Technical Assistance Publication Series

Systems-Level

Implementation of

Screening, Brief 

Intervention, and 

Referral to Treatment 

TAP 33 
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Systems-Level Implementation 

of Screening, Brief Intervention, 

and Referral to Treatment 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

1 Choke Cherry Road 

Rockville, MD 20857

TAP

Technical Assistance Publication Series

33
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

ii 

Acknowledgments 

This publication was prepared for the

Substance Abuse and Mental Health 

Services Administration (SAMHSA) by the

Knowledge Application Program (KAP),

a Joint Venture of The CDM Group, Inc.,

and JBS International, Inc., under contract 

numbers 270-04-7049 and 270-09-0307, 

with SAMHSA, U.S. Department of Health

and Human Services (HHS). Christina

Currier served as the Contracting Officer’s

Representative. 

Disclaimer 

The views, opinions, and content of this

publication are those of the authors and do

not necessarily reflect the views, opinions,

or policies of SAMHSA or HHS. 

Public Domain Notice 

All materials appearing in this publication

except those taken from copyrighted

sources are in the public domain and may

be reproduced or copied without permission

from SAMHSA or the authors. Citation 

of the source is appreciated. However,

this publication may not be reproduced or

distributed for a fee without the specific,

written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies 

of Publication 

This publication may be ordered or

downloaded from SAMHSA’s Publications 

Ordering Web page at http://store.

samhsa.gov. Or, please call SAMHSA

at 1-877-SAMHSA-7 (1-877-726-4727)

(English and Español). 

Recommended Citation 

Substance Abuse and Mental Health 

Services Administration. Systems-Level 

Implementation of Screening, Brief 

Intervention, and Referral to Treatment. 

Technical Assistance Publication (TAP)

Series 33. HHS Publication No. (SMA)

13-4741. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 2013. 

Originating Office 

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental 

Health Services Administration, 1 Choke 

Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 13-4741 

Printed 2013 
iii 

Contents
 

Chapter 1—Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 

Purpose and Audiences 1
 

Background .............................................................. 1
 

SAMHSA’s SBIRT Initiative ................................................. 2
 

Colleges and Universities ................................................ 2
 

Medical Residency Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 

State Cooperative Agreements ............................................ 3
 

Cohort 1 Cross-Site Evaluation............................................... 3
 

Terminology .............................................................. 5
 

Organization of the TAP .................................................... 5
 

Chapter 2—SBIRT Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 

Defining Screening, Brief Intervention, Brief Treatment,

and Referral to Treatment................................................ 7
 

Screening ............................................................. 8
 

Brief Intervention ...................................................... 8
 

Brief Treatment ........................................................ 9
 

Referral to Treatment ................................................... 9
 

The SBIRT Process ....................................................... 10
 

Why SBIRT? The Problem.................................................. 11
 

Why SBIRT? Benefits and Efficacy........................................... 12
 

Alcohol Misuse, Abuse, and Prevention .................................... 12
 

Illicit Drugs .......................................................... 14
 

SAMHSA SBIRT Grantees .............................................. 15
 

.....................................................
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Why SBIRT? Cost-Effectiveness/Benefit Cost .................................. 17
 

SBIRT for Other Behavioral Health Disorders ................................. 18
 

Tobacco Use .......................................................... 18
 

Depression ........................................................... 19
 

Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
 

Psychological Trauma .................................................. 20
 

Chapter 3—SBIRT Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
 

...................................................... 21
 

Initiate the Planning Process and Develop Collaborations and Partnerships ......... 22
 

Assess Organizational Readiness for Change ............................... 22
 

Involve as Many Staff Members as Possible ................................ 22
 

Assess What Is Needed ................................................. 23
 

Set Clear Goals........................................................ 23
 

Assign Clear Roles and Responsibilities.................................... 23
 

Develop Collaborations and Partnerships .................................. 23
 

Identify the Settings for SBIRT Services ...................................... 23
 

Select a Staffing Model .................................................... 24
 

In-House Generalist.................................................... 24
 

In-House Specialist .................................................... 25
 

Contracted Specialist................................................... 25
 

Staffing Models and SBIRT Grantees...................................... 25
 

Develop a Staff Training and Supervision Plan................................. 26
 

Develop a Screening Procedure.............................................. 27
 

Develop BI and BT Procedures .............................................. 29
 

Develop Referral Procedures and Identify Referral Resources ..................... 30
 

Develop a Recordkeeping Procedure and Evaluation Plan ........................ 30
 

Develop a Funding and Reimbursement Strategy............................... 31
 

iv 

 Model Framework
Contents 

Chapter 4—Implementation and Sustainability Issues . . . . . . . . . . . . . . . . . . . . . 33
 

Barriers to and Facilitators of Successful SBIRT Implementation ................. 33
 

Leadership and Positive Interagency Collaboration .......................... 33
 

Provider Buy-in ....................................................... 33
 

Contextual Factors..................................................... 34
 

Confidentiality ........................................................... 34
 

Uniform Accident and Sickness Policy Provision Law ........................... 34
 

Reimbursement for SBIRT ................................................. 35
 

Commercial Insurance and Medicare ...................................... 35
 

Medicaid and Working With State Medicaid Agencies ........................ 36
 

Sustainability: Beyond Reimbursement....................................... 37
 

Chapter 5—Case Examples: The Substance Abuse and Mental Health 

Services Administration SBIRT Grantee Experience . . . . . . . . . . . . . . . . . . . . 39
 

Washington State Screening, Brief Intervention, Referral, and Treatment .......... 39
 

Program Overview ..................................................... 39
 

The Process........................................................... 39
 

Program Implementation ............................................... 40
 

Implementation Challenges ............................................. 40
 

Six-Month Followup Survey ............................................. 40
 

New Mexico Human Services Department, Behavioral Health Services Division ..... 41
 

Program Overview ..................................................... 41
 

The Process........................................................... 41
 

Program Implementation ............................................... 41
 

Choosing and Cultivating Collaborators ................................... 42
 

Flexibility and Fidelity ................................................. 42
 

Staff Training......................................................... 42
 

Working With Native American Populations................................ 42
 

v 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Contractual Relationships............................................... 42
 

Six-Month Followup Survey ............................................. 43
 

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 

Appendix B—Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
 

Appendix C—State Grantees by Cohort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
 

Appendix D—SBIRT Initiative Cohort 1 State Cooperative

 Agreement Grantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
 

Appendix E—Selected Screening Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
 

Appendix F—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
 

vi 
Exhibits 

Exhibit 1-1. C1 Evaluation Data Collection Techniques ........................... 4
 

Exhibit 2-1. SBIRT at the Intersection of Prevention and Treatment ................ 7
 

Exhibit 2-2. SBIRT Process ................................................. 10
 

Exhibit 2-3. C1 Evaluation Results of Patients Reporting Any Substance Use

in Past 3 Months at 6-Month Followup .................................... 17
 

Exhibit 2-4. Priorities Among Effective Clinical Preventive Services ............... 18
 

Exhibit 3-1. SBIRT Model Matrix............................................ 21
 

Exhibit 3-2. Selected SAMHSA SBIRT Grantee Service Settings .................. 23
 

Exhibit 3-3. Selected Screening Service Instruments ............................ 28
 

Exhibit 4-1. Key Elements of Sustainability ................................... 37
 

vii 
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1 

Chapter 1—Introduction
 

Purpose and Audiences 

This Technical Assistance Publication (TAP)

describes the core elements of screening, brief

intervention, brief treatment, and referral to 

treatment (SBIRT) programs and provides

general administrative and managerial

information relevant to implementing SBIRT

services, including: 

• SBIRT effectiveness. 

• Implementation models. 

• Challenges and barriers to

implementation. 

• Issues of cost and sustainability. 

• Real-life program anecdotes and case

studies. 

The TAP does not address clinical issues in 

implementation; Appendix B includes sources

of information about clinical models. 

Primary audiences for this TAP are healthcare

providers and administrators (including those

in educational institutions) and governmental

and private entities interested in integrating

SBIRT programs into systems of care (e.g.,

State prevention or treatment systems,

hospital systems, community healthcare

systems, primary care practices). Secondary

audiences include Addiction Technology

Transfer Centers, Single State Agencies, and

State mental health and substance abuse 

program directors. 

Background 

The SBIRT model represents a paradigm

shift in substance use and abuse 

interventions. Traditionally, interventions

have focused on individuals who have 

severe substance use or those who meet the 

criteria for substance abuse or dependence

as defined by the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition, 

Text Revision (DSM-IV-TR; American

Psychiatric Association [APA], 2000). The

SBIRT model provides for services on a full

continuum of substance involvement. In 

addition to providing for specialty substance

use disorder (SUD) treatment, SBIRT also

targets people who do not yet meet criteria

for an SUD and provides effective strategies

for early intervention before the need

develops for more extensive or specialized

treatment. In fact, many such individuals

may never meet the criteria for substance

abuse or dependence, but they may still

place themselves and others at risk for harm

because of excessive substance use (e.g., binge

drinking). The Centers for Disease Control

and Prevention (CDC) estimates that in 2001,

approximately 76,000 deaths in the United

States were attributable to the excessive use 

of alcohol (CDC, 2004). 

SBIRT is a comprehensive, integrated

public health model designed to provide

universal screening, secondary prevention

(detecting risky or hazardous substance use

before the onset of abuse or dependence),

early intervention, and timely referral and

treatment for people who have SUDs (Babor

et al., 2007; Babor & Higgins-Biddle, 2001;

Substance Abuse and Mental Health Services 

Administration [SAMHSA], 2011). One of

the strengths of the SAMHSA SBIRT model

is that it screens all patients regardless of

an identified disorder, allowing healthcare

professionals in a variety of settings to

address the spectrum of such behavioral

health problems even when the patient is not

actively seeking an intervention or treatment

for his or her problems. 
2 

Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment 

SAMHSA supports a research-based

comprehensive behavioral health SBIRT

model that reflects the six following

characteristics (SAMHSA, 2011): 

•	 It is brief . The initial screening is

accomplished quickly (modal time about

5–10 minutes), and the intervention

and treatment components indicated by

the screening results are completed in

significantly less time than traditional

substance abuse specialty care. 

•	 The screening is universal . All 

patients, clients, students, or other target

populations are screened as part of the

standard intake process. 

•	 One or more specific behaviors are

targeted . The screening tool addresses

specific problematic behaviors or behaviors

that are preconditional to substance abuse

or dependence. 

•	 The services occur in a public health,

medical, or other non-SUD treatment 

setting . The settings include, for example,

emergency departments (EDs), primary

care physicians’ offices, and schools. 

•	 It is comprehensive . The program

includes a seamless transition between 

brief universal screening, a brief

intervention (BI) and/or brief treatment

(BT), and referral to specialty SUD care. 

•	 Strong research or substantial

experiential evidence supports the 

model . At a minimum, programmatic

outcomes demonstrate a successful 

approach. 

As a comprehensive or model approach,

SBIRT has been demonstrated to be 

effective only for risky alcohol use. There is

substantial evidence for the effectiveness 

of BIs for harmful drinking when delivered

by a physician or other qualified health

professional (Bien, Miller, & Tonigan,

1993; Kahan, Wilson, & Becker, 1995; 

Wilk, Jensen, & Havighurst, 1997). There

is a growing body of literature showing the

effectiveness of SBIRT for risky drug use,

but the results vary by the characteristics 

of the provider, the specific setting, and the

patient population that is targeted for SBIRT

implementation. Some studies have found

SBIRT to be quite effective (Bernstein et al.,

2005; Madras et al., 2009), while others have

found mixed results (Humeniuk, Dennington,

& Ali, 2008). 

However, it should be noted that most of the 

SBIRT research addresses only the screening

and BI components of the model. Research

regarding the efficacy and cost effectiveness

of the RT component of SBIRT is still lacking.

When research cited in this TAP addresses 

only some of the components of the model, the

components are specified in the text. 

Although SBIRT interventions are

increasingly recognized as a necessary

approach to addressing public health, they

are not yet fully integrated into healthcare

systems. In October 2003, SAMHSA’s Center

for Substance Abuse Treatment (CSAT) began

its SBIRT Initiative. This initiative promotes

widespread adoption of SBIRT within systems

of medical care as well as education about how 

SBIRT works in these settings. 

SAMHSA’s SBIRT Initiative 

The SAMHSA SBIRT Initiative provides

grants and support through three basic 

avenues: 

• Colleges and universities 

• Medical residency programs 

• State cooperative agreements 

Colleges and Universities 

In 2005, SAMHSA’s CSAT awarded Targeted

Capacity Expansion Campus Screening and

Brief Intervention Grants to 12 colleges and

universities to combat underage drinking and

substance use. The grants provided funds to

colleges and universities to initiate or expand

campus-based medical services and to include

SBIRT services for students with hazardous 

drinking and other SUDs through student

healthcare services. 
Chapter 1―Introduction 

Medical Residency Programs 

SAMHSA initiated the Medical Residency

Program in 2008 to develop and implement

SBIRT training programs for medical

residents in diverse medical settings (e.g.,

hospitals, EDs, outpatient clinics, Federally

Qualified Health Centers). Grantees are

developing both online and live training

curricula focusing on SUDs, medical issues

related to those disorders, and principles

and implementation of SBIRT. In addition

to providing didactic training, grantees

are implementing experiential approaches,

including role-plays, supervised practice,

and mentoring programs. A list and brief

profiles of medical residency grantees are

on the SAMHSA SBIRT Web site at http://

www.samhsa.gov/prevention/sbirt/grantees/

medres.aspx. 

State Cooperative Agreements 

As of 2011, SAMHSA has funded 24 SBIRT 

State cooperative agreements in 4 groups

(referred to as cohorts): 

• Cohort 1 (6 State grantees and 1 tribal

council grantee) in 2003 

• Cohort 2 (4 State grantees) in 2006 

• Cohort 3 (4 State grantees) in 2008 

• Cohort 4 (8 State grantees and 1 territorial

grantee [American Samoa]) in 2011 

A list of State grantees (by cohort) is in

Appendix C. 

SAMHSA’s cooperative agreements have

demonstrated how SBIRT can be integrated

effectively into a variety of systems. Some

grantees (e.g., California, Illinois, Texas,

Washington) focused on EDs and trauma

settings. Other grantees (e.g., Pennsylvania)

used funds to implement SBIRT in

community health clinics and primary care

offices. Others (e.g., Colorado, Massachusetts,

New Mexico, Wisconsin) developed SBIRT

programs in a range of settings and

populations statewide. Several State grantees

developed SBIRT programs for specific 

target populations (e.g., adolescent, rural,

and ethnic populations in New Mexico; rural

and ethnic populations in Colorado; native

populations in the Cook Inlet Tribe [Alaska];

elderly population in Florida). 

Grantees implemented SAMHSA-funded 

SBIRT services in a range of healthcare

settings, including inpatient, ED,

ambulatory, primary, and specialty

healthcare settings, as well as community

health clinics. Diverse patient populations

(e.g., Alaska Natives, American Indians,

African Americans, Caucasians, Hispanics)

have been and continue to be screened and 

offered risk-based levels of intervention 

BI, BT, or RT). Grantee programs screen

patients for both illegal drug use and problem

alcohol consumption. Patients with a positive

screening result are determined to need BI,

BT, or RT. 

As part of the SBIRT Initiative, SAMHSA

conducted a cross-site evaluation of cohort 1’s 

grantee programs. Brief profiles of cohort 1

programs are presented in Appendix D. 

Cohort 1 Cross-Site Evaluation 

The cohort 1 cross-site (C1) evaluation, the

most comprehensive assessment of SBIRT to

date, has been completed. Cohort 1 grantees

implemented SBIRT programs in 118 sites.

Between October 2005 and February 2009, the

programs screened more than 658,000 patients. 

The C1 evaluation comprised four 

components: 

• A process evaluation answered questions

about the implementation of SBIRT

across cohort 1 grantees—including

models used, consistency with research

literature, and barriers to and facilitators 

of implementation. 

• An outcome evaluation provided

information on the impact of SBIRT on

substance use and other health-related 

outcomes. 

3 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Evaluation 

Component 

Data Collection Techniques 

Process • Document review (e.g., proposals, annual and quarterly reports, service delivery materials) 

• Services Accountability Improvement System (SAIS) Government Performance and Results Act 

(GPRA) data 

• In-person and telephone interviews with key stakeholders, program administrators, and 

direct-service practitioners 

• 2 onsite visits to 25 selected sites 

• 198 direct observations 

Outcome • Document compilation and review (e.g., followups to the patient survey by computer assisted 

telephone interviews) 

• SAIS/GPRA patient data—three types of patient-level data were entered into the database: 

baseline characteristics (assessed via a structured interview conducted by SBIRT program staff), 

discharge information regarding service utilization for patients who screened positive for alcohol or 

drugs, and 6-month followup status for a random subset of patients for whom BI, BT, or RT services 

were recommended 

• Surveys of 2,210 randomly selected patients using the Alcohol, Smoking and Substance 

Involvement Screening Test (ASSIST) 

• Surveys of 88 practitioners 

Economic • 6 site visit interviews 

• 7 observational visits 

• Substance Abuse Services Cost Analysis Program (Zarkin, Dunlap, & Homsi, 2004) 

• An economic evaluation provided cost

and cost-benefit information on SBIRT 

interventions. 

• A systemwide evaluation examined the

impact, implementation, and sustainability

of SBIRT across systems and settings. 

In the outcome evaluation, 2,210 unique

baseline interviews were completed with

patients who received SBIRT services

at 31 cohort 1 sites (an average of 71

patients per site). Of the total baseline

sample, 865 patients (39 percent) screened

positive for some level of problem alcohol

or illegal substance use. Of these patients,

511 (59 percent) were categorized for BIs,

170 (20 percent) for BTs, and 184 (21

percent) for referral to more intensive

specialty treatment. The evaluation used

a multimethod approach to capture data

(Exhibit 1-1). 

Overall, the C1 evaluation team found that: 

• SAMHSA SBIRT grantees implemented

SBIRT using evidenced-based practices

and maintained a high level of fidelity. 

•	 SBIRT was associated with significant

reductions in substance use (i.e., drugs and

alcohol; as much as a 27-percent reduction 

for high-risk patients who received BI, BT,

or RT) and a reduction in associated harms

(e.g., driving under the influence of drugs

or alcohol). 

• SBIRT appears to be an economically

viable strategy for reducing substance use

(i.e., alcohol and drugs) and its associated

harms. 

• SBIRT is sustainable.
 

Final data from the evaluation, along with

some preliminary findings from cohorts 2

and 3 and from the college and university

grantees, inform this TAP. Unless otherwise

indicated, SAMHSA SBIRT Initiative data 

are from as-yet-unpublished reports. These

sources are not formally cited in the text. 

Exhibit 1-1. C1 Evaluation Data Collection Techniques 

4 
Chapter 1―Introduction 

Terminology 

Several concepts and terms used in this TAP

can have different meanings in different

contexts. For clarity’s sake, these concepts

and terms, as used in this TAP to describe 

SBIRT interventions, are defined as follows: 

Binge drinking means drinking so much

within about 2 hours that the level of blood 

alcohol concentration increases to 0.08g/dL.

This may occur after 4 drinks for women and

after 5 drinks for men (National Institute on

Alcohol Abuse and Alcoholism [NIAAA], n.d.). 

Excessive alcohol use includes binge drinking

(see definition above), heavy drinking (an

average of more than one drink per day for

women or more than two drinks for men), any

alcohol use by pregnant women, and any alcohol

use by people under the age of 21 (CDC, 2012). 

Generalist refers to medical staff and can 

include doctors, nurses, and physician

assistants. 

Harmful drinking refers to a pattern of

alcohol consumption that results in negative

consequences (i.e., to the individual’s physical

and mental health or to society) (Babor,

Higgins-Biddle, Saunders, & Monteiro, 2001). 

Hazardous drinking means that a person

drinks more than the recommended 

consumption limits. NIAAA (n.d.) defines

these limits as 4 standard drinks on any

single day AND no more than 14 standard

drinks per week for men and 3 standard

drinks on any single day AND no more than 7

drinks per week for women. 

Risky alcohol use refers to any alcohol use that

increases the probability of harm (e.g., physical,

mental, social) occurring because of drinking. 

Specialist refers to a substance abuse 

treatment provider, mental health

professional, social worker, or someone

specifically trained to provide SBIRT services. 

Substance dependence (drugs and alcohol) is

a pattern of substance use at any time within 

a 12-month period that is characterized by

three or more of the following symptoms

(DSM-IV-TR, APA, 2000): 

• Tolerance (i.e., a need for increased

amounts of the substance to reach the 

desired effect OR experiencing less of an

effect with the use of the same amount of 

the substance) 

• Withdrawal 

• More of the substance was used than 

intended 

• A desire to cut down or control the 

substance use (without success) 

• Spending a lot of time obtaining the

substance, using the substance, or

recovering from using the substance 

• Life activities are reduced (or given up)

because of substance use 

• Substance use continues in spite of

knowing that it is causing physical or

psychological problems 

Provider refers to any professional who treats,

diagnoses, or assesses people to improve or

promote their health. This includes both

medical and nonmedical personnel. 

Patient refers to anyone who receives SBIRT

services from a medical, specialty, or other

type of provider. 

C1 evaluation refers to the cohort 1 cross-site 

evaluation. 

Organization of the TAP 

Chapter 2 provides an overview of SBIRT. It

describes SBIRT components, briefly outlines

the evidence that supports SBIRT’s efficacy,

and provides highlights of SAMHSA’s SBIRT

Initiative. Chapter 3 discusses options for

implementing SBIRT, including settings and

staffing models, and provides information

on implementing SBIRT components.

Chapter 4 describes key implementation and

sustainability issues, and Chapter 5 provides

case studies from SBIRT grantee programs. 

5 
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7 

Chapter 2—SBIRT Overview 

Defining Screening, Brief 

Intervention, Brief Treatment, 

and Referral to Treatment 

Over the past decade, substance abuse

services policy has tended toward a more

unified, integrated system that combines

prevention and treatment. Providers and

researchers increasingly recognize that

prevention entails more than discouraging

use—it can include any effort to prevent

negative consequences (e.g., auto crashes,

health problems, unemployment,

homelessness) that result from harmful

drug or alcohol use, as well as attempts to 

prevent hazardous use from progressing to

dependence. Effective intervention efforts

need to be helpful to a wide spectrum of

people, from those who occasionally misuse

alcohol or drugs to those who are severely

dependent. 

A primary aspect of screening, brief

intervention, brief treatment, and referral 

to treatment (SBIRT) is the integration and

coordination of screening and treatment

components into a system of services that

provides a needed intersection between

specialty treatment and prevention (Exhibit

2-1). 

Exhibit 2-1. SBIRT at the Intersection of Prevention and Treatment 

Prevention 

Treatment 

Screening 

Brief Intervention 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

8 

Screening 

Screening is a process of identifying patients

with possible substance misuse or abuse

problems and determining the appropriate

course of future action for these individuals. 

The screening process does not exactly

identify what kind of problem a person might

have or how serious it might be; screening

simply determines whether a problem exists

or whether further assessment is needed. 

Screening should be conducted using a

validated brief instrument to classify a

patient’s pattern of alcohol or drug use. In

the past, screening instruments were used

to identify active cases of alcohol and drug

dependence, but in recent years, screening

use has expanded to identify individuals

across the full spectrum of use––from risky

substance use to alcohol or drug dependence.

Screening provides healthcare professionals

the opportunity to initiate discussions with

patients about their alcohol and drug use and

to provide intervention as needed. 

Patients who indicate little or no risky

behavior and have a low screening score may

not need an intervention, but they may still

benefit from primary or universal prevention

activities for maintenance of nonrisky use.

Those who have moderate risky behaviors

and/or reach a moderate threshold on the

screening instrument may be referred to

brief intervention. Patients who score high

may need either a brief treatment or further

diagnostic assessment and more intensive,

long-term specialty treatment. 

Screening typically takes 5–10 minutes

and can be repeated at various intervals as

needed to determine changes in patients’

progress over time, depending on the

setting. Some commonly used screens for

the implementation of SBIRT for alcohol

and drug use are the Alcohol Use Disorders

Identification Test (AUDIT; Babor,

Higgins-Biddle, Saunders, & Monteiro, 2001), 

the Drug Abuse Screening Test (DAST;

Skinner, 1982), the Alcohol, Smoking and

Substance Involvement Screening Test

(ASSIST; Humeniuk, Henry-Edwards, Ali,

Poznyak, & Monteiro, 2010), the Cut Down, 

Annoyed, Guilty, Eye-Opener (CAGE; Ewing,

1984), and the National Institute on Drug

Abuse (NIDA) Drug Use Screening Tool (see

Appendix E). In addition, recent studies have

found a single question related to alcohol or

drug use to be effective in detecting alcohol

use (Smith, Schmidt, Allensworth-Davies, 

& Saitz, 2009) or drug use (Smith, Schmidt,

Allensworth-Davies, & Saitz, 2010) among 

primary care patients. 

Brief Intervention 

Brief intervention (BI) is appropriate for

patients identified through screening to

be at moderate risk for substance use 

problems. BI can be provided through a single 

session or multiple sessions of motivational

interventions (see Appendix B for more

information on motivational interventions).

These interventions focus on increasing a

patient’s insight into and awareness about

substance use and behavioral change. BI

can be tailored to a particular population or

setting. It can be a stand-alone treatment

for those at risk or a vehicle for engaging

those in need of more intensive levels of care. 

BI typically is provided at the same site as

screening. 

The majority of patients report minimal or no

problems with alcohol or drugs and as such

may be candidates for primary or universal

prevention activities for maintenance of

nonrisky use or abstinence. With respect

to alcohol use, in general only a small

proportion (3 to 5 percent) of patients in

primary care settings screen positive for

alcohol dependence (Babor & Higgins-Biddle, 

2001). However, levels for hazardous and

harmful drinking range from 15 to 40 percent

of the population (Babor & Higgins-Biddle,

2001). The goal of a BI (which usually

involves one to five sessions lasting about

5 minutes to 1 hour) is to educate patients

and increase their motivation to reduce risky

behavior. 
Chapter 2―SBIRT Overview 

Brief Treatment 

Brief treatment (BT) (sometimes called

brief intensive intervention) is a specialty

outpatient treatment modality. BT is a

systematic, focused process that relies

on assessment, patient engagement, and

implementation of change strategies. The goal 

of BT is to change not only the immediate

behavior or thoughts about a risky behavior

but also to address long standing problems

with harmful drinking and drug misuse and

help patients with higher levels of disorder

obtain more intensive care. The treatment 

consists of assessment and a limited 

number (typically 6 to 20) of evidence-based, 

highly focused, and structured clinical

sessions (e.g., solution-focused therapy, 

cognitive–behavioral therapy, motivational

enhancement) to help patients address

unhealthy cognitions and behaviors

associated with current use patterns and

adopt change strategies. Patients may

receive BT onsite but more commonly are

referred to an outside program or another

component of a medical system. One

potential challenge to implementation is

that substance use disorder (SUD) clinicians

trained in traditional long-term approaches

are sometimes resistant to or not well trained 

in structured brief approaches. 

Although the time required to execute either

BI or BT is generally considered brief, they

are often considered too lengthy for primary

care providers to perform. Also, providers

cite concerns about angering or insulting

patients by bringing up sensitive issues

such as alcohol and drug use. Although

these concerns are understandable, when 

SBIRT is implemented properly, the time

commitment is reasonable and acceptably low

given the demonstrated success in identifying

persons requiring referral to treatment.

Similarly, concerns about patient reactions

can be neutralized by proper training for the

providers and ensuring that access to referral

services is available. In addition, SBIRT is 

frequently implemented by allied health

professionals such as nurses, social workers,

or health educators, with results and actions 

noted in the patient chart for primary care

provider notification and oversight. 

Patients referred to a BT often have higher

risk factors than those referred to a BI. If 

patients report greater risk factors than BT

can address, they are referred to specialty

SUD care. In some cases, a patient may

receive a BI first and then move on to a BT or 

longer-term care. 

Referral to Treatment 

Patients identified as needing BT or more

intensive treatment than BI are referred 

to specialty SUD treatment providers. The

primary goals of referral to treatment (RT)

are to identify an appropriate treatment

program and to facilitate engagement of the

patient in treatment. RT can be a complex

process involving coordination across

different types of services. It requires a

proactive and collaborative effort between

SBIRT providers and those providing

specialty treatment to ensure that a patient,

once referred, has access to and engages in

the appropriate level of care. To facilitate

patient engagement, SBIRT providers may

use motivational enhancement techniques to

help patients with any ambivalence toward

treatment, provide transportation to intake

appointments, follow up with patients after

an appointment, and maintain contact with

the specialty treatment provider. 

The absence of linkages to treatment referrals

can be a significant barrier to the adoption

of SBIRT. Referral is recommended when 

patients meet the diagnostic criteria for

substance abuse or dependence (or SUD)

or other mental illnesses, as defined by the 

Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition, Text Revision 

(DSM-IV-TR). For patients in primary care

settings, the lack of a proper treatment

referral will prevent access to appropriate and

timely care that can affect other psychosocial

and medical issues. Research findings suggest

that motivational-based BIs can increase 

patient participation and retention in SUD

treatment (Dunn & Ries, 1997). 

9 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

10 

Strong referral linkages are critical, as is

tracking these patient referrals (Hillman,

McCann, & Walker, 2001). The Substance

Abuse and Mental Health Services 

Administration (SAMHSA) requires SBIRT

grantees to have a comprehensive RT and

followup system in place for the duration

of the program. In the case where RT is

incorporated into an integrated care model,

this incorporation may require shifts in

provider allocation and hiring. 

The SBIRT Process 

Exhibit 2-2 provides a chart of the SBIRT 

process. 

Exhibit 2-2. SBIRT Process 

Screening 

Brief Treatment 

(onsite or via 

referral) 

Referral to 

Specialty 

Treatment 

Brief 

Intervention 

No Further 

Intervention 

Moderate to 

High Risk 

Severe Risk, 

Dependence No or Low Risk Moderate Risk

The process can also include changes in

level or intensity of care if a patient needs

a different intervention. Screening can be

repeated at intervals, as needed. 

The following characteristics have formed the

foundation for the SAMHSA SBIRT programs

for identifying behavioral health problems: 

•	 SBIRT uses brief, validated, universal 

prescreening/screening tools . These 

tools allow healthcare professionals

to address the problem behavior even

when the patient is not actively seeking

treatment for the problem. Prescreening/

screening tools accurately and quickly

identify individuals with problematic

conditions in as little time as 2–4 minutes. 

Because of its briefness and its universal 

application (i.e., it can be used with all

patients), SBIRT may be more generally

accepted by busy healthcare providers. 

•	 SBIRT is relatively easy for diverse

providers to learn . The SBIRT approach

is easy to learn relative to other behavioral

treatment techniques that may require

lengthy specialized training. Therefore, it

can be implemented by various healthcare

providers such as physicians, nurses,

social workers, health educators, and 

paraprofessionals who work in busy

medical settings. 
11 

Chapter 2―SBIRT Overview 

Prescreening 

Prescreening, which is not a core component of SBIRT but is frequently used, reduces the time 

needed by busy clinic staff to identify patients with risky behavior. Some grantee programs added a 

prescreening component to adapt SBIRT to accommodate their real-world circumstances. Prescreening 

using an abbreviated screening tool allows staff to triage patients quickly to additional screening or 

necessary treatment services, depending on responses. Babor et al. (2007) concluded that shortened 

screening approaches may facilitate healthcare providers’ implementation of SBIRT services because 

they require less time to administer than do standard screening approaches. Shorter approaches 

eliminate a commonly cited time barrier to SBIRT implementation. 

Few prescreening tools for alcohol and illicit drug use have been validated. One validated tool is the 

Alcohol Use Disorders Identification Test—Consumption (AUDIT-C), which uses the first three alcohol 

consumption questions of the full, 10-item AUDIT questionnaire (Bradley et al., 2007). Other useful tools 

include the National Institute on Alcohol Abuse and Alcoholism (NIAAA) prescreening question (“How 

many times in the past year have you had 5 drinks or more in a day [for men] OR 4 or more drinks in a 

day [for women]?”; NIAAA, 2005), the one-question prescreening tool for illicit drug use (“How many 

times in the past year have you used an illegal drug or used a prescription medication for nonmedical 

reasons?”; Smith et al., 2010, p. 1155), and the NIDA Drug Use Screening Tool (see Appendix E for more 

information about screening tools). If a patient scores high on any domain in the prescreen, a full screen 

is conducted. 

•	 SBIRT incorporates a strong

referral component to link patients 

to specialty treatment . Effective 

approaches integrate comprehensive

strategies that include referral to

specialty treatments (Babor et al.,

2007). Although RT may be difficult in

underserved areas, this should not deter 

programs from developing screening

and BI (SBI) activities because they

have beneficial effects separate from the

referral (i.e., even short conversations

with a healthcare professional can

reduce a patient’s substance use [Babor

et al., 2007]). However, the goal of the

RT component is to provide a quick

handoff of patients to specialty SUD

treatment if the screening site cannot

provide more intensive SUD services. The

availability of well-established referral 

linkages to specialty care is essential to

the implementation and maintenance of

SBIRT. In addition, monitoring patient

compliance with SUD treatment is critical

to good healthcare provision. 

Why SBIRT? The Problem 

According to the 2011 National Survey on

Drug Use and Health (NSDUH; SAMHSA, 

2012), more than 19 million people (7.5

percent of those ages 12 and older) were

in need of but did not receive specialty

treatment in the past year for illicit drug or

alcohol use problems. The vast majority of

these individuals (95 percent) believed they

did not need treatment. Of those who believed 

they needed treatment, only 30.8 percent

made an effort to obtain treatment. 

The health and economic costs of substance 

abuse are considerable—not only for

the individuals involved but also for the 

healthcare system. A study on the costs of

excessive alcohol consumption estimated

that the total cost of excessive drinking

in the United States was $223.5 billion in 

2006 (Bouchery, Harwood, Sacks, Simon, &

Brewer, 2011), a 21-percent increase from

the $184.6 billion in 1992 (Harwood, 2000).

The National Drug Intelligence Center (2011)

estimated that the cost of illicit drug use (in

the United States) was $193 billion. 

Medical conditions are more common 

among patients with SUDs than among

those without those disorders (Mertens, Lu,

Parthasarathy, Moore, & Weisner, 2003).

Substance abuse has been associated with 

higher levels of numerous medical conditions, 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

12 

including cancer, cardiovascular disease,

gastrointestinal disorders, infectious diseases, 

and hepatic disorders. A disproportionate

percentage of the burden for treating

substance abuse and its consequences

increasingly falls on public institutions. 

Why SBIRT? Benefits and Efficacy 

If only people with the most extreme alcohol

and drug use problems are recognized as

being in need of treatment, people who

misuse substances but do not meet the 

criteria for an SUD are not identified. SBIRT 

provides a systematic means of identifying

and providing appropriate services to people

who clearly need but are not receiving

treatment and those who use substances but 

do not meet SUD criteria. Equally important,

SBIRT may prevent problems. The model

applies an “upstream” approach; it attempts

to identify and intervene in substance

misuse before an SUD develops. The Office

of National Drug Control Policy (ONDCP)

(2011) stated that: 

It is critical for medical professionals to be

able to identify the early signs of substance

abuse in their patients and to intervene

early. These early interventions can result

in savings to the healthcare system and,

most important, saves lives. SBIRT is a

tool that enables healthcare professionals

to ask patients about substance use

during routine medical visits. SBIRT helps

healthcare providers identify individuals

with problems related to substance use,

provide medical advice to help patients

who have been identified as having risky

substance use to understand the related 

health risks and consequences, and refer

patients with more severe substance

use-related problems to treatment. (p. 27) 

The evidence supporting the effectiveness of

BI suggests that even short conversations

with a healthcare professional (e.g., nurse,

physician assistant, physician) can reduce a

patient’s substance use (Babor et al., 2007).

For example, BIs are effective in reducing 

risky and harmful alcohol use by adult

primary care patients (men and women)

(Whitlock, Polen, Green, Orlean, & Klein,

2004). Svikis and Jones (2005) found that

screening pregnant women for smoking was

a useful way to identify women who were at

risk for alcohol and drug use. BIs for patients

screening positive for cocaine, heroin, and

amphetamine are also showing promising

results in various settings (Cunningham et

al., 2009). With prescription drugs being the

second most prevalent category of illicit drug

use (second only to marijuana) (SAMHSA,

2012), many are advocating for SBIRT

(for prescription drug abuse) to be taught

to healthcare providers as part of their

education, either in medical school (Brown,

Swiggart, Dewey, & Ghulyan, 2012; Rasyidi,

Wilkins, & Danovitch, 2012) or through

continuing education courses (Swiggart,

Ghulyan, & Dewey, 2012). 

Alcohol Misuse, Abuse, and Prevention 

Several studies have found SBIRT to be 

effective for those who misuse alcohol. 

Based on a review of the literature, the U.S. 

Preventive Services Task Force (USPSTF)

found “good evidence that screening in

primary care settings can accurately identify

patients [including pregnant women] whose

levels or patterns of alcohol consumption do

not meet criteria for alcohol dependence, but

place them at risk for increased morbidity

and mortality” (USPSTF, 2004, p. 1). 

The USPSTF review also noted that: 

• Brief behavioral counseling interventions

(with followup) can lead to small

to moderate reductions in alcohol 

consumption. 

• These reductions are sustained for 1 year

or longer. 

• If screened for alcohol abuse using a

validated instrument, between 8 and 18 

percent of general primary care patients

screen positive for abuse. 
13 

Chapter 2―SBIRT Overview 

Combined study results in the USPSTF (2004)

review suggest mean reductions in alcohol

consumption that ranged from 3 to 9 drinks

per week (13- to 34-percent net reduction in

drinking) in the intervention groups compared

with the control groups at 6- and 12-month

followups. Of the participants who received

interventions in primary care, between 10 and

19 percent more participants stopped drinking

at harmful or risky levels than did the

individuals who did not receive interventions. 

Research also indicates that, despite the

robustness of the evidence for SBIRT’s 

effectiveness for unhealthy alcohol use,

other factors can influence its effects. For 

example, studies have shown that multiple

contacts or sessions (in contrast to a single

contact) with a provider can increase the

impact of SBIRT in reducing risky alcohol

consumption (Brown, Saunders, Bobula,

Mundt, & Koch, 2007; Longabaugh et al.,

2001). Moreover, demographic factors and

psychosocial conditions (e.g., medical illness

or hospitalization) also have been shown to

influence SBIRT’s effects on alcohol misuse 

(Saitz, Svikis, D’Onofrio, Kraemer, & Perl,

2006). 

The conduct of SBIRT for alcohol use 

disorders has been found to be effective in 

various healthcare settings for diverse patient

populations including primary care (Babor

et al., 2007), emergency departments (EDs),

(Gentilello et al., 1999), and schools and

colleges (Baer, Kivlahan, Blume, McKnight,

& Marlatt, 2001; Dimeff, Baer, Kivlahan, 

& Marlatt, 1999). Data are currently being

collected that suggest that SBIRT may also

be effective in addressing alcohol problems

in employee assistance programs (Goplerud

& McPherson, 2010; McPherson et al., 

2009). Research also has demonstrated the

efficacy of conducting SBIs using innovative

strategies, such as the use of personalized

feedback via the Internet (Cunningham et al.,

2009) and the use of Web-based programs to 

monitor patient outcomes and to assist with

making treatment decisions (Roy-Byrne et al., 

2010). Gentilello et al. (1999) found that brief

interventions at a regional trauma center 

resulted in reduced alcohol consumption.

Patients in the intervention group with

intermediate Michigan Alcohol Screening

Test (MAST; Selzer, 1971) scores experienced

an alcohol consumption reduction of 21.6

percent from baseline to 12 months. This

group of patients also had a 47-percent 

reduction in new injuries requiring ED

treatment and a 48-percent reduction in new 

injuries that required hospital readmission. 

Research on the efficacy of SBIRT for

patients admitted to medical facilities is

limited, and the results are mixed (Emmen,

Schippers, Bleijenberg, & Wollersheim,

2004). Saitz et al. (2007) found that BIs

with hospital patients were not sufficient for

linking medical inpatients who had alcohol

dependence with appropriate treatment and

that BI had no effect on patients’ level of

alcohol consumption. They concluded that

these patients needed more extensive and

tailored interventions. 

The use of computerized interventions has

been shown to be effective in augmenting and

complementing the gains made through the

initial face-to-face brief interventions. The 

Department of Veterans Affairs, for example,

examined the use of electronic reminders 

placed in patients’ electronic medical records

to encourage providers to offer brief alcohol

counseling to patients who screened positive

for unhealthy alcohol use on the AUDIT-C. 

These reminders were associated with 

moderate drinking reductions at followup

(Williams et al., 2010). Other research

reviews indicate that electronic methods can 

improve the effectiveness and accessibility

of SUD treatment by offering online

assessment and feedback tools for patients,

providing tools for providers to monitor

patients’ treatment progress, and providing

educational opportunities for clinicians

(Cucciare, Weingardt, & Humphreys, 2009).

Electronic intervention can also help bridge

the treatment capacity gap by providing

another source of assistance for women who 

do not complete traditional substance abuse

treatment (VanDeMark et al., 2010). 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

14 

The Community Preventive Services Task

Force (CPSTF), an independent, volunteer

body appointed by the Director of the

Centers for Disease Control and Prevention 

(CDC), reviewed 31 studies involving

electronic screenings and brief interventions

(e-SBIs; e.g., telephones and other mobile

devices, computers) to reduce alcohol

consumption. The CPSTF concluded that

e-SBI is applicable to various settings (e.g.,

healthcare, universities) and had positive

effects across various outcomes related to 

alcohol consumption (e.g., binge drinking,

overall consumption) (CPSTF, 2012).

Based on this review, the CPSTF recently

recommended e-SBI as an effective tool for 

reducing alcohol consumption. 

The cost savings offered by the

implementation of the SBI components alone

are significant. One study (Gentilello, Ebel,

Wickizer, Salkever, & Rivara, 2005) showed

that for every $1.00 spent on providing

SBI approximately $3.81 is saved. The

Washington State SBIRT program cost study

also reflects similar savings. Notwithstanding

the potential effectiveness and cost savings,

many opportunities to intervene in patients’

risky alcohol use are lost. A 2003 study found

that although 70 percent of people who smoke

nicotine were advised to quit smoking by a

healthcare provider, only 23 percent of binge

drinkers were asked by a provider to discuss

their alcohol use (Denny, Serdula, Holtzman,

& Nelson, 2003). 

The concept of SBIRT can be applied

across the continuum of care for alcohol 

problems. Based on the severity of the

problem indicated by the screening results,

interventions ranging from universal

prevention to BIs to traditional specialty

treatment can be provided to healthcare

patients. For individuals who are abstinent,

universal prevention practices can be

implemented to sustain alcohol abstinence.

For moderate risky drinking, the first

two components of SBIRT—SBI—may be

implemented and can address inappropriate

expectancies (beliefs about substance use

effects and social norms of acceptable 

behavior) and lack of motivation to change

risk factors that contribute to substance 

abuse (Dimeff et al., 1999). Therefore, SBIs

incorporate motivational interviewing

components (Miller & Rollnick, 2002) that are

also integrated in BT for higher-risk patients. 

SBIs have proven effective in decreasing

overall consumption binge drinking (Babor

et al., 2007; Heather, Dallolio, Hutchings,

Kaner, & White, 2004; Kunz, French, & 

Bazargan-Hejazi, 2004; Martens et al., 2007;

Murphy et al., 2001; Toumbourou et al., 2007)

and increasing productivity (Osilla et al.,

2010). Evidence further demonstrates that

strengthening resiliency, competencies, and

social connectedness supports recovery for

those individuals who show early symptoms

of alcohol misuse. 

Extensive reviews of the effectiveness of 

SBI (Babor, 2008; Babor et al., 2007) have

found that SBI can lead to both short-term 

and long-term health benefits. However,

to achieve long-term effects, SBI must

be implemented with fidelity through

targeted training for providers (Babor,

Higgins-Biddle, Higgins, Gassman, & 

Gould, 2004; Bray et al., 2009; Cameron,

Lee, & Harney, 2010; Christensen, Boisse,

Sanchez, & Friedmann, 2004; Heather et al., 

2004; Seale, Shellenberger, Boltri, Okosun,

& Barton, 2005; Tollison et al., 2008). In

many instances providers implementing

SBI may not necessarily be physicians but

may be allied health professionals such as

nurses, counselors, health educators, and 

peers (Blume & Marlatt, 2004; Mastroleo,

2009), who may experience fewer barriers in

service provision than physicians do (Babor

et al., 2004). Some studies have found even

telephone interventions to be efficacious

(Brown et al., 2007; Oslin et al., 2003). 

Illicit Drugs 

Based on the scant availability of published

research on SBIRT for drug use, USPSTF

(2008) concluded that the evidence regarding

screening for illicit drug use was inadequate

to evaluate the balance of benefits and 
15 

Chapter 2―SBIRT Overview 

harms of screening adolescents, adults, and

pregnant women. Some researchers have

cited the relative scarcity of validated brief

drug screening tools (Smith et al., 2010)

and the low prevalence rates of drug use

in primary care settings as two reasons for

the comparatively small number of studies

showing SBIRT’s effects with drug use

(Saitz, 2010). Nevertheless, since 1995,

investigator-initiated SBIRT research has

grown, and findings from SAMHSA-funded

SBIRT projects have emerged. As a whole,

the work shows promising results for the use

of the comprehensive SBIRT approach (and

the selected use of individual components)

in reducing risky drug use (Copeland, Swift,

Roffman, & Stephens, 2001; Madras et al.,

2009). For instance, a randomized controlled

trial indicated that BIs can reduce cocaine 

and heroin use (Bernstein et al., 2005).

Motivational interviewing coupled with a

self-help booklet given to people who use 

amphetamine regularly also resulted in

reduced levels of drug use (Baker et al.,

2005). SBIs have been linked with reductions

in the use of marijuana, amphetamine-type 

stimulants, cocaine, and heroin (Madras

et al., 2009; see the next section, SAMHSA 

SBIRT Grantees, for more information).

In a study sponsored by the World Health

Organization, Humeniuk et al. (2008)

found that SBIs resulted in short-term 

reductions in the use of a wide variety of

illicit drugs, including marijuana, cocaine,

amphetamine-type stimulants, and opioids. 

SBIRT is also a key component of the 2011

and 2012 National Drug Control Strategy

(ONDCP, 2011, 2012a). 

Universal and selective prevention efforts

may be targeted to those with minimal or

mild drug misuse—just as they are with those 

who abuse alcohol—and identified abstainers 

can benefit from supportive and normative

information to maintain healthy lifestyles.

For individuals at risk for drug problems,

early identification and BIs that address

false expectancies and skill acquisition can

prevent progression to more severe drug

problems. In addition, tools that can be used

for universal screening of drug use in health 

settings—such as the DAST and the ASSIST

as well as online tools such as eCHECK UP 

TO GO (eCHUG), the electronic THC Online

Knowledge Experience (e-TOKE; San Diego

State University Research Foundation, 2009–

2012), and the NIDA Drug Use Screening

Tool (see Appendix E)—are prevention-ready 

applications designed to detect the presence

of drug use. 

SAMHSA SBIRT Grantees 

SAMHSA grantees provide additional

evidence of SBIRT’s effectiveness with both 

alcohol and illegal drug use. For example,

Madras et al. (2009) performed a secondary

analysis of initial SAMHSA SBIRT Initiative

data from the program sites of six State

grantees. Of 459,599 patients screened at the

time of the analysis, 22.7 percent screened

positive for use defined as “risky/problematic”

or “abuse/addiction.” Of the patients who

screened positive: 

• 15.9 percent were recommended for BI. 

• 3.2 percent were recommended for BT. 

• 3.7 percent were recommended for RT. 

A comparison of the rates at the start of

the study (baseline) with rates at 6-month

followup shows that in the majority of cases

self-reported alcohol and drug use rates

diminished from baseline to followup for

those patients reporting heavy alcohol use

and illicit drug use. 

Among patients reporting illegal drug use at

baseline, rates of use at the 6-month followup

were 67.7 percent lower than at baseline,

and heavy alcohol use was 38.6 percent

lower than at baseline. Among persons

recommended for BT or RT, patients not only

reported reductions in criminal behavior,

but also reported significant improvements

in general health, mental health, and

employment and housing status. 

Madras et al. (2009) noted some possible

limitations to the study, particularly the

absence of control groups. Without control

groups, it is possible that the improvements 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

16 

noted were unrelated to the interventions. 

However, the authors concluded that SBIRT 

was feasible to implement, and that the

patients’ self-reported status at the 6-month

followup indicated significant improvements

in alcohol or drug use and functional domains

over baseline. They also stated that the

findings were comparable across sites and

gender, racial/ethnic, and age subgroups. 

The final cohort 1 cross-site (C1) evaluation

team found significant decreases in alcohol

and drug use after the intervention. Overall,

an association was found between SBIRT 

participation and reduced substance use as

exhibited by declines in ASSIST substance

use risk scores. Responses to questions on

the ASSIST have a numerical score; added 

together they produce an ASSIST score. A

number of different scores can be calculated 

for the ASSIST, including: 

• The Total Substance Involvement (TSI)

score, which measures global risk for SUDs

across all substances. 

•	 The Specific Substance Involvement score,

which measures risk within particular

drug classes. 

The C1 evaluation team found that total 

substance use risk for all patients who had

positive screening results decreased from an

ASSIST TSI score of about 33 to 29, but this 

decrease was not statistically significant.

However, when patients who were screened

for BI but classified as low risk1

 were 

removed from the analysis, the remaining

SBIRT patients who screened positive had a

statistically significant average decrease in

TSI scores, from approximately 52 to 38 (a

27-percent decrease). 

Both the BT and RT groups had more

significant declines in average TSI scores

than either of the BI groups. The TSI score 

for patients receiving BTs fell from 50.2

to 34.4, a significant decrease of about 31

percent. The RT group experienced an even

larger decrease in TSI score, falling from 64.3

to 34.5, a significant decrease of 46 percent. 

The C1 evaluation team also looked at 

changes in use of specific substances, as

measured by the percentage of patients at

6-month followup who reported having used

the substance within the past 3 months

(Exhibit 2-3). 

The C1 evaluation team found that SBIRT’s 

impact on opioid use was not as strong as

its impact on other substance use. In fact,

the percentage of patients reporting any

opioid use actually increased at followup,

although the increase was not statistically

significant. The RT group showed no change.

The BT group was the only group that

showed decreased opioid use (a statistically

significant decrease of 24 percent). 

In addition to measuring changes in

substance use, the C1 evaluation team 

found the following improvements in other

health-related functional domains among 

patients with positive screening results: 

• The percentage of patients receiving

routine preventive care (e.g., physical

examination; routine blood tests; 

screening for hypertension, cancer, cardiac

abnormalities) increased overall. Those

in the low-risk BI group had the biggest

increase (34 percent to 73 percent). 

• The percentage of patients receiving

outpatient medical treatment (e.g.,

treatment in an office or clinic for a 

physical health problem) generally

increased. The RT group had the largest

increase in percentage of patients receiving

outpatient medical treatment (49 percent

to 63 percent). 

1

Patients who screened positive but with low TSI scores presented a potential for skewing overall results. A low score left little room 

for score improvement at followup and could not be distinguished clearly from the score of those who screened negative. Patients 

who screened positive but had a low score also were less likely to perceive a need for significant behavior change. To ensure more 

meaningful results, the C1 evaluation team split the BI group into two subgroups: low risk and higher risk. This separation was 

accomplished by determining whether a patient’s baseline TSI was below or above the median TSI score among all individuals 

screened for BI. 
Chapter 2―SBIRT Overview 

Exhibit 2-3. C1 Evaluation Results of Patients Reporting Any Substance Use in 

Past 3 Months at 6-Month Followup 

Substance All Groups 

(BI, BT, RT) 

Low-Risk BI 

Group 

High-Risk BI 

Group 

BT Group RT Group 

Alcohol Statistically 

significant 

decrease in 

reported use: 

from 81 to 69 

percent 

No change Significant 

decrease in 

reported use: 

from 84 to 72 

percent 

Significant 

decrease in 

reported use: 

from 91 to 69 

percent 

Significant 

decrease in 

reported use: 

from 91 to 64 

percent 

Marijuana Statistically 

significant 

decrease in 

reported use: 

from 40 to 33 

percent 

No change Small but not 

significant 

decrease 

Significant 

decrease in 

reported use: 

from 53 to 40 

percent 

Significant 

decrease in 

reported use: 

from 47.5 to 21 

percent 

Cocaine No significant 

change 

No significant 

change 

No significant 

change 

Significant 

decrease in 

reported use: 

from 24 to 13 

percent 

Significant 

decrease in 

reported use: 

from 47 to 20 

percent 

The probability of ED use generally

decreased among patients, especially for

those in the BT group and low-risk BI group.

Emergency treatment for these two groups

had statistically significant decreases of

20 percent and 24 percent, respectively.

However, among patients who used ED

services, the number of ED visits increased 

significantly for all those who screened

positive and increased substantially for those

in the RT group. 

Those in the BT and RT groups decreased

their probability of any drinking and driving.

Approximately 36 percent of individuals in

both groups reported driving while under

the influence at baseline. Rates of driving

under the influence decreased substantially

to 18 percent in the BT group (a 50-percent

decrease) and 14 percent in the RT group (a

60-percent decrease). 

Why SBIRT? Cost-Effectiveness/ 

Benefit Cost 

The cost savings of SBIRT vary by screening

instrument, staffing model, and setting.

Cost-benefit analyses suggest that screening 

and brief counseling of risky alcohol use

provide a cost savings of $43,000 in future

healthcare costs for every $10,000 invested

in early intervention (Fleming et al., 2002).

Patients receiving BIs had fewer hospital

days and fewer ED visits. The BI cost $205

per unit—$166 in costs to the clinic and $39

to the patient—and saved $712 in healthcare 

costs. 

A meta-analysis of 15 studies analyzing

cost benefit, cost-effectiveness, and cost 

utility of SBIs for unhealthy alcohol use

found cost-saving benefits when performed 

in medical settings that met or exceeded

standardized preventive care, such as

influenza immunization or colorectal 

screening (Kraemer, 2007). The analysis

demonstrated a strong economic benefit of

alcohol SBI when compared with usual care.

Maciosek et al. (2006) identified the most 

17 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

18 

valuable clinical preventive services that

can be offered in medical settings. Screening

for problem drinking and brief counseling

ranked high among effective preventive

services, based on a combined score of two 

measures—clinically preventable burden and 

cost-effectiveness (Exhibit 2-4). 

Exhibit 2-4. Priorities Among Effective Clinical 

Preventive Services 

Preventive Service Combined 

Score* 

Discussion of daily use of aspirin 10 

Childhood immunization series 10 

Tobacco use screening and BI 10 

Colorectal cancer screening 8 

Hypertension screening 8 

Influenza immunization 8 

Pneumococcal immunization 8 

Problem drinking screening and 

brief counseling 

8 

Vision screening—adults 8 

Cervical cancer screening 7 

*Possible scores ranged from 2 to 10. 

Adapted from Maciosek et al. (2006). 

SBIRT for Other Behavioral 

Health Disorders 

The prevalence of issues such as depression,

anxiety, and emotional trauma among primary

care patients calls for further exploration to

determine whether SBIRT can be adapted

and implemented to address mental disorders

among patients in primary care. 

Although the comprehensive SBIRT model

has been demonstrated to be effective for 

risky alcohol use, it has not been consistently

demonstrated to be effective in addressing

depression, trauma, or anxiety symptoms

or diagnoses. Programmatic data from the

SAMHSA State SBIRT programs show

promising results for identifying and providing

interventions targeting depression among 

primary care patients (Wisconsin Initiative

to Promote Healthy Lifestyles [WIPHL],

n.d.). Public health approaches that are

consistent with the SBIRT model have also 

been recommended for tobacco use and are 

recognized to be cost effective (Exhibit 2-4). 

Tobacco Use 

Cigarette smoking continues to be the leading

cause of preventable disease and death in the

United States (U.S. Department of Health

and Human Services, 2004) and contributes

to approximately 443,000 deaths per year

(CDC, 2008) from lung cancer, ischemic

heart disease, chronic obstructive pulmonary

disease, strokes, and other diagnoses. In

spite of the well-documented risks of smoking

and the potential health benefits of quitting,

approximately 1.4 million people younger

than age 18 became regular smokers in 2010,

and more than 27 percent of individuals ages

12 or older in the United States continue 

to smoke (SAMHSA, 2012). Smoking also

affects health outcomes of people other than

the smokers, with smoking during pregnancy

resulting in premature births, intrauterine

growth retardation, fetal respiratory

distress, and low infant birth weight (CDC,

2008; USPSTF, 2009a). Secondhand smoke

contributes to the deaths of an estimated 

38,000 people every year (USPSTF, 2009a). 

Research has also shown that mental 

disorders and cigarette smoking are

frequently co-occurring conditions 

(Degenhardt & Hall, 2001; Dome, Lazary,

Kalapos, & Rihmer, 2010; Grant, Hasin,

Chou, Stinson, & Dawson, 2004; Ziedonis 

et al., 2008). A study using data from the

2005–2006 NSDUH reported that adults with

lifetime depression, anxiety, anxiety with

depression, or major depressive episodes were

“more likely to be current smokers, smoke

with higher intensity and frequency, have

more dependence, and have lower success

at quitting” when compared to individuals

without these disorders (Trosclair & Dube,

2010, p. 438). Individuals with serious

mental illness (SMI; e.g., schizophrenia)

are also more likely to smoke than are 
19 

Chapter 2―SBIRT Overview 

individuals without mental illness (Epstein,

Barker, Vorburger, & Murtha, 2004; Kelly &

McCreadie, 2000), but Banham and Gilbody

(2010) found that treatment for tobacco

dependence can be effective for individuals

with SMI and, if their mental disorders are 

stable, treatment for tobacco dependency

does not worsen their symptoms. Because

70 percent of smokers see a primary care

provider each year (Fiore et al., 2008),

clinicians have a unique opportunity to

intervene and implement tobacco SBIRT in

primary care settings and EDs. 

Consequently, USPSTF (2009a) recommends

that clinicians screen all adults for tobacco 

use and provide interventions for smoking

cessation. USPSTF issued a separate

recommendation that clinicians screen all 

pregnant women for tobacco use and provide

counseling specifically designed for pregnant

women who use tobacco products. 

USPSTF (2009a) recommends that the

clinical interventions for tobacco cessation 

that are cited in the 2008 U.S. Public 

Health Service Clinical Practice Guideline, 

Treating Tobacco Use and Dependence

(Fiore et al., 2008), become integrated in

standard clinical practice. The Guideline

recommends that clinicians use the screening

instrument known as the 5A’s of tobacco use 

intervention, which provides a useful strategy

for engaging all medical patients in smoking

cessation discussions. The 5A’s are consistent 

with the SBIRT approach and parallel the

screening and brief intervention or counseling 

components of the SBIRT model: 

1. Ask about tobacco use. 

2. Advise to quit through clear personalized 

messages. 

3. Assess willingness to quit. 

4. Assist to quit. 

5. Arrange followup and support. 

The guideline’s behavioral treatments include

counseling, social support, problem solving,

and cessation skills training offered in

face-to-face individual or group formats or via 

telephone “quit lines.” Medication-assisted

treatments for tobacco use/dependence have

also been suggested and include several

Food and Drug Administration-approved

medications (Fiore et al., 2008). 

Depression 

USPSTF (2009c) supports depression

screening for adults only when accurate

diagnosis services, effective treatment,

and followup are available. USPSTF also

recommends screening adolescents (12

to 18 years of age) for major depressive

disorder, again when accurate diagnosis,

psychotherapy (cognitive–behavioral or

interpersonal), and followup are available

(USPSTF, 2009b). There are many

commonly used screening tools for depressive

symptoms that have established validity and

reliability data, such as the Patient Health

Questionnaire 9 (PHQ-9; Kroenke, Spitzer,

& Williams, 2001) and the Patient Health

Questionnaire 2 (PHQ-2; Kroenke, Spitzer, &

Williams, 2003). 

Primary care physicians are the providers

most likely to see patients when they first

become depressed, and these providers are

most capable of initiating and monitoring

treatments with pharmacologic agents

(McNaughton, 2009). Previous studies,

however, have shown that at least half of 

patients with active depression seen by

primary care physicians remain undiagnosed

(Ormel, Koeter, van den Brink, & van de

Willige, 1991; Schulberg & Burns, 1988).

Depression is particularly prevalent among

“high utilizers” of medical care, of whom as

many as 40 percent have been found to have a

current depressive illness (Katon et al., 1990). 

Promising but preliminary data are

available from SBIRT grantees funded by

SAMHSA that indicate that the SBIRT 

approach may be adapted for depression

treatment. For example, the State of

Wisconsin incorporated depression screening

into the WIPHL pilot program. Patients with

mild or moderate depression were provided

behavioral activation by health educators 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

20 

using specific protocols developed by the

program (WIPHL, n.d.). 

Behavioral activation offers promise as a

strategy for BI, and there is some evidence

that it would fit an SBIRT-like approach. 

Behavioral activation assists individuals to 

identify and engage in daily activities and

situations they find positively reinforcing

and consistent with their long-term goals

(Dimidjian et al., 2006). Behavioral activation

as a BI has been demonstrated in three 

meta-analyses, one randomized controlled 

trial, and one followup study of a previous

randomized controlled trial to be an effective 

intervention for the treatment of depression

(Sturmey, 2009). 

Anxiety Disorders 

The National Comorbidity Survey Replication

(Kessler et al., 2005) found anxiety disorders

to have the highest percentage of lifetime

prevalence of all the mental disorders in

the United States (28.8 percent), so it is not

surprising that anxiety disorders are among

the most common mental disorders seen in 

primary care settings. One study showed

that 19.5 percent of primary care patients

participating in the study had a current

anxiety disorder, and approximately 33

percent of those patients had more than one

anxiety disorder, with levels of impairment

and healthcare utilization increasing with

the number of disorders (Kroenke, Spitzer,

Williams, Monahan, & Löwe, 2007). However,

screening tools are available. The Brief

Symptom Checklist-18 (Derogatis, 2001)

is a screening tool for both anxiety and

depression, and My Mood Monitor (M-3;

Gaynes et al., 2010) is a valid and efficient 

one-page tool for screening multiple common 

psychiatric illnesses in primary care and

other settings. The M-3 can function both as a

screen for specific anxiety and mood disorder

diagnoses and as a general screen for the

presence of any mood or anxiety disorder. 

Interventions such as passive

psychoeducation, including bibliotherapy,

have been shown to reduce symptoms

of anxiety, psychological distress, and

depression (Donker, Griffiths, Cuijpers, &

Christensen, 2009). These approaches may be

offered as a BI to patients who screen positive

for mild or moderate levels of anxiety.

Passive psychoeducational interventions are

cost effective, can be easily put into practice

by nonmedical professionals, and may have

a less prejudicial impact on consumers,

especially when delivered through a Web site,

email, or brochure (Donker et al., 2009). 

Psychological Trauma 

Evidence of emotional trauma is also common 

in primary care. Walker, Torkelson, Katon,

and Koss (1993) report that rates as high

as 37 percent for childhood sexual abuse

and 29 percent for adult sexual assault are

evident in primary care settings. Walker et

al. found that 61 percent of women reported

that they believed that it was appropriate

for their primary care physician to ask about

previous victimization, but only 4 percent

had been asked. Tools for screening trauma

and anxiety include the Trauma Symptom

Inventory (Briere, 1995) and the PTSD-8

(Hansen et al., 2010) and Primary Care PTSD 

Screen (PC-PTSD; Prins et al., 2003) for

posttraumatic stress disorder (PTSD). 
Exhibit 3-1. SBIRT Model Matrix 

Service 

Component 

Contracted Specialist 

In-House Generalist 

In-House Specialist 

Screening

Brief Treatment

Brief Intervention

Referral to Treatment Hospital Inpatient Emergency/Trauma Ambulatory

Clinic/Hospital

Settings 

Implementation 

Model 

SBIRT Model Matrix In-house Generalist

In-house Specialist

Contracted Specialist

Chapter 3—SBIRT Implementation
 

A Model Framework 

Program implementation of screening,

brief intervention, brief treatment, and 

referral to treatment (SBIRT) services

depends on a variety of factors, including the

treatment program setting, available system

resources, State and other service systems

requirements, and organizational structure.

Exhibit 3-1 provides a framework for SBIRT 

and illustrates the multidimensional nature 

of SBIRT implementation. 

Note: “ATOD Use” refers 

to combined alcohol, 

tobacco, and drug use. 

“ATOD Use +” refers to 

alcohol, tobacco, drug 

use, and other behavioral 

risk factors (e.g., poor 

diet, physical inactivity). 

Source: Babor & McRee 

(2006). 

The model provides a pictorial reminder

of the overarching who, what, and where 

questions that must be considered during

SBIRT implementation planning: 

• Service delivery—What SBIRT services 

will be delivered? What risk factors will be 

assessed? 

• Implementation model—How will 

services be provided? Who will provide

what services? How will staff be paid? 

• Settings—What are the unique

characteristics (and challenges) of the

program? Who are the target populations?

Where and how can they best be reached? 

This chapter offers general steps to

implementing SBIRT and discusses a range

of considerations, options, and questions

for each step. The steps were derived

and adapted from several sources: the

American Public Health Association and 

21 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

22 

Education Development Center, Inc. (2008);

Henry-Edwards, Humeniuk, Ali, Poznyak, 

and Monteiro (2003); and Kleinschmidt

and Forman (2009). See Technical

Assistance Publication 31, Implementing 

Change in Substance Abuse Treatment 

Programs (Center for Substance Abuse

Treatment, 2009), for general information on

implementing change at the program level. 

Initiate the Planning Process 

and Develop Collaborations 

and Partnerships 

Assess Organizational Readiness 

for Change 

Organizations differ in their capacity to

implement new practices. Several factors—

staff workload, organizational structure and

culture, financial considerations—help or

hinder successful implementation of SBIRT

programs within a system of care. As does

any evidence-based practice, implementation

requires careful planning, flexibility to adapt

to new programs, and the structure necessary

to ensure fidelity with SBIRT. 

Bohman et al. (2008) evaluated a new measure

to gauge organizational readiness for change

during the implementation of an SBIRT

program at a trauma hospital emergency

department (ED) and three community health

program sites. The new measure, the Medical

Organizational Readiness for Change (MORC)

scale, was adapted from the instrument,

Organizational Readiness for Change (ORC;

Lehman, Greener, & Simpson, 2002). The new

measure includes multiple scales, comprising

18 content domains in four key areas: 

• Motivation for change (e.g., perceptions

of current functioning, needs for

improvement) 

• Institutional resources (e.g., adequacy of

office space, staffing) 

• Attributes of staff members (e.g.,

confidence in counseling abilities,

adaptability) 

• Organizational climate (e.g., clarity of

mission, staff cohesiveness) 

The evaluation found differences in readiness 

to change between clinical staff and

administrative staff and between EDs and 

community healthcare clinics. The MORC

scale helps an organization understand

its operations, focus on its strengths when

implementing strategies, tailor strategies

to different settings, and guide the

implementation process. 

Involve as Many Staff Members as Possible 

The support of management and stakeholders

is important to implementing SBIRT,

regardless of setting. In addition, staff

members are more likely to invest in SBIRT

implementation if they are involved in

planning from the start. In a small system

(e.g., a primary care practice), it may be

best to involve all staff members in the 

process. In a large system (e.g., a hospital

system), an important first step is identifying

appropriate planning participants from

among service components. Who are the 

primary stakeholders? Who has useful skills 

and experience? Involving staff members

from a range of disciplines and experiential

backgrounds facilitates effective planning. 

Washington State SBIRT 

Cohort 1 State Grantee 

The Washington State Division of Alcohol and Substance Abuse joined forces with a number of 

partners, including the Governor’s Office, the Department of Social and Health Services Medical 

Assistance Administration, the Department of Health, participating counties and hospitals, chemical 

dependence treatment providers, and a broad range of policymakers who are represented on the 

Washington State SBIRT Policy Steering Committee. 
23 

 

 

Chapter 3―SBIRT Implementation 

Assess What Is Needed 

A careful assessment of current system

resources (both physical and personnel) can

save time and money. Is it possible to use 

existing staff members to provide at least 

some SBIRT services? If so, what training will 

they need? If not, for what SBIRT services 

must new staff members be hired? What 

qualifications must they have? Is existing 

space adequate, or can space be reconfigured 

for more privacy? 

Set Clear Goals 

It is important to know exactly what is to be

accomplished and within what timeframe. 

What is realistic given the resources available 

or that can be obtained? 

Assign Clear Roles and Responsibilities 

Appointing one staff member as the SBIRT

coordinator may be helpful. This person can

ensure that all staff members understand 

their roles and responsibilities and that all

necessary planning tasks are completed. 

Develop Collaborations and Partnerships 

Collaboration is critical, no matter the size 

of a system. System (or program) leaders

should identify potential public and private

collaborators and partners early on and begin

developing relationships. 

For example, the SBIRT team at the

University of Hawaii at Manoa developed

collaborations with the following university

departments and organizations: 

• Clinical and Health Promotion Services 

• Student Housing 

• Judicial Affairs 

• Counseling and Student Development

Center 

• Athletics Advisors 

• Sexual Assault Task Force 

Identify the Settings for 

SBIRT Services 

Hospitals, EDs, trauma centers, primary care

offices, and community health centers are

obvious settings in which to initiate SBIRT.

The American College of Surgeons (2007)

now requires Level I and Level II trauma

centers to establish mechanisms to identify

patients who have drinking problems.

However, SBIRT services are provided in a

much wider range of settings. Exhibit 3-2 

provides examples of other settings in which

Substance Abuse and Mental Health Services 

Administration (SAMHSA) grantees have

implemented SBIRT services. 

Questions to be answered when choosing a

setting include: 

• Who is the target population? 

• What is the patient flow? 

• In what type of setting are patients most

likely to be reached? 

• Is the setting/facility accessible to the

target population? 

• What resources are available? 

• Can partnerships expand screening

options? 

• Does the potential facility allow for privacy

and secure record storage? 

Exhibit 3-2. Selected SAMHSA SBIRT 

Grantee Service Settings 

Federally Qualified Health Center 

Public health department office 

High school-based clinic 

Planned Parenthood office 

Specialty health clinic (e.g., women, 

adolescents) 

Senior nutrition program 

Senior center 

HIV and sexually transmitted diseases clinic 

Tribal clinic 

College/university student union kiosk 

College/university athletic department, 

counseling center, health clinic 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

24 

Bristol Community College (Fall River, MA), CORE 

College and University Grantee 

One of Campus Outreach and Resource Enhancement’s (CORE’s) challenges was that student 

participation in CORE was 100-percent voluntary. In addition, available campus health services were 

limited at the start of the project. With no mandate to participate and the majority of students not 

identifying drug or alcohol use as a problem, project staff had to effectively motivate students to 

participate. Providers had to find students willing to participate and a location where feedback could be 

provided confidentially. A particularly successful situation was to offer screening and brief intervention 

(BI) to new students who were on campus for placement testing and meetings with academic advisors 

before the start of the semester. Because testing took place in a group format as well as in one-on-one 

encounters, students had a considerable amount of free time and could meet with CORE staff members 

outside of classes. 

Outreach was accomplished through classroom presentations, health and wellness events in the student 

center, and special events during which CORE had a strong presence. The activities provided a social 

marketing function with a strong prevention message and were successful in opening a dialog on 

campus about the use of drugs and alcohol by students and in the broader community. 

Select a Staffing Model 

Studies of SBIRT programs have shown good

results with a variety of staffing models.

Cost-benefit analyses suggest that some 

functions may be performed as equally well

(and at lower costs) by midlevel or support

staff as by senior staff. 

Where understaffing is a problem, community

workers or others not on staff may administer

some or all parts of an SBIRT program. For

example, a trauma center may contract with

a nearby substance abuse treatment provider

to conduct screening and intervention.

Alternatively, a designated staff person may

be hired and trained to conduct screening. 

The cohort 1 cross-site (C1) evaluation team

identified three basic implementation (or

staffing) models appropriate for SBIRT

services delivery: in-house generalist (IHG),

in-house specialist (IHS), and contracted

specialist (CS). 

In-House Generalist 

An IHG is a staff member who is trained to 

perform SBIRT functions in addition to his or

her regular job functions (e.g., a triage nurse

in an ED, a health educator in a community

health clinic). Such a person is not a

substance abuse treatment professional. 

Using an IHG to perform screening and

BI can be effective and can offer important

benefits. Patients may already have a

relationship with or be familiar with the

IHG. Moreover, when a medical staff member 

addresses substance abuse, behavioral 

recommendations can be tied to the patient’s

health or medical problem. This specificity

may help the patient feel less shameful or

uncomfortable talking about substance abuse. 

The generalist model poses certain

limitations, however. For example,

generalists often do not have the time to

perform SBIRT. Even very brief encounters

can impinge on other crucial functions.

However, screening does not necessarily take

a lot of time. Results from the C1 evaluation 

indicate that, regardless of the staff position

of the person performing SBIRT services (e.g.,

physician, nurse, counselor), the duration of

initial screening ranged from 2 to 5 minutes. 

Other limitations might include staff

members who are uncomfortable with 

people who misuse substances or who

lack confidence in their ability to perform

SBIRT functions. In training hospitals, high

physician turnover results in the need for

constant retraining of residents or interns in

performing SBIRT. 
25 

Chapter 3―SBIRT Implementation 

Lessons learned from SAMHSA SBIRT 

grantees provide insights into effective ways

to overcome the challenges of an IHG model: 

• Implement SBIRT in ways that minimize

the time burden for staff. 

• Develop strong “champions” of SBIRT. 

• Provide time for staff to “buy into”

activities. 

• Provide adequate training, ongoing direct

supervision and monitoring, and regular

feedback. 

• Institute SBIRT training as a regular part

of employee orientation. 

• Collect and share aggregate and

patient-level outcomes data so that staff 

members can see the help they provide to

patients. 

• Combine SBIRT with other behavioral 

interventions (e.g., smoking cessation). 

In-House Specialist 

An IHS provides only SBIRT services,

freeing regular staff members from having

to conduct SBIRT activities. A program

may hire someone who is already trained

in SBIRT or may train a person already on

staff. This model can be efficient because 

few people need to be trained (or none, if an

already-trained specialist is hired specifically 

for SBIRT), and it provides consistency

because only a specific person or people

perform SBIRT activities. 

SAMHSA grantees using this model

encountered several challenges. EDs

or trauma centers can be difficult work 

environments for nonmedical staff, 

occasionally leading to turf wars between

medical and nonmedical staff. In-house 

supervision and management issues can

arise regarding ED staff supervising a

person without ED skills. SBIRT specialists

reported the expectation from ED staff that

they conduct non-SBIRT activities. Very

clear organizational structures need to be

in place to prevent these types of problems. 

Finally, the SBIRT model is not accepted by

all substance abuse treatment specialists.

Careful hiring practices ensure that specialist

staff members are trained in SBIRT and will 

provide services with fidelity. 

Contracted Specialist 

A third model for SBIRT is an outside 

provider who conducts SBIRT services.

This model has the advantage of providing

specialized, informed professionals dedicated

to conducting SBIRT, relieving regular staff

members of the additional time burden and 

providing a seamless integration of different

SBIRT components. 

There also are challenges to implementing

this model. A CS may not be fully integrated

into the team and may need time to become

familiar with the organizational culture,

the setting, and other staff members. This

situation can be particularly challenging for a

CS working in a hospital or trauma center for

the first time. A CS may find working in EDs

difficult; these settings differ greatly from

substance abuse treatment facilities. Finally,

insurance reimbursement for SBIRT in a 

medical setting can be a problem. Insurance

companies may be reluctant to pay for

services not directly related to a hospital stay

or for services provided by nonmedical staff. 

Staffing Models and SBIRT Grantees 

SBIRT grantees often used blended models

for multiple service components (e.g., IHG

for prescreening or screening, CS for BI or

brief treatment [BT]). All SBIRT grantees

migrated toward CS models for most

components of treatment delivery, both to

increase the number of patients screened and

to reduce the burden on medical staff. The CS 

model was successful across settings. 

An advantage of the CS model is that staff

members were less likely to stop SBIRT

services when the broader organization got

very busy. A potential disadvantage is that,

although the CS model is a viable approach

in high-volume settings, it may not be ideal 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

26 

in settings with a small number of patients

because there may be insufficient patient

flow to justify having a dedicated SBIRT

specialist. 

Regardless of which staffing model grantees

implemented, they used a wide variety

of professionals and paraprofessionals to

provide SBIRT services: nurses, physicians,

nurse practitioners, physician assistants,

social workers, psychologists, certified or

licensed addiction professionals, health

educators, hospital interns and residents,

school counselors, and others. 

Develop a Staff Training and 

Supervision Plan 

Because SBIRT occurs outside traditional 

substance abuse provider systems, training

for all staff members is critical. Effective 

training includes the following topics: 

• Importance of the SBIRT program 

•	 Efficacy of SBIRT as demonstrated in

clinical trials 

• Implementation procedures to be used 

• Staff roles and functions 

• Administration of screening tests and

calculating scores (including role-playing

and supervised practice) 

• Providing screening feedback to patients 

• Referral collaborations and procedures 

• BI and BT techniques if staff members will

be providing these services 

Staff members providing BIs and BTs must

be thoroughly trained in the evidence-based

clinical model employed and have access to

onsite or contracted supervision. All training

should include role-playing and supervised

practice so staff members are comfortable

performing BI and BT and perform them

with fidelity. The staff training plan should

institutionalize ongoing training for all

staff members and tie the training to staff

supervision and individual needs. 

SBIRT programs can obtain training

for staff members through a number of

combinations. For medical professionals,

continuing education units and continuing

medical education units are available through 

organizations such as the American Medical

Association; some units are available online. 

SAMHSA and its partners host trainings at

national and regional professional events.

(See Appendix B for training resources.) 

InSight, Harris County Hospital System (Houston, TX) 

Cohort 1 State Grantee 

InSight used a brief motivational intervention (BMI) approach for screening, intervention, and followup. 

BMI specialists received thorough training in motivational interviewing (MI). Training included a 2-day 

workshop on the principles and techniques of MI followed by standardized patient training (SPT). SPT 

enables trainees to practice skills using scripted mock sessions with trained actors as “clients.” An 

expert coach observed these sessions, then provided immediate feedback. Trainees practiced targeted 

skills in subsequent mock sessions. 

Expert coaches also provided BMI specialists with ongoing supervision and review of audiotaped 

sessions with real patients. Review of taped sessions included standardized MI behavior coding* and 

monthly feedback to specialists. This monitoring and feedback process helped ensure continued growth 

of specialists and fidelity to the MI model. For more information on the MI coding system, see Miller, 

Moyers, Ernst, and Amrhein, 2008. 

* Behavior coding is an objective and detailed method of providing skills feedback. The reviewer codes instances of specific 

behavior, such as “affirming” or “supporting autonomy.” 

Source: InSight Project Research Group (2009). 
27 

Chapter 3―SBIRT Implementation 

Training can be arranged through

organizational collaborations. For example,

the Washington Division of Alcohol

and Substance Abuse contracted with 

nationally recognized trainers from the

University of Washington’s Harborview

Medical Center and the Northwest Frontier 

Addiction Technology Transfer Center to

provide training on BI and MI counseling.

Other grantees, such as the New Mexico

Department of Health, found creative

solutions to providing ongoing training and

monitoring through partnerships with local

universities and teletraining to multiple sites. 

All grantees contracted clinical training and

monitoring services through expert trainers.

Contracted trainers typically conducted

initial training that lasted from several

days to 1 week, depending on the model

and expertise of staff, and often provided

followup training or consultation. Some

grantees used trainers for several weeks

during a year, whereas others employed

them full time. Grantees with many rural

sites used more contracted trainers than did 

those concentrated in one or two large EDs.

Grantees also used onsite clinical supervisors 

to reinforce training and to monitor daily

performance of SBIRT staff. 

Develop a Screening Procedure 

The screening procedure needs to ensure

that screening is timely, systematic, and

efficient but also provides enough flexibility

to allow staff members to make the most of 

unexpected opportunities for screening. A first

step in developing a screening protocol is to

decide who will be screened. Will screening 

be universal? Will prescreening be used? Will 

only a subset of the population be screened? If 

so, how will these patients be identified? Do 

screening priority guidelines need to be set? 

What is realistic given the program’s resources? 

Once the population for screening has been

identified, the frequency of each person’s

screening must be considered: Will patients 

be screened at every visit or at regular 

intervals? When during a patient’s visit will 

screening occur? 

SBIRT programs also need to decide for what 

they will screen. Risky/harmful alcohol use? 

Illegal drug use? Prescription medication 

New Mexico Department of Health SBIRT: Sangre de Cristo Site 

Cohort 1 State Grantee 

A project goal was to create, in conjunction with the Governor’s Commission on Telehealth, a statewide 

telehealth system to support SBIRT, particularly in rural areas. The initial phase of the project was to use 

telehealth technology to: 

• Provide clinical supervision of the SBIRT behavioral health counselors (BHCs). 

• Conduct clinical staffing discussions and consultations regarding patient care. 

• Provide continuing professional clinical education to the New Mexico SBIRT BHCs and the New 


Mexico SBIRT partner site clinical providers and staff members.
 

Massachusetts: Heywood Hospital SBIRT Site 

Cohort 2 State Grantee 

This site implemented a protocol that allows ED triage nurses to ask prescreening questions and refer 

patients to the health-promotion advocate (HPA), the staff member who provides SBIRT. When patients’ 

answers to prescreening questions indicate a potential for alcohol and/or drug abuse or high-risk/ 

dependent behavior, the patients’ names are sent to the HPA. Although universal screening remains the 

norm at this site, prescreening by the triage nurse identifies patients who most need to be seen during 

their ED visits. 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

28 

misuse and abuse? Tobacco use? Patients in 

the SAMHSA SBIRT study abused a wide

range of prescription medications and illicit

substances. Many individuals who reported

consuming large quantities of alcohol also used

illicit drugs. The C1 evaluation team found

that screening for drug use can be combined

with screening for tobacco and at-risk use of

alcohol in a broad range of general medical

settings. Because multiple drug use is

common, screening for multiple substances

improved efficiency, resource allocation, and

clinical intervention/treatment. 

In addition to screening for alcohol and drugs, 

SBIRT programs can include other health

issues (e.g., eating disorders, depression) in

the screening or combine screening for alcohol 

and drug use into existing screening protocols

for health issues. 

How patients will be screened is an important

consideration. Several self-report screening

instruments are available. Self-report 

instruments that measure substance use are 

generally reliable, but present some problems.

Accuracy depends on the patient’s perceptions

of potential negative consequences for truthful

responses (e.g., criminal sanctions, physician

disapproval, implications for insurance,

child welfare involvement). Patients may

intentionally misrepresent their drinking and

drug use if they fear consequences. Memory, 

cognition, and motivation also play roles in a

patient’s ability to understand and participate

in screening. 

Despite these limitations, self-report

instruments have many benefits. Compared

with biological tests, they generally take less

time and training to administer. Screening

tests range from brief, straightforward

questions that can be administered in 1 or

2 minutes to those requiring more time and

training and/or professional licensure. One

screening tool is a single question, “How

many times in the past year have you used an

illegal drug or used a prescription medication

for nonmedical reasons?” (Smith et al., 2009;

Smith et al., 2010). This question is also

included in the NIDA Quick Screen, the first 

question of the NIDA Drug Use Screening

Tool. Exhibit 3-3 is an alphabetical list of 

commonly used screening instruments. These

instruments can be used as pen-and-paper 

or electronic self-report tests or as

clinician-administered questions. 

Some evidence suggests that the mode of

administration affects the accuracy of results.

For example, Graham, Goss, Xu, Magid, and

Diguiseppi (2007) found that administering

the AUDIT-C electronically was more

likely to identify hazardous drinking than

assessment via the paper version. 

Exhibit 3-3. Selected Screening Service Instruments 

• Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) 

• Alcohol Use Disorders Identification Test (AUDIT) 

• AUDIT-C 

• CAGE (Cut down, Annoyed, Guilty, Eye-opener) 

• CRAFFT (Car, Relax, Alone, Forget, Family or Friends, Trouble) 

• Drug Abuse Screening Test (DAST) 

• DAST-A 

• Fagerstrom Test for Nicotine Dependence 

• Michigan Alcohol Screening Test (MAST) 

• NIDA Drug Use Screening Tool 

• Problem-Oriented Screening Instrument for Teenagers (POSIT) 

• TWEAK (Tolerance, Worried, Eye-openers, Amnesia, [K] Cut down) 

Note: For more information about these instruments and how to obtain them, see Appendix E. 
Chapter 3―SBIRT Implementation 

SBIRT program administrators can maximize

cost savings and effectiveness of screening

components through careful selection of

screening instruments. Short, simple screens

can identify hazardous use or dependence as

accurately as longer, more complex screening

tools and at a lower cost. More than 25 

validated self-report screening tools are now

available (Babor et al., 2007). These tools,

alone or in combination, identify risk level of

use and guide followup decisions. 

When selecting a screening instrument, some

important questions are: 

• What are the key characteristics of the

target population (e.g., age, level of

literacy, cognitive functioning)? 

• What is the percentage of patients who

cannot self-administer the tool? 

• What languages do patients understand? 

• How much time is available for 

administering and scoring the instrument? 

• Should a staff person administer

the instrument, or should patients

self-complete it? 

Test administrators must consider the 

number of questions in a screening

instrument. Long, time-consuming 

questionnaires may be unrealistic to

use. Instruments that have just one or

two questions may not provide enough

information. 

SBIRT programs also need to determine

screening followup procedures. Who will 

interpret the results and provide the patient 

with feedback? How will a patient be referred 

to BI, BT, or more intensive specialty 

treatment if screening is positive? 

Develop BI and BT Procedures 

Questions to consider regarding BI and BT

include: 

• Where and when will BI and BT occur, 

onsite or by referral to specialty substance

use disorder (SUD) treatment programs? 

• If BI or BT will be provided onsite, who

will provide these services? 

• What educational materials will be used? 

• What community resources need to be

tapped? 

• What training will staff members need? 

SBIRT programs also need to decide on

what clinical models (or combination of

models) and BI and BT techniques are most

appropriate and feasible. Traditionally,

BIs have been provided as a stand-alone

treatment to patients with less severe SUDs.

Recent evidence suggests, however, that BIs

can be effective with a range of patients. 

Models for BI include: 

• Brief Negotiated Interview (see Appendix

B) and simple advice. 

• Brief counseling. 

• FRAMES (Feedback, Responsibility,

Advice, Menus of options, Empathy,

Self-efficacy). 

• MI techniques. 

State University of New York, University at Albany 

College and University Grantee 

The university’s SBIRT initiative targets first-year students, student athletes, and students who seek 

health-related services at the University Health Center. Students are asked to log into a secure Web 

site to enroll in the SBIRT project and complete questionnaires. Data from the questionnaires are 

downloaded to a spreadsheet and used to create a personalized feedback sheet. Students who screen 

positive and receive BI, BT, or intensive specialty treatment receive an email with a Web link to followup 

questionnaires at discharge and at 6 weeks and 6 months after the intervention. 

29 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

30 

BT is frequently a stand-alone first treatment

but also can be useful for patients who

have undergone traditional treatment but

relapsed, as an alternative to longer-term 

treatment when patients cannot afford

treatment, or while patients wait for

specialized SUD treatment. 

Commonly used models for BT include: 

• Cognitive–behavioral therapy. 

• Motivational enhancement therapy. 

• Community reinforcement approach. 

• Solution-focused therapy. 

Appendix B identifies resources for more

information about clinical models. 

Develop Referral Procedures and 

Identify Referral Resources 

Research suggests that BI or BT alone

will not suffice for people who are severely

dependent on alcohol or drugs (Babor et al.,

2007) or who have co-occurring disorders

(e.g., depression, conduct disorders) (Fleming

& Graham, 2001). Some patients who meet

criteria for substance abuse/dependence

need referrals to more intensive specialty

treatment and mutual-help groups, such 

as Alcoholics Anonymous, Narcotics

Anonymous, Women for Sobriety, or SMART

(Self-Management and Recovery Training). 

SBIRT programs should develop referral

procedures that both motivate patients to 

enter treatment and connect them with 

convenient, accessible specialty treatment

programs. SAMHSA grantees found many

innovative ways to facilitate treatment entry: 

• Initiation of onsite treatment (at the

screening facility) 

• Provider-initiated appointments 

• Peer/mentor health educator support 

• Case management services 

• Transportation to treatment facilities 

• Negotiation for dedicated treatment slots

for SBIRT patients 

Most SBIRT grantees contracted with

community specialty providers to facilitate

referral processes. Prearranged referral

relationships ensure smooth transitions for

patients at the appropriate level of care and

facilitate followup. Cultivating collaboration

across systems—such as medical, SUD

treatment, mental health service centers, 

and criminal justice—is important for

successful implementation. Most grantees

developed referral relationships with a range

of community treatment resources to ensure

that referrals were appropriate to patients’

needs and cultural backgrounds. 

Develop a Recordkeeping 

Procedure and Evaluation Plan 

Patients’ participation in SBIRT should be

indicated in their records; some programs 

Massachusetts: Mercy Hospital SBIRT Site 

Cohort 2 State Grantee 

SBIRT patients have priority for service at Mercy Hospital. The hospital SBIRT program has working 

relationships with social workers from other area hospitals and ongoing relationships with SUD 

treatment providers from western to central Massachusetts. The program is a member of the Western 

Massachusetts Substance Abuse Providers Association and the Massachusetts Organization for 

Addiction Recovery. SBIRT staff members have toured many sites to which they refer patients and have 

met with nearly every admissions director and coordinator for those programs. Referral relationships 

include local counseling agencies, transitional programs, the Department of Public Health regional 

office, Healthcare for the Homeless and other nonprofit healthcare sites, detoxification hospitals, and 

residential substance abuse treatment programs. 
31 

Chapter 3―SBIRT Implementation 

attach a colored sticker to the paper record.

Patient-level information essential to 

effective patient care and program evaluation

includes: 

• Initial screening scores. 

• Interventions undertaken. 

• Progress notes. 

• Referrals made. 

• Followup screening scores/outcomes and

treatment utilization. 

• Physical and mental health symptoms or

diagnoses. 

• Next scheduled screening. 

Evaluation is critical to SBIRT sustainability.

Process and outcome evaluations can guide

change, encourage staff members, and provide

justification to funders. SBIRT program

personnel should begin to research evaluation

strategies early in the SBIRT implementation

process, including considering possible

State, regional, and local partners, such as

universities. The following organizations

or associations provide information about

evaluation (see Appendix B): 

• American Evaluation Association 

• Centers for Disease Control and 

Prevention 

• Innovation Network 

• Network for the Improvement of Addiction

Treatment 

• University of Wisconsin Cooperative

Extension course: Enhancing Program

Performance with Logic Models 

• W. K. Kellogg Foundation 

Providing regular feedback of evaluation

results to all participating staff members

is essential for ongoing improvement of the

program and for maintaining staff motivation

and commitment to the program. Ongoing

feedback from staff is also important;

it provides information about how the

implementation processes are working,

identifies problems early in the process, and

generates ideas for improvements. 

SBIRT grantees typically contracted with

external evaluators for monitoring and

assessing performance indicators. 

Develop a Funding and 

Reimbursement Strategy 

Funding and reimbursement are critical to

SBIRT program success and sustainability.

SBIRT program leaders should begin early

in the implementation process to identify

potential Federal, State, and private funding

resources and fully understand public and

private insurance reimbursement procedures

and issues. Program costs, reimbursement,

and sustainability are discussed in Chapter 4. 
PAGE INTENTIONALLY LEFT BLANK
 
Chapter 4—Implementation and 


Sustainability Issues
 

Barriers to and Facilitators of 

Successful SBIRT Implementation 

The cohort 1 cross-site (C1) evaluation team

noted three common themes associated with 

successful screening, brief intervention, brief

treatment, and referral to treatment (SBIRT)

systems-level program implementation: 

• Leadership and positive interagency

collaboration 

• Provider buy-in 

• Favorable setting and contextual factors 

Leadership and Positive Interagency 

Collaboration 

Grantees reported that competing missions,

values, procedures, and policies in each

referral agency led to communication

challenges and hindered successful

implementation. Grantees noted the following

helpful factors to overcome these challenges: 

• Positive interagency relationships,

including cooperation before and after

the implementation, collaboration,

communication, and leadership at all

levels 

• Strong leaders who delivered clear,

consistent messages about program goals

and values and encouraged communication

among key stakeholders 

• At least one person at each level who

championed SBIRT 

Provider Buy-in 

Staff resistance to a new program is common.

Grantees reported that some generalist

providers in medical settings had difficulty

shifting their attention from patients’ 

physical conditions to also focusing on

patients’ nondependent, risky substance use.

Generalists may also be inexperienced in

using motivational interviewing techniques

and incorporating behavioral health practices

in medical care settings. Further, grantees

reported that generalist providers were

reluctant to add procedures to their already

busy schedules. 

Grantees indicated the following helpful

factors: 

• A planning and development phase that is

long enough for program directors to elicit

and secure the support and cooperation of

personnel at all organizational levels 

• Staff members at all levels of planning

who help obtain support for the program

(In particular, grantees noted that support

from senior leaders, such as onsite 

physicians and nurses, was a critical

element for success.) 

• Standardized staff training 

Grantees’ experiences provided additional

ideas for overcoming staff resistance: 

• Teach staff members about alcohol and 

other substance use disorders (SUDs) and

the cost effectiveness and health benefits of 

SBIRT. 

• Provide specific and ongoing training. 

• Design programs that minimize the time

burden for onsite staff. 

• Elicit support from opinion leaders. 

• Establish program goals and provide

ongoing feedback and incentives to staff

members. 

33 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

34 

• Create in-house, interdisciplinary teams to

formulate policies and procedures. 

• Use alternative screening procedures, such

as electronic screening instruments, that

are effective with some populations and

save staff time. 

Contextual Factors 

Grantees noted a number of contextual 

factors that facilitated SBIRT 

implementation, including: 

• Useful available technology (e.g., video

or telephone intervention and treatment

services). 

• Screening and other data collection tools

to supplement existing assessment and/or

enhance electronic health records. 

• Short screening or prescreening tools. 

However, grantees noted a lack of physical

space for the delivery of SBIRT services as a

barrier to implementation, leading to lack of

privacy (e.g., administering the screening in

the patient waiting room, hallway, or other

public area), particularly in high-volume

settings (e.g., emergency departments [EDs],

trauma centers). This lack of privacy led to

concerns about confidentiality and patients’

rights (see Confidentiality, below). 

Confidentiality 

Privacy can be difficult to maintain in busy

healthcare settings, especially in a busy

ED with only a curtain separating patients.

However, care needs to be taken to provide

privacy during screening. 

The Federal Health Insurance Portability

and Accountability Act (HIPAA) contains

strict provisions for guarding patient records,

regardless of setting. Another regulation,

42 Code of Federal Regulations (CFR) Part

2, specifically protects the privacy of people

seeking treatment for substance abuse.

This regulation applies to organizations

that provide any type of substance abuse 

treatment services in any component of the

organization and receive direct or indirect

Federal monies (including Medicare or

Medicaid). For resources providing more

information about 42 CFR Part 2 and HIPAA, 

see Appendix B. 

Uniform Accident and Sickness 

Policy Provision Law 

The Uniform Accident and Sickness Policy

Provision Law (UPPL) poses a significant

barrier to SBIRT in many States. First

enacted in 1947, the law allows insurance 

companies to deny payments to individuals

injured while under the influence of alcohol.

To deny reimbursement, the insurer must

demonstrate that alcohol to some degree

caused the insured person’s injury or other

medical problem. Recently, several States

have moved to repeal these laws, and some

States have regulations explicitly prohibiting

insurers from denying payment for medical

costs resulting from the intoxication of the

insured. Some States do not have UPPLs 

but implicitly allow insurers to use alcohol

exclusions by ruling that, in the absence

of explicit laws, insurance companies may

include alcohol exclusions in policies to limit

liability (Fornili & Goplerud, 2006). 

Some healthcare providers are reluctant to

screen patients for SUDs because they are

concerned that the patient’s health insurance

carrier may deny reimbursement for the

visit if an alcohol problem is identified. This

may be especially common in EDs because

of the risk that insurers will not reimburse 

for the treatment if the patient was under

the influence of alcohol or drugs (Gentilello,

Donato, et al., 2005; Rivara, Tollefson, Tesh, 

& Gentilello, 2000). Gentilello, Donato, et al.

(2005) reported that 24 percent of trauma

surgeons had encountered an insurance

reimbursement denial in the past 6 months

because of a patient’s alcohol or drug use.

Bloss, Chen, and Yi (2008) assessed the

frequency of substance abuse identification in

EDs and trauma centers in Maryland before

and after the State UPPL was repealed. 
35 

Chapter 4—Implementation and Sustainability Issues 

They found a 20- to 34-percent increase in

the frequency of alcohol-related conditions

identified after the law was repealed. 

UPPL presents a barrier to SBIRT because

patients and/or providers may have to

absorb the cost of the treatment if substance 

abuse is identified. At this time, there is no 

solution to this problem other than working

toward repeal in States that have UPPLs.

The National Institute on Alcohol Abuse 

and Alcoholism’s Alcohol Policy Information

System provides information on States

with and without UPPLs (see Appendix B).

Anderson, Aromaa, Rosenbloom, and Enos 

(2008) suggest that when hospital, ED, or

trauma center staff dedicated to providing

SBIRT services collect information about 

a patient’s substance use (such as during

SBIRT screening), the specific information

gathered may be protected under 42 CFR

Part 2 and may not need to be reported to

insurers. If, however, information is collected 

through medical tests (such as blood alcohol

levels or toxicology) to treat the patient, such

information is not protected from disclosure

to insurers. SBIRT providers should obtain

legal counsel before establishing policies on

UPPL provisions and confidentiality. In any

case, patients need to be informed of SBIRT

screening and provide their consent to be

screened. 

Reimbursement for SBIRT 

SBIRT costs vary greatly according to setting,

staffing model, and services offered. Looking

at staffing models, for example, the C1

evaluation team found that: 

• The in-house generalist (IHG) model had

the lowest annual operating costs and

could most likely be supported by revenues

from insurance reimbursement. 

• The in-house specialist model could be

supported by service-reimbursement

revenues if the specialist engages in other

(non-SBIRT) revenue-generating activities

and if training and administrative

management costs are contained. 

• The contracted specialist (CS) model

is likely to require State or local funds

in addition to service reimbursement 

revenues to be financially viable. The

extent to which the CS can engage in

non-SBIRT revenue-generating activities

greatly influences the model’s financial

viability. 

Reimbursement is available through

commercial insurance Current Procedural 

Terminology (CPT) codes, Medicare G codes,

and Medicaid Healthcare Common Procedure 

Code System (HCPCS) codes. 

Commercial Insurance and Medicare 

CPT is a numeric coding system maintained

by the American Medical Association (AMA).

Recognizing the potential health and cost

benefits of SBIRT, AMA instituted new 

healthcare codes specifically for substance

abuse screening and brief intervention. Four

codes can be used—two are for privately

insured patients (99408 and 99409), and

two are for Medicare patients (G0396 and

G0397). Fees are determined by the duration

of the screening and/or brief intervention. A

description of the four codes is as follows: 

• CPT 99408: Alcohol and/or substance

(other than tobacco) abuse structured

screening and brief intervention services,

15–30 minutes 

• CPT 99409: Alcohol and/or substance

(other than tobacco) abuse structured

screening and brief intervention services,

greater than 30 minutes 

• G0396: Alcohol and/or substance (other

than tobacco) abuse structured assessment

(e.g., Alcohol Use Disorders Identification

Test [AUDIT], Drug Abuse Screening Test

[DAST]) and brief intervention, 15–30

minutes 

• G0397: Alcohol and/or substance (other

than tobacco) abuse structured assessment

(e.g., AUDIT, DAST) and intervention,

greater than 30 minutes 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

36 

Medicare will instruct its carriers to pay for

G0396 and G0397 “only when considered

reasonable and necessary.” 

Other codes may be used for SBIRT 

reimbursement, such as some codes for: 

• Alcohol and drug testing (biologic assays). 

• Psychotherapy. 

• Health and behavior assessment/

intervention. 

Additional information regarding Medicare

reimbursement is available in the fact sheet, 

Substance (Other Than Tobacco) Abuse 

Structured Assessment and Brief Intervention 

(SBIRT) Services. (See Appendix B.) 

Medicaid and Working With State Medicaid 

Agencies 

The Centers for Medicare and Medicaid 

Services Medicaid HCPCS billing codes for

screening and brief intervention are: 

• H0049: Alcohol and/or drug screening. 

• H0050: Alcohol and/or drug services, brief

intervention, per 15 minutes. 

However, each State must activate or unlock 

the HCPCS codes. In other words, the State 

Medicaid agency must agree to reimburse for 

the services. This process of unlocking codes

varies by State. State Medicaid systems are

complex, and sustained effort is required

to effect change in these systems. The C1

evaluation team found that many grantees

underestimated the difficulties of working

with their State Medicaid agencies. 

Historically, Medicaid did not consider

substance abuse a medical issue, and 

providers may have been resistant to

unlocking SBIRT reimbursement codes.

However, the Affordable Care Act (ACA; P.L.

111-148, as amended by the Health Care and

Education Reconciliation Act of 2010; P.L. 

111-152) includes substance use disorders

as “one of the ten elements of essential 

health benefits.” Beginning in 2014, all

health insurance sold on Health Insurance 

Exchanges or provided by Medicaid (to newly

eligible adults) will be required to include

substance use disorder treatment (Office

of National Drug Control Policy, 2012b).

These factors require State substance abuse

treatment agencies to use strategies that

stress the cost benefit of SBIRT and consider 

political realities. The ACA has created new

opportunities for SBIRT across a wide range

of healthcare settings, but implementation

challenges still exist. 

Medicaid Strategies: Washington State SBIRT Program 

Cohort 1 State Grantee 

Lessons learned from the Washington State SBIRT program suggest several strategies for working with 

the State Medicaid agency to unlock HCPCS codes for SBIRT (Gelber & O’Neil, 2007): 

• Understand how the State Medicaid agency works before attempting to influence it. 

• Develop talking points that explain SBIRT as a medically necessary activity. 

• Outline practice standards, provider types, and work units. 

• Frame arguments in terms of cost benefit or political expediency. 

• Do the homework, gather supporting data, and be prepared to perform followup analysis as needed. 

• Think broadly—focus on systems change. 

• Be prepared to drive the process. 

• Have a clear sense of mission. 

• Engage those with experience in implementing SBIRT. 

• Seek advocates at State and local levels. 
Chapter 4—Implementation and Sustainability Issues 

Sustainability: Beyond 

Reimbursement 

The level of insurance reimbursement 

may not cover all SBIRT costs. More

important, not all patients are eligible for

reimbursement: the C1 evaluation team 

found that all sites had a high proportion

of SBIRT patients who were uninsured and

ineligible for Medicaid. Grantees’ financial

sustainability efforts include several

strategies: 

• Accessing State or local funding, including

convincing local hospital or treatment

agencies to support some services 

• Obtaining research and other grant

funding for ongoing support 

• Changing from a CS model to an IHG

model 

• Screening for substance use within the

context of a broad behavioral health 

screening protocol 

• Placing continuation funding in pending

State legislation 

The Florida grantee (cohort 2) developed a

sustainability guide for its partner agencies

that offers the following suggestions for

achieving financial sustainability (Florida

Brief Intervention and Treatment for Elders 

[BRITE], 2009): 

• Check Substance Abuse and Mental 

Health Services Administration and 

Department of Health and Human

Services funding announcements. 

• Explore State substance abuse program

funding (both prevention and treatment). 

• Be aware of funding available through

local departments of health, education,

justice, and corrections. 

• Check the Foundation Directory on the

Foundation Center Web site (see Appendix

B). 

• Ask stakeholders for donations and 

annuities. 

• Obtain external fundraising expertise. 

• Start a related for-profit or not-for-profit

business entity or product line that

contributes to programming. 

Sustainability entails more than financing.

Maintaining staff motivation and program

support at the organizational, local, and

State levels is crucial. Also critical are 

effective management, quality assurance,

ongoing training, program evaluation, and

communication among all involved. Exhibit

4-1 provides a list of eight key elements of

sustainability. 

Exhibit 4-1. Key Elements of Sustainability 

Element Tasks 

Vision • Know what is to be sustained: scope of activities, scale of operation, and timeline. 

• Know how the initiative fits within the larger community. 

Results 

Orientation 

• Adopt a results framework. 

• Clearly state the results to be achieved for the target population. 

• Use indicators and performance measures to track progress and improve services. 

Strategic 

Financing 

Orientation 

• Determine expected fiscal needs. 

• Make the best use of existing resources (fiscal and in-kind). 

• Maximize available sources of revenue. 

• Create greater flexibility in categorical funding. 

• Create public–private partnerships. 

• Monitor announced opportunities for funding. 

• Explore State and local revenue sources. 

37 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Exhibit 4-1. Key Elements of Sustainability, continued 

Element Tasks 

Adaptability 

to Changing 

Conditions 

• Consider new ways to frame the work to interest different funders. 

• Identify opportunities to improve the policy climate. 

• Participate in collaborative advocacy to encourage change. 

• Work to improve the organization’s ability to participate in these efforts. 

Broad Base of 

Community 

Support 

• Develop a plan to create a desired identity. 

• Nurture a community presence and support. 

• Encourage involvement of clients and recipients of services. 

• Support public education and engagement. 

• Build partnerships that foster collaboration rather than competition. 

Key 

Champions 

• Identify decisionmakers and opinion leaders. 

• Develop an effective outreach plan. 

• Cultivate a broad base of champions: elected officials, business professionals, peers, 

patients and their families, community leaders, philanthropists. 

Strong 

Internal 

Systems 

• Know and involve the people who carry out the organization’s mission: staff members, 

board members, volunteers, other interested parties. 

• Develop strong fiscal management, accounting, information, and personnel procedures. 

• Use those systems to review strategies and make changes as needed. 

Sustainability 

Plan 

• Develop a comprehensive plan that takes into account short- and long-term needs. 

• Identify challenges and barriers and address them. 

• Identify strategies to obtain needed resources. 

• Identify and communicate with key partners. 

Adapted from Florida BRITE (2009). 

38 
Chapter 5—Case Examples: The Substance 

Abuse and Mental Health Services 

Administration SBIRT Grantee Experience 

This chapter discusses the experiences of the

cohort 1 grantees. The cohort 1 programs

were both geographically and clinically

diverse. Geographically, they spanned from

the East Coast to the West Coast of the 

United States and represented a range of

communities (e.g., rural, urban). Clinically,

they differed in the types of screening

instruments used, the types of professionals

who performed screening and offered brief

treatment (BT), and the number of BT

sessions offered. Clinical settings differed

as well, ranging from community health

centers, Indian Health Service clinics, and 

primary care clinics, to hospital emergency

departments (EDs) and ED trauma centers. 

Washington State Screening, 

Brief Intervention, Referral, and 

Treatment 

Program Overview 

The Washington State Screening, Brief

Intervention, Referral, and Treatment 

(WASBIRT) program was part of the

Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s)

cohort 1 cooperative agreement and was

implemented in 2004. WASBIRT placed 27

substance use disorder (SUD) professionals

in 9 of Washington State’s busiest hospital

EDs to provide frontline screening and

early identification of substance abuse

treatment needs. In the past, the State had

difficulty identifying individuals with SUDs

and providing them with access to prompt

treatment. Furthermore, individuals seeking

treatment encountered waiting lists. 

This project was operated by the State’s

Department of Social and Health 

Services’ Health and Recovery Services

Administration. The goals of the WASBIRT 

program were to: 

•	 Improve identification of patients coming

to the ED with SUDs. 

• Conduct screening and brief interventions

(BIs) in the ED. 

• Deliver BT on an outpatient basis at

certified treatment centers. 

• Increase referrals of people needing

specialty treatment. 

• Reduce ED utilization, medical costs, 

criminal behavior, substance-related 

disability, and death of patients with

alcohol or drug problems. 

• Improve links between hospitals and

treatment services and expand services to

include early intervention. 

The Process 

In the first 18 months, SUD treatment 

professionals used the Alcohol Use Disorders

Identification Test (AUDIT) to screen more

than 27,000 patients for substance use

problems. Forty-six percent of patients had

positive screening results for substance use

problems. Patients with positive results

received BIs or were referred for followup

treatment. About one-third of patients

approached declined to participate, were

too ill, or did not meet the selected criteria 

(e.g., were too young, spoke a language

for which the program did not have the

capacity to translate, were in police custody).

Five percent of patients had two screening

sessions, and 1 percent had three or more

sessions during the year. Depending on

screening results, patients were screened out,

provided BIs, referred for assessment and 

39 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

40 

brief therapy, or referred for assessment and

possibly full substance abuse treatment. 

Program Implementation 

Program leadership developed educational

tools for State hospital trauma coordinators,

enabling consistent training across the nine

sites. Program staff conducted site visits and

provided train-the-trainer sessions. 

An in-house generalist, such as the trauma

coordinator, led the program at each site.

These generalists supervised the counselors

who performed the screening. At each site,

a BI group directed policy and procedure

development and implementation. This group

included: 

• ED clinician 

• ED case manager 

• Hospital case manager/social worker 

• Trauma coordinator 

• Trauma medical director 

• Trauma billing representative 

• Chaplain services 

Implementation Challenges 

WASBIRT encountered some implementation

obstacles, such as limited resources for 

assistance, busy schedules, and pushback

from some provider groups. To overcome

these obstacles, the program identified and

positioned regional program representatives

who provided additional training to staff

members. This training convinced ED staff

of SBIRT’s usefulness. Support from service

directors and trauma medical directors was 

crucial in facilitating implementation. 

Six-Month Followup Survey 

During the baseline screening survey at

admission to the ED, patients who received

a BI and/or a referral to further treatment

were randomly selected for a followup

survey even if they did not engage in further 

treatment. The counselor obtained patient

contact information; then interviewers 

used administrative records to update and

supplement the information of patients who

gave permission to use their personal records

in the study. A staff member sent a reminder

letter 1 week before the followup interview.

An interviewer then attempted to contact

the person over a 3-month period, using

telephone calls and letters to the patient’s

alternate contacts as necessary. 

Between April 2004 and March 2006,

WASBIRT screened 34,762 patients.

SBIRT professionals provided at least a

BI to 52 percent of these patients based on

their screening results. Of the more than

15,000 patients who received at least a BI,

2,648 were randomly selected for followup

telephone interviews 6 months after the

intervention. Of those, 78 percent completed

the survey. 

The effects of receiving BIs on subsequent

substance use were positive. The average

days of reported recent alcohol and drug use

declined, and abstinence rates increased. 

Among patients who received at least a 

BI, substance use reported in the 6-month

followup interview changed significantly

compared with use reported at screening: 

• Of 1,398 patients who drank alcohol, 80

percent reduced the number of drinking

days (in the past 30 days), with the overall

average declining from 10.4 to 5.3 days

(p<0.05). 

• The percentage of patients reporting

abstinence from alcohol in the past 30 days

increased from 28 percent to 47 percent

(p<0.05). 

• Of 857 patients who reported binge

drinking (five or more drinks in one sitting

in the last 30 days), 87 percent reduced

the number of heavy drinking days, with

the average declining from 10.1 to 2.9 days

(p<0.05). 

• Of 878 patients who reported drug use in

the past 30 days, 84 percent reduced the

number of days of use, with the overall 
41 

Chapter 5—Case Examples: The Substance Abuse and Mental Health Services Administration SBIRT Grantee Experince 

average declining from 13.7 to 6.5 days

(p<0.05). 

• The percentage of patients reporting

abstinence from illicit drugs in the past

30 days increased from 55 percent to 71

percent (p<0.05). 

• Among patients with a high risk for SUDs,

declines in alcohol use and in illegal drug

use were significantly greater for those

who received BT or more intensive SUD 

treatment than for those who received only

BI. 

• Illegal drug use declined among high-risk

patients who used marijuana, cocaine,

methamphetamine, and heroin or other

opioids (p<0.05). 

• Among high-risk patients who used

marijuana, cocaine, or methamphetamine,

declines in overall drug use were greater

for those who also received BT or 

substance abuse treatment than for those 

who received only BI (p<0.05). 

New Mexico Human Services 

Department, Behavioral Health 

Services Division 

Program Overview 

In partnership with Sangre de Cristo

Community Health Partnership (SDCCHP),

the New Mexico Human Services 

Department, Behavioral Health Services

Division, used SAMHSA funds to establish 

a statewide SBIRT program focusing on

bringing integrated behavioral health and

medical care services to minority populations

in rural areas. Begun in 2004, the program

in New Mexico gradually expanded the model

to include school-based health centers, public

health offices, Indian Health Service units, 

and 1 rural hospital, for a total of 34 sites. 

The Process 

SBIRT activities were conducted by 24

master’s-level behavioral health consultants 

(BHCs). A clinical director and four regional 

supervisors provided supervision. Fidelity

was established through regularly scheduled

clinical supervision (both onsite and via

teleconference) and continuous training of

BHCs. 

Program Implementation 

The program provided pre-implementation

training in motivational interviewing (MI)

and the community reinforcement approach

(CRA) to BHCs. A basic training module for

clinic providers was developed that explained

the purpose of SBIRT, the work of the health

consultants, and approaches to integrating

SBIRT services into the primary care

services. 

The program emphasized early screening

and intervention at rural community-level

sites, such as community-based primary

care clinics, which were trusted by the

community. Program officials hoped that the

use of established and trusted sites would 

increase the comfort level of individuals being

screened. 

BI was provided immediately to all patients

who had a positive screening result. BHCs

provided feedback to patients about their

scores and engaged patients in conversations

about their health. The BT consisted of 6 

to 10 sessions of CRA. Those at very high

risk were referred by BHCs for intensive

treatment to specialized community agencies. 

New Mexico’s SBIRT program also

implemented a statewide Telehealth

Initiative that provides telecommunication

equipment and connection to 20 rural

partner sites. This infrastructure provides

supervision, training, and consultant

support to BHCs throughout the State.

The New Mexico program faced numerous

implementation challenges, including serving

several diverse populations and meeting their

needs in many large rural areas. 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

42 

Choosing and Cultivating Collaborators 

Lessons learned from New Mexico’s 

SBIRT program suggest that partnering

organizations should be assessed for their

readiness to change, most notably having the

support of key managers within agencies and

from staff members at all levels. New Mexico 

hosted an orientation meeting for potential

partners to determine which organizations

could participate. Each potential partner

organization was asked to complete an

Organizational Readiness Questionnaire

developed by the Texas Christian University

Institute of Behavioral Research. 

New Mexico’s recommendations for 

cultivating partnerships include the

following: 

• Use collaboration to select the appropriate

screening tools. Consider differences in

populations being served and staff and

patient time constraints. 

• Hold regularly scheduled meetings and

training sessions. 

• Develop memoranda of agreement between

partner sites and SBIRT management that

specify roles, responsibilities, program

targets, and outcomes. 

• Obtain support from clinic staff at all

levels at each site. Seek staff input on

organization and program changes. 

•	 Use financial incentives—To improve

cooperation, the New Mexico grantee

offered $20 to patients who completed the

followup. 

Flexibility and Fidelity 

Although New Mexico’s SBIRT

implementation team recognized the need to

adapt to regional and cultural differences,

staff members found working in a clinic

environment challenging. They revised

the implementation plan to better meet

the needs of different settings, situations,

tribal cultures, and staff backgrounds and

attitudes. 

The initial protocol also called for a 1- to

2-minute transfer in which the clinic’s 

physician introduced the patient to the

BHC. In busy clinics, however, this was not

feasible, so a very brief introduction was

substituted. 

Staff Training 

New Mexico’s SBIRT program hired

master’s-level mental health counselors 

and social workers as BHCs. Most BHCs 

did not have SUD treatment experience,

requiring ongoing training and supervision

by the SBIRT clinical director and regional

clinical supervisors. New employees were

trained in MI, CRA, or both. New Mexico’s 

SBIRT program invested significantly in the

training and clinical supervision of its clinical

staff. Because acquiring new skills, such as

MI, requires ongoing support and feedback,

the training process allowed for practice,

continual followup, and reinforcement.

The program developed training tools that

included tapes and checklists. 

Working With Native American Populations 

New Mexico’s SBIRT program worked with

three clinics operated by the Taos Pueblo,

Jicarilla Apache, and Zuni Tribes. Although

the contractual relationship was the same

across the three tribes, the level of staffing

varied by site. Working at these sites

required coordination with two additional

organizations, each with its own culture and

requirements—the Indian Health Service and

the specific Native American tribal council. 

Contractual Relationships 

In 2003, the New Mexico Governor’s 

Office restructured the State’s behavioral 

health services. Under the new system,

ValueOptions New Mexico (VONM) serves as

the funding passthrough entity for Federal

behavioral health grant dollars. In July 2005,

VONM assumed responsibility for contract

oversight of the New Mexico SBIRT grant. 
43 

Chapter 5—Case Examples: The Substance Abuse and Mental Health Services Administration SBIRT Grantee Experince 

New Mexico’s decision to implement its

project through a contractual agreement with

an independent agency (i.e., SDCCHP) had

significant advantages. The agreement: 

• Allowed for rapid implementation; the

project was running within 4 months. 

• Eliminated the need to work through State

bureaucratic systems, allowing for the

quick hiring of staff. 

•	 Offered the flexibility to implement SBIRT

at different sites simultaneously. 

• Freed program staff to develop and

implement the Telehealth network and

psychiatric consultation services through

the University of New Mexico’s Office of

Rural Psychiatry. 

• Allowed for the centralization of project

and patient data at the SDCCHP office,

supporting easy and timely access to data. 

Six-Month Followup Survey 

Data compiled over 20 months indicate more

than 19,000 patients in New Mexico were

screened. Some 1,817 patients reported

high-risk levels of substance use and received 

onsite BIs and BTs from SBIRT BHCs. Of 

these 1,817 individuals, 1,148 scored at 

“moderate risk” for alcohol- and drug-related

problems, 576 patients scored at “high risk”

for problems, and 93 scored at “very high

risk” for problems. 

Of the 1,817 individuals reporting some

high-risk level of substance use, at 6-month

followup: 

• Forty-seven percent of the patients had

decreased their alcohol use, and 29 percent

reported a decrease in drug use. 

• There was a 58-percent increase in

patients reporting no alcohol or drug use. 

• The number of days of drinking to

intoxication significantly decreased from

an average of 4.75 days at intake to 3.35

days at followup, a mean change of 1.4

days (p<0.01). 

• The number of days of drug use decreased

from a mean of 5.11 days at intake to a

mean of 2.62 days at followup, a mean

change of 2.5 days (p<0.01). 
PAGE INTENTIONALLY LEFT BLANK
 
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54 
Appendix B—Resources
 

Documents About SBIRT 

Alcohol Screening and Brief Intervention: A Guide for Public Health Practitioners (2008).

American Public Health Association, Education Development Center, Inc., National Highway

Traffic Safety Administration, U.S. Department of Transportation. 

Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: Committee on Trauma 

Quick Guide (2007). Center for Substance Abuse Treatment, Substance Abuse and Mental

Health Services Administration, U.S. Department of Health and Human Services. 

Pennsylvania Screening, Brief Intervention, and Referral to Treatment Web site

http://www.ireta.org/sbirt 

A Pocket Guide for Alcohol Screening and Brief Intervention (2005). National Institute on

Alcohol Abuse and Alcoholism, National Institutes of Health, U.S. Department of Health and

Human Services. 

Screening & Brief Intervention: Making a Public Health Difference (2008). Boston: Join

Together. 

Screening and Brief Intervention (SBI) for Unhealthy Alcohol Use: A Step-by-Step 

Implementation Guide for Trauma Centers (2009). John Higgins-Biddle, Dan Hungerford, and

Kathryn Cates-Wessel, Centers for Disease Control and Prevention, National Center for Injury

Prevention and Control. Available at: 

http://www.cdc.gov/InjuryResponse/alcohol-screening/pdf/SBI-Implementation-Guide-a.pdf 

Screening for Drug Use in General Medical Settings: Quick Reference Guide (2009). National

Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human

Services. 

Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention,

and Referral to Treatment Web site 

http://www.samhsa.gov/prevention/sbirt/ 

Reimbursement and Sustainability 

Coding, Billing and Reimbursement Manual (2010).

Wisconsin Initiative to Promote Healthy Lifestyles. Available at:

http://www.wiphl.com/uploads/media/SBIRT_Manual.pdf
 

The Foundation Center Web site 

http://foundationcenter.org
 

55 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

56 

Implementing Change in Substance Abuse Treatment Programs (2009). Technical 

Assistance Publication 31. Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration. Available at: http://store.samhsa.gov/product/

TAP-31-Implementing-Change-in-Substance-Abuse-Treatment-Programs/SMA09-4377 

Introduction to Sustainability of Screening, Brief Intervention, Referral and Treatment (SBIRT) 

Services (2009). Florida Brief Intervention and Treatment for Elders. Available at:

http://brite.fmhi.usf.edu/BRITEIntrotoSustainability2009.pdf 

The Substance Use Disorder Calculator 

Ensuring Solutions to Alcohol Problems, George Washington University Medical Center

http://www.alcoholcostcalculator.org/sub/payment/ 

Substance (Other Than Tobacco) Abuse Structured Assessment and Brief Intervention (SBIRT) 

Services [Fact Sheet]. Available at: http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf 

Training 

Addiction Technology Transfer Center Network

http://www.attcnetwork.org/learn/topics/motivation/ 

Alcohol Education: Clinical Skills Training for Health Professionals

http://www.larasig.com/alcohol 

Alcohol Screening and Brief Intervention Curriculum

Alcohol Clinical Training, Boston Medical Center and Boston University Schools of Medicine

and Public Health 

http://www.bu.edu/act/mdalcoholtraining/index.html 

Motivational Interviewing Network of Trainers

http://www.motivationalinterviewing.org/ 

SBIRT Training and Consulting

The BNI ART Institute, Boston University School of Public Health.

http://www.ed.bmc.org/sbirt/services.php 

Program Evaluation Resources 

American Evaluation Association 

http://www.eval.org 

Centers for Disease Control and Prevention 

http://www.cdc.gov/eval 

Innovation Network 

http://www.innonet.org/?section_id=4&content_id=16 

Network for the Improvement of Addiction Treatment

https://www.niatx.net/Home/Home.aspx 
57 

Appendix B—Resources 

University of Wisconsin Cooperative Extension course: Enhancing Program Performance with

Logic Models

http://www.uwex.edu/ces/lmcourse 

W. K. Kellogg Foundation

http://www.wkkf.org/knowledge-center/resources/2006/02/

WK-Kellogg-Foundation-Logic-Model-Development-Guide.aspx 

Brief Intervention/Brief Treatment 

Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care

(2001). Thomas F. Babor and John C. Higgins-Biddle, World Health Organization. Available at:

http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf

In Spanish: http://www.who.int/substance_abuse/activities/en/BImanualSpanish.pdf
 

Brief Interventions and Brief Therapies for Substance Abuse (1999).

Treatment Improvement Protocol 34. Center for Substance Abuse Treatment, Substance Abuse

and Mental Health Services Administration.
 

Brief Negotiated Interview

http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-brief-negotiated-interview-bni/
 

Motivational Interviewing Web site

http://www.motivationalinterview.org
 

Referral to Treatment 

National Tobacco Quitlines 

http://www.smokefree.gov/expert.aspx 

SAMHSA Behavioral Health Treatment Services Locator 

http://findtreatment.samhsa.gov 

State Substance Abuse Agencies

http://findtreatment.samhsa.gov/TreatmentLocator/faces/abuseAgencies.jspx 

Confidentiality 

Applying the Substance Abuse Confidentiality Regulations 42 CFR Part 2 (Revised). Available at: 

http://www.samhsa.gov/about/laws/SAMHSA_42CFRPART2FAQII_Revised.pdf 

The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA 

Privacy Rule: Implications for Alcohol and Substance Abuse Program. Available at: 

http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf 

Frequently Asked Questions: Applying the Substance Abuse Confidentiality Regulations to 

Health Information Exchange (HIE). Available at: 

http://www.samhsa.gov/healthprivacy/docs/ehr-faqs.pdf 

National Institute on Alcohol Abuse and Alcoholism’s Alcohol Policy Information System

http://www.alcoholpolicy.niaaa.nih.gov 
PAGE INTENTIONALLY LEFT BLANK
 
Appendix C—State Grantees by Cohort
 

Cohort 1 (2003–2008) 

California 

Cook Inlet Tribal Council 

Illinois 

New Mexico 

Pennsylvania 

Texas 

Washington 

Cohort 2 (2006) 

Colorado 

Florida 

Massachusetts 

Wisconsin 

Cohort 3 (2008) 

Alaska (Tanana Chiefs Conference) 

Georgia 

Michigan 

West Virginia 

Cohort 4 (2011) 

American Samoa 

Colorado 

Connecticut 

Illinois 

Indiana 

New York 

North Carolina 

Tennessee 

Washington 

59 
PAGE INTENTIONALLY LEFT BLANK
 
Appendix D—SBIRT Initiative Cohort 1 


State Cooperative Agreement Grantees
 

California Department of Alcohol and Drug Programs 

Population and Settings Screening Brief Intervention Brief Treatment Program 

Features 

Who: Adults 

Where: Community 

health center and hospital 

emergency departments 

(EDs) (including burn and 

trauma units) 

SBIRT Web site: http:// 

www.ethicodewebdesign. 

com/examples/casbirt/ 

Who: Prescreening 

by hospital intake 

employees 

Screening by peer 

health educators 

trained and 

monitored by the 

San Diego State 

University Center 

for Alcohol and 

Other Drug Studies 

and Services 

What: Alcohol, 

Smoking, and 

Substance 

Involvement 

Screening Test 

(ASSIST) 

Who: Peer 

health educators 

(bachelor’s degree 

or higher) 

What: Feedback, 

Responsibility, 

Advice, Menu, 

Empathy, SelfEfficacy (FRAMES) 

and motivational 

interviewing (MI) 

Who: SBIRTtrained certified 

counselors 

(master’s or Ph.D. 

level) 

What: 6 to 12 

sessions, in person 

or by phone 

MI and cognitive– 

behavioral 

techniques 

Bilingual health 

educators and 

alcohol/drug 

counselors 

English/Spanish 

interpretation 

for medical staff 

and patients 

Referrals/ 

transport of 

intoxicated 

patients to 

sobering 

stations 

61 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Cook Inlet Tribal Council (CITC), Alaska, With the Southcentral Foundation
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults and 

adolescents (largely 

rural) 

Where: Primary 

care family 

health clinics 

and generalist 

community settings 

SBIRT Web site: 

None 

Who: Certified 

medical assistants 

or licensed practical 

nurses trained in 

SBIRT 

What: Alcohol 

Use Disorders 

Identification Test 

(AUDIT) and one 

drug use question 

in conjunction 

with other health 

screening 

Who: Onsite SBIRT 

specialist 

What: MI, FRAMES, 

and basic alcohol/ 

drug education 

Who: SBIRT-trained 

counselors 

What: 6 to 8 

MI sessions 

and community 

reinforcement 

approach (CRA) 

Pretreatment 

groups, one-on-one 

counseling, and 

case management 

for up to 6 months 

for patients on 

specialty substance 

use disorder 

treatment waiting 

lists 

An assessment 

instrument 

developed by 

CITC based on 9 

years of working 

with the Alaska 

Native population; 

supplemental 

questions 

enhance cultural 

appropriateness 

and relevance 

SBIRT services 

marketed via 

press releases, 

newspaper ads, and 

radio broadcasts 

62 
Appendix D—SBIRT Initiative Cohort 1 State Cooperative Agreement Grantees 

Illinois Office of the Governor
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults 

Where: County 

Bureau of Health 

Services hospitals 

(EDs, clinics), 

Federally Qualified 

Health Centers 

SBIRT Web site: 

http://www.dhs. 

state.il.us/page. 

aspx?item=47893 

Who: Contracted 

health counselors 

(most certified 

alcohol and drug 

counselors) 

What: A single 

question about 

alcohol use 

(recommended 

by the National 

Institute for 

Alcohol Abuse 

and Alcoholism 

[NIAAA]), a single 

question about 

illicit drug use, and 

a single question 

about tobacco use 

Who: Contracted 

health counselors 

(most certified 

alcohol and drug 

counselors) 

What: Up to six 

15–30-minute 

sessions; FRAMES 

Who: Participating 

Illinois-licensed 

substance use 

disorder treatment 

providers 

What: Varies by 

provider 

A centralized SBIRT 

treatment referral 

coordinator 

The Great 

Lakes Addiction 

Technology 

Transfer Center 

provides training 

and monitoring of 

screening and brief 

intervention (BI) 

clinicians 

Community peer 

mentors work with 

health counselors 

and generalist 

healthcare staff 

(Community 

peer mentors are 

volunteers who 

have successfully 

recovered from 

substance 

dependence and 

are recruited, 

trained, and 

supervised by 

professional staff) 

63 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

New Mexico Department of Health
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults and 

adolescents 

Where: Primary 

care clinics, Indian 

Health Service 

clinics, public 

health offices, and 

high school-based 

health centers 

SBIRT Web site: 

None 

Who: Nurse or 

medical assistant 

What: 

Adults: Personal 

Health Profile, the 

Substance Abuse 

Subtle Screening 

Inventory, AUDITAID (AUDIT 

Adapted for Illicit 

Drug Use), and 

the Mental Health 

Screening Form III 

Adolescents: 

Healthy Lifeways 

Questionnaire; 

Car, Relax, Alone, 

Forget, Family or 

Friends, Trouble 

(CRAFFT); and 

the Depression 

Identification and 

Treatment Protocol 

Who: Referrals to BI 

made by licensed 

behavioral health 

counselors, primary 

care providers, 

and promoters 

(community health 

workers/case 

managers) 

What: Brief MI 

Who: Behavioral 

health counselors 

(master’s-level and/ 

or licensed alcohol 

and drug abuse 

counselors) 

What: 

Adults: Treatment 

protocols and 

modalities based 

on brief cognitive– 

behavioral therapy 

and brief strategic 

interactional 

therapies 

Adolescents: CRA 

and the Alcohol 

Treatment Targeting 

Adolescents in 

Need model 

Telehealth 

technology is used 

for conducting 

patient clinical 

interviews and 

counseling at more 

than 20 telehealth 

sites 

Regularly scheduled 

televideo 

psychiatric 

consultation 

support and 

training via contract 

with University 

of New Mexico 

Department of 

Psychiatry 

64 
Appendix D—SBIRT Initiative Cohort 1 State Cooperative Agreement Grantees 

Pennsylvania Department of Health
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults 

Where: 

Community-based 

clinics and hospital 

outpatient clinics 

and ED trauma 

centers 

SBIRT Web site: 

None 

Who: 

Paraprofessional 

healthcare 

professionals 

What: Health 

Behavior 

Assessment 

and AUDIT (as 

indicated) 

Who: Licensed 

healthcare 

professionals 

What: 3–5 minutes 

of brief advice 

to a 1-hour BI 

conducted in 

person or via 

the telephone, 

provided at one 

time or over several 

visits as the patient 

attends followup 

care 

Five essential 

components: 

assessment, goalsetting, behavior 

modification, selfhelp information, 

and followup 

Who: Licensed 

healthcare 

professionals 

What: MI and 

cognitive– 

behavioral therapy 

provided at the 

generalist site or 

via an active and 

facilitated referral 

to a community 

treatment provider 

Paraprofessional 

healthcare 

specialists 

employed by the 

Single County 

Authority for each 

of the four counties 

served, supervised 

by a county 

coordinator 

65 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Texas Department of State Health Services (InSight)
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults and 

adolescents 

Where: Community 

health clinics, 

school-based 

clinics, and hospital 

settings 

SBIRT Web site: 

None 

Who: Nurses, 

medical assistants, 

patient care 

technicians, 

or physicians 

(prescreening) 

What: NIAAA 

quantity and 

frequency question, 

single substance 

use question 

related to drug 

use, the CAGE-AID 

(CAGE Questions 

Adapted to 

Include Drugs), 

and a tobacco use 

question 

Who: InSight 

specialists 

(vocational nurses, 

registered nurses, 

and counselors) 

What: Further 

screening using 

AUDIT and the 

Drug Abuse 

Screening Test 

(DAST) 

BI using the 

FRAMES model 

Who: InSight 

specialists 

(vocational nurses, 

registered nurses, 

and counselors) 

What: Up to 12 

treatment sessions 

of motivational 

enhancement 

therapy 

InSight specialists 

employed by the 

Harris County 

Hospital District, 

trained and 

supervised by 

collaborators within 

clinical departments 

at Baylor College 

of Medicine 

and research/ 

technology centers 

in the University of 

Texas system 

Washington Department of Social and Health Services
 

Population and 

Settings 

Screening Brief Intervention Brief Treatment Program Features 

Who: Adults 

Where: Hospital 

EDs 

SBIRT Web site: 

http://www. 

kingcounty.gov/ 

healthservices/ 

SubstanceAbuse/ 

Services/ 

Intervention/ 

WASBIRT.aspx 

Who: Hospitalbased chemical 

dependence 

professionals 

What: AUDIT and 

DAST-10 

Who: Hospitalbased chemical 

dependency 

professionals 

What: MI 

Who: Chemical 

dependency 

professionals at 

local treatment 

agencies 

What: 1 to 12 

sessions 

Involvement 

of chemical 

dependence 

professionals at 

every level of 

service provides for 

increased clinical 

expertise at each 

point of contact 

Linkages between 

screening sites and 

community provider 

agencies allow for 

seamless transition 

of patients from 

screening to BI, to 

brief treatment, to 

traditional chemical 

dependency 

services 

66 
Appendix E—Selected Screening 

Instruments 

Instrument Population(s) Description Access/More Information 

Alcohol, 

Smoking, and 

Substance 

Involvement 

Screening 

Test (ASSIST) 

Adults, 

Adolescents 

An 8-item screening tool 

developed for the World Health 

Organization (WHO) by an 

international group of substance 

abuse researchers to detect 

and manage substance use and 

related problems in primary and 

general medical care settings. 

Includes a patient feedback 

report card. Available in several 

languages. 

http://www.who.int/substance_ 

abuse/activities/assist/en 

The Alcohol, Smoking and Substance 

Involvement Screening Test (ASSIST): 

Manual for Use in Primary Care 

(Humeniuk et al., 2010) 

Alcohol Use 

Disorders 

Identification 

Test (AUDIT) 

Adults, 

Adolescents 

A 10-item screening tool 

developed by WHO to identify 

persons whose alcohol 

consumption has become 

hazardous or harmful to their 

health. Available in English-, 

Spanish-, and Slovenian-language 

versions. 

http://www.who.int/substance_ 

abuse/activities/sbi/en/index.html 

AUDIT: The Alcohol Use Disorders 

Identification Test Guidelines for 

Use in Primary Care, Second Edition 

http://whqlibdoc.who.int/hq/2001/ 

WHO_MSD_MSB_01.6a.pdf 

AUDIT-C Adults The first 3 questions of AUDIT 

(those that focus on alcohol 

consumption). 

http://www.hepatitis.va.gov/provider/ 

tools/audit-c.asp#S1X 

CAGE 

(Cut down, 

Annoyed, 

Guilty, Eyeopener) 

Adults (people 

older than age 

16) 

A 4-item, nonconfrontational 

questionnaire for detecting 

alcohol problems. Questions 

are usually phrased as “have 

you ever” but may also focus on 

present alcohol problems. 

http://pubs.niaaa.nih.gov/ 

publications/inscage.htm 

CRAFFT (Car, 

Relax, Alone, 

Forget, Family 

or Friends, 

Trouble) 

Adolescents A 6-item screening instrument. 

Test covers alcohol and drugs 

and situations that are relevant to 

adolescents. 

http://www.projectcork.org/clinical_ 

tools/pdf/CRAFFT.pdf 

67 
Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

Appendix E—Selected Screening Instruments continued
 

Instrument Population(s) Description Access/More Information 

Drug Abuse 

Screening 

Test (DAST) 

Adults A 20- and 28-item adaptation 

of the Michigan Alcohol 

Screening Test (MAST) to detect 

consequences related to drug 

abuse without being specific 

about the drug, thus alleviating 

the necessity of using different 

instruments specific to each drug. 

20-item instrument: http://adai. 

washington.edu/instruments/pdf/ 

Drug_Abuse_Screening_Test_105.pdf 

28-item instrument: http://www. 

projectcork.org/clinical_tools/html/ 

DAST.html 

DAST-A Adolescents A 28-item DAST for adolescents http://www.dbhds.virginia.gov/ 

documents/scrn-adol-DAST-AInstrument.pdf 

Fagerstrom 

Test for 

Nicotine 

Dependence 

Adults A 6-item test evaluating cigarette 

consumption, the compulsion to 

use, and dependence. Screens 

for nicotine dependence. Severity 

rating can be used for treatment 

planning. 

http://www.tobaccofree.org/facts_ 

figures/documents/FagerstromNicotine-Dependence-Test.pdf 

Michigan 

Alcohol 

Screening 

Test (MAST) 

Adults, 

Adolescents, 

Seniors 

A 25-item instrument providing 

a general measure of lifetime 

alcohol problem severity that can 

be used for choosing treatment 

intensity and guiding inquiry into 

alcohol-related problems. A 13­

item version (Short MAST) and 

geriatric version (MAST-G) are 

available. 

Original MAST (Selzer, 1971) 

13-item Short MAST: http://www. 

projectcork.org/clinical_tools/html/ 

ShortMAST.html 

MAST-G: http://www.ssc.wisc.edu/ 

wlsresearch/pilot/P01-R01_info/ 

aging_mind/Aging_AppB5_MAST-G. 

pdf 

NIDA Drug 

Use Screening 

Tool 

Adults A 1- to 7-question screening tool 

adapted by the National Institute 

on Drug Abuse from the WHO’s 

ASSIST. 

http://www.drugabuse.gov/nidamed/ 

nmassist 

TWEAK 

(Tolerance, 

Worried, 

Eye-openers, 

Amnesia, [K] 

Cut down) 

Adults, 

Pregnant 

women 

A 5-item scale to screen for risky 

drinking. 

http://adai.washington.edu/ 

instruments/pdf/TWEAK_252.pdf 

68 
Appendix F—Acknowledgments
 

This publication was produced under the Knowledge Application Program (KAP), a Joint

Venture of The CDM Group, Inc., and JBS International, Inc. (JBS), for the Substance Abuse

and Mental Health Services Administration, Center for Substance Abuse Treatment. 

Lynne MacArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project Co-Director, and

Barbara Fink, RN, M.P.H., served as the JBS KAP Managing Project Co-Director. Other JBS

KAP personnel included Candace Baker, M.S.W., MAC, Senior Writer/Content Expert; Martha

J. Horn, Ph.D., Senior Writer; Frances Nebesky, M.A., Quality Assurance Editor; and Suzanne

Garber, M.A., Quality Assurance Editor. 

69 
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