1. ONE SKY CENTER: Best Practice Behavioral Health Approaches for American Indians and Alaska Natives Elizabeth Hawkins, PhD, MPH Dale Walker, MD, Patricia Silk Walker, PhD, Douglas Bigelow, PhD, Laura Loudon, MS Warrior Spirit Conference, Albuquerque, April 22-23, 2004

2. Overview  Introduction to One Sky Center  Overview of comorbidity issues  AI/AN comorbidity  Comorbidity best practices  Barriers to integrated treatment  Solutions

3. INTRODUCTION TO ONE SKY CENTER

4. One Sky Center  Funded by SAMHSA (CSAT & CSAP)  “Envisioned as an innovative NRC dedicated to identification and fostering of effective and culturally appropriate substance abuse prevention and treatment.” -Charles Currie, SAMHSA, July 2003

5. OSC Goals  Promote and nurture effective and culturally appropriate prevention and treatment  Identify and disseminate evidence-based prevention and treatment practices  Provide training and technical assistance  Help to expand capacity and improve quality in behavioral health care services

6. National Indian Youth Leadership Project Jack Brown Adolescent Treatment Center White Bison Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Eastern U.S. Tribal Consortium Tribal Colleges and Universities One Sky Center OSC Partners

7. Alaska Native Tribal Health Consortium  ANTHC is a non-profit health organization owned and operated by Alaska Native tribal governments and their regional health corporations.  Provides comprehensive services statewide to Alaska Natives.  Offers:  Medical Center specialty services  Health and sanitation facility development  Training for Alaska Native health professionals  Health system statewide network support  Community and environmental health services http://www.anthc.org

8. Jack Brown Youth Treatment Center  Operated by the Cherokee Nation Health Service and located in Tahlequah, OK  Catchment area is primarily Kansas, Oklahoma, and Texas  Number of tribes served 1997-2003: 71  CARF accredited, 20-bed co-educational facility for youth 13-18 years of age  Usual length of stay is between 30 to 120 days  Dual Diagnosis approach that targets physical, mental, emotional, and spiritual growth  Special emphasis on art therapy as a means of health promotion

9. National Indian Youth Leadership Project  A non-profit organization located in Gallup, NM (founder is McClellan Hall)  Youth development programs include:  Service learning  Experiential learning  Traditional, culturally-derived rites of passage  Academic enrichment  Ongoing projects include:  Project Venture  Walking in Beauty  Web of Life  21st Century Learning Center  Turtle Island Project  Sacred Mountain Learning Center http://www.niylp.org

10. United Indian Involvement  A non-profit organization that provides services to the Los Angeles American Indian community.  The Los Angeles American Indian Health Project  Robert Sundance Family Wellness Center  Robert Sundance Workforce Development Program  Ah-No-Ven (Healing) Home – Youth Regional Treatment Center  American Indian Clubhouse  Seven Generations Child and Family Counseling Center  Native Pathways to Healing  Circles of Care Program http://www.laindianhealth.com

11. White Bison Inc.  An American Indian non-profit organization based in Colorado Springs (founder is Don Coyhis)  Offers sobriety, recovery, addictions prevention, and wellness/wellbriety learning resources  White Bison’s mission is to assist in bringing 100 Native American communities into healing by 2010  The principle underlying White Bison is living in harmony with natural law  Ceremonies are used to help individuals and communities get back into harmony http://www.whitebison.org

12. Sample of OSC Current Projects  SAMHSA portfolio project  Best practices consensus panel  Needs assessment of IHS Youth Regional Treatment Centers  Alaska Behavioral Health Aide program  CAPT and ATTC needs assessment  Recruitment and training of AI/AN professionals  Technical assistance  Development and dissemination of prevention and treatment resources

13. OVERVIEW OF COMORBIDITY ISSUES

14. Comorbidity Defined “Individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person….at least one disorder of each type can be diagnosed independently of the other.” - Report to Congress of the Prevention and Treatment of Co- Occurring Substance Abuser Disorders and Mental Disorders, SAMHSA, 2002

15. Lifetime History Mental Disorder 22.5% Comorbidity 29% 3.1% 1.5% 1.7% 1.1% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990

16. Prevalence and Pattern of COD  7-10 million Americans are affected each year  Antisocial personality disorder, bipolar disorder, and schizophrenia are most likely to coexist with a substance use disorder  Individuals with COD have a high prevalence of trauma histories and related symptoms  Individuals with COD are more likely to have cardiovascular disease, cirrhosis, or cancer than someone without such a diagnosis

17. Prevalence and Pattern in Youth  Among adolescents entering substance abuse treatment, 62% of males and 83% of females had at least one emotional/behavioral disorder  Almost 90% of those with a lifetime co-occurring disorder had at least one mental health disorder prior to the onset of a substance abuse disorder  Mental disorder likely to occur in early adolescence, followed by the substance abuse disorder 5-10 years later

18. Multiple Diagnoses Increase  Treatment seeking  Use of services  Likelihood of no services  Treatment costs  Poor outcome  Suicide risk

19. Affective Disorders and SUD  56% of people with Bipolar Disorder have a substance use disorder  32% of people with other affective disorders have a substance use disorder  ~20% of youth with depression have history of substance abuse  15 – 75% of patients in substance abuse treatment have affective disorder  Use of TCAs and SSRIs show hope for treating affective disorder and reducing alcohol and drug intake

20. Schizophrenia and SUD  47% have substance use disorders  Alcohol use may decrease negative symptoms (depression, apathy, anhedonia, passivity and withdrawal)  May also decrease positive symptoms of hallucinations and paranoia  Schizophrenics often use and abuse stimulants  Drug-induced psychosis marked by prominent hallucinations or delusions

21. Anxiety Disorders and SUD  27% have a substance use disorder  Anxiety disorders may be treated with TCAs, SSRIs and Benzodiazepines (with caution)  Generalized anxiety disorder: Buspirone shown to treat anxiety and reduce alcohol consumption  Social anxiety is a big risk factor for alcohol and drug use  With PTSD, people will often use drugs or alcohol to sleep and stop recurrent nightmares, or to reduce anxiety

22. Disruptive Disorders and SUD  23% of people with ADHD have a substance use disorder  Combination of ADHD and CD place a child at greater risk of substance abuse than either one alone  The greater the number of CD symptoms, the more severe the substance abuse is likely to be  When CD precedes substance abuse, youth are at highest risk for ongoing delinquency and drug use in adulthood  Stimulants are a primary treatment choice but risk of abuse is high

23. Rates of Treatment by Type and Severity Level of the Disorder Level of Mental Disorder Level of Substance Abuse Disorder Type of Treatment 12-month serious mental illness 12-month other mental illness 12-month substance dependence Neither MH nor SA29%71% MH only49%25% SA only3%1% Both MH and SA19%4% 12-month substance abuse Neither MH nor SA51%78% MH only49%19% SA only0% Both MH and SA0%3%

24. COMORBIDITY AMONG AMERICAN INDIANS AND ALASKA NATIVES

25. American Indians  Have same disorders as general population  Greater prevalence  Greater severity  Much less access to treatment  Cultural relevance more challenging  Social context disintegrated

26. Mental Health: Culture, Race and Ethnicity American Indians:  Less likely to receive needed mental health services  Often receive a poorer quality of mental health care  Are underrepresented in mental health research  Have more homelessness and incarceration  Have more trauma exposure, suicide, homicide

27. Trends among AI/AN Youth  Lifetime substance use rates are similar to non-Indian teens, but AI/AN youth are more likely to:  Use tobacco, inhalants, alcohol, and marijuana daily  Consume alcohol in a binge-drinking style  Engage in high risk behaviors and experience harmful consequences  AI/AN youth tend to initiate substance use at a younger age  Higher rates of polysubstance use  Substance use often does not follow the “Gateway” model  Highest rates of emotional/behavioral problems and suicide

28. Alcohol and Other Drug Use  May cause or mimic psychiatric symptoms  May initiate or exacerbate a psychiatric disorder  Can mask psychiatric symptoms  May last for days to weeks  Drug-induced psychiatric symptoms may clear spontaneously

29. Inpatient Psychiatric Care/100,000 TotalMaleFemale National 44 56 32 AI/AN 99 78 21 Asian 23 13 10 Black171123 48 Hispanic 63 46 21 SAMHSA, 2000

30. Native American Admissions, 1999 Total Male Female Admissions (Thousands)43.2 28.215.0 Primary Substance (percent) Alcohol 62.265.755.6 Marijuana 12.413.011.4 Opiates 9.0 8.010.8 Cocaine 6.4 5.0 8.9 Stimulants 5.4 4.0 8.2 Other 4.7 4.5 5.0 Total 100.0 100.0 100.0 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

31. Past Year Illicit Drug Use Total Female Male Total 11.9 9.814.1 Native American19.823.315.6 Non-Hispanic White11.8 9.913.9 Non-Hispanic Black13.110.216.6 Hispanic – Central American 5.7 4.2 7.7 Hispanic – Cuban 8.2 5.511.4 Hispanic – Mexican12.7 9.215.8 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

32. Prevalence of Alcohol Dependence Source: 1999 SAMHSA Treatment Episode Data Set (TEDS). Total Female Male Total3.52.14.9 Native American5.66.84.3 Non-Hispanic White3.42.24.8 Non-Hispanic Black3.42.05.2 Hispanic – Central American2.80.85.4 Hispanic – Cuban0.90.51.3 Hispanic – Mexican5.62.68.4

33. COMORBIDITY BEST PRACTICES

34. Best Practices “Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness.” - WHO

35. Service Planning Guidelines 1. Dual diagnosis is an expectation, not an exception.

36. Service Planning Guidelines 1. Dual diagnosis is an expectation, not an exception. 2. People with COD can be organized into 4 subgroups for service planning purposes.

37. Co-occurring Disorders by Severity III Less severe mental disorder/ more severe substance abuse disorder IV More severe mental disorder/ more severe substance abuse disorder I Less severe mental disorder/ less severe substance abuse disorder II More severe mental disorder/ less severe substance abuse disorder Alcohol and other drug abuse Mental Illness High Severity Low Severity High Severity

38. Service Planning Guidelines 1. Dual diagnosis is an expectation, not an exception. 2. People with COD can be organized into 4 subgroups for service planning purposes. 3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships.

39. Service Planning Guidelines 1. Dual diagnosis is an expectation, not an exception. 2. People with COD can be organized into 4 subgroups for service planning purposes. 3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships. 4. Treatment success is enhanced by providing interventions for both disorders continuously across multiple treatment episodes.

40. Unified Services Plan Case management should address:  Mental health  Education/vocation  Leisure/social  Parenting/family  Housing  Financial  Daily living skills  Physical health

41. Service Planning Guidelines 1. Dual diagnosis is an expectation, not an exception. 2. People with COD can be organized into 4 subgroups for service planning purposes. 3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships. 4. Treatment success is enhanced by providing interventions for both disorders continuously across multiple treatment episodes. 5. Integrated dual diagnosis-specific interventions are recommended.

42. Service Planning Guidelines 6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change.

43. precontemplation relapse contemplation maintenance action preparation Stages of Change

44. Service Planning Guidelines 6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change. 7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies.

45. Service Coordination by Severity III Locus of care: substance abuse system IV Locus of care: state hospitals, jails, prisons, emergency rooms, etc. I Locus of care: primary health care settings II Locus of care: mental health system Alcohol and other drug abuse Mental Illness High Severity Low Severity High Severity

46. Service Planning Guidelines 6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change. 7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies. 8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized.

47. Service Planning Guidelines 6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change. 7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies. 8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized. 9. Outcomes of treatment interventions are similarly individualized.

48. Treatment Models  Sequential treatment: First one provider, then the other  Parallel treatment: Two separate providers at the same time  Integrated treatment: Both services provided by same clinician or group of clinicians

49. Integrated Treatment “Any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting.” -CSAT

50. Effective Interventions for Adults  Cognitive/Behavioral Approaches  Motivational Interventions  Psychopharmacological Interventions  Modified Therapeutic Communities  Assertive Community Treatment  Vocational Services  Dual Recovery/Self-Help Programs  Consumer Involvement  Therapeutic Relationships

51. Effective Interventions for Youth  Family Therapy  Multisystemic Therapy  Case Management  Therapeutic Communities  Circles of Care

52. NIDA Recommended Approaches  Contingency Management  Relapse Prevention Therapy  Community Reinforcement Approach  Motivational Enhancement Therapy

53. BARRIERS TO INTEGRATED TREATMENT

54. Disconnect Between Systems  Professionals are undertrained in one of two domains  Patients are underdiagnosed  Patients are undertreated  Neither integrates well with medical and social service

55. Difficulties of Integrated Approach  Separate funding streams and coverage gaps  Agency turf issues  Different treatment philosophies  Different training philosophies  Lack of resources  Poor cross training  Consumer and family barriers

56. Agencies Involved in Health Services  Indian Health Services  Bureau of Indian Affairs  Tribal health programs  Urban Indian health programs  County and state agencies

57. Reasons for lack of partnership  Stigma  Limited access  No critical mass  Time  Cost  Competing priorities  Disparate agenda  History of unsuccessful collaboration

58. SOLUTIONS

59. Identify Best Practices Best Practice Clinical/services Research Traditional Healing Mainstream Practice

60. World Conference on Science Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing with culture, environment and chronic illness. - 1999

61. Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

62. What makes a partnership work?  Trust – do away with stereotypes  Real participation at all levels  Build in incentives for all stakeholders  Education and training of all stakeholders  Dissemination of knowledge  Enhanced communication  Social to scientific interaction

63. Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

65. Resources  National Clearinghouse of Alcohol and Drug Information (NCADI)  http://www.health.org  National Institute of Alcohol Abuse and Alcoholism (NIAAA)  http://www.niaaa.nih.gov  National Institute of Drug Abuse (NIDA)  http://www.nida.nih.gov  National Institute of Mental Health (NIMH)  http://www.nimh.nih.gov  Treatment Improvement Protocol (TIP) Series  (800) 729-6686  Monitoring the Future Study  http://www.monitoringthefuture.org

66. For more information, contact: Elizabeth Hawkins, PhD, MPH One Sky National Resource Center 503-494-3703 hawkinse@ohsu.edu Visit us online at www.oneskycenter.org