The Indian Country Methamphetamine Initiative: Taking Interventions to Scale

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The Indian Country Methamphetamine Initiative
Taking Interventions to Scale

• Association of American Indian Physicians
• 39th Annual Meeting
• R Dale Walker, MD Patricia Silk Walker, PhD
  Michelle Singer
• August 9, 2010
• Santa Ana Pueblo, New Mexico

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Native Communities
Advisory Council / Steering Committee
Opportunity, Research
Education
Mentorship
One Sky Center
Training, Consultation, Technical
Assistance
Excellence
Tribal Leadership
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Goals for Today

• The methamphetamine problem
• The methamphetamine initiative
• The Mission Going-to-Scale
• ICMI Tribal Sites
• General Approaches
• Logic Models
• Examples

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Scope of the Meth Problem Worldwide

• The most widely used illicit drug in the world
  except for cannabis.
• Worldwide it is estimated there are over 42
  million regular users compared to approximately
  15 million heroin users and 10 million cocaine
  users
• Meth use is increasing and expanding!

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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

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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

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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/

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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 users 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 Use in Past Year among Persons
Aged gt11, by Percentage and by Race/Ethnicity
2002 - 2004
Percentage
Source SAMHSA 2004 NSDUH.
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Methamphetamine Epidemiology
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Methamphetamine Users (n 1016) LIFETIME
SUICIDE ATTEMPTS and BEHAVIOR PROBLEMS
ASI Item Overall Males Females Test Statistic
Attempted Suicide () 27 13 28 35.42
Violent behavior problems () 43 40 46 3.29
Assault Charges (mean number) 0.29 0.46 0.15 4.46
Weapons charges (mean number) 0.13 0.21 0.07 4.09
Mantel-Haenszel chi-square was used to test differences in proportions by gender, df1 Students two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df1013. p lt 0.00001 0.1 lt p lt0.05 Mantel-Haenszel chi-square was used to test differences in proportions by gender, df1 Students two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df1013. p lt 0.00001 0.1 lt p lt0.05 Mantel-Haenszel chi-square was used to test differences in proportions by gender, df1 Students two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df1013. p lt 0.00001 0.1 lt p lt0.05 Mantel-Haenszel chi-square was used to test differences in proportions by gender, df1 Students two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df1013. p lt 0.00001 0.1 lt p lt0.05 Mantel-Haenszel chi-square was used to test differences in proportions by gender, df1 Students two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df1013. p lt 0.00001 0.1 lt p lt0.05
Zweben, et al., 2004
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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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The Methamphetamine Effect
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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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ICMI Partners
Yakama
Chippewa Cree
Salt River
San Carlos
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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
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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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

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Why Logic Models?

• Logic models are useful
• Clarification
• Group work
• Planning project mgmt evaluation
• Logic models are required
• Grant applications

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Logic Model

• Causes
• Social Determinants
• Risk and Protective Factors
• Target Populations
• Individuals Families Communities Society
• Approach/Strategy
• Theory of Action
• Manualized Activity and Materials Details
• Outcomes (short median long)

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Fighting Meth, Healing FamiliesSeven Promising
Solutions

• 1. 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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ICMI Intervention Models

• Community Mobilization
• Capacity Development
• Information
• Treatment
• Law Enforcement and Justice
• Cultural Renaissance

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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-
• Community Mobilization

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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

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

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Northern Arapaho Tribe a
Comprehensive Systems Plan

• The Solution Works
• client-centered
• multi-agency
• comprehensive
• coordinated
• Efficient

• The Problem
• turf
• gaps
• duplications
• crossed purposes
• Fragmented Service System

Implement Best Practice Treatment 1.
Information 2. Multi-Systemic Family Therapy 3.
Critical Incident Counseling
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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
• Treatment.
• 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. Law

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Cultural Renaissance

• All Sites

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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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Partnered Collaboration
State/Federal

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
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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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Six Key PrinciplesEvidence-based predictors of
change

• Leadership
• Mobilization Community driven
• Public health approach
• Strength based
• Culturally informed
• Proactive

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Contact us at 503-494-3703 E-mail Dale Walker,
MD onesky_at_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