Our Native Methamphetamine Crisis: An Integrated Care Solution

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. Native Communities Advisory Council / Steering Committee One Sky Center

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

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

8. Methamphetamine AssociatedHospital Admissions (2002)

9. Oregon Methamphetamine Admissions

10. OHSU Substance Abuse Clinic Enrollees

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

12. Methamphetamine: Epidemiology

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

14. Methamphetamine Indicators

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

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

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 Alcoholism 6X Tuberculosis 6X Diabetes 3.5X Accidents 3X Suicide 1.7 to 4x Health care access -3x Poverty 3x Poor educational achievement Substandard housing Methamphetamines?

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 • State and Local Agencies • Federal Agencies: SAMHSA, Edn

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

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

26. The Intervention Spectrum for Behavioral Disorders T r e a t m e n t C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t n o f o r K n o w n i Indicated— Diagnosed Youth M t D i s o r d e r s n a e i n v t e r e P n C o m p l i a n c e a Selective— Health Risk Groups n w i t h L o n g - T e r m c e T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.),Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

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

28. Ecological Model Society Community/Tribe Peer/Family Individual

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. 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. 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. Prevention ProgramsReduce Risk Factors • 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

33. Prevention ProgramsEnhance 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. PreventionPrograms Should . . . . Target all Forms of Drug Use . . .and be Culturally Sensitive

35. WHAT ARE SOME PROMISING STRATEGIES?

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. 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. 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. 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. 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. 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. Youth Treatment Completion: WA State

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. AmJP, November 3, 2006

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

48. 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 Potential Organizational Partners

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