# Presentation: 740084

## Indian Health ServiceNCCD 2006 Methamphetamine, the Tsunami

*Anthony Dekker, DO*
*Phoenix*
*IHS Methamphetamine Team*

##   "Methamphetamine has become an   epidemic in our Indian Country,“   said Jan Morley, assistant U.S. attorney...             			"We're losing our                               children to this                               drug war, and                               we need to take                                   our children back.“Associated Press, Walker MN, August 2003 

## Slide 3

## Myths:

*People never get off meth.*
*Detox takes 1-3 mo. so you can’t start treatment until after that*
*Meth is a drug; therefore the substance abuse program should take care of it*
*Meth is illegal; therefore law enforcement should take care of it.*

## Newsweek 1-30-06

***Tennessee will start to report names on line to allow anyone to search for convicted meth dealers or producers.  Jennifer Johnson, spokesperson for Tennessee Bureau of Investigation***

## Midwest Emergency Rooms

*Reported January 2006-over 10% of Midwest Emergency Room admissions are related to Methamphetamine abuse-www.jointogether.org    *
*Recent surveys of American Indian youth reveal 30% have experimented with methamphetamine*

## Slide 7

## Meth Admissions

- Drug and Alcohol Services Information Systems 2-11-05

## Meth Admissions/100,000

- Drug and Alcohol Services Information Systems 2-11-05

## Meth Admission rates by state1992 and 2002 per 100K

***Iowa ******	******	******9.2 ******	*****198.1 **
***Kansas******	******	******9.8******	****** *****61.3***** ***
***Minnesota******	******           4.6 ******	****** 7*****7.6 **
***Missouri                5.2******	****** *****86.2***** ***
***Nebraska               6.8     ******	*****102.2 **
***North Dakota        2.3 ******	****** *****65.4*****   ***
***South Dakota        4.0******	****** *****68.9**
**Idaho                    9.7     ****	****116.2**
**Montana             33.5     ****	****118.6**
**Nevada               34.6     ****	****156.8**
**Oregon               72.4   ****	**** 323.6**

## Slide 11

##     Why is meth so devastating?

***Cheap, readily available, local production***
***Stimulates, gives intense pleasure***
***Meth damages the user’s brain***
***Paranoid, delusional thoughts, acute use***
***Depression when stop using, dopamine drain***
***Craving overwhelmingly powerful***
***Brain healing takes up to 2 years***
***We are not familiar with treating it***

## “Speed Kills”

***1967 Summer of Love***
***Golden Gate Park***
***Haight  and Ashbury***
***David Smith, MD starts the Haight Ashbury Free Clinic***

## Costs in Past 5 years 

***Medical and Behavioral Health Visits for amphetamine-related problem:   58,000***
***Cost estimate: $11,071,589***
***     ***
***                                    ******Indian Health Service***
***                                    ******Behavioral Health  Dept***
***                                                   ******August 22, 2005***
*   *

##  Health Problems from Meth

*Acute:       trauma*
*                     **psychosis*
*                    **overdose*
*                     **vascular (stroke, MI)*
*                     **suicidal behavior*
*                     **pregnancy complications*
*                     **IDU complications*

## Health Problems, con’t:

***Chronic:     Dental***
***                      ******Mental Health --psychosis***
***                                              ******--depression***
***	******	******	******	******	******	******--suicide***
***	******	******	******	******	******	******--homicide***
***	******	******	****** ******Increased incarceration issues***
***                      ******Rehab post stroke***
*                 *

## Behavioral/Social Problems

***Substance abusers with chronic mental illness***
***Child neglect and abuse***
***Pre-natal exposure***
***Drug-exposed children***
***Family violence***
***Diversion of prescription meds***

## Behavioral/Social con’t:

***Suicide and the survivors***
***Opioid abuse/dependence***
***Indiscriminate anonymous sex***
***Home and Workplace violence***

## Communicable Diseases: Sexual and Injection transmitted

***Chlamydia***
***Syphilis***
***Human Papilloma Virus (HPV)***
***Hepatitis C***
***Hepatitis B (Cascade Cty, MT 1999)***
***HIV***
*                        *

##              Recovery from          Methamphetamine

*    ****Individual***
***                    ******Family***
***                               ******Community****    *

## IHS/Tribal/Urban Health Care:We specialize in Primary Care

## Methamphetamine requires Primary, Secondary, and Tertiary Care Responses

***We have to do better what we already do well.***
***We have to stretch to address the multitude of problems from methamphetamine use.***
***Methamphetamine recovery is not possible without teamwork.  ***

## Primary Care’s Role with Meth

***Screening and early intervention***
***Assessment and stabilization in E.D.***
***Test and treat sexually transmitted diseases***
***Immunize***
***Identify at risk children***
***Educate ourselves, our patients and parents***
***Join the community response team***

## Challenges to I/T/U Clinics

***Increase in patients presenting with psychosis***
***Increase in incarcerated population***
***Increase in complicated pregnancies***
***Drug Diversion***
***Pharmacy Break-ins***
***Threats and violence in the workplace***

## Public Health Nursing

***Increasing numbers of contacts to STD’s***
***Younger and younger STD patients***
***Child abuse/neglect reporting***
***Home visits:  unsafe?***
***Enlarging tribal jails-who cares for the inmates when toxic or withdrawing?***

## Behavioral Health

***I/T/U system is mostly outpatient***
***Demand for services increased***
***Patients have co-occurring addiction and mental health disorders***
***Crisis orientation***
***Lack of secure inpatient beds***
***Frequent suicide attempts***

## Tribal/Urban Addiction Services

* ****Methamphetamine clients have different needs***
***“******Alcohol counselors” not comfortable with clients who have mental illness***
***Counselor pool is aging***
***Young people not entering the field***
***Clients with co-occurring disorders slip through the cracks***

## Administration/Leadership Issues

***Workplace safety***
***Employees and our family members using***
***Staff burnout***
***Patients with need for higher level of care (e.g. psych hospitalization)***
***Pharmacy costs increasing***

## Indian Health Response

***IHS Director’s three initiatives address:***
***Chronic Disease***
***Behavioral Health***
***Health Promotion/Disease Prevention***
***                          ******Director’s Initiatives 2005***

## System-Wide Effort

***Change approach from crisis orientation to ongoing behavioral health promotion***
***Seek new and sustainable resources:  multiple funding sources***
***Maximize current program effectiveness: collaborations, data-driven models***
***Technology and clinically sound behavioral approaches integrated with traditions and healing practices of the community.***
*                                          ****Director’s Initiatives, 2005***

##        Components to Response

| Primary Care  and Emergency Depts. | Co-occurrin Mental Health and 
Addictions
Treatment | Community Focus:
Leadership,
Culture and Traditions  | Drug Task Forces |
| --- | --- | --- | --- |
| Environ-mental 
Health | Drug-
Exposed 
Children,
CPS | Interdiction
Corrections
Drug Court | Health 
Education |

## Teamwork is vital  

| Train doctors, nurses, CD counselors, mental health | Develop, implement protocols | Specialist 
Consults: Addictions, Psychiatric | Emergency assessment and stabilization  |
| --- | --- | --- | --- |
| Train CPS, SW’s, Law Enforce.,
Corrections,
Judicial | Case managers for chronic mentally ill | Safety in the workplace | Public information campaigns |

## Community Networks Response

***Well-formulated continuum of care based on availability of local services***
***Example: Project First Aid for Addiction, ***
***    ******Miami,  Florida***
***3-evening education series***
***Teaches nature of addiction and how friends and family members can intervene with addict***
*                                          **J. Hall, P. Broderick*
*                                          **NIDA Research Monograph #115*

## Choctaw Nation Chi Hullo Li

***Tribal residential treatment program***
***Talihina, OK***
***Specializes in culturally-based , multi-disciplinary treatment***
***For women and their children***
***Designed for unique aspects of methamphetamine addiction***
***SAMHSA/CSAT funded***

## Cherokee Nation Multi-Disciplinary Meth Task Force

***Prevention***
***Education***
***Treatment***
***Two full-time, one 1⁄2 time counselors***
***Community coalition building***
***Started in 2005***

## IHS Training Programs

***Comprehensive Update on Substance Abuse and Dependence (CUSAD) Phoenix, Arizona, May 9 to 12, 2006     (D Eppehimer) and Bangor, Maine, June 20 to 23, 2006 (A Dekker)***
***Methamphetamine Summits 2006-Aberdeen and Albuquerque and the Phoenix 2005 program had over 450 ***

##          Suicide Prevention

***SAMHSA and Indian Health Service***
***One Sky Center, Portland***
***White Bison, Colorado Springs***
***Indian Health National Suicide Prevention Network***
***Methamphetamine is major contributor to current suicides***

##       Treatment Manual for           Native Americans

***Matrix Institute, L.A. ***
***Friendship House, San Francisco***
***Native American Meth Treatment***
***Adapted from Matrix Model for Treatment of Stimulant Abuse ***
***Currently in development***
***Funded by CSAT, SAMHSA***

## “We’re treating the complications:what about the addiction?Do people ever get off methamphetamine?”

## Medical Specialty Access

*Real-time Addiction Medicine consults now provided from Phoenix Indian Medical Center via telemedicine*
*CDC STD Program sponsors training in Emergency Assessment and Stabilization*
*Pediatric, OB, Psychiatric specialists available for phone consults*

## Addiction Medicine Services

*IHS Chief Consultant in Addiction Medicine available to make site-visits,  review and make recommendations for chemical dependency treatment programs anywhere in the country*
*Technical Assistance to Tribal and Urban Programs*

## Guide to Recovery from Meth

*                          **Four Steps*
*Get started*
*Get clean*
*Stay clean*
*Stay healthy*

## Relapse Prevention

**Relapse Prevention**

**Access to Health**

**Get Started**

**Engagement**

**Access to Hope**

**Alliance**

**Access to Help**
**Outpatient or **
**Inpatient**

**Rehabilitation**

**Access to Support**

**Get Clean**

**Stay Clean**

**Stay Healthy**

**1st Week**

**2nd Week—12 Week**

**3—9 Months**

**9-24 Months**

_**Guide to Recovery from Meth**_

**Draft**

**Billings Area **
**Behavioral Health**

***Get Medical care & Exercise***

***Sleep, Eat & Drink Water***

## Step One:  Get Started

*What do I need to know in order to help a friend or loved one start to get off meth?*

## Starting to get off methamphetamine

***Methamphetamine is poisonous to the brain***
***Getting off meth can be started at home, in the hospital, in a treatment center, in jail, as long as methamphetamine isn’t around***
***It’s safer if someone who cares about you is with you when you stop using***
***People don’t always have to have medication to stop using methamphetamine***

## Brain damage and Brain healing

***Meth poisons the brain ***
***Meth takes away your ability to feel “OK” ***
***It takes about 2 years to heal the brain***
***The healing starts as soon as the use stops***

## Withdrawal symptoms

***Feeling sad, depressed, and/or suicidal***
***Extremely tired and sleepy***
***Stimulant cravings***
***Hard to concentrate***
***Anxiety***
***No energy***
***Don’t care about anything (apathy)***

## The brain has to heal!

***People who use meth have abnormal brain imaging***
***People who use meth lose the ability to feel good without methamphetamine***
***Meth affects the part of the brain that enables us to feel OK ***
***When you stop using methamphetamine, you don’t feel “better” right away.***

## What helps in Step One

***Keep as far away from meth as you can.***
***Don’t be around people who use.***
***Tell someone you trust that you are going to stop using.***
***Ask them to take you to for help if you become suicidal, if you are hallucinating, or if you can’t eat and sleep.***

## Broken Brain?

***You need to rest the brain, give it good nutrition, and sometimes medication.***
***Spiritual and Traditional Indian Medicine has an important role***

## Tweaking

***Tweaking is a behavior that is a direct result of meth brain damage.***
***It usually improves and goes away after use is stopped.***
***It’s hard to tell a former user from a current user because it takes time for the brain to heal.***

## When is medical care needed?

***Can’t eat or drink***
***Seeing things/hearing voices/paranoid***
***Feeling things that are not there***
***Severe anxiety***
***Feels like killing him/herself***
***Scaring other people/violent***

## Don’t take unnecessary risks

***Paranoid delusions can cause people to commit violent acts***
***Calling police may save a life***
***Could prevent the addict from spending his/her life in jail for a violent crime***
***Be prepared; talk about this with someone you trust ***

## Hope:  a strong medicine

***Studies show that up to 30% of meth users  can be clean and sober a year following treatment that is specific for methamphetamine.***
***    ******UCLA Integrated Substance***
***   ******Abuse Programs***

## Step 2:  Get clean

***After the first week or two, you feel better***
***Step 2 is all about not using methamphetamine.***
***Craving is the enemy.***

## Getting Clean:What do I do now?

***2 weeks to 3 months off meth***
***You need structure***
***Schedule your days***
***Get medical care***
***Get dental care***
***Get inpatient or outpatient addiction treatment.***

## Drug Courts

***Drug Court wants the person to stop using.***
***Urine drug screens need to be “clean.” ***
***A drug screen will be ordered 12 hours after leaving jail, and many more.***
***If it is “clean,” then the person can stay out of jail.***
***When it is “dirty,” they go back to jail.***
***                                   ******DEA***

## Craving: “drug hunger”

*If you were starving, and you knew where you could get some food----that’s what craving feels like*
*Getting clean from meth means learning how to stay away from the drug and people who use it*

## Getting clean: get rid of reminders of meth

***Clean up your environment***
***              ******Are there any drugs around?***
***              ******Any paraphenalia? (light bulbs, needles)***
***               ******Ask a non-using friend or family member to help you collect and throw these away.***
***                                                                                  ******CSAT, 1999                                       ***

## Getting clean: Stay away from users

***Stay away from your using friends/dealers.***
***Get rid of their phone numbers.***
***Maybe you need to get rid of your cell phone.***
***Avoid high-risk areas: neighborhoods, houses, bars, anywhere you used to get or use drugs.***
***                                                                               ******CSAT, 1999***

## Getting clean:Going to treatment

***Step 2 is a good time to start addiction treatment.***
***Craving is very powerful and you need all the help you can get.***
***You don’t want to have**** ****to do this all over again, do you?***

## Triggers:You need a plan

***Triggers are reminders of using meth.***
***They can lead to craving, and use.***
***Triggers can be internal or external.***
***You need a plan to deal with triggers.***
***Plan how to avoid them***
***Plan what to do if you start thinking about using.***
***                                                                ******CSAT, 1999***

## Withdrawal symptomscan come back

***You may have had withdrawal symptoms, which went away***
***They can come back weeks or months later***
***This is delayed stimulant withdrawal***
***It is normal***
***People can get through this***
***It helps to be in a recovery (treatment) program***

## Meth and Depression

***People who use methamphetamine may become depressed when they stop.***
***Depression feels like fatigue, apathy, sadness, and hopelessness.***

## What helps depression?

***Exercise***
***Non-using friendships***
***Spiritual support/practices***
***Cultural activities***
***Knowing that you can get through this***
***Knowing that people believe in you***
***Medication for depression may be needed***

## Step 3: Stay Clean

***3-9 months off of meth***
***Some days are better than others***
***Craving is less***
***Risk of relapse still high***
***Stay away from meth and meth users***

## Step 3:Avoiding Relapse

***Don’t use alcohol or other drugs***
***Don’t go back with drug-using friends***
***Don’t go back to drug-using sex***
***Watch out for triggers***
***“******Get a (positive) life!”***
***                                      ******from Havassy et al., 1993***

## Boredom: a trigger to use

***Boredom can result in craving.***
***The community can help by organizing clean/sober activities.***
***Exercise***
***Sweat lodge***
***12 Step or other recovery groups***
***Helping others ***

## Step 4:  Stay Healthy

***It takes up to two years for the brain to heal from meth***
***Holistic wellness ***
***Physical***
***Mental***
***Social***
***Spiritual wellness***

## Summary

***Methamphetamine is toxic to the brain***
***The sooner you get off it the better***
***Brain healing starts when use stops***
***Healing can take up to two years***
***Medication may be needed***
***Addiction treatment helps***
***Family/community support is crucial****.*

## Slide 71

## Thanks to: (partial list)

***Pat Calf Looking MA***
***Jeanne Obert MA***
***Gordon Belcourt MPH***
***LeeAnn Johnson MPH***
***Diana Hu MD***
***Tom Drouhard MD***
***Tom Freese PhD***
***Billings Area Native American Chemical Dependency Program Directors***
***Rocky Mtn Region BIA***
***Billings Area I H S***
***Joy Klundt ***
***Kathy Masis, MD***
***CSAT Meth Treatment Project***
***Mary Wall***

***Steve Holve MD***
***Millie Stewart MSN***
***Lori DeRavello MPH***
***Richard Rawson PhD***
***Earl Sutherland PhD***
***Margene Tower MSN***
***Wilbur Woodis MA***
***Jon Perez PhD***
***Dan Dunlap, DEA Billings***
***Deb Durkin, Meth Lab         Coordinator, State of Minn.              Dept of Health***
***Rhonda Stennerson***
***Bonnie Pipe***
***CC Nuckols PhD***
***MT DPHHS, Addictive             Disorders***

## References

*CSAT, SAMHSA “Treatment for Stimulant Use Disorders”  TIP #33, 1999*
*Gonzales and Rawson.  Methamphetamine Addiction: Does Treatment Work? *_*Counselor*_* Oct 2005*
* **Durkin. Presentation to Northern Cheyenne I H S and Tribal Health, July, 2005*