The structural, political, and cultural contexts through which the implementation process will proceed.
Factors cited as the biggest barriers to implementing adolescent SBI include insufficient time and training; limited access to referral options; competing needs to triage youths' other medical conditions; privacy, including the inability to have conversations about substance use with parents/guardians in the room; and confidentiality policies and regulations including fear that documenting substance use in EHRs will adversely affect adolescent patients.319, 322, 325, 328
School-based health programs generally consider treatment to be beyond their scope of services. SBI implemented as prevention, or even counseling, is more acceptable and less disruptive than treating adolescents with SUDs. Care must be taken to minimize role conflicts, role overload, and ideological conflicts for the school staff who assist in implementing program components. Delivery of SBIRT services must not be seen as interfering with educational activities or school attendance; services should be delivered during non-academic periods and physically located in the school. Careful considerations should be made to ensure that confidentiality and privacy procedures are in place and customized to school settings and operations.319, 320, 329