Difference between revisions of "Expand SBIRT Program"

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<div class="mw-parser-output"><div class="mw-parser-output"><div class="mw-parser-output"><div class="mw-parser-output"><div class="mw-parser-output"><div class="mw-parser-output">''Return to &nbsp;[[ZOOM_MAP_-_Increase_Early_Intervention_for_People_Misusing_Drugs|Zoom Map - Increase Early Intervention for People Misusing Drugs]]''
= Introductory Paragraph =
''Go to [[ZOOM_MAP_-_Expand_SBIRT_Program|Zoom Map - Expand SBIRT Program]]''


----
SBIRT is an abbreviation for Screening, Brief Intervention, and Referral to Treatment. SBIRT is "a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders." <ref>https://www.samhsa.gov/sbirt/about</ref> It is a popular model for prevention and early intervention because all patients are screened regardless of an identified disorder. This allows healthcare professionals to reach a wider range of people - not just those who are seeking treatment for substance use disorder (SUD) or behavioral health. This is especially critical for those who may be at risk for substance use disorder but may not meet established criteria. Additionally, SBIRT screens for all types of substance use, not just dependencies.
 
This evidence-based, public health approach is a paradigm shift in substance-use treatment because SBIRT places risky substance use where it belongs—in the realm of healthcare. Routine screening helps identify and intervene with patients whose use puts them at risk for health issues. SBIRT focuses on identifying risky substance use to help prevent the onset of the more costly disease of addiction. It is similar to preventive screenings for chronic diseases such as cancer, diabetes, and hypertension. Since SBIRT is an effective tool for identifying risk levels related to substance use and for providing the appropriate intervention, expanding the use of SBIRT provide opportunities for more people to access treatment earlier.
 
= Key Information =
 
Communities can expand the use of SBIRT by increasing public awareness of the approach and the value of identifying people who are at high risk or might be using substances. SAMHSA supports a research-based comprehensive behavioral health SBIRT model which reflects the six following characteristics: <ref>https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf</ref>
 
* It is brief. The initial screening is accomplished quickly (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.
 
* Screening is universal. The patients, clients, students, or other target populations are all screened as part of the standard intake process.
 
* One or more specific behaviors are targeted. The screening tool addresses a specific behavioral characteristic deemed to be problematic, or pre-conditional to substance dependence or other diagnoses.
 
* The services occur in a public health, or other non-substance use treatment setting.
 
* It is comprehensive. The program includes a seamless transition between brief universal screening, brief intervention and/or brief treatment, and referral to care.
 
* Strong research or substantial experiential evidence supports the model. At a minimum, programmatic outcomes demonstrate a successful approach.
 
According to SAMHSA, one of the benefits of the SBIRT approach is that it is easy to learn relative to other behavioral treatment techniques which require lengthy specialized training. As such, it can be implemented by diverse health professionals who work in busy medical settings -- physicians, nurses, social workers, health educators, and paraprofessionals. The first step in increasing the implementation of SBIRT is to embed it in standard care by delivering staff-wide trainings and making SBIRT a routine part of evaluations and medical health records. Physicians, especially primary care physicians, are overburdened by time, making it important to involve other staff in screenings. Other creative options include expanding types of screening, such as computer-assisted and peer-based screenings.
 
'''The SBIRT Process'''
 
* Screening. The first step of the SBIRT process is screening. Ideally, it is used universally -- whether at an annual physical exam or other regularly occurring appointments with a provider or healthcare specialist. It uses a quick and simple method of identifying patients who are experimenting with or using alcohol or other substances. It can help identify individuals who use substances at risky levels, as well as those who are already experiencing substance use-related issues. SBIRT screening uses non-judgmental and caring tone. Patients are usually not offended by questions about substance use if asked in caring and nonjudgmental manner. Questions are normalized by embed them in other health behavior question and by prefacing questions with a statement that all patients are asked about substance use. Permission is requested. Fore example, “Is it OK if I ask you some questions about smoking, alcohol and other drugs?" Closed-ended questions are avoided, such as, “You don’t smoke or use drugs, do you?”
 
* Brief Intervention. After an initial screening, the individual may be referred for a brief intervention where a healthcare professional engages a patient in a short conversation, providing feedback and advice. According to SAMHSA, commonly used models for brief interventions treatment include: Cognitive-Behavioral Therapy (CBT), Motivational Enhancement Therapy, Community Reinforcement Approach, and Solution-focused Therapy. <ref>https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf</ref>
 
* Referral to Treatment. If the patient requires additional services, the healthcare professional may recommend therapy or treatment. SAMHSA recommends that referral to treatment is a critical component of the SBIRT process for patients who screen showing that they need additional services. It involves establishing a clear method of follow-up with patients who have been identified as having a possible dependency on a substance or in need of specialized treatment. The referral to treatment process assists a patient to access specialized treatment, select treatment facilities, and help navigate any barriers such as treatment cost or lack of transportation which could hinder treatment in a specialty setting. Models for brief treatment recommended by SAMHSA include Brief Negotiated Interview, Brief Counseling, FRAMES (Feedback, Responsibility, Menu of options, Empathy, Self-efficacy), and Motivational Interviewing (MI) techniques. <ref>https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf</ref>
 
'''Integration of SBIRT'''
 
Besides typical healthcare settings, there are many other places where professionals come into contact with people who may be at risk of substance use disorder.


Screening, Brief Intervention and Referral to Treatment (SBIRT) is used to provide care for substance users across the spectrum from early intervention to extensive specialized treatment. This represents a paradigm shift in substance-abuse treatment, which has historically focused on people that meet the criteria for substance abuse or dependence as defined by the ''Diagnostic and Statistical Manual of Mental Disorders,'' Fourth Edition.
* '''Hospitals and Emergency Rooms.''' Individuals with SUD or occasional use regularly access emergency care. Utilizing the SBIRT approach with individuals seeking care can be beneficial. One study examined an SBIRT program in Allegheny County, Pennsylvania emergency rooms and measured Medicaid claims data. It concluded that SBIRT had the potential to reduce healthcare costs and that SBIRT use in the emergency department can be readily incorporated into existing practice settings. <ref>https://warmhandoff.org/wp-content/uploads/2019/07/Safe-Landing-ED.pdf</ref>


The SBIRT model screens all patients regardless of an identified disorder, allowing healthcare professionals in a variety of settings to address a patient's behavioral health even when that patient is not actively seeking treatment or care for their behavioral health problems. While SBIRT is well-established as an effective intervention for risky alcohol use researchers and clinicians are just beginning to explore it as an intervention for risky drug use.<sup class="reference"><ref>[1]Page Not Found </ref></sup>
* '''Dentists and Oral Surgeons''' can play an important role in SBIRT. A study in the Journal of the American Dental Association (JADA)  showed that in the late 90s, dentists were the top specialty providers of immediate-release opioids, accounting for 15.5% of those prescriptions. <ref>https://jada.ada.org/article/S0002-8177(18)30419-7/pdf</ref> The American Dental Association recommends dentists and oral surgeons incorporate NIDA's "Screening for Substance Use in the Dental Setting" to help dental professionals recognize the signs of risky substance use and addiction. <ref>https://www.drugabuse.gov/nidamed-medical-health-professionals/science-to-medicine/screening-substance-use/in-dental-setting</ref>


By expanding the use of SBIRT and improving SBIRT practices, communities should be able to reduce the number of people who develop a dependency on opioids or Opioid Use Disorder. It should provide pathways for people to get appropriate help sooner--which reduces the potential negative impact of using opioids. SBIRT can be done in many different settings, and there are a variety of ways to do each element of SBIRT. This creates many opportunities to expand and improve SBIRT practices. &nbsp;
* '''Community Health Centers and Clinics.''' Community health providers offer excellent opportunities for early intervention with at-risk substance users and intervention for persons with SUDs and mental health issues. The state of New Hampshire was an early adopter of SBIRT in a community setting and documented increased positive outcomes for patients. They found that universal screening lowers the barriers to early intervention and treatment and integrated care. <ref>http://sbirtnh.org/wp-content/uploads/2016/05/The-Power-of-Best-Practices-Launching-SBIRT-in-a-Community-Health-Center.pdf</ref>


__TOC__
* '''Schools.''' In response to the alarming number of adolescents (aged 12-17) who misuse prescription drugs,  <ref>https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report</ref> many states have moved forward to expand SBIRT in school settings. Schools offer a prime opportunity to identify, support, and redirect students in middle school and high school. One study found that universal delivery of school-based SBIRT to all students, not just substance-using students, provides two types of prevention. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753915/</ref> First, it can prevent the onset of substance use by motivating abstinent students to remain abstinent. Second, it can reduce substance use among students by educating them on consequences and by providing students who are ready to cut down or quit with specific strategies.


&nbsp;
= Relevant Research =


= Research on the Effectiveness of SBIRT =
'''SAMHSA National Cross-site Evaluation.''' This report titled, "Screening, Brief Intervention and Referral to Treatment: Implications of SAMHSA’s SBIRT Initiative for Substance Abuse Policy and Practice," examined eleven of SAMHSA's multi-site 5-year SBIRT programs. The report reflects a growing body of evidence demonstrating SBIRT’s effectiveness in creating positive outcomes for those with substance use disorder. It involved more than 1 million screenings and reviewed five years of research and concluded that SBIRT made the following improvements in treatment system equity, efficiency, and economy: <ref>https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.13675</ref>


While the strongest evidence for the effectiveness of SBIRT relates to using it to address alcohol misuse, there is growing evidence in its effectiveness in accelerating people getting help with misuse of opioids.<br/> &nbsp; This [https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.13675 2017 report summarizes five years of research on SBIRT]<br/> &nbsp; The research covered eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the use and sustained implementation of SBIRT. They screened more than 1 million people. The programs used substance use specialists instead of medical generalists to deliver services.
* Greater intervention intensity was associated with larger decreases in substance use.
* Brief intervention and treatment had positive outcomes and were more cost-effective for most substances.
* Adapts successfully to the needs of early identification efforts for harmful use of alcohol and illicit drugs.
* Integrates management of substance use disorders into primary care and general medicine.


&nbsp;
'''This SAMHSA White Paper''' discusses the evidence supporting the effectiveness of SBIRT as a comprehensive approach and individual components of SBIRT for different non-medical behavioral health conditions. The report includes a literature review and addresses the question of what a model SBIRT program is, compared to programs which include or adapt components of the comprehensive SBIRT approach.  <ref>https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf</ref>


*Greater intervention intensity was associated with larger decrease in substance use.  
'''NIDA Study.''' The National Institute on Drug Abuse funded research on SUMMIT (Substance Use, Motivation, Medication and Integrated Treatment). It looked at ways to implement MAT and behavioral treatment for patients with opioid and alcohol use disorders in a community health clinic. The project helped the clinic implement SBIRT and evaluated whether integrated collaborative care helped patients get the care they needed. The manual titled, “SUMMIT Study Protocol: Step-by-Step Procedures for Providing Screening, Brief Intervention, and Treatment Services to Primary Care Patients with Opioid or Alcohol Use Disorders,” is useful for researchers, primary care clinics, and policymakers providing treatment in primary care settings. The introduction provides a general overview of the study for readers, and the remainder of the manual is presented in the step-by-step instructional format used during the study. <ref>https://www.rand.org/pubs/tools/TL219.html</ref>
*Brief intervention and treatment had positive outcomes, brief intervention was more cost effective for most substances.  


<br/> Four factors influenced SBIRT sustainability:


*Presence of a program champion
*'''This study''' examined an SBIRT program in emergency rooms in Allegheny County, Pennsylvania.  It concluded that SBIRT had the potential to reduce healthcare costs and utilization, as measured by Medicaid claims data and that SBIRT use in the emergency department can be readily incorporated into existing practice settings. <ref>https://warmhandoff.org/wp-content/uploads/2019/07/Safe-Landing-ED.pdf</ref>
*Availability of funding
*Systematic change
*Effective management of SBIRT provider challenges


<br/> Key Findings:
=Impactful Federal, State, and Local Policies=


*SBIRT was adapted successfully to the needs of early identification efforts for harmful use of alcohol and illicit drugs
SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.
*SBIRT is an innovative way to integrate management of substance use disorders into primary care and general medicine
*SBIRT improved treatment system equity, efficiency, and economy


&nbsp;
= Available Tools and Resources =


= SBIRT Training =
'''SAMHSA''' offers a wide list of general resources for SBIRT with links to technical assistance, online apps, and other research. <ref>https://www.samhsa.gov/sbirt</ref>


== General Training ==
'''SAFE Project:'''
*'''Bridging Prevention and Recovery (BPR): A Community Approach to Systems Change.''' This SAFE Project program, offered in-person and virtually, guides community leaders through an action-oriented model to systemically integrate prevention and recovery systems to strengthen programs and improve outcomes. BPR is a 3.5 day training program that culminates with 6 technical assistance sessions tailored to each community’s unique set of needs to support implementation and sustainability of joint prevention and recovery community projects.<ref>https://www.safeproject.us/bridging-prevention-recovery/</ref>
*See the wiki titled "Expand SBIRT in Maternity Care Clinics" for more detailed information on the use of the SBIRT tool for mother's and their pregnancies as a method to prevent/intervene in substance use disorders.<ref>https://www.yoursafesolutions.us/wiki/Expand_SBIRT_Program</ref>


One of the keys to expanding the use of Screening and SBIRT tools is to increase the general awareness of the SBIRT approach and the value of identifying people who are misusing substances (or at risk of misusing substances) as soon as possible.&nbsp;
'''The Institute for Research, Education and Training in Addictions (IRETA)''' provides a toolkit to enhance the impact of SBIRT by integrating information from the process into the Electronic Health Records (EHR). <ref>https://ireta.org/resources/electronic-health-record-toolkit/</ref> <ref>https://www.indianasbirt.org/ehr-modification</ref> This youtube provided by IRETA and SAMHSA's Addiction Technology Transfer Center Network <ref>https://attcnetwork.org/</ref> provides a good overview on implementing the integration of SBIRT data into EHRs. <ref>https://www.youtube.com/watch?v=faO_bJdNyBQ</ref>


This set of Webinars provides valuable background and could be shared with many different community stakeholders:&nbsp;&nbsp;[https://sbirt.webs.com/webinars https://sbirt.webs.com/webinars]
'''National Association of Addiction Professionals (NAADAC)''' provides a webinar that outlines a plan on how to work collaboratively with clinics in rural settings to build a SBIRT practice. <ref> "Implementing SBIRT in Rural Clinics: A How to Guide" https://www.naadac.org/SBIRT-rural-clinics-webinar</ref>


More SBIRT Training Resources are available at&nbsp; [http://www.sbirteducation.com http://www.sbirteducation.com]&nbsp;
'''The Massachusetts Toolkit''' is a step-by-step guide for implementing SBIRT. <ref>https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3522.html</ref>


&nbsp;
'''Technology-Supported Trainings:'''


= Promising Programs =
*'''IRETA ''' provides online training for both professionals and the public, as well as free webinars and on-site prescriber education. <ref>https://ireta.org/training/overview/</ref>
*'''NORC''' is a public policy and social research organization affiliated with the University of Chicago. They provide hosted Webinars on Screening, Brief Intervention, and Referral to Treatment (SBIRT) training includes resources for professionals, adolescent SBIRT, workplace/EAP, community stakeholders, and other addiction or behavioral professionals. NORC provides SBIRT education in both on-demand and live webinars. <ref>https://www.sbirteducation.com/</ref> 
*'''Kognito''' offers accredited technology-based training on SBIRT for youth using innovative simulations to evaluate the skills of those taking the training. <ref>https://kognito.com/products/sbi-with-adolescents</ref> The program was developed in collaboration with NORC at the University of Chicago and has been adopted by more than 40 schools of health professions and state agencies. Additionally, the Kognito Conversation Platform<ref>https://kognito.com/approach</ref> has an innovative behavior change model that integrates several evidence-based models and techniques, game mechanics, and learning principles. Kognito is listed in the National Registry of Evidence-based Programs and Practices (NREPP).


SBIRT in Schools
'''Technology-Supported Screening Tools''' make it easier for health professions to expand initial screenings while opening up a new avenue to engage patients and individuals. Screening tools may include phone apps, tablet-based screening, computer-administered screening, and interactive voice response.
*'''SBIRT Oregon App''' The Department of Family Medicine at Oregon Health and Science University designed online resources and an SBIRT app for primary care and emergency medicine settings. The patient uses a web-based screening app for tablet, phone, or desktop, which quickly screens and assesses them for substance use and depression, converts answers into chart-ready notes, reads questions out loud for patients with low literacy, and delivers screening tools in English or Spanish. <ref>http://www.sbirtoregon.org/screening-app/</ref>
*'''Screen for Opioid Abuse Risk (SOAR in Ohio, also known as OARS)''' was developed as a comprehensive self-administered measure of potential risk. It includes a wide range of critical elements noted in the literature to be relevant to opioid risk. The 43-question assessment is administered using a tablet and takes about 10 - 12 minutes to complete. The assessment is instantly scored with a report available to the prescribing physician. The report provides a summary opioid risk profile and a multidimensional assessment of risk factors. SOAR also provides depression and anxiety scores that can be used for SBIRT assessments and wellness visits. <ref>https://intera.solutions/soar-ohio-screen-opioid-abuse-risk/</ref>
*'''WellScreen''' integrates technology-based screening tools with the SBIRT model. <ref>https://wellscreen.health/</ref>


Some states, like Massachusetts have been moving to significantly expand SBIRT in schools.<ref> [2]SBIRT in Schools | Massachusetts Screening, Brief Intervention and Referral to Treatment (MASBIRT). (n.d.). Retrieved December 5, 2019, from https://www.masbirt.org/schools
'''The University of Missouri-Kansas City'''
</ref><br/> &nbsp; A research report shared early findings:&nbsp;<sup><ref>[3]Brenda L, Curtis (2014). Translating SBIRT to public school settings: An initial test of feasibility, Journal of Substance Abuse Treatment, Retrieved from https://www.integration.samhsa.gov/Translating_SBIRT_Curtis_etal.pdf
</ref></sup><br/> &nbsp; Training on using SBIRT in schools to address alcohol use:&nbsp;<sup><ref>[4]School SBIRT: Identifying and Addressing Substance Use, (n.d), Retrieved from: https://neushi.org/student/programs/attachments/SBIRTHandouts.pdf.</ref></sup><br/> &nbsp; This article has encouraging updates and resources on using SBIRT in School-Based Health Clinics:<sup><ref>[5]Substance Use Prevention in SBHC | School-Based Health Alliance Substance Use Prevention in SBHC | Redefining Health for Kids and Teens. (n.d.). Retrieved December 5, 2019, from http://www.sbh4all.org/current_initiatives/sbirt-in-sbhcs/
</ref></sup><br/> &nbsp;


&nbsp;
This website provides links to all of the following resources for three different populations -  adolescents, older adults, and women: <ref>https://www.sbirt.care/resources.aspx</ref>
<div class="mw-parser-output">
== SBIRT in Emergency Room Settings ==


Add information here
''For Adolescents:''


[https://www.bu.edu/bniart/files/2011/02/SBIRT-emergency-care-setting.pdf https://www.bu.edu/bniart/files/2011/02/SBIRT-emergency-care-setting.pdf]
* '''SBIRT for Adolescents.''' Sharon Levy, MD, MPH is a board-certified Developmental-Behavioral Pediatrician and has recorded a webinar with valuable information about screening and brief intervention to prevent or reduce substance use in youth. <ref>https://www.youtube.com/watch?v=JtCd4jATtFw</ref>.  


&nbsp;
*'''SBIRT Oregon''' offers screening forms, clinical tools, curriculum, and video demonstrations
</div>
== SBIRT in Community Clinics & FQHCs ==


Add information here.<br/> &nbsp;
* '''SBIRT for Youth Learning Community''' contains information about applying SBIRT in various settings with live and webinar information. <ref>https://ireta.org/resources/sbirt-for-youth-learning-community-webinar-introduction-review-of-research/</ref>


&nbsp;
*'''Adolescent SBIRT Curriculum''' - skills based education on Adolescent SBIRT. Contains Instructor's Toolkit with a Learner's Guide to Adolescent SBIRT with supplemental resources, and web-based SBI with simulation program. <ref>https://sbirt.webs.com/curriculum</ref>
<div class="mw-parser-output"><div class="mw-parser-output">
== SBIRT in Mental Health Settings ==


Add information here<br/> [https://ireta.org/resources/what-is-sbirt-and-why-might-it-fit-well-in-mental-health-settings-the-research-is-just-beginning https://ireta.org/resources/what-is-sbirt-and-why-might-it-fit-well-in-mental-health-settings-the-research-is-just-beginning/]
*'''NIAAA Alcohol Screening And Brief Intervention For Youth: A Practitioner's Guide''' provides information on screening and brief intervention for youth ages 9 to 18 years of age. <ref>https://www.niaaa.nih.gov/alcohols-effects-health/professional-education-materials/alcohol-screening-and-brief-intervention-youth-practitioners-guide</ref>
</div> <div class="mw-parser-output"><div class="mw-parser-output"><div class="mw-parser-output">
== SBIRT in Dental Settings ==


Add information here
*'''NIDA Principles Of Adolescent Substance Use Disorder Treatment: A Research-Based Guide''' contains a guide with 13 researched-based principles of adolescent substance use disorder treatment. <ref>https://nida.nih.gov/sites/default/files/podata_1_17_14.pdf</ref>


The Journal of the American Dental Association, Volume 142, Issue 7, July 2011, Pages 800-810&nbsp;&nbsp;[http://attcnetwork.org/userfiles/file/NFA-SBIRT/110727_The_Applicability_of_SBIRT_in_Dental_Settings_CABHP_Lit_Rev https://www.sciencedirect.com/science/article/pii/S0002817714622649]
''For Older Adults:''
 
*'''Prescription Drug Abuse: Older Adults.''' NIDA highlights issues surrounding prescription drug misuse among older adults. <ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse</ref>


The Journal of the American Dental Association, Volume 144, Issue 6, June 2013, Pages 627-638&nbsp;[https://www.sciencedirect.com/science/article/pii/S0002817714607674 https://www.sciencedirect.com/science/article/pii/S0002817714607674]
*'''SBIRT and Older Adults.''' This website contains webinars that address the use of SBRIT with older adults. <ref>https://bigsbirteducation.webs.com/</ref>
</div>  
= Funding =
<div class="mw-parser-output"><div class="mw-parser-output">
The following organizations are currently funding research and initiatives to expand SBIRT:


&nbsp;
*'''Florida BRITE Project''' is  funded by SAMHSA and focuses on implementing SBIRT with older adults.


#Conrad N. Hilton Foundation<sup class="reference"><ref>[6]Foundation 818.851.3700, C. N. H. (n.d.). Grants. Retrieved December 5, 2019, from Conrad N. Hilton Foundation website: https://www.hiltonfoundation.org/grants
*'''Older Americans Behavioral Health Issue Brief 3: Screening And Preventative Brief Interventions For Alcohol And Psychoactive Medication Misuse/Abuse''' - covers the basics of SBIRT published by SAMHSA and the Administration on Aging <ref>https://www.ncoa.org/wp-content/uploads/Issue-Brief-3-Screening-Brief-Intervention_508_Color.pdf</ref>
</ref></sup>
#Substance Abuse and Mental Health Service Administration<sup class="reference"><ref>[7]michelle.harrington. (2014, April 3). SBIRT Grantees [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/sbirt/grantees
</ref></sup>
#A report by Catalyst shares several innovative ways to fund SBIRT in schools&nbsp;&nbsp;<br/> [https://www.communitycatalyst.org/resources/publications/document/Funding-and-Sustaining-SBIRT-in-Schools-December-2015.pdf?1451325931 Funding Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Public Schools]
</div> </div> <div class="mw-parser-output">
= Screening =


More information about [[Improve_&_Expand_Screening_for_Risk_Factors_&_Testing_for_Misuse|screening and testing for misuse]].
''For Women:''
</div>
= Brief Intervention =


Models for brief treatment recommended by SAMHSA<sup class="reference"><ref>[8]Page Not Found </ref></sup> include:
* '''Substance Use and Women''' covers substance use issues among women, including sex and gender differences in substance use, substance use while pregnant and breastfeeding, sex and gender differences in substance use disorder treatment, and other sex and gender issues for women related to substance use from the NIDA. <ref>https://nida.nih.gov/publications/drugfacts/substance-use-in-women</ref>


&nbsp;
*'''Special Considerations for Women.''' This article provides information on the role of SBIRT in averting fetal alcohol spectrum disorder (FASD) <ref>https://pubmed.ncbi.nlm.nih.gov/31334924/</ref>


#[[Resources_on_Brief_Negotiated_Interview|Brief Negotiated Interview]]
*'''ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Families''' contains resources on a family-centered approach to behavioral health support for pregnant and postpartum women, including links to recent literature and government publications, online courses, and training. <ref>https://attcppwtools.org</ref>
#Brief counseling
#[[Additional_Info_on_FRAMES|Feedback, Responsibility, Menu of options, Empathy, Self-efficacy (FRAMES)]]
#[[Additional_Info_on_Motivational_Interviewing|Motivational Interviewing (MI) techniques]]
<div class="mw-parser-output">&nbsp;</div> </div>  
= Referral to Treatment =


According to SAMHSA<sup class="reference"><ref>[9]Page Not Found </ref></sup> , commonly used models for brief treatment include:
*'''SBIRT Oregon Pregnancy Clinical Tools.'''  SBIRT Oregon offers a reference sheet, pocket card, and patient handout for providers to use with pregnant women who are using substances. <ref>https://www.sbirtoregon.org/clinic-tools/</ref>


&nbsp;
*'''Behavioral Health Risks Screening Tool For Pregnant Women.''' This tool used to screen pregnant women for substance use was developed by the Institute for Health and Recovery. <ref>https://d3vz56oilt3wha.cloudfront.net/resources/5p_forms/5Ps%20screening%20tool%20-%20English.pdf</ref>


#[[Resources_on_Cognitive_Behavioral_Therapy|Cognitive-Behavioral Therapy]] (CBT)
= Promising Practices =
#Motivational Enhancement Therapy
#Community Reinforcement Approach
#Solution-focused Therapy
</div> <div class="mw-parser-output">
= Scorecard Building =


Potential Objective Details(Under Construction)&nbsp;<br/> Potential Measures and Data Sources(Under Construction)&nbsp;<br/> Potential Actions and Partners(Under Construction)&nbsp;
'''New Hampshire''' was an early adopter of SBIRT in a community setting. By incorporating SBIRT, New Hampshire found that universal screening lowers the barriers to early intervention and treatment, integrated care, and increased positive outcomes for patients. <ref>http://sbirtnh.org/wp-content/uploads/2016/05/The-Power-of-Best-Practices-Launching-SBIRT-in-a-Community-Health-Center.pdf</ref>
</div>  
= Tools & Resources =


[[TR_-_Expand_SBIRT_Program|TR - Expand SBIRT Program]]
'''Massachusetts''' was one of the first states to require SBIRT in a school setting and is considered a model for school-based SBIRT.  <ref>https://www.communitycatalyst.org/resources/publications/document/Massachusetts-Provides-a-Model-for-Addressing-Students-Risky-Substance-Use-7_6_18.pdf</ref>.
<div class="mw-parser-output">
= Resources to Investigate =


[[RTI_-_Expand_SBIRT_Program|More RTI on SBIRT]]<br/> <br/> <span style="background-color: #ffffff; color: #222222; font-family: arial,sans-serif; font-size: 12.8px">'''<span style="color: #4d4d4d">PAGE MANAGER</span>:''' </span><span style="background-color: #ffffff; color: #ff0000; font-family: arial,sans-serif; font-size: 12.8px">[insert name here]</span><br/> <span style="background-color: #ffffff; color: #222222; font-family: arial,sans-serif; font-size: 12.8px">'''<span style="color: #4d4d4d">SUBJECT MATTER EXPERT</span>''': </span><span style="background-color: #ffffff; color: #ff0000; font-family: arial,sans-serif; font-size: 12.8px">[fill out table below]</span>
'''Other states''' now incorporating SBIRT in schools include New York, Pennsylvania, California, Florida, and Texas.  


{| class="wiki_table"
'''The School-Based Health Alliance''' is testing and refining the adaptation of school-based SBIRT into 17 health care settings in seven states. <ref>http://www.sbh4all.org/current_initiatives/sbirt-in-sbhcs/</ref>
|-
| '''Reviewer'''
| '''Date'''
| '''Comments'''
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[[Category:SAFE-Full Spectrum Prevention]]
[[Category:SAFE-Full Spectrum Prevention]]

Latest revision as of 13:29, 25 September 2024

Introductory Paragraph

SBIRT is an abbreviation for Screening, Brief Intervention, and Referral to Treatment. SBIRT is "a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders." [1] It is a popular model for prevention and early intervention because all patients are screened regardless of an identified disorder. This allows healthcare professionals to reach a wider range of people - not just those who are seeking treatment for substance use disorder (SUD) or behavioral health. This is especially critical for those who may be at risk for substance use disorder but may not meet established criteria. Additionally, SBIRT screens for all types of substance use, not just dependencies.

This evidence-based, public health approach is a paradigm shift in substance-use treatment because SBIRT places risky substance use where it belongs—in the realm of healthcare. Routine screening helps identify and intervene with patients whose use puts them at risk for health issues. SBIRT focuses on identifying risky substance use to help prevent the onset of the more costly disease of addiction. It is similar to preventive screenings for chronic diseases such as cancer, diabetes, and hypertension. Since SBIRT is an effective tool for identifying risk levels related to substance use and for providing the appropriate intervention, expanding the use of SBIRT provide opportunities for more people to access treatment earlier.

Key Information

Communities can expand the use of SBIRT by increasing public awareness of the approach and the value of identifying people who are at high risk or might be using substances. SAMHSA supports a research-based comprehensive behavioral health SBIRT model which reflects the six following characteristics: [2]

  • It is brief. The initial screening is accomplished quickly (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.
  • Screening is universal. The patients, clients, students, or other target populations are all screened as part of the standard intake process.
  • One or more specific behaviors are targeted. The screening tool addresses a specific behavioral characteristic deemed to be problematic, or pre-conditional to substance dependence or other diagnoses.
  • The services occur in a public health, or other non-substance use treatment setting.
  • It is comprehensive. The program includes a seamless transition between brief universal screening, brief intervention and/or brief treatment, and referral to care.
  • Strong research or substantial experiential evidence supports the model. At a minimum, programmatic outcomes demonstrate a successful approach.

According to SAMHSA, one of the benefits of the SBIRT approach is that it is easy to learn relative to other behavioral treatment techniques which require lengthy specialized training. As such, it can be implemented by diverse health professionals who work in busy medical settings -- physicians, nurses, social workers, health educators, and paraprofessionals. The first step in increasing the implementation of SBIRT is to embed it in standard care by delivering staff-wide trainings and making SBIRT a routine part of evaluations and medical health records. Physicians, especially primary care physicians, are overburdened by time, making it important to involve other staff in screenings. Other creative options include expanding types of screening, such as computer-assisted and peer-based screenings.

The SBIRT Process

  • Screening. The first step of the SBIRT process is screening. Ideally, it is used universally -- whether at an annual physical exam or other regularly occurring appointments with a provider or healthcare specialist. It uses a quick and simple method of identifying patients who are experimenting with or using alcohol or other substances. It can help identify individuals who use substances at risky levels, as well as those who are already experiencing substance use-related issues. SBIRT screening uses non-judgmental and caring tone. Patients are usually not offended by questions about substance use if asked in caring and nonjudgmental manner. Questions are normalized by embed them in other health behavior question and by prefacing questions with a statement that all patients are asked about substance use. Permission is requested. Fore example, “Is it OK if I ask you some questions about smoking, alcohol and other drugs?" Closed-ended questions are avoided, such as, “You don’t smoke or use drugs, do you?”
  • Brief Intervention. After an initial screening, the individual may be referred for a brief intervention where a healthcare professional engages a patient in a short conversation, providing feedback and advice. According to SAMHSA, commonly used models for brief interventions treatment include: Cognitive-Behavioral Therapy (CBT), Motivational Enhancement Therapy, Community Reinforcement Approach, and Solution-focused Therapy. [3]
  • Referral to Treatment. If the patient requires additional services, the healthcare professional may recommend therapy or treatment. SAMHSA recommends that referral to treatment is a critical component of the SBIRT process for patients who screen showing that they need additional services. It involves establishing a clear method of follow-up with patients who have been identified as having a possible dependency on a substance or in need of specialized treatment. The referral to treatment process assists a patient to access specialized treatment, select treatment facilities, and help navigate any barriers such as treatment cost or lack of transportation which could hinder treatment in a specialty setting. Models for brief treatment recommended by SAMHSA include Brief Negotiated Interview, Brief Counseling, FRAMES (Feedback, Responsibility, Menu of options, Empathy, Self-efficacy), and Motivational Interviewing (MI) techniques. [4]

Integration of SBIRT

Besides typical healthcare settings, there are many other places where professionals come into contact with people who may be at risk of substance use disorder.

  • Hospitals and Emergency Rooms. Individuals with SUD or occasional use regularly access emergency care. Utilizing the SBIRT approach with individuals seeking care can be beneficial. One study examined an SBIRT program in Allegheny County, Pennsylvania emergency rooms and measured Medicaid claims data. It concluded that SBIRT had the potential to reduce healthcare costs and that SBIRT use in the emergency department can be readily incorporated into existing practice settings. [5]
  • Dentists and Oral Surgeons can play an important role in SBIRT. A study in the Journal of the American Dental Association (JADA) showed that in the late 90s, dentists were the top specialty providers of immediate-release opioids, accounting for 15.5% of those prescriptions. [6] The American Dental Association recommends dentists and oral surgeons incorporate NIDA's "Screening for Substance Use in the Dental Setting" to help dental professionals recognize the signs of risky substance use and addiction. [7]
  • Community Health Centers and Clinics. Community health providers offer excellent opportunities for early intervention with at-risk substance users and intervention for persons with SUDs and mental health issues. The state of New Hampshire was an early adopter of SBIRT in a community setting and documented increased positive outcomes for patients. They found that universal screening lowers the barriers to early intervention and treatment and integrated care. [8]
  • Schools. In response to the alarming number of adolescents (aged 12-17) who misuse prescription drugs, [9] many states have moved forward to expand SBIRT in school settings. Schools offer a prime opportunity to identify, support, and redirect students in middle school and high school. One study found that universal delivery of school-based SBIRT to all students, not just substance-using students, provides two types of prevention. [10] First, it can prevent the onset of substance use by motivating abstinent students to remain abstinent. Second, it can reduce substance use among students by educating them on consequences and by providing students who are ready to cut down or quit with specific strategies.

Relevant Research

SAMHSA National Cross-site Evaluation. This report titled, "Screening, Brief Intervention and Referral to Treatment: Implications of SAMHSA’s SBIRT Initiative for Substance Abuse Policy and Practice," examined eleven of SAMHSA's multi-site 5-year SBIRT programs. The report reflects a growing body of evidence demonstrating SBIRT’s effectiveness in creating positive outcomes for those with substance use disorder. It involved more than 1 million screenings and reviewed five years of research and concluded that SBIRT made the following improvements in treatment system equity, efficiency, and economy: [11]

  • Greater intervention intensity was associated with larger decreases in substance use.
  • Brief intervention and treatment had positive outcomes and were more cost-effective for most substances.
  • Adapts successfully to the needs of early identification efforts for harmful use of alcohol and illicit drugs.
  • Integrates management of substance use disorders into primary care and general medicine.

This SAMHSA White Paper discusses the evidence supporting the effectiveness of SBIRT as a comprehensive approach and individual components of SBIRT for different non-medical behavioral health conditions. The report includes a literature review and addresses the question of what a model SBIRT program is, compared to programs which include or adapt components of the comprehensive SBIRT approach. [12]

NIDA Study. The National Institute on Drug Abuse funded research on SUMMIT (Substance Use, Motivation, Medication and Integrated Treatment). It looked at ways to implement MAT and behavioral treatment for patients with opioid and alcohol use disorders in a community health clinic. The project helped the clinic implement SBIRT and evaluated whether integrated collaborative care helped patients get the care they needed. The manual titled, “SUMMIT Study Protocol: Step-by-Step Procedures for Providing Screening, Brief Intervention, and Treatment Services to Primary Care Patients with Opioid or Alcohol Use Disorders,” is useful for researchers, primary care clinics, and policymakers providing treatment in primary care settings. The introduction provides a general overview of the study for readers, and the remainder of the manual is presented in the step-by-step instructional format used during the study. [13]


  • This study examined an SBIRT program in emergency rooms in Allegheny County, Pennsylvania. It concluded that SBIRT had the potential to reduce healthcare costs and utilization, as measured by Medicaid claims data and that SBIRT use in the emergency department can be readily incorporated into existing practice settings. [14]

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.

Available Tools and Resources

SAMHSA offers a wide list of general resources for SBIRT with links to technical assistance, online apps, and other research. [15]

SAFE Project:

  • Bridging Prevention and Recovery (BPR): A Community Approach to Systems Change. This SAFE Project program, offered in-person and virtually, guides community leaders through an action-oriented model to systemically integrate prevention and recovery systems to strengthen programs and improve outcomes. BPR is a 3.5 day training program that culminates with 6 technical assistance sessions tailored to each community’s unique set of needs to support implementation and sustainability of joint prevention and recovery community projects.[16]
  • See the wiki titled "Expand SBIRT in Maternity Care Clinics" for more detailed information on the use of the SBIRT tool for mother's and their pregnancies as a method to prevent/intervene in substance use disorders.[17]

The Institute for Research, Education and Training in Addictions (IRETA) provides a toolkit to enhance the impact of SBIRT by integrating information from the process into the Electronic Health Records (EHR). [18] [19] This youtube provided by IRETA and SAMHSA's Addiction Technology Transfer Center Network [20] provides a good overview on implementing the integration of SBIRT data into EHRs. [21]

National Association of Addiction Professionals (NAADAC) provides a webinar that outlines a plan on how to work collaboratively with clinics in rural settings to build a SBIRT practice. [22]

The Massachusetts Toolkit is a step-by-step guide for implementing SBIRT. [23]

Technology-Supported Trainings:

  • IRETA provides online training for both professionals and the public, as well as free webinars and on-site prescriber education. [24]
  • NORC is a public policy and social research organization affiliated with the University of Chicago. They provide hosted Webinars on Screening, Brief Intervention, and Referral to Treatment (SBIRT) training includes resources for professionals, adolescent SBIRT, workplace/EAP, community stakeholders, and other addiction or behavioral professionals. NORC provides SBIRT education in both on-demand and live webinars. [25]
  • Kognito offers accredited technology-based training on SBIRT for youth using innovative simulations to evaluate the skills of those taking the training. [26] The program was developed in collaboration with NORC at the University of Chicago and has been adopted by more than 40 schools of health professions and state agencies. Additionally, the Kognito Conversation Platform[27] has an innovative behavior change model that integrates several evidence-based models and techniques, game mechanics, and learning principles. Kognito is listed in the National Registry of Evidence-based Programs and Practices (NREPP).

Technology-Supported Screening Tools make it easier for health professions to expand initial screenings while opening up a new avenue to engage patients and individuals. Screening tools may include phone apps, tablet-based screening, computer-administered screening, and interactive voice response.

  • SBIRT Oregon App The Department of Family Medicine at Oregon Health and Science University designed online resources and an SBIRT app for primary care and emergency medicine settings. The patient uses a web-based screening app for tablet, phone, or desktop, which quickly screens and assesses them for substance use and depression, converts answers into chart-ready notes, reads questions out loud for patients with low literacy, and delivers screening tools in English or Spanish. [28]
  • Screen for Opioid Abuse Risk (SOAR in Ohio, also known as OARS) was developed as a comprehensive self-administered measure of potential risk. It includes a wide range of critical elements noted in the literature to be relevant to opioid risk. The 43-question assessment is administered using a tablet and takes about 10 - 12 minutes to complete. The assessment is instantly scored with a report available to the prescribing physician. The report provides a summary opioid risk profile and a multidimensional assessment of risk factors. SOAR also provides depression and anxiety scores that can be used for SBIRT assessments and wellness visits. [29]
  • WellScreen integrates technology-based screening tools with the SBIRT model. [30]

The University of Missouri-Kansas City

This website provides links to all of the following resources for three different populations - adolescents, older adults, and women: [31]

For Adolescents:

  • SBIRT for Adolescents. Sharon Levy, MD, MPH is a board-certified Developmental-Behavioral Pediatrician and has recorded a webinar with valuable information about screening and brief intervention to prevent or reduce substance use in youth. [32].
  • SBIRT Oregon offers screening forms, clinical tools, curriculum, and video demonstrations
  • SBIRT for Youth Learning Community contains information about applying SBIRT in various settings with live and webinar information. [33]
  • Adolescent SBIRT Curriculum - skills based education on Adolescent SBIRT. Contains Instructor's Toolkit with a Learner's Guide to Adolescent SBIRT with supplemental resources, and web-based SBI with simulation program. [34]
  • NIAAA Alcohol Screening And Brief Intervention For Youth: A Practitioner's Guide provides information on screening and brief intervention for youth ages 9 to 18 years of age. [35]
  • NIDA Principles Of Adolescent Substance Use Disorder Treatment: A Research-Based Guide contains a guide with 13 researched-based principles of adolescent substance use disorder treatment. [36]

For Older Adults:

  • Prescription Drug Abuse: Older Adults. NIDA highlights issues surrounding prescription drug misuse among older adults. [37]
  • SBIRT and Older Adults. This website contains webinars that address the use of SBRIT with older adults. [38]
  • Florida BRITE Project is funded by SAMHSA and focuses on implementing SBIRT with older adults.
  • Older Americans Behavioral Health Issue Brief 3: Screening And Preventative Brief Interventions For Alcohol And Psychoactive Medication Misuse/Abuse - covers the basics of SBIRT published by SAMHSA and the Administration on Aging [39]

For Women:

  • Substance Use and Women covers substance use issues among women, including sex and gender differences in substance use, substance use while pregnant and breastfeeding, sex and gender differences in substance use disorder treatment, and other sex and gender issues for women related to substance use from the NIDA. [40]
  • Special Considerations for Women. This article provides information on the role of SBIRT in averting fetal alcohol spectrum disorder (FASD) [41]
  • ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Families contains resources on a family-centered approach to behavioral health support for pregnant and postpartum women, including links to recent literature and government publications, online courses, and training. [42]
  • SBIRT Oregon Pregnancy Clinical Tools. SBIRT Oregon offers a reference sheet, pocket card, and patient handout for providers to use with pregnant women who are using substances. [43]
  • Behavioral Health Risks Screening Tool For Pregnant Women. This tool used to screen pregnant women for substance use was developed by the Institute for Health and Recovery. [44]

Promising Practices

New Hampshire was an early adopter of SBIRT in a community setting. By incorporating SBIRT, New Hampshire found that universal screening lowers the barriers to early intervention and treatment, integrated care, and increased positive outcomes for patients. [45]

Massachusetts was one of the first states to require SBIRT in a school setting and is considered a model for school-based SBIRT. [46].

Other states now incorporating SBIRT in schools include New York, Pennsylvania, California, Florida, and Texas.

The School-Based Health Alliance is testing and refining the adaptation of school-based SBIRT into 17 health care settings in seven states. [47]

Sources

  1. ↑ https://www.samhsa.gov/sbirt/about
  2. ↑ https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
  3. ↑ https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
  4. ↑ https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
  5. ↑ https://warmhandoff.org/wp-content/uploads/2019/07/Safe-Landing-ED.pdf
  6. ↑ https://jada.ada.org/article/S0002-8177(18)30419-7/pdf
  7. ↑ https://www.drugabuse.gov/nidamed-medical-health-professionals/science-to-medicine/screening-substance-use/in-dental-setting
  8. ↑ http://sbirtnh.org/wp-content/uploads/2016/05/The-Power-of-Best-Practices-Launching-SBIRT-in-a-Community-Health-Center.pdf
  9. ↑ https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report
  10. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753915/
  11. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.13675
  12. ↑ https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
  13. ↑ https://www.rand.org/pubs/tools/TL219.html
  14. ↑ https://warmhandoff.org/wp-content/uploads/2019/07/Safe-Landing-ED.pdf
  15. ↑ https://www.samhsa.gov/sbirt
  16. ↑ https://www.safeproject.us/bridging-prevention-recovery/
  17. ↑ https://www.yoursafesolutions.us/wiki/Expand_SBIRT_Program
  18. ↑ https://ireta.org/resources/electronic-health-record-toolkit/
  19. ↑ https://www.indianasbirt.org/ehr-modification
  20. ↑ https://attcnetwork.org/
  21. ↑ https://www.youtube.com/watch?v=faO_bJdNyBQ
  22. ↑ "Implementing SBIRT in Rural Clinics: A How to Guide" https://www.naadac.org/SBIRT-rural-clinics-webinar
  23. ↑ https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3522.html
  24. ↑ https://ireta.org/training/overview/
  25. ↑ https://www.sbirteducation.com/
  26. ↑ https://kognito.com/products/sbi-with-adolescents
  27. ↑ https://kognito.com/approach
  28. ↑ http://www.sbirtoregon.org/screening-app/
  29. ↑ https://intera.solutions/soar-ohio-screen-opioid-abuse-risk/
  30. ↑ https://wellscreen.health/
  31. ↑ https://www.sbirt.care/resources.aspx
  32. ↑ https://www.youtube.com/watch?v=JtCd4jATtFw
  33. ↑ https://ireta.org/resources/sbirt-for-youth-learning-community-webinar-introduction-review-of-research/
  34. ↑ https://sbirt.webs.com/curriculum
  35. ↑ https://www.niaaa.nih.gov/alcohols-effects-health/professional-education-materials/alcohol-screening-and-brief-intervention-youth-practitioners-guide
  36. ↑ https://nida.nih.gov/sites/default/files/podata_1_17_14.pdf
  37. ↑ https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse
  38. ↑ https://bigsbirteducation.webs.com/
  39. ↑ https://www.ncoa.org/wp-content/uploads/Issue-Brief-3-Screening-Brief-Intervention_508_Color.pdf
  40. ↑ https://nida.nih.gov/publications/drugfacts/substance-use-in-women
  41. ↑ https://pubmed.ncbi.nlm.nih.gov/31334924/
  42. ↑ https://attcppwtools.org
  43. ↑ https://www.sbirtoregon.org/clinic-tools/
  44. ↑ https://d3vz56oilt3wha.cloudfront.net/resources/5p_forms/5Ps%20screening%20tool%20-%20English.pdf
  45. ↑ http://sbirtnh.org/wp-content/uploads/2016/05/The-Power-of-Best-Practices-Launching-SBIRT-in-a-Community-Health-Center.pdf
  46. ↑ https://www.communitycatalyst.org/resources/publications/document/Massachusetts-Provides-a-Model-for-Addressing-Students-Risky-Substance-Use-7_6_18.pdf
  47. ↑ http://www.sbh4all.org/current_initiatives/sbirt-in-sbhcs/
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