Partners in prevention of youth substance abuse

Karen Ertler’s job is to turn a bad situation in a better direction.

But when it comes to getting kids who’ve landed in the emergency room into treatment for drug or alcohol use, a lecture is rarely a selling point.

“A lot of times they have this idea that (treatment is) just going to be somebody preaching to them and telling them why they shouldn’t use and that drugs are bad,” said Ertler, who runs the Rapid Response program, a joint effort by Daybreak Youth Services and Providence Health Care. “They know all those things.”

So, faced with a young person in the hospital whose injury or illness seems related to drinking or drug use, the chemical dependency counselor explains to him or her why many kids use substances: to escape something that’s hard to deal with.

Treatment, she tells youths, can help them learn to cope without the bad results that might have landed them in the ER: broken bones, lacerations, overdoses, concussions.

“It helps them see there is a different way of doing things,” Ertler said.

Rapid Response puts Ertler inside emergency rooms at Sacred Heart and Holy Family hospitals to help assess young patients’ potential substance-use problems and direct them into treatment – before the urgency of the situation fades. At the start of its second year, the program is reaching adolescents whose substance use may be otherwise overlooked.

That means a better chance of addiction recovery for the kids, its founders say. And they hope treating more kids now will mean fewer adult addicts land in the ERs later.

Problems come to a head in the emergency department, which makes it a good place to identify youths who are using and steer them into treatment. The program grew out of concern that those interventions weren’t happening, said Kathy Kramer, Daybreak’s development director.

Doctors were reporting that youths were repeatedly coming to the ER with drug- or alcohol-related problems, but then bouncing through the system without those problems being addressed, Kramer said.

And staff at Daybreak, which provides substance-abuse treatment to about 700 young people a year, knew their clients visited emergency rooms at a rate four to five times higher than the national average for teenagers.

Crowded departments are hustling to minimize wait times and boost efficiency, said Dr. Joel Edminster, who works in Sacred Heart’s adult and pediatric emergency departments.

The program is leading to several interventions a week that otherwise would have been “missed opportunities,” he said.

“You have a narrow opportunity or window of time to make an impact,” Edminster said. “The problem is that it requires some sort of intervention, which, in a busy emergency department, doesn’t always happen.”

‘The crisis of the moment’

The program launched in March 2013, with Providence’s money and Daybreak’s staff and know-how.

Providence Health Care, through its community benefits fund, is footing the program’s $50,000 annual bill for its first three years, then kicking in a projected $35,000 and $20,000 for the fourth and fifth years. Kramer said she hopes Rapid Response becomes self-sustaining as Daybreak gains clients through referrals and as more doctors learn about its services.

“The cost of treating is more expensive than prevention and early intervention,” said Sara Clements-Sampson, Providence’s community benefits manager. “We were really looking at ‘How can we get to some of those preventive measures with substance abuse?’ ”

The goal is to prevent substance abuse from becoming a recurrent behavior as the kids grow up.

“Believe me,” Edminster said, “I see a profound increase of that population on the adult side. And the ability to intervene on adults – you just don’t have the influence that you do with the pediatric population.”

In some cases, the complicated process of “plugging in” to treatment frustrated parents, said Dr. Renata Moon, a pediatric hospitalist at Sacred Heart who’s on Daybreak’s advisory board. It required a parent to “contact a facility, fill out reams of paperwork, convince that child to attend the session.”

Now, “one phone call, and we can have a counselor who comes and speaks to the family and can figure out what will work for that particular family,” Moon said. “And we’re able to do that in a rapid way.”

But the program also aims to take advantage of critical moments in youths’ and families’ lives, Kramer said.

The sense of crisis surrounding an ER visit presents a chance to shine a light on the youth’s possible substance use and offer help.

Parents are “not sitting at home thinking, ‘Gee, my kid has a drug problem, and, gee, I need to face it,’ ” Kramer said. “And the kid’s not thinking, ‘Hey, I better face I have a drug problem and I better go get treatment.’ It’s been exacerbated and brought to light because of the emergency that’s happened – the drama, the trauma, the crisis of the moment.”

Wait too long, and “the urgency is gone,” Kramer said. “A sense of complacency befalls the parent. The crisis is over: ‘Susie doesn’t really have a problem anyway. We’ll just take her home, and she’ll be fine.’ Until the next crisis happens.”

Doctors see kids who’ve been drinking or using drugs come in more frequently when school’s out, sometimes several kids in one night, Edminster said. It’s mostly “tweens and teens.”

A combative, injured youth delivered to the ER in custody of the police “is a pretty easy one – you anticipate that kid’s going to have problems with substance abuse,” Edminster said. But a youth who fell off his skateboard and hurt himself may just be clumsy – or may have been drinking.

“Sometimes I’m sure we miss some of these things,” he said. “But you just have to be vigilant.”

‘Life can be different’

When she’s not around, hospital staffers call Ertler when a youth is flagged for possible substance use by a urine screen or through questioning.

But Ertler often takes her laptop to the emergency departments at Sacred Heart and Holy Family and stations herself amid the working doctors and nurses. She watches and listens, asks providers whether patients have been screened, offers to do screenings herself.

She sometimes sees things that others don’t, she said, and asks questions that might not otherwise be asked. As a dependency counselor, she’s seen kids from every socioeconomic class. Some have family histories of drug use; others don’t.

“I know that substance use affects everyone, and it doesn’t affect just certain types of kids,” Ertler said.

If she or the program’s other on-call counselor aren’t already in the emergency department when a youth with a possible problem arrives, they get a call from the ER and arrive within 30 minutes or a day, depending on the situation.

They do a more thorough assessment at the hospital or schedule one for later, asking the adolescent about their alcohol or drug use, but also about their family, school and overall health.

If they believe the youth needs treatment, they issue a referral to Daybreak or another inpatient or outpatient center.

They set up the youth’s initial appointment, then follow up to ask if he or she went.

The kids don’t always show up at that appointment. And sometimes they start treatment but don’t finish.

Numbers from the program’s first six months show 90 percent of the 48 youths flagged for help completed an assessment. Of those, 98 percent were referred to treatment and 59 percent actually entered treatment.

Ertler equated substance addiction with cancer. You go in for treatment, maybe you go into remission, and the disease comes back. You need more treatment.

Addiction is a lifelong illness that some youths end up fighting every day, she said.

“But getting them to walk in that door and start the process can be amazing,” Ertler said. “And giving them time where they can be sober and see that life can be different, sometimes that all it takes. They didn’t realize there was another way to deal with things.”