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One Sky Center: Best Practices in Native Populations

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. Goals for Today. What is the problem?

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One Sky Center: Best Practices in Native Populations

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  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

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

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

  4. Native American Admissions, 1999 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 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

  5. 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).

  6. 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).

  7. 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

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

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

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

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

  12. 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

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

  14. Prevention Programs Should . . . . Reduce Risk Factors • 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

  15. Prevention Programs Should . . . . 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

  16. PreventionPrograms Should . . . . Target all Forms of Drug Use . . .and be Culturally Sensitive

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

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

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

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

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

  22. Lifetime Psychiatric DiagnosesAmong Primary Caretakers (N=207) R. Dale Walker, M.D. (7/97)

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

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

  25. 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

  26. 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. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.

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

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

  29. 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 (-)

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

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

  32. The Future 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

  33. 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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