Public Substance Use Disorder Treatment for Youth in California County Behavioral Health Directors Association of California – All Members Meeting October 12, 2017 Molly Brassil, MSW, Director of Behavioral Health Integration

Report Overview Background / Introduction Medicaid Coverage of Substance Use Disorder (SUD) Treatment State-Only Medi-Cal Minor Consent Program Financing Public Resources and Promising Practices Conclusion Note: Citations for data in this presentation are available in the CHCF Report: http://www.chcf.org/publications/2017/09/california-public-treatment-for-youth-suds

Inconsistencies in Defining Youth In this presentation, and in the report, we use the term ‘youth’ generally to mean children and adolescents below age 21. However, definitions for child / youth / adolescent differ among programs. Resource Definition Diagnostic and Statistical Manual of Mental Disorders No minimum age limitation for SUD diagnoses. Prevalence estimates for youth generally include ages 12-17. The American Society of Addiction Medicine Criteria Defines adolescence in its glossary as ages 13-18. The American Academy of Pediatrics Defines adolescence as ages 11 to 21. Early and Periodic Screening, Diagnostic and Treatment Benefit covers individuals under age 21.

Impact of Substance Use on Youth Brain development occurs throughout adolescence, making youth particularly vulnerable to SUDs. Early use of drugs increases an individual’s chance of developing addiction and can impact memory, motivation, learning, judgement, and behavior control. 90% of Americans who meet the clinical criteria for an SUD began smoking, drinking, or using other drugs, before the age of eighteen. The earlier substance use begins, the more likely that it will continue into adulthood. Image source: http://scienceandenvironment1.blogspot.com/p/humans-1st-year.html

California Prevalence and Incidence Roughly 21% of youth (12-20) reported past month alcohol use; 15% (12-17) reported marijuana; and less than 1% (12-17) heroin. [2015 National Survey on Drug Use and Health, SAMHSA] 8% of youth under age 18 have an SUD, which is similar to the statewide prevalence estimate for adults with SUD. [2012 DHCS Statewide BH Needs Assessment] Current-use rates among 11th graders were self- reported as 29% for alcohol, 18% for binge drinking, and 20% for marijuana. This is roughly 3x higher than what was reported in 7th grade. [California Healthy Kids Survey, 2013-2015]

Medi-Cal Coverage for SUD Youth Services Screening (Health Plans) AAP Periodicity Schedule SBIRT Treatment Services (County) Drug Medi-Cal & Drug Medi-Cal Pilot Program (waiver) Pharmacy and Detox (State) DHCS Fee-for-Service

Other Programs State-Only Medi-Cal Minor Consent Program: Eligible minors who wish to receive confidential care, including SUD services, may do so under the Medi-Cal Minor Consent Program (must be at least twelve years old). Substance Abuse Prevention and Treatment (SAPT) Block Grant Funding: Pays for local prevention and treatment programs, for activities not reimbursable by Medicaid.

Federal Financial Participation Funding Streams SAPT Block Grant Federal Financial Participation Local Funds 2011 Realignment State General Funds

Best Practices for Treating Youth with SUD Youth with SUDs SUD Treatment Supportive Services Assessment Evidence-Based Treatment Substance Use Monitoring Clinical & Case Management Recovery Support Programs Employment Mental Health Medical Continuing Care Education Child Welfare HIV/AIDS services Family & Community Criminal Justice Adapted from https://www.drugabuse.gov

Key Themes and Best Practices Patient-Centered Care Treatment should be age-appropriate, as well as developmentally, culturally, and gender-appropriate. Patient should be engaged in decision-making when possible. Integrate other needs into treatment beyond the drug use, such as medical, social, and psychological factors. Use an integrated care treatment approach that addresses co-occurring SUD and mental health disorders, as well as primary care services. Screen / Address Co-Occurring Disorders Family Involvement Support from family members and community resources (e.g., school counselors, parents, peers) during treatment can support recovery.

Key Themes and Best Practices Evidence Based Practices Motivational enhancement therapy with or without cognitive behavioral therapy, and family-based treatments have demonstrated effectiveness for youth with SUDs. Residential treatment can also support youth in moving to an outpatient setting Ongoing Support Continuing care should be available within two weeks of leaving treatment in a variety of settings.

Considerations for Improving Access to Effective Treatment for Youth in California System Complexity. The complex nature of the Medi-Cal program and the unique role of counties in administering components of the program can make accessing covered services challenging for youth and their families. Limited Provider Network / Workforce Challenges. Access to services is often limited by a lack of available providers in the region, particularly residential treatment providers equipped to effectively serve youth. Access is especially limited in rural areas of the state. Few providers have received focused training for youth treatment. Specialized Care Needs. Treatment should be age-appropriate, with developmentally, culturally, and gender-appropriate care. Adaptations of adult SUD models geared at addressing youth often fall short.

Considerations for Improving Access to Effective Treatment for Youth in California How can we address capacity and workforce challenges within the system of care for youth with SUDs? Provider Training Intensive Outpatient vs. Residential Coordination with Juvenile / Criminal Justice and Education Partners Medi-Cal Reimbursement Rates Are we building the right system of care for youth with SUDs? Stigma Social Media Non-punitive Intervention

Considerations for Improving Access to Effective Treatment for Youth in California How can we develop and inventory of evidence-based practice approaches to screening for and treating SUDs in youth? ASAM Limits Youth-Specific Recovery Supports Youth Screening, Engagement, and Prevention How can we improve access to youth-specific data to better evaluate the treatment needs and outcomes of youth with SUDs? Youth vs. Adult

Contact Our Behavioral Health Team Don Kingdon, PhD, Principal, Behavioral Health Integration don@harbageconsulting.com Molly Brassil, MSW, Director, Behavioral Health Integration molly@harbageconsulting.com www.harbageconsulting.com