1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Methamphetamine Problems: Development of Native Prevention Models Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer Laura Loudon, MS Doug Bigelow, PhD August 1, 2007 Sioux Falls, South Dakota

2. 2 One Sky Center

3. 3 One Sky Center Partners Jack Brown Adolescent Treatment Center Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Na'nizhoozhi Center Tribal Colleges and Universities National Indian Youth Leadership Project Cook Inlet Tribal Council Tri-Ethnic Center for Prevention Research Red Road Prairielands ATTC Harvard Native Health Program One Sky Center

4. 4 Presentation Overview What’s the story on methamphetamine? Discuss prevention theory and models Integrated care approaches and interagency coordination are best overall solutions

5. R. Dale Walker, M.D., 2003 Methamphetamine Abuse Eastward Movement Based on Hospital Admissions

6. 6 Arizona Methamphetamine Admissions Governor’s Council on Addictions 2006

7. 7 S.D. METH LABS SEIZED Meth admissions/100,000 (2003) =92

8. 8 Oregon Methamphetamine Admissions 2003=257

9. 9 OHSU Substance Abuse Clinic Enrollees 1998- 2000 2002- 2004 N= 108percentN= 172percent Alcohol2523%2213% Marijuana mixed 8 7% 5 3% Marijuana only2321%3822% Methadone/heroin3028%4727% Methamphetamine3431% 8449% Narcotics 5 4% 6 3% Benzodiazepines 2 2% 6 3% Hallucinogens 3 3% 1 1%

10. 10 National Methamphetamine Initiative Survey Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006

11. 11 National Methamphetamine Initiative Survey Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006

12. 12 Methamphetamine: Epidemiology

13. 13 Methamphetamine Use in 2004 Percentage Source: SAMHSA 2004 NSDUH.

14. 14 IHS-Wide Outpatient Encounters for Amphetamine Related Visit by Calendar Year

15. 15 Lifetime, Past Year, and Past Month Methamphetamine Use Numbers of Users (in Thousands) a = Significant change 2003 to 2004; b = Significant change 2002 to 2004 Richard Kopanda, CSAT

16. 16 Why is Methamphetamine so Devastating? Cheap, readily available Stimulates, gives intense pleasure Damages the user’s brain Paranoid, delusional thoughts Depression when stop using Craving overwhelmingly powerful Brain healing takes up to 2 years We are not familiar with treating it

17. Douglas Jackobs 2003 R. Dale Walker, M.D., 2003 17 Native Adolescents: Multiple Life Risks -Edn,-Econ,-Rec Family Disruption Domestic Violence Family Disruption Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse CHILD

18. 18 Adolescent Problems In Schools School Environment Bullying Fighting and Gangs Alcohol Drug Use Weapon Carrying Sexual Abuse Truancy Domestic Violence Drop Outs Attacks on Teachers Staff Unruly Students Sale of Alcohol and Drugs 12

19. 19 Methamphetamine, Why Now? The Internet Diffused local production, less reliance on imports Multi-drug use – no one uses only crystal National outbreak Varied sub-populations More smoking Strong association with HIV, hepatitis C Community level responses to AIDS deaths, 9/11, war National discussion

20. 20 The Methamphetamine Effect

21. 21 Difficulties of System Integration Separate funding streams and coverage gaps Agency turf issues Different philosophies Lack of resources Poor cross training Consumer and family barriers

22. 22

23. 23 Developmental Paths for Multi-Problem Behavior Dennis D. Embry

24. 24 The Intervention Spectrum for Behavioral Disorders Case Identification Standard Treatment for Known Disorders Compliance with Long-Term Treatment (Goal: Reduction in Relapse and Recurrence) Aftercare (Including Rehabilitation) P r e v e n t i o n T r e a t m e n t M a i n t e n a n c e Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994. Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

25. 25 Prevention Theory Explains the causes and mechanisms of action Identifies the variables influencing these mechanisms, including cultural Predict points to interrupt the course leading to substance abuse; and Specifies the interventions to prevent the onset of substance abuse.

26. 26 Theories of Prevention Cognitive-Affective Social Learning Intrapersonal Comprehensive

27. 27 Cognitive-Affective: Theory: The consequences of experimenting with a drug contributes to decision to use. Intervention: Increase beliefs about negative consequences of drugs, highlight benefits of not using drugs, and correct inflated estimates or perceptions of drug use.

28. 28 Social Learning: Theory: Adolescents acquire their beliefs about substance use and other delinquent behaviors from their role models, friends, and parents. Intervention: Provide adolescents with positive role models, and to teach them refusal skills and the belief that they can resist drugs.

29. 29 Conventional Commitment and Social Attachment: Theory: Emotional attachments adolescents have with peers who use substances is the cause of substance use. Intervention: Improve bonds between adolescents and positive peer groups and prosocial institutions. Focus on improving academic and career skills, provide career opportunities, and teach parents how to socialize and reinforce their children.

30. 30 Intrapersonal: Theory: Examine how personality characteristics, emotions, and behavioral skills contribute to substance use. Examples; stress at school, self- esteem, social interaction skills, coping skills, and emotional distress. Interventions: Target many of the individual characteristics of children rather than focusing on their beliefs about specific drugs and behaviors.

31. 31 Comprehensive Combines components from all of the other theories. They attempt to account for how adolescents' biology, personality, relationships with peers and parents, and culture or environment interact to cause drug use.

32. 32 Conclusions: Before selecting an approach, consider the following: Who are the people in the support system? Are they contributor to the adolescent's level of risk for using substances? What are the adolescent's attitudes toward specific substances? How might values communicated through an adolescent's culture influence decisions to experiment with substances? What are the personality characteristics, emotional states, and/or behavioral skills of adolescents at risk for using substances?

33. 33 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

34. 34 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

35. 35 Effective Family Intervention Strategies: Critical Role of Families Parent training Family skills training Family in-home support Family therapy Different types of family interventions are used to modify different risk and protective factors.

36. 36 Community Driven/School Based Prevention Interventions Public awareness and media campaigns Youth Development Services Social Interaction Skills Training Approaches Mentoring Programs Tutoring Programs Rites of Passage Programs

37. 37 Risk Factors Exist in multiple domains. The more risk factors present, the greater the risk. Reducing the overall number can have a significant impact on future problem behaviors. Show the same effect across different races, cultures and classes. Can be buffered by protective factors.

38. 38 Protective Factors the opportunity for involvement in productive, pro- social roles in family, friends, community, society the skills to be successfully involved in those roles recognition and reinforcement for their involvement Individual is given:

39. 39 ineffective parenting chaotic home environment lack of mutual attachments/nurturing inappropriate behavior in the classroom failure in school performance poor social coping skills affiliations with deviant peers perceptions of approval of drug-using behaviors Prevention Programs Reduce Risk Factors

40. 40 Prevention Programs Enhance Protective Factors strong family bonds parental monitoring parental involvement success in school performance pro social institutions (e.g. such as family, school, and religious organizations) conventional norms about drug use

41. 41 Target all Forms of Drug Use...and be Culturally Sensitive Prevention Programs Should....

42. 42 WHAT ARE SOME PROMISING STRATEGIES?

43. 43 Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: decrease in hospitalization lessening of psychiatric and substance abuse severity better engagement and retention (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

44. 44 Comprehensive School and Behavioral Health Partnership Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

45. 45 Treatment Approaches Effective with Methamphetamine Use Disorder Motivational Interviewing - MI Therapeutic Use of Urinalysis Contingency Management (motivational incentives) Community Reinforcement Approach Cognitive Behavioral Therapy - CBT Matrix Model (combination of above) (Data show that methamphetamine treatment outcomes are not very different than those for other addictive drugs)

46. 46 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

47. 47 Potential Organizational Partners Education Family Survivors Health/Public Health Mental Health Substance Abuse Elders, traditional Law Enforcement Juvenile Justice Medical Examiner Faith-Based County, State, and Federal Agencies Student Groups

48. 48 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org