ROCHELLE GALEY PEGGY BAIKIEMAC, LAC, LCSW, RYT, SOMB APPROVED TX PROVIDER DNP, RN, PNP-BC, NNP-BCSUBSTANCE USE TREATMENT COORDINATOR MEDICAL OPERATIONS COORDINATOR

ADDRESSING INTOXICATION AND WITHDRAWAL NEEDS AS PART OF A CONTINUUM OF CARE

WITHIN SECURE JUVENILE JUSTICE SETTINGS

NATIONAL SYMPOSIUM ON JUVENILE SERVICES

Colorado Division of Youth Services

OBJECTIVES

• Identify the steps needed to implement a toxicology screening and withdrawal protocol with the establishment of policy and training to support this endeavor.

• Discuss the use of the ASAM criteria, withdrawal tools such as the COWS and CIWA-Ar to develop responsive health care plans.

• Examine concepts for developing consent forms for toxicology screening and implementing confidentiality rules for 42 C.F.R.

PUBLIC HEALTH CRISIS

• 142 Americans die every day from a drug overdose.

• Over 40% of people with a substance use disorder also have a mental health problem.

• 4 out of 5 new heroin users begin with nonmedical use of prescription opioids.

• 2.14 million people ages 12 and older had an opioid use disorder in 2016, including 153,000 12- to 17-year-olds.

• 91 Americans die every day from opiate overdose.

•••••

• In Colorado, there is an opiate overdose every 36 hours.

RISKS OF SUBSTANCE USE & SUICIDALITY

As kids develop relationships with drugs or alcohol, their chances of suicide increase! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2538629/#b19-0130027

• Suicide is the third-leading cause of death for kids aged 10–14 (and the second for young people aged 15–24). https://www.therecoveryvillage.com/drug-addiction/drugs-and-suicide/#gref

• People with substance use disorders are about six times more likely to commit suicide than the general population. https://www.elementsbehavioralhealth.com/mental-health/substance-abuse-and-suicide/

• Teens using marijuana on a daily basis are 7 times more likely to die from suicidehttps://www.therecoveryvillage.com/drug-addiction/drugs-and-suicide/#gref

• Research has shown that the strongest predictor of suicide is alcoholism, not a psychiatric diagnosis. https://www.rehabs.com/how-are-addiction-depression-and-suicide-linked/

• Roughly one in three people who die from suicide are under the influence of drugs, typically opiates such as oxycodone or heroin, or alcohol. https://www.psychologytoday.com/blog/real-healing/201402/suicide-one-addiction-s-hidden-risks

• Repeated opioid intoxication or withdrawal may be associated with severe depression that, although temporary, can be intense enough to lead to suicide attempts and completed suicides. DSM 5(2013). Diagnostic and statistical manual of mental disorders : DSM-5. Arlington, VA :American Psychiatric Publishing,

WHY SHOULD WE DRUG TESTING IN THE JUVENILE JUSTICE SYSTEM?

EARLY IDENTIFICATION AND HARM REDUCTION https://www.ncjrs.gov/html/ojjdp/jjbul9712-1/testing.html

• Screening and assessment activities may need to be completed over the course of several days for juveniles who are intoxicated.

• Drug testing also provides a means for juvenile justice professionals to monitor substance-abusing behaviors and observe changes early.

• Identifying substance-abusing youth in the juvenile justice system is an important first step for intervening in both their substance abuse and their delinquent behavior.

•Such long-term data can be used to help develop an effective intervention plan.

WHAT DO DYS YOUTH LOOK LIKE?

Upon Commitment: JASAE 890 youth, 86% male, 14% females• Approximately 82% need treatment, per ASAM level of

care (1, 2.1, 2.5, 3.1, 3.5, 3.7, or 4)• Males -69% list marijuana as substance MOST OFTEN

USED and 29% list alcohol as the secondary.• Females- marijuana 40%, amphetamine 21%, heroin 16%• Drinking problem 58%• Drug Addiction 82%• 78% with severe problems• 57% of females have a residential treatment level of

care indicated vs 34% of boys• No nicotine question/date gathered

DRUGS USED IN LIFETIME

• 89% of all youth have used marijuana

• Only 11% indicate no drug or alcohol use.

• Females are twice as likely to use amphetamines and heroin than males.

• 60% of youth have had no prior drug treatment

• 61% have substance abuse related arrests• 10% have 4 or more (SUD

related arrests)

HOW THESE POLICIES ASSIST STAFF AND YOUTH IN DYS

• Intervention• “We should react at the earliest possible stage in a person’s

interaction with the criminal justice system—following arrest.” Pres. Bill Clinton (1995)

• Detect security breach/contraband• Comprehensive assessment

• Determine intoxication and withdrawal risks and needs• Reduce denial

• Sobriety monitoring during treatment• Prevent overdose deaths and suicide• Drug and alcohol withdrawal clinical guidelineshttp://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2008_011.pdf

Sanctuary ModelDYS’ Framework for Practice

Theory-based, trauma-informed, trauma-responsive, evidence-supported, whole culture approach that has a clear and structured methodology for creating or changing an organizational

culture.

7 Sanctuary Commitments

The Sanctuary Commitments provide the anchoring values and are tied directly

to developmentally grounded, trauma-informed treatment goals as well as the

overall health of the organizational culture.

Commitment to Nonviolence

Commitment to Emotional Intelligence

Commitment to Social Learning

Commitment to Open Communication

Commitment to Democracy

Commitment to Social Responsibility

Commitment to Growth and Change

DYS POLICY RESPONSE

Every youth will be swabbed on admission or discovery unless they have been in direct

supervision or are being transferred from one secure placement to DYS

CO DYS Policy 12.20

DYS POLICYINTOXICATION AND WITHDRAWAL

• During the Admission Process or Upon Discovery of Suspected

Substance Use, All Juveniles Shall Be SCREENED in a Confidential Setting for Substance Use Disorders and Potential Acute Withdrawal.• Swab• Health Screen

• MEDICAL CLEARANCE Prior to Admission is Required if the Juvenile or Collateral Contact/Information Reports Current Intoxication or Withdrawal Symptoms and/or Substance Use Within the Last 24 Hours.

• Upon a Suspected Overdose of an Opiate (Such as a Prescription Painkiller or Heroin), 911 Will Be Initiated. Staff Who Are Trained in the ADMINISTRATION OF NARCAN Spray Shall Administer the Medication to the Juvenile if the Juvenile is Not Responding or Has Difficulty Breathing.

SWABS

• Assessment is the first step in determining what interventions or services are needed. • By swabbing every youth upon intake, we relieve the guess work

of who to swab and why.

• Identify, assess, and prioritize medical needs

• All staff were trained in administering the swabs and interpreting results. Weekly phone support was available.

• Ongoing annual web based training is required

WHAT, HOW, & WHEN MATTERS

•What substances do you use?•How do you use them (smoke, snort, inject…eat?)

•When is the last time that you used?

DOCUMENTATION

• Medical Drug Screen Consent & Results form• Obtain youth consent • Record results• Provide document to medical staff

42 CFR PART 2Protects substance use information and PROHIBITS the disclosure

of such information unless you have a:• Written consent (release of information) from the youth • Notifications to medical personnel in a medical emergency• Reports of child abuse and neglect• Notifications to law enforcement: Law enforcement agencies

can be notified if an immediate threat to the health or safety of an individual exists due to a crime on program premises or against program personnel. • Part 2 permits a program to disclose information regarding the

circumstances of such incident, including the suspect’s name, address, last known whereabouts, and status as a patient in the program.

• Court ordered disclosures: Under the regulations, “any person having a legally recognized interest in the disclosure which is sought” may apply to a court for an order authorizing disclosure of protected patient information [42 CFR § 2.64].

INTOXICATION AND WITHDRAWALPOLICY 12.20

Intake staff ASKHealth Screening for all youth

• Are you currently intoxicated?• Are you experiencing

withdrawal?• When is the last time that you

used drugs or alcohol?“No” and negative drug screen proceed as usual

Admits Medication Assisted Treatment

• Continue meds• Contact medical

YES• Monitor vital signs• Keep under staff supervision• Regularly monitor that youth

has not vomited and is breathing

• Offer fluids and snack• Positive Swab for Opiates,

Alcohol, or Benzos • Administer COWS,CIWA-Ar

and/or CIWA-B• Positive swab for other

substance or refuses swab and appears impaired do minimum of 15 min. checks until medically cleared

CLINICAL OPIOID WITHDRAWAL SCALE (COWS)

CLINICAL INTOXICATION AND WITHDRAWAL ALCOHOL- REVISED

CIWA-AR (CONT.)

CIWA - B

CIWA-B (cont.)

http://www.sahealth.sa.gov.au/wps/wcm/connect/0f6337804077201f9318bb222b2948cf/benzodiazepine_withdrawal_scale_ciwab_dassa%5B1%5D.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-0f6337804077201f9318bb222b2948cf-looayGm

Withdrawal Management by the ASAM Criteria

• Becomes the first (but not sole) priority in treatment• HCP stabilize and resolve symptoms• Training & experience in assessing & managing WD

is necessary• Provides an adult Risk Rating Matrix for mild,

moderate, significant and severe: Suggested services needs (monitoring and re-assessment) and treatment interventions• Adolescent-specific considerations: Integrated

withdrawal management approach at location youth is receiving SUD care in effort to break the cycle.

● Available in text: CIWA, COWS, CINA, & Nicotine

HOW TO INTERPRET THESE RESULTS AND RESPOND THERAPEUTICALLY

Observation until medically cleared

COWS CIWA-B5-12 Mild 1-20 Mild

q 15 min q 15 min13-24 Moderate 21-40 Moderate

-10 min -10 min25+ Severe 41+ Severe

- 4 min - 4 min

CIWA-Ar

1-10 Mild-min.q 15 min

11-20 Moderate-10 min

21+ Severe- 4 min

Withdrawal scales do not diagnose withdrawal but are merely guides to the severity of an already diagnosed withdrawal syndrome.

Re-evaluate the youth regularly to ensure that it is withdrawal and not another underlying medical condition that is being monitored particularly if the youth

is not responding well to treatment.

INTOX/WD CROSSWALK

DURING OBSERVATIONJUVENILES WHO ARE INTOXICATED AND/OR IN NEED OF WITHDRAWAL MONITORING SHALL BE HOUSED IN A SAFE LOCATION THAT ALLOWS FOR CONSTANT MONITORING IN ACCORDANCE WITH WITHDRAWAL LEVEL (MILD, MODERATE, SEVERE) UNTIL MEDICALLY CLEARED BY FACILITY HEALTH CARE STAFF OR FOR 24-48 HOURS OR UNTIL A QUALIFIED HEALTHCARE PROFESSIONAL OR THE ON-CALL PHYSICIAN PROVIDES MEDICAL CLEARANCE. DURING THIS TIME THE FOLLOWING SHALL OCCUR:

1. JUVENILES SHALL BE OFFERED ADDITIONAL FLUIDS IN THEIR ROOM OR IN PROGRAMING AREAS IN ORDER TO DETER DEHYDRATION AND RE-ESTABLISH ELECTROLYTES.

2. JUVENILES SHALL BE OFFERED ADDITIONAL MEALS AND/OR SNACKS IN THEIR ROOMS OR IN PROGRAMING IN EFFORTS TO INCREASE NUTRIENTS.

3. JUVENILES SHALL BE ALLOWED TO SLEEP DURING PROGRAMMING HOURS UPON REQUEST, WITHOUT CONSEQUENCE.

4. CLINICAL STATUS AND INTOXICATION/WITHDRAWAL PLANS SHALL BE DOCUMENTED IN THE JUVENILE’S HEALTH RECORD.

Sample Health Plan

• Administer Withdrawal Scales (COWS -opiate or CIWA-Ar- alcohol)• Offer additional fluids• Offer additional meals or snacks• Allow to sleep during programming hours• Additional instructions: __________________________________________________________________________

**When to call Medical (staff or on-call physician)**• Youth is vomiting or has multiple episodes of diarrhea in 24 hours • Incoherent speech • Difficulty breathing • Persistent or increasing agitation

• Blood pressure where top number is greater than 140 or bottom number is greater than 90. • Heart rate 140 or higher • Temperature over 101o F

• Youth verbalizes or exhibits self-harming behaviors (place on SPM) • Youth exhibits or verbalizes hallucinations

**Emergency: Call 911** **After hours and weekend on-call Medical (555)901-0526**

Opiate Withdrawal• Sweating• Runny Nose or watery eyes (tearing)• Abdominal Pain• Nausea, Vomiting and/or Diarrhea• Joint/Bone aches• Dilated pupils• Excessive yawning• Goosebumps (skin)• Tremors (shakiness)• Anxiety or Irritability• Restlessness

Alcohol Withdrawal• Sweating• Headache or fullness in head• Nausea and or Vomiting• Tremors (shakiness)• Itching (tactile disturbance)• Increased sensitivity to sound (auditory disturbance)• Increased sensitivity to light (visual disturbance)• Anxiety• Agitation• Disorientation

Opiate Withdrawal• Symptoms usually start 6-12 hours after last drug use• Symptoms peak after 1-3 days of last drug use• Symptoms usually subside after 1 week but can last longer

Alcohol Withdrawal• Symptoms can start as early as 2 hours after last drink• Symptoms usually peak within 24 to 48 hours after last drink• Prolonged side effects can last from a few weeks to a year (Post-Acute Withdrawal Syndrome [PAWS])

HOW DO I DOCUMENT MONITORING OF A YOUTH?

• Medical Observation Check Sheet (open door)

• Seclusion Room Check Sheet (door closed)• Always follow Suicide Prevention Monitoring checks when indicated

MEDICAL OBSERVATION SHEET

• Used for providing medical observation• Minimum 15 minute checks for mild withdrawal• Minimum 10 minute checks for moderate

withdrawal• Minimum 4 minute checks for severe withdrawal• Only used if room door is open

ALWAYS use Suicide Prevention Monitoring sheet if youth expresses thoughts of self-harm

M.A.T.

WHEN A JUVENILE IS ADMITTED WITH OPIOID DEPENDENCE AND IS ON MEDICATION ASSISTED TREATMENT (e.g., PRESCRIBED SUBOXONE, NALOXONE, OR METHADONE).

1. A QUALIFIED HEALTH CARE PROFESSIONAL SHALL BE NOTIFIED.

2. DOSAGE SHALL BE MAINTAINED FOR UP TO THREE DAYS (PER [CODE OF FEDERAL REGULATION] 21 C.F.R. § 1306.07, b) AND A QUALIFIED PRESCRIBING CLINICIAN SHALL BE CONTACTED.

3. Medical-review policy for continued care

WHAT IS AN OVERDOSE?

 An overdose means having too much of a drug (or combination of drugs) for the body to be able to cope with. There are a number of signs and symptoms that show someone has overdosed, and these differ with the type of drug used. All drugs can cause an overdose, including over-the counter meds or prescription medication prescribed by a doctor.

Requires emergency

medical assistance

WHAT IS WITHDRAWAL?

Withdrawal refers to the physical problems and emotions one experiences if one is dependent on a substance. Symptoms of withdrawal are caused by decreased amounts of the substance in the blood or tissues of the person. • Drugs have different effects and withdrawal

symptoms• The symptoms of drug withdrawal, and the length of

that withdrawal vary depending on the drug of abuse and the length of the addiction

• Substances make changes to the way the brain processes emotions and regulates mood

ALCOHOL INTOXICATION & OVERDOSE

• disorientation• loss of coordination• vomiting• seizures• irregular or slow breathing (less than eight breaths a minute)• blue-tinged or pale skin• low body temperature (hypothermia)• stupor (being conscious but unresponsive)

Dangerous withdrawal: Alcohol and tranquilizers

Grand mal seizuresHeart attacksStrokesHallucinationsDelirium tremens (DTs)

STIMULANT INTOXICATION

• Stimulants are generally abused for their euphoric, energetic effects.

• Intense feelings of happiness.• Increased energy/sociability and self-esteem.• Improved attention.• Increased sexual desire and performance.• Opened breathing passages/easier breathing.• Suppressed appetite.

Psychological Side Effects

HallucinationsDelusions

Persistent anxietyParanoia

Depression

STIMULANT WITHDRAWAL

• Mental and physical exhaustion• Insomnia• Anhedonia (inability to feel pleasure)• Irritability• Anxiety and agitation• Excessive sleep• Intense hunger• Drug cravings• Depression with suicidal thoughts

While stimulant withdrawal may not be deadly, the accompanying psychological symptoms can be very dangerous.

STIMULANT OVERDOSE

Amphetamine overdoses look different from an opioid OD, and signs and symptoms include:• chest pain• disorientation/confusion• severe headache• seizures• high temperature (overheating, but not sweating)• difficulty breathing• agitation and paranoia• hallucinations• unconsciousness.

MARIJUANAWHAT WE DO & DON’T KNOW

Marijuana• Increased in ED admissions • Increased SUD treatment admissions (for adults) for

marijuana use• THC content in marijuana is approximately 40% for

flowers• 5mg per serving for edibles but packaged in larger

quantities• Shatter, dab, wax has been found to be 80+ THCNo research has been conducted on the toxicity to the user of marijuana with these concentration levels.

CO adolescent MJ rates

CO MJ Treatment Rates

MARIJUANA WITHDRAWAL

• Onset: Within 24 hours.

• Duration: 1–2 weeks.

• Clinical Studies show that 50-75% of dependent users will experience 4 or more symptoms

OPIATE INTOXICATION

• Contracted pupils (appear small)

• Muscles are slack and droopy

• They might “nod out”• Scratch a lot due to itchy

skin• Yawning• Speech may be slurred• They might be out of it,

but they will respond to outside stimulus like loud noise or a light shake from a concerned friend

OPIOID WITHDRAWAL

OPIOID WITHDRAWAL

• Enlarged pupils• rapid speech• Increased heart rate• Yawning

MIXING DRUGS

Taking more than one kind of drug at a time puts strain on the body and can increase both effect and the risk. For example, most heroin-related overdoses are caused when other depressant drugs are taken too. Alcohol and benzos (like Xanax and Temaze are depressants) and mixing them with drugs like heroin, oxycodone (Oxycontin®) or morphine (MS Contin®) greatly increases the risk of an overdose.

Warning

OVERDOSE  • Loss of consciousness• Unresponsive to outside stimulus• Awake, but unable to talk• Breathing is very slow and shallow, erratic, or has stopped• For lighter skinned people, the skin tone turns bluish purple,

for darker skinned people, it turns grayish or ashen.• Choking sounds, or a snore-like gurgling noise • Vomiting• Body is very limp• Face is very pale or clammy• Fingernails and lips turn blue or purplish black• Pulse (heartbeat) is slow, erratic, or not there at all

RESPONDING TO AN OPIOID OVERDOSEWITH NARCAN

• Assess: Alert, Breathing, Color• Stimulation-sternum rub• Call 911• Administer Narcan- Lay youth on back. Tilt the head back

and insert into either nostril. Press the plunger firmly to administer the dose.

• If there is no breathing or breathing continues to be shallow, continue to perform rescue breathing for them while waiting for the naloxone to take effect

• Aftercare-inform paramedics when you administered the Narcan spray

• Video (~ 7 minutes) available at https://www.narcan.com WHO CAN? YOU CAN! With NARCAN

“GOOD SAMARITAN LAW”

SENATE BILL 13-014• SECTION 2. In Colorado Revised Statutes:Immunity for a person who administers an opiate antagonist during an opiate-related drug overdose event - definitions. (1) Legislative declaration. THE GENERAL ASSEMBLY HEREBY ENCOURAGES THE ADMINISTRATION OF OPIATE ANTAGONISTS FOR THE PURPOSE OF SAVING THE LIVES OF PEOPLE WHO SUFFER OPIATE-RELATED DRUG OVERDOSE EVENTS. A PERSON WHO ADMINISTERS AN OPIATE ANTAGONIST TO ANOTHER PERSON IS URGED TO CALL FOR EMERGENCY MEDICAL SERVICES IMMEDIATELY. (2) General immunity. A PERSON OTHER THAN A HEALTH CARE PROVIDER OR A HEALTH CARE FACILITY WHO ACTS IN GOOD FAITH TO ADMINISTER AN OPIATE ANTAGONIST TO ANOTHER PERSON WHOM THE PERSON BELIEVES TO BE SUFFERING AN OPIATE-RELATED DRUG OVERDOSE EVENT SHALL BE IMMUNE FROM CRIMINAL PROSECUTION FOR SUCH ACT.

IMPLEMENTATION

• Time• Cost• Barriers• Training & training continuum• Data

NEXT STEPS

• Increase withdrawal resources to staff and medical• CIWA-B• Stimulant withdrawal tool• Nicotine withdrawal recognition

• Continue to work with staff to improve consent rate

• Regular review of data• Adjust swab capabilities to ensure testing

of most common drugs used

Questions???

TEST

All of the following are reasons why, within DYS, we swab youth at admission except?1. To tell police and charge the youth for being high2. To have an informed medical response3. To address substance use treatment needs4. To understand the types of drugs being used by

youth in the surrounding community

To tell police and charge the youth for being high

TEST

Nasal spray that is a medication used to halt an opioid overdose is called?1. Afrin2. Narcan3. Antabuse4. Oxycodone

Narcan

TEST

If a youth has a positive swab for alcohol, you should?1. Call the police to report the use2. Administer the breathalyzer each hour until the

youth blows zero3. Let the youth sleep it off. No observation is

necessary until they are sober.4. Call their parent and tell them the results

Administer the breathalyzer each hour until the youth blows zero

TEST

A Health Care plan is used when?1. Never for intoxication or withdrawal2. A MDT decides it is necessary3. A youth is intoxicated or experiencing withdrawal 4. A youth does not want to participate in

programming

A youth is intoxicated or experiencing withdrawal

TEST

“Medical Clearance” means all of the following except:1. The youth has been seen by the emergency

department and cleared for admission2. Although the youth reports using methamphetamine

today, their medical has seen the youth and determined they are safe to be in regular programming.

3. The youth is no longer intoxicated and the health care plan is discontinued.

4. The youth complains of irritability, a stomach ache, and has runny eyes. He testing positive for opiates but your shift supervisor says “it’s just a cold”.

• The youth complains of irritability, a stomach ache, and has runny eyes. He testing positive for opiates but your shift supervisor says “it’s just a cold”.

TEST

Withdrawal from a substance occurs when1. You have a physical dependence on a substance2. You want to keep using more and more 3. You are high and see or hear things that aren’t

there4. You pass out from using more of a substance than

your body can process

You have a physical dependence on a substance

TEST

Signs of overdose include1. Lips turning blue or purple2. Shallow breathing or gurgling breath3. Appearing conscious but unresponsive4. All of the above

All of the above

TRUE OR FALSE?

1. When reading the results of the swab test, you should note the time that you read the results.

2. Swab readings tell you drug use results for the last 30 days.

3. Police officers, parole officers and parents can be told the youth’s swab results, even if the youth hasn’t signed a release of information

4. Marijuana is not addictive; therefore, a user will never experience withdrawal

TRUE-Swab results should be read within 10 minutes of administering the swab and the

results and time read are to be noted on the form

FALSE, Swab readings detect use within the last few hours and possibly days depending on the type of drug used and how

much was used.

FALSE, Swab results are to determine the need for medical intervention. This is protected health information and may NEVER be released without the youth’s written consent or a court order.

FALSE, Marijuana is addictive and withdrawal may look an inability to sleep , loss of appetite, and

irritability.

PEGGY.BAIKIE@STATE.CO.US303-916-1277

THANK YOU

ROCHELLE.GALEY@STATE.CO.US303-866-7348

Recovery is

possible