American Indian Families With Addictions: Problem, Treatment, And Prevention

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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

• What is the problem?
• What do we know about addictions?
• What do we know about Indians?
• 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
Total Female Male Admissions
(Thousands) 43.2 15.0 28.2 Primary Substance
(percent) Alcohol 62.2
55.6 65.7 Marijuana 12.4 11.4
13.0 Opiates 9.0 10.8 8.0 Cocaine
6.4 8.9 5.0 Stimulants 5.4
8.2 4.0 Other 4.7 5.0
4.5 Total 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 N
on-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

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.
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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 1.1
Alcohol Disorder 13.5 Comorbidity 45
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"
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
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
Percentage ever used
R. Dale Walker, M.D. (4/99)

100 Completion Sample
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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 . . . .
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
  in the school, peer, and community environments

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Prevention Programs Should . . . .
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

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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

• 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

• 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 (N207)
R. Dale Walker, M.D. (7/97)
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Lifetime Psychiatric DiagnosesAmong Primary
Caretakers (N207)
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

• Cognitivebehavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
• 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
Feedback
relapse
Self-efficacy
contemplation
Responsibility
maintenance
preparation
Advice
Empathy
action
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
• 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
Mental Health
Financial
Vocational
Housing Transportation
Educational
Child Care
Legal
Family
AIDS / HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB)
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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
• [phone]
• walkerrd_at_ohsu.edu
• loudonl_at_ohsu.edu
• Website http//www.ohsu.edu/som-psychresearch/aih
  erhome.htm

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