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					 The American Indian/Alaska Native National Resource Center
      for Substance Abuse and Mental Health Services



        Our Native
Methamphetamine Crisis:
An Integrated Solution for
Prevention and Treatment
 Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer
                        April 2007
                   Portland, Oregon                           1
One Sky
 Center




          2
       One Sky Center Partners
                                      Cook Inlet Tribal Council       Tribal Colleges
                                                                      and Universities

Alaska Native Tribal                                        Prairielands ATTC
Health Consortium

                                                           Red Road
Northwest Portland Area         One Sky
Indian Health Board             Center                                      Harvard Native
                                                                            Health Program
United American
Indian Involvement
                                                                         Jack Brown
                                                                         Adolescent
                                                                         Treatment Center
     National Indian Youth
     Leadership Project
                                                 Tri-Ethnic Center for
                             Na'nizhoozhi Center Prevention Research


                                                                                            3
           Presentation Overview


•   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


                                                 4
 Methamphetamine Abuse Eastward Movement
       Based on Hospital Admissions




R. Dale Walker, M.D., 2003
Oregon Methamphetamine Admissions
                           Meth admissions by state

 1,800
 1,600
 1,400
 1,200
 1,000
                                                                                   OR
  800
  600
  400
  200
   -
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                                                                                        6
    OHSU Substance Abuse Clinic
            Enrollees
                   1998-          2002-
                   2000           2004
                   N= 108 percent N= 172   percent
Alcohol            25     23%     22       13%
Marijuana mixed    8      7%      5        3%
Marijuana only     23     21%     38       22%
Methadone/heroin   30     28%     47       27%
Methamphetamine    34     31%     84       49%
Narcotics          5      4%      6        3%
Benzodiazepines    2      2%      6        3%
Hallucinogens      3      3%      1        1%    7
National Methamphetamine
     Initiative Survey




 Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006




                                                                                                 8
National Methamphetamine
     Initiative Survey




Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006


                                                                                                9
National Methamphetamine
     Initiative Survey




 Mark Evans Tactical Intelligence Supervisor New Mexico Investigative Support Center 4-12-2006



                                                                                                 10
Methamphetamine: Epidemiology
      Methamphetamine:
       Epidemiology




  Past Month Illicit Drug Use among Youths Aged 12 to 17, by   11

                        Race/Ethnicity: 2002
  IHS-Wide Outpatient Encounters for
Amphetamine Related Visit by Calendar Year




                                             12
  Methamphetamine Indicators
                                        Meth indicators

40,000
35,000
30,000
                                                                         Possession arrests
25,000                                                                   Treatment cases
20,000                                                                   ER admissions
15,000                                                                   ID theft cases
                                                                         Purity*
10,000
 5,000
   -
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                                                                                         13
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
                                            14
                Native Adolescents: Multiple Life Risks

                                    Psychiatric Illness
                                        & Stigma

                Cultural Distress                         -Edn,-Econ,-Rec

                                                                       Impulsiveness
     Substance
     Use/Abuse
                                                                        Hopelessness

 Family Disruption                     CHILD
 Domestic Violence                                                     Family History


Negative Boarding School                                           Psychodynamics/
                                                               Psychological Vulnerability

                       Historical Trauma         Suicidal
                                                 Behavior

     Douglas Jackobs 2003                                                          15
     R. Dale Walker, M.D., 2003
Adolescent Problems In Schools
                         Fighting     Alcohol
                           and         Drug
                          Gangs         Use
                                                   Weapon
          Bullying                                 Carrying



     Sale of
     Alcohol
                               School                         Sexual
                                                              Abuse
    and Drugs
                          Environment
       Unruly                                              Truancy
      Students
                     Attacks
                 on Teachers        Drop        Domestic
                                    Outs        Violence
                      Staff




                                                                       16

                                                                            12
    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

                                                        17
Native Health/ Educational Problems
     1. Alcoholism 6X
     2. Tuberculosis 6X
     3. Diabetes 3.5X
     4. Accidents 3X
     5. Suicide 1.7 to 4x
     6. Health care access -3x
     7. Poverty 3x
     8. Poor educational achievement
     9. Substandard housing
     10. Methamphetamines?
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
      5. State and Local Agencies
      6. Federal Agencies: SAMHSA, Edn         19
        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


                                             20
Different goals
                                         Resource silos




One size fits all
                                                     Activity-driven




              How are we functioning?
                     (Carl Bell, 7/03)
                                                               21
      Culturally      Outcome
       Specific        Driven
          Best     Integrating
        Practice   Resources




We need Synergy and an Integrated
        System (Carl Bell, 7/03)    22
23
      The Intervention Spectrum
       for Behavioral Disorders

                                                Case
                                            Identification Standard
                                                          Treatment
                                  Indicated—               for Known
                                  Diagnosed                Disorders
                                  Youth

                         Selective—                             Compliance
                         Health Risk                            with Long-Term
                         Groups                                 Treatment
                                                                (Goal:Reduction in
                                                                Relapse and Recurrence)

                    Universal—                                                Aftercare
                    General Population                                       (Including
                                                                           Rehabilitation)




Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC: National Academy Press, 1994.


                                                                                             24
       An Ideal Intervention
• Includes individual, family, community, tribe
  and society
• Comprehensive:
     Universal
     Selective
     Indicated
     Treatment
     Maintenance


                                                  25
          Ecological Model




Society    Community/   Peer/Family Individual
             Tribe




                                                 26
     Individual Intervention

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


                                            27
   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.
                                                 28
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



                                                    29
    Prevention Programs Reduce
            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
                                                30
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
                                                  31
Prevention Programs Should . . . .


   Target all Forms of Drug Use




   . . .and be Culturally Sensitive   32
WHAT ARE SOME PROMISING STRATEGIES?




                                33
      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.)

                                                                             34
 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




                                          35
 Treatment Approaches Found
   Effective in Working with
Methamphetamine Use Disorder
• Motivational Interviewing - MI
• Therapeutic Use of Urinalysis
• Contingency Management (AKA
  motivational incentives)
• Community Reinforcement Approach
• Cognitive Behavioral Therapy - CBT
• Matrix Model (combination of above)

                                        36
                 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
                                                       37
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
                                               38
          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.


                                                39
Youth Treatment Completion:
         WA State
                             Youth
70%
                                             62%
60%
       55%
                 50%                  50%             52%
50%                         46%
40%

30%

20%

10%

0%
      Alcohol   Cocaine   Marijuana   Meth   Heroin   Other

                                                              40
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   41
AmJP, November 3, 2006   42
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   43
      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


                                                 44
Partnered Collaboration


Grassroots        Community-Based
Groups            Organizations




  Research-Education-Treatment


                                    45
   Potential Organizational
           Partners
• Education              • Law Enforcement

• Family Survivors       • Juvenile Justice

• Health/Public Health   • Medical Examiner

• Mental Health          • Faith-Based

• Substance Abuse        • County, State, and
                           Federal Agencies
• Elders, traditional
                         • Student Groups
                                                46
Contact us at
503-494-3703
E-mail
Dale Walker, MD
onesky@ohsu.edu
Or visit our website:
www.oneskycenter.org
                             2
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