1. 1 One Sky Center: Best Practices in Native Populations R. Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD Laura Loudon, BA February 19, 2004 Bellingham, Washington

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3. 3 Goals for Today 1.What is the problem? 2.What do we know about addictions? 3.What do we know about Indians? 4.What are some solutions?

4. 4 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

5. 5 Native American Admissions, 1999 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS). Total Female Male Admissions (Thousands)43.2 15.0 28.2 Primary Substance (percent) Alcohol 62.2 55.6 65.7 Marijuana 12.4 11.4 13.0 Opiates 9.0 10.8 8.0 Cocaine 6.4 8.9 5.0 Stimulants 5.4 8.2 4.0 Other 4.7 5.0 4.5 Total 100.0 100.0 100.0

6. 6 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 Percentage using any illicit drugs in the past year Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

7. 7 Percentage reporting dependence on alcohol 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

8. 8 Lifetime History Regier, 1990 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%

9. 9 Multiple Diagnoses Increases: treatment seeking use of services poor outcome suicide risk likelihood of no services treatment costs

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12. 12 Definitions of Drinking: "Any" vs. "More Than a Sip or Taste" R. Dale Walker, M.D. (4/99) Note: 100% completion sample

13. 13 Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample

14. 14 Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years R. Dale Walker, M.D. (4/99) * 100% Completion Sample Percentage ever used

15. 15 Age of Onset of Substance Use Among Urban American Indian Adolescents, by Substance Used R. Dale Walker, M.D. (5/2000) *Cohorts 4 & 5 were sampled every third year; recall and sampling bias apply

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17. 17 Prevention Primary Risk factors Protective factors Prevent 1st use Secondary Prevent kids who use from continuing Prevent kids who misuse from experiencing use related problems or dependency

18. 18 Prevention Programs Should.... 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 in the school, peer, and community environments Reduce Risk Factors

19. 19 Enhance Protective Factors strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family, school, and religious organizations) conventional norms about drug use Prevention Programs Should....

20. 20 Target all Forms of Drug Use...and be Culturally Sensitive Prevention Programs Should....

21. 21 Include Interactive Skills-Based Training Resist drugs Strengthen personal commitments against drug use Increase social competency Reinforce attitudes against drug use Prevention Programs Should....

22. 22 Family-Focused Provides greater impact than parent-only or child-only programs Include at each stage of development Involve effective parenting skills Prevention Programs Should be....

23. 23 Involve Communities and Schools Media campaigns and policy changes Strengthen norms against drug use Address specific nature of local drug problem Prevention Programs Should....

24. 24 Implications for Treatment Teach adolescents how to cope with difficulties and adversity Increase their repertoire of coping strategies Cognitive therapy is most effective approach

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26. 26 Lifetime Substance Disorder Diagnoses Among Primary Caretakers (N=207) R. Dale Walker, M.D. (7/97)

27. 27 Lifetime Psychiatric Diagnoses Among Primary Caretakers (N=207) R. Dale Walker, M.D. (7/97)

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29. 29 Treatment Settings - Social Support Tribal Community Family Sibs Peers Individual

30. 30 Cultural Approach Original Holistic Approach Psychopharmacology Approach The unconscious has always been there Group Therapy Network Therapy Recreational / Outdoors Traditional Interventions Indian is...

31. 31 Selection of a Best Practice Identify the state of the art Select and prioritize the best practices Organize the stakeholders for follow-through Evaluation of effort Incentives

32. 32 Evidence-Based Practices for Alcohol Treatment Brief intervention Social skills training Motivational enhancement Community reinforcement Behavioral contracting Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2 nd ed., pp 12 – 44). Boston: Allyn & Bacon.

33. 33 Scientifically-Based Approaches to Addiction Treatment Cognitive–behavioral interventions Community reinforcement Motivational enhancement therapy 12-step facilitation Contingency management Pharmacological therapies Systems treatment 1.L. Onken (2002). Personal Communication. National Institute on Drug Abuse. 2.Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

34. 34 Stages of Change Enhancing Motivation F R A M E S pre-contemplation relapse contemplation maintenance action preparation Menu Options Feedback Responsibility Advice Self-efficacy Empathy

35. 35 Cognitive Behavioral Therapy What are determinants of substance use –social –environmental –emotional –cognitive –physical What skills or resources does the patient lack Treatment goals highly individualized Therapy sessions structured; with homework Self monitoring form: situation, craving, intensity, coping used Triggers: thoughts, feelings, behaviors, (+) or (-)

36. 36 Unified Services Plan Case management should address: Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health

37. 37 Core Components of Comprehensive Services Medical Mental Health Vocational Educational Legal AIDS / HIV Risks Financial Housing & Transportation Child Care Family Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmaco-therapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment PlansCoreTreatment Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

38. 38 1. Predictable Funding 2. Long Term Planning 3. Improve Critical Mass of Health Care Systems 4. Tribal Coordinated Self Governance 5. Department of Indian Trust The Future

39. 39 Contact information R. Dale Walker, MD Laura Loudon Center for American Indian Health, Education and Research Oregon Health & Science University (503)494-8112 walkerrd@ohsu.edu loudonl@ohsu.edu Website: http://www.ohsu.edu/som-psychresearch/aiherhome.htm

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