Transcript American Indian Families With Addictions: Problem

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
Admissions (Thousands)
Primary Substance
Alcohol
Marijuana
Opiates
Cocaine
Stimulants
Other
Total
Total Female Male
43.2 15.0 28.2
(percent)
62.2 55.6 65.7
12.4 11.4 13.0
9.0 10.8
8.0
6.4
8.9
5.0
5.4
8.2
4.0
4.7
5.0
4.5
100.0 100.0 100.0
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
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Percentage using any illicit drugs in the past year
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
12.7
9.2
15.8
Hispanic – Mexican
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
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Percentage reporting dependence on alcohol
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
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
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Lifetime History
Mental Disorder
22.5%
Comorbidity
29%
3.1%
1.5%
1.7%
Alcohol Disorder
13.5%
Comorbidity
45%
1.1%
Drug Disorder
6.1%
Comorbidity
72%
Regier, 1990
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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"
120
100
Percentage
80
60
40
20
0
T1
(n=224)
T2
(n=221)
T3
(n=215)
T4
(n=213)
T5
(n=206)
Ever tasted alcohol
T6
(n=203)
T7
(n=199)
T8
(n=195)
T9
(n=186)
Ever drank more than a sip or taste
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R. Dale Walker, M.D. (4/99)
Note: 100% completion sample
Lifetime, Annual and 30 Day Prevalence of
Intoxication Among 224* Urban Indian Youth
100
Percentage
80
60
40
20
0
T1
(n=224)
T2
(n=221)
T3
(n=215)
T4
(n=213)
Ever intoxicated
R. Dale Walker, M.D. (4/99)
T5
(n=206)
T6
(n=203)
Intoxicated past year
T7
(n=199)
T8
(n=195)
T9
(n=186)
Intoxicated past 30 days
*100% completion sample
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Changes in Lifetime Substance Use Among
Urban Indian Youth * Over Nine Years
Chewing Tobacco
T1
T2
T3
T4
T5
T6
T7
T8
T9
Marijuana
Smoking Tobacco
Alcohol
0
20
40
60
80
(n=224)
(n=221)
(n=215)
(n=213)
(n=206)
(n=203)
(n=199)
(n=195)
(n=186)
100
Percentage ever used
R. Dale Walker, M.D. (4/99)
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* 100% Completion Sample
Age of Onset of Substance Use Among Urban
American Indian Adolescents, by Substance Used
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14
12
10
Age 8
6
4
2
0
Alcohol
Smokeless
Cigarettes
Marijuana
Age Range
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
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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 . . . .
Reduce Risk Factors
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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 in
the school, peer, and community environments
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Prevention Programs Should . . . .
Enhance Protective Factors
 strong family bonds
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parental monitoring
parental involvement
success in school performance
prosocial institutions (e.g. such as family,
school, and religious organizations)
 conventional norms about
drug use
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Prevention Programs Should . . . .
Target all Forms of Drug Use
. . .and be Culturally Sensitive
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Prevention Programs Should . . . .
Include Interactive Skills-Based Training
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


Resist drugs
Strengthen personal commitments against
drug use
Increase social competency
Reinforce attitudes against drug use
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Prevention Programs Should be. . . .
Family-Focused



Provides greater impact than parent-only
or child-only programs
Include at each stage of development
Involve effective parenting skills
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Prevention Programs Should . . . .
Involve Communities and Schools
 Media campaigns and policy changes
 Strengthen norms against drug use
 Address specific nature of local drug
problem
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Implications for Treatment
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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)
40
Percentage
30
20
10
0
Alcohol
Marijuana
Stimulants
Abuse
R. Dale Walker, M.D. (7/97)
Cocaine
Opioids
Sedatives
Dependence
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Lifetime Psychiatric Diagnoses
Among Primary Caretakers (N=207)
40
Percentage
30
20
10
0
Lifetime
Depression
Panic Disorder
Antisocial
Personality
Clean
R. Dale Walker, M.D. (7/97)
Current
Depression
Dysthymia
Confounded
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Treatment Settings - Social Support
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Tribal
Community
Family
Sibs
Peers
Individual
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Cultural Approach
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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
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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
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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
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Cognitive–behavioral interventions
Community reinforcement
Motivational enhancement therapy
12-step facilitation
Contingency management
Pharmacological therapies
Systems treatment
1.
2.
L. Onken (2002). Personal Communication. National Institute on Drug Abuse.
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-contemplation
relapse
contemplation
maintenance
action
preparation
Feedback
Self-efficacy
Empathy
Responsibility
Advice
Menu Options
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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 Plan
Case management should address:
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Mental health
Education/vocation
Leisure/social
Parenting/family
Housing
Financial
Daily living skills
Physical health
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Core Components of Comprehensive
Services
Medical
Financial
Housing &
Transportation
Core
Treatment
Intake
Assessment
Child Care
Treatment
Plans
Group/Individual
Counseling
Abstinence
Based
Pharmaco-therapy
Mental
Health
Urine
Monitoring
Vocational
Case
Management
Continuing
Care
Educational
Self-Help
(AA/NA)
Family
AIDS / HIV
Risks
Legal
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Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)
The Future
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
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Contact information
R. Dale Walker, MD
Laura Loudon
Center for American Indian Health, Education and
Research
Oregon Health & Science University
(503)494-8112
[email protected]
[email protected]
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Website: http://www.ohsu.edu/som-psychresearch/aiherhome.htm
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