Methamphetamine Resources and Treatment: Families and Communities

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Methamphetamine Resources and Treatment: Families and Communities Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer July 24, 2007 Phoenix, Arizona

2. Native Communities Advisory Council / Steering Committee One Sky Center

3. One Sky Center Partners Tribal Colleges and Universities Cook Inlet Tribal Council Alaska Native Tribal Health Consortium Prairielands ATTC Red Road Northwest Portland Area Indian Health Board One Sky Center Harvard Native Health Program United American Indian Involvement Jack Brown Adolescent Treatment Center National Indian Youth Leadership Project Tri-Ethnic Center for Prevention Research Na'nizhoozhi Center

4. One Sky Center Outreach

5. Goals for Today • Background: The environment and the system of care • The methamphetamine problem • Contributing factors • Indigenous Knowledge + Evidence Based Knowledge = Best Practice • Promising programs • Integrated care approaches are best for treatment of these chronic illnesses

10. Adolescent Problems In Schools 1. School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services Alcohol Drug Use Fighting and Gangs Bullying Weapon Carrying School Environment Sale of Alcohol and Drugs Sexual Abuse Unruly Students Truancy Attacks on Teachers Staff Domestic Violence Drop Outs 12

11. Key Adolescent Risk Factors Aggressive/Impulsive Substance Abuse Depression Trauma

12. Six behaviors that contribute to serious health problems: • Tobacco use • Poor nutrition • Alcohol and other drug abuse – Methamphetamine! • Behaviors resulting in intentional or unintentional injury • Physical inactivity • Risky sex

13. 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)

14. Kathryn P. Jett Director California Department of Alcohol and Drug Programs

15. Methamphetamine: Epidemiology

16. Native Health Problems Alcoholism 6X Tuberculosis 6X Diabetes 3.5 X Accidents 3X Poverty 3x Depression 3x Suicide 2x Violence?

17. AmericanIndians • Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

18. Percentage reporting dependence on alcohol Total Female Male Total 3.5 2.1 4.9 Native American5.6 6.8 4.3 Non-Hispanic White 3.4 2.2 4.8 Non-Hispanic Black 3.4 2.0 5.2 Hispanic – Central American 2.8 0.8 5.4 Hispanic – Cuban 0.9 0.5 1.3 Hispanic – Mexican 5.6 2.6 8.4 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

19. Percentage using any illicit drugs in the past year Total Female Male Total 11.9 9.8 14.1 Native American19.8 23.3 15.6 Non-Hispanic White 11.8 9.9 13.9 Non-Hispanic Black 13.1 10.2 16.6 Hispanic – Central American 5.7 4.2 7.7 Hispanic – Cuban 8.2 5.5 11.4 Hispanic – Mexican 12.7 9.2 15.8 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

20. Lifetime History 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% Regier, 1990

21. Agencies Involved in B.H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health • State and Local Agencies • Federal Agencies: SAMHSA, VAMC, Justice

22. 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

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

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

26. The Methamphetamine Effect

27. The Intervention Spectrum for Behavioral Disorders T r e a t m e n t C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t n o f o r K n o w n i Indicated— Diagnosed Youth M t D i s o r d e r s n a e i n v t e r e P n C o m p l i a n c e a Selective— Health Risk Groups n w i t h L o n g - T e r m c e T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.),Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

28. Treatment Brief Intervention Universal/Selective Prevention Spectrum of Intervention Responses Thresholds for Action No Problems Mild Problems Severe Problems Moderate Problems

29. Ecological Model Society Community/ Tribe Peer/Family Individual

30. Environmental Interpersonal societal Stigma Community Tribal attitudes Parents Peers National attitudes Personality Attitudes beliefs Genetics Individual Cultural beliefs Schools Local legal Interpersonal State attitudes Personal situations Individual Portrayal in media

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

32. 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.

33. Sources of Strength Access to Mental Health Family Support Positive Friends Access to Medical Spirituality Caring Adults Positive Activities Generosity/Leadership

34. Effective Interventions for Adults • Cognitive/Behavioral Approaches • Motivational Interventions • Psychopharmacological Interventions • Modified Therapeutic Communities • Assertive Community Treatment • Vocational Services • Dual Recovery/Self-Help Programs • Consumer Involvement • Therapeutic Relationships

35. Effective Interventions for Youth • Family Therapy • Multisystemic Therapy • Case Management • Therapeutic Communities • Community Reinforcement • Circles of Care • Motivational Enhancement

37. Treatment Settings - Social Support: A Native Advantage • Tribal • Community • Family • Sibs • Peers • Individual

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

39. Possible Treatment/Prevention Activities • The Talking Circle • Smudging • Story telling • Traditional Healers • Medicine Person • Herbal remedies • Traditional ceremonies • Sweat Lodge • Traditional Experiences Preservation

40. Use of Traditional Medicine Forty-four percent of respondents used Traditional Healing Services in past year. Kevin Foley, Ph.D.

42. Definitions: Indigenous Knowledge • Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs.

43. Definitions: Traditional Medicine • The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002

44. Definitions: Evidence-based Practices • Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings. SAMHSA 2003

45. Definitions: Best Practices • Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness. WHO 2002

46. ID Best Practice Best Practice Clinical/services Research Mainstream Practice Traditional Healing

47. Circle of Care Traditional Healers Child & Adolescent Programs Primary Care Best Practices A&D Programs Boarding Schools Colleges & Universities Prevention Programs Emergency Rooms

49. Clinical Challenges for Treatment of Methamphetamine Addiction • Poor treatment engagement rates • High dropout rates • Severe paranoia • High relapse rates • Ongoing episodes of psychosis • Severe craving • Protracted dysphoria Many patients may require medical/psychiatric supervision and need ongoing treatment with antipsychotic medications

50. Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses 50 to 70% 50 to 70% 40 to 60% 30 to 50% 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.