require review and approval by an Institutional Review Board (IRB).
    These requirements apply whether SAMSHA funds or funds from other
    sources are used to carry out the evaluation activities.

    SAMHSA will place restrictions on the use of funds until all
    participant protection issues are resolved. Problems with
    participant protection identified during peer review of your
    application may result in the delay of funding. See Part II of the
    RFA for more information on participant protection.

    You [must]{.underline} address each element regarding participant
    protection in your supporting documentation. If any one or all of
    the elements is not relevant to your project, you must document the
    reasons that the element(s) does not apply.

    This information will:

1.  Reveal if the protection of participants is adequate or if more
    protection is needed.

2.  Be considered when making funding decisions

    Projects may expose people to risks in many different ways. In this
    section of your application, you will need to:

-   Identify and report any possible risks for participants in your
    project.

-   State how you plan to protect participants from those risks.

-   Discuss how each type of risk will be dealt with, or why it does not
    apply to the project.

    Each of the following elements [must be discussed]{.underline}:

    [Protect Clients and Staff from Potential Risks]{.underline}

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-   Identify and describe any foreseeable physical, medical,
    psychological, social, legal, or other risks or adverse affects.

-   Discuss risks that are due either to participation in the project
    itself, or to the evaluation activities.

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-   Describe the procedures that will be followed to minimize or protect
    participants against potential risks, including risks to
    confidentiality.

-   Give plans to provide help if there are adverse effects to
    participants.

-   Where appropriate, describe alternative treatments and procedures
    that may be beneficial to the participants. If you do not decide to
    use these other beneficial treatments, provide the reasons for not
    using them.

    [Fair Selection of Participants]{.underline}

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-   Describe the target population(s) for the proposed project. Include
    age, gender, racial/ethnic background and note if the population
    includes homeless youth, foster children, children of substance
    abusers, pregnant women, or other groups.

-   Explain the reasons for including groups of pregnant women,
    children, people with mental disabilities, people in institutions,
    prisoners, or others who are likely to be vulnerable to HIV/AIDS.

-   Explain the reasons for [including or excluding]{.underline}
    participants.

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-   Explain how you will recruit and select participants. Identify who
    will select participants.

    [Absence of Coercion]{.underline}

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-   Explain if participation in the project is voluntary or required.
    Identify possible reasons why it is required. For example, court
    orders requiring people to participate in a program.

-   If you plan to pay participants, state how participants will be
    awarded money or gifts.

-   State how volunteer participants will be told that they may receive
    services even if they do not complete the study.

    [Data Collection]{.underline}

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-   Identify from whom you will collect data; for example, participants
    themselves, family members, teachers, others. Describe the data
    collection procedure and specify the sources for obtaining data; for
    example, school records, interviews, psychological assessments,
    questionnaires, observation, or other sources. Where data are to be
    collected through observational techniques, questionnaires,
    interviews, or other direct means, describe the data collection
    setting.

-   Identify what type of specimens (e.g., urine, blood) will be used,
    if any. State if the material will be used just for evaluation or if
    other use(s) will be made. Also, if needed, describe how the
    material will be monitored to ensure the safety of participants.

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-   Provide in **Appendix 4**, "Data Collection Instruments/Interview
    Protocols," copies of [all]{.underline} available data collection
    instruments and interview protocols that you plan to use.

    [Privacy and Confidentiality:]{.underline}

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-   Explain how you will ensure privacy and confidentiality. Include who
    will collect data and how it will be collected.

-   Describe:

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-   How you will use data collection instruments.

-   Where data will be stored.

-   Who will or will not have access to information.

-   How the identity of participants will be kept private. For example,
    through the use of a coding system on data records, limiting access
    to records, or storing identifiers separately from data.

    **NOTE:** If applicable, grantees must agree to maintain the
    confidentiality of alcohol and drug abuse client records according
    to the provisions of **Title 42 of the Code of Federal Regulations,
    Part II.**

    [Adequate Consent Procedures:]{.underline}

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-   List what information will be given to people who participate in the
    project. Include the type and purpose of their participation.
    Include how the data will be used and how you will keep the data
    private.

-   State:

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-   Whether or not their participation is voluntary,

-   Their right to leave the project at any time without problems,

-   Possible risks from participation in the project,

-   Plans to protect clients from these risks.

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-   Explain how you will get consent for youth, the elderly, and people
    with limited reading skills, and people who do not use English as
    their first language.

    NOTE: If the project poses potential physical, medical,
    psychological, legal, social or other risks, you **must** get
    [written]{.underline} informed consent.

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-   Indicate if you will get informed consent from participants or from
    their parents or legal guardians. Describe how the consent will be
    documented. For example: Will you read the consent forms? Will you
    ask prospective participants questions to be sure they understand
    the forms? Will you give them copies of what they sign?

-   Include sample consent forms in your **Appendix 5**, titled "Sample
    Consent Forms." If needed, give English translations.

    NOTE: Never imply that the participant waives or appears to waive
    any legal rights, may not end involvement with the project, or
    releases your project or its agents from liability for negligence.

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-   Describe if separate consents will be obtained for different stages
    or parts of the project. For example, will they be needed for both
    participant protection in treatment intervention and for the
    collection and use of data.

-   Additionally, if other consents (e.g., consents to release
    information to others or gather information from others) will be
    used in your project, provide a description of the consents. Will
    individuals who do not consent to having individually identifiable
    data collected for evaluation purposes be allowed to participate in
    the project?

     [Risk/Benefit Discussion:]{.underline}

    Discuss why the risks are reasonable compared to expected benefits
    and importance of the knowledge from the project.

    **[Special Considerations and Requirements]{.underline}**

    SAMHSA's policies, special considerations, and requirements related
    to grants and cooperative agreements are found in **Part II** of the
    RFA. The policies, special considerations, and requirements related
    to this program are:

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-   Population Inclusion Requirement

-   Government Performance and Results Act

-   Healthy People 2010

-   Letter of Intent

-   Intergovernmental Review (E.O.12372)

-   SAMHSA Participant Protection

# Appendix A 

**Resources for Implementing**

**Screening, Brief Intervention, Referral, and Treatment**

#### Background {#background .unnumbered}

For purposes of this cooperative agreement, CSAT will not require a
specific methodology for determining need, implementing systems change,
or introducing SBIRT within its continuum of care. CSAT is not requiring
specific protocols for carrying out the individual activities involved
(viz., screening, brief intervention, referral, assessment, patient
placement, and brief treatment). CSAT is not recommending a specific
approach for developing collaboration among participating generalist and
specialist providers. Rather, the applicant is required to describe and
justify the strategies that will be implemented under the proposed
cooperative agreement project and to describe the methods that will be
used to assess need, eliminate barriers to access, and to carry out each
of these activities. Wherever possible, the applicant should provide a
description of any prior services or research projects on which their
proposed approach is based.

In order to introduce some commonality in responses, we will present a
brief overview of terminology and anticipated issues and provide
illustrative references that can serve as resources for proposal
development and project implementation. The resources and references
provided are not presented as an inclusive listing that must be used in
proposal preparation.

# Terminology

From the scientific and policy perspectives, there have been two
distinct approaches for responding to the social and health problems
posed by drug abuse and addiction---the **clinical**, or diagnostic,
approach and the **environmental**, or problems, approach (Gerstein and
Green, 1993; Institute of Medicine, 1990). Over the years, drug policy
has been shaped by these perspectives, shifting between punitive and
rehabilitative strategies for reducing consumption of illicit drugs and
the criminal behaviors associated with illicit drug use (Gerstein and
Harwood, 1990).

The two perspectives have led to differences in how persons receiving
and seeking treatment are characterized in developing resource
allocation and financing schemes and create potential problems in
consolidating funding streams to carry out SBIRT. The financing of
treatment for substance use problems has differed from the rest of
health care financing in part because the public sector through block
and categorical grants has been the major payer for services (e.g.,
Horgan and Merrick, 2001). The shifting perspectives and orientations of
the policymakers and legislators have also influenced these systemic
perspectives (Gerstein and Harwood, 1990). Criminal justice funding,
originally through the Federal Law Enforcement Administration block and
categorical grant programs (more recently, the Office of Justice
Programs and the Office of Juvenile Justice programs) created a public
safety orientation, while funds from the poverty programs (e.g., the
Social Services Block grant) created a welfare orientation. On the other
hand, health insurance, like Blue Cross and Medicaid created a medical
orientation. All three orientations have co-existed in the categorical
grant and block grants directly targeted at treatment of substance use
disorders, notably, the Substance Abuse Prevention and Treatment Block
Grant, which attempts to integrate the perspectives, creating what has
been labeled the mixed medical and social model orientation (IOM, 1990;
Reader and Sullivan, 1992). For example, Medicaid and other forms of
health insurance require a clinical diagnosis and a determination of
medical necessity for admission to treatment, while the Substance Abuse
Prevention and Treatment Block Grant does not. The lack of common
terminology has created problems in understanding who receives what
services for treatment of substance use disorders with what outcomes
(Coffey et al., 2001)

Developing the policies and data for studying utilization and designing
policies to increase access to clinically appropriate treatment requires
use of common terms with clear definitions, starting with identifying
the conditiions for which treatment is needed. Diagnosis is the process
of identifying and labeling specific diseases; diagnostic criteria for
substance abuse and dependence disorders reflect the consensus of
researchers and clinicians as to precisely which patterns of behavior or
physiological characteristics constitute symptoms of these conditions.
(Babor, 2001; NIAAA, 2002; NIDA, 1997) Agreement on diagnosis in this
field is relatively new, and the definitions and techniques for
establishing diagnoses are evolving. Having a consistent set of
diagnostic criteria allows clinicians to plan treatment and monitor
treatment progress; enables policymakers, and planners to ensure the
availability of needed treatment resources in each community; helps
health care insurers and other funders to decide whether treatment will
be reimbursed; and allows patients access to medical insurance coverage.

As noted in the RFA, in accord with the National Drug Control Strategy's
new approach to using diagnosis as the criterion for determining the
size of the treatment gap, the need for treatment is discussed in terms
of the categories used in the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV; 1994).[^14] DSM-IV includes a category called \"Substance
Related Disorders\" that is divided into two major subcategories,
Substance Induced Disorders and Substance Use Disorders. The focus of
this program is on that part of the continuum of care that addresses
treatment of Substance Use Disorders and not the treatment of Substance
Induced Disorders, namely Substance Intoxication and Substance
Withdrawal. Patients manifesting signs of intoxication, withdrawal
symptoms, and other physical problems that require emergency care or
urgent action would be managed in other components of the generalist or
specialist treatment systems, stabilized and medically cleared before
being screened for presence of a Substance Use Disorder (VHA/DoD, 2001).

Substance Use Disorders are further differentiated by type of drug
primarily involved (e.g., amphetamine, alcohol, cocaine,
marijuana/cannabis). DSM-IV is the diagnostic approach primarily used in
this county for determining treatment eligibility, developing
substance-specific treatments, and conducting epidemiological and
clinical research.

Based on the DSM-IV, *Substance Abuse Disorder* is characterized by the
presence of social or health-related problems related to the person's
consistent pattern of substance use. *Substance* D*ependence* Disorder
is characterized by a cluster of recognizable symptoms, including
physical withdrawal, loss of control over use episodes, and continued
use of substance despite knowledge of having a physical or psychological
problem that is likely caused by substance.

The World Health Organization has also developed diagnostic criteria for
the purpose of compiling statistics on all causes of death and illness,
including those related to substqance abuse or dependence. These
criteria are published as the *International Classification of Diseases*
(ICD). In the current revision, ICD-10, substance dependence is defined
in a way that is similar to the DSM-IV. The diagnosis focuses on an
interrelated cluster of psychological symptoms, such as craving;
physiological signs, such as tolerance and withdrawal; and behavioral
indicators , such as the use of alcohol to relieve withdrawal
discomfort. However, in a departure from the DSM-IV, rather than include
the category \"abuse,\" ICD-10 includes the concept of \"harmful use.\"
This category was created so that health problems related to alcohol and
other drug use would not be underreported. Harmful use implies alcohol
or drug use that causes either physical or mental damage in the absence
of dependence (Babor, 2001). The ICD classification approach has served
as the basis for much of the research underlying the use of brief
interventions.

Review of the literature and discussions with practitioners and State
Substance Abuse Authorities (SSAs) established that, while most of the
research establishing the effectiveness of this approach has focused on
alcohol use problems and disorders and has used the **problems**
approach rather than the **clinical** approach, there is an emerging
body of research and clinical experience that supports use of the SBIRT
approach for nondependent persons who are experiencing problems related
to the use of illicit drugs, particularly for marijuana use disorders
(e.g., Stephens et a., 1994; Samet et al., 1996; Sullivan et al., 1997:
Babor et al. 2002; Barry, 1999; Bernstein et al., 1997; Zweben and
Fleming, 1999; Roffman, 1999; Dennis, et al. 2002a and b; Conrod et al.,
2000; Baker et al. 2001; Babor, et al., 2002; Blow, 1999: Fleming, 2002;
Kelso, 2002; WHO ASSIST Working Group, 2002).

While the effort to develop brief interventions for nondependent drug
users has not been as extensive as that for persons with alcohol
problems, there have been several precedents. Early in the effort to
develop a national drug strategy, the Treatment Subcommittee of the
Cabinet Committee on Drug Abuse Prevention, Treatment and Rehabilitation
in responding to pressure on the limited availability of treatment
slots, recommended the establishment of distinct, lower cost
"Alternative Educational Programs" (Bloom, 1977). These "alternatives to
treatment or incarceration were recommended as the vehicle for "treating
the casual and recreational marijuana users" who were being
"inappropriately" referred to drug abuse treatment centers, most often
by the criminal justice system through diversion efforts (Domestic
Council Drug Abuse Task Force, 1975). The stated goal was to allow the
specialty drug abuse treatment system to focus on the "abusers of high
risk drugs." Marijuana, at that time, was considered a low risk drug.

The model programs presented by NIDA were short-term, inexpensive
educational programs with both didactic presentations and group
discussions. These alternative educational programs became the
forerunners of many of the intervention programs that still exist in the
gray area between prevention and treatment---often having statutory
authorization as diversion programs.

There is evidence that a number of States have already begun to
introduce protocols for screening and brief intervention for both
alcohol and drug use problems and disorders into their continuum of care
(e.g., New York OASAS, 1996; Harrison et al., 1996; Hartwell et al.,
1996: Kroutil et al., 1997).[^15] Yet, in contrast to more traditional
treatment services, early intervention services are often not
specifically defined or regulated (IOM, 1990; Klitzner, et al., 1992).
For purposes of this announcement, early intervention services (brief
interventions) are those treatment procedures designed for persons who
are exhibiting some problems associated with alcohol or other drug use
but whose problems are not deemed serious enough to warrant treatment
within a specialist setting (i.e., those nondependent persons at high
risk of or already diagnosed with a substance abuse disorder). Early
intervention services are sometimes identified as pre-treatment
interventions (Blow, 1998) or clinical preventive services (U.S.
Preventive Task Force, 1998) or indicated preventive interventions
(Haggerty and Mrazek, 1994). The goal of early intervention is to
prevent the problems from becoming more serious, and to promote total
abstinence from alcohol and other illegal drugs. Early intervention
could include an assessment of substance use and related problems,
individual counseling provided by a health care practitioner, or
participation in school-­based or community-based educational or
counseling programs designed to deter further substance use and promote
healthier alternatives.

CSAT's approach to early intervention through screening, brief
intervention, and brief treatment is to be differentiated from the
parallel efforts within CSAP. While both approaches use the same
technologies, CSAP funded early intervention programs address persons
who are at high risk of developing a substance use disorder through
indicated preventive interventions,[^16] while CSAT funded programs
address persons who would achieve a diagnosis of substance use disorder.
CSAP and CSAT are working together to jointly assist the States in
implementing the entire continuum of care as presented in the Institute
of Medicine report, **Reducing Risks for Mental Disorders** as modified
by CSAT for the National Treatment Plan (CSAT, 2000). The IOM report
recommends that the traditional public health classifications of
primary, secondary, and tertiary prevention be replaced by new
classification system for the continuum of care:

> **Universal preventive interventions:** targeted to the general public
> or a whole population group that has not been identified on the basis
> of individual risk. The intervention is desirable for everyone in that
> group. Universal interventions have advantages in terms of cost and
> overall effectiveness for large populations.
>
> **Selective preventive interventions:** targeted to individuals or a
> subgroup of the population whose risk of developing a mental or
> substance use disorder is significantly higher than average. The risk
> may be imminent or it may be a lifetime risk. The basis may be
> biological, psychological, or environmental.
>
> **Indicated preventive interventions:** targeted to high risk
> individuals who are identified as having minimal but detectable signs
> or symptoms foreshadowing a mental or substance use disorder, or
> biological markers indicating predisposition for a disorder, but who
> do not meet accepted clinical diagnostic criteria at the time.
>
> **Treatment interventions:** therapeutic services designed to reduce
> the length of time a disorder exists, halt its progression of
> severity, or if not possible, increase the length of time between
> acute episodes. There are two categories of treatment interventions:
> (1) case finding; and (2) standard treatment for the known disorders,
> which includes interventions to reduce the likelihood of future
> co-occurring disorders.

**Maintenance interventions:** services, generally supportive,
educational, and/or pharmacological in nature, provided on a long-term
basis to individuals who have met DSM-IV diagnostic criteria, are
considered in remission, and whose underlying illness continues. The two
components of maintenance interventions are (1) patient's compliance
with long-term treatment to reduce relapse and recurrence and (2) the
provision of after-care services, including rehabilitation. (Haggerty
and Mrazek, 1994:23-24)

Rather than negating the public health approach to defining primary,
secondary, and tertiary prevention as some have held, the IOM model can
be seen as complementary, expanding the public heath approach. The newer
IOM model can be seen as actually further differentiating the public
health construct of primary prevention into the categories of universal,
selected, and indicative interventions, and the public health constructs
of secondary and tertiary prevention into the categories of treatment
and maintenance, respectively. The early intervention activities overlap
the boundaries between primary prevention (indicated prevention) and
secondary prevention (case finding).

­In filling out the treatment portion of a State's continuum of care, the
purpose of screening for substance use problems is to identify those
persons who should receive either a brief intervention for a Substance
Abuse Disorder or referral for additional screening and assessment to
establish whether more intensive treatment for a Substance Use Disorder
(SUD) is needed. The persons screened *may* or *may not* meet the DSM-IV
criteria for a substance abuse or dependence disorder (American
Psychiatric Association, 1994). If they do not, but are deemed to be at
risk users, than the same technology is employed as a clinical
preventive service (or indicated preventive intervention). In practice,
the activities are the same. However, the distinction is important for
developing financing policies, for conducting epidemiological research
and for tracking treatment access, appropriateness, utilization, and
effectiveness.

Since diagnosis has not always been used as a criterion for admission to
treatment in publicly funded treatment programs, States and service
providers will need to introduce and agree upon a uniform approach to
diagnosis as part of their implementation of this program and efforts to
provide sustained funding for SBIRT, particularly through public and
private health insurance mechanisms.

**Integrating the Diagnostic and Problems Approaches**

As noted, the DSM-IV term *substance use disorders* can be used to refer
to a range of substance-related problems that require treatment. A
spectrum of substance use disorders, from least to most serious, which
encompasses the problems approach used in developing screening protocols
for the use of brief interventions might be represented as follows:

Problem Use Substance Abuse Disorder Substance Dependence Disorder

or At Risk Use

In general, *problem or at-risk use* means use that exceeds an
established threshold. The threshold may be defined in different ways
depending on the source, the population, and other local conditions. The
majority of work for developing such classifications in order to
identify persons who could benefit form a brief intervention has been
carried out for alcohol use problems and disorders. For example, the WHO
manuals for introducing screening and brief intervention into primary
care present general guidelines for assigning "risk levels" based upon
AUDIT scores, that conform the spectrum above and lay out a spectrum of
intervention and treatment responses.

**Table 1: AUDIT Guidelines for Determining Intervention Strategy**[^17]

The risk levels are used as a basis for making clinical judgments to
tailor interventions to the particular conditions of individual
patients, assuming that higher AUDIT scores are generally indicative of
more severe levels of risk and problems or dependence. The guidelines
are to serve as a starting point for an appropriate intervention. If a
patient is not successful at the initial level of intervention, than the
protocol calls for follow-up to develop a plan to step the patient up to
the next level of intervention. (Babor and Higgins-Biddle, 2001; Babor
et al., 2001)

This approach is similar to that used for other screening tests, such as
the Drug Abuse Screening Test (DAST).

> **Table 2: DAST Guidelines for Determining Intervention
> Strategy**[^18]

  --------------- --------------------------- ---------------------------
  ***Score***     ***Degree of Problems\      ***Suggested Action***
                  Related to Drug Abuse***    

  0               No Problems Reported        None At This Time

  1-2             Low Level                   Monitor, Reassess At A
                                              Later Date

  3-5             Moderate Level              Further Investigation

  6-8             Substantial Level           Intensive Assessment
  --------------- --------------------------- ---------------------------

These classification systems reflect the different patterns of drug use
consumption and problems that call for differential societal responses
that reflect differences in the drug (substance) used, the history,
frequency, and amount used, as well as the existence and severity of
associated physical, emotional, and social consequences of use. The
Institute of Medicine committee that carried out a Congressionally
mandated study of the evolution, effectiveness and financing of public
and private drug treatment systems (Gerstein and Harwood, 1990)
described a four level classification system reflecting these patterns
that was a starting point in developing their initial estimates of the
need for treatment, a model that was adapted for creating national
estimates of the treatment gap. Table 3 depicts individual drug use
patterns and interventions associated with each pattern of use. Each
stage of use elicits a different type of societal response. The
definitions for the categories are:

**Use**: Low or infrequent doses: experimental, occasional, "social."
Damaging consequences are rare or minor.

> **Abuse**: Higher doses and/or frequencies: sporadically heavy,
> intensive. Effects are unpredictable, sometimes severe.
>
> **Dependence**: High, frequent doses: compulsion, craving, withdrawal.
> Severe consequences are very likely.

##  Table 3: Individual Drug Use Patterns and Intervention Strategies[^19] 

+--------+---------+--------+----------+-----------+--------+-------+
| **S    | **Cat   | **Use  | **       | **Conse   | **Soci |       |
| tage** | egory** | Pat    | Reason** | quences** | etal** |       |
|        |         | tern** |          |           |        |       |
|        | **of    |        |          |           | *      |       |
|        | Use**   |        |          |           | *Respo |       |
|        |         |        |          |           | nses** |       |
+--------+---------+--------+----------+-----------+--------+-------+
|        | Abs     |        |          |           | Prev   |       |
|        | tinence |        |          |           | ention |       |
|        |         |        |          |           |        |       |
|        |         |        |          |           | pr     |       |
|        |         |        |          |           | ograms |       |
+--------+---------+--------+----------+-----------+--------+-------+
| Early  | Use     | Low or | Exper    | Minor     | Prev   | Mild  |
| /light |         | infr   | imental, |           | ention |       |
|        |         | equent | occ      |           |        | sanc  |
|        |         | doses  | asional, |           | pr     | tions |
|        |         |        | "social" |           | ograms |       |
+--------+---------+--------+----------+-----------+--------+-------+
| Late   | Abuse   | Higher | Spor     | Unpre     |        |       |
| /heavy |         | doses  | adically | dictable, |        |       |
|        |         | and/or | heavy    | sometimes |        |       |
|        |         | frequ  |          | severe    |        |       |
|        |         | encies |          |           |        |       |
+--------+---------+--------+----------+-----------+--------+-------+
| Late   | Dep     | High,  | Com      | Severe    | Tre    | S     |
| /heavy | endence | fr     | pulsion, |           | atment | evere |
|        |         | equent | craving, |           | pr     | sanc  |
|        |         | doses  | wi       |           | ograms | tions |
|        |         |        | thdrawal |           |        |       |
+--------+---------+--------+----------+-----------+--------+-------+

In the SBIRT approach, all persons are first screened and referred to
the appropriate sector (community generalist, non-specialty or
specialty) for intervention or treatment. Persons with a mild or
moderate level of substance use problems would most often be offered a
brief intervention in the non-specialty primary health care, criminal
justice, educational, employment, or social service setting. Referral to
intensive treatment in the specialty sector would be made only for those
whose life situation is so unstable that prognosis is poor without
specialty treatment or for those who fail to respond to an initial brief
intervention\--the stepped care approach (Sobell and Sobell, 1999,
2000).

Persons with substantial or severe problems would be referred from
screening to specialty sequential assessment and treatment where problem
and personal assessment would lead to assignment to more differentiated
types of treatment modalities and levels of care, using a formal set of
patient placement criteria.

Recent efforts have attempted to integrate the problem and diagnostic
approaches, using both the research literature and clinical experience
to refine the methods for screening, referring, and treating person's
based on these concepts (e.g., ASAM, 2000; APA, 1994; VHA/DoD, 2001). A
possible model for this integration is presented in Table 4. The model
also attempts to integrative the public health and IOM models for
defining the continuum of care.

**Table 4: Integrating the Problem and Diagnostic Perspectives\--A
Possible Model**

<table style="width:100%;">
<colgroup>
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 15%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 27%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 0%" />
<col style="width: 28%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><strong>Problems</strong></td>
<td colspan="2"><p><strong>Risk Category or</strong></p>
<p><strong>Diagnosis</strong></p></td>
<td colspan="3"><strong>Intervention Strategy</strong></td>
<td colspan="2"><strong>Exposures\ Sessions</strong></td>
<td><p><strong>Follow-up Suggested:</strong></p>
<p><strong>Track: use, risk factors, and problems</strong></p></td>
</tr>
<tr class="even">
<td colspan="2">No problems</td>
<td colspan="2"><p>No risk</p>
<p>Or low risk</p></td>
<td colspan="3">Universal prevention</td>
<td colspan="2">Variable</td>
<td><p>Periodic re-screen:</p>
<p>every year</p></td>
</tr>
<tr class="odd">
<td colspan="2">Mild problems</td>
<td colspan="2">At low risk</td>
<td colspan="3"><p>Clinical preventive service</p>
<p>Selective prevention-brief advice</p></td>
<td colspan="2">1-2</td>
<td><p>Periodic re-screen:</p>
<p>every year</p></td>
</tr>
<tr class="even">
<td>Moderate problems</td>
<td colspan="2">At high risk</td>
<td colspan="3"><p>Clinical preventive service</p>
<p>Indicated prevention</p>
<p>Brief advice</p>
<p>Brief intervention</p></td>
<td colspan="2">1-2</td>
<td colspan="2"><p>Periodic re-screen</p>
<p>every 6 months for 3 years, every year if no relapse</p></td>
</tr>
<tr class="odd">
<td colspan="2">Moderate problems</td>
<td colspan="3"><p>Substance</p>
<p>Abuse</p>
<p>Disorder</p>
<p>(DSM-IV, Axis I)</p></td>
<td colspan="2"><p>Brief advice</p>
<p>Brief intervention</p>
<p>Brief treatment</p></td>
<td colspan="2"><p>1-2</p>
<p>1-5</p>
<p>6-20</p></td>
<td><p>Periodic re-screen and booster session:</p>
<p>every 3 months for 2 years, every 6 months for 2 years, every year if
no relapse</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Substantial</p>
<p>problems</p></td>
<td colspan="2"><p>Substance</p>
<p>Dependence</p>
<p>Disorder</p>
<p>(DSM-IV, Axis I)</p></td>
<td colspan="3">Sequential assessment; match to clinically appropriate
consumption and quality of life treatment strategies</td>
<td colspan="2">21-60+</td>
<td>Periodic re-screen: every 3 months for 2 years, every 6 months for 2
years, every year if no relapse</td>
</tr>
<tr class="odd">
<td colspan="2">Severe problems</td>
<td colspan="2"><p>Substance</p>
<p>Dependence</p>
<p>Disorder</p>
<p>(DSM-IV, Axis I)</p></td>
<td colspan="3">Sequential assessment; match to clinically appropriate
consumption and quality of life treatment strategies</td>
<td colspan="2">Variable; Based on individual response to treatment</td>
<td>Periodic re-screen: every 3 months for 2 years, every 6 moths for 2
years, every year if no relapse</td>
</tr>
</tbody>
</table>

Using either the problems approach or the clinical approach, it is well
recognized that within each community there is a spectrum of persons
with substance use-related problems. In keeping with recent summaries of
the international research literature, it is estimated that the majority
of adults are either abstainers or light or moderate nondependent users
of alcohol or illicit drugs, and experience either no problems or mild
or moderate substance use-related problems (estimated at approximately
75%). There is a small but often highly visible minority of heavy,
dependent users with major substance-related problems (estimated at
approximately 5%). In between these extremes, there is a sizeable group
of persons (20%) who may be drinking or using illicit drugs
substantially or heavily and who have encountered substantial or severe
problems related to their substance use. The concepts have been more
difficult to address for illicit drugs, since any use could be seen as
"abuse" because of potentially legal consequences. As will be noted
below, treatment is not necessarily the best societal response for these
nondependent persons, but a brief intervention, early in their use
career may well be.

These findings suggest that the continuum of care in each community must
include a spectrum of primary, secondary, and tertiary prevention
responses that parallels the spectrum of problem associated with use and
that the diagnostic and problems approaches must be reconciled to ensure
introduction of evidence based clinical protocols (NIDA, 1999). Research
on effectiveness of specific approaches continues, but there is
sufficient evidence available to lead to the policy conclusion that more
widespread SBIRT efforts will decrease the medical and social costs of
illicit drug use.

Using a method similar to that employed by Skinner and his colleagues in
the original development of screening for establishing brief
interventions as a valid technology, persons can be classified into four
graded categories of drug and alcohol use problems, each of which should
lead to a different treatment or intervention strategy being employed
and to a different set of resource requirements (See Table 4.):

> **Mild level of substance use problems**. Use is light or moderate;
> symptoms are rated as mild or moderate; dependence is probably not
> present or, if present, is psychological rather than physical; life
> problems related to use are rated as absent, mild, or moderate.
>
> **Moderate level of substance use problems**. Use is medium,
> substantial, or heavy; symptoms are rated as moderate; psychosocial
> problems related to use are likely and rated as moderate;
> psychological dependence may still be characteristic, but there are
> increasing signs of physical dependence, such as withdrawal symptoms;
> related life problems are rated as mild and/or moderate.
>
> **Substantial level of substance use problems**. Use is substantial or
> heavy; symptoms are rated as substantial; physical dependence is
> likely; physical disorders, mental disorders, and psychosocial
> problems related to substance use are rated as moderate and/or
> substantial.
>
> **Severe level of substance use problems**. Use is heavy; symptoms are
> rated as substantial and/or severe; physical dependence is highly
> pronounced; life problems are rated as substantial and/or severe;
> serious physical disorders and mental disorders related to use, such
> as liver disease, are likely.

As presented in Table 4, persons can also be classified as either
nondependent users (those with mild or moderate problems) or dependent
users (those with substantial and severe problems) and also be diagnosed
as meeting the clinical criteria for a DSM-IV abuse disorder or a
dependence disorder. The act of diagnosis shifts the nature of the
services from prevention to treatment.

In measuring the size of the treatment gap and developing strategies to
increase access to clinically appropriate treatment, ONDCP and SAMHSA
want the States to focus on the resources needed for improved screening,
intervention, referral and treatment for substance use disorders in
order to increase the resources devoted to identifying and intervening
with the nondependent users as part of the generalist health care
system.

States should be able to provide for a similar linkage between whatever
classification system your State is using and the DSM-IV categories in
the protocol.

###### Resources for Implementing Screening 

In health care, screening refers to a process designed to identify
people who have, or who are at risk of having, an illness or disorder.
The purpose of screening is to target persons for treatment, so as to
reduce the long-term morbidity and mortality related to the condition.
In addition, by intervening early and raising the individual's level of
concern about the risk factors and substance-related problems, it is
expected that screening for drug and alcohol problems in community
settings can itself reduce subsequent use.

Two types of screening procedures are typically used. The first type
includes self-report questionnaires and structured interviews; the
second, clinical laboratory tests that can detect biochemical changes
associated with excessive alcohol consumption or illicit drug use.

There are a variety of screening instruments available. As noted, the
majority of studies and implementation efforts have focused on screening
for alcohol problems, with the CAGE and the AUDIT being the most
commonly used screening tools. The DAST has also been used in
conjunction with the AUDIT in several projects, where there has been an
effort to implement this approach for persons with or at risk of a
Substance Use Disorder. Several new instruments have been developed, but
not yet rigorously tested to assess harmful use of either alcohol or
drugs (e.g., the CAGE-D, the ASSIST, the TCUDS, the GAIN-QS, the PDES).

> Brown, RL and Rounds LA. 1995. Conjoint screening questionnaires for
> alcohol and other drug abuse: criterion validity in a primary care
> practice. *Wisconsin Medical Journal*, 94, 135-140.
>
> Brown R, Leonard T, Saunders LA, et al. (1997). A two-item screening
> test for alcohol and other drug problems. *Journal of Family
> Practice*, 44, 151-160.

A bibliography containing descriptions and evaluations of various
interview, questionnaire, and laboratory test screening approaches is
available from Project Cork

> Project Cork. 2002. *CORK Bibliography: Screening Tests.* 2001-2002,
> 58 Citations.
> [http://www.projectcork.org/bibliographies/data/Bibliography_Screening_Tests.html]{.underline}

Screening instruments have been developed or modified for use with
different target populations, notably adolescents, offenders within the
criminal justice system, and welfare recipients, women, and the elderly.
Several have been translated into other languages and have been
evaluated for cultural sensitivity. Again, CSAT is not requiring a
specific instrument or protocol, but choice of instruments or laboratory
tests must be justified.

It is well recognized that screening instruments used with adolescents
must be developmentally appropriate, valid and reliable, and practical
for use in busy medical settings.  One example of a brief substance
abuse screening instrument recently developed specifically for use with
adolescents is the CRAFFT test.

> Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. 2002. Validity
> of the CRAFFT substance abuse screening test among adolescent clinic
> patients. *Arch Pediatr Adolesc Med*. 156(6): 607-14.

Additional screening tests and procedures targeted at adolescents,
including the PDES and the GAIN-QS, are described in these publications:

> Winters KC. 1992. Development of an adolescent alcohol and other drug
> abuse screening scale: Personal Experience Screening Questionnaire.
> *Addict Behav*. 17(5): 479-90.
>
> Winters KC. 1999. **Screening and Assessing Adolescents For Substance
> Use Disorders**. Treatment Improvement Protocol (TIP) Series 31 DHHS
> Publication No. (SMA*)* 99-3282.
>
> Winters KC. 1999. **Treatment of Adolescents With Substance Use
> Disorders.\
> **Treatment Improvement Protocol (TIP) Series 32*.* DHHS Publication
> No. (SMA*)* 99-3283.
>
> Winters KC. 2001. Assessing adolescent substance use problems and
> other areas of functioning: State of the art. In: PM Monti, SM. Colby,
> and TA. O\'Leary (eds). **Adolescents, Alcohol, and Substance Abuse:
> Reaching Teens Through Brief Interventions**. New York, Guilford
> Publications, Inc., pp. 80-108.
>
> Dennis ML 1998. **Global Appraisal of Individual Needs (GAIN) manual:
> Administration, Scoring and Interpretation**, (Prepared with funds
> from CSAT TI 11320). Bloomington IL: Lighthouse Publications.
> http://www.chestnut.org/LI/GAIN/GAIN_QS/index.html
>
> Martino S, Grilo CM, and Fehon DC 2000. Development of the drug abuse
> screening test for adolescents (DAST-A). *Addictive Behaviors* 25(1):
> 57-70.

Screening tests and procedures targeted at the elderly are described in
these publications:

> Blow, F.C. Consensus Panel Chair. 1998. **Substance Abuse Among Older
> Adults**. Treatment Improvement Protocol (TIP) Series 26. DHHS
> Publication No. (SMA) 98-3179.
>
> Blow FC and Barry KL. 1999-2000. Advances in alcohol screening and
> brief intervention with older adults. *Advances in Medical
> Psychotherapy*. 10:107-124

Screening tests and procedures targeted at persons in the criminal
justice system are described in these publications:

> Inciardi JA Consensus Panel Chair 1994. **Screening and Assessment for
> Alcohol and Other Drug Abuse Among Adults in the Criminal Justice
> System.** Treatment Improvement Protocol (TIP) Series 7. DHHS
> Publication No. (SMA) 94B2076
>
> Peters, RH, Greenbaum, PE, Steinberg, ML, Carter, CR, Ortiz, MM, Fry,
> BC, Valle, SK. 2000. Effectiveness of screening instruments in
> detecting substance use disorders among prisoners. *Journal Substance
> Abuse Treatment*: 18(4): 349-58.
>
> Simpson DD. 2001. Core set of TCU forms. Fort Worth: Texas Christian
> University, Institute of Behavioral Research.
> [www.ibr.tcu.edu](http://www.ibr.tcu.edu/).

Efforts are also ongoing to develop methods for screening within the
dual diagnosis population:

> Maisto SA, Carey MP, Carey KB, Gordon CM, and Gleason JR. 2000. Use of
> the AUDIT and the DAST-10 to identify alcohol and drug use disorders
> among adults with a severe and persistent mental illness.
> *Psychological Assessment* 12(2): 186-192.

**Resources for Implementing Brief Interventions and Brief Treatments**

There are now a variety of approaches that have been labeled as Brief
Interventions (BI) and Brief Treatments (BT). Examples of approaches
that address specific drugs are the Cannabis Youth Treatment protocol
and the Adult Marijuana Treatment protocol, developed through CSAT
funded testing of models originally developed through NIDA and NIAAA
research.

Brief intervention and brief treatment strategies range from relatively
unstructured advice-giving, to counseling and formalized feedback, to
formal structured manuals for the number, duration, frequency, and
content of sessions. Many of the protocols are based on behavioral
self-control training, motivational interviewing, and
cognitive-behavioral psychotherapy.

One of the most extensive efforts to attempt to conceptualize and
differentiate Brief Interventions and Brief Treatments (and Long Term
Treatments) was CSAT's TIP 34: **Brief Interventions and Brief Therapies
for Substance Abuse**, published in 1999. The Consensus Panel for CSAT
TIP #34 describes the two activities as follows:

> ***Brief Intervention***
>
> Brief interventions are those practices that aim to investigate a
> potential problem and motivate an individual to begin to do something
> about his substance abuse, either by natural, client-directed means or
> by seeking additional substance abuse treatment.

# 

# *Brief Treatment (Therapy)*

> Brief treatment (therapy) is a systematic, focused process that relies
> on assessment, client engagement, and rapid implementation of change
> strategies. Brief therapies usually consist of more (as well as
> longer) sessions than brief interventions. The duration of brief
> therapies is reported to be anywhere from 1 session (Bloom, 1997) to
> 40 sessions (Sifneos, 1987), with the typical therapy lasting between
> 6 and 20 sessions. Twenty sessions usually is the maximum because of
> limitations placed by many managed care organizations. Any therapy may
> be brief by accident or circumstance, but the focus of this TIP is on
> *planned* brief therapy. The therapies described here may involve a
> set number of sessions or a set range (e.g., from 6 to 10 sessions),
> but they always work within a time limitation that is clear to both
> therapist and client.

In distinguishing between Brief Intervention and Brief Treatments,
Zweben and Fleming (1999) characterize Brief Interventions as a
low-cost, effective treatment alternative for alcohol and drug problems
that use time-limited, self-help and preventive strategies to promote
reductions in the case of nondependent clients, and in the case of
dependent clients to facilitate their referral to specialized treatment
programs. The primary goal in all cases is to increase motivation for
behavior change. Brief interventions do not teach specific cognitive or
behavioral skills, nor do they attempt to change a client's social
environment.

Some researchers, practitioners, and policy analysts have suggested that
the differentiation should be made on the basis of the number of
sessions, with Number range CHAPTERBrief Intervention typically lasting
1-3 sessions, not more than 5 sessions, and Brief Treatment typically
consisting of 6 or more sessions but not more than 20 sessions. Others
have limited Brief Interventions to only 1 or 2 sessions and Brief
Treatments to no more than 6 sessions.

Brief interventions and brief therapies may be thought of as elements on
a continuum of care, but they can be distinguished from each other
according to differences in outcome goals. Interventions are generally
aimed at motivating a client to perform a particular action (e.g., to
enter treatment, change a behavior, think differently about a
situation), whereas therapies are used to address larger concerns (such
as altering personality, maintaining abstinence, or addressing
long-standing problems that exacerbate substance abuse).

A bibliography containing descriptions and evaluations of various brief
intervention and brief treatment approaches is available from Project
Cork

> Project Cork. 2002. *CORK Bibliography: Brief Treatment in Substance
> Abuse*: *2000-2002*, 78 Citations.
> [http://www.projectcork.org/bibliographies/data/Bibliography_Brief_Treatment.html]{.underline}
>  

**Resources for Protocol Development**

Treatment Improvement Protocols (TIPs) are best practice guidelines for
the treatment of substance abuse. CSAT draws on the experience and
knowledge of clinical, research, and administrative experts to produce
the TIPs, which are distributed to a growing number of facilities and
individuals across the country. Examples of protocols, screening
instruments, and methods for carrying out activities required to
implement the SBIRT program can also be found in several Treatment
Improvement Protocols (TIPS) published by CSAT. TIPS can be accessed on
the internet through the Treatment Improvement Exchange at:
<http://www.treatment.org/Externals/tips.html>

> Barry KL Consensus Panel Chair. 1999. **Brief Interventions And Brief
> Therapies for Substance Abuse.** Treatment Improvement Protocol (TIP)
> Series 34. DHHS Publication No. (SMA) 99-3353.
>
> Blow FC. Consensus Panel Chair. 1998. **Substance Abuse Among Older
> Adults**. Treatment Improvement Protocol (TIP) Series 26. DHHS
> Publication No. (SMA) 98-3179.
>
> Miller WR. Consensus Panel Chair. 1999. **Enhancing Motivation for
> Change in Substance Abuse Treatment.** Treatment Improvement Protocol
> (TIP) Series 35. DHHS Publication No. (SMA) 99-3354.
>
> Rostenberg PO. Consensus Panel Chair. 1995. **Alcohol and Other Drug
> Screening of Hospitalized Trauma Patients.** Treatment Improvement
> Protocol (TIP) Series 16. DHHS Publication No. (SMA) 95-3039.
>
> Siegal H.A Consensus Panel Chair. 1998. **Comprehensive Case
> Management for Substance Abuse** Treatment. Treatment Improvement
> Protocol (TIP) Series 27. DHHS Publication No. (SMA) 98-3222.
>
> Sullivan E., Fleming, M. Consensus Panel Co-Chairs. 1997. **A Guide to
> Substance Abuse Services for Primary Care Clinicians**. Treatment
> Improvement Protocol (TIP) Series 24. DHHS Publication No. (SMA)
> 97-3139.

# Winters KC. Consensus Panel Chair. 1999. Treatment of Adolescents With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 32. DHHS Publication No. (SMA***)* 99-3283.**

An excellent example of a protocol that can guide implementation of a
systematic approach to expanding the continuum of care is that developed
by the VA/DoD Evidence-Based Clinical Practice Guideline Working Group,
Veterans Health Administration, Department of Veterans Affairs, and
Health Affairs, Department of Defense (2001). Electronic copies of the
guideline are available from: Office of Quality and Performance web
site: <http://www.oqp.med.va.gov/cpg/SUD/SUD_Base.htm>.

The VA/DoD guideline consists of five modules that address inter-related
aspects of care for patients with Substance Use Disorders. Module A,
Assessment and Management in Primary Care, provides a summary of the
evidence base for the use of screening and brief interventions and
outlines pathways for referral to specialty treatment.

**Module A:** **Assessment and Management in Primary Care** includes
screening, brief intervention, and specialty referral considerations.

**Module C:** **Care Management** emphasizes chronic disease management
for patients unwilling or unable to pursue rehabilitation goals.

**Module P:** **Addiction-Focused Pharmacotherapy** addresses use of
currently approved medications as part of treatment for alcohol and
opioid dependence.

**Module R:** **Assessment and Management in Specialty Care** focuses on
patients in need of further assessment or motivational enhancement or
who endorse rehabilitation goals.

**Module S:** **Stabilization** addresses detoxification and
pharmacological management of withdrawal symptoms.

The VA/DOD Guidelines and the TIPS are to presented here as examples
that may or may not fit a particular State's definition of its continuum
of care. New York State has developed its own procedures, as may have
other States:

New York State Office of Alcoholism and Substance Abuse Services (New
York OASAS). 1996. **Changing Directions: Reference Manual for Early
Intervention Services.** Albany NY: New York OASAS.

**Brief Intervention Manuals**

As noted in the RFA, CSAT has recently supported development and
evaluation of manualized brief intervention and brief treatment
strategies for adolescents and adults with marijuana use disorders that
can be utilized.

Manuals in the Cannabis Youth Treatment (CYT) Series include:

> Sample S., and Kadden R. 2002. **Motivational Enhancement Therapy and
> Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5
> Sessions**. Cannabis Youth Treatment (CYT) Series, Volume 1.
> <http://ncadi.samhsa.gov/govpubs/bkd384/>
>
> Webb C, Scudder M, Kaminer Y, and Kadden R 2002. **The Motivational
> Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7
> Sessions of Cognitive Behavioral Therapy for Adolescent Cannabis
> Users**. Cannabis Youth Treatment (CYT) Series, Volume 2.
> <http://ncadi.samhsa.gov/govpubs/bkd385>
>
> Hamilton NL., Brantley LB, Tims FM, Angelovich N., and McDougall B.
> 2002. **Family Support Network for Adolescent Cannabis Users**.
> Cannabis Youth Treatment (CYT) Series, Volume 3.
> http://ncadi.samhsa.gov/govpubs/bkd386/cyt3.pdf
>
> Godley SH., Meyers RJ, Smith JE, Karvinen T, Titus JC, Godley MD.,
> Dent G, Passetti L, and Kelberg P. 2002. **The Adolescent Community
> Reinforcement Approach for Adolescent Cannabis Users.** Cannabis Youth
> Treatment (CYT) Series, Volume 4.
>
> Liddle, HA. 2002. **Multidimensional Family Therapy for Adolescent
> Cannabis Users**, Cannabis Youth Treatment (CYT) Series, Volume 5.

These efforts build on prior research done under the auspices of the
National Institute on Drug Abuse (NIDA), the National Institute on
Alcoholism and Alcohol Abuse (NIAAA) and the World Health Organization
(WHO), which have has also issued several manuals that can also serve as
resources in project development:

> Babor TF and Higgins-Biddle JF. 2001**. Brief Intervention For
> Hazardous And Harmful Drinking: A Manual for Use in Primary Car**e.
> Geneva: World Health Organization. WHO/MSD/MSB/01.6b.
>
> Babor TF, Higgins-Biddle JC, Saunders JB, and Monteiro, MG. 2001.
> **AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for
> Use in Primary Care. Second Edition**. Geneva: World Health
> Organization. WHO/MSD/MSB/01.6a.
>
> Carroll KM 1998. **A Cognitive-Behavioral Approach: Treating Cocaine
> Addiction**. National Institute on Drug Abuse Therapy Manuals for Drug
> Addiction, Manual 1, NIH Publication 98-4308.
>
> Miller WR, Zweben A, DiClemente CC, et al. 1992. **Motivational
> Enhancement Therapy Manual: A Clinical Research Guide for Therapists
> Treating Individuals with Alcohol Abuse and Dependence.** NIAAA
> Project MATCH Monograph Series Vol. 2. DHHS Publication No. (ADM)
> 92-1894.
>
> National Institute on Alcohol Abuse and Alcoholism (NIAAA) 1995. **The
> Physicians\' Guide to Helping Patients With Alcohol Problems***.* NIH
> Publication No. 95-3769.
>
> National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2003.
> **Helping Patients with Alcohol Problems: A Health Practitioner's
> Guide**. NIH Publication No. 03-3769. Bethesda, MD: U.S. Department of
> Health and Human Services, Public Health Service, National Institutes
> of Health.
>
> Roberts LJ and McCrady BS 2002. **Alcohol Problems in Intimate
> Relationships: Identification and Intervention - A Guide for Marriage
> and Family Therapists**. Rockville MD: National Institute on Alcohol
> Abuse and Alcoholism.

#### Resources for Analyzing Barriers and Implementing Systems Change {#resources-for-analyzing-barriers-and-implementing-systems-change .unnumbered}

Additional resources for analyzing barriers to access and linkage
between the generalist and specialist agencies and devising policy
changes are provided by CSAT Technical Assistance Publications (TAPs).
TAPS are publications, manuals, and guides developed by CSAT to offer
practical responses to emerging issues and concerns in the substance
abuse treatment field. Each TAP is developed by an expert who has had
firsthand experience with the topic. TAPS can be accessed on the
internet through the Treatment Improvement Exchange at:
<http://www.treatment.org/Taps/>

TAPS that may be useful resources include:

> Crowe AH. and R Reeves. 1994. **Treatment for Alcohol and Other Drug
> Abuse: Opportunities for Coordination**. Technical Assistance
> Publication (TAP) Series 11.DHHS Publication No. (SMA) 94-2075.
>
> Hansen C. 1995. **Forecasting the Cost of Chemical Dependency
> Treatment Under Managed Care: The Washington State Study**. Technical
> Assistance Publication (TAP) Series 15. DHHS Publication No. (SMA)
> 95--3045).
>
> Moss S. 1998. **Contracting for Managed Substance Abuse and Mental
> Health Services: A Guide for Public Purchasers.** CSAT Technical
> Assistance Publication Series, Number 22.
> <http://www.treatment.org/taps/tap22/TAP22TOC.htm>

Other publications that can be used to understand development of cost
estimates, financing analyses, and systems change strategies are.

> Broskowski A and Smith S. 2001. **Estimating the Cost of Preventive
> Services in Mental Health and Substance Abuse Under Managed Care**.
> Substance Abuse and Mental Health Services Administration.
>
> [http://www.mentalhealth.org/publications/allpubs/SMA‑02‑3617R/appendix.asp](http://www.mentalhealth.org/publications/allpubs/SMA%1E02%1E3617R/appendix.asp)
>
> Denmead G and Rouse BA (eds) 1994. **Financing Drug Treatment Through
> State Programs.** Services Research Monograph No1. NIH Publication
> No.94-3543. Rockville MD: National Institute on Drug Abuse.
>
> Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL
> 2000. Benefit-cost analysis of brief physician advice with problem
> drinkers in primary care settings. *Med Care* 38(1): 7-18.
>
> French MT, et al. 2001. Using the drug abuse screening test to analyze
> health services utilization and cost for substance users in a
> community-based setting (DAST-10). *Substance Use and Misuse* 36(6-7):
> 927-46.

Fortney J and BM Booth. 2001. Access to substance abuse services in
rural areas. In Galanter M (ed). **Recent Developments in Alcoholism:
Volume 15. Services Research in the Era of Managed Care**. New York:
Plenum Press, pp. 177-197.

Horgan CM. and EL Merrick. 2001. Financing of substance abuse treatment
services. In Galanter M (ed) Recent Developments in Alcoholism: Volume
15. **Services Research in the Era of Managed Care**. New York: Plenum
Press, pp. 229-252.

> Libertoff K 1999. **Fighting for Parity in an Age of Incremental
> Health Care Reform**. Montpelier VT: Vermont Association for Mental
> Health.
>
> McCrady BS and Langenbucher JW. 1996. Alcohol treatment and health
> care system reform. *Archives of General Psychiatry*, 53(8): 737-746.
>
> National Association of State Alcohol and Drug Abuse Directors
> (NASADAD). 2002. **Identification and Description of Multiple Alcohol
> and Other Drug Treatment Systems.**
>
> Physician Leadership on National Drug Policy (PLNP). 2000. **Position
> Paper on Drug Policy.** Providence RI: Brown University Center for
> Alcohol and Addiction Studies
>
> <http://www.caas.brown.edu/plndp/Resources/researchrpt.pdf>
>
> Weisner C. 1992. The Merging of Alcohol and Drug Treatment: A Policy
> Review. *Journal of Public Health Policy* 13(1): 66‑80.
>
> Weisner C, Mertens J, Parthasarathy S, Moore C, and Lu Y. 2001.
> Integrating Primary Medical Care with Addiction Treatment: A
> Randomized Controlled Trial. *Journal of the American Medical
> Association* 286(14): 1715-1723.
>
> Weisner C, and Schmidt L. 1993. Alcohol and drug problems among
> diverse health and social service populations. *American Journal of
> Public Health* 83:824-829.
>
> Weisner C and Schmidt L 2001. Rethinking access to alcohol treatment.
> In Galanter M. (ed). **Recent Developments in Alcoholism: Volume 15.
> Services Research in the Era of Managed Care**. New York: Plenum
> Press, pp. 107-135.
>
> Weisner C, Matzger H, Tam T, and Schmidt L.  2002.  Who goes to
> alcohol and drug treatment? Understanding utilization within the
> context of insurance. *J. Stud. Alcohol* 63**:** 673-682.

Zarkin GA, Galinis DN, French MT. Fountain DL, Ingram PW, and Guyett JA.
1995. Financing strategies for drug abuse treatment programs. 1995.
Journal of *Substance Abuse Treatment*. 12(6): 385-399.

Additional articles that address strategies for overcoming resistance
and implementing systems change include:

> Babor TF and Higgins-Biddle JF. 2000. Alcohol screening and brief
> intervention: dissemination strategies for medical practice and public
> health. *Addiction.* 95(5): 677-686.
>
> Lock CA and Kaner E 2000. Use of Marketing to Disseminate Brief
> Alcohol Intervention to General Practitioners: Promoting Health Care
> Interventions to Health Promoters. *Journal of Evaluation in Clinical
> Practice*. 6(4): 345-357.
>
> Fleming MF. 2002. Screening, Assessment, and Intervention for
> Substance Use Disorders in Settings. In: ***Strategic Plan for
> Interdisciplinary Faculty Development: Arming the Nation's Health
> Professional Workforce for a New Approach to Substance Use
> Disorders*.** Providence RI: Association for Medical Education and
> Research in Substance Abuse (AMERSA).
>
> <http://www.projectmainstream.net/mainstream/supportdata/part1.pdf>
>
> Physician Leadership on National Drug Policy (PLNP). 2002**. Project
> Vital Sign.** Providence RI: Brown University Center for Alcohol and
> Addiction Studies.

The emphasis in this RFA is on expanding the State's continuum of care
to include screening, brief intervention, referral, and brief treatment
(SBIRT) in general medical settings. It is recognized that SBIRT
activities are being, or could be, carried out in non-medical community
settings (viz., student assistance programs, employee assistance
programs, and welfare offices, drug courts, senior citizen centers).

While most of the research has been focused on screening in primary care
medical settings, the approach can be effectively applied in many other
contexts as well. In many cases, procedures have already been developed
and used in these community settings for specific instruments, such as
the AUDIT. To provide an example, Table 5 summarizes information about
the settings, screening personnel, and target groups considered
appropriate for a screening program using the a screening instrument.

+----------------------+------------------------+---------------------+
| **Table 5:           |                        |                     |
| Personnel, Settings  |                        |                     |
| and Groups           |                        |                     |
| Considered           |                        |                     |
| Appropriate for a    |                        |                     |
| Screening Program    |                        |                     |
| Using Screening      |                        |                     |
| Instruments**[^20]   |                        |                     |
+----------------------+------------------------+---------------------+
| **Setting**          | **Target Group**       | **Screening         |
|                      |                        | Personnel**         |
+----------------------+------------------------+---------------------+
| Primary care clinic  | Medical patients       | Nurse, social       |
|                      |                        | worker              |
+----------------------+------------------------+---------------------+
| Emergency room       | Accident victims,      | Physicians, nurses, |
|                      | Intoxicated patients,  | or staff, health    |
|                      | trauma victims         | educators           |
+----------------------+------------------------+---------------------+
| Physician's office   | Medical patients       | General             |
|                      |                        | practitioners,      |
| Surgery              |                        |                     |
|                      |                        | family physicians,  |
| Prenatal and         |                        | physician           |
| perinatal clinics    |                        | extenders, nurses,  |
|                      |                        | or staff            |
+----------------------+------------------------+---------------------+
| General Hospital     | Patients with          | Internists,         |
| wards                | hypertension, heart    | physician           |
|                      | disease,               | extenders, nurses,  |
| Outpatient clinic    | gastrointestinal       | staff               |
|                      |                        |                     |
|                      | or neurological        |                     |
|                      | disorders              |                     |
+----------------------+------------------------+---------------------+
| Psychiatric hospital | Psychiatric patients,  | Psychiatrists,      |
|                      | particularly those who | psychologists,      |
|                      | are suicidal           | counselors, staff   |
+----------------------+------------------------+---------------------+
| Court, jail, prison  | DWI offenders, violent | Officers,           |
|                      | criminals              | counselors,         |
|                      |                        | probation officers  |
+----------------------+------------------------+---------------------+
| Other health-related | Persons demonstrating  | Health and human    |
| facilities           | impaired social or     | service workers     |
|                      | occupational           |                     |
|                      | functioning            |                     |
|                      |                        |                     |
|                      | (e.g. marital discord, |                     |
|                      |                        |                     |
|                      | child neglect, etc.)   |                     |
+----------------------+------------------------+---------------------+
| Military Services    | Enlisted men and       | Medics              |
|                      | officers               |                     |
+----------------------+------------------------+---------------------+
| Welfare Offices      | Applicants and clients | Social Workers,     |
|                      |                        | case aides          |
+----------------------+------------------------+---------------------+
| Workplace            | Workers, especially    | Employee assistance |
|                      | those                  | staff               |
| Employee Assistance  |                        |                     |
| Program              | having problems with   |                     |
|                      |                        |                     |
|                      | productivity,          |                     |
|                      | absenteeism            |                     |
|                      |                        |                     |
|                      | or accidents           |                     |
+----------------------+------------------------+---------------------+

A State could include such efforts in their proposal but must recognize
these efforts must comport to the diagnostic considerations outlined
here. Examples of such activities can be found in these and other
publications:

> Inciardi JA Consensus Panel Chair 1994. **Screening and Assessment for
> Alcohol and Other Drug Abuse Among Adults in the Criminal Justice
> System.** Treatment Improvement Protocol (TIP) Series 7. DHHS
> Publication No. (SMA) 94B2076
>
> White WL and Dennis M. 20002. Number range CHAPTERThe cannabis youth
> treatment experiment: Key lessons for student assistance programs.
> *Student Assistance Journal,* 14: 16-19.
>
> Young, N. K. 1996. **Alcohol and Other Drug Treatment: Policy Choices
> in Welfare Reform**. Washington DC: National Association of State
> Alcohol and Drug Abuse Directors.
>
> Young N. K., S. L. Gardner, and K. Dennis. 1998. **Responding to
> Alcohol and other Drug Problems in Child Welfare: Weaving Together
> practice and Policy**. Washington DC: Child Welfare League of America
> Press.
>
> Young NK and Gardner SL. 2002. **Navigating the Pathways: Lessons and
> Promising Practices in Linking Alcohol and Drug Services with Child
> Welfare**. . Technical Assistance Publication (TAP) Series 27. SAMHSA
> Publication No. (SMA) 02--3639.

**Resources for Developing Need Estimates**

Resources that can be referred to for developing estimates of need for
treatment and resource availability are:

> DeWit DJ and Rush B 1996. Assessing the Need for Substance Abuse
> Services: A Critical Review of Needs Assessment Models. *Evaluation
> and Program Planning*. 19(1): 41-64.
>
> Epstein JF 2002. **Substance Dependence, Abuse, and Treatment:
> Findings from the 2000 National Household Survey on Drug Abuse**
> (*DHHS Publication No. SMA 02-3642, NHSDA Series A-16*). Rockville MD:
> Substance Abuse and Mental Health Services Administration, Office of
> Applied Studies
>
> Gerstein D and Harwood H (eds). 1990. **Treating Drug Problems**, Vol.
> I. Washington DC: National Academy Press. (Chapter 3)
>
> Institute of Medicine. 1990. **Broadening the Base of Treatment for
> Alcohol Problems**. Washington DC: National Academy Press. (Chapters 7
> and 9)
>
> Maxwell JC (ed). 2001. **Multiple Indicator Analysis: Using Secondary
> Data to Analyze Illicit Drug Use**. DHHS Publication No. (SMA)
> 01-3539. Rockville, MD: Center for Substance Abuse Treatment and
> Center for Mental Health Services, Substance Abuse and Mental Health
> Services Administration.
>
> McAuliffeWE, Woodworth R, Zhang CH, and Dunn, RP. 2002. Identifying
> substance abuse treatment gaps in substate areas. J. *Substance Abuse
> Treatment*. 23(3): 199-208.
>
> Office of Applied Studies. 2002. **National and State Estimates of the
> Drug Abuse Treatment Gap: 2000 National Household Survey on Drug
> Abuse** *(NHSDA Series H-14, DHHS Publication No. SMA 02-3640)*.
> Rockville, MD: Substance Abuse and Mental Health Services
> Administration. http://www.samhsa.gov/oas/TXgap/toc.htm
>
> Number range CHAPTERRush B. 1996. Alcohol and other drug problems and
> treatment systems: A framework for research and development.
> *Addiction*. 91(5): 629-642.

#### Collaboration with Addiction Technology Training Centers as a Training Resource {#collaboration-with-addiction-technology-training-centers-as-a-training-resource .unnumbered}

SAMHSA/CSAT funds a network of 14 independent regional Addiction
Technology Transfer Centers (ATTCs) and a National Office
(http://www.nattc.org). The ATTCs constitute a nationwide,
multi-disciplinary resource that draws upon the knowledge, experience
and latest work of recognized experts in the field of addictions. A list
of ATTCs, the States covered, and contact information is provided in
Table 5. Each ATTC serves as a resource to 2 or more States, having
memoranda of understanding with the State Substance Abuse Authorities
(SSAs).

Table 5:Addiction Technology Transfer Center Contacts

+-----------------------------------+-----------------------------------+
| **Maine, New Hampshire,           | #                                 |
| Vermont,**                        |                                   |
|                                   | # Georgia, South Carolina         |
| Massachusetts, Connecticut, Rhode |                                   |
| Island                            | Southeast ATTC                    |
|                                   |                                   |
| ATTC of New England               | Morehouse School of Medicine      |
|                                   |                                   |
| Center for Alcohol and Addiction  | CORK Institute                    |
|                                   |                                   |
| Studies                           | Atlanta, Georgia 30310            |
|                                   |                                   |
| Brown University                  | \(404\) 756-5742                  |
|                                   |                                   |
| Providence, Rhode Island 02912    | [www.s                            |
|                                   | attc.org](http://www.sattc.org/)  |
| \(401\) 444-1808                  |                                   |
|                                   | Director: Wyeuca Johnson, LCSW,   |
| [www.attc                         | ACSW                              |
| -ne.org](http://www.attc-ne.org/) |                                   |
|                                   | Virginia, Maryland, North         |
| Director: Susan Storti, PhD, RN   | Carolina,\                        |
|                                   | West Virginia                     |
| # N                               |                                   |
| ew York, New Jersey, Pennsylvania | Mid-Atlantic ATTC                 |
|                                   |                                   |
| Northeast ATTC                    | Virginia Commonwealth University  |
|                                   |                                   |
| Institute for Research, Education | Richmond, Virginia 23298-0469     |
| and                               |                                   |
|                                   | \(804\) 828-9910                  |
| Training in Addictions            |                                   |
|                                   | [www.mid-at                       |
| Pittsburgh, Pennsylvania 15219    | tc.org](http://www.mid-attc.org/) |
|                                   |                                   |
| \(866\) 246-5344                  | Director: Paula Horvatich, PhD    |
|                                   |                                   |
| [www.ireta.org                    |                                   |
| /attc](http://www.ireta.org/attc) |                                   |
|                                   | **Illinois, Ohio, Wisconsin,      |
| Director: Michael Flaherty, PhD   | Indiana, Michigan**               |
|                                   |                                   |
| District of Columbia, Delaware,\  | Great Lakes ATTC                  |
| Kentucky, Tennessee, Maryland     |                                   |
|                                   | Jane Addams College of Social     |
| Central East ATTC                 | Work                              |
|                                   |                                   |
| DANYA Institute                   | University of Illinois-Chicago    |
|                                   |                                   |
| Silver Spring, Maryland 20910     | Chicago, Illinois 60612           |
|                                   |                                   |
| \(240\) 645-1145                  | \(312\) 996-1373                  |
|                                   |                                   |
| [www.ce                           | [www.gl                           |
| attc.org](http://www.ceattc.org/) | attc.org](http://www.glattc.org/) |
|                                   |                                   |
| Director: Linda Kaplan, MA        | Director: Lonnetta Albright       |
+-----------------------------------+-----------------------------------+
| **Iowa, Nebraska, North Dakota,   | **California, Arizona, New        |
| South Dakota, Minnesota**         | Mexico**                          |
|                                   |                                   |
| Prairielands ATTC                 | Pacific Southwest ATTC            |
|                                   |                                   |
| University of Iowa                | UCLA Integrated Substance Abuse   |
|                                   |                                   |
| Iowa City, Iowa 52242             | Programs                          |
|                                   |                                   |
| \(319\) 335-5368                  | Los Angeles California 90025      |
|                                   |                                   |
| [www.p                            | \(310\) 312-0500                  |
| attc.org](http://www.pattc.org/)  |                                   |
|                                   | <http://www.psattc.org/>          |
| Director: Anne Helene Skinstad,   |                                   |
| PhD                               | Director: Thomas Freese, PhD\     |
|                                   | Co-Director: Michael Shafer, PhD  |
| **Nevada, Montana, Wyoming, Utah, |                                   |
| Colorado**                        |                                   |
|                                   |                                   |
| Mountain West ATTC                | # Puerto Rico, US Virgin Islands  |
|                                   |                                   |
| University of Nevada, Reno        | Caribbean Basin and Hispanic ATTC |
|                                   |                                   |
| Reno, Nevada 89557                | Centro de Estudios en Adiccion    |
|                                   |                                   |
| \(775\) 784-6265                  | Universidad Central del Caribe    |
|                                   |                                   |
| [www.mw                           | Call Box 60-327                   |
| attc.org](http://www.mwattc.org/) |                                   |
|                                   | Bayamon, Puerto Rico 00960-6032   |
| Principal Investigator: Nancy     |                                   |
| Roget, MS\                        | \(787\) 785-4211                  |
| Co-PI: Gary L. Fisher, PhD        |                                   |
|                                   | web <http://cbattc.uccaribe.edu/> |
|                                   |                                   |
|                                   | Director: Rafaela Robles, EdD     |
| **Alaska, Washington, Oregon,     |                                   |
| Idaho,**                          | # Alabama, Florida                |
|                                   |                                   |
| **Hawaii, Pacific Islands**       | Southern Coast ATTC               |
|                                   |                                   |
| Northwest Frontier ATTC           | Florida Certification Board       |
|                                   |                                   |
| Salem, Oregon 97303               | Tallahassee Florida 32301         |
|                                   |                                   |
| \(503\) 373-1322                  | \(850\) 222-6731                  |
|                                   |                                   |
| [www.nf                           | [www.sc                           |
| attc.org](http://www.nfattc.org/) | attc.org](http://www.scattc.org/) |
|                                   |                                   |
| Director: Steve Gallon, PhD       | Director: Pam Waters              |
|                                   |                                   |
| **Texas, Louisiana, Mississippi** | # National Office                 |
|                                   |                                   |
| Gulf Coast ATTC                   | University of Missouri - Kansas   |
|                                   | City                              |
| University of Texas               |                                   |
|                                   | Kansas City, MO 64110-2499        |
| Center for Social Work Research   |                                   |
|                                   | \(816\) 482-1200                  |
| Austin, Texas 78703               |                                   |
|                                   | <http://www.nattc.org/>           |
| \(512\) 232-0616                  |                                   |
|                                   | Director: Mary Beth Johnson, MSW  |
| [www.ut                           |                                   |
| attc.net](http://www.utattc.net/) |                                   |
|                                   |                                   |
| Director: Richard Spence, PhD     |                                   |
+-----------------------------------+-----------------------------------+

**APPENDIX B**

**CSAT=s GPRA STRATEGY**

**OVERVIEW**

The Government Performance and Results Act of 1993 (Public Law-103-62)
requires all federal departments and agencies to develop strategic plans
that specify what they will accomplish over a three to five year period,
to annually set performance targets related to their strategic plan, and
to annually report the degree to which the targets set in the previous
year were met. In addition, agencies are expected to regularly conduct
evaluations of their programs and to use the results of those
evaluations to Aexplain@ their success and failures based on the
performance monitoring data. While the language of the statute talks
about separate Annual Performance Plans and Annual Performance Reports,
ASMB/HHS has chosen to incorporate the elements of the annual reports
into the annual President=s Budget and supporting documents. The
following provides an overview of how the Center for Substance Abuse
Treatment, in conjunction with the Office of the Administrator/SAMHSA,
CMHS, and CSAP, are addressing these statutory requirements.

**DEFINITIONS**

Performance Monitoring The ongoing measurement and reporting of program
accomplishments, particularly progress towards preestablished goals. The
monitoring can involve process, output, and outcome measures.

Evaluation Individual systematic studies conducted periodically or Aas
needed@ to assess how well a program is working and why particular
outcomes have (or have not) been achieved.

Program For GPRA reporting purposes, a set of activities that have a
common purpose and for which targets can (will) be established.[^21]

Activity A group of grants, cooperative agreements, and contracts that
together are directed toward a common objective.

Project An individual grant, cooperative agreement, or contract.

**CENTER (OR MISSION) GPRA OUTCOMES**

The mission of the Center for Substance Abuse Treatment is to support
and improve the effectiveness and efficiency of substance abuse
treatment services throughout the United States. However, it is not the
only agency in the Federal government that has substance abuse treatment
as part of its mission. The Health Care Financing Administration,
Department of Veterans Affairs, and the Department of Justice all
provide considerable support to substance abuse treatment. It shares
with these agencies responsibility for achieving the objectives and
targets for Goal 3 of the Office of National Drug Control Policy=s
[Performance Measures of Effectiveness:]{.underline}

Reduce the Health and Social Costs Associated with Drug Use.

Objective 1 is to support and promote effective, efficient, and
accessible drug treatment, ensuring the development of a system that is
responsive to emerging trends in drug abuse. The individual target areas
under this objective include reducing the treatment gap (Goal 3.1.1),
demonstrating improved effectiveness for those completing treatment
(Goal 3.1.2), reducing waiting time for treatment (Goal 3.1.3),
implementing a national treatment outcome monitoring system (Goal
3.1.4), and disseminating treatment information (Goal 3.1.5). Objective
4 is to support and promote the education, training, and credentialing
of professionals who work with substance abusers.

CSAT works closely with ONDCP, and other Federal demand reduction
agencies to develop annual targets and to implement a data
collection/information management strategy that will provide the
necessary measures to report on an annual basis on progress toward the
targets presented in the ONDCP plan. These performance measures will, at
an aggregate level, provide a measure of the overall success of CSAT=s
activities. While it will be extremely difficult to attribute success or
failure in meeting ONDCP=s goals to individual programs or agencies,
CSAT is committed to working with ONDCP on evaluations designed to
attempt to disaggregate the effects. With regard to the data necessary
to measure progress, the National Household Survey on Drug Abuse
(conducted by SAMHSA) is the principal source of data on prevalence of
drug abuse and on the treatment gap. Assessing progress on improving
effectiveness for those completing treatment requires the implementation
of a national treatment outcome monitoring system (Target 3.1.4). ONDCP
is funding an effort to develop such a system and it is projected in
[Performance Measures of Effectiveness]{.underline} to be completed by
FY 2002.

Until the system is able to provide data CSAT will rely on more limited
data, generated within its own funded grant programs, to provide an
indication of the impact that our efforts are having in these particular
target areas. It will not be representative of the overall national
treatment system, nor of all Federal activities that could affect these
outcomes. For example, from its targeted capacity expansion program CSAT
can present baseline data on the numbers of individuals treated, percent
completing treatment, percent not using illegal drugs, percent employed,
and percent engaged in illegal activity (i.e., measures indicated in the
ONDCP targets) in its FY 2002 report with targets for future years. As
the efforts to incorporate outcome indicators into the SAPT Block Grant
are completed over the next several years, these will be added to the
outcomes reported from the targeted capacity expansion program.

In addition to these Aend@ outcomes, it is suggested that CSAT consider
a routine customer service survey to provide the broadest possible range
of customers (and potential customers) with a means of providing
feedback on our services and input into future efforts. We would propose
an annual survey with a short, structured questionnaire that would also
include an unstructured opportunity for respondents to provide
additional input if they so choose.

**CSAT's APROGRAMS@ FOR GPRA REPORTING PURPOSES**

All activities in SAMHSA (and, therefore, CSAT) have been divided into
three broad areas or Aprogrammatic goals@ for GPRA reporting purposes:

-   Goal 1: Assure services availability;

-   Goal 2: Meet unmet and emerging needs;

-   Goal 3: Identify and implement best practices

For each GPRA \[program\] goal, a standard set of output measures has
been identified for CSAT activities to provide the basis for
establishing targets and reporting performance.

**1. ASSURE SERVICES AVAILABILITY**

Into this program goal area fall the major services activities of CSAT:
the Substance Abuse Prevention and Treatment Block Grant. In FY 2000 the
Block grant application was revised and approved by the Office of
Management and Budget to permit the voluntary collection of data from
the States. More specifically:

-   Number of clients served (unduplicated)

-   Increase % of adults receiving services who:

\(a\) were currently employed or engaged in productive activities;

\(b\) had a permanent place to live in the community;

\(c\) had no/reduced involvement with the criminal justice system.

-   Percent decrease in

\(a\) Alcohol use;

\(b\) Marijuana use;

\(c\) Cocaine use;

\(d\) Amphetamine use

\(e\) Opiate use

In addition, in the Fall of 1999 a customer satisfaction survey was
designed and approved for collection from each state on the level of
satisfaction with Technical Assistance and Needs Assessment Services
provided to the States. More specifically:

-   Increase % of States that express satisfaction with TA provided

-   Increase % of TA events that result in systems, program or practice
    improvements

**2. MEET UNMET OR EMERGING NEEDS**

Into this program goal area fall the major services activities of CSAT:
Targeted Capacity Expansion Grants. Simplistically, the following
questions need to be answered about these activities within a
performance monitoring context:

-   Were identified needs met?

-   Was service availability improved?

-   Are client outcomes good (e.g., better than benchmarks)?

The client outcome assessment strategy mentioned earlier will provide
the data necessary for CSAT to address these questions. The strategy,
developed and shared by the three Centers, involves requiring each
SAMHSA project that involves services to individuals to collect a
uniform set of data elements from each individual at admission to
services and 6 and 12 months after admission. The outcomes (as
appropriate) that will be tracked using this data are:

-   Percent of adults receiving services who:

a\) were currently employed or engaged in productive activities

b\) had a permanent place to live in the community

c\) had reduced involvement with the criminal justice system

d\) had no past month use of illegal drugs or misuse of prescription
drugs

> e\) experienced reduced alcohol or illegal drug related health,
> behavior, or social consequences, including the misuse of prescription
> drugs

-   Percent of children/adolescents under age 18 receiving services who:

a\) were attending school

b\) were residing in a stable living environment

c\) had no involvement in the juvenile justice system

> d\) had no past month use of alcohol or illegal drugs
>
> e\) experience~~d~~ reduced substance abuse related health, behavior,
> or social. consequences.

These data, combined with data taken from the initial grant
applications, will enable CSAT to address each of the critical success
questions.

**3. IDENTIFY AND IMPLEMENT BEST PRACTICES**

This Aprogram@ involves promoting the adoption of best practices and is
synonymous currently with Knowledge Application.[^22] Within CSAT, these
activities currently include the Product Development and Targeted
Dissemination contract (to include TIPS, TAPS, and Substance Abuse in
Brief), the Addiction Technology Transfer Centers, the Practice
Improvement Collaboratives, and the Conference Grants.

Activities in this program have the purpose of moving Abest practices@,
as determined by research and other knowledge development activities,
into routine use in the treatment system. Again simplistically, the
immediate success of these activities can be measured by the extent to
which they result in the adoption of a Abest practice.@[^23] In order to
provide appropriate GPRA measures in this area, CSAT plans to require
that all activities that contribute to this goal to collect information
on the numbers and types of services rendered, the receipt of the
service by the clients and their satisfaction with the services, and
whether the services resulted in the adoption of a best practice related
to the service rendered.

**EVALUATIONS**

As defined earlier, evaluation refers to periodic efforts to validate
performance monitoring data; to examine, in greater depth, the reasons
why particular performance measures are changing (positively or
negatively); and to address specific questions posed by program managers
about their programs. These types of evaluation are explicitly
described, and expected, within the GPRA framework. In fact, on an
annual basis, the results of evaluations are to be presented and future
evaluations described.

To date, CSAT has not developed any evaluations explicitly within the
GPRA framework. The initial requirements will, of necessity, involve
examinations of the reliability and validity of the performance measures
developed in each of the four program areas. At the same time, it is
expected that CSAT managers will begin to ask questions about the
meaning of the performance monitoring data as they begin to come in and
be analyzed and reported. This will provide the opportunity to design
and conduct evaluations that are tied to Areal@ management questions
and, therefore, of greater potential usefulness to CSAT. CSAT will be
developing a GPRA support contract that permits CSAT to respond flexibly
to these situations as they arise.

On a rotating basis, program evaluations will be conducted to validate
the performance monitoring data and to extend our understanding of the
impacts of the activities on the adoption of best practices.

Number range CHAPTERForm Approved

OMB No. 0930-0208

Expiration Date 12/31/2005

**APPENDIX C**

**CSAT GPRA Client Outcome**

**Measures for Discretionary Programs**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
client/participant; to the extent that providers already obtain much of
this information as part of their ongoing client/participant intake or
followup, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information to
SAMHSA Reports Clearance Officer, Room 16-105, 5600 Fishers Lane,
Rockville, MD 20857. An agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it
displays a currently valid OMB control number. The control number for
this project is 0930-0208.

**A. RECORD MANAGEMENT**

**Client ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Contract/Grant ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Grant Year** \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

> Year

**Interview Date** \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Interview Type**

> 1\. Intake 2. 6 month follow-up 3. 12 month follow-up 4. 3 month
> follow-up

**Service Type**

> **For *intake* interview: What service type *will* the client receive
> in your program?** (Check all
>
> that apply.)
>
> \_\_\_\_\_ 1. Case Management
>
> \_\_\_\_\_ 2. Day Treatment
>
> \_\_\_\_\_ 3. Inpatient
>
> \_\_\_\_\_ 4. Outpatient
>
> \_\_\_\_\_ 5. Outreach
>
> \_\_\_\_\_ 6. Intensive Outpatient
>
> \_\_\_\_\_ 7. Methadone
>
> \_\_\_\_\_ 8. Residential
>
> \_\_\_\_\_ 9. Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_ 10. Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_ 11. Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B. DRUG AND ALCOHOL USE

+-------------------------------------------------------+---------------+
| **1. During the past 30 days how many days have you   | **Number of   |
| used the following:**                                 | Days**        |
+-------------------------------------------------------+---------------+
| > a\. Any alcohol                                     | \|\_\_\_\     |
|                                                       | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| > b1. Alcohol to intoxication (5+ drinks in one       | \|\_\_\_\_\|\ |
| > sitting)                                            | _\_\_\_**\|** |
+-------------------------------------------------------+---------------+
| > b2. Alcohol to intoxication (4 or fewer drinks and  | **\|\_\_\_\_\ |
| > felt high)                                          | |\_\_\_\_\|** |
+-------------------------------------------------------+---------------+
| > c\. Illegal drugs                                   | **\|\_\_\_\_\ |
|                                                       | |\_\_\_\_\|** |
+-------------------------------------------------------+---------------+
| **2. During the past 30 days, how many days have you  | **Number of   |
| used any of the following:**                          | Days**        |
+-------------------------------------------------------+---------------+
| > a\. Cocaine/Crack                                   | \|\_\_\_\_\   |
|                                                       | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| > b\. Marijuana/Hashish (Pot, Joints, Blunts,         | \|\_\_\_\_\   |
| > Chronic, Weed, Mary Jane)                           | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| > c\. Heroin (Smack, H, Junk, Skag), or other         | \|\_\_\_\_\   |
| > opiates:                                            | _\|\_\_\_\_\| |
| >                                                     |               |
| > 1\. Heroin (Smack, H, Junk, Skag)                   | \|\_\_\_\_\   |
| >                                                     | _\|\_\_\_\_\| |
| > 2\. Morphine                                        |               |
| >                                                     | \|\_\_\_\_\   |
| > 3\. Diluadid                                        | _\|\_\_\_\_\| |
| >                                                     |               |
| > 4\. Demerol                                         | \|\_\_\_\_\   |
| >                                                     | _\|\_\_\_\_\| |
| > 5\. Percocet                                        |               |
| >                                                     | \|\_\_\_\_\   |
| > 6\. Darvon                                          | _\|\_\_\_\_\| |
| >                                                     |               |
| > 7\. Codeine                                         | \|\_\_\_\_\   |
| >                                                     | _\|\_\_\_\_\| |
| > 8\. Tylenol 2,3,4                                   |               |
|                                                       | \|\_\_\_\_\   |
|                                                       | _\|\_\_\_\_\| |
|                                                       |               |
|                                                       | \|\_\_\_\_\   |
|                                                       | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| > d\. Non-prescription methadone                      | \|\_\_\_\     |
|                                                       | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| e\. Hallucinogens/psychedelics, PCP (Angel Dust,      | **\|\_\_\_\_\ |
| Ozone, Wack, Rocket Fuel) MDMA (Ecstasy, XTC, X,      | |\_\_\_\_\|** |
| Adam), LSD (Acid, Boomers, Yellow Sunshine),          |               |
| Mushrooms or Mescaline                                |               |
+-------------------------------------------------------+---------------+
| f\. Methamphetamine or other amphetamines (Meth,      | **\|\_\_\_\_\ |
| Uppers, Speed, Ice, Chalk, Crystal, Glass, Fire,      | |\_\_\_\_\|** |
| Crank)                                                |               |
+-------------------------------------------------------+---------------+
| > []{.mark}                                           | **\|\_\_\_\_\ |
| >                                                     | |\_\_\_\_\|** |
| > g\. 1. Benzodiazepines: Diazepam (Valium);          |               |
| > Alpeazolam (Xanax); Triazolam (Halcion); and        | **\|\_\_\_\_\ |
| > Estasolam (Prosom and Rohypnol--also known as       | |\_\_\_\_\|** |
| > roofies, roche, and cope)                           |               |
| >                                                     | **\|\_\_\_\_\ |
| > 2\. Barbiturates: Mephobarbital (Mebacut); and      | |\_\_\_\_\|** |
| > pentobarbital sodium (Nembutal)                     |               |
| >                                                     | **\|\_\_\_\_\ |
| > 3\. Non-prescription GHB (known as Grievous Bodily  | |\_\_\_\_\|** |
| > Harm; Liquid Ecstasy; and Georgia Home Boy)         |               |
| >                                                     | **\|\_\_\_\_\ |
| > 4\. Ketamine (known as Special K or Vitamin K)      | |\_\_\_\_\|** |
|                                                       |               |
| 5\. Other tranquilizers, downers, sedatives or        |               |
| hypnotics Number range CHAPTER                        |               |
+-------------------------------------------------------+---------------+
| > h\. Inhalants (poppers, snappers, rush, whippets)   | \|\_\_\_\     |
|                                                       | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+
| > i\. Other illegal drugs (specify)                   | \|\_\_\_\     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                    | _\|\_\_\_\_\| |
+-------------------------------------------------------+---------------+

**3. In the past 30 days have you injected drugs**?  Yes  No

If no, go to Section C.

4.  **In the past 30 days, how often did you use a syringe/needle,
    cooker, cotton or water that someone else used?**

>  Always
>
>  More then half the time
>
>  Half the time
>
>  Less then half the time
>
>  Never

**C. FAMILY AND LIVING CONDITIONS**

+---------------------------------------------------------------------+---+
| **1. In the past 30 days, where have you been living most of the    |   |
| time?**                                                             |   |
|                                                                     |   |
| >  Shelter (safe havens, TLC, low demand facilities, reception     |   |
| > centers, other temporary day or evening facility)                 |   |
| >                                                                   |   |
| >  Street/outdoors (sidewalk, doorway, park, public or abandoned   |   |
| > building)                                                         |   |
| >                                                                   |   |
| >  Institution (hospital, nursing home, jail/prison)               |   |
| >                                                                   |   |
| >  Housed:                                                         |   |
| >                                                                   |   |
| >  Own/rent apartment, room, or house                              |   |
| >                                                                   |   |
| >  Someone else's apartment, room or house                         |   |
| >                                                                   |   |
| >  Halfway house                                                   |   |
| >                                                                   |   |
| >  Residential treatment                                           |   |
| >                                                                   |   |
| >  Other housed                                                    |   |
| > (specify)\_\                                                      |   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |
+---------------------------------------------------------------------+---+
| 2.  **During the past 30 days, how stressful have things been for   |   |
|     you because of your use of**                                    |   |
|                                                                     |   |
| > **alcohol or other drugs?**                                       |   |
| >                                                                   |   |
| >  Not at all                                                      |   |
| >                                                                   |   |
| >  Somewhat                                                        |   |
| >                                                                   |   |
| > Considerably                                                   |   |
|                                                                     |   |
| -   Extremely                                                       |   |
|                                                                     |   |
| -   Not applicable                                                  |   |
|                                                                     |   |
| 3.  **During the past 30 days, has your use of alcohol or other     |   |
|     drugs caused you to reduce or give**                            |   |
|                                                                     |   |
| > **up important activities?**                                      |   |
| >                                                                   |   |
| >  Not at all                                                      |   |
| >                                                                   |   |
| >  Somewhat                                                        |   |
| >                                                                   |   |
| >  Considerably                                                    |   |
|                                                                     |   |
| -   Extremely                                                       |   |
|                                                                     |   |
| -   Not applicable                                                  |   |
+---------------------------------------------------------------------+---+

**4**. **During the past 30 days, has your use of alcohol or other drugs
caused you to have emotional problems?**

>  Not at all
>
>  Somewhat
>
>  Considerably

-   Extremely

-   Not Applicable

#### 

#### D. EDUCATION, EMPLOYMENT, AND INCOME

1.  **Are you currently enrolled in school or a job training program?
    (IF ENROLLED: Is that full time or part time?)**

>  Not enrolled
>
>  Enrolled, full time
>
>  Enrolled, part time
>
>  Other (specify)\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  **What is the highest level of education you have finished, whether
    or not you received a degree?** (01=1st grade, 12=12th grade,
    13=college freshman, 16=college completion)

\|\_\_\_\_\|\_\_\_\_\| level in years

**2a. If less than 12 years of education, do you have a GED (General
Equivalency Diploma)?**

 Yes  No

3.  **Are you currently employed?** (Clarify by focusing on status
    during most of the previous week, determining whether client worked
    at all or had a regular job but was off work)

>  Employed full time (35+ hours per week, or would have been )
>
>  Employed part time
>
>  Unemployed, looking for work
>
>  Unemployed, disabled
>
>  Unemployed, volunteer work
>
>  Unemployed, retired
>
>  Unemployed, not looking for work
>
>  Other (specify) \_\_\_\_\_\_\_\_\_\_\_

4.  **Approximately, how much money did YOU receive (pre-tax individual
    income) in the past 30 days from...**

> INCOME

  ---------------------------------- ---- ---- ---- ---- --- ---- ---- ---- -----
  a\. Wages                          \$                  ,                  .00

  b\. Public assistance              \$                  ,                  .00

  c\. Retirement                     \$                  ,                  .00

  d\. Disability                     \$                  ,                  .00

  e\. Non-legal income               \$                  ,                  .00

  f\. Other (specify)                \$                  ,                  .00
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                          
  ---------------------------------- ---- ---- ---- ---- --- ---- ---- ---- -----

**E. CRIME AND CRIMINAL JUSTICE STATUS**

+---------------------------------------------------------+------------+
| 1.  In the past 30 days, how many times have you been   | \|         |
|     arrested?                                           | \_\_\_\_\| |
|                                                         | \_\_\_\_\| |
| > If no arrests, go to item E3                          | times      |
+---------------------------------------------------------+------------+
| **2. In the past 30 days, how many times have you been  | \|         |
| arrested for drug-related offenses?**                   | \_\_\_\_\| |
|                                                         | \_\_\_\_\| |
|                                                         | times      |
+---------------------------------------------------------+------------+
| **3. In the past 30 days, how many nights have you      | \|         |
| spent in jail/prison?**                                 | \_\_\_\_\| |
|                                                         | \_\_\_\_\| |
|                                                         | nights     |
+---------------------------------------------------------+------------+

**F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT**

+-------------------------------------------------------+--------------+
| **1. How would you rate your overall health right     |              |
| now?**                                                |              |
|                                                       |              |
| >  Excellent                                         |              |
| >                                                     |              |
| >  Very good                                         |              |
| >                                                     |              |
| >  Good                                              |              |
| >                                                     |              |
| >  Fair                                              |              |
| >                                                     |              |
| >  Poor                                              |              |
+-------------------------------------------------------+--------------+

**2. During the past 30 days, did you receive:**

**a. Inpatient Treatment for: If yes, altogether**

No Yes  for how many nights

(DK=98)

i\. Physical complaint   \_\_\_\_\_\_\_\_\_\_\_

ii\. Mental or emotional difficulties   \_\_\_\_\_\_\_\_\_\_\_

iii\. Alcohol or substance abuse   \_\_\_\_\_\_\_\_\_\_\_

**b. Outpatient Treatment for: If yes, altogether**

No Yes  how many times

(DK=98)

i\. Physical complaint   \_\_\_\_\_\_\_\_\_\_\_

ii\. Mental or emotional difficulties   \_\_\_\_\_\_\_\_\_\_\_

iii\. Alcohol or substance abuse   \_\_\_\_\_\_\_\_\_\_\_

**c. Emergency Room Treatment for: If yes, altogether**

No Yes  for how many times

(DK=98)

i\. Physical complaint   \_\_\_\_\_\_\_\_\_\_\_

ii\. Mental or emotional difficulties   \_\_\_\_\_\_\_\_\_\_\_

iii\. Alcohol or substance abuse   \_\_\_\_\_\_\_\_\_\_\_

[]{.mark}

**3. During the past 30 days, did you engage in sexual activity?**

-   Not permitted to ask  Yes  No

> **If yes, altogether**
>
> How many
>
> (DK=98) how many
>
> (DK=98)
>
> a\. Sexual contacts (vaginal, oral, or anal) did you have?
> \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|
>
> b\. Unprotected sexual contacts did you have?
> \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|
>
> c\. Unprotected sexual contacts were with an individual who is or was:
>
> 1\. HIV positive or has AIDS \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|
>
> 2\. An injection drug user \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|
>
> 3\. High on some substance \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

[]{.mark}

4.  **In the past 30 days (not due to your use of alcohol or drugs) how
    many days have you:**

> a\. Experienced serious depression \|\_\_\_\_\|\_\_\_\_\|
>
> b\. Experienced serous anxiety or tension \|\_\_\_\_\|\_\_\_\_\|
>
> c\. Experienced hallucinations \|\_\_\_\_\|\_\_\_\_\|
>
> d\. Experienced trouble understanding, concentrating, or remembering
> \|\_\_\_\_\|\_\_\_\_\|
>
> e\. Experienced trouble controlling violent behavior
> \|\_\_\_\_\|\_\_\_\_\|
>
> f\. Attempted suicide \|\_\_\_\_\|\_\_\_\_\|
>
> g\. Been prescribed medication for psychological/emotional problem
> \|\_\_\_\_\|\_\_\_\_\|

**4a. If you reported one or more days in question 4, how much have you
been bothered by**

**these psychological or emotional problems in the past 30 days?** (If
you did not report

any days to the items in question 4, skip to the next question.)

>  Not at all
>
>  Slightly
>
>  Moderately
>
>  Considerable
>
>  Extremely

**H. DEMOGRAPHICS (ASKED ONLY AT BASELINE)**

**1. Gender**

>  Male
>
>  Female
>
>  Transgender
>
>  Other (specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Are you Hispanic or Latino?**

 Yes  No

> If yes, what ethnic group do you consider yourself? **(CSAT ONLY)**
>
>  Central American
>
>  Cuban
>
>  Dominican
>
>  Mexican
>
>  Puerto Rican
>
>  South American
>
>  Other, specify
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. What is your race? (Select one or more)**

>  Black or African American  Alaska Native
>
>  Asian  White
>
>  American Indian  Other (specify)\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  Native Hawaiian or other \
> Pacific Islander

4.  **What is your date of birth?** \|\_\_\_\_\|\_\_\_\_\| /
    \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Month / Day / Year

I.  **FOLLOW-UP STATUS** **(REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY
    AT FOLLOW-UP)**

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1.  What is the follow-up status of the client?

>  01 = Deceased at time of due date
>
>  11 = Completed within specified window

 21 = Located, but refused, unspecified

 22 = Located, but unable to gain institutional access

 23 = Located, but otherwise unable to gain access

 24 = Located, but withdrawn from project

 31 = Unable to locate, moved

>  32 = Unable to locate, other

J.  **DISCHARGE STATUS (REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT
    FOLLOW-UP)**

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```
1.  **On what date was the client discharged?** \|\_\_\_\_\|\_\_\_\_\| /
    \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

> Month / Day / Year

2.  **What is the client's discharge status?**

>  01 = Completion/Graduate
>
>  02 = Termination
>
> If the client was terminated, what was the reason for termination?
> (Select one response.)
>
>  01 = Left on own against staff advice with satisfactory progress
>
>  02 = Left on own against staff advice without satisfactory progress
>
>  03 = Involuntarily discharged due to nonparticipation
>
>  04 = Involuntarily discharged due to violation of rules
>
>  05 = Referred to another program or other services with satisfactory
> progress
>
>  06 = Referred to another program or other services with
> unsatisfactory progress
>
>  07 = Incarcerated due to offense committed while in treatment with
> satisfactory
>
> progress
>
>  08 = Incarcerated due to offense committed while in treatment with
> unsatisfactory
>
> progress
>
>  09 = Incarcerated due to old warrant or charged from before entering
> treatment with
>
> satisfactory progress
>
>  10 = Incarcerated due to old warrant or charged from before entering
> treatment with
>
> unsatisfactory progress
>
>  11 = Transferred to another facility for health reasons
>
>  12 = Death
>
>  13 = Other
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. During the course of treatment in your project, what types of
services did the client receive?** (Check all that apply and tell how
many weeks the client spent in each service.)

> \_\_\_\_\_ 1. Case Management \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 2. Day Treatment \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 3. Inpatient \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 4. Outpatient \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 5. Outreach \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 6. Intensive Outpatient \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 7. Methadone \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 8. Residential \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 9. Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 10. Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_ weeks
>
> \_\_\_\_\_ 11. Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_ weeks

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[^1]: For purposes of this announcement, in accord with the National
    Drug Control Strategy's (NDCS) new approach to using diagnosis as
    the criterion for determining the size of the treatment gap, the
    need for treatment is discussed in terms of the categories used in
    the American Psychiatric Association **Diagnostic and Statistical
    Manual of Mental Disorders** (DSM-IV; 1994).

[^2]: For purposes of this announcement, a community may be a
    geopolitical unit (city, county), a health district or human
    services region, or a substate planning area as defined for purpose
    of allocating Substance Abuse Prevention and Treatment Block Grant
    (SAPTBG) funds.

[^3]: Renamed the National Survey on Drug Use and Health.

[^4]: There are two usages for the term community-based substance abuse
    treatment: (1) specialist treatment services that are not hospital
    based; and (2) community institutions whose primary function does
    not involve identification and treatment of substance use problems
    but serves another human service function: general health care,
    education, social service, employment and vocational training, and
    criminal justice. (IOM, 1990; Rivto and Shore, 1999; Horgan et al.,
    2001) Persons with substance use problems can be identified in a
    wide variety of health care, social services, educational,
    corrections, and specialty mental health organizations; it is in
    this second sense that the term "community settings" is used here.

[^5]: The complexity of these multiple treatment subsystems at the State
    level has recently been described in a report submitted to
    SAMHSA/CSAT by the National Association of State and Drug Abuse
    Directors (NASADAD, 2002)

[^6]: References and resources that support this model, including CSAT
    Treatment Improvement Protocols (TIPs) and Technical Assistance
    Publications (TAPs) are included in Appendices A and D.

[^7]: Continuous reporting is defined as entering client level data into
    the GPRA web based data system within 7 business days of collection.

[^8]: OMB approval for these aggregated measures will be sought.

[^9]: OMB approval for using this more limited data set will be sought.

[^10]: Continuous reporting is defined as entering client level data
    into the GPRA web based data system within 7 business days of
    collection.

[^11]: OMB approval for this interview protocol will be sought by CSAT.

[^12]: The State may wish to consider subcontracting with the
    SAMHSA/CSAT funded Addiction Technology Training Centers (ATTCs)
    already working with its SSA or an in-state resource. A list of
    ATTCs, the States covered by each, and contact information is
    provided in Appendix A. If a subcontract with the ATTC, another
    academic institution, or a vender is used, the plan should include
    the cost for providing these activities as a separate budget
    component.

[^13]: Limited technical assistance on implementation, reporting, and
    monitoring progress toward meeting the SBIRT targets will be
    available if problems arise that cannot be resolved with the
    project's resources alone .

[^14]: For a discussion of the methodology change, see Epstein, 2002.
    Substance Dependence, Abuse, and Treatment: Findings from the 2000
    National Household Survey on Drug Abuse, Appendix C: Measurement of
    Dependence, Abuse, Treatment, and Treatment Need.

[^15]: A number of other States have included similar characterizations
    for differentiating intervention and treatment in their rules or
    planning efforts (e.g., Louisiana, Minnesota, Florida, North
    Carolina, Connecticut, Vermont, Washington). For example, South
    Dakota has defined its approach as part of the regulations governing
    licensure of treatment facilities: "A facility that provides Early
    Intervention and Outpatient Services is a nonresidential facility
    that provides direct supportive client contact, indirect or
    collateral client contact, community information and liaison
    services. The program also provides formally planned counseling
    services to those persons harmfully affected by alcohol or drugs and
    who have been determined not to be in need of or accepting of
    structured outpatient or residential services."
    <http://legis.state.sd.us/rules/rules/6716A.htm#67:16:11:03.04>.
    Apparently some States (e.g., Florida) define intervention as both a
    treatment and non-treatment activity.

[^16]: The CSAP strategy for this activity had previously been
    designated as "Problem Identification and Referral Programs" that
    may screen, identify and serve persons who could be diagnosed as
    having a substance use disorder as well as those individuals who
    could be classified as non-users, at risk users, and at high risk
    users. Many, if not all, of the programs are operated as primary
    prevention programs and use a problem count (e.g., the AUDIT) to
    classify those persons served rather than a clinical diagnosis. This
    difference in perspectives leads them to intervene (i.e., provide
    advice and feedback; counsel with) persons who may be in either an
    at risk category or with a diagnosis, without always clearly
    differentiating between the two classes. In clinical settings, when
    delivered by licensed health practitioners, such activities would be
    considered a clinical preventive service.

[^17]: Based on Babor and Higgins-Biddle (2001) Brief Intervention For
    Hazardous And Harmful Drinking: A Manual for Use in Primary Care,
    Box 2, p.12

[^18]: Based on Skinner HA (1982).

[^19]: Based on Figure 3-1. A model of individual drug history, Gerstein
    and Harwood (1990:61).

[^20]: Modified from Box 1, Personnel, Settings and Groups Considered
    Appropriate for a Screening Programme Using the AUDIT (Babor et al.,
    2001).

[^21]: GPRA gives agencies broad discretion with respect to how its
    statutory programs are aggregated or disaggregated for GPRA
    reporting purposes.

[^22]: Most, if not all, of the activities conducted under the rubric of
    technical assistance and infrastructure development are
    appropriately classified as activities supporting this program goal.
    Technical assistance activities within GPRA have not been discussed
    within CSAT. Further, at this time, SAMHSA has a separate program
    goal for infrastructure development (see AEnhance Service System
    Performance,@ below).

[^23]: Ultimately, the increased use of efficient and effective
    practices should increase the availability of services and
    effectiveness of the system in general. However, measures of
    treatment availability and effectiveness are not currently
    available. Within existing resources, it would not be feasible to
    consider developing a system of performance measurement for this
    purpose.