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

The Indian Country Methamphetamine Initiative: a Problem Uniquely Affecting

Indian Country

Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer

July 29, 2007Nashville, Tennessee

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Special Thanks and Recognition

• AAIP and the Executive Board• Margaret Knight• Rachel Crawford• Heather Levi• Vincent Knight

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One Sky Center

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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

One Sky Center

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 Partners

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One Sky Center Outreach

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Goals for Today

• Background: The environment and the system of care• The methamphetamine problem• The methamphetamine initiative• The toolkit• Treatment works!• Integrated care approaches are best for treatment of

these chronic illnesses

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1491

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Agencies Involved in B.H. Delivery

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

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

3. Tribal Health4. Urban Indian Health5. State and Local Agencies6. Federal Agencies: SAMHSA, VAMC,

Justice

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Difficulties of Program Integration

• Separate funding streams and coverage gaps• Agency turf issues• Different treatment philosophies• Different training 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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Partnered Collaboration: AAIP Style

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

State/Federal

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American Indians

• Have same disorders as general population

• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated

Native Health Problems1. Alcoholism 6X

2. Tuberculosis 6X

3. Diabetes 3.5 X

4. Accidents 3X

5. Poverty 3x

6. Depression 3x

7. Suicide 2x

8. Violence?

9. Methamphetamine?

Six Behaviors That Contribute to Serious Health

Problems:• Tobacco use• Poor nutrition• Alcohol and other drug abuse – • Behaviors resulting in intentional or unintentional

injury• Physical inactivity• Risky sex

Methamphetamine!

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Percentages of Young Adults Aged 18 to 25 Reporting Past Year Methamphetamine Use, by State: 2002, 2003, 2004, and 2005

Source: SAMHSA, 2002-2005 .

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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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Methamphetamine/Amphetamine Admissions, by Race/Ethnicity and

Urbanization: 2004 Race/

Ethnicity

Large Central Metro

Large Fringe Metro

Small Metro

Non-Metro with City

Non-Metro without

City

White 56% 77% 78% 86% 87%

Black 5% 3% 2% 1% 1%

Hispanic 28% 14% 11% 6% 4%

American Indian/ Alaska Native

2% 1% 3% 4% 6%

Asian Pacific Islander

3% 2% 3% 2% 1%

Other 6% 3% 3% 1% 1%

Source: 2003 SAMHSA Treatment Episode Data Set (TEDS).

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Recent Methamphetamine Reports

Five arrested for drugs and meth in South Dakota (04/30) Meth dealers targeted Wind River Reservation (04/30) Crow students hold second walk against meth (04/30) Belcourt: Indian Country takes path of healthy living (04/30) Paiute Tribe of Utah cites increased meth use (04/26) BIA ties violence against women to meth abuse (04/26) HHS holds consultation session in Salt Lake City (04/25) Fired U.S. Attorneys praised for Indian Country work (04/19) Tribal methamphetamine bill clears House (04/17) Coyote Valley Band on new track with new chairman (04/09) Four await trial for meth-related triple homicide (04/04) California court throws out search on reservation (04/03)

Artman ushers in leadership changes at BIA (04/02) Pechanga man sentenced to 44 years for deaths (04/01)

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The Methamphetamine Effect

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Methamphetamine Identified as the Primary Health/Community

Concern

• In 2006, Tribal Round Table sessions, HHS Regional Tribal Consultations, and numerous tribal community gatherings with SAMHSA, OMH, and IHS identified Methamphetamine abuse as the primary health concern in Indian Country.

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“Tribal leaders unveil new meth Initiative” Indian Country Today  

NCAI President, Joe Garcia Anchorage, Alaska June 15, 2007

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HHS Indian Country Methamphetamine Initiative

• $1.2 million awarded to Association of Indian Physician (AAIP) its partners (National Congress of American Indians, One Sky Center, South and Eastern Tribes, and Northwest Portland Area Indian Health Board)

• Tribal Sites– Navajo Nation – Winnebago Tribe – Northern Arapaho Tribe– Crow Nation – Choctaw Nation

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ICMI Project Description

• Create a National education and information outreach campaign for all Native communities.

• Establish and transfer knowledge from community based to promising practices for prevention, intervention and treatment.

• Work across Federal agencies for a coordinated and consistent outreach strategy.

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The Indian Country Methamphetamine Initiative: Project

Partners

SAMHSA

AAIP

USET NPAIHB OSC NCAI

Choctaw Crow Navajo Northern Arapaho Winnebago

IHS OMH HHS

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Winnebago

Navajo

Choctaw

Crow

Northern Arapaho

NPAIHB

AAIP

USET

OSC

NCAI

ICMI Partners

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ICMI Major Project Deliverables

• Outreach/Education Kit for Tribes and other Groups• Identification of Partners ( also Advisory Groups)• Coordinated Federal-Tribal-State-Local Indian

Country Communication and Training Strategy• Minimum 5 Tribal Specific Projects Identified and

Evaluated for Potential Transfer to Other NA Communities

• Final Project Evaluation• Year 3 - Promising Practices Transfer Kits

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Toolkit Essentials

• Leadership Information• Methamphetamine Basics• Tribal Code-Policy • Media• Educational Materials and Presentations

Prevention and Treatment

Educational for Students, Parents, Community• Community Organizing • Fun Youth Items•  Additional Resources

                                                                                                                         

                            

                                                                                           

                                                           

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How to Use the Toolkit

• Leadership and decision making• Overview of each module• Specific topics, issue pages• Promising Practice approaches• What the culture and science says• Training, technical assistance, and consultation• Reference documents • Toolkit webpage

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ID Best Practice

Best Practice

Clinical/servicesResearch

TraditionalHealing

MainstreamPractice

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Circle of Care

Best Practices

Child & Adolescent Programs

Prevention Programs

Primary Care

EmergencyRooms

TraditionalHealers

A&D Programs

Colleges & Universities

Boarding Schools

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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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No No ProblemsProblems

Universal/Selective Universal/Selective PreventionPrevention

Brief InterventionBrief Intervention

TreatmentTreatment

Mild Mild ProblemsProblems

Moderate Moderate ProblemsProblems

Severe Severe ProblemsProblems

Thresholds for ActionThresholds for Action

Spectrum of Intervention Responses

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Treatment Settings - Social Support: A Native Advantage

• Tribal

• Community

• Family

• Sibs

• Peers

• Individual

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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 therapyDifferent types of family interventions are used

to modify different risk and protective factors.

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Sources of Strength

Family Support

Positive Friends

Caring Adults

Positive ActivitiesGenerosity/Leadership

Spirituality

Access to Medical

Access to Mental Health

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Recommended Behavioral Treatment Approaches

• Cognitive Behavioral Therapy

• Psychosocial Treatment

• Community Reinforcement - Plus Vouchers

• Contingency Management

• Relapse Prevention

• The Matrix Model

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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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Relapse Rates Are Similar for Drug Dependence and Other Chronic

Illnesses

Relapse Rates Are Similar for Drug Dependence and Other Chronic

Illnesses

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

Drug Dependence

Drug Dependence

Type I DiabetesType I

DiabetesHypertensionHypertensionAsthmaAsthma

40 t

o 60

%40

to

60%

30 t

o 50

%30

to

50% 50

to

70%

50 t

o 70

%

50 t

o 70

%50

to

70%

Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse

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