1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Methamphetamine Interventions and Treatment Dale Walker, MD Patricia Silk Walker, PhD The Confederated Tribes of Warm Springs June 26, 2006

2 One Sky Center

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 One Sky Center Outreach

5

6 Presentation Overview One Sky Center introduction What’s the story on methamphetamine? Fragmentation and Integration of systems Discuss prevention and treatment Integrated care approaches and interagency coordination are best overall solutions

7 Indianz.com Methamphetamine Stories 1.Wyoming governor addresses meth at Wind River (06/01)Wyoming governor addresses meth at Wind River 2.Upper Sioux Community adopts banishment policy (06/01)Upper Sioux Community adopts banishment policy 3.Gila River women speak out against meth use (05/29)Gila River women speak out against meth use 4.Methamphetamine ring leads to charges against 53 (05/26)Methamphetamine ring leads to charges against 53 5.Editorial: Northern Cheyenne Tribe fights meth (05/23)Editorial: Northern Cheyenne Tribe fights meth 6.Story on Crow Tribe and gangs draws most comments (05/19)Story on Crow Tribe and gangs draws most comments 7.Domenici seeks special federal judge for meth cases (05/18)Domenici seeks special federal judge for meth cases 8.Crow Tribe seeks help in combating gangs (05/18)Crow Tribe seeks help in combating gangs 9.Couple sentenced for meth and drug ring on Wind River (05/17)Couple sentenced for meth and drug ring on Wind River 10.Northern Cheyenne Tribe rallies against meth use (05/15)Northern Cheyenne Tribe rallies against meth use 11.Pine Ridge meth task force proposes tougher laws (05/09)Pine Ridge meth task force proposes tougher laws 12.Weapons cache seized on Soboba Reservation (05/05)Weapons cache seized on Soboba Reservation 13.Rincon man convicted for meth-related murders (05/05)Rincon man convicted for meth-related murders 14.Nisqually Tribe's law enforcement scrutinized (05/04)Nisqually Tribe's law enforcement scrutinized 15.Pine Ridge concert promoters tout 'Death to Meth' (05/02)Pine Ridge concert promoters tout 'Death to Meth'

R. Dale Walker, M.D., 2003 Methamphetamine Associated Hospital Admissions (2002)

9 Oregon Methamphetamine Admissions

10 OHSU Substance Abuse Clinic Enrollees 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%

11 Methamphetamine: Epidemiology

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

Native Health/ Educational Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5X 4.Accidents 3X 5.Suicide 1.7 to 4x 6.Health care access -3x 7.Poverty 3x 8.Poor educational achievement 9.Substandard housing 10.Methamphetamines?

14 Agencies Involved in Behavioral Health 1. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 2. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 3. Tribal Education/Health 4. Urban Indian Education/Health 5.State and Local Agencies 6.Federal Agencies: SAMHSA, Edn

15 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

16 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

17 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

18 Methamphetamine Indicators

19 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

20 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, Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

21 An Ideal Intervention Includes individual, family, community, tribe and society Comprehensive: Universal Selective Indicated Treatment Maintenance

22 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

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

24 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.

25 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

26 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

27 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

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

29 WHAT ARE SOME PROMISING STRATEGIES?

30 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.)

31 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

32 Evidence Based Cognitive and/or Behavioral Treatments Cognitive/Behavioral Therapy-CBT Motivational Interviewing-MI Contingency Management-CM Community Reinforcement Approach-CRA Matrix Model of Outpatient Treatment-MM (Combination of above)

33 Cognitive Behavioral Therapy Key Concepts –Encouraging and reinforcing behavior change –Recognizing and avoiding high risk settings –Behavioral planning (scheduling) –Coping skills –Conditioned “triggers”

34 Motivational Interviewing Key Concepts Empathy and therapeutic alliance Give feedback and reframe Create dissonance Focus of discrepancy of expected and actual Reinforce change Roll with resistance

35 Contingency Management Key concepts Behavior to be modified must be objectively measured Behavior to be modified (eg urine test results) must be monitored frequently Reinforcement must be immediate Penalties for unsuccessful behavior (eg positive Ua) can reduce voucher amount Vouchers may be applied to a wide range of prosocial alternative behaviors

36 Matrix Model Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence. Designed to integrate several interventions into a comprehensive approach. Elements include: –Individual counseling –Cognitive behavioral therapy –Motivational interviewing –Family education groups –Urine testing –Participation in 12-step programs

37 Matrix Model Treatment Key Concept: Thought Stopping Prevents the thought from developing into an overpowering craving Requires practice TriggerThought Continued ThoughtsUseCravings

38 Is Treatment for Methamphetamine Effective? Analysis of: Drop out rates Retention in treatment rates Re-incarceration rates Other measures of outcome All these measures indicate that MA users respond in an equivalent manner as do individuals admitted for other drug abuse problems.

39 Youth Treatment Completion: WA State

40 Treatment Outcomes Myth Clients addicted to Methamphetamine have poorer treatment outcomes Reality Data show that methamphetamine treatment outcomes are not very different than those for other addictive drugs

41 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

42 Potential Organizational Partners Education Family Survivors Health/Public Health Mental Health Substance Abuse Law Enforcement Juvenile Justice Medical Examiner Faith-Based County, State, and Federal Agencies

43 Contact us at Dale Walker, MD Or visit our website: