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One Sky Center: Best Practices in Native Populations

R. Dale Walker, MD

Patricia Silk Walker, PhD Douglas Bigelow, PhD

Bentson McFarland, MD Laura Loudon, BA

February 19, 2004

Bellingham, Washington

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Goals for Today

1. What is the problem?

2. What do we know about addictions?

3. What do we know about Indians?

4. What are some solutions?

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American Indians

• Have same disorders as general population

• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated

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Native American Admissions, 1999

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

Total Female MaleAdmissions (Thousands) 43.2 15.0 28.2

Primary Substance (percent) Alcohol 62.2 55.6 65.7Marijuana 12.4 11.4 13.0Opiates 9.0 10.8 8.0Cocaine 6.4 8.9 5.0Stimulants 5.4 8.2 4.0Other 4.7 5.0 4.5Total 100.0 100.0 100.0

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Total Female Male

Total 11.9 9.8 14.1

Native American 19.8 23.3 15.6

Non-Hispanic White 11.8 9.9 13.9

Non-Hispanic Black 13.1 10.2 16.6

Hispanic – Central American 5.7 4.2 7.7

Hispanic – Cuban 8.2 5.5 11.4

Hispanic – Mexican 12.7 9.2 15.8

Percentage using any illicit drugs in the past year

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

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Percentage reporting dependence on alcohol

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

Total Female Male

Total 3.5 2.1 4.9

Native American 5.6 6.8 4.3

Non-Hispanic White 3.4 2.2 4.8

Non-Hispanic Black 3.4 2.0 5.2

Hispanic – Central American 2.8 0.8 5.4

Hispanic – Cuban 0.9 0.5 1.3

Hispanic – Mexican 5.6 2.6 8.4

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Lifetime History

Regier, 1990

Mental Disorder22.5%

Comorbidity29%

3.1% 1.5%

1.7%

1.1%

Alcohol Disorder13.5%

Comorbidity45%

Drug Disorder6.1%

Comorbidity72%

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Multiple Diagnoses Increases:

• treatment seeking• use of services • poor outcome• suicide risk• likelihood of no services• treatment costs

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Definitions of Drinking: "Any" vs. "More Than a Sip or Taste"

0

20

40

60

80

100

120

T1(n=224)

T2(n=221)

T3(n=215)

T4(n=213)

T5(n=206)

T6(n=203)

T7(n=199)

T8(n=195)

T9(n=186)

Pe

rce

nta

ge

Ever tasted alcohol Ever drank more than a sip or taste

R. Dale Walker, M.D. (4/99) Note: 100% completion sample

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Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth

0

20

40

60

80

100

T1(n=224)

T2(n=221)

T3(n=215)

T4(n=213)

T5(n=206)

T6(n=203)

T7(n=199)

T8(n=195)

T9(n=186)

Pe

rce

nta

ge

Ever intoxicated Intoxicated past year Intoxicated past 30 days

R. Dale Walker, M.D. (4/99) *100% completion sample

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Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years

R. Dale Walker, M.D. (4/99) * 100% Completion Sample

0 20 40 60 80 100

Chewing Tobacco

Marijuana

Smoking Tobacco

Alcohol

T1 (n=224)T2 (n=221)T3 (n=215)T4 (n=213)T5 (n=206)T6 (n=203)T7 (n=199)T8 (n=195)T9 (n=186)

Percentage ever used

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0

2

4

6

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10

12

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Age

Cohort 1 (n=224) 13.64 13.29 13.05 14.30 1.25

Cohort 2 (n=66) 13.89 13.81 13.21 14.60 1.39

Cohort 3 (n=78) 12.99 13.97 13.64 13.84 0.98

Cohort 4*(n=72) 13.32 14.88 14.12 15.14 1.82

Cohort 5*(n=79) 13.64 12.17 12.75 13.20 1.47

Alcohol Smokeless Cigarettes Marijuana Age Range

Age of Onset of Substance Use Among Urban American Indian Adolescents, by Substance Used

R. Dale Walker, M.D. (5/2000) *Cohorts 4 & 5 were sampled every third year; recall and sampling bias apply

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Prevention

• Primary

• Risk factors

• Protective factors

• Prevent 1st use

• Secondary

• Prevent kids who use from continuing

• Prevent kids who misuse from experiencing use related problems or dependency

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Prevention Programs Should . . . .

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 in

the school, peer, and community environments

Reduce Risk Factors

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Enhance Protective Factors strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family,

school, and religious organizations) conventional norms about

drug use

Prevention Programs Should . . . .

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Target all Forms of Drug Use

. . .and be Culturally Sensitive

Prevention Programs Should . . . .

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Include Interactive Skills-Based Training

Resist drugs Strengthen personal commitments against

drug use Increase social competency Reinforce attitudes against drug use

Prevention Programs Should . . . .

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Family-Focused

Provides greater impact than parent-only or child-only programs

Include at each stage of development Involve effective parenting skills

Prevention Programs Should be. . . .

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Involve Communities and Schools

Media campaigns and policy changes Strengthen norms against drug use Address specific nature of local drug

problem

Prevention Programs Should . . . .

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Implications for Treatment

• Teach adolescents how to cope with difficulties and adversity

• Increase their repertoire of coping strategies

• Cognitive therapy is most effective approach

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Lifetime Substance Disorder Diagnoses Among Primary Caretakers (N=207)

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10

20

30

40

Alcohol Marijuana Stimulants Cocaine Opioids Sedatives

Perc

enta

ge

Abuse Dependence

R. Dale Walker, M.D. (7/97)

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Lifetime Psychiatric DiagnosesAmong Primary Caretakers (N=207)

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10

20

30

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LifetimeDepression

Panic Disorder AntisocialPersonality

CurrentDepression

Dysthymia

Pe

rce

nta

ge

Clean Confounded

R. Dale Walker, M.D. (7/97)

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Treatment Settings - Social Support

• Tribal

• Community

• Family

• Sibs

• Peers

• Individual

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Cultural Approach

• Original Holistic Approach• Psychopharmacology Approach• The unconscious has always been there• Group Therapy• Network Therapy• Recreational / Outdoors• Traditional Interventions• Indian is...

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Selection of a Best Practice

• Identify the state of the art• Select and prioritize the best practices• Organize the stakeholders for follow-through• Evaluation of effort• Incentives

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Evidence-Based Practices for Alcohol Treatment

• Brief intervention• Social skills training• Motivational enhancement• Community reinforcement• Behavioral contracting

Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.

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Scientifically-Based Approaches

to Addiction Treatment• Cognitive–behavioral interventions

• Community reinforcement

• Motivational enhancement therapy

• 12-step facilitation

• Contingency management

• Pharmacological therapies

• Systems treatment

1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.

2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

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Stages of Change Enhancing Motivation

F R A M E S

pre-contemplationpre-contemplation

relapserelapsecontemplationcontemplation

maintenancemaintenance

actionaction

preparationpreparation

Menu OptionsMenu Options

FeedbackFeedback

ResponsibilityResponsibility

AdviceAdvice

Self-efficacySelf-efficacy

EmpathyEmpathy

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Cognitive Behavioral Therapy• What are determinants of substance use

– social

– environmental

– emotional

– cognitive

– physical

• What skills or resources does the patient lack

• Treatment goals highly individualized

• Therapy sessions structured; with homework

• Self monitoring form: situation, craving, intensity, coping used

• Triggers: thoughts, feelings, behaviors, (+) or (-)

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Unified Services PlanCase management should address:

• Mental health• Education/vocation• Leisure/social• Parenting/family• Housing• Financial• Daily living skills• Physical health

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Core Components of Comprehensive Services

MedicalMedicalMental Mental HealthHealth

VocationalVocational

EducationalEducational

LegalLegalAIDS / HIV AIDS / HIV

RisksRisks

FinancialFinancial

Housing & Housing & TransportationTransportation

Child CareChild Care

FamilyFamily

Continuing Care

Case Management

Urine Monitoring

Self-Help(AA/NA)

Pharmaco-therapy

Group/Individual Counseling

AbstinenceBasedIntake

Assessment

Treatment Plans

CoreCoreTreatmentTreatment

Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

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1. Predictable Funding

2. Long Term Planning

3. Improve Critical Mass of Health

Care Systems

4. Tribal Coordinated Self

Governance

5. Department of Indian Trust

The Future

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Contact information

R. Dale Walker, MDLaura Loudon

Center for American Indian Health, Education and ResearchOregon Health & Science University

(503)494-8112walkerrd@ohsu.eduloudonl@ohsu.edu

Website: http://www.ohsu.edu/som-psychresearch/aiherhome.htm

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