Association of American Indian Physicians

38th Annual MeetingR Dale Walker, MD

July 26, 2009Alexandria, Virginia

The Indian Country Methamphetamine Initiative:

Taking Care of Home

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One Sky

Center

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Goals for Today

• Background: The environment and the system of care

• The methamphetamine problem

• The methamphetamine initiative

• Integrated care approaches are best for treatment of these chronic illnesses

• Treatment works!

• MA is the most widely used illicit drug in the world except for cannabis.

• Worldwide it is estimated there are over 42 million regular users of MA, compared to approximately 15 million heroin users and 10 million cocaine users.

Meth use is increasing and expanding!

Scope of the Meth Problem Worldwide

What is methamphetamine?

• A powerful stimulant drug, classified as a psychostimulant

• A Schedule II drug (along with cocaine and several other drugs) under the Federal Controlled Substances Act

• A highly addictive drug

Why do people use meth?

• Initially, methamphetamine decreases fatigue and appetite, heightens attention, and increases activity and respiration, creating feelings of high energy.

• Meth enables people to stay awake and be physically (also sexually) active for long periods.

Source: National Institute on Drug Abuse. April 1998, Reprinted January 2002. Research Report Series: Methamphetamine Abuse and Addiction. www.nida.nih.gov/ResearchReports/methamph/methamph.html

How does meth work?• Methamphetamine releases large amounts of dopamine

in the brain, causing feelings of pleasure and euphoria.

Source: National Institute on Drug Abuse. April 1998, Reprinted January 2002. Research Report Series: Methamphetamine Abuse and Addiction. www.nida.nih.gov/ResearchReports/methamph/methamph.html

• Withdrawal symptoms may include fatigue, depression, anxiety, paranoia, aggression, and an intense craving for more of the drug. In some cases, psychotic symptoms may persist for months or years following use. Source: Office of National Drug Control Policy. November 2003. Fact Sheet: Methamphetamine. www.whitehousedrugpolicy.gov/publications/factsht/methamph/

How is meth used?

• Injecting or smoking methamphetamine produces a short but intense and pleasurable “rush.”

• When taken orally or by snorting, meth causes a less intense but much longer-lasting high that persists for several hours.Source: National Institute on Drug Abuse. April 1998, Reprinted January 2002. Research Report Series: Methamphetamine Abuse and Addiction. www.nida.nih.gov/ResearchReports/methamph/methamph.html

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Why is Meth 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

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Young Adults (18 to 25) Reporting Past Year Methamphetamine Use: 2002 to 2005

Source: SAMHSA, 2002-2005 .

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Methamphetamine: Epidemiology

Past Month Illicit Drug Use among Youths Aged 12 to 17, by Race/Ethnicity: 2002

Methamphetamine: Epidemiology

Methamphetamine Users (n= 1016) LIFETIME SUICIDE ATTEMPTS and BEHAVIOR

PROBLEMS

ASI ItemASI Item OverallOverall MalesMales FemalesFemales Test Test Statistic*Statistic*

Attempted Suicide (%)Attempted Suicide (%) 27%27% 13%13% 28%28% 35.42**35.42**

Violent behavior problems (%)Violent behavior problems (%) 43%43% 40%40% 46%46% 3.29***3.29***

Assault Charges (mean number)Assault Charges (mean number) 0.290.29 0.460.46 0.150.15 4.46**4.46**

Weapons charges (mean number)Weapons charges (mean number) 0.130.13 0.210.21 0.070.07 4.09**4.09**

*Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; *Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013. continuous dependent variables reflecting the number of charges, df=1013.

**p < 0.00001 ***0.1 **p < 0.00001 ***0.1 << p <0.05 p <0.05 Zweben, et al., 2004

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The Methamphetamine Effect

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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.

“Tribal leaders unveil new meth Initiative” Indian

Country Today

• Create a National outreach campaign for all Native communities.

• Establish and transfer community based, promising practices for prevention and treatment.

• Work across Federal agencies for coordinated and consistent outreach strategy.NCAI President, Joe Garcia June 15, 2007

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Winnebago

Navajo

Choctaw

Crow

Northern Arapaho

NPAIHB

AAIP

USET

OSC

NCAI

ICMI Partners

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San Carlos

Yakama Chippewa Cree

Salt River

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Clinical Challenges for Treatment of

Methamphetamine Addiction

• Poor treatment engagement rates• High dropout rates• Severe paranoia• High relapse rates• Ongoing episodes of psychosis• Severe craving• Protracted dysphoria

Many patients may require medical/psychiatric supervision and need ongoing treatment with antipsychotic medications

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ID Best Practice

Best Practice

Clinical/servicesResearch

TraditionalHealing

MainstreamPractice

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Circle of Care

Best Practices

Child & Adolescent Programs

Prevention Programs

Primary Care

EmergencyRooms

TraditionalHealers

A&D Programs

Colleges & Universities

Boarding Schools

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WHAT ARE SOME PROMISING STRATEGIES?

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An Ideal Intervention• Broadly based:

Includes individual, family,

community, tribe and society

• Comprehensive:

Prevention: Universal, Selective,

Indicated

Treatment

Maintenance

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Domains Influencing Drug Use Behavior: A Native Ecological

Model

Individual Peers/Family Society/Cultural

Community/Tribe

Risk

Protection

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Individual Intervention

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

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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.

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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

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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

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• 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

Fighting Meth, Healing Families:

Seven Promising Solutions1. Media Campaigns

2. Expanding Permanency Options

3. Interagency Collaborations

4. New Supports for Grandfamilies

5. Enhancing Treatment Options

6. Family Drug Courts

7. Targeted Community Supports in Indian Country

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AI/AN Prevention, Treatment, and Rehabilitation Interventions

• Story Telling• Talking Circles• Sweat Lodge• Ceremonies and Ritual

– Purification– Passages– Naming– Grieving

• Drumming, Singing, Dancing

• Vision Quest

• Flute playing/meditation

• Reconciliation

• Mentoring

• Service Learning

• Traditional Experiences

Preservation29

Choctaw Nation of Oklahoma

Adventure Therapy• “Natural Highs Program”• Transformation process • Experiential activities• Relationship building• Changing the way you live and think • Changing how you think and how

you believe about life and yourself• Creation of challenge in a safe

environment • Horses, Canoes, Tradition Camps

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Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation Meth Free Crowalition

• Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment

• Combine forces for Unity.• Diverse community

representation• Youth and Community

Development: mentorship, leadership, trust, establish community norms

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Dine Nation: What Works?

• Community Education – Age-appropriate presentations, brochures, ads

• Enforcement– Arrest and detainment for trafficking

• Caring members of the community• Partnerships

– Communities, chapters, private businesses and tribal divisions and programs

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• Training for best, evidence based practice, integrated public health model.• Experienced at mobilizing communities across large area for interventions.

Northern Arapaho Tribe:: a Comprehensive Systems Plan

The Problem: – “turf” – gaps – duplications – crossed purposes

Fragmented Service System

The Solution: “Works”– client-centered – multi-agency– comprehensive– coordinated– Efficient

The Solution: “Works”– client-centered – multi-agency– comprehensive– coordinated– Efficient

Implement Best Practice Treatment1.Multi-Systemic Family Therapy2.Critical Incident Counseling 33

Winnebago Tribe: Meth Task Force

Goals and Objectives • Develop/maintain a Comprehensive Meth

Prevention Strategy • Collectively plan and implement • Use Proactive measures• Use available funds - take immediate

action• Working together to determine what fits • Broad based, multi-agency, systematic,

family/community focused prevention-

Will it reduce treatment need? 34

“Best Practices”

• Families and Schools Together (Rural Wisconsin Res)

• Parenting Wisely• Preparing for Drug Free Years• Project Alert• Project Venture (NIYLP)

• Promoting Alternative Thinking Strategies• American Indian Life Skills (Zuni Pueblo)

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“Best Practices”

• Cultural Enhancement Through Story Telling (Tohono O’odham Res)

• AI Strengthening Families Program (U UT)

• Creating Lasting Family Connections• Dare to Be You (Ute Res)

• With Eagles Wings (N. Arapaho Nat)

• Families That Care—Guiding Good Choices • Across Ages (Mentoring) (Temple U)

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Clinical Challenges for Treatment of

Methamphetamine Addiction• Poor treatment engagement rates• High dropout rates• Severe paranoia• High relapse rates• Ongoing episodes of psychosis• Severe craving• Protracted dysphoria

Many patients may require medical/psychiatric supervision and need ongoingtreatment with antipsychotic medications

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Effective Treatment Approaches For Methamphetamine Use

Disorder• Motivational Interviewing• Therapeutic Use of Urine Testing• Contingency Management ( motivational

incentive based) • Cognitive Behavioral Therapy - CBT• Community Reinforcement Approach• Matrix Model (combination of above)

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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.

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Youth Treatment Completion: WA State

50%

62%

52%46%

55% 50%

0%

10%

20%

30%

40%

50%

60%

70%

Alcohol Cocaine Marijuana Meth Heroin Other

Youth

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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

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Partnered Collaboration

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

State/Federal

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Potential Organizational Partners

• Education

• Family Survivors

• Health/Public Health

• Mental Health

• Substance Abuse

• Elders, traditional

• Law Enforcement

• Juvenile Justice

• Medical Examiner

• Faith-Based

• Student Groups

• County, State, and Federal Agencies

Problem is bigger, broader and more complex than

current solutions• Broad-based, integrated, interagency

changes are needed• State, county, and city relationships to be

developed with tribes and communities• Training and tribal leadership development• A Marshall Plan for all Native America that

effects: economics, housing, social services, education, law/governance, and health

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Contact us at503-494-3703

E-mailDale Walker, MDonesky@ohsu.edu

Or visit our website:www.oneskycenter.org

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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

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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