1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Native Communities Respond to Methamphetamine Abuse: Organize, Mobilize, and Work Together Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer September 13, 2007 Confederated Tribes of Grand Ronde

2. 2 One Sky Center

3. 3 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

4. 4 One Sky Center Outreach

5. 5 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

6. 6 A Major Reason People Take a Drug is they Like What It Does to Their Brains A Major Reason People Take a Drug is they Like What It Does to Their Brains The first use is usually voluntary

7. Why do people take drugs? To feel good To have novel: Feelings Sensations Experiences AND To share them To feel better To lessen: Anxiety Worries Fears Depression Hopelessness Withdrawal

8. 8 nucleus accumbens hippocampus striatum frontal cortex substantia nigra/VTA Dopamine Pathways Principal “Pleasure” System of the Brain Dopamine Pathways Principal “Pleasure” System of the Brain 0 50 100 150 200 0 60120180 Time (min) % of Basal DA Output NAc shell Empty BoxFeeding Di Chiara et al. FOOD 100 150 200 DA Concentration (% Baseline) Mounts Intromissions Ejaculations 15 0 5 10 Copulation Frequency Sample Number 12345678 91011121314151617 Scr BasFemale 1 Present Scr Female 2 Present Scr Fiorino and Phillips SEX Natural Rewards Elevate Dopamine 0 0 100 200 300 400 0 0 1 1 2 2 3 3 4 4 5 hr Time After Cocaine % of Basal Release DA Accumbens COCAINE 0 0 100 200 300 400 500 600 700 800 900 1000 1100 0 0 1 1 2 2 3 3 4 4 5 hr Time After Amphetamine % of Basal Release DA Accumbens AMPHETAMINE Source: Di Chiara and Imperato Effects of Drugs on Dopamine

9. 9 1491

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13. 13 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

14. 14 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

15. 15 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

16. 16 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

17. Douglas Jackobs 2003 R. Dale Walker, M.D., 2003 17 Native Peoples: 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/ ADULT

18. 18 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

19. 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?

20. 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!

21. 21 Percentages of Young Adults Aged 18 to 25 Reporting Past Year Methamphetamine Use, by State: 2002, 2003, 2004, and 2005 Source: SAMHSA, 2002-2005.

22. 22 Methamphetamine: Epidemiology

23. 23 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).

24. 24 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

25. 25 The Methamphetamine Effect

26. 26 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.

27. 27 “Tribal leaders unveil new meth Initiative” Indian Country Today NCAI President, Joe Garcia Anchorage, Alaska June 15, 2007

28. 28 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

29. 29 ICMI Project Description Create a National education and information outreach campaign for all Native communities. Establish and transfer knowledge from community based, promising practices for prevention, intervention and treatment. Work across Federal agencies for a coordinated and consistent outreach strategy.

30. 30 The Indian Country Methamphetamine Initiative: Project Partners SAMHSA AAIP USETNPAIHBOSCNCAI ChoctawCrowNavajoNorthern ArapahoWinnebago IHS OMHHHS

31. 31 ICMI Partners

32. 32 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

33. 33 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

34. 34 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

35. 35 ID Best Practice Best Practice Clinical/services Research Traditional Healing Mainstream Practice

36. 36 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

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

38. 38 Ideas?

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40. 40 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

41. 41 Treatment Settings - Social Support: A Native Advantage Tribal Community Family Sibs Peers Individual

42. 42 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

43. 43 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

44. 44 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.

45. 45 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

46. 46 Recommended Behavioral Treatment Approaches Cognitive Behavioral Therapy Psychosocial Treatment Community Reinforcement - Plus Vouchers Contingency Management Relapse Prevention The Matrix Model

47. 47 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.

48. 48 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

49. 49 Youth Treatment Completion: WA State

50. 50 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org