Daniel Dickerson, D.O., M.P.H., Inupiaq Assistant Research Psychiatrist

1. American Indians/Alaska Natives and Substance Abuse Treatment Outcomes: Positive Signs and Continuing Challenges Daniel Dickerson, D.O., M.P.H., Inupiaq Assistant Research Psychiatrist UCLA, Integrated Substance Abuse Programs (ISAP) Addiction Psychiatrist United American Indian Involvement, Inc. July 23, 2009

2. Acknowledgements Co-Investigators (UCLA, ISAP): • Yih-Ing Hser, Ph.D. • Suzi Spear, M.P.H. • Libo Li, Ph.D. • Richard Rawson, Ph.D. Funding: • Funding for this study was partially supported by National Institutes of Health (NIH) grants: P30DA106383 and K05PA017648.

3. Background: • Compared to other racial/ethnic groups in the U.S., American Indians/Alaska Natives (AI/AN) have the highest rates of alcohol, marijuana, cocaine, and hallucinogen use disorders (USDHHS, 2007). • AI/AN have the 2nd highest with regards to methamphetamine rates only behind another Indigenous group, Native Hawaiians (USDDH, 2005).

4. Reasons for high rates of substance abuse among AI/AN • Factors related to low socioeconomic status, i.e., low insurance coverage and financial resources • Stigma associated with substance abuse in AI/AN communities • High rates of traumatic exposure and stress • Historical trauma over the past 500 years • Some suggestions of genetic causations • Limited funding and a shortage of culturally-relevant comprehensive substance abuse services

5. Effects of substance abuse among AI/AN • The effects of substance abuse in this population have been significant. • A more frequent association between alcohol use and suicide has been observed among AI/AN compared to the general U.S. population (Olson, et al. 2006; May et al., 2002). • High rates of traumatic exposure have been identified among AI/AN with alcohol use disorders (Boyd-Ball, et al. 2006; Whitbeck et al., 2004). • The recent rise in methamphetamine abuse in this population over the past decade has also significantly impacted AI/AN communities (Spear et al., 2007).

6. Substance abuse treatment outcomes among AI/AN • Studies have been limited with most studies conducted in small, community samples and have focused primarily on alcoholism (Evans et al., 2006; Abbott, 1998). • Among 45 hospitalized alcoholic American Indians, only 7 improved 10-years post-treatment although improvements in employment and relationship stability were observed (Westermeyer and Peake, 1983). • Posttreatment outcomes among a sample of 642 American Indians who received outpatient and residential care, found that 28% demonstrated clear improvement (Shore and von Fumetti, 1972). • In a study conducted among a sample of urban American Indians composed of 39 tribes receiving both inpatient and outpatient care, positive treatment outcomes were documented (Walker et al., 1989).

7. Previous study utilizing a comparison group (Evans et al., 2006) • To our knowledge, only one study has been conducted analyzing treatment outcomes between AI/ANs and a matched comparison group • A previous study conducted by our group compared alcohol and drug treatment outcomes between California AI and a non-AI comparison group utilizing the California Treatment Outcome Project (CalTOP). • AI and non-AI demonstrated similar levels of severity before treatment in all 7 domains measured by ASI: alcohol, drug, medical, psychiatric, family, legal, and employment. • AI and non-AI also demonstrated similar levels of improvement posttreatment in all 7 ASI domains. • AI demonstrated lower treatment retention and completion rates.

8. Study overview • In the present study, we analyzed data from a sample of 279 AI/AN and 279 from a matched comparison group utilizing data from the Treatment System Impact (TSI) project and Methamphetamine Treatment Project (MTP). • Our goals were to examine: 1) drug and alcohol use treatment outcomes between AI/AN and non-AI/AN samples 2) specific services received during treatment 3) treatment retention and completion patterns, and 4) pre- and post-treatment psychosocial, medical, and psychiatric characteristics.

9. Hypotheses • AI/AN would: 1) have less successful substance abuse treatment outcomes 2) although demonstrating more medical and psychiatric problems, would receive less of these services 3) demonstrate lower retention and completion rates, and 4) have more baseline medical and psychiatric problems.

10. Study samples • Our study sample included 490 participants from the TSI study (245 AI/ANs and 245 from a comparison group) and 68 participants from the MTP study (34 AI/ANs and 34 from a comparison group). • AI/ANs were required to have biological/psychosocial identity as an AI/AN based on both the subject’s self-reported tribal identity and the judgment of the research assistants who interviewed participants. No information was obtained on blood quantum. • To protect the confidentiality of these tribal members, we chose not to identify specific tribal groups (Norton and Manson, 1996). • The Institute Review Boards at University of California, Los Angeles (UCLA) approved both studies and. In addition, the California Health and Human Services Agency approved the TSI study.

11. Treatment System Impact (TSI) • TSI is a National Institutes of Drug Abuse (NIDA)-funded, multi-site prospective treatment outcome study designed to assess the impact of California Proposition 36 on California’s drug treatment delivery system and evaluate the effectiveness of services delivered (Hser et al., 2003). • California’s Proposition 36, enacted as the Substance Abuse and Crime Prevention Act of 2000, allows non-violent drug offenders to receive treatment in lieu of incarceration or probation/parole without treatment.

12. Treatment System Impact (TSI) • The TSI recruited a total of 1,134 participants from 2003-2006. Assessments for TSI were conducted by interviewers. • The 12-month follow-up rates for AI/ANs and the matched comparison group combined was 18.37% combined. Intake data for this study were collected from 36 sites in five counties (Kern, Riverside, Sacramento, San Diego, and San Francisco). • Programs were community-based or county programs and offered both individual and group counseling. • Only programs that have been certified or licensed by the California Department of Alcohol and Drug Programs can treat Proposition 36 patients and were included in this study. • Participants were compensated for their time at each interview.

13. Methamphetamine Treatment Project (MTP) • MTP was a multi-site randomized, controlled trial of psychosocial treatments for methamphetamine dependence conducted from 1999-2001 (Rawson et al., 2004). • The MTP recruited a total of 938 participants between 1999 and 2001. • Assessments for MTP were conducted in-person at baseline and for each follow-up period by trained research staff at baseline and each follow up period. • The 12-month follow-up rates for AI/AN and the matched comparison group combined was 88.24% combined for the MTP.

14. Methamphetamine Treatment Project • This study was designed to compare the Matrix Model of treatment with “Treatment As Usual” at eight outpatient treatment sites in California, Hawaii, and Montana. • The Matrix Model is a multi-element package of evidence-based practices delivered in a 16-week intensive outpatient program (Rawson, et al., 2005). • Participants were required to meet DSM-IV criteria for methamphetamine dependence and be current methamphetamine users (having used methamphetamine within one month prior to treatment admission unless in a constrained environment such as jail). • Most programs were community-based, hospital, and independent organizations. • Participants were compensated for their time at each interview.

15. Matrix Model: Beginnings • Developed in Los Angeles in 1984 for cocaine and methamphetamine abusers • Based on a set of evidence-based practices delivered in a structured intensive outpatient treatment program. • Manual created to guide both clinical staff and patients. • An AI/AN culturally adapted version of the Matrix Model is available.

16. Matrix Model Components • Substance abuse intensive outpatient treatment for 3-4 months • Early recovery groups • Relapse prevention groups • Family education groups • 12-Step meetings • Social support groups • Individual Counseling • Urinalysis and breath alcohol testing

17. Outpatient Treatment Strategies Structure and expectations *** Weekly urine testing, breath alcohol testing and individual sessions

18. Instruments and Measures: Pre and post-treatment problem severity • Pretreatment and posttreatment problem severity was assessed utilizing the Addiction Severity Index (ASI) (McLellan et al. 1992). • The ASI is the most commonly used instrument used in the substance abuse field and has demonstrated validity in ethnically diverse populations (McLellan et al., 1980, McLellan et al., 1992, Carise & McLellan, 1999). • The ASI assesses problem severity in seven areas: alcohol use, drug use, employment, family and social relationships, legal, medical, and psychological. • A composite score was calculated for each scale with a range of 0 to 1 with higher scores indicating greater problem severity • The ASI was administered at both intake and at 12-month follow-up for both the TSI and MTP.

19. Instruments and Measures: Treatment Services Review (TSR) • Treatment services received were based on the TSR (TSR; McLellan et al. 1992). • The TSR was administered at the 3-month follow-up for TSI and weekly for the MTP. • The TSR documents the number of services received in each of the seven problem areas of the ASI. • Services included both medical services (e.g., medication, doctor’s appointment) and psychotherapy (e.g., individual or group therapy, 12-step groups).

20. Treatment retention/completion and Legal History • Treatment Retention was based on treatment and administrative records from participating clinics and was defined as the number of days between treatment admission and treatment discharge. • Treatment completion was defined those who completed their treatment program. • Legal history was based on arrest records. Arrest records were available among TSI participants only and were obtained from the California Department of Justice.

21. Analytic Approach • Group differences in pretreatment characteristics and treatment retention/completion were examined using chi-square tests for categorical variables and t tests for continuous variables. • T-tests were conducted to examine group differences in service intensity. • In regard to outcome data, we first used paired t tests to assess whether changes in ASI composite scores from admission to follow-up were significantly different from zero. • ANCOVA was applied to examine the differences between AI/AN and controls on ASI composite scores controlling for covariates (age, gender, treatment modality, and baseline problem severity). • We applied logistic regression analysis to examine the probability of any arrest since last interview at 12 month follow-up, the probability of any drug use posttreatment, the probability of any psychiatric problem posttreatment, and the probability of any arrest posttreatment. • In these analyses, project (or ‘study’ from which the data came) was included as a covariate to control for potential confounding effect. Unless otherwise indicated, the significance level (two-tailed) was set at p < .05.

22. Demographic Information

23. Drug/Alcohol Use Characteristics

32. Logistic regression on the probability of any drug use in past 30 day at 12 month follow-up (TSI and MTP combined and AI/AN and non-AI/AN combined)

33. Logistic regression on the probability of any psychiatric problem in past 30 day at 12 month follow-up (TSI and MTP combined)

34. Logistic regression on the probability of any arrest since last interview at 12 month follow-up (for TSI, the last interview is 3 month follow-up; for MTP the last interview is 6 month follow-up)

35. Discussion: Treatment outcomes • Contrary to our hypothesis, substance abuse treatment outcomes between AI/ANs and a matched comparison group were similar. • Our results mirror the California treatment outcomes study conducted by Evans et al. (2006) where similar reductions were found in problem severity. • Our current study consisted of patients from a more geographically-diverse population covering 44 sites in 3 states (California Montana, and Hawaii) and a greater proportion of patients with methamphetamine dependence.

36. Discussion: Treatment outcomes • These results suggest that AI/AN can be equally responsive to substance abuse treatment as non-AI/AN. • However, further studies comparing treatment outcomes in specific treatment settings [i.e., rural, urban, Indian Health Service (IHS) clinics, community clinics in the general population] and among specific tribal groups and U.S. regions are needed.

37. Addressing barriers to substance abuse treatment for AI/AN • Results from our study highlight the need for improving access to substance abuse treatment for AI/AN since receiving substance abuse services may be effective for AI/AN. • A need to address barriers with regard to AI/AN receiving substance abuse treatment including transportation barriers, low levels of insurance coverage, stigma, and a shortage of integrated substance abuse treatment models.

38. Recognizing fundamental principles of Wellness among AI/AN • Among AI/ANs, Wellness encompasses the mental, emotional, spiritual, and physical. • Among AI/ANs, treatment of substance abuse necessitates that we embrace our AI/AN philosophies and traditions by recognizing these connections. • Thus, further efforts towards integrating primary care with substance abuse and psychiatric services are suggested.

39. Importance of culturally-relevant substance abuse treatment approaches • Many AI/AN substance abuse treatment programs incorporate traditional methods of healing including sweat lodge ceremonies, use of talking circles, and traditional healing services. • White Bison approach by Don Coyhis is used by a large amount of programs serving AI/ANs with substance abuse problems. • Native American version of Matrix Model • Native American Motivational Interviewing (Venner & Feldstein, 2006) • Can culturally-tailored treatment programs assisted towards improving treatment retention, completion, and outcomes?

40. Short Brief Intervention and Referral to Treatment (SBIRT) • Another useful strategy towards increasing access to substance abuse treatment is utilization of the Short Brief Intervention and Referral to Treatment (SBIRT) protocol. • SBIRT is a comprehensive, integrated approach to the delivery of early intervention and treatment services for individuals with substance abuse disorders and individuals at risk of developing these disorders • This approach has demonstrated efficacy in a large sample of AI/AN (Madras et al., 2009)

41. Short Brief Intervention and Referral to Treatment (SBIRT) The vast majority of people with a diagnosable illicit drug or alcohol problem are unaware they have a problem or do not feel they need help. Public Health Challenge

42. Definitions of Screening, Brief Interventions, and Brief Treatments Screening: Brief questionnaire yields a scorethatidentifies and quantifies substance abuse and associated problems. Brief Intervention (BI): Give feedback about screening results, inform patient about consuming substances, advise on change, assess readiness to change, establish goals, strategies for change, and follow-up. Brief Treatment (BT): Enhanced level of interventionwith more than one session. Referral (RT): Referral to treatment for substance abuse or dependence.

43. Discussion: Services received • Unexpectedly, no statistically significant differences were observed with regard to specific treatment services received between AI/ANs and the matched comparison group. • However, AI/ANs did receive more family-related services, abuse-related services, and psychiatric services.

44. Trauma exposure within AI/AN communities • Within AI/AN communities, the effects of substance abuse have been further exacerbated by historically-based trauma. • AI/AN societies have been adversely affected by genocide, removal from homelands, forced placement into boarding schools, and the breakdown of traditional family systems throughout U.S. history (Weaver & Yellow Horse Brave Heart, 1999). • These effects associated with historically-based trauma have been implicated as a causative factor for substance abuse among AI/ANs (Nebelkopf and Phillps, 2004). • Individual and group trauma-related treatments and community-based healing strategies are needed among AI/AN in substance abuse treatment.

45. Treatment retention and completion • Our hypothesis that AI/ANs would have decreased treatment completion and retention rates was also not found. • With regards to treatment retention, our results differed from the Evans et al. study that demonstrated significantly shorter treatment retention among AI/ANs receiving residential treatment. • Further studies analyzing and comparing treatment retention and completion, and patient satisfaction levels in diverse treatment settings (i.e., rural, urban, tribally-based clinics, etc.) are suggested.

46. Health-related disparities among AI/AN with substance abuse problems • As predicted, notable differences were observed between AI/AN and non-AI/AN entering substance abuse treatment as evidenced by AI/AN having significantly more medical and psychiatric problems at baseline. • These characteristics were expected and not surprising since AI/ANs are known to experience significant health-related disparities (Jones, 2006). • These results further highlight the need for more culturally-tailored, comprehensive treatments addressing medical and psychiatric comoribidites among AI/ANs seeking substance abuse treatment.

47. Study Limitations • The agencies participating in TSI and MTP were not randomly selected. Therefore, it is therefore possible that our findings are not generalizable to other programs that do not provide similar services. • The reliability and validity of self-reported information is uncertain and the cross-cultural validity and applicability to AI/AN have not been established. • Treatment program information was incomplete, limiting our ability to analyze culturally-specific aspects of treatments which may have been provided in some facilities. • AI/ANs are a heterogeneous population with 562 federally-recognized tribes. • Generalizing these results to all AI/AN is not possible.

48. Conclusions • Similar substance abuse treatment outcomes were observed between a group of AI/AN and a non-AI/AN comparison group with illicit drug and alcohol problems. • These results suggest that AI/AN can be equally responsive to substance abuse treatment as non-AI/AN. • A significant need exists with regard to increasing access to substance abuse treatment services for AI/AN and addressing treatment barriers since there may be potential for adequate substance abuse treatment outcomes in this population. • Improve screening and referrals for substance abuse problems. • Further studies analyzing and comparing substance abuse treatment outcomes in more diverse treatments may assist towards identifying potentially-effective treatment outcomes for AI/AN with substance abuse problems.

49. Contact Information Daniel Dickerson, D.O., M.P.H. e-mail: daniel.dickerson@ucla.edu phone: 562-277-0310