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Published in final edited form as: Clin Pediatr (Phila). 2021 Sep;60(9-10):418–426. doi: 10.1177/00099228211034334 Search in PMC Search in PubMed View in NLM Catalog Add to search Provider and practice characteristics and perceived barriers associated with different levels of adolescent SBIRT implementation among a national sample of US pediatricians Christopher J Hammond Christopher J Hammond , MD, PhD 1. Division of Child & Adolescent Psychiatry; Department of Psychiatry & Behavioral Sciences at Johns Hopkins University School of Medicine, Baltimore, MD Find articles by Christopher J Hammond 1 , Iman Parhami Iman Parhami , MD, MPH. 2. Los Angeles County Department of Mental Health and Children’s Hospital Los Angeles Find articles by Iman Parhami 2 , Andrea S Young Andrea S Young , PhD 1. Division of Child & Adolescent Psychiatry; Department of Psychiatry & Behavioral Sciences at Johns Hopkins University School of Medicine, Baltimore, MD 4. Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Find articles by Andrea S Young 1, 4 , Pamela Matson Pamela Matson , PhD 3. Division of Adolescent/Young Adult Medicine; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD Find articles by Pamela Matson 3 , Rachel Alinsky Rachel Alinsky , MD MPH 3. Division of Adolescent/Young Adult Medicine; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD Find articles by Rachel Alinsky 3 , Hoover Adger Jr Hoover Adger Jr , MD 3. Division of Adolescent/Young Adult Medicine; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD Find articles by Hoover Adger Jr 3 , Sharon Levy Sharon Levy , MD, MPH 5. Boston Children’s Hospital and Harvard Medical School, Boston, MA Find articles by Sharon Levy 5 , Michelle Horner Michelle Horner , DO 6. Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Find articles by Michelle Horner 6 Author information Copyright and License information 1. Division of Child & Adolescent Psychiatry; Department of Psychiatry & Behavioral Sciences at Johns Hopkins University School of Medicine, Baltimore, MD 2. Los Angeles County Department of Mental Health and Children’s Hospital Los Angeles 3. Division of Adolescent/Young Adult Medicine; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 4. Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 5. Boston Children’s Hospital and Harvard Medical School, Boston, MA 6. Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD ✉ Corresponding Author : Christopher Hammond, MD PhD, Johns Hopkins Bayview, 5500 Lombard Street, Baltimore, MD 21224. [email protected] Fax: 410-550-1302 PMC Copyright notice PMCID: PMC13065241 NIHMSID: NIHMS2134935 PMID: 34342242 The publisher's version of this article is available at Clin Pediatr (Phila) Abstract Pediatrician Screening Brief Intervention Referral to Treatment (SBIRT) practices vary widely, though little is known about the correlates of SBIRT implementation. Using data from a national sample of US pediatricians that treat adolescents (n=250), we characterized self-reported utilization rates of SBIRT among US pediatricians and identified provider- and practice-level characteristics and barriers associated with SBIRT utilization. All participants completed an electronic survey querying demographics, practice patterns, and perceived barriers related to SBIRT practices. Our results showed that 88% of respondents reported screening for substance use annually, but only 26% used structured/validated screening instruments. Further, 40% of respondents provided evidence-based brief interventions and only 11% implemented all core SBIRT practices. Common barriers (e.g. confidentiality and insufficient time) and unique provider- and setting-specific barriers to implementation were identified. These findings indicate that while most pediatricians deliver some SBIRT components in their practice, few implement the full SBIRT model, and barriers persist. Keywords: Adolescents, Substance Use, Prevention, Implementation, Screening, Brief Intervention, Referral to Treatment (SBIRT) 1. INTRODUCTION Substance use and related problems and disorders are common among American youth and have neurodevelopmental and familial origins. 1 Over 80% of American adults report using alcohol or other drugs before age 18 years, and approximately 5% of US adolescents aged 12–17 years meet criteria for a substance use disorder (SUD). 2 , 3 Alcohol and other drug use during adolescence, especially high frequency use and problematic use, are associated with increased risk for adverse health and developmental outcomes including unintentional injury, suicide, aggression, motor vehicle crashes, academic and vocational failure, sexually transmitted infections, unintended pregnancy along with addictive and psychiatric disorders. 4 – 7 Few youth who could benefit from treatment receive it. In 2016, while 1.1 million US adolescents met criteria for a SUD, fewer than one in 10 received substance abuse treatment. 8 , 9 Recent data suggests that this treatment gap has widened over the past decade. 10 In light of this growing public health problem, novel approaches are needed to better identify, engage, and treat adolescent-onset substance use and SUDs. One public health approach that has gained traction in the US in recent years due to its focus on systems of care is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model. 11 The SBIRT model is an approach to screening, identification, and provision of prevention and intervention services for adolescent substance use in pediatric primary care settings, promoted by the US Substance Abuse and Mental Health Services Administration (SAMHSA). 12 SBIRT is predicated on the premise that as substance use behaviors exist across a continuum of risk levels in adolescents, that they should, in kind, be addressed through a continuum of care encompassing prevention, brief intervention, and referral to specialty SUD treatment services provided to youth based upon their risk level. 11 The majority of care provision in the SBIRT model occurs in the pediatric primary care setting by pediatricians and their staff, as most adolescents, including those who use alcohol and other drugs regularly, have at least annual contact with a pediatrician or other medical provider. 13 The SBIRT clinical framework includes four key practices: (1) screening with a validated screening tool, (2) promoting prevention messages that delay initiation of substance use in non-users, (3) providing brief advice and/or brief interventions utilizing motivational interviewing aimed at cessation or reduction in use for youth who are using substances but do not meet SUD criteria and for youth with mild to moderate SUD, and (4) referring youth who engage in high risk substance use or who meet criteria for moderate to severe SUDs to specialized SUD treatment. 14 An updated review by the US Preventive Services Task Force published in 2020 has determined that there continues to be insufficient data regarding the benefits and harms of SBIRT for adolescents. 15 In spite of this report, there is promising preliminary evidence for SBIRT from studies indicating that screening for alcohol and other drug use in pediatric primary care settings is feasible and may detect at-risk youth 16 , 17 and from studies showing that brief motivational interventions are effective at reducing youth substance use behaviors. 18 , 19 These findings in combination with its low cost and low risk for harm has led to a growing list of pediatric societies and US government agencies, including the American Academy of Pediatrics (AAP), SAMHSA, and the National Institutes of Health (NIH) recommending that SBIRT for tobacco, alcohol, and other substance use be incorporated in routine health care for adolescents. 12 , 14 The AAP has included SBIRT as part of their adolescent substance use prevention and early intervention national practice guidelines since 2011, and currently recommends that pediatricians incorporate the SBIRT practices into their annual health maintenance examinations. 14 Based upon these national guidelines, the US government and private foundations have invested millions of dollars on large-scale implementation and dissemination efforts to train physicians, behavioral health counselors, nurses, social workers, and clinical trainees on the SBIRT framework over the past decade. 11 , 20 Despite these efforts, little is known about rates of SBIRT implementation by US pediatricians, which provider-and practice-level factors predict high versus low utilization of SBIRT practices, and which barriers impede implementation. In the present study, we used data from a national sample of US pediatricians that characterized self-reported SBIRT practices and perceived barriers to implementation of the SBIRT framework. Given the large-scale implementation efforts underway and limited data to guide a national dissemination strategy, the aims of this study were threefold: (1) to characterize self-reported implementation rates of SBIRT practices in a national sample of US pediatricians, (2) to identify provider- and practice-level characteristics associated with high versus low SBIRT utilization rates; and (3) to identify perceived barriers to SBIRT implementation among US pediatricians, and determine if unique barriers to implementation exist among low SBIRT utilizers. 2. METHODS Data Collection This analysis used data from an AAP Pediatrician Substance Abuse Practices and Attitudes Survey developed and administered by the AAP with assistance and funding from the Center for Disease Control (CDC) in 2014. The survey was designed to obtain information from providers on socio-demographics, practice setting, and training, and queried adolescent substance use and SUD screening practices and attitudes. It was approved by the AAP Institutional Review Board as exempt from human subjects review. Following AAP IRB approval, a cover letter describing the survey with an attached link to the survey was embedded in an AAP electronic newsletter and distributed via an email invitation to all AAP members, with access was made available from January 1, 2014– Dec 31, 2014. In the cover letter, participants were informed that the survey was anonymous, and that their participation was optional. No compensation was offered for survey completion. Survey Instrument The survey was administered electronically and branching logic was used. The first survey question served as a screening question asking “In an average week do you see at least 10 patients ages 9–20 years-old?” Participants who answered yes to the screening question were then administered the full survey. The full survey included 50 questions covering substance use screening (11 items; e.g. frequency, type of screening instrument used, etc.), brief interventions (10 items; e.g. response to negative screens, use of brief advice, motivational interviewing, and making referrals), perceived barriers for implementation of SBIRT practices (12 items), and respondent demographics (e.g. sex, years since completion of training) and practice characteristics (e.g. practice type, geographic region). SBIRT practices/components included (1) using structured screeners at appropriate time intervals, (2) providing prevention messages and positive reinforcement for negative screens, (3) providing brief advice and brief interventions based on motivational interviewing for adolescents that reported past year substance use, and (4) referring high-risk adolescents to specialized substance use treatment as needed. For comparative analyses, SBIRT-related variables were dichotomized based upon respondents “yes” or “no” response to survey questions. Full SBIRT utilizers were defined as pediatricians whose survey responses indicated that they had implemented all of the AAP-recommended SBIRT practices/components described above, versus pediatricians who used none or only some components of SBIRT. Sample Characteristics Three hundred and sixty-three currently practicing US-based pediatricians completed screening and demographic questions; 306 indicated that they see at least 10 patients aged 9–20 years, in an average week; 250 (81.7% of eligible respondents) proceeded to answer questions about the frequency with which they screen adolescents for substance use (the remainder did not answer questions about SBIRT practices). Respondents from the analytic sample reported practicing for an average of 18.0±12.0 years since residency and were mostly female (67.2%). All geographic regions in the continental US were represented with 32.0% of respondents practicing in the Mid-Atlantic/Southern US, 25.5% practicing in the North/South Central US, 26.3% practicing in the Pacific/Mountain regions of the US, and 16.2 % practicing in New England. Of the 250 respondents, 168 (68.6%) worked in private practices, 45 (18.4%) in hospitals, and 18 (7.3%) in public health centers or other locations. At the time of the survey, US AAP membership was approximately 65,000 pediatricians. 21 While the survey represents a convenience sample of currently practicing US pediatricians who provide regular medical care to adolescents, based upon a comparison to national data on US pediatrician demographic and practice characteristics 22 , survey respondents were representative of the US pediatrician workforce in terms of sex, geographic region of practice, and practice focus ( Supplemental Table 1 .) Statistical Analysis Analyses were conducted using IBM SPSS Statistics Analytic software V25.0 – 27.0 (IBM, Armonk, NY). Missing data on variables of interest was minimal (ranging from 0 to 3.2%) and were multiply imputed. Descriptive statistics and frequency distributions examined pediatrician characteristics and rates of substance use screening, brief intervention, and referral behaviors along with perceived barriers to SBIRT implementation in the total sample. Logistic regression analyses examined whether provider demographic and practice characteristics (sex, years since completing residency, practice setting, practice region) were associated with being a full SBIRT utilizer (compared to using only some components of SBIRT) or being a low SBIRT utilizer (using only 1 SBIRT component vs. using 2 or more) Binary logistic regressions applying firth’s bias reduction 23 were used to assess whether provider’s ratings of barriers to using SBIRT components were associated with being a full SBIRT utilizer. Finally, factors shown in prior analyses to be associated with being a full SBIRT utilizer were examined in a multivariable logistic regression to determine whether those factors were associated with SBIRT use status while controlling for other significant factors. We were also interested in whether the implementation of AAP screening recommendations, the first component of SBIRT, influenced uptake of other SBIRT practices. As such, exploratory analyses were conducted to examine relationships between screening frequency (yearly or more vs. less frequently) and SBIRT utilization rates. This study was approved by the Johns Hopkins Medicine Institutional Review Board. 3. RESULTS Substance Use Screening, Brief Intervention Practices, and SBIRT utilization Data on SBIRT practices from the total sample are reported in Table 1 . The majority of respondents (88%) reported screening for substance use at every health maintenance exam or more often, but only 26% reported using validated screening instruments. When asked about what types clinical practices they performed following a positive screen for substance use in adolescents, 91% of respondents reported providing brief advice but only 40% reported that they provide brief interventions using motivational interviewing. Sixty eight percent of respondents reported that making referrals to SUD specialty care was one of the types of clinical practices they performed in response to a positive screen. Only 11% of respondents reported utilizing all SBIRT components. Table 1. Self-reported use of SBIRT components among total sample of US pediatricians who treat adolescents SBIRT Component Total Sample (N=250) (1) Screened regularly using structured/validated screening instruments 65 (26.0%) - Screened for alcohol and drug use at least annually 221 (88.4%) - Used structured/validated screening instruments 65 (26.0%) (2) Provided prevention messages and responded to negative screens 230 (92.0%) (3) Provided Brief Advice and Brief Interventions 101 (40.4%) - Provided brief advice 229 (91.6%) - Provided brief intervention based on motivational interviewing 101 (40.4%) (4) Made referrals to substance use treatment 169 (67.6%) Utilized all SBIRT components 27 (10.8%) Open in a new tab Provider and Practice Factors associated with SBIRT utilization In a multivariable logistic regression analysis, providers’ sex, years since residency, and practice type were not associated with being a full SBIRT utilizer. Geographic region of pediatric practice was associated with full SBIRT utilization such that providers practicing in the New England region were more likely to be full SBIRT utilizers than those practicing in the Mid & South Atlantic (OR = 1.34, 95% CI: 1.11 – 2.34, p = .02), North & South Central (OR = 1.26, 95% CI: 1.07 – 2.12, p = .02), or Pacific & Mountain regions (OR = 1.20, 95% CI: 1.05 – 1.88, p < .01) of the US. None of the examined demographic or practice factors were associated with being a low SBIRT utilizer (all p’s > . 05 ). Perceived barriers to SBIRT utilization Perceived barriers to SBIRT implementation from the total sample and stratified by SBIRT utilization group status are reported in Table 2 . Confidentiality issues (52%) and insufficient time during appointments (52%) were the most commonly reported SBIRT barriers among all respondents. Other perceived barriers to SBIRT implementation with moderate frequency in the total sample included lack of expertise for managing substance use in the practice (38%) and in the surrounding community (32%), limited opportunity to talk to patients without parent being present (34%), reimbursement issues (30%), and limited access to referral services (27%). Concerns about confidentiality between patients and their parents (OR = 2.31, 95% CI: 1.02 – 5.67, p = .04) and insufficient time (OR = 2.36, 95% CI: 1.04 – 5.78, p = .04) were significantly associated with SBIRT utilization status, such that these barriers were more likely to be reported by full SBIRT-utilizers compared to non-full SBIRT-utilizers, while unfamiliarity with screening tools was less likely to be reported as a barrier by full SBIRT users ( OR = 0.07, 95% CI: 0.00 – 0.54, p < .01). Table 2. Self-reported barriers to SBIRT implementation, by SBIRT utilizer group * Reported Barrier Total (N=250) SBIRT utilizer groups * p Full SBIRT utilizers (n=27) Non-full SBIRT utilizers (n=223) Odds Ratio (full SBIRT users vs. non-full users) (95% CI) Confidentiality issues between patient and parent 130 (52.0%) 19 (70.4%) 111 (49.8%) 2.31 (1.02 – 5.67) .044 Insufficient time during appointment 129 (51.6%) 19 (70.4%) 110 (49.3%) 2.36 (1.04 – 5.78) .040 Lack of appropriate clinical expertise in the practice 95 (38.0%) 6 (22.2%) 89 (39.9%) 0.45 (0.17 – 1.08) .076 Limited opportunity to talk to patient without parent present 84 (33.6%) 9 (33.3%) 75 (33.6%) 1.01 (0.42 – 2.27) .981 Lack of appropriate clinical expertise/ unfamiliar with clinical expertise in the community 81 (32.4%) 7 (25.9%) 74 (33.2%) 0.73 (0.29 – 1.71) .484 Reimbursement issues (unclear how to bill visit) 70 (30.0%) 11 (40.7%) 64 (28.7%) 1.72 (0.75 – 3.83) .193 Limited access to referral services 68 (27.2%) 9 (33.3%) 59 (26.5%) 1.42 (0.59 – 3.22) .419 Insufficient time for follow-up 54 (21.6%) 4 (14.8%) 50 (22.4%) 0.66 (0.20 – 1.74) .420 Unfamiliar with available screening tools 44 (17.6%) 0 (0%) 44 (19.7%) 0.07 (0.00 – 0.54) .004 Limited time and resources to adequately train staff 37 (14.8%) 6 (22.2%) 31 (13.9%) 1.85 (0.66 – 4.60) .226 Unfamiliar with how to conduct brief intervention or respond to screening results 31 (12.4%) 1 (3.7%) 30 (13.5%) 0.36 (0.04– 1.46) .173 Unfamiliar with how to implement screening in practice setting 13 (5.2%) 0 (0%) 13 (5.8%) 0.28 (0/00 – 2.25) .292 Open in a new tab * Pediatricians who utilized the full recommended SBIRT approach (screening at every health maintenance exam, using structured screening, responding to negative screens with positive reinforcement, providing brief advice for low risk, motivational interviewing for mild/moderate risk and referrals to substance use treatment for high risk adolescents). Multivariable model combining factors related to SBIRT utilization In a multivariable logistic regression analysis examining the impact of all factors identified in the main analyses as being significantly associated with being a full SBIRT utilizer (practice region, concerns about confidentiality, insufficient appointment time, and lack of familiarity with available screening tools), insufficient appointment time was positively associated (OR = 2.97, 95% CI: 1.26 – 7.56, p = .01) with being a full SBIRT utilizer. Conversely, lack of familiarity with available screening tools was negatively associated (OR = 0.06, 95% CI: 0.00 – 0.49, p = .003) with being a full SBIRT user. Providers in North and South Central (OR = 0.28, 95% CI: 0.08 – 0.89, p = .03) and Pacific & Mountain (OR = 0.27, 95% CI: 0.07 – 0.88, p = .03) regions were less likely to be full SBIRT users than those in New England. Screening Practices and their association with SBIRT utilization In exploratory analyses comparing frequent and infrequent screeners ( supplemental data section 2 ), respondents who endorsed screening on at least an annual basis (termed “frequent screeners”) were significantly more likely to use structured screening instruments compared to infrequent screeners (28.1% vs. 10.3%; p = .04). 4. DISCUSSION In this national survey of practicing US pediatricians who provide regular medical care for adolescents, implementation of some SBIRT practices, in particular routine screening for substance use in adolescent patients, was common, but only a minority of pediatricians used validated screening tools or regularly implemented all components of the SBIRT framework (screening, prevention messaging, brief intervention, and referral to treatment). Common and unique barriers to SBIRT implementation and distinct provider and practice characteristics were associated with high vs. low SBIRT utilization rates. These findings carry implications for national SBIRT dissemination efforts and US pediatrician workforce training. We found that while some SBIRT practices are consistently implemented among US pediatricians, others such as provision of evidence-based brief interventions and referral to specialty substance use treatment have been under implemented despite multiple policy statements, evidence reviews, and guidelines from the AAP and SAMHSA. 12 , 14 Rates of substance use screening (88%), provision of brief interventions (40%), referral to substance use treatment (68%), and implementation of all four SBIRT practices (11%) are consistent with those observed in a recently published survey of pediatricians from Massachusetts. 24 Compared to prior national survey data from the mid-1990s 25 , our results show higher rates of routine substance use screening (88% vs. 45%) and higher, albeit still low, rates of using validated screening instruments (26% vs. 5%) among US pediatricians. Collectively, these findings indicate that uptake of specific SBIRT practices among US pediatricians who treat adolescents are not uniform, and that while substance use screening has increased over the past two decades, treatment and referral practices lag behind. Under-utilization of structured screening with validated tools, use of evidence-based brief interventions, and referral practices represent areas for improvement in SBIRT dissemination efforts. Structured screening of adolescents for alcohol and drug use with validated tools is one of the most critical component of SBIRT given that that the use of routine ‘unstructured’ clinical questioning often fails to detect substance-related problems and is less sensitive. 14 , 17 , 26 Structured screening tools for substance use in primary care are very brief, can be self-administered, and have excellent detection rates. 18 , 27 , 28 For example, the S2BI screening tool is a highly specific/sensitive (approximately 90%) seven item questionnaire for identifying moderate and severe alcohol and cannabis use disorders in adolescents. 29 Once adolescents who use alcohol or drugs or who meet criteria for SUD are identified, multiple studies have shown that brief interventions using motivational interviewing approaches are effective at reducing youth substance use behaviors 30 and can be successfully implemented in pediatric primary care settings. 18 , 27 , 28 , 31 Lastly, approaches to enhance the rate and effectiveness of referral practices by US pediatricians warrant further study given the lower rates of implementation of this SBIRT practice. Another strategy to enhance uptake of SBIRT practices among US pediatricians is to identify pediatricians and practice environments that are low SBIRT utilizers and experience greater barriers to implementation and provide targeted resources and training. Our results identified differences in SBIRT utilization rate based upon geographic region and provider and practice characteristics that were associated with distinct barriers to SBIRT implementation. Our findings are consistent with previous studies that have reported significant regional variability in health screening and surveillance among US pediatricians across a range of childhood conditions (developmental delay, maternal depression, social determinants of health, etc.). 32 , 33 Region-specific systems-level dissemination strategies may be necessary to achieve recommended SBIRT implementation goals. While requiring replication, these provider and practice factors could inform targeted dissemination efforts to improve SBIRT utilization among the pediatricians, practices, and regions most likely to under-utilize SBIRT practices. Prior studies have shown that pediatricians who completed SBIRT training were more likely to screen and provide brief interventions for substance use. 34 , 35 Thus, future implementation efforts should address these barriers and knowledge gaps and attempt to implement targeted SBIRT training for under-utilizers. Our results identified common and unique self-reported barriers to SBIRT implementation among US pediatricians according to their level of SBIRT utilization that may inform policy decisions and future SBIRT dissemination efforts. Consistent with previous studies 36 – 39 , the main barriers reported by pediatricians from our sample were insufficient time to learn and incorporate SBIRT practices, lack of familiarity with structured/validated screening tools, confidentiality issues, and low comfort-level with performing brief interventions and making referrals. Further, some of the barriers were more frequently reported among full compared to non-full SBIRT utilizers and vise-versa. For example, unfamiliarity with screening tools and concerns about confidentiality were more frequently reported by providers who did not routinely use all of the recommended SBIRT components. On the other hand, insufficient time was more frequently reported by providers who report using all of the SBIRT components. These results converge with findings from prior studies and suggest that provider- and setting-specific factors may influence SBIRT uptake. 40 , 41 Provider- and setting-specific barriers to SBIRT implementation represent an important area of future study. Future research should seek to replicate these findings and develop targeted implementation/dissemination approaches tailored to specific provider types and practice settings. There are several relevant limitations to this study. Our findings are based upon self-report data rather than observed testing or treatment delivered in practice. Respondents may have given answers that they perceived to be more acceptable to themselves, their peers, employers, or the AAP, reflecting a social desirability bias. There are also some limitations regarding the sample’s generalizability; while the study sample had broad representation from all US geographic regions and showed similar composition to the US general pediatrician workforce in terms of sex, practice setting types, and for most geographic regions, the findings may not be generalizable to family practitioners, nurse practitioners, pediatricians with subspecialty training, or pediatricians that are not AAP members. The survey drew from the currently practicing AAP membership, and thus it is possible that AAP members and survey respondents specifically may be more familiar with SBIRT guidelines and, therefore, more inclined to screen and treat adolescent substance use. If this were the case, rates of SBIRT utilization among US pediatricians overall may be even lower than we report. The study also has relevant strengths. The survey’s comprehensive questions querying substance use screening and intervention, SBIRT practices, barriers, and importantly provider and practice characteristics allowed for the investigation of SBIRT utilization rates and associated predictors and barriers to implementation in the sample. While the sample is a convenience sample, its representativeness of the US pediatrician workforce may also be viewed as a strength. In conclusion, the majority of US pediatricians in this sample reported screening for substance use annually, but few implement the full spectrum of the SBIRT framework as recommended in the AAP practice guidelines, and many report implementation barriers. Addressing these barriers and combining general and subgroup-targeted dissemination efforts may improve uptake of SBIRT by US pediatricians. Supplementary Material Supplement NIHMS2134935-supplement-Supplement.docx (21.9KB, docx) Funding: Support for this study came from a National Institute on Drug Abuse (NIDA) and American Academy of Child & Adolescent Psychiatry (AACAP) Resident Training Research Award in Substance Abuse and Addiction (Parhami), from NIH-grants including K12DA000357 (Hammond), K23DA044288 (Young) and K01 DA035387 (Matson), and from a NARSAD Young Investigator Award (Young). Dr. Hammond receives grant support from the National Institute on Drug Abuse (K12DA000357, R34DA050292), the American Academy of Child & Adolescent Psychiatry, the Substance Abuse and Mental Health Services Administration (SAMHSA, H79 SP082126-01), the National Network of Depression Centers, and the Armstrong Institute at Johns Hopkins Bayview and serves as a scientific advisor for the National Courts and Science Institute and as a subject matter expert for SAMHSA. Dr. Parhami received funding from a National Institute on Drug Abuse (NIDA) and American Academy of Child & Adolescent Psychiatry (AACAP) Resident Training Research Award in Substance Abuse and Addiction. Dr. Matson receives grant support from the National Institute on Drug Abuse (K01 DA035387). Dr. Young receives or has received research funding from NIDA, the Brain and Behavior Research Foundation, Psychnostics, LLC, and Supernus Pharmaceuticals, has served as a consultant/grant reviewer for PCORI, NIH and Montana State University, and serves on editorial boards for American Psychological Association journals. Dr. Levy’s preparation of this article was supported in part by the Substance Abuse and Mental Health Services Administration (TI025389), NIAAA (AA021913), and the Conrad N Hilton Foundation (20140273). Drs. Alinsky, Adger, and Horner have no disclosures to report. 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