Successes and Challenges in the Nations Efforts to Combat Methamphetamine Use

1
Successes and Challenges in the Nations Efforts
to Combat Methamphetamine Use

• New England Methamphetamine Summit
• Boston, Massachusetts
• July 24, 2009
• Edwin M. Craft, Dr.P.H., M.Ed., LCPC
• Lead GPO and Activities Coordinator for
  Methamphetamine
• Center for Substance Abuse Treatment
• Substance Abuse and Mental Health Services
  Administration
• U.S. Department of Health Human Services

2
Briefing Overview

• Epidemiology
• Challenges and Opportunities in Treating
  Methamphetamine Clients
• Recovery-Oriented Systems of Care
• Unique Needs of Critical Populations
• SAMHSA/CSAPs Response to Methamphetamine
  Prevention
• SAMHSA/CSATs Response to Methamphetamine
  Treatment

3
Calendar Year 20075,910 National Laboratory
Incidents, DEA
4
Calendar Year 20086,783 National Laboratory
Incidents, DEA 873 More Than 2007Orange
Significantly Less Incidents Than 2007Red
Significantly More Incidents Than 2007
5
Lifetime Methamphetamine Use by Gender
5
Source 2007 NSDUH
6
Past Year Use of Methamphetamine, by Age Group
2002-2007
7
Past Year Methamphetamine Use among Persons Aged
12, by Region 2002 and 2006
Percent Using in Past Year
Note Estimates are based on new 2006 questions.
2002 estimates are adjusted for comparability.
Difference between this estimate and the 2006
estimate is statistically significant at the .05
level.
8
Past Year Methamphetamine Initiates
Past Year Initiates, Age 12 or older
Mean Age at First Use
Mean-age-at-first-use estimates are for recent
initiates aged 12 to 49.
Source NSDUH 2007
9
Average Annual Percent Changes in Youth Substance
Use, by Survey
Note Numbers reflect the percent change
occurring each year that would result in the
overall change in prevalence from the base year
to 2007. PMPast Month LTLifetime.
10
Primary Methamphetamine/Amphetamine Admission
Rates by State TEDS 1997, 2001, 2004 and 2007
(per 100,000 Population Aged 12 and Over)
1997 (range lt1 262)
2001 (range 1 300)
2004 (range 2 282)
2007 (range lt1 255)
SOURCE Office of Applied Studies, Substance
Abuse and Mental Health Services Administration,
Treatment Episode Data Set (TEDS). Data received
through 10.6.08.
lt 7
66 110
210 or more
7 - 65
Incomplete data
KEY YEAR 1997
111 - 209
11
Primary Methamphetamine or Other Amphetamine
Admissions TEDS, 1997-2007
Admissions, in thousands
12
Treatment Admissions by Primary Substance of
Abuse - 2007
Source SAMHSA, TEDS 2007
13
Five-Year Trend of Admissions of Pregnant Women
to Substance Abuse Treatment Facilities by
Primary Substance Abuse Problem
Source TEDS, 2002 -2006
14
Challenges and Opportunities in Treating
Methamphetamine Clients
15
Economic Impact

• The Economic Cost of Methamphetamine Use in the
  United States, 2005 (Rand Drug Policy Research
  Center) estimates the economic burden of meth use
  in the US in 2005 at 23.4 billion.
• Cost factors considered were drug treatment,
  health care, intangibles/premature death, lost
  productivity, crime and criminal justice, child
  endangerment, meth production/effects on the
  environment.
• Authors caution relying solely on national
  household surveys and school-based studies as
  true indicators of the meth problem, and stress
  those who are most affected by meth are not
  adequately captured in these venues.

16
Challenges for Methamphetamine Treatment

• Methamphetamine users do not present for
  treatment on their own until an average of 7.5
  years of use, or they enter the justice system,
  experience a family/employer/school intervention,
  etc.
• The significant HIV-risk to methamphetamine users
  (especially MSM) puts emphasis on the need for
  expediting outreach and initiation of testing and
  treatment.
• Need for treatment in rural areas greatly exceeds
  capacity (transportation, facility, and staffing
  issues, etc.)
• Women fear losing custody of children.
• MSM congregation and use has gone underground
  and relies primarily on internet communication.
• Retention in outpatient treatment is frequently
  poor.
• Residential treatment is often cost-prohibitive.

17
Challenges for Methamphetamine Treatment

• Stigma associated with meth use acts as a
  deterrent to recruitment.
• Some communities believe that meth use is not a
  substantial problem and crack cocaine should be
  emphasized instead.
• Known meth-using clients do not acknowledge meth
  use for fear of retribution by the criminal
  justice system.
• Clients frequently drop out of service and lose
  contact with care coordinators.
• Educating community providers about meth use has
  been a problem.

18
Can Methamphetamine Users Be Successfully Treated?

• Successful treatment of methamphetamine users
  employs many elements in common with treatment
  strategies for other groups of drug users.
• There is no evidence that methamphetamine users
  have poorer outcomes than other groups of drug
  users.
• However, with attention to some specific clinical
  issues and application of some specific clinical
  strategies, treatment outcomes can be
  substantially improved.

19
Clinical Challenges with Methamphetamine
Dependent Individuals

• Limited Understanding of Addiction
• Cognitive Impairment
• Anhedonia
• Sexual Reactivity and Meth Craving
• Elevated Potential for Violence
• Persisting Flashbacksof Meth Paranoia
• Sleep Disorders
• Poor Retention in Outpatient Treatment
• Elevated Rates of Psychiatric Co-morbidity

20
Recommended Behavioral/Cognitive Behavioral
Treatments

• Cognitive/Behavioral Therapy-CBT
• Motivational Interviewing-MI
• Contingency Management-CM
• 12 Step Facilitation Therapy
• Community Reinforcement Approach-CRA
• Matrix Model of Outpatient Treatment
• Relapse Prevention
• Recovery-Oriented Systems of Care

21
Recovery-Oriented Systems of Care
22
Recovery is a Holistic Process

• Recovery is a holistic process that benefits
  from the participation of a diverse group of
  private and public resources.
• Every resource, system, service, etc., that
  contributes to the recovery of an individual
  owns a piece of the recovery process.
• The Federal government has a role, but the
  approach is much larger encompassing a wide
  spectrum of State, local, Tribal,
  community-based, faith-based, and peer-to-peer
  supports, services, and systems.

23
ROSC provides responsive, outcomes-driven
approaches to care.
24
The Benefits of ROSC for SA Programs

• The ROSC approach contributes to the effective
  application of SA treatment programs.
• Recovery support services in conjunction with
  clinical treatment help to establish a more
  continuous treatment response.
• The ROSC approach ultimately means that the
  program focuses on reducing the acute and severe
  relapses that substance abusing clients often
  experience.

25
Unique Needs of Critical Populations
26
Critical Populations Affected by Methamphetamine

• Justice-involved
• Many states are experiencing high rates of
  incarceration of meth users with medical, dental,
  and treatment needs.
• Lesbian, Gay, Bi-sexual, Transgender (LGBT)
• Disproportionately affected population based on
  the unique characteristics of meth (high lasting
  12 hours, hyper sexuality) that increase risk of
  unprotected sex. Culturally relevant treatment is
  critical.
• Women
• Higher rates of meth use compared to men than
  other drugs, women of child-bearing age most
  at-risk, impact of clandestine labs on children.
  Gender-specific treatment is critical.

Source SAMHSA National Meth Summit
27
Unique Needs of Critical Populations

• Justice Involved Individuals
• According to the US Department of Justice,
  methamphetamine addiction is seen as one of the
  most difficult substance abuse problems to treat.
• Individuals addicted to methamphetamine need
  careful supervision upon release from
  incarceration that is geared not only towards
  successful termination of their probation or
  parole term, but also towards their long-term
  sobriety and effective use of community
  resources.

28
Unique Needs of Critical Populations

• Lesbian, Gay, Bisexual Transgender (LGBT)
  Individuals
• Psychosocial pressures including homophobia,
  discrimination, fear, loss and stigma resulting
  from HIV/AIDS often result in internalized
  homophobia, feelings of low self worth, and
  depression,
• For some gay men suffering from these
  conditions, methamphetamine seems like a useful
  tool to erase these everyday pains and burdens.
• These conditions increase susceptibility to
  drug addiction in some individuals.

Source Gay Lesbian Medical Assn (GLMA),
Breaking the grip treating crystal
methamphetamine addiction among gay bisexual
men, November 2006
29
Unique Needs of Critical Populations

• Women
• Over 70 of methamphetamine-dependent women
  report histories of physical sexual abuse, and
  are more likely than men to present for treatment
  with greater psychological distress. 
• Many women with young children do not seek
  treatment or drop out early due to the fear of
  not being able to take care of or keep their
  children -- as well as fear of punishment from
  authorities in the larger community. 
• Consequently, women may require treatment that
  goes beyond treating their substance abuse
  disorder to also respond to social and
  psychological issues.

Source UCLA Integrated Substance Abuse Programs,
accessed at http//www.methamphetamine.org/html/s
pecial-pops-women.html
30
Strategies and Tools to Address Critical
Populations Needs

• New SAMHSA/CSAT TIP Substance Abuse Treatment
  Addressing the Specific Needs of Women (June 2009
  )
• New SAMHSA/CSAT Video Intensive Outpatient
  Treatment Family Education Video will address
  triggers and craving, a roadmap for recovery, and
  families in recovery (Summer 2009)
• New SAMHSA/CSAT gender-specific adaptation of The
  Matrix Model to address needs of women (Concept
  Development Stage)

31
Strategies and Tools to Address Critical
Populations Needs

• SAMHSA/CSAT is supporting Training of Trainers
  (TOTs) to deliver the curriculum for the SAMHSA
  publication A Providers Introduction to
  Substance Abuse Services for Lesbian, Gay,
  Bisexual, and Transgender Individuals (2001)
  nationally.
• Getting Off A Behavioral Treatment Intervention
  For Gay and Bisexual Male Methamphetamine Users
  (based on the Matrix Model) (Friends Research
  Institute/UCLA).
• Minority MSM Training Curriculum (Developed by
  ATTC Network to provide culturally relevant
  treatment to multiple minority cultures).

32
SAMHSA/ CSAPs Response to Methamphetamine
Prevention
33
Methamphetamine Prevention Grant History

• 3 Cohorts of Grants
• FY 2002
• 14, one-year planning grants
• Total funds 4.3M
• FY 2003-2005
• 12, 3-year infrastructure and intervention grants
• Total funds 5M per year
• FY 2006-2009
• 10, new 3-year infrastructure and intervention
  grants
• Total funds 4M per year
• FY 2009
• 12 supplemental awards
• 1.2M.

34
States Receiving CSAP Methamphetamine Prevention
Grants

• Colorado Hawaii
• Illinois Arizona
• Massachusetts Iowa
• Oregon Missouri
• Oklahoma Maine
• Tennessee Pennsylvania
• Texas Ohio
• Washington Nevada
• New Mexico Illinois

35
CSAPs Interests

• Build capacity and infrastructure at the
  community level to support interventions.
• Help communities initiate or develop
  interventions designed to change attitudes and
  norms about methamphetamine.
• Prevent and/or delay the use of methamphetamine.

36
Examples of Infrastructure Projects

• Training State and local law enforcement
  officials, prevention and education personnel,
  health professionals, members of community
  anti-drug coalitions and parents.
• Establishing prevention referral and linkages
  systems to other supportive services such as
  transportation, child-care, counseling, etc.

37
Examples of Prevention Intervention Projects

• Conduct school-based programs about the dangers
  of methamphetamine and inhalant abuse.
• Replicate, develop, implement, and/or adopt
  evidence-based effective prevention interventions.

38
Infusion of the Strategic Prevention Framework

• State Systems
• Prevention
• Infrastructure

General Public Awareness and Outreach
Community Coalitions Action Mechanism
39
SPF SIG Awards Targeting Methamphetamine

• State epidemiological workgroups identify
  priority consumption and consequence areas of
  their states and communities by reviewing
  profiles on each of the areas. These profiles
  include a summary of statistics surrounding the
  problem, an assessment of current resources
  targeting the problem, and basic available county
  level data.
• As of January, 2009, 3 States (Indiana, Kentucky,
  and Tennessee) have identified methamphetamine as
  their SPG SIG priority areas.

40
SPF SIG Awards Targeting Methamphetamine FY 09

• Approximately 38.1M will be awarded for new FY
  09 SPF SIG Grants to address areas of highest
  need (including methamphetamine)
• Approximately 20 Awards for States/Territories
  and/or Federally recognized Tribes will be made
• Anticipated Award Amount Up to 2.3 million per
  year
• Length of Project Period Up to five years

41
SAMHSA/CSATs Response toMethamphetamine
Treatment
42
CSAT Programs that serve Methamphetamine Clients

• Access to Recovery (ATR)
• FY 2007 cohort of grantees includes funding
  specifically for Methamphetamine Treatment
• Screening, Brief Intervention, and Referral to
  Treatment (SBIRT)
• Treatment Drug Courts
• Minority AIDS Initiative (Includes Targeted
  Capacity Expansion HIV/AIDS Outreach Program
• Homeless Addictions Treatment Program
• Pregnant Post-Partum Women Program
• Targeted Capacity Expansion Methamphetamine
• Substance Abuse Prevention and Treatment Block
  Grant (SAPTBG)

43
Discretionary Program Percent Using Meth in
States Reporting High Methamphetamine Rates
Program of clients
using Meth
44
Methamphetamine Use and CSATs Discretionary
Services Program

• 17,975 clients who reported methamphetamine use
  have been served by currently active
  Discretionary Services grantees.
• This represents 2.1 of all clients in the CSAT
  Discretionary Programs.

Source GPRA, May 15, 2009
45
Outcomes Data Clients Using Meth All CSAT
Discretionary Programs
Overall, the number of clients using
methamphetamine was reduced by 73.8 between
Intake and 6-month follow-up.
Source SAMHSA, Services Accountability
Improvement System, 2003 6/11/09
46
Methamphetamine Clients Demographics

• 19.3 of clients also consider themselves
  Hispanic or Latino

Source SAMHSA, SAIS
47
Methamphetamine Using Clients Age Group
More than half (61.6) of clients were 18-34
years old.
Source SAMHSA, SAIS, data collected through
6/11/09
48
Methamphetamine Using Clients Gender
49
CSATs TCE-Meth Program

• There have been 5,457 clients served by TCE-Meth
  grantees since program initiation.
• For a sample of 4,111 of these TCE-Meth clients,
  outcomes data collected at six months post
  baseline are shown on following slides.

Source GPRA 6/15/2009
50
TCE-Meth Grantees Gender

• The majority of clients served were male
  (59.5).

Source GPRA 6/15/2009
51
TCE-Meth Grantees Race

• 27.0 of Clients reported being Hispanic/Latino

Source GPRA 6/15/2009
52
TCE-Meth Grantees Age Group

• More than half (63.4) of clients served were
  between 25-44 years old

Source GPRA 6/15/2009
53
TCE-Meth Grantees Meth Use

• Rate of Change -71.6

Source GPRA 6/15/2009
54
TCE-Meth Grantees Employed

• Rate of Change 49.7

Source GPRA 6/15/2009
55
Methamphetamine Use and CSATs Discretionary
Services Program New England States

• 131 clients in the New England region who
  reported methamphetamine use have been served by
  currently active Discretionary Services grantees.
• This represents 0.2 of all clients in the CSAT
  Discretionary Programs in the New England region.

Source GPRA, July 15, 2009
56
Outcomes Data Clients Using Meth All CSAT
Discretionary Programs
Overall, the number of clients using
methamphetamine was reduced by 86.6 between
Intake and 6-month follow-up.
Source SAMHSA, Services Accountability
Improvement System, 2003 7/15/09
57
Methamphetamine Clients Demographics

• 26.1 of clients also consider themselves
  Hispanic or Latino

Source SAMHSA, SAIS
Source SAMHSA, SAIS, data collected through
7/15/09
58
Methamphetamine Using Clients Age Group
More than half (58.0) of clients were 18-34
years old.
Source SAMHSA, SAIS, data collected through
7/15/09
59
Methamphetamine Using Clients Gender
Source SAMHSA, SAIS, data collected through
7/15/09
60
ATR-II Top 5 Substances Used
Source SAMHSA, SAIS, data collected through May
19, 2009
61
ATR Successes

• After significant challenges in some ATR States,
  a combination of targeted technical assistance
  from CSAT, development of targeted media
  campaigns, encouraging peer referral, and efforts
  to increase communication and forge partnerships
  with providers and community stakeholders has
  contributed to improvements with recruitment and
  retention of meth clients in many ATR States.
• The CSAT targeted technical assistance package
  for ATR grantees has included individual coaching
  with States, implementation of national Matrix
  Model training for all ATR treatment providers,
  and development of a series of webinars to
  educate grantees on the core issues of
  establishing effective methamphetamine services.

62
Estimated. Block Grant in States with Highest
Use of MATreatment Episode Data Set (TEDS) 2007
63
Estimated Block Grant Expenditures in New
England States with Use of Methamphetamine
64
Other CSAT Initiatives, Products and Solutions
65
CSAT Initiatives and Solutions

• SAMHSA National Methamphetamine Summit
• Governors Summits to Address Methamphetamine
• Collaborations to Address Native American Meth
  use
• Collaboration with ACF
• Collaboration with CDC
• Addiction Technology Transfer Centers (ATTCs)
• Evidence-Based Practices (Matrix Model)

66
SAMHSA National Meth Summit Description

• Held November 16-19, 2008 at Hilton Washington.
• Convened a Steering Committee of Federal
  partners, state officials, national
  organizations, and critical population experts
  and representatives. Steering Committee continues
  to function post-Summit to coordinate
  implementation of action plans.
• Federal partners and co-sponsors include HRSA,
  CDC, NIDA, the HHS Office of Womens Health, and
  the HHS Office of Minority Health. Partners from
  the Department of Justice include the Bureau of
  Justice Assistance, The office of Community
  Oriented Policing Services, and the DEA.
• Funded participation by 20 State/Territory Action
  Teams to develop meth action plans for three
  critical populations (Justice-Involved, LGBT, and
  Women)

67
SAMHSA National Meth Summit Outcomes

• Each State/Territory noted that participation in
  the National Meth Summit has enhanced their
  strategic planning process related to the three
  critical populations.
• Several State Action Teams are focusing on
  integrating and expanding their data systems to
  more effectively serve the critical populations.
• Each of the State/Territory Action Teams has
  expressed the need for ongoing TA and training
  from SAMHSA and its partners to address their
  unique circumstances of addressing services
  challenges related to meth specifically, and to
  the critical populations generally.

68
SAMHSA National Meth Summit Outcomes

• SAMHSA is developing a gender-specific adaptation
  of the Matrix Model to meet the specific
  treatment needs of women.
• SAMHSA is facilitating cultural competency
  training for the critical populations in States.
  Demand is high.
• Nearly 100 of the State/Territory Action Teams
  expressed concern related to reduced funding and
  increased need for services.

69
Governors Summits on Methamphetamine

• CSAT provides funding support and coordinates
  with the Department of Justice to sponsor these
  State meetings. Summits have been held in the
  following States
• 2000 2003 2005 2008
• California Ohio Wisconsin
  Washington State
• 2001 Oregon West Virginia Indiana
• Washington South Dakota Hawaii
• 2002 Georgia 2006
  2009
• Kentucky 2004 Washington
  Arizona
• Arkansas Montana Utah
  Florida Oklahoma Nebraska Northeast States
• Hawaii 2007 Regional
  Summit
• Iowa Arizona Minnesota
• Kentucky

70
Collaborations to Address Native American
Methamphetamine Use

• Assure Tribal issues and concerns are addressed
  in the action plans from SAMHSAs National Meth
  Summit.
• Active member of the Office of National Drug
  Control Policys Executive Tribal Law Enforcement
  Workgroup.
• Partner with the National Institute on Drug Abuse
  in an effort to foster appropriate treatment
  strategies.
• Partner with the Centers for Disease Control to
  address the infectious disease aspects of
  methamphetamine use and abuse.
• Participant on the IHS Methamphetamine Monthly
  Conference Call

71
Collaboration With CDC

• SAMHSA/CDC Interagency Work Group to address
  intersection of meth use and transmission of
  HIV/AIDS and other STDs established in 2007.
• Strategic plans including joint presentations at
  conferences, potential plans to develop
  collaborative funding announcements to maximize
  resources, and coordinating efforts related to
  data collection/ research, development and
  dissemination of evidence-based practices,
  increasing cultural competence in service
  delivery, and reducing stigma.

72
Partnership With ACF

• CSAT coordinates with ACF on grant programs,
  treatment protocols, recruitment and retention
  efforts, and other mutual areas of interests
  related to delivering and evaluating effective
  methamphetamine services to children and families.

73
Treatment Improvement Protocols (TIPs)

• Best Practice Guidelines for Treatment of
  Substance Abuse
• Researched, Drafted, and Reviewed by Field
  Experts

74
Matrix Model

• Matrix Intensive Outpatient Treatment for People
  with
• Stimulant Use Disorders
• Counselors Treatment Manual
• Counselors Family Education Manual
• Clients Handbook and Clients Treatment
  Companion
• Culturally specific handouts for use of the
  Matrix
• Model with American Indians/Alaskan Natives.

75
Matrix Model Outpatient Treatment Client Manual
Culturally-Adapted for American Indians/Alaskan
Natives

• The Matrix Model
• Evidence-based structured treatment program.
• Developed in response to stimulant use disorders
• Widely used in outpatient settings

76
ATTCs Methamphetamine Training Module

• SAMHSAs Addiction Technology Transfer Centers
  (ATTC)
• Pacific Southwest ATTC
• http//www.psattc.org/events/cates/I/presentations
  /index.html
• Methamphetamine 101
• Etiology and Physiology of an Epidemic

77
ATTCs Introduction to Evidence-Based Treatments
for Methamphetamine

• CD-ROM Learning Tools
• DVD Training Module
• Produced by Applied Behavioral Health Policy at
  the University of Arizona for the Pacific
  Southwest ATTC
• web www.psattc.org

78
Meth Inside Out
79
Meth Inside Out

• State-of-the-art three DVD presentation (Human
  Impact, Brain and Behavior, Windows to Recovery)
• Produced jointly by UCLA's Integrated Substance
  Abuse Programs (ISAP) and Eyes of the World Media
  Group
• Visit web site to learn more, access free
  resources, and order the DVD series
  http//www.methinsideout.com/partner.html

80
Additional Information on Methamphetamine

• Contact
• Edwin Craft, Dr. P.H., M.Ed., LCPC
• 240 276 1571
• ed.craft_at_samhsa.hhs.gov
• www.samhsa.gov
• www.grants.gov
• To Order Publications from the SAMHSA Health
  Information Network (SHIN) http//store.health.or
  g/catalog/