In the last two years, about a quarter of the babies born on the San Carlos Apache Indian Reservation in Arizona tested positive for methamphetamine. The Navajo Nation has seen a doubling of methamphetamine use on the reservation over the last five years. And on the Wind River Indian Reservation in Wyoming, assaults and criminal charges for drug possession tripled, thefts doubled and reported incidents of child abuse increased by 85% between 2003 and 2004.
These aren’t isolated cases. The grim statistics are cropping up throughout Indian Country.
“Methamphetamine is killing our people and devastating our communities,” Joe Garcia, president of the National Congress of American Indians, stated earlier this year in a “Call for Action” that included a request for a White House partnership to combat the problem.
Federal, state, tribal and private health care agencies are joining forces to tackle what many tribal leaders are calling a crisis. And nurses, of course, are working with other health care professionals on the front lines.
“Nurses play an important role,” says Love Foster-Horton, public health advisor for the federal Substance Abuse and Mental Health Services Administration (SAMHSA)’s Center for Substance Abuse Treatment. “They’re usually the first responders. They’re educated to know what to look for and they can serve as referral sources for patients to help them into treatment.”
People have abused methamphetamine for decades, but the problem is a relatively new phenomenon in Indian Country. Indian Health Service clinics first began seeing the signs about six years ago. Since then, the number of IHS patient services related to amphetamine abuse have more than doubled—to 7,004 contacts in 2005 compared to 3,000 contacts in 2000.
Today meth is the third most commonly used drug in Indian Country, says Dr. Anthony Dekker, associate director of clinical services for the Phoenix Indian Medical Center in Arizona. Alcohol remains by far the most frequently used substance, followed by marijuana.
Meth abuse has drawn much media attention because it has such an immediate and devastating impact on users. Alcohol, Dekker says, tends to be a slow killer. But chronic meth abuse causes anxiety, emotional swings and paranoia, often leading to violent behavior, including assault, homicide and suicide. “People start using it and end up in jail or end up dead,” he says.
Annette James, DPhN, BSN, RN, public health director for the Mille Lacs Band of Ojibwe in north-central Minnesota, says she doesn’t think of meth as a drug but as a toxic substance. Meth labs wreak havoc on the environment as well as on people’s lives, especially children.
“Meth just turns the user into a totally different person, and [as a result, the user’s children receive] no care,” says James, a member of the Creek and Seminole nations.
Meth addicts lose their appetites, so they neglect feeding their kids, she explains. And the chemicals used to make the drug are poisonous. Children found living around meth labs have to go through a decontamination process. “I don’t think we even know the effects on these children living in the environment where these substances are being cooked,” says James, who is finishing her master’s thesis on the effects of methamphetamine abuse and labs on young children. “It’s just so frightening what’s going on.”
In April, Kathleen Kitcheyan, chairwoman of the San Carlos Apache Tribe, told the U.S. Senate Committee on Indian Affairs that homicides and suicides on her reservation have spiked, most likely as a result of meth abuse. “The use, production and trafficking of meth is destroying my community—shattering families, endangering our children and threatening our cultural and spiritual lives,” she stated.
The highest rates of meth usage in American Indian communities are among people ages 15 to 44. Dekker says an estimated one-third of teens on reservations in the Southwest have experimented with meth.
Kitcheyan told of one patient who was brought to the San Carlos Hospital, high on meth and hallucinating. He was nine years old.
Meth usage seems to be equal among men and women. “Twenty years ago, [most Indian] women didn’t drink or do drugs,” says Judy Whitecrane, CNM, director of nurse-midwifery services at the Phoenix Indian Medical Center. But now, out of the eight or nine patients on the hospital’s maternity ward at any one time, at least one tests positive for methamphetamine use, she estimates. The drug can lead to a variety of complications for both the mother and baby. In the worst-case scenario it causes abruption. The placenta breaks away from the uterine wall, causing massive bleeding, killing the baby and threatening the mother’s life.
A variety of factors have led to the meth addiction epidemic in Indian Country. Meth use has increased in rural communities throughout the United States. Some drug cartels have targeted reservations, taking advantage of the complex web of jurisdictional issues that make prosecution more challenging. Poverty and limited resources also come into play.
For instance, of the 13,000 people who live on the 1.8-million-acre San Carlos Apache Reservation, 65% are unemployed. “We suffer from a poverty level of 69%, which must be unimaginable to many people in this country who would equate a situation such as this as one found only in Third World countries,” Kitcheyan told the Senate committee.
Furthermore, meth is relatively easy to produce. “It’s cooked up in the back of cars, in motel rooms and basements,” James says. “In the winter, some people [here in Minnesota] are using ice fishing huts on the lakes to make it.”
Plus, it’s cheap. “A lot of people use substances to treat feelings. When they’re numb, they don’t think about how bad they feel,” says CAPT Lonna Gutierrez, a family nurse practitioner at the Phoenix Indian Medical Center and an officer in the U.S. Public Health Service Commissioned Corps. “People will treat with whatever they can afford. If they can afford it, they’ll buy a bottle of Wild Turkey whiskey. If they can’t, they’ll sniff paint or use meth.”
While there are no easy solutions to a problem of this magnitude, the Indian Health Service, other federal agencies, private sector health organizations and tribal officials across the country are partnering to respond to the meth epidemic with culturally appropriate interventions. A variety of promising programs have been developed and are available nationally.
The Matrix Model outpatient drug and alcohol treatment program—which focuses on lifestyle changes, training in relapse prevention, education on dependencies and family involvement—now includes a culturally relevant component designed specifically for use in American Indian and Alaska Native communities. The patient questionnaire, for instance, uses interviewing techniques that motivate rather than confront people. As a result, patients are more likely to come forward because they don’t feel they are being judged or attacked, Foster-Horton says. Developed by the Matrix Institute on Addictions (http://www.matrixinstitute.org/), the Matrix Model has earned the support of SAMHSA, the IHS and many tribes, who are training their staffs to use the program.
In Montana, the Billings Area of the IHS has developed a four-step recovery program that combines traditional Indian medicine with Western psychological and recovery components.
White Bison (www.whitebison.org), an American Indian-owned non-profit in Colorado Springs, Colo., offers sobriety, recovery, addictions prevention and wellness learning resources to the Indian community, including a culturally appropriate 12-step program based on the medicine wheel. White Bison champions the concept of “wellbriety,” which focuses on the opportunity for recovered people to not just survive but thrive.
Rather than declaring war against drugs, wellbriety strategies declare healing, Foster-Horton says. “The belief is that if you declare war on something, you bring it in[to yourself].”
Annette James became interested in learning more about methamphetamine after seeing abuse of the drug run rampant through Oklahoma, where she went to nursing school. “I noticed that on reservations there was denial and not a full understanding of meth and meth labs and what they’re doing to the environment,” she says.
That situation is rapidly changing, though. Today many tribes are working tirelessly to address the meth crisis, and they are making progress. This past April, White Bison, the National Indian Health Board (NIHB) and the Native American Rehabilitation Association of the Northwest co-sponsored the conference “Taking a Stand Against Meth: Recovery Is Possible.” The conference featured many “what’s working” education sessions showcasing successful strategies being used by tribes in various parts of the country.
The San Carlos Apache Tribe held a meth forum earlier this year for the staff of all of its tribal programs and has created a Methamphetamine Prevention Coalition. Tribal police underwent training and the tribe revised its legal code to improve enforcement capability. The tribe also launched a media campaign to educate the community and implemented an outreach program for employees.
Similarly, the Mille Lacs Band of Ojibwe created a methamphetamine coalition to increase awareness in the community and among reservation employees after its chief called attention to the issue.
But much work still lies ahead. James says more research and training are needed for public health workers, social workers and nurses who work in Indian Country.
Tribal leaders have called for more resources and assistance from the federal government. Jefferson Keel, first vice president of the National Congress of American Indians, told U.S. senators that the IHS and tribal health programs are funded at less than 60% of the level needed to provide adequate health care services. Among other steps, he called for central coordination of federal Indian Country methamphetamine resources, more funding for tribal anti-meth efforts, an increase in SAMHSA grants and at least enough IHS funding for the agency to maintain current services so it doesn’t fall further behind.
Hospitals and clinics in Indian Country are also strategizing about how they can better serve their patients who are suffering from meth addictions. Here, especially, nurses and nurse-midwives are making significant contributions.
After seeing a growing number of pregnant women using methamphetamine, nurses and midwives at the Phoenix Indian Medical Center met with substance abuse counselors and pediatricians to figure out how to address the problem. They researched best practices and examples of successful model programs to develop an evidence-based intervention. The result was the creation of a Special Care Clinic to offer mental health and substance-abuse counseling and treatment to pregnant women with drug, alcohol or behavioral health problems.
The clinic’s substance abuse counselors are all American Indian women, and the clinic is in the same building where patients get their regular prenatal care, so help is just a few steps away for anyone who needs it.
“Women [with drug abuse problems] are already ashamed,” Whitecrane says. “We create a welcoming environment. Instead of sending patients to another building, I just walk them right over to the social worker or substance abuse counselor.”
The clinic staff set the criteria for referral to the program. Any pregnant patient who misses an appointment, admits to previous drug use or delays prenatal care, for instance, undergoes a drug screening test. Patients who test positive are then referred to the Special Care Clinic.
The program also utilizes other evidence-based practices, such as drug contracts and incentives for staying drug-free. A group called Mothers Lifeline provides gift certificates for the mother and items for the baby. The gifts help make the patients feel special and serve as incentives to stay healthy. And the items for the baby make the pregnancy feel more real to the expectant mothers, giving them further incentive to take care of themselves.
Whitecrane says she has had to learn about methamphetamine in the last few years as the incidence of meth abuse began growing among her patients. She believes there is hope for these mothers and their children. “We often see these things turn around,” she notes.
Most of Gutierrez’s patients with addictions have alcohol problems, but she is seeing a growing number of young people who abuse methamphetamine. An expert in pain management and addiction medicine, Gutierrez says meth addiction is difficult to treat because the drug distorts people’s judgment, making them overly confident or paranoid.
Gutierrez, whose grandfather and great-grandfather were American Indians, began working in Indian Country 27 years ago after she joined the U.S. Public Health Service. “I’ve learned more from my patients than they have learned from me,” she declares. “In Western medicine, we impose healing from the outside in. In Indian Country, people heal from the inside out. [Indian] people believe your health starts with spiritual harmony.”
She says she tries to motivate patients to get in touch with what’s inside them, and she meets them where they are. “You have to have a relationship with that person,” she explains. “I ask them, ‘What is missing from your life and what do you need?’ The trick is to appeal to a person’s will to live. That’s the art of medicine.
“The saddest thing is to see a patient who doesn’t want to help himself and has decided to continue with the addiction,” Gutierrez continues. “When a person comes to me like that I can’t help him. What I try to do for those patients is keep the door open.”
But for other patients battling meth addiction, victories are occurring. Gutierrez knows of many people who, suffering from addictions, “went to the bottom of the pit and stared death in the face” and then chose to recover. “When those people emerge from that abyss,” she says, “they have incredible wisdom and personal dignity, and they’re able to help others [who come after them].”