Addictions Treatment Technical Assistance in Native Populations R. Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD National Webcast May 10, 2006 Rockville, Maryland

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

One Sky Center Program Goals Promote and nurture effective and culturally appropriate prevention and treatment Identify and disseminate evidence-based prevention and treatment practices Provide training and technical assistance Help to expand capacity

Technical Assistance and Consultation Approach Individually focused, supportive Establish study groups for emerging issues Expand by developing national partners Establish Association of First Nations Behavioral Health Professionals

One Sky Center Outreach

AI/AN HEALTH DISPARITIES Alcoholism 6X Tuberculosis 6X Diabetes 3.5X Accidents 3X Suicide 1.7 to 4x 60% Over 65 live in poverty (US 27%) Jan-19R. Dale Walker, M.D., 2003

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

Lifetime History Mental Disorder 22.5% Comorbidity 29% 3.1% 1.5% 1.7% 3.1% 1.5% 1.7% 1.1% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990

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

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 Jan-19R. Dale Walker, M.D., 2003

How is it working? Different goals Resource silos One size fits all Activity-driven KIM How is it working? (Carl Bell and Dale Walker, 7/03)

Culturally specific Outcome driven Best Practice Integrating resources Requires cooperation and coordination Much higher level of working together required Communities will not see benefits until we are at this point Have begun the process, but we still have some distance to go We need Collaboration, Integration, and Synergy : Community Mobilization (Carl Bell and Dale Walker, 7/03)

Indigenous Knowledge (IK) Definitions: Indigenous Knowledge (IK) 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.

Traditional Medicine Definitions: 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

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

Best Practices Definitions: 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

Best Practice = IK + EB Best Practice Clinical/Services Mainstream Research EB Mainstream Practice Traditional Healing IK

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

The Intervention Spectrum for Behavioral Disorders Indicated— Diagnosed Youth f o r K n o w n M t i n D i s o r d e r s a i e n v t e e r P n Selective— Health Risk Groups C o m p l i a n c e a n w i t h L o n g - T e r m c T r e a t m e n t e ( 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 ) Universal— General Population A f t e r c a r e ( 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.

Spectrum of Intervention Responses Thresholds for Action No Problems Mild Problems Moderate Problems Severe Problems Treatment TRAINER: Explain that it is possible to match individual students to treatment approaches in ways that increase the probability of treatment effectiveness and efficiency and that BASICS as a brief intervention is also appropriately described as “indicated” prevention Speaking Points: “Treatment matching” is based on the notion that a spectrum of alcohol consumption and related problems exists, that no single treatment approach is effective in treating all persons with alcohol problems, and that different programs may be optimal for different types of people. Indicated interventions are those that focus on individual students who already drink heavily and have experienced, or are at risk of experiencing, alcohol-related problems at the “Threshold for Action” on the graphic. Brief interventions are one type of indicated intervention. Brief Intervention Universal/Selective Prevention

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

Ecological Model Society Community Tribe Peer/Family Individual

Environmental Interpersonal societal Individual 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

Treatment Settings - Social Support Tribal Community Family Sibs Peers Individual

Evidence-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

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

Selected Treatment/Prevention Activities The Talking Circle Smudging Story telling Traditional healers Medicine Person Herbal remedies Traditional ceremonies Sweat Lodge Traditional Experiences Preservation Jan-19R. Dale Walker, M.D., 2003

Unified Treatment Plan Addresses Mental health Education/vocation Culture Leisure/social Parenting/family Community Housing Financial Daily living skills Physical health

One Sky Center Partners Jack Brown Adolescent Treatment Center Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Eastern U.S. Tribal Consortium Tribal Colleges and Universities One Sky Center National Indian Youth Leadership Project

Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org