California Behavioral Health Directors Association Children’s System of Care Subcommittee July 21, 2016 Department of Health Care Services Office of Women, Perinatal, and Youth Services 9/17/2018

Primary Prevention 9/17/2018

What is Substance Abuse Primary Prevention? SAPT definition: “Primary prevention includes activities directed at individuals who do not require treatment for substance abuse. Such activities may include education, counseling, and other activities designed to reduce the risk of substance abuse by individuals. Note that under the SAPT Block Grant statute, early intervention activities are not included as part of primary prevention.” Contract definition: “Public Health Services Act Section 96.125: each State/Territory shall develop and implement a comprehensive prevention program which includes a broad array of prevention strategies directed at individuals not identified to be in need of treatment.”

Five Steps of Strategic Prevention Framework (SPF) Assessment Profile population needs, resources, readiness to address needs and gaps Capacity Mobilize and/or build capacity to address needs Planning Develop a comprehensive Strategic Plan Implementation Implement evidence-based prevention programs and activities Evaluation Monitor, evaluate, sustain, and improve or replace those that fail Also keep in mind that Sustainability and Cultural Competence should be considered at every stage of the SPF. SAMHSA requires us to use the SPF. This framework is much like USDOE Principles of Effectiveness and mental health’s PEI planning requirements in that it requires data informed decision making. Your program decisions should be strategic and make sense; you should work with partners and build the capacity of your community to take action; your programs must have research behind it, and you should work to be able to demonstrate that you’ve made a difference. CalOMS Pv is a web-based prevention data collection application designed around the Strategic Prevention Framework

Institute of Medicine Addresses the entire population. 1994—Institute of Medicine full continuum of care model for mental health 2000—CSAP adopts language 2003—CSAP mandates use by states Primary prevention’s focus is on the universal, selective, and indicated populations. Universal Prevention : Addresses the entire population. Aim is to prevent/delay use of ATOD. Deter onset through a variety of broad level approaches Selective Prevention : Addresses needs of subsets of population considered at risk by virtue of their membership in a particular subgroup. Targets the entire subgroup regardless of the degree of risk in the group. Indicated Prevention : Focuses on individuals who are exhibiting early signs or consequences of AOD use or problem behavior associated with substance use.

Youth Treatment FY 2013-14 SAPT BG Adolescent SUD treatment services About $7.3 million in FY 2013-14 Decreased over the last 2 FY to $6.85 million Concerns Decreasing funds Sustainability of services Outcome of this meeting and workgroup Input and continued collaboration Development of a system of care for youth and Better serve California’s adolescent population 9/17/2018

Substance Use Disorders Services for Youth Funding sources Substance Abuse Prevention and Treatment Block Grant (SAPT BG) Youth Treatment Allocation SAPT Discretionary Drug Medi-Cal Residential Intensive Outpatient Treatment Outpatient Drug Free 9/17/2018

Youth Treatment Fundamental principle Holistic continuum of care Promotion of wellness Prevention of substance use disorders Move through the entire continuum Relationships between promotion, prevention, treatment, and recovery support State-County Contract 2015 Youth Services Policy Manual 9/17/2018

Primary Prevention by Age FY 2013-14 CalOMS Pv by age for FY 2013-14 Peak ages 12 to 14 Onset of adolescence Around 37% Between ages 5-11 Less than half (14%) Note: Counties are only required to report services in CalOMS Pv that are funded with SAPT BG dollars; services provided with other funds are not reflected. *CalOMS Pv Data retrieved 7/3/15, FY 2014/15 data represents a six month time period from 7/1/14 to 12/31/14 9/17/2018

Age of First Use for Youth in SUD Treatment FY 2013-14 Unique client counts collected by CalOMS Tx Individual counted only once during a given time period FY 2013-14 14,946 adolescent clients 24% were age 13 19% were age 12 and 14. Elevated numbers at age 10 and younger Drug use at younger age 9/17/2018

Age of Youth in SUD Treatment FY 2013-14 In contrast to the previous slide, Adolescents in Tx Peak age – 17 Around 30% of total adolescents in Tx Trend Increased numbers in Tx at the end of adolescence Age 15 – 21 % Age 16 – 28% Age 17 – 30% Possible reasons for increased numbers at the end of adolescence Accessibility of educational material at an older age Physical, experienced awareness that comes with maturity and physical development Considerations Begin Pv at younger age and deliver more rigorous Pv programs Pv programs prior to peak age 9/17/2018

Primary Prevention by Race/Ethnicity FY 2013-14 CalOMS Pv by race/ethnicity FY 2013-14 Hispanic – 39% White Not Hispanic – 30% African American – 11% Asian /Asian American – 10% Multi-ethnic – not Hispanic 7% Other – Not Hispanic 2% Hawaiian/Pacific Islander – 2% American Indian or Alaska Native – 1% 9/17/2018

Youth Treatment by Race/Ethnicity FY 2013-14 This graph shows percentages of adolescents who received treatment services by race/ethnicity. Hispanics – 67% White-not Hispanic – 14% Black-not Hispanic – 12% All other race/ethnicity groups are significantly less and constitute fewer than 10% of the total adolescent treatment population. Does not reflect propensity to substance use i.e., Not a race issue May be due to cultural beliefs Example: Asians Deal within own community Take care of their own Other Tx practices The next slide presents a situation that is problematic and perhaps can lead to further discussions today as well. 9/17/2018

Keyword Analysis of County Strategic Prevention Plans FY 2013-14 9/17/2018

Primary Drug Reported at Admission FY 2013-14 In FY 2013-14, marijuana is the highest-used substance 77 percent Second is alcohol – 15 percent Aligns with national statistics According to SAMHSA, marijuana is the most common-used illicit drug in the United States 9/17/2018

Number of Adolescents Served in SUD Treatment by County FY 2013-14 500+ adolescents admitted to Tx: Fresno* Los Angeles* Riverside Sacramento San Diego* Santa Barbara Santa Clara Tulare Counties with over 500 adolescents admitted to treatment in FY 2013-14 Top three: Fresno, Los Angeles, and San Diego. (If asked: CalOMS Tx FY 2013-14: an adolescent is counted once in each county but the same individual may be counted twice if treatment services were sought in two different counties) 9/17/2018

Referral Source for Youth Clients in SUD Treatment FY 2013/14 School and educational sources – 28 percent Criminal justice referrals – 27 percent Problematic Diagnoses by a non-licensed person in the field Criminal justice referrals Uncertified person (judge, probation office, etc.) Sentencing became the focus of treatment Not actual time necessary for Tx and recovery Necessity to develop an infrastructure Individualized, holistic treatment service Access to a healthy lifestyle for California’s adolescents with SUDs Note: If necessary or if asked, percentages have been rounded up and therefore may not equal 100%. 9/17/2018 FY 2013-14

Treatment Provider Service Type FY 2013-14 83% Outpatient <1% Outpatient NTP 13% Intensive Outpatient <1% Residential Detox 1% Residential Short Term 4% Residential Long Term Majority of youth clients seen in Outpatient: 83 % Outpatient Followed by: 13 % Intensive Outpatient 4 % Residential Long Term Less significant numbers in: 1 % Residential Short Term < 1% of clients seen in Outpatient NTP < 1 % OP NTP Detoxification < 1 % Residential Detox Note: FY 2013-14 CalOMS Tx Data (Clients served aged 17 or younger; non-fixed dataset). Due to rounding, percentages may not equal 100% 9/17/2018

Median Income Levels in 2014* Fresno Household: $43,335 Rank 45 Los Angeles Household: $55,686 Rank 24 San Diego Household: $66,034 Rank 15 *County Health Rankings & Roadmaps Top three counties with over 500 adolescents in treatment Year of data used was 2014 income data listed on website for 2016, from The California County Health Rankings & Roadmaps 58 counties Fresno ranked 45, Higher rank number means the lower the income level Household median level – $43,335 Los Angeles ranked 24 Household median level – $55,686 San Diego ranked 15 Household median level – $66,034 Range in California (Min-Max): $35,000-100,800 Overall in California: $61,900 Unemployment rate (U.S. Department of Labor, Bureau of Labor Statistics) San Diego Total population – Approximately 3.2 million, which ranked second in the state Less than 6% unemployment rate Higher numbers of adolescents admitted to SUD Tx Fresno 11% unemployment rate Illustrates that adolescents with SUDs cannot be categorized as those in lower income or high unemployment rate areas. *Has no barriers – socioeconomic Identification of adolescents with SUDs cannot be limited to one demographic For example, we cannot limit to race/ethnicity or low income areas Moreover, even within those demographics, determining root causes for SUD use are complex and varied (e.g., cultural beliefs, San Diego, etc.) Note / if asked: Los Angeles had a 7.3% unemployment rate. 9/17/2018

For more information contact: Denise Galvez, Chief Policy and Prevention Branch SUD Program, Policy and Fiscal Division Department of Healthcare Services 916-327-2749 denise.galvez@dhcs.ca.gov Summary of Information Challenges to delivering SUD services across the continuum to adolescents: Culturally and linguistically diverse population Diverse socioeconomic situations Diverse sub-populations LGBTQI Residency status Homeless Single parent homes, etc. How can we best serve our adolescents State, counties, and local providers collaborate to simultaneously provide: Increase program capacity Sustain adolescent SUD treatment services Ensure data is meaningful and accurate Ensure all adolescent SUD treatment facilities provide effective, developmentally, culturally, and linguistically appropriate care Ask for questions 9/17/2018