INTEGRATED CARE CONFERENCE 2019 CHLA EMERGENCY DEPARTMENT & SBIRT- SUBSTANCE USE PREVENTION & TREATMENT APPROACHES FOR ADOLESCENTS & YOUNG ADULTS OCTOBER 24, 2019 CHRISTINA ESQUIBEL, CATC-I - BRETT MCGILLIVRAY , LCSW - IRENE LIM, LCSW
Disclaimer CHLA has no relevant financial relationships with the manufacturer(s) or any commercial product(s) and/or provider of commercial products or services discussed in this CME/CE activity. We do not intend to discuss unapproved/investigative use of commercial product(s)/device(s) in this presentation. 1
Learning Objectives 1. Learn how a screening tool can be used as a way to develop rapport. 2. Describe how SBIRT is implemented at CHLA Emergency Department (ED) 3. Demonstrate the importance of interdisciplinary flexibility needed when working with an Emergency Department. 2
Substance Use Prevention & Treatment Program • At the Division of Adolescent and Young Adult Medicine (DAYAM) • Funded by LA County Department of Public Health, Substance Abuse Prevention and Control Department and SAMHSA • At-Risk and SUD Treatment services for youth and young adults ages 12-25 • Walk-in clinic on Tuesdays, 8:30am – 11:00am • 5000 Sunset Blvd. 7th Floor, Suite 701, LA, CA 90027 3
CHLA Emergency Department • Located on the ground floor of the Main Hospital • Level I Trauma Center (1 of 2 in LA County) • Cannot deny service to anyone • Not for Profit Hospital • 4650 Sunset Blvd. Ground Floor, LA, CA 90027 4
Programs at DAYAM • Teenage and Young Adult Health Center • Substance Use Prevention and Treatment • Training, Research and Community Engagement Program • Project NATEEN – for expectant and parenting teens • Homeless Adolescent Wellness Clinic • HIV Prevention and Treatment Program • Center for Transyouth Health and Development • Behavioral Health Program 5
SAMHSA TREE Design • Integrate SUD & CHLA ED more intentionally • Work with 2 local high schools • Outpatient SUD services for youth/young adults • Youth Leadership development • Intergenerational family support 6
CHLA Level 1 Trauma Center 3,000+ overdoses/ingestion coming through ED annually 382 patients admitted through the ED daily Not enough resources for outpatient AOD Counseling 7
Demographics of SUPT Youth Marijuana Drug of Choice Alcohol Hallucinogens Benzodiazepines Methamphetamine 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 0% Inhalants Other Illegal Drugs 20% Cocaine/Crack Heroin Morphine Percocet 76% Codeine OxyContin Methadone Ketamine *GPRA 18-19 Tranquilizers 8
Demographics of SUPT Youth Gender 37% 63% Male Female 9
Demographics of SUPT Youth Ethnicity Latino 7% 2% African American 9% Caucasian Other 82% 10
Demographics of SUPT Youth Other Characteristics Trauma 11% Probation 12% 34% Homeless 14% Pregnant 29% DCFS 11
Objective 1 Learn how a screening tool can be used as a way to develop rapport. 12
Screeners used in ED • Distress Response Survey (Blue Triangle) • CRAFFT • S2BI
Systems collide? Emergent Therapeutic Medical Environment Environment 14
Blue Triangle and Confidentiality Distress Response Survey (Blue Triangle) Do you feel like hurting/killing yourself/others? • • Do you drink alcohol or use drugs often or a lot? Do you frequently feel sad, down or depressed? • • Anyone touch private parts/you didn’t want them to? Hit with anything so hard it left a bruise/mark? • Do you hear/see thing other people cannot see/hear? • • Do you often feel upset, anxious and nervous? Seen your parents hit/use objects to hurt the other? • Awful thing happened affected you physically or emotionally? • • Have you ever been bullied or bullied someone? 15
Screening Tools Car, Relax, Alone, Forget, Family/Friends, Trouble 16
S2BI 17
SUD Services in CHLA ED When is the SUD counselor called into the ED? 18
Preparing for S2BI 19
Confidentiality/ Sensitive Services “A minor who is 12 years of age or older may consent to medical care and counseling relating to the diagnosis and treatment of a drug or alcohol related problem.” Cal. Fam. Code § 6929(b) California minor consent and confidentiality laws: Minor consent and when parents may access related medical information, http://www.publichealth.lacounty.gov/dhsp/Providers/toolkit2.pdf 20
Minor Consent Discretion to Inform Parents without Minor’s Consent? Providers may not disclose information to parents without a minor’s written authorization. However, an exception allows a program to share with parents if the program director determines the following three conditions are met: (1) that the minor’s situation poses a substantial threat to the life or physical wellbeing of the minor or another; (2) that this threat may be reduced by communicating relevant facts to the minor’s parents; and (3) that the minor lacks the capacity because of extreme youth or a mental or physical condition to make a rational decision on whether to disclose to their parents. 42. C.F .R. 2.14. 21
Parental Vignette 22
Objective 2 Describe how SBIRT is implemented at CHLA Emergency Department (ED) 23
What is SBIRT? Brief Referral to Screen Intervention Treatment • Warm hand off • BLUE TRIANGLE • Positive reinforcement • S2BI • Express • CRAFFT concern and explore Endorsed by: American Medical Association, National Institute Of Health, American College Of Surgeons, Federation Of State Medical Boards, SAMHSA, NIAAA, Office Of National Drug Control Policy, World Health Organization 24 24
Goals Of Brief Intervention • To increase awareness of the problem • To increase motivation to change • To create behavior change ➢ Brief interventions trigger change ➢ A little counseling can lead to significant change, e.g., 5 minutes has same impact as 20 minutes
PRE-SCREEN @ CHLA ED Blue Triangle • Ex: “ Do you drink alcohol or use drugs often or a lot? ” • “No”: Screening is complete* • “Yes”: Social Work is called, then SUD Counselor 26
Questions/Answers • Provider: “So tell me what brings you in to the ED today?” • Client: “I thought that vaping was safer than weed because you can’t smell it. So I tried it and I think I had too much. I just wanted to try it like everyone else.”
S2BI 28
Positive Reinforcement Transitional Statement “Thank you for being honest about what happened to you. Based on what you told me, it sounds like you thought vaping was safer but you took too much. I think that it’s great that you want to be safer. ” Can I give you more information about vaping?”
Brief Intervention • Provider: “Thank you for letting me talk to you about vaping. Tell me what you’ve heard about vaping in the news recently? Or what you know about it?” • Client responds…. Provider provides education and positive reinforcement. Education may include recent info, a handout, discussion about commercials, social media, etc.. 30
Referral to Treatment • Client: “Yeah, I started drinking last year. I’m not sure why I blacked out. I’m not doing very well in school and my mom never trusts me anymore.” • Client: “I drink all of the time. I’m not sure why I blacked out this time. It’s not a big deal.” • Client: “I smoke everyday but it doesn't effect me. But I don’t want it to get worse.”
Referral to Treatment Transitional Statement - “Thank you for being open and honest with me. Based on what you told me about your use, it sounds like you might have some consequences happening like being here in the Emergency. I’m going to recommend that you come in so we can talk about this further. What do you think about that? I can give you letters and deal with school as well as help educate your parents on some of the struggles you're dealing with. Would you like to talk more about it?
Warm Hand Off o Describe options based on available services o Facilitate hand-off by connecting youth with appropriate treatment provider o What else can be done?
“Brief advice from a primary care provider has shown to significantly decrease initiation of drinking and increase cessation rates for alcohol and marijuana use among adolescents.” Massachusetts Department of Public Health Bureau of Substance Abuse Services, Provider Guide March 2009 34
Many health care providers feel they: • Don’t have the tools • Don’t have the training • Don’t have resources • Don’t have the time 35
Objective 3 Demonstrate the importance of interdisciplinary flexibility needed when working with an Emergency Department. 36
Collaborative Vignette 37
Champagne Vignette • 16yr old complains of nausea and stomach pains • Patient tests negative for AOD on Distress Response Survey ( 🔽 ) 38
Multi-Disciplinary Vignette
Reality Testing “My use isn’t a problem” “This isn’t a big deal” I
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