The Indian Country Methamphetamine Initiative: Taking Interventions to Scale Association of American Indian Physicians 39th Annual Meeting R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer August 9, 2010 Santa Ana Pueblo, New Mexico

2 One Sky Center Opportunity, Research Excellence Tribal Leadership Training, Consultation, Technical Assistance Education Mentorship

Goals for Today The methamphetamine problem The methamphetamine initiative The Mission: Going-to-Scale ICMI Tribal Sites General Approaches Logic Models Examples 3

The most widely used illicit drug in the world except for cannabis. Worldwide it is estimated there are over 42 million regular users compared to approximately 15 million heroin users and 10 million cocaine users  Meth use is increasing and expanding! Scope of the Meth Problem Worldwide

What is methamphetamine? A powerful stimulant drug, classified as a psychostimulant A Schedule II drug (along with cocaine and several other drugs) under the Federal Controlled Substances Act A highly addictive drug

Why do people use meth? Initially, methamphetamine decreases fatigue and appetite, heightens attention, and increases activity and respiration, creating feelings of high energy. Meth enables people to stay awake and be physically (also sexually) active for long periods. Source: National Institute on Drug Abuse. April 1998, Reprinted January Research Report Series: Methamphetamine Abuse and Addiction.

How does meth work? Methamphetamine releases large amounts of dopamine in the brain, causing feelings of pleasure and euphoria. Source: National Institute on Drug Abuse. April 1998, Reprinted January Research Report Series: Methamphetamine Abuse and Addiction. Withdrawal symptoms may include fatigue, depression, anxiety, paranoia, aggression, and an intense craving for more of the drug. In some cases, psychotic symptoms may persist for months or years following use. Source: Office of National Drug Control Policy. November Fact Sheet: Methamphetamine.

How is meth used? Injecting or smoking methamphetamine produces a short but intense and pleasurable “rush.” When taken orally or by snorting, meth causes a less intense but much longer-lasting high that persists for several hours. Source: National Institute on Drug Abuse. April 1998, Reprinted January Research Report Series: Methamphetamine Abuse and Addiction.

Why is Meth so Devastating? Cheap, readily available Stimulates, gives intense pleasure Damages the user’s brain Paranoid, delusional thoughts Depression when stop using Craving overwhelmingly powerful Brain healing takes up to 2 years We are not familiar with treating it 9

Young Adults (18 to 25) Reporting Past Year Methamphetamine Use: 2002 to Source: SAMHSA,

Methamphetamine Use in Past Year among Persons Aged >11, by Percentage and by Race/Ethnicity: Percentage Source: SAMHSA 2004 NSDUH.

12 Methamphetamine: Epidemiology

Methamphetamine Users (n= 1016) LIFETIME SUICIDE ATTEMPTS and BEHAVIOR PROBLEMS ASI Item OverallMalesFemales Test Statistic* Attempted Suicide (%) 27%13%28%35.42** Violent behavior problems (%) 43%40%46%3.29*** Assault Charges (mean number) ** Weapons charges (mean number) ** *Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013. **p < ***0.1 < p <0.05 Zweben, et al., 2004

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 14 Many patients may require medical/psychiatric supervision and need ongoing treatment with antipsychotic medications

The Methamphetamine Effect 15

“Tribal leaders unveil new meth Initiative” Indian Country Today Create a National outreach campaign for all Native communities. Establish and transfer community based, promising practices for prevention and treatment. Work across Federal agencies for coordinated and consistent outreach strategy. 16 NCAI President, Joe Garcia June 15, 2007

ICMI Partners 17 San Carlos YakamaChippewa Cree Salt River

18 WHAT ARE SOME PROMISING STRATEGIES? 18

19 An Ideal Intervention Broadly based: Includes individual, family, community, tribe and society Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance

20 Domains Influencing Drug Use Behavior: A Native Ecological Model IndividualPeers/FamilySociety/ Cultural Community/Tribe Risk Protection

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

22 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.

23 Community Driven/School Based Prevention Interventions Public awareness and media campaigns Youth Development Services Social Interaction Skills Training Approaches Mentoring Programs Tutoring Programs Rites of Passage Programs

24 Prevention Programs Enhance Protective Factors strong family bonds parental monitoring parental involvement success in school performance pro social institutions (e.g. such as family, school, and religious organizations) conventional norms about drug use

25 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 Prevention Programs Reduce Risk Factors

Why Logic Models? Logic models are useful –Clarification –Group work –Planning; project mgmt; evaluation Logic models are required –Grant applications 26

Logic Model Causes –Social Determinants –Risk and Protective Factors Target Populations –Individuals; Families; Communities; Society Approach/Strategy –Theory of Action –Manualized Activity and Materials Details Outcomes (short; median; long) 27

Fighting Meth, Healing Families: Seven Promising Solutions 1. Media Campaigns 2. Expanding Permanency Options 3. Interagency Collaborations 4. New Supports for Grandfamilies 5. Enhancing Treatment Options 6. Family Drug Courts 7. Targeted Community Supports in Indian Country 28

ICMI Intervention Models Community Mobilization Capacity Development Information Treatment Law Enforcement and Justice Cultural Renaissance 29

Winnebago Tribe: Meth Task Force Goals and Objectives Develop/maintain a Comprehensive Meth Prevention Strategy Collectively plan and implement Use Proactive measures Use available funds - take immediate action Working together to determine what fits Broad based, multi-agency, systematic, family/community focused prevention- Community Mobilization 30

Dine Nation: What Works? Community Education –Age-appropriate presentations, brochures, ads Enforcement –Arrest and detainment for trafficking Caring members of the community Partnerships –Communities, chapters, private businesses and tribal divisions and programs 31 Capacity development. Training for best, evidence based practice, integrated public health model. Experienced at mobilizing communities across large area for interventions.

: Northern Arapaho Tribe : a Comprehensive Systems Plan The Problem: –“turf” –gaps –duplications –crossed purposes Fragmented Service System The Solution: “Works” –client-centered –multi-agency –comprehensive –coordinated –Efficient The Solution: “Works” –client-centered –multi-agency –comprehensive –coordinated –Efficient 32 Implement Best Practice Treatment 1. Information 2. Multi-Systemic Family Therapy 3. Critical Incident Counseling

Choctaw Nation of Oklahoma Adventure Therapy “Natural Highs Program” Transformation process Experiential activities Relationship building Changing the way you live and think Changing how you think and how you believe about life and yourself Treatment. Creation of challenge in a safe environment Horses, Canoes, Tradition Camps 33

Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation Meth Free Crowalition Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment Combine forces for Unity. Diverse community representation Youth and Community Development: mentorship, leadership, trust, establish community norms. Law 34

Cultural Renaissance All Sites 35

Effective Treatment Approaches For Methamphetamine Use Disorder Motivational Interviewing Therapeutic Use of Urine Testing Contingency Management ( motivational incentive based) Cognitive Behavioral Therapy - CBT Community Reinforcement Approach Matrix Model (combination of above) 36

37 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

Problem is bigger, broader and more complex than current solutions Broad-based, integrated, interagency changes are needed. State, county, and city relationships to be developed with tribes and communities Training and tribal leadership development. A Marshall Plan for all Native America that effects: economics, housing, social services, education, law/governance, and health. 38

Six Key Principles Evidence-based predictors of change Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 39

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41 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

42 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