1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Our Native Methamphetamine Crisis: An Integrated Care Solution Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer Affiliated Tribes of Northwest Indians Portland, Oregon February 14, 2006

2. 2 One Sky Center

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

4. 4 Presentation Overview One Sky Center introduction What’s the story on methamphetamine? Fragmentation and Integration of systems Discuss prevention and treatment Integrated care approaches and interagency coordination are best overall solutions

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8. R. Dale Walker, M.D., 2003 Methamphetamine Associated Hospital Admissions (2002)

9. 9 Oregon Methamphetamine Admissions

10. 10 OHSU Substance Abuse Clinic Enrollees 1998- 2000 2002- 2004 N= 108percentN= 172percent Alcohol2523%2213% Marijuana mixed 8 7% 5 3% Marijuana only2321%3822% Methadone/heroin3028%4727% Methamphetamine3431% 8449% Narcotics 5 4% 6 3% Benzodiazepines 2 2% 6 3% Hallucinogens 3 3% 1 1%

11. 11 National Methamphetamine Initiative Survey Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006

12. 12 Methamphetamine: Epidemiology

13. 13 IHS-Wide Outpatient Encounters for Amphetamine Related Visit by Calendar Year

14. 14 Methamphetamine Indicators

15. 15 Why is Methamphetamine 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

16. Douglas Jackobs 2003 R. Dale Walker, M.D., 2003 16 Native Adolescents: Multiple Life Risks -Edn,-Econ,-Rec Family Disruption Domestic Violence Family Disruption Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse CHILD

17. 17 Adolescent Problems In Schools School Environment Bullying Fighting and Gangs Alcohol Drug Use Weapon Carrying Sexual Abuse Truancy Domestic Violence Drop Outs Attacks on Teachers Staff Unruly Students Sale of Alcohol and Drugs 12

18. 18 Methamphetamine, Why Now? The Internet Diffused local production, less reliance on imports Multi-drug use – no one uses only crystal National outbreak Varied sub-populations More smoking Strong association with HIV, hepatitis C Community level responses to AIDS deaths, 9/11, war National discussion

19. Native Health/ Educational Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5X 4.Accidents 3X 5.Suicide 1.7 to 4x 6.Health care access -3x 7.Poverty 3x 8.Poor educational achievement 9.Substandard housing 10.Methamphetamines?

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21. 21 Agencies Involved in Behavioral Health 1. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 2. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 3. Tribal Education/Health 4. Urban Indian Education/Health 5.State and Local Agencies 6.Federal Agencies: SAMHSA, Edn

22. 22 Difficulties of System Integration Separate funding streams and coverage gaps Agency turf issues Different philosophies Lack of resources Poor cross training Consumer and family barriers

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

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

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26. 26 The Intervention Spectrum for Behavioral Disorders Case Identification Standard Treatment for Known Disorders Compliance with Long-Term Treatment (Goal: Reduction in Relapse and Recurrence) Aftercare (Including Rehabilitation) P r e v e n t i o n T r e a t m e n t M a i n t e n a n c e Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994. Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

27. 27 An Ideal Intervention Includes individual, family, community, tribe and society Comprehensive: Universal Selective Indicated Treatment Maintenance

28. 28 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

29. 29 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

30. 30 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.

31. 31 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

32. 32 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

33. 33 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

34. 34 Target all Forms of Drug Use...and be Culturally Sensitive Prevention Programs Should....

35. 35 WHAT ARE SOME PROMISING STRATEGIES?

36. 36 Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: decrease in hospitalization lessening of psychiatric and substance abuse severity better engagement and retention (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

37. 37 Comprehensive School and Behavioral Health Partnership Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

38. 38 Evidence Based Cognitive and/or Behavioral Treatments Cognitive/Behavioral Therapy-CBT Motivational Interviewing-MI Contingency Management-CM Community Reinforcement Approach-CRA Matrix Model of Outpatient Treatment-MM (Combination of above)

39. 39 Matrix Model Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence. Designed to integrate several interventions into a comprehensive approach. Elements include: –Individual counseling –Cognitive behavioral therapy –Motivational interviewing –Family education groups –Urine testing –Participation in 12-step programs

40. 40 Contingency Management Key concepts Behavior to be modified must be objectively measured Behavior to be modified (eg urine test results) must be monitored frequently Reinforcement must be immediate Penalties for unsuccessful behavior (eg positive UA) can reduce voucher amount Vouchers may be applied to a wide range of prosocial alternative behaviors

41. 41 Is Treatment for Methamphetamine Effective? Analysis of: Drop out rates Retention in treatment rates Re-incarceration rates Other measures of outcome All these measures indicate that MA users respond in an equivalent manner as do individuals admitted for other drug abuse problems.

42. 42 Youth Treatment Completion: WA State

43. 43 Study Says Incentive-Based Meth Treatment Works The contingency management (CM) program gave patients who had drug-free urine tests plastic chips that could be exchanged for prizes; those who did not follow program rules could lose chips. John Roll of Washington State University AmJP, November 3, 2006

44. 44 AmJP, November 3, 2006

45. 45 Study Says Incentive-Based Meth Treatment Works "The Matrix Model of psychosocial treatment currently is thought to be the most effective therapy for methamphetamine addiction, and CM has shown itself to increase the therapeutic effectiveness of treatments for other drug abuse disorders. Combining these two treatments gives us an even more powerful weapon against methamphetamine abuse." NIDA Director Dr. Nora D. Volkow November 3, 2006

46. 46 Treatment Outcomes Myth Clients addicted to Methamphetamine have poorer treatment outcomes Reality Data show that methamphetamine treatment outcomes are not very different than those for other addictive drugs

47. 47 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

48. 48 Potential Organizational Partners Education Family Survivors Health/Public Health Mental Health Substance Abuse Elders, traditional Law Enforcement Juvenile Justice Medical Examiner Faith-Based County, State, and Federal Agencies Student Groups

49. 49 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org