Department of Health and Human Servces 
OFFICE OF 
INSPECTOR GENERAL 
INDIAN ALCOHOL AND SUBSTANCE ABUSE: 
LEGISLATIVE INTENT AND REALITY 
-, sERVICE" 
JI7 
'l1ti'dW 
OCOBER 199  OFFCE OF INSPECTOR GENERA 
The mission of the Offce of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Servce' (HHS)
programs as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components: the Offce of Audit Servce, the 
Offce of Investigations, and the Offce of Evaluation and Inspections. The OIG also informs 
the Secretary of HHS of program, and management problems, and recommends courses to 
correct them. 
OFFICE OF AUDIT SERVICE 
The OIG's Offce of Audit Servces (OAS) provides all auditing servces for HHS, either by
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrng out their respective responsibilties and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste
, abuse, and 
mismanagement and to promote economy and effciency throughout the Department. 
OFFICE OF INTIGATIONS 
The OIG's Offce of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
AN 
OFFCE OF EVALUATION  INSPECTONS 
The OIG's Offce of Evaluation and Inspections (OEI) conducts short-term management and
program evaluations (called inspections) that focus on issues of concern to the Department 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the effciency, vulnerabilty, 
and effectiveness of departmental programs. This report was prepared in the San Francisco 
regional offce under the direction of Kaye D. Kidwell, Regional Inspector General, and
Paul A Gottlober, Deputy Regional Inspector General. Project staff: 
REGION  HEQUARTERS 
Deborah Harvey  Alan Levine

Donald Loeb 
Brian Pattison 
For additional copies of this report, please contact Kathy Dezotte at (415) 556-6830.  +~'- 
;",. 
Department of Health and Human Servces 
OFFICE OF 
INSPECTOR GENERAL 
INDIAN ALCOHOL AND SUBSTANCE ABUSE: 
LEGISLATIVE INTENT AND REALITY 
, sERVICE" 
JI7 
'1 
'l1ti'd3U 
OcrOBER 199 OEI- 00l0 
09-92- EXECUTIVE  SUMMAR Y

PUROSE
This inspection assesses the Indian Health Servce s coordination of alcohol and
substance abuse programs. 
BACKGROUN
Alcohol and substance abuse are the foremost health concerns for American Indians 
and Alaska Natives (hereafter referred to as "Indians ). Four of the top 10 causes of 
death among Indians are alcohol- and drug-related injuries, chronic liver disease and 
cirrhosis, suicide, and murder. 
The Office of Inspector General (OIG) conducted this inspection at the request of the 
Senate Select Committee on Indian Afairs. The Committee requested that the OIG 
provide information to assist in the reauthorization of Indian alcohol and substance 
abuse legislation. Congress enacted the Indian Alcohol and Substance Abuse 
Prevention and Treatment Act of 1986, P.L. 99-570, to provide a coordinated and 
comprehensive attack on Indian alcohol and substance abuse with a particular 
emphasis on youth. As required by the law, the Secretaries of Interior and Health and 
Human Servces entered into a Memorandum of Agreement. To determine the extent 
to which Congressional intent has been implemented, we intervewed officials from the 
Public Health Servce s (PHS) Indian Health Servce (IHS) and the Bureau of Indian 
Afairs (BIA) and reviewed laws, regulations, and policies that address the 
coordination of Indian alcohol and substance abuse programs. 
FIINGS
ms and BIA hove not achied th leel of coordintin envine by Congres 
lied  unrm  cont 
coorditin 
of care and an holiti approach 
for treatig Indian alcohol and sustance abuse 
RECOMMNDATION
Indn 
rTh ev Heallh Service, in conjuntin wih the Bureau of Indian Affair, shoul
, updte, and streaml the Memrand of 
Ageement wiJh the goal of
deeloping a practical plan of actin 
AGENCY COMMNT
The PHS agreed with the OIG recommendation and in its comments on the draft
report discusses actions it has taken or plans to take to address the specific 
issues. . . . . . . . . . ..  ..  ..  . .. . . . . . . . . . . . . . . . . ..   ...   ....    ....    ....    ....   . ..  . ...    ....    ........    
. . . . . . . . ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  . . . . . . . . 
TABLE OF CONTENTS

EXCU SUMY

INOl)l1CTON 
............................................... 1 
FIINGS. . 
Fragmentary, Sporadic, and l)eficient Coordination 
l1ndermined and Incomplete Servces 
RECOMMNDATION 
APPENICE 
Appendix A:  Memorandum of Agreement: Status of Major Provisions 
as of Spring 1992 ............................... A-
Appendix B:  Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B- INTRODUCTION
PUROSE
This inspection assesses the Indian Health Servce s coordination of alcohol and
substance abuse programs. 
BACKGROUN
Alcohol and substance abuse are the foremost health concerns for American Indians 
and Alaska Natives (hereafter referred to as "Indians 
). Four of the top 10 causes of 
death among Indians are alcohol and drug related injuries (18 percent of all deaths), 
chronic liver disease and cirrhosis (5 percent), suicide (3 percent), and murder 
(3 percent ). 
The Office of Inspector General (OIG) conducted this inspection at the request of the 
Senate Select Co=ittee on Indian Afairs. The Committee requested that the OIG 
provide information to assist in the reauthorization of Indian alcohol and substance 
abuse legislation. The Committee also requested the Department of Interiors Offce 
of Inspector General to review compliance with legislative requirements for alcohol 
and substance abuse programs.

In 1976, Congress enacted the Indian Health Care Improvement Act, P.L. 94-437, to 
respond to all aspects of Indian health including prevention and primary care. The 
Act s stated purpose is to "meet the national goal of providing the highest possible 
health status to Indians no." As part of the Act, Congress has appropriated funds
annually for the treatment and control of alcohol and substance abuse among Indians.
The 1988 amendments to the Act call for the Department of Health and Human
Servces' Indian Health Servce (IHS), the Department of Interior s Bureau of Indian 
Afairs (BIA), and the Indian tribes to coordinate their alcohol and substance abuse
programs with their mental health programs.
The Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986

L. 99-570, Subtitle C, more specifically addresses Indian alcohol and substance 
abuse. With this Act, Congress sought to provide a comprehensive coordinated attack 
on Indian alcohol and substance abuse with a particular emphasis on youth. Congress 
directed the Secretaries of Interior and Health and Human Servces to enter into a 
Memorandum of Agreement no later than 120 days after the law was enacted. 
The IHS funds or directly provides comprehensive health servces, including alcohol
and substance abuse programs, for Indians. Within each of the 12 IHS area offices 
full-time coordinators provide training and technical assistance to Indian alcohol and 
Anti-Drug Abuse Act of 1986 " Section 4202 (4)-(5).  substance abuse programs. To meet the needs of the Indian communities
, area offices 
can vary their staffing and operations. The area directors report directly to the IHS 
Deputy l)irector. At the headquarters level, IHS created the Alcoholism and 
Substance Abuse Program Branch, now located in Albuquerque, New Mexico. The
branch, which has no line authority over the area offices, provides training, technical 
assistance, guidance, oversight, and fuding to the area offices and the alcohol and 
substance abuse programs. 
The BIA serves as the Federal Government s principal agent with federally-recognized 
Indian tribes. It provides or funds law enforcement, judicial servces, social servces 
and education through 12 area offices, 84 local-level agencies, and 180 schools. Within 
BIA the Offce of Alcohol and Substance Abuse Prevention provides leadership and
direction for all BIA alcohol and substance abuse prevention activities.
METHOl)OLOGY
To determine the extent to which Congressional intent has been implemented, we 
identifed, collected, and reviewed laws, regulations, and policies that address the 
coordination of Indian alcohol and substance abuse programs. We obtained 
information through wrtten requests to IHS headquarters. We focused first on the 
Memorandum of Agreement between IHS and BIA and requested (1) the 
Organizational Master Action Plan, (2) review guidelines, (3) the minimum standards 
compliance plan, (4) Tribal Action Plans and Local Action Plans, and (5) tribal 
comprehensive reports. We then focused on Memoranda of Agreement between IHS 
and other Federal agencies and departments and requested documentation that 
ilustrates coordination activities. 
We intervewed offcials from IHS and BIA headquarters offices and discussed
coordination and Memorandum of Agreement implementation. We visited IHS 
headquarters offces in Rockvlle, Maryland and Albuquerque, New Mexico. We 
visited BIA headquarters in Washington, nc. and spoke with officials from the Office 
of Alcohol and Substance Abuse Prevention, Division of Law Enforcement, Branch of 
Judicial Servces, Division of Social Servces, and Office of Indian Education Programs.
We conducted 21 headquarters intervews and spoke with 31 individuals. 
We also intervewed offcials from all IHS and BIA area offices. We conducted in-
person intervews with offcials in four IHS and four BIA offices and visited selected 
alcohol and substance abuse programs. We conducted telephone intervews with 
officials in all other area offices. In each case, we intervewed the area director and 
the alcohol and substance abuse coordinator. In some offices, we spoke with project 
officers, alcohol and substance abuse specialists, or others who administer or monitor 
the alcohol and substance abuse programs. We conducted 61 area office intervews 
and spoke with 67 individuals. 
We also intervewed headquarters officials from the Department of Education. They
described their l)rug Free Schools program and their coordination activities with BIA.  , "

FINDINGS
IHS AN BIA HAVE NOT ACHVED TH LEVE OF COORlINATION
ENIONE 
BY CONGRE 
Memra 
coordtin 
Th  of Ageemnt formlied th need for 
As required by the law, the Secretaries of Interior and Health and Human Servces 
entered into a Memorandum of Agreement. The Agreement was published in the 
Federal Register on March 26, 1987 and specifically directs IHS and BIA to 
coordinate resources to "assist Indian tribes and Alaska Native villages to achieve their 
goals in the prevention, intervention, treatment, and follow-up of alcohol and 
substance abuse." It outlines the roles and responsibilities of IHS, BIA and the tribes 
and details short- and long-term goals. 
Many IHS and BIA offcials praised the Memorandum of Agreement for initiating
coordination where none previously existed. Typical was the comment of an IHS 
offcial  Before the legislation, BIA washed their hands of substance abuse because 
it's a disease. IHS would not treat people with law and order problems because it was 
not their jurisdiction. 
ms and BIA hove not implemented many of th Ageement's provisons
Despite their mutual desire for coordination, IHS and BIA officials have had limited 
success in accomplishing the Agreement s goals. Major provisions that remain 
incomplete include periodic reviews of both the Memorandum of Agreement and the 
Organizational Master Action Plan, Tribal Action Plans and Local Action Plans, and
tribal comprehensive reports. For more detailed information on the major provisions 
of the Memorandum of Agreement, please see the Appendix. 
The law requires the Departments of Interior and Health and Human Servces to 
review the Memorandum of Agreement annually. This has not been done since 
1988. 
Both IHS and BIA officials believe the Memorandum of Agreement should be 
updated to reflect their accomplishments and to refocus their efforts. At the
beginning of her term, the current Director of BIA's Office of Alcohol and Substance 
Abuse Prevention declined an invitation from IHS to update the Memorandum of 
Agreement. She wanted time to gain a better understanding of her 
responsibilities.
Later, both agencies deferred the update until IHS issued its report on the scope of
the Indian alcohol and substance abuse problem. The IHS did release this report in
February 1992.
 , " 
Severl barrrs iniJ efective coordtin between ms and BIA 
Barriers to coordination include: 
Differing missions 
As indicated in the background section of this report, IHS and BIA have very 
different roles and missions. An IHS official summarized  We have different 
missions. Cooperation is realistic, but should reflect these missions." Many 
IHS and BIA offcials believe that (a) IHS should take the lead in 
implementing the legislation and have control over programs related to 
treatment and assessment and (b) BIA should provide support by using their 
law enforcement, judicial servces, social servces, and educational activities to 
provide referrals, prevention, and aftercare. 
Differing headquarters staff structures 
For IHS, the Alcoholism and Substance Abuse Program Branch has primary 
responsibilty for all headquarters activities related to alcohol and substance 
abuse. In contrast, BIA's Office of Alcohol and Substance Abuse Prevention 
attempts to coordinate efforts of the Division of Law Enforcement, l)ivision of 
Social Servces, Branch of Judicial Servces, and Office of Indian Education 
Programs. 
Lack of area office and headquarters collocation 
The alcohol and substance abuse branches for IHS and BIA are located in 
Albuquerque, New Mexico and Washington, D.  , respectively. A few IHS 
headquarters officials noted that collocation would make their work easier. 
Ten of the 24 area offices have difficulty coordinating because their 
counterparts are in different cities. In contrast, close proximity of area offices 
faciltates coordination. In some areas, BIA and IHS staff travel together to 
perform program reviews and conduct joint training. 
High staff turnover 
Although Congress established BIA' s Office of Alcohol and Substance 
Prevention with a permanent director position , five different temporary 
directors have been appointed since the office s inception in 1986. Officials 
from both IHS and BIA expressed frustration with the lack of a permanent 
director as mandated by the legislation. 
At the area and local levels, burnout is common as staff handle many, 
sometimes conflcting, assignments. Both IHS and BIA officials described their 
jobs as responding to "fire drils" and operating in a "crisis mentality." Once 
trained, staff frequently leave to find higher-paying positions.  , "

Lack of full-time BIA area alcohol and substance abuse coordinators 
Both IHS and BIA officials expressed frstration at the lack of full-time BIA 
area coordinators. For example, an IHS offcial stated  We have not 
coordinated with BIA for 1 1/2 years. BIA does not have the staff to faciltate 
these activities. It would be better if BIA had funded coordinator positions.
At th loallee 
headrt coordtin occu regardl of the efort of area offes and
At the local level, coordination occurs because of community needs, not Memorandum 
of Agreement requirements. Many officials cited coordination efforts with State, local 
and private agencies. Often, the cooperation is in the form of information sharing and 
referrals. "Social servce workers frequently interact with the State on family and 
youth problems " a BIA official noted. In Alaska, BIA's role is severely reduced as
State agencies handle law enforcement and schools for the tribes and villages. 
Nationally, coordination among IHS, States, and tribes has led to joint programs with 
local schools and churches and agreements with hospitals and clinics. These 
coordinated efforts allow the tribal programs to provide a greater range of servces to 
their communities. LI 
UNER  CONT 
COORlINATION  OF CAR 
AN HOLITIC APPROACH FOR TRTIG INIA ALHOL AN 
S1JTANCE ABl1SE 
Alcohol and substance abuse laws currently provide a broad spectrum of prevention 
treatment, and aftercare servces and programs for adults, youth, and familes. The 
IHS, through its mental health and substance abuse fuctions, is responsible for the 
direct treatment of alcohol and substance abuse. The BIA utilzes its education, social 
servces, and law enforcement components to provide prevention, referrals, and 
aftercare. 
Nevertheless, offcials from IHS and BIA agree that existing coordination is not 
suffcient, and servces are neither integrated nor complete. l)espite the wide range of 
programs and servces authorized by the legislation, these individual efforts do not 
provide a comprehensive solution to Indian alcohol and substance abuse. 
COORDINATION IS ESENTI FOR EFFECTVE PREVENTON,
TRATMNT, AN AFfRCARE 
Regional Treatment 
Centers 
Recretion Centers 
 Detention Centers
TeCen Heenathters  Triba Police, Triba 
Court  ""'"'''''' ''' . .....".,,.,., '.'''.'....''.. .''.''. ............. '..'.'-'. .."..,  ...'.'..''...................''., ..' ', "."...'.'...
Presen, Indn 
cont  alcohol and sustance abuse seres do not offer a comprehense
of care 
While treatment is essential for any 
successful alcohol or substance abuse 
program, many offcials mentioned the 
need for a strengthened continuum of
care. Almost all IHS and BIA area
coordinators want stronger prevention and aftercare programs. 
The IHS and BIA currently fund some prevention activities in BIA 
schools such as 
I)rug Abuse Resistance Education (I).A.R.E.) and Basic Alcohol and Addiction 
Beginning Education Studies (BABES). While these programs exist
, officials
expressed the need to improve as well as add programs. Currently, more Indian 
students attend public schools than BIA schools. Officials believe that some Indian 
education and prevention funds should be used for public school prevention programs 
designed specifically for Indian youth. 
Afercare and transitional living programs, which include emergency shelters, halfway
houses, and detention centers, are insuffcient. For example, only 10 of the
33 authorized emergency shelters are operational. Offcials complained that site 
selection, construction time, and staffing considerations hinder program development. 
They also believe the abilty to expand existing programs and add new programs would 
help extend the continuum of care. 
offls 
Most ms  recommnd a 
more holiti approach to th treatmnt of alcohol 
and sustance abuse 
Offcials believe that treatment of alcohol
c.. 
and substance abuse purely as diseases is  9t?iljgfq!i ;1!lq  ljgXqfitrm
not always successful and that programs 
Lqiflf4tBiJtqR nZep  fft9J;qt
should address the multiple problems of 
9Iq9JW?!i9ff  ifqfrqnS  9qif  P9ij iJ'i
individuals. Officials from 10 IHS area 
offces believe that IHS should integrate  lili 
its mental health and social servces with  llt!1111  111
alcohol and substance abuse servces. 
Some area offces already have integrated
their servces, but headquarters branches remain separate. 
Intervention teams and child protection teams are examples of effective coordination
among IHS, BIA tribes, and other government entities, but not all area offices use 
these approaches effectively. Generally, teams adopt a case management approach 
for placement and treatment plans. Both intervention and child protection teams 
consist of personnel from various disciplines, including chemical dependency, mental
health, social servces, medical servces, law enforcement
, and the courts. This assures 
treatment of an individual's total needs. For example , during child protection team  meetings, participants discuss alcohol and substance abuse as a factor in most child
abuse and neglect cases. Many officials said that the child protection teams have done 
the most to foster coordination and focus attention on the problems of substance
abuse.
Intervention teams focus on both adult and youth alcohol and substance abuse clients.
One area offcial summaried the views of many who strongly support the team 
concept for assessing and treating clients. He stated: 
Congress should know that the team approach has increased greatly our 
abilty to handle clients. We have gone from around 300 to 1 
600 clients 
per year since 1986. We are able to get a client into treatment in half a 
day. Others, who does not use the team approach, say it takes them 
3 weeks. Plus it allows us to deal with multiple problems.  RECOMMENDATION
The Indian Health Servce, in conjunction with the Bureau of Indian Afairs, should 
review, update, and streamline the Memorandum of Agreement with the goal of 
developing a practical plan of action. Consideration should be given to:

(a)(cid:1) updating and revising the Organizational Master Action Plan and area 
office workplans 
(b)  completing and/or updating Tribal Action Plans and Local Action Plans
(c)  collocating headquarters alcohol and substance abuse program offices 
(d)  resolving staff turnover problems
(e)  issuing the emergency shelter guidelines, and 
implementing an holistic approach for treating Indian alcohol and 
(f)(cid:1)
substance abuse. 
AGENCY COMMNT
The Public Health Servce agreed with the OIG recommendation and in its co=ents 
on our draft report discusses some of the actions IHS has taken or plans to take to 
address the specific problems. The IHS is working actively with BIA on several issues. 
Representatives from IHS and BIA met on June 3, 1992 to revise the Memorandum 
of Agreement. After review and comment, both agencies expect to sign the 
Agreement in the near future. The IHS and BIA also met in June 
1992 to discuss
emergency shelters and in July to discuss detention centers. The emergency shelter 
guidelines have not been issued yet.
The IHS reported there are now Tribal Action Plans in place for 381 tribal groups out 
of a possible 546 plans. The agency expects to complete 69 more Tribal and Local 
Action Plans soon. The IHS is working dilgently to recruit and retain more well-
trained alcohol and substance abuse and mental health staff. According to IHS
collocating IHS and BIA staff would involve significant tribal consultation.
The complete text of the comments is contained in appendix B. APPENDIX A
MEMORA1J OF AGREEME: STAT1S OF MAOR PROVISIONS AS 
OF SPRIG 199 
The Memorandum of Agreement Review Process 
The Memorandum of Agreement directed BIA and IHS to review the 
Agreement annually within a month of its signing. A formal review of the 
original Agreement was completed in August 
1988. No subsequent reviews 
have occurred. 
Area Office Workplans 
The Memorandum of Agreement requires that IHS and BIA area offices revise 
their workplans annually. Most area offces submitted one workplan with only
one update. This corresponds with the single review of the Agreement that was 
completed in 1988. The IHS officials stated that the focus on workplans has 
dimished since 1989 because "many of the original items being tracked in the 
workplans have been completed" and "IHSIBIAribal coordination is less than 
optimal in a number of areas. 
Tribal Action PlanslLcal Action Plans
Overall, only 241 Tribal Action Plans and 6 Local Action Plans, out of a 
possible 546, have been completed. The Tribal Action Plans and Local Action
Plans establish a basis for coordination at the tribal level. According to the 
legislation, IHS servce unit directors and BIA agency and education 
superintendents were to enter into a Tribal Action Plan at the request of the 
tribe. The plan s purpose was "to coordinate resources and programs relevant 
to alcohol and substance abuse prevention and treatment." Indian tribes were 
to develop a Tribal Action Plan 90 days after the Memorandum of Agreement 
Federal Register.  If this did not occur, IHS and BIA offcials 
publication in the 
were to develop a Local Action Plan for the tribe. Although five IHS area 
offces completed plans for all their tribal groups, two large area offces 
completed only 19 percent of their required plans. 
The Newsletter
According to P.L. 99-570, BIA was to publish and distribute a newsletter 
highlighting exemplary Indian alcohol and substance abuse programs. Partial 
funding was to come from IHS. This requirement has been partially and 
sporadically met. The OIG received copies of "Linkages " a bi-monthly 
newsletter dedicated to children s mental health issues. Beginning  , "
February 1987  Indians Against Drug Abuse" was published as an insert to 
Linkages." The last edition of "Indians Against Drug Abuse" was distributed in
June 1990.
For more than a year, no newsletter was published while BIA established a new 
contract. "
Prevention Quarterly" replaced the former insert. It focuses on 
alcohol and substance abuse prevention and treatment. The first issue was 
published in September 1991. 
Communitv Training 
As the lead agency for providing community training, IHS developed a trainer 
manual that included daily schedules, modules, and guidance on group behavior 
and training techniques. AIl IHS area offices submitted documentation on 
completed trainig. The OIG did not assess the quality or effectiveness of the
training materials.
Judicial Servces and Law Enforcement Training 
As the lead agency in developing and implementing training for tribal judges 
and law enforcement personnel, BIA contracted with the National Indian 
Justice Center to develop a training program. The Center prepared a manual 
that includes training schedules, laws, court cases, and other background 
information.
Identification of Programs
In response to this requirement, IHS produced a listing of alcohol and 
substance abuse programs for fiscal years 1988-1992. The listings include the 
program s name, director s name, contract information, program components 
program costs, total staff, total number of counselors, and number of certified 
counselors. 
Emergem;y Medical Assessment
L. 99-570 mandates "the emergency medical assessment and treatment of 
every Indian youth arrested or detained by BIA or tribal law enforcement 
personnel for an offense relating to or involving alcohol or substance abuse. 
The IHS and BIA developed another Memorandum of Agreement to 
coordinate these servces. Due to IHS staff limitations and continuity concerns 
with BIA staff, the degree to which this was successfully implemented has never 
been evaluated.  ,... 
,,  ""
 
Minimum Standards Compliance Plan
In consultation with Indian tribes, IHS and BIA were to establish minimum
standards for alcohol and substance abuse programs. They did
, in fact
establish a work group that included representatives from Indian-operated
alcohol and substance abuse programs, IHS area coordinators, and members of
the IHS Alcoholism and Substance Abuse Program Branch. Although IHS
co=itted key resourCes to this effort, BIA did not play an active role in
developing or reviewig the guidelines. All Indian alcohol and substance abuse
program managers received draft standards.
Scope of the Problem
Congress directed IHS, BIA and the tribes to determine the scope of the
problem of alcohol and substance abuse among Indian people and to report on
the financial and human costs of people directly or indirectly affected by such
abuse. The IHS and BIA accomplished this task. First, the I)epartment of
Interiors Offce of Program Analysis issued a November 1987 report entitled
Scope of the Problem and Economic Costs Interim Report.
" Second, IHS
contracted with the American Indian Health Care Association to conduct a
follow-up study and released the study s final report in February 1992.
Assessment of Resources
According to the Memorandum of Agreement  IHS, in cooperation with BIA
and tribes, will conduct an assessment of the existing and needed resources and
provide an estimate of funding necessary for a program of prevention of
alcohol and substance abuse and the treatment of Indians affected by alcohol
and substance abuse  " Most IHS area offices developed a listing of resources
that identify and group Federal, tribal, State, local, and private resources.
Emergenq Shelters
According to the Memorandum of Agreement  BIA in cooperation with the
IHS will promulgate standards by which the emergency sheltersno
shall be
established and operating, by September 1987
,no" The standards have not been

issued. I)raft guidelines are stil under 
review.
The Tribal Comprehensive Report
According to the Memorandum of Agreement, the tribal comprehensive report
was to "provide tribes with...(a) report of BIA and IHS alcohol and substance
abuse data." The Organizational Master Action Plan identified a work group of
IHS and BIA representatives. The group was responsible for 
establishing
guidelines for the collection, coordination, and distribution of this information.
The work group developed draft materials
, which were made available to the , "
area offces. These materials were never fialized, however. Only one IHS 
area office used the draft guidelines to develop its tribal comprehensive report. 
Child Abuse and Neglect 
According to the Memorandum of Agreement  BIA in cooperation with IHS 
wil compile data relating to the number and 
tyes of child abuse and neglect
cases and the tye of assistance provided, reflecting those that involve, or 
appear to involve, alcohol and substance abuse, those which are recurring and 
those that involve other minor siblings." As required, BIA issued a report 
entitled "Fiscal Year 1988 Chid Abuse and Neglect Data" that includes 
information on the total and suspected number of cases involving alcohol or 
substance abuse.
Curriculum Assessment 
The Memorandum of Agreement requires that "BIA in cooperation with IHS 
will provide technical assistance as necessary to develop and implement 
currcula in kindergarten and grades 1 through 12 relating to alcohol and 
substance abuse prevention and treatment." The IHS and BIA coordinated the 
assessment of BIA-funded school curricula. The IHS conducted a study 
entitled "School/Co=unity-Based Alcoholism and Substance Abuse Prevention 
Survey," and BIA used the study s results to develop the Drug Free Schools 
program with the I)epartment of Education. 
Crisis Intervention 
The Memorandum of Agreement requires that "BIA in cooperation with the 
IHS will provide for individual student crisis intervention in schools funded by 
BIA and a reporting of all incidents relating to alcohol and substance abuse.... 
The BIA took the lead in developing a crisis intervention plan for its schools. 
The plan coordinates school, tribal, IHS, and BIA programs to place students 
who are in crisis into a treatment setting. 
Model Juvenile Code 
The Memorandum of Agreement directed BIA IHS, and the tribes to 
cooperate in developing a model juvenile code. The National Indian Justice 
Center developed a code under a BIA contract. Indian judges, tribes, and IHS 
offcials reviewed the code before it was finalized.  APPENDIX B 
AGENCY COMMNT  (-,
DEPARTME OF HETH &. HUMA SERVICE  I'blic Hea Ser 
Memorandum
AUG 3 I 1992
Date
Assiseane Secreeary for Healca

From
Subjec Office of Inspeceor General (OIG) Drafe Reporc -Indian Alcohol 
and Subscance Abuse: Legis lacive
 Incenc and Realiey, 
oEI-09-92-000 10

Accing Inspeceor 
General, OS 
Aeeacaed are eae Public Healca Service commencs on cae subj ecc
drafc repore. We concur wica cae recommendaeion. In our 
commencs we discuss some accivicies undereaken by cae IHS 
respond co cae issues idencified in cae repore.

(J'Iv
Mason , M.  . Dr.P.-
Accacamenc GEN 
PHS COMMENTS ON THE OFFICE OF INSPECTOR  (OIG 1 DRAT
INDIA  AN 
REPORT "  ALCOHOL  SUBSTANCE ABUSE: LEGISLATIV 
INTEN AN REAITY, " OEI-09-92-00010 
General Comments
tw 
The OIG report cites  major findigs: (1) the Indian
Health Service (IRS) and the Bureau of Indian Affairs (BIA)
have not achieved the level of coordination envisioned by 
Congress, and (2) limted coordation undezmes the 
continuum of care for treating alcoholism and substance abuse. 
IRS agrees that the five barriers to coordiation between IRS 
and BIA, that OIG has identified, have contributed
signficantly to 
these findings. 
to facilitate 
Actions could be taken by IRS and BIA 
coordination by lessenig or elimnating some of these 
barriers. Some of these actions could be accomplished rather
easily and others, for historical or political 
reasons, would 
be very difficult to take. . For example, IRS believes that
hiring full-time BIA Alcoholism Coordinators would greatly
improve coordination between these organizations. However, 
collocation of IRS and BIA Area Offices is a barier not 
easily addressed and would involve signficant tribal 
consul tation. 
dicted 
99-570 and its amendments  funds
Ppublric iLamw (P ily 
for youth services, a previously identified gap in 
programs initially established under the Indian Health. 
437. 
Improvement Act, P.L. 94- However, it must be noted that 
remin in the 
significant gaps  continuum of care as each tribe 
contracted for a slightly different focus in the scope of
work. 
Access to IRS-funded prevention services; adult 
treatment services, both inpatient and outpatient; adolescent 
and adult group homes; halfway houses; and services targeting
sub-populations s 
ch as women, pregnant women, and elders
remin variable  commty to the nex. 
from one  Al though
curntly 
regional treatment centers (RTCs) are  funded for 
adolescents, the majority of IRS- and BIA-funded program
continue to be contracted with individual tribes for services 
for their respective memership in accordance with 
638. Coordation of 
93-
resources among IRS, BIA and
L.  in plang 
other agencies remins critical 
for and site 
selection of additional services. 
The issue of merging the Mental Health Program and the 
Alcoholism and Substance Abuse Program Branch (ASAPB) into a
single organizational entity comes up fro time to tie when 
the coordination of increasingly complex medcal disciplines
is discussed. Curntly, 
since these disciplines are housed 
in branches that are part of IHS' Division of Clincal and 
Preventive Services, there is considerable cotohrdt ation of 
efforts. At this time, IRS does not believe  the  ging of these tw 
disciplines at headquarers would result 
occus 
in better coordination, since such coordiation already 
level. 
at the  division 
tie 
The IHS believes that benefits remin at ths  for 
maintaining separate disciplines while monitoring
implementation-of the new IRS alcoholism stadards. These
stadards requre a muti-dsciplin 
approach for treatment 
of alcoholism, includig mental health and social work
services. 
Conc=ent with ths effort, IR will focus on
imroving the recrutment and retention of alcoholism and 
substance abuse, and mental health staff. These efforts will 
address cross-traing of 
both disciplines. 
The Appendix Section of the report lists the status of 12 
major provisions of the Memorandum of Agreement (MOA) between 
IHS and BIA. Although only 241 Tribal Action Plans (TAPs) of 
a possible 546 were identified as completed, it should be 
subtted by 
noted that nine of these plans were  Alaska Native 
Health Corporations representing a total of 149 tribal
entities.  cuently 
Therefore, 
s are in place 
completed 
for 381 tribal entities. In  s and Local 
Action Plans (LAs) are in theadd ition, 69 
development stage soon to be
confirmed . 
The memorandum transmtting the report includes the Issues and 
Responses prepared by OIG for the Senate Select Commttee on 
Septemer 24, 1991. It 
Indian Affairs on  includes a statement 
that the P . 
L. 99-570 appropriations totalled $12 million for 
construction and renovation of adolescent treatment centers 
for Fiscal Years (FY) 1989 - 1992. The actual amount 
appropriated for constrction of RTCs for FY 1987 - 1992 was 
$9. 612 million. 
One final point should be considered when viewing the
availabili ty and quality of 
alcoholism and substance abuse 
treatment provided by ms. 
The OIG review of the IHS reality 
of implementation of the intent of Congress focused on the
MOA. aowever, IRS contiues to address several major item of 
the legislation which are not included in the MOA, includig
RTCs, commty reili ta tion and aftercare. IRS, although
madated to collaborate with 
BIA opn rdeitment ion centers and 
responsibility for
emergency shelters, does not have 
contiues to 
implementing these program.  work 
IRS has and 
with BIA in workgroups and focused meetings on these topics. 
OIG RECOMMATION 
The IHS, in conjunction with BIA, should review, update, and
streamine the 
MOA with the goal of developing a practical 
plan of action. Consideration should be qiven to:  a) Updating and revising the Organzational Master Action
Plan (OMA) and Area Office Workplans;
b) Comleting and/or updating TAs and LAs; 
c) Collocating Headquarers ASAPB. offices;
d ) Resolving 
staff turover problems; 
e). Issuing the 
emergency shelter guidelines; and, 
f) Imlementing an holistic approach for treating Indian
alcohol and substance abuse.
PHS COMMS 
has 
We concur with the OIG recommendation. Actions that IHS 
. to 
taken or plans to take  address the specific issues 
highlighted by OIG follow: 
a) Representatives of IHS and BIA ASAPB offices met on 
to develop a draft revision of the MOA. 
June 3,  1992 
After the BIA and IRS staff review and comment on the 
draft and subsequent revisions, the MOA will be
subtted 
to both Agencies for signature. The target 
date for completion is October 1992. The proposed
revisions include specific language relative to
admtted to 
coordination of services for adolescents 
detention centers, emergency shelters and regional
treatment centers. 
b) Joint Area Workplans, as outlined in the MOA and OMA,
are to reflect TAs.  cuently being revised, 
The MOA 
updtig 
reinfQrce the IRS and BIA role in  TAPs or 
wtilhl  e development of LAs. National Headquers Offices 
workgrup with Ara 
of both BIA and IRS will identify a 
and local level representation to develop a formt and 
gudelines for workplans and LAs. 
ASB Chef to 
advertising for a new 
c) The IRS (cid:1) is 
located in Rockville. Interim plans include
identification of staff within the cuent Headquarters
Offices as the focal point for coordation 
with BIA
staff. 
meetigs also
Ongoing joint IRS and BIA 
continue regardg 
emergency shelters and detention 
centers. Most recent meetings include an emergency
shelter meeting in ' Aluquerqe on June 23-25 and a 
C. on July 7. 
detention center meeting in Washington, D.  with 
d) Staff turover remains a challenge  both 
maintain coordiation with the 
Agencies.p Trhiem   
IHS  fowcill us, assigng 
BIA as a  responsibilities to 
staff to assure continuity, even during future 
personnel changes. The IHS continues to rec=it well 
trained staff to address alcoholism and substance abuse
problem; 
however, competing employers who offer more 
hider efforts
lucrative salaries and lighter workloads 
to retain qualified staff. 
remin a responsibility of the
e) The emergency shelters 
BIA. The IH continues to particisptaatne dina sH.e adquarers 
level meetings regardig shelter  This focus 
will be broadened to include Area level BIA and IHS
coordination to develop services (taking into 
consideration other resources) to address the continuum 
of care. 
te= "
f) The use of the  holistic" in the present context 
is not clear. The desire is for broader coordination 
and integration of different disciplines, to bring to 
aray of
those with alcoholism, the most comprehensive 
coordation 
serVices. IRS agrees that closer  between 
mental health and substance abuse treatment services 
would greatly benefit the program. 
The greatest
barier is 
the shortge of mental health workers
thughout IHS. 
However, IRS believes also that the 
concept should not be limted only to mental health, 
includig
but should involve other disciplines 
education, rehabilitation, physical and recreation 
therapy, medicine, social services, and others. The 
MOA between IHS and BIA, and the ASAPB standards 
adapted in May 1991, reflect a goal of multi-
disciplina4 treatment. 
thugh its 
th Division of 
The IRS coordinates services 
Clincal and Preventive Services, wi  whch these 
disciplines are encompassed. Adolescent RTC reviews 
ar cuently conducted by a Headquarers team, which 
includes representatives from Mental Health. The 
recently hired Quality Assurance (QA) Officer for the
ASB, 
met with the Mental Health QA Officer to begin 
regaring 
work on Area and program review elements, 
imroved coordation among the Branches, to enhance
patient services. 
Several Area Offices, for example, 
Alaska, California and Oklahoma, continue to function 
as a behavioral health model includig alcoholism and 
mental health as a single unit.  ths  coordtion 
report,  often occus at 
As noted in 
the local level. This applies not only to BIA and IRS 
may of which 
interaction, but also services of IR, 
Severl tribal health 
a:e often contracted by tribes. 
dceopmariennqts  now operate as a behavioral health mod=els,s 
alcohol and mental. heal.th serices and 
;n;nq of staff. 
The TAs and LAs may (dependiq on independent tribes)
simla:ly reflect a 
mdoerel ievfefi,c ioefntte nan cd o"mhoilnisqt ipcr"o  qr
approach to service 
IR 
services and funds.  continues to support separte
Branches, but closer workiq relationships to proide 
assessment and tratment 
multi-disciplinar team 
approaches.