1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Best Practices in Native Communities: Strengthening Our System of Care The Oregon Tribal Forum Portland. Oregon February, 2006 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Laura Loudon, MS Toma Timothy Michelle Singer

2 Best Practices Overview

3 Disconnect Between Drug/Alcohol/ Mental Health Professionals are undertrained in at least one of the domains Patients are underdiagnosed Patients are undertreated None integrates well with medical and social service

4 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

5 Best Practices: Historical Evolution Agencies: IOM, I.H.S., NIAAA, NIDA, NIMH, SAMHSA, NIAAA, VAMC Businesses: Managed care, economics Quality care, effectiveness care

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

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

8 How Are Evidence-Based Practices Documented? Gold Standard Multiple randomized clinical trials Silver Standard Consensus reviews of available science Bronze Standard Expert opinion based on clinical observation (Drake, et al Implementing evidence based practices in routine mental health service settings. Psychiatric Services, 52, 179 – 182)

9 Three Types of Treatment Have Demonstrated Similar Success Rates Cognitive behavior therapy –Learning skills to cope with situations that precipitate drinking 12-step programs –Alcoholism is a disease –AA involvement Motivational-enhancement therapy –Motivational interviewing outlined in guidebooks Treatments Abstinent 85% of days (vs. 20%–30% of days at start of study) 2/3 still abstinent Success Rates At 1 Year At 3 Years Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:

10 A Selected Sample of Manuals Time Out! For Me - Workshop for Women Time Out! For Men Cognitive Behavior Therapy for Adolescents Multidimensional Family Therapy Enhancing Motivation for Change Mapping New Roads to Recovery

11 Nine Steps to Help Prevent Long- Term Disability from Unhealthy Alcohol/Drug Use 1. Gather information 2. Express concern 3. Provide feedback 4. Express empathy 5. Offer help 6. Know local referral options 7. Reinforce self worth 8. Assist with a plan 9. Follow up

12 Integrated Treatment “Any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting.” -CSAT

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16 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 5.State and Local Agencies 6.Federal Agencies: SAMHSA, VAMC

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

18 Behavioral Health Issues Addiction Suicide Domestic Violence Community Violence Co morbidity Chart indicates deaths per 1000 people. Blue = AI, Burgundy = U.S. Average

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

20 We need Collaboration, Integration, and Synergy : Community Mobilization Culturally specific Best Practice Integrating resources Integrating resources Outcome driven (Carl Bell, 7/03)

21 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. Definitions:

22 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 Definitions:

23 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 Definitions:

24 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 Definitions:

25 World Conference on Science Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing with culture, environment and chronic illness A partnership begins!

26 ID Best Practice Best Practice Clinical/Services Research Traditional Healing Mainstream Practice

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

28 Community Mobilization Partnered Collaboration Treatment-Education-Research Grassroots Groups Community-Based Organizations

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31 One Sky Center Outreach

32 Contact us at Dale Walker, MD Or visit our website: