Working Together to Prevent Meth in Rural, Tribal Communities

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Working Together to Prevent Meth in Rural,
Tribal Communities

• B. J. Boyd, Ph.D. u Levi Keehler, M.S. u Bert
  Thomas, Ph.D.
• Cherokee Nation Behavioral Health Services

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Presentation Overview

• Behavioral Health Services at the Cherokee Nation
• Methamphetamine Prevention Programs in the
  Community
• Research Evaluation

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Behavioral Health Services at the Cherokee Nation

• B. J. Boyd, Ph.D.
• Director of Behavioral Health Services
• Cherokee Nation
• Adjunct Professor of Psychology
• Oklahoma State University

4
Words of Wisdom

• It is easier to build strong children than to
  repair broken men.
• - Frederick Douglas
• Far better is it to dare mighty things, to
  win glorious triumphs, even though checkered by
  failure... than to rank with those poor spirits
  who neither enjoy nor suffer much, because they
  live in a gray twilight that knows not victory
  nor defeat.
• - Theodore Roosevelt
• All of you strengthen each other, always.
• - Benny Smith, Cherokee Elder

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The Cherokee Nation

• Tribal Jurisdictional Service Area (TJSA)
• 8,854 square miles
• Relative in size to New Jersey Vermont
• AI/AN Population 116,598
• AI/AN Population lt 18 41,869
• 35.9
• The TJSA is not a reservation
• Urban, Rural, and Very Rural Native Americans
• Either embedded within or isolated from the
  larger community

SOURCES U.S. Census, Cherokee Nation Tribal
Registration
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AI/AN Percent of Population by County(U.S.
Census, 2000)
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Cherokee Lifestyle in NE Okla.

• Level of acculturation varies dramatically
• Most families have lived in the area for several
  generations
• Frequent contact with non-Indian culture
• Often more comparable to that of other Ozark
  communities than to that of Reservation Indians
• Each community has a distinct culture in and of
  itself

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Cherokee Nations Three Strategic Priorities

• Jobs, economic development, viable workforce.
• Language, preservation of culture, knowledge of
  our history.
• Community, safe and healthy environment living
  and working together for common goals and values.

Behavioral Health Services
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Ga-Du-Gi Definition

• Working together as individuals, families, and
• communities for a quality of life for this and
  future
• generations by promoting confidence, the tribal
• Culture, and an effective sovereign government.

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Ga-Du-GiCherokee Nations Philosophy of Mutual
Contribution

• Communities provide
• Participation
• Contributions
• Knowledge of their community
• Cherokee Nation provides
• Resources
• Information
• Technical Assistance

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Models of Behavioral Health Service

• SAMHSAs Strategic Prevention Framework
• Institute of Medicines Continuum of Care

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Divisions of Behavioral Health Services

• Clinical Programs
• Outpatient Services at 2 hospitals and 8 clinics.
• Inpatient Services available through contract
  health.
• Comprehensive substance abuse services through
  the Many Paths (Access to Recovery) Program.
• ATR Coalition of Providers

• Prevention Programs
• Prevention Specialists are Certified at the state
  and national level.
• Spend most of their time in the community, not in
  the office.
• Includes a network of 11 partner community
  coalitions and counting.

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What a Coalition is

• A coalition is an alliance among individuals or
  distinct groups, during which they cooperate in
  joint action, each in their own self-interest.
• Coalition members retain their separate
  identities while working together, rather than
  merging into
  single entity.
• A coalition has a defined
  mission or objective for
  which
  all members
  contribute something towards
  accomplishing.

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What a Coalition is NOT

• A coalition is not a community forum or town hall
  meeting.
• A coalition is not an agency or extension of
  government.
• A coalition is not a meeting to report out on
  individual accomplishments or go over a community
  calendar.

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What a Coalition can be

• A coalition can be a formal or semi-formal
  alliance among individuals or organizations.
• A coalition can be sponsored by an agency,
  government, or larger organization, as long as
  the sponsor does not exert dominance over
  decision-making.
• A coalition can be a not-for-profit organization,
  and can even employ its own staff under the right
  circumstances.

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Methamphetamine Prevention Programs in the
Community

• Levi Keehler, MS, LPC, LADC, CPS
• Associate Director, Prevention Programs
• Access to Recovery (ATR) Treatment Coordinator
• Cherokee Nation Behavioral Health Services
• Adjunct Professor, Psychology and Counseling
• Northeastern State University

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Legislation Hindering Tribal Sovereignty

• Supreme Court ruling Oliphant v. Suquamish Indian
  Tribe (1978)
• Tribes do not have criminal jurisdiction over
  violations of the law committed by non-Indians in
  Indian Territory
• Nearly 70 of crimes in Indian country involve a
  non-Indian
• Indian Civil Rights Act
• Limits tribal courts to imposing 1-yr. sentences
  /or fines up to 5,000

SOURCE Thompson, NCAI (2008)
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Tribal Trust Land
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Cherokee Lifestyle in NE Okla.

• Cultural Traditions (May vary depending on clan
  and location)
• Baskets
• Marbles
• Stickball
• Chunkey Ball
• Cornstalk Shoot
• Cherokee Stomp Dance

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Cherokee Nation Prevention Programs Educational
Component

• Alcohol/Other Drugs Prevention
• Domestic Violence Prevention
• HIV/STD Prevention
• The Sex Lady
• Date But Wait
• I Believe Guy
• Motivational Speaker
• World Record Holder
• Juvenile Drug Court
• Meth Prevention

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Use Your Marbles, Dont Use Meth

• Traditional game of Cherokee Marbles
• Cultural Education/ Preventive Approach

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Keeping Meth in Check

• Chess
• Builds Cognitive Ability
• Builds Self-Esteem for certain at-risk groups

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Events Leading to Action by Tribe

• Fall 2000 We began to see an increase in Indian
  Child Welfare cases involving methamphetamine and
  increased request for treatment of meth
  addiction.
• In one 2 week period , 8 children were born
  testing positive for drugs at our IHS Hospitals.
• 7 methamphetamine
• 1 cocaine
• Feb. 2003 Directive from the Principal Chief to
  reduce methamphetamine in the Cherokee Nation
• 50 reduction in 5 years

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The Cherokee Nation Anti-Meth Plan

• April 2003 Formulation of 5-year plan
• Not in Our Nation
• Calls for internal changes in CN structure
• Calls for community-based anti-drug efforts in
  Cherokee communities
• April 2004 Cherokee Nation Anti-Meth Coalition
  (CNAMC)
• Team charged with looking at multidisciplinary
  effects of meth on systems within the Cherokee
  Nation
• Team charged with assisting communities to
  conduct anti-drug efforts

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Cherokee Nation Anti-Meth Coalition

• Multidisciplinary team consisting of
  representatives from
• Health/Behavioral Health
• Human Services
• Community Services
• Law Enforcement
• Environmental Protection
• Housing Authority

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Barriers are Multidisciplinary in Nature

• Tribal Lands versus Non-Tribal Lands
• No identified standards for assessment and
  clean-up of clandestine meth labs
• Need of Foster Families is paramount
• Under-funded systems across the board
• Human Services (i.e. Indian Child Welfare)
• Treatment/Prevention
• Law Enforcement (i.e. Marshal Services)
• Economics, etc. are also involved

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The Question Is.

• How do you deal with all of these issues in a
  comprehensive and effective way?

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Comprehensive Prevention Includes

• Coalitions
• Multidisciplinary Input
• Evidence-based Programs
• Education
• Environmental Strategies
• Effective Evaluation Techniques
• FLEXIBILTY
• Outside the Box Thinking

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So What Are We Doing?

• Utilize SAMHSAs Strategic Prevention Framework
• Institute of Medicines Continuum of Care

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Institute of Medicines Continuum of Care
SOURCE Gordon (1983)
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Institute of Medicines Continuum of Care
SOURCE Gordon (1983)
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Universal Prevention

• Measures address an entire population
• National, local, community, school, or
  neighborhood
• Messages and programs aimed at preventing or
  delaying the use of ATOD
• The mission is to deter the onset of substance
  abuse by providing all individuals with the
  information and skills necessary to prevent the
  problem
• The entire population is considered at risk and
  able to benefit from prevention programs

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Selective Prevention

• Measures target subsets of the total population
  that are considered at risk for substance abuse
  by virtue of their membership in a particular
  segment of the population
• Children of adult alcoholics
• Students who are failing academically
• Students who live in high drug use neighborhoods
• Targets the entire subgroup, regardless of the
  degree of risk of any individual within the group

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Indicated Prevention

• Measures are designed to prevent the onset of
  substance abuse in individuals who do not meet
  the medical criteria for addiction, but who are
  showing early danger signs
• Falling grades and some use of alcohol and/or
  marijuana
• The mission is to identify individuals who are
  exhibiting early signs of substance abuse and
  other problem behaviors and to involve them in
  special programs

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Use/Abuse Continuum
Addiction is a Treatable Disease Substance Abuse
is a Preventable Behavior
SOURCE Whalen Fleming (2005)
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SAMHSAs Strategic Prevention Framework
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SPF Goals

• Prevent the onset and Reduce the Progression of
  Substance Abuse, with an Emphasis on Reducing
  Underage Drinking
• Reduce Substance Abuse Related Problems
• Build Capacity and Infrastructure

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SPF Implements Prevention By

• Profiling Needs and Response Capacity
• Mobilizing and Building Needed Capacity
• Developing a Prevention Plan
• Implementing Programs, Policies, and Practices
  (Strategies) Based on What is Known to be
  Effective
• Evaluating Program Effectiveness
• Sustaining What Has Worked Well
• Making Needed Changes to Improve Effectiveness

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Prevention Domains
For the SPF the community domain is the priority!
SOURCE SWCAPT
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Key Principles of the SPF

• Adheres to a Public Health Model
• Utilizes Data-Driven Decision Making
• Emphasizes Outcomes-Based Prevention

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Community Dissemination

• This information can be confusing..How do we
  disseminate it to the community?
• Cherokee Nation does it through the tools taught
  by the Community Anti-Drug Coalitions of America
  (CADCA)

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Cherokee Nation Anti-Meth Coalition

• CNAMC is an affiliate of the Community Anti-Drug
  Coalitions of America (CADCA)
• Promotes the formation of anti-drug coalitions in
  Cherokee communities
• The anti-drug coalition is organized,
  administered, and sustained by community members,
  not CNAMC staff
• Community members must be INVESTED in the process
  for anti-drug efforts to be successful
• CNAMC Members are trained to be technical experts
  to communities

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Cherokee Nations Philosophy of Mutual
Contribution

• Communities provide
• Participation
• Contributions
• Knowledge of their community
• CNAMC provides
• Resources
• Information
• Technical Assistance

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This Works Well in our Communities
But Why?
Problem
But Why Here?
SOURCE CADCA (2007)
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CADCAs Community Logic Model
Windows of convenience stores are covered with
alcohol ads
Marketing
Alcohol industry sponsorship if community events
Underage Drinking
Local bars / clubs sponsor
teen night
Copying Adult Behaviors
High school-aged youth attend social events with
college students
Problem Statement
But Why?
But Why Here?
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CADCAs Intervention Core Competency

• Seven behavior change strategies
• Provide Information
• Build Skills
• Provide Support
• Enhance Access / Reduce Barriers
• Change Incentives / Disincentives
• Change Policies or Regulations
• Change the Physical Design of the Environment

SOURCE CADCA (2007)
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CADCAs Community Logic Model
Leaflets Training L. E. Partnership Recognitio
n Provide Assistance Sign Removal City
Ordinance
Windows of convenience stores are covered with
alcohol ads
Marketing
Alcohol industry sponsorship of community events
Underage Drinking
Local bars / clubs sponsor
teen night
Copying Adult Behaviors
High school-aged youth attend social events with
college students
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CNAMC Overview
Resource Team
SatelliteCommunity
Hub Community
SatelliteCommunity
SatelliteCommunity
SatelliteCommunity
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Why is data so important?

• Data is the fuel, Coalitions are the engine
• Without baseline data, you do not have a clear
  picture of the problem
• With baseline data, you may be able to implement
  an existing prevention program and avoid
  reinventing the wheel
• Without outcome data, you dont have an idea as
  to whether youve had any impact.

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Why is data so important?

• Data tells us where the hot spots are
• With limited resources, data can tell us where
  best to allocate them
• Data maximizes our chance of having an impact

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Mapping Risk Factors
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Implementation is Key to Success
Unevaluated programs
Effective evidence-based programs
and Ineffective E-B programs
Obtained from Aos (2005)
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SAMSHAs Not in Our Nation Meth Prevention Grant

• Baseline Survey
• Exit Survey
• 3-Month Follow-up Survey
• Ages 12-17 Youth Survey
• 42 Questions
• Ages 18 - Adult Survey
• 40 Questions
• Group Dosage Forms

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Too Good For Drugs and Violence

• SAMHSA Model Program
• Universal Prevention Program
• Addresses decision-making, goal setting, and peer
  resistance
• Separate, developmentally appropriate curriculum
  for each grade level
• Instructional design enables students to learn
  important skills sequentially year after year
• Infusion lessons in Science/Health, Social
  Studies, and English

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AI/AN Percent of Population by County(U.S.
Census, 2000)
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1st Cohort
Treatment Control Future Sites
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2nd Cohort
Treatment Control Future Sites
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3rd Cohort
Treatment Future Sites
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Universal Direct Approach

• 1,378 Participants Served to Date
• Mean age 14.3 years
• 52 male, 45 Female, 3 Unidentified
• 48 American Indian, 43 Caucasian, 5 Other, 4
  Unidentified
• 560 in Control Group
• Attrition is a concern being addressed
• Entry of NOMS into CSAMS has been a challenge
  with limited staff

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Intervention Basic Information

• 14.5 had been offered meth
• 22.1 thought it would be somewhat easy/very easy
  to get meth
• 17 live with grandparents or other
  relative/guardian
• Unique issue for our population??

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Intervention Data Baseline to Follow-up

• Perception of Refusal Skills
• 7.4 increase - all drugs combined
• 6.1 increase - methamphetamine
• Someone Your Age Using Methamphetamine
• Strongly Disapprove 4.2 increase
• Perception of Benefits AND Harm of
  Methamphetamine
• Significant increases on nearly every question

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Universal Indirect Approach

• Community Presentations
• Community Events
• Radio Ads
• Original scripts developed through NCAI
  Methamphetamine Task Force and the Partnership
  for a Drug-Free America
• Personalized ads for our area and target
  population
• An estimated 50,000 community members reached
  through these strategies

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Partnerships are Key

• Internal Partnerships
• CNAMC
• Human Resources
• Passport Training
• Collaborative efforts
• Johnson OMalley
• Healthy Nation
• SWAT
• STEPS

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Partnerships are Key

• External Partnerships
• Oklahoma Department of Mental Health and
  Substance Abuse
• Methamphetamine Collaborative
• Government-to-Government Meetings
• Community Coalitions within and outside our TJSA
• SWCAPT
• Training
• CADCA
• Training

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Sustainability

• Trainers of Curriculum and Prevention Theory
• Internal and External Partnerships that are based
  on mutual respect and not solely on
• MOAs to help ensure compliance
• Youth Coalitions voice in larger SPF-SIG
  Coalitions
• Bringing communities and organizations together
  successfully for the first time

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Conclusion

• The CAUSE of the PROBLEM IS the PROBLEM
• Prevention
• Risk Factors
• Protective Factors
• Treatment
• Maintenance

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Bert Thomas, Ph.D. President, American
Indian Research Group Lead Evaluator, CN SPF-SIG
Meth Prevention Grants

• Somethings happenin here,
• what it is aint exactly clear.
• Steven Stills
• Crosby, Stills, and Nash

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• Inform project management and tribal leadership
• Justify need and expenditures
• Supply critical data to support implementation
  (Process)
• Define outcomes (Outcomes GPRA/NOMS)
• Supply timely and community-specific data to
  support future initiatives

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Cherokee Nation
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• Large geographic area (8800 sq miles)
• Diverse population distribution (Urban, rural,
  very rural)
• Determination of traditional and non-traditional
  practices
• Individual vs population-level outcomes
• That all voices be heard (numbers vs need)

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• Many available data sets are not reflective of
  prevalence especially in AI populations
• Little is known about specific communities
• Little is known about similarities and
  differences (community)
• Data may conflict with perceptions
• Share data within the community (consensus)
• Use of data to influence policy

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• 10 Hub communities
• 63 Satellite communities
• 73 total communities
• Will allow contrast and comparison between
• Hubs
• Total Cherokee Nation service area
• Satellites communities only
• Hubs communities only

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• Source MULTIPLE SOURCES

Local
Regional
National
Archival
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• Methods
  MULTIPLE METHODS

Focused Surveys (Future)
Surveys
Focus Groups
Structured Interviews
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• Multiple methods including
• Routine informal communication
• Activity reports
• Satisfaction surveys
• Surveillance data
• Structured reports
• Focus groups

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• Coalitions established
• Coalitions working together
• Coalitions working with other coalitions
• Tribe and communities united in common goal
• Established meaningful communications
• Improved cooperation with agencies, communities,
  schools, and individuals
• Detailed data and surveillance
• Sustainability

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• Choice in treatment
• Many locations
• Other tribes
• Other treatment organizations
• Cooperation and communication between tribe and
  multiple providers
• Improved understanding
• Large increase in individuals in treatment

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• Schools (school boards, agencies, leading
  citizens) cooperating closely with tribe
• Coordination and cooperation across locations
• Coordination with other projects
• Sustainability

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• Optimism, said Candide,
• is a mania for maintaining that
• all is well when things are
• going badly.
• Voltaire (Candide)
• 1759