1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Methamphetamine in Native Communities: Incidence, Interventions, and Treatment Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer InterTribal Council of Arizona October 24, 2006

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 One Sky Center Outreach

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6. 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. 7 Indianz.com Methamphetamine Stories 1.Meth epidemic a top issue at NCAI annual conference (10/04)Meth epidemic a top issue at NCAI annual conference 2.Pine Ridge drug trafficking case sent to jury (10/04)Pine Ridge drug trafficking case sent to jury 3.NCAI kicks off annual meeting in Sacramento (10/03)NCAI kicks off annual meeting in Sacramento 4.Border fence will further divide Tohono O'odham Nation (09/25)Border fence will further divide Tohono O'odham Nation 5. Tribes receive substance abuse prevention grants (09/21)Tribes receive substance abuse prevention grants 6.Task force recommends help for Native meth addicts (09/21)Task force recommends help for Native meth addicts 7.Five on trial for trafficking cocaine to Pine Ridge (09/20)Five on trial for trafficking cocaine to Pine Ridge 8.Tohono O'odham Nation opposes border fence (09/20)Tohono O'odham Nation opposes border fence 9.Conference to present models for meth treatment (09/18)Conference to present models for meth treatment 10.Tohono O'odham Nation caught in border battle (09/15)Tohono O'odham Nation caught in border battle 11.Navajo Nation makes biggest drug seizure in it history (09/14)Navajo Nation makes biggest drug seizure in it history 12.Crow chairman testifies at Senate hearing on meth (09/13)Crow chairman testifies at Senate hearing on meth 13.Elders hear dangers of meth at Oklahoma conference (09/07)Elders hear dangers of meth at Oklahoma conference 14.Indian mothers who use meth part of birth weight study (09/06)Indian mothers who use meth part of birth weight study 15.Salt River Pima-Maricopa voters go to the polls (09/05)Salt River Pima-Maricopa voters go to the polls

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

9. 9 Oregon Methamphetamine Admissions

10. 10 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%

11. 11 Methamphetamine: Epidemiology

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

13. 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. 14 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

15. 15 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

16. 16 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

17. 17 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

18. 18 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

19. 19 Methamphetamine Indicators

20. 20 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

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22. 22 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

23. 23 An Ideal Intervention Includes individual, family, community, tribe and society Comprehensive: Universal Selective Indicated Treatment Maintenance

24. 24 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

25. 25 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

26. 26 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.

27. 27 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

28. 28 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

29. 29 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

30. 30 Target all Forms of Drug Use...and be Culturally Sensitive Prevention Programs Should....

31. 31 WHAT ARE SOME PROMISING STRATEGIES?

32. 32 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.)

33. 33 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

34. 34 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)

35. 35 Cognitive Behavioral Therapy Key Concepts –Encouraging and reinforcing behavior change –Recognizing and avoiding high risk settings –Behavioral planning (scheduling) –Coping skills –Conditioned “triggers”

36. 36 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

37. 37 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

38. 38 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

39. 39 Matrix Model Treatment Key Concept: Thought Stopping Prevents the thought from developing into an overpowering craving Requires practice TriggerThought Continued ThoughtsUseCravings

40. 40 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.

41. 41 Youth Treatment Completion: WA State

42. 42 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

43. 43 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

44. 44 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

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47. 47 American Indian and Alaska Native Substance Abuse Treatment The Native Programs Directory Prepared by: One Sky National Resource Center for American Indian and Alaska Native Substance Abuse Prevention and Treatment Services

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