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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

Our Native Methamphetamine Crisis:

An Integrated Care SolutionDale Walker, MD Patricia Silk Walker, PhD Michelle Singer

Affiliated Tribes of Northwest Indians Portland, Oregon February 14, 2006

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One Sky Center

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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

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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

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R. Dale Walker, M.D., 2003

Methamphetamine AssociatedHospital Admissions (2002)

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Meth admissions by state

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

OR

Oregon Methamphetamine Admissions

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OHSU Substance Abuse Clinic Enrollees

1998-2000

2002-2004

N= 108 percent N= 172 percent

Alcohol 25 23% 22 13%

Marijuana mixed 8 7% 5 3%

Marijuana only 23 21% 38 22%

Methadone/heroin 30 28% 47 27%

Methamphetamine 34 31% 84 49%

Narcotics 5 4% 6 3%

Benzodiazepines 2 2% 6 3%

Hallucinogens 3 3% 1 1%

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National Methamphetamine Initiative Survey

Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006

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Methamphetamine: Epidemiology

Past Month Illicit Drug Use among Youths Aged 12 to 17, by Race/Ethnicity: 2002

Methamphetamine: Epidemiology

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IHS-Wide Outpatient Encounters for Amphetamine Related Visit by Calendar

Year

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Meth indicators

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Possession arrestsTreatment casesER admissionsID theft casesPurity*

Methamphetamine Indicators

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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

Douglas Jackobs 2003 R. Dale Walker, M.D., 2003

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Native Adolescents: Multiple Life Risks

-Edn,-Econ,-Rec-Edn,-Econ,-Rec

Family DisruptionDomestic ViolenceFamily DisruptionDomestic Violence

ImpulsivenessImpulsiveness

Negative Boarding SchoolNegative Boarding School

HopelessnessHopelessness

Historical TraumaHistorical Trauma

Family HistoryFamily History

SuicidalBehaviorSuicidal

Behavior

Cultural DistressCultural Distress

Psychiatric Illness& StigmaPsychiatric Illness& Stigma

Psychodynamics/Psychological VulnerabilityPsychodynamics/Psychological Vulnerability

Substance Use/AbuseSubstance

Use/Abuse

CHILD

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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

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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

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?

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Agencies Involved in Behavioral Health

1. Bureau of Indian Affairs (BIA)A. EducationB. VocationalC. Social ServicesD. Police

2. Indian Health Service (IHS)A. Mental HealthB. Primary HealthC. Alcoholism / Substance

Abuse3. Tribal Education/Health4. Urban Indian Education/Health5. State and Local Agencies6. Federal Agencies: SAMHSA, Edn

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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

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How are we functioning?(Carl Bell, 7/03)

One size fits allOne size fits all

Different goals Different goals Resource silosResource silos

Activity-drivenActivity-driven

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We need Synergy and an Integrated System (Carl Bell, 7/03)

Culturally Specific

Culturally Specific

Best Practice

Best Practice

IntegratingResources

IntegratingResources

Outcome Driven

Outcome Driven

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The Intervention Spectrum for Behavioral Disorders

CaseIdentification Standard

Treatmentfor KnownDisorders

Compliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)

Aftercare(Including

Rehabilitation)

Prev

entio

n

TreatmentM

aintenance

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 RiskGroups

Universal—General Population

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An Ideal Intervention

• Includes individual, family, community, tribe and society

• Comprehensive:

Universal

Selective

Indicated

Treatment

Maintenance

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Ecological Model

IndividualPeer/FamilySociety Community/Tribe

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Individual Intervention

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

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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.

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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

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• 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

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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

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Target all Forms of Drug Use

. . .and be Culturally Sensitive

Prevention Programs Should . . . .

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WHAT ARE SOME PROMISING STRATEGIES?

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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.)

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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

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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)

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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

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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

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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.

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Youth Treatment Completion: WA State

50%

62%

52%46%

55% 50%

0%

10%

20%

30%

40%

50%

60%

70%

Alcohol Cocaine Marijuana Meth Heroin Other

Youth

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Study Says Incentive-Based Meth Treatment Works

• The contingency management (CM) program gave patients who had drug-free urine tests plastic chips that could be exchanged for prizes; those who did not follow program rules could lose chips.

• John Roll of Washington State University

AmJP, November 3, 2006

44AmJP, November 3, 2006

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Study Says Incentive-Based Meth Treatment Works

• "The Matrix Model of psychosocial treatment currently is thought to be the most effective therapy for methamphetamine addiction, and CM has shown itself to increase the therapeutic effectiveness of treatments for other drug abuse disorders. Combining these two treatments gives us an even more powerful weapon against methamphetamine abuse."

NIDA Director Dr. Nora D. Volkow November 3, 2006

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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

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Partnered Collaboration

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

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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

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Contact us at503-494-3703E-mailDale Walker, MDonesky@ohsu.eduOr visit our website:www.oneskycenter.org