Association of American Indian Physicians 38th Annual Meeting R Dale Walker, MD July 26, 2009...
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Transcript of Association of American Indian Physicians 38th Annual Meeting R Dale Walker, MD July 26, 2009...
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, [email protected]
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