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. 

OFFCE OF EVALUATION AN 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-09-92-00l0 
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 coorditin unrm cont of care and an holiti approach 

for treatig Indian alcohol and sustance abuse 

RECOMMNDATION€

Th Indn Heallh Service, in conjuntin wih the Bureau of Indian Affair, shoul€ rev€, 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 ............................... AAppendix 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 Interior s 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 inperson 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 

Th € Memra of Ageemnt formlied th need for coordtin 

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 coordtin occu regardl of the efort of area offes and headrt€

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 COORlINATION UNER CONT 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 


Teen Heath Centers 

Detention Centers€

Triba Police, Triba 

Court 
. ............... .. ,,,, . . ... ... .., . .. ... , , ....... .

Presen, Indn alcohol and sustance abuse seres do not offer a comprehense cont 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. 

Most ms offls 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 

its mental health and social servces with lili 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) 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 

(f) implementing an holistic approach for treating Indian alcohol and 

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 welltrained 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 

publication in the Federal Register. If this did not occur, IHS and BIA offcials 

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€ Interior s 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 sheltersnoshall 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 

(,

Date€

From€

Subjec€

AUG 3 I 1992€

Assiseane Secreeary for Healca


Office of Inspeceor General (OIG)€

and Subscance Abuse: Legis lacive


oEI-09-92-000 10


Accing Inspeceor General, OS 

Memorandum€

Drafe Reporc - Indian Alcohol Incenc and Realiey, 

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€
PHS COMMENTS ON THE OFFICE OF INSPECTOR GEN (OIG 1 DRAT REPORT " INDIA ALCOHOL AN SUBSTANCE ABUSE: LEGISLATIV 

INTEN AN REAITY, " OEI-09- 92-00010 

General Comments€

The OIG report cites tw 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. 

Actions could be taken by IRS and BIA to facilitate 

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. 

Public Law (P 99-570 and its amendments dicted funds primily for youth services, a previously identified gap in 

programs initially established under the Indian Health. 

Improvement Act, P. L. 94-437. However, it must be noted that 

significant gaps remin in the 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 from one commty to the nex. Al though regional treatment centers (RTCs) are curntly 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 L. 93-638. Coordation of resources among IRS, BIA and other agencies remins critical in plang 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 coordation of 

efforts. At this time, IRS does not believe tht the 
ging of these tw disciplines at headquarers would result 

in better coordination, since such coordiation already occus at the division level. 

The IHS believes that benefits remin at ths tie 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 

noted that nine of these plans were subtted by Alaska Native 

Health Corporations representing a total of 149 tribal entities. Therefore, cuently completed s are in place 

for 381 tribal entities. In addition, 69 s and Local 

Action Plans (LAs) are in the 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 

Indian Affairs on Septemer 24, 1991. It 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 on detention centers and 

emergency shelters, does not have prim responsibility for implementing these program. IRS has and contiues to work 

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 

We concur with the OIG recommendation. Actions that IHS has 

taken or plans to take . to address the specific issues 

highlighted by OIG follow: 

a) Representatives of IHS and BIA ASAPB offices met on 

June 3, 1992 to develop a draft revision of the MOA. 

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€

coordination of services for adolescents admtted to 

detention centers, emergency shelters and regional€

treatment centers. 

b) Joint Area Workplans, as outlined in the MOA and OMA, are to reflect TAs. The MOA cuently being revised, will reinfQrce the IRS and BIA role in updtig TAPs or 

the development of LAs. National Headquers Offices 

of both BIA and IRS will identify a workgrup with Ara 

and local level representation to develop a formt and 

gudelines for workplans and LAs. 

c) The IRS  is advertising for a new ASB Chef to 

located in Rockville. Interim plans include identification of staff within the cuent Headquarters Offices as the focal point for coordation with BIA staff. Ongoing joint IRS and BIA meetigs also continue regardg emergency shelters and detention 

centers. Most recent meetings include an emergency

shelter meeting in ' Aluquerqe on June 23-25 and a 

detention center meeting in Washington, D. C. on July 7. 
d) Staff turover remains a challenge with both 

Agencies. The IHS will maintain coordiation with the 

BIA as a prim focus, assigng 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 

lucrative salaries and lighter workloads hider efforts to retain qualified staff. 

e) The emergency shelters €remin a responsibility of the BIA. The IH continues to participate in Headquarers 

level meetings regardig shelter standas. 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. 

f) The use of the €te= "holistic" in the present context 

is not clear. The desire is for broader coordination 

and integration of different disciplines, to bring to 

those with alcoholism, the most comprehensive aray of serVices. IRS agrees that closer coordation 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, 

but should involve other disciplines includig

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. 

The IRS coordinates services thugh its Division of 

Clincal and Preventive Services, wi th 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 

work on Area and program review elements, regaring 

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. 
As noted in ths report, coordtion often occus at 

the local level. This applies not only to BIA and IRS 

interaction, but also services of IR, may of which 

a:e often contracted by tribes. Severl tribal health 

deparents now operate as a behavioral health model, cominq alcohol and mental. heal.th serices and =ss 

;n;nq of staff. 

The TAs and LAs may (dependiq on independent tribes) simla:ly reflect a more efficient and "holistic" 

approach to service delive, often cominq proqr services and funds. IR continues to support separte Branches, but closer workiq relationships to proide 

multi-disciplinar team assessment and tratment 

approaches.