The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

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The American Indian/Alaska Native National
Resource Center for Substance Abuse and Mental
Health Services
Oregon Summit on Evidence Based Practice
Traditional and Contemporary Medicine as Partners
in Healing Salem, Oregon October 3, 2006
Dale Walker, MD Patricia Silk Walker, PhD
Douglas Bigelow, PhD Bentson McFarland, MD,
PhD, Michelle Singer 0HSU Portland, Oregon
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Native Communities
Advisory Council / Steering Committee
One Sky Center
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Program Goals

• Promote and nurture effective and culturally
  appropriate prevention and treatment
• Identify and disseminate evidence-based
  prevention and treatment practices
• Provide training and technical assistance
• Help to expand capacity

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One Sky Center Outreach
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Six Missions Impossible?

• How do we
• Define ourselves?
• Define health care?
• Ask for help?
• Get Federal and State agencies to work together
  and with us?
• Build our communities?
• Restore what is lost?

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Overview

• An Environmental Scan
• Behavioral Health Care Issues
• Fragmentation and Integration
• Best Practice Evidence-Based Indigenous
  Knowledge
• You do both

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Scientifically Based Approaches to Drug Addiction
Treatment

• Relapse Prevention
• Matrix Model
• Supportive-Expressive Psychotherapy
• Individualized Drug Counseling
• Motivational Enhancement Therapy
• Behavioral Therapy for Adolescents
• Multidimensional Family Therapy (MDFT) for
  Adolescents
• Multisystemic Therapy (MST)
• Combined Behavioral and Nicotine Replacement
  Therapy for Nicotine Addiction
• Community Reinforcement Approach (CRA) Plus
  Vouchers
• Voucher-Based Reinforcement Therapy in Methadone
  Maintenance Treatment
• Day Treatment with Abstinence Contingencies and
  Vouchers

http//www.nida.nih.gov/PODAT/PODATindex.html
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10 Leading Causes of Disability in the World
(WHO, 1997)

• Unipolar Depression
• Iron-deficiency Anemia
• Falls
• Alcohol Use
• COPD
• Bipolar disorder
• Congenital anomalies
• Osteoarthritis
• Schizophrenia
• Obsessive-compulsive disorder

• 10.7
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2

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Health Problems

• Alcoholism 6X
• Tuberculosis 6X
• Diabetes 3.5 X
• Accidents 3X
• Physicians 72/100,000 (US 242)
• 60 Over 65 live in poverty
  (US 27)

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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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Agencies Involved in B.H. Delivery

• 1. Indian Health Service (IHS)
• A. Mental Health
• B. Primary Health
• C. Alcoholism / Substance Abuse
• 2. Bureau of Indian Affairs (BIA)
• A. Education
• B. Vocational
• C. Social Services
• D. Police
• 3. Tribal Health
• 4. Urban Indian Health
• State and Local Agencies
• Federal Agencies SAMHSA, VAMC

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Disconnect Between Addictions / Mental Health

• Professionals are undertrained in one of two
  domains
• Patients are underdiagnosed
• Patients are undertreated
• Neither integrates well with medical and social
  service

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Difficulties of Program Integration

• Separate funding streams and coverage gaps
• Agency turf issues
• Different treatment philosophies
• Different training philosophies
• Lack of resources
• Poor cross training
• Consumer and family barriers

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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning? (Carl Bell, 7/03)
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Best Practice
Culturally Specific
Outcome Driven
Integrating Resources
We need Synergy and an Integrated System (Carl
Bell, 7/03)
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Indigenous Knowledge
Definitions

• Is local knowledge unique to a given culture or
  society it has its own theory, philosophy,
  scientific and logical validity, which is used as
  a basis for decision-making for all of lifes
  needs.

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Traditional Medicine
Definitions

• The sum total of health knowledge, skills and
  practices based upon theories, beliefs and
  experiences indigenous to different culturesused
  in the maintenance of health.
• WHO 2002

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Evidence-based Practices
Definitions

• Interventions that show consistent scientific
  evidence of improving a persons outcome of
  treatment and/or prevention in controlled
  settings.
• SAMHSA 2003

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Best Practices
Definitions

• Examples and cases that illustrate the use of
  community knowledge and science in developing
  cost effective and sustainable survival
  strategies to overcome a chronic illness.
• WHO 2002

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World Conference on Science

• Recommended that scientific and indigenous
  knowledge be integrated in interdisciplinary
  projects dealing with culture, environment and
  chronic illness.
• 1999

A partnership begins!
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ID Best Practice
Best Practice
Clinical/services Research
Mainstream Practice
Traditional Medicine
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Circle of Care
Traditional Healers
Child Adolescent Programs
Primary Care
Best Practices
AD Programs
Boarding Schools
Colleges Universities
Prevention Programs
Emergency Rooms
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Traditional and complementary medicine is widely
and increasingly used in all regions of the world
Sources Eisenberg DM et al. 1998 Fisher P
Ward A, 1994 Health Canada, 2001 World Health
Organization, 1998 and government reports
submitted to WHO.
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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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Selected Treatment/Prevention Activities

• The Talking Circle
• Smudging
• Story telling
• Traditional healers
• Medicine Person
• Herbal remedies
• Traditional ceremonies
• Sweat Lodge
• Traditional Experiences Preservation

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What Is Integrative Medicine?
Wellness
Basic Science
CAM literacy
Patient Centered Care
Evidence Based Medicine
Cultural Sensitivity
Power Of the Mind
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Principles of Integrative Medicine

• It is better to prevent than to treat later.
• Recognition of the interaction between body,
  mind, spirit, and environment.
• Integrate the best of conventional and
  traditional medicine.
• Belief that bodies respond uniquely, so treatment
  must be customized.
• Belief in innate healing powers of the body.

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The Intervention Spectrum for Behavioral
Disorders
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Source Mrazek, P.J. and Haggerty, R.J. (eds.),
Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC National Academy
Press, 1994.
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Ecological Model
Individual
Peer/Family
Society
Community/ Tribe
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Interpersonal societal
Environmental
Stigma
Community
Tribal attitudes
Parents
Peers
National attitudes
Personality
Attitudes beliefs
Individual
Genetics
Cultural beliefs
Schools
Local legal
Interpersonal
State attitudes
Personal situations
Individual
Portrayal in media
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Treatment Settings - Social Support

• Tribal
• Community
• Family
• Sibs
• Peers
• Individual

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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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Evidence-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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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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Partnered Collaboration

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
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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