1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services The Indian Country Methamphetamine Initiative: a Problem Uniquely Affecting Indian Country Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer July 29, 2007 Nashville, Tennessee

2. 2 Special Thanks and Recognition AAIP and the Executive Board Margaret Knight Rachel Crawford Heather Levi Vincent Knight

3. 3 One Sky Center

4. 4 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 One Sky Center 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 Partners

5. 5 One Sky Center Outreach

6. 6 Goals for Today Background: The environment and the system of care The methamphetamine problem The methamphetamine initiative The toolkit Treatment works! Integrated care approaches are best for treatment of these chronic illnesses

7. 7 1491

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11. 11 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, Justice

12. 12 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

13. 13 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

14. 14 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

15. 15 Partnered Collaboration: AAIP Style Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

16. 16 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

17. Native Health Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5 X 4.Accidents 3X 5.Poverty 3x 6.Depression 3x 7.Suicide 2x 8.Violence? 9.Methamphetamine?

18. Six Behaviors That Contribute to Serious Health Problems: Tobacco use Poor nutrition Alcohol and other drug abuse – Behaviors resulting in intentional or unintentional injury Physical inactivity Risky sex Methamphetamine!

19. 19 Percentages of Young Adults Aged 18 to 25 Reporting Past Year Methamphetamine Use, by State: 2002, 2003, 2004, and 2005 Source: SAMHSA, 2002-2005.

20. 20 Methamphetamine: Epidemiology

21. 21 Methamphetamine/Amphetamine Admissions, by Race/Ethnicity and Urbanization: 2004 Race/Ethnic ity Large Central Metro Large Fringe Metro Small Metro Non-Metro with City Non-Metro without City White56%77%78%86%87% Black5%3%2%1% Hispanic28%14%11%6%4% American Indian/ Alaska Native 2%1%3%4%6% Asian Pacific Islander 3%2%3%2%1% Other6%3% 1% Source: 2003 SAMHSA Treatment Episode Data Set (TEDS).

22. 22 Recent Methamphetamine Reports Five arrested for drugs and meth in South Dakota (04/30) Meth dealers targeted Wind River Reservation (04/30) Crow students hold second walk against meth (04/30) Belcourt: Indian Country takes path of healthy living (04/30) Paiute Tribe of Utah cites increased meth use (04/26) BIA ties violence against women to meth abuse (04/26) HHS holds consultation session in Salt Lake City (04/25) Fired U.S. Attorneys praised for Indian Country work (04/19) Tribal methamphetamine bill clears House (04/17) Coyote Valley Band on new track with new chairman (04/09) Four await trial for meth-related triple homicide (04/04) California court throws out search on reservation (04/03)Five arrested for drugs and meth in South Dakota Meth dealers targeted Wind River Reservation Crow students hold second walk against meth Belcourt: Indian Country takes path of healthy living Paiute Tribe of Utah cites increased meth use BIA ties violence against women to meth abuse HHS holds consultation session in Salt Lake City Fired U.S. Attorneys praised for Indian Country work Tribal methamphetamine bill clears House Coyote Valley Band on new track with new chairman Four await trial for meth-related triple homicide California court throws out search on reservation Artman ushers in leadership changes at BIA (04/02) Pechanga man sentenced to 44 years for deaths (04/01)Artman ushers in leadership changes at BIA Pechanga man sentenced to 44 years for deaths

23. 23 The Methamphetamine Effect

24. 24 Methamphetamine Identified as the Primary Health/Community Concern In 2006, Tribal Round Table sessions, HHS Regional Tribal Consultations, and numerous tribal community gatherings with SAMHSA, OMH, and IHS identified Methamphetamine abuse as the primary health concern in Indian Country.

25. 25 “Tribal leaders unveil new meth Initiative” Indian Country Today NCAI President, Joe Garcia Anchorage, Alaska June 15, 2007

26. 26 HHS Indian Country Methamphetamine Initiative $1.2 million awarded to Association of Indian Physician (AAIP) its partners (National Congress of American Indians, One Sky Center, South and Eastern Tribes, and Northwest Portland Area Indian Health Board) Tribal Sites –Navajo Nation –Winnebago Tribe –Northern Arapaho Tribe –Crow Nation –Choctaw Nation

27. 27 ICMI Project Description Create a National education and information outreach campaign for all Native communities. Establish and transfer knowledge from community based to promising practices for prevention, intervention and treatment. Work across Federal agencies for a coordinated and consistent outreach strategy.

28. 28 The Indian Country Methamphetamine Initiative: Project Partners SAMHSA AAIP USETNPAIHBOSCNCAI ChoctawCrowNavajoNorthern ArapahoWinnebago IHS OMHHHS

29. 29 ICMI Partners

30. 30 ICMI Major Project Deliverables Outreach/Education Kit for Tribes and other Groups Identification of Partners ( also Advisory Groups) Coordinated Federal-Tribal-State-Local Indian Country Communication and Training Strategy Minimum 5 Tribal Specific Projects Identified and Evaluated for Potential Transfer to Other NA Communities Final Project Evaluation Year 3 - Promising Practices Transfer Kits

31. 31 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

32. 32 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

33. 33 ID Best Practice Best Practice Clinical/services Research Traditional Healing Mainstream Practice

34. 34 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

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37. 37 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

38. 38 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

39. 39 Treatment Settings - Social Support: A Native Advantage Tribal Community Family Sibs Peers Individual

40. 40 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

41. 41 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

42. 42 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.

43. 43 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

44. 44 Recommended Behavioral Treatment Approaches Cognitive Behavioral Therapy Psychosocial Treatment Community Reinforcement - Plus Vouchers Contingency Management Relapse Prevention The Matrix Model

45. 45 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.

46. 46 Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses 0 0 10 20 30 40 50 60 70 80 90 100 Drug Dependence Drug Dependence Type I Diabetes Type I Diabetes Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000. Percent of Patients Who Relapse

47. 47 Youth Treatment Completion: WA State

48. 48 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org