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Testimony

Statement by
H. Westley Clark  M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Services Administration
U.S. Department of Health and Human Services

on
Creating Healthier Tribal Communities 

before
Indian Affairs Committee
United States Senate


Wednesday August 15, 2007

Chairman Dorgan and Members of the Committee, I am Dr. H. Westley Clark, Director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration or commonly called SAMHSA. I bring greetings from Dr. Terry Cline, SAMHSA Administrator. I am pleased to have this opportunity to join you and share with you how SAMHSA is working to create healthier tribal communities.  However, before I detail a few of SAMHSA’s initiatives, I think it is important to underscore the extent of substance use and mental health problems experienced among American Indians and Alaska Natives.

American Indians and Alaska Natives suffer disproportionately from substance use disorders (defined by symptoms such as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major obligations at work, school, or home during the past year) compared with other racial/ethnic groups in the United States. According to combined data from the 2002-2005 National Survey on Drug Use and Health (NSDUH) conducted by SAMHSA, American Indian and Alaska Natives over the age of 12 were more likely than members of other racial/ethnic groups to have a past year alcohol use disorder (10.7 vs 7.6 percent). They were also more likely to have a past year illicit drug use disorder (5.0 vs 2.9 percent). Specifically, rates of past year marijuana, cocaine, and hallucinogen use disorders were higher among American Indians and Alaska Natives than among other racial/ethnic groups.

One factor that may be driving the disparity in substance use between American Indian/Alaska Native youth and other youth is a higher rate of substance use risk factors among American Indian and Alaska Native youth.  For example, data from the 2002 and 2003 National Survey on Drug Use and Health show that American Indian/Alaska Native youth are more likely than youth of other racial/ethnic groups to perceive moderate to no risk of substance use and less likely to perceive strong parental disapproval of substance use.

With respect to mental health concerns among American Indian and Alaska Natives, between 1999 and 2004, suicide was the second leading cause of death among youth between the ages of 10 and 24, compared to the third leading cause of death among the youth population as a whole. Spirituality may play a protective role in reducing suicide attempts.  Specifically, a study of American Indian tribal members living on or near their Northern Plains reservations between 1997 and 1999 showed that those with a high level of cultural spiritual orientation had a reduced prevalence of suicide compared with those with a low level of cultural spiritual orientation.

Our work at SAMHSA does not stand alone – it requires partnership and the passion of others in order to make the largest positive impact.  For example, our partners at the Indian Health Service, the Department of Justice (DOJ) and the Bureau of Indian Affairs are instrumental in our success in assisting tribal communities in training and technical assistance. Our State partners are partnering with Tribes and Tribal communities to meet service needs. In addition, our grantees are hard at work in the field providing services. And, Tribal leaders across the country are expanding the dialogue with SAMHSA everyday.  All are examples of the type of collaborative efforts that create a wider reach than any single agency can provide alone.

The Tribal Training and Technical Assistance Sessions that SAMHSA, the Department of Justice, Office of Justice Programs (DOJ/OJP), and the Bureau of Indian Affairs at the Department of the Interior (DOI) have conducted this past year focus on tribal priorities related to public safety and public health for families and communities, and are an important tool to enhance collaboration.  Four sessions were held in FY 2007. It should be noted that the fourth session included a one-day Tribal Methamphetamine Summit hosted by the Office of National Drug Control Policy (ONDCP). These cross-agency sessions are designed so that Federal agency partners can share information on funding opportunities and agency initiatives with Tribes in one setting. Community challenges, best practices and lessons learned have been embedded into the session agendas to provide Tribes the opportunity to share their experiences and adapt strategies to their unique circumstances in their tribal communities.  Also included on the agenda for these sessions are opportunities for Tribal leaders to consult with Federal officials on public safety, justice and public health issues.  And, of course, we also rely on these Tribal Consultation Sessions to gain insight on Tribal priorities and gauge needs on pressing health and human services issues in tribal communities.  Some of the most pronounced areas of concerns expressed at these sessions surround methamphetamine use, suicide and access to Federal grants.

SAMHSA’s proposed FY 2008 Budget reflects those concerns.  Our mission in Indian Country and around the country has become much more focused and more clear with the release of the FY 2008 proposed budget.  SAMHSA Administrator Dr. Terry Cline has completed testimony on the FY 2008 SAMHSA budget and there are a few highlights I would like to share about the $3.2 billion proposed for SAMHSA. 

We are continuing to invest available resources in program priority areas such as: Screening, Brief Intervention, Referral and Treatment (SBIRT); Criminal/Juvenile Justice and Drug Courts; Access to Recovery; Substance Abuse Prevention; Children’s Mental Health Services; Suicide and School Violence Prevention; HIV/AIDS; and Mental Health System Transformation.  A comprehensive list of our grants can be found on our website:  www.samhsa.gov/grants/.

I want to draw your attention to a few of these priorities briefly.  Two of these priorities – the SBIRT program and the Treatment Drug Courts – have received increases this budget year and tribes are eligible to apply for both.  Currently, the Cook Inlet Tribal Council in Anchorage, Alaska operates an SBIRT grant.  For FY 2008, approximately $25 million is proposed for new SBIRT grants to increase screening, brief interventions, and referral to treatment in general medical and community health care settings. Approximately $32 million is proposed to fund about 75 Treatment Drug Court grants.  Tribes and Tribal Organizations are encouraged to apply for both of these important initiatives.  

With respect to suicide prevention, SAMHSA’s FY 2008 Budget includes $3 million for youth suicide prevention which will expand on a long-term commitment to tribal youth through the Native Aspirations project.  The Native Aspirations initiative is a five-year project that is operated through a contract with Kauffman and Associates, Inc. (KAI) – a Native American business located in Spokane, Washington.  SAMHSA consulted with Tribes through the contractor and to date 24 tribal communities are participating in the Native Aspirations project.  With continued input from Tribal leaders, we expect to expand this project in future years to include additional tribal sites.

I don’t want to just talk about proposed grant opportunities, but also current ones as well. One grant program I want to highlight is SAMHSA’s Targeted Capacity Expansion Grants (TCE) program.  In May 2007, SAMHSA announced $10.2 million in TCE Grants to expand or enhance a community’s ability to provide a comprehensive, integrated, and community-based response to a targeted, well-documented substance abuse treatment capacity problem and/or improve the quality and intensity of services. Applications were accepted under four Categories: 1)Native American/Alaska Native/Asian American/Pacific Islander Populations; 2) E-Therapy; 3) Grassroots Partnerships; and 4) Other Populations or Emerging Substance Abuse Issues.  Tribes were eligible to apply under all four categories and SAMHSA expects to award up to 16 grants in 2007, with an average grant amount of $500,000 per year for up to three years.  

Another program priority area is SAMHSA’s Access to Recovery (ATR) program. The ATR program permits grantees (i.e., States and Tribal Organizations) to provide clinical substance abuse treatment as well as recovery support services through a voucher-based system. The ability to provide recovery support services is a key issue of this grant program because it allows clients to pursue and maintain their recovery through many different and personal pathways, including traditional healing practices. The California Rural Indian Health Board was one of the first ATR grantees and it continues to serve as an example of what can be accomplished through tribal collaborations. For our second round of ATR grants, up to $98 million is available to fund approximately 18 new ATR grants in FY 2007 of which $25 million is expected to support treatment for clients using methamphetamine. 

Since the recognition of a growing methamphetamine problem nationwide, SAMHSA has continued to put a strong emphasis on prevention.  In FY 2006 SAMHSA awarded 10 Methamphetamine Prevention grants of approximately $350,000 each for up to 3 years The grant program is to support expansion of methamphetamine prevention, interventions and/or infrastructure development.  Of the 10 grant awards 2 were to Tribes, the Cherokee Nation of Oklahoma and the Native American Rehabilitation Association of NW, Inc., of Portland, Oregon. The grant program is designed to address the growing problem of methamphetamine abuse and addiction by assisting localities to expand prevention interventions that are effective and evidence-based and/or to increase capacity through infrastructure development.

SAMHSA is a member of the Office of National Drug Control Policy, Executive Native American Law Enforcement Workgroup along with members from DOJ, Indian Health Services, DOI, Tribal Police, and the Federal Bureau of Investigation. This workgroup is designed to coordinate and address the multidimensional aspect of methamphetamine use in Indian Country.  In addition, SAMHSA is part of the HHS Indian Country Methamphetamine Initiative (ICMI) along with the Office of Minority Health and the National Institutes of Health.  Through this project, nearly $1.2 million was awarded to the American Association of Indian Physicians (AAIP) and its partners to address the outreach and education needs of Native American communities on methamphetamine abuse. The partners are developing a culturally appropriate national information and outreach campaign on methamphetamine use in Indian Country.  They are also developing a methamphetamine abuse education kit, documenting and evaluating promising practices in education on methamphetamine use, and creating methamphetamine awareness multi-disciplinary education teams.  Five Tribes are included in this project – the Winnebago Tribe, which has been funded as a prevention site, the Navajo Nation and the Northern Arapaho Tribe, which are intervention and treatment sites, and the Crow Tribe and Choctaw Nation which are treatment and recovery sites

The Montana-Wyoming Tribal Leaders Council has received a SAMHSA suicide prevention grant and as a grantee they are implementing the “Planting of Seeds of Hope Project.”  In many ways, this Council has led the way in developing new collaborations between all of the Tribes in Montana and Wyoming, along with the States, in order to share resources, ideas, and truly work together on Suicide Prevention activities. These new collaborations are building hope across the Tribes and the States to overcome what once seemed an overwhelming and impossible problem to solve alone.  These partnerships are leading the country in developing new strategies for saving the lives of our youth and together they are spreading the word that suicide is a preventable tragedy.

In the Aberdeen Area, SAMHSA continues to work closely with the Standing Rock Sioux Tribe to respond to an outbreak of suicide clusters on their reservation.  In 2005, through a SAMHSA Emergency Response Grant (SERG), SAMHSA staff and the One Sky Center staff began working with the Tribe to design and implement a suicide prevention program at Standing Rock.  Based on SAMHSA’s recommendation, tribal leadership mandated that the program must be Addiction and Dependency certified by the State of North Dakota.  A Bismarck-based consultant from SAMHSA’s Disaster Technical Assistance Center (DTAC) has assisted the Tribe with this process. The Tribe has funded two additional behavioral health staff positions to provide case management services and arrange for treatment and ancillary services for at-risk clients, which is making a difference.  The strategic suicide prevention plan that was developed and implemented at Standing Rock is being considered as a model by other Indian reservations and the Indian Health Service. Although the SERG grant funding ended in December 2006, the Tribe was competitively awarded a Youth Suicide Prevention and Early Intervention Program grant in October 2006.  This new grant is bringing together community leaders to implement a comprehensive tribal youth suicide prevention and early intervention plan at Standing Rock that is identifying and increasing youth referrals to mental health services and programs, increasing protective factors, reducing risk factors for youth suicide, and improving access to intervention services.

SAMHSA is also working with the Office of National Drug Control Policy, the Office of Justice Programs/Bureau of Justice Assistance within the Department of Justice and with the National Alliance for Model State Drug Laws on regional planning events to identify common issues and concerns among States that may require interstate resolutions or a federal focus to address methamphetamine use. Through this partnership, three regional planning events were conducted in FY 2007. Attendance included representatives of substance abuse programs, law enforcement agencies, the criminal justice system, community coalitions and counties, cities and local municipalities. The goal was the identification of best practices that will be replicated in other States. 

In response to the inescapable link between addiction, mental illness, and crime, SAMHSA is coordinating across federal agencies through our participation on the Native American Law Enforcement Task Force. When prevention and treatment services are targeted to adult and juvenile offenders the benefits are three-fold.  First, if we prevent addiction, drug related crime will decrease. Second, if we intervene early and get the appropriate treatment services in place, recidivism rates drop.  And third, as SAMHSA increases recovery support services, reentry success rates climb and public safety is increased.  It just makes sense for SAMHSA to strengthen partnerships with the law enforcement communities both in Indian Country and around the country.  We have reached out to police organizations, correctional organizations, as well as the National District Attorneys Association to open the paths to collaboration.  And, we will continue working closely with DOJ as well.

As you may know, the Department of Health and Human Services (HHS) revised its Tribal Consultation Policy in March 2005.  Members of the Tribal-Federal Team contributed to developing the necessary recommendations.  In early 2006, SAMHSA used the HHS document as a basis to create a starting point for revising the SAMHSA policy.  We shared that document with tribes at each of the Regional sessions to solicit comments.  During that process, we asked for volunteers interested in serving on a workgroup to assist with further review and revision of the Tribal Consultation Policy. In June of 2006, a Technical Team workgroup was formed.  The first meeting of the workgroup produced a second draft of the SAMHSA Tribal Consultation Policy which was reviewed and comments as well as resulting edits were incorporated in the final Tribal Consultation Policy.  SAMHSA’s goal was to have a signed Tribal Consultation Policy by early 2007 and I’m very proud to say we have accomplished that.  Additionally, SAMHSA is establishing a new Tribal Advisory Committee and is accepting nominations for committee members.  Similar to other SAMHSA advisory committees, the purpose of the Tribal Advisory Committee is to assist SAMHSA in carrying out its mission in Indian Country.

Key to carrying out our Agency mission in Indian Country is increasing awareness of and access to our grants.  In response to comments at the 2006 HHS Tribal Consultation Meetings and the HHS/ASPE published “Barriers to American Indian/Alaska Native/Native American Access to DHHS Programs” report (April 2006) SAMHSA convened an internal workgroup to develop strategies to remove barriers in discretionary grant announcements. As a result, in August 2006 a Tribal Grants Review Team – with members from four Tribes/tribal organizations – reviewed nine previously published SAMHSA Requests for Proposals (RFAs).  Their findings and recommendations were provided to SAMHSA grants and policy officials, some of which have already been incorporated into FY 2007 SAMHSA RFAs. 

In addition to increasing the voice of Tribes and Tribal Organizations through the various avenues mentioned, SAMHSA is also committed to increasing technical assistance to our tribal partners on improving services.  For instance, through SAMHSA’s Addiction Technology Transfer Centers (ATTCs), SAMHSA is planning one or more special projects to provide technical assistance on treatment-related issues through partnerships with Regional Indian Health Boards.   We are very excited about this new partnership and expect to have it underway in early FY 2008.  Also, SAMHSA’s Center for Substance Abuse Prevention will be awarding a contract for a Native American Technical Assistance Resource Center that will provide targeted technical assistance to current Tribal Strategic Prevention Framework State Incentive Grants grantees and prospective grant applicants.

I also want to mention that recently we participated in the IHS-SAMHSA 5th Annual National Behavioral Health Conference held June 11-14 in Albuquerque, New Mexico.  This annual conference is an important training and networking opportunity for American Indians and Alaska Natives working in the behavioral health fields with the Indian Health Service.

Similarly, I’m pleased to announce that plans are underway at SAMHSA for a Tribal Policy Academy on Co-Occurring Substance Abuse and Mental Health Disorders in September 2007. The purpose of this Academy is to improve and expand access to effective, culturally relevant, and appropriate prevention and treatment services and supports for individuals with and at-risk for co-occurring substance use and mental disorders. The Academy will bring together Tribal Teams of officials with policy-making influence in conjunction with nationally recognized faculty and facilitators who will assist the Teams to develop an Action Plan for expanding access and improving co-occurring treatment and prevention services in their communities.  The Academy will also help to identify promising practices in Tribal communities that may assist other Tribes to address co-occurring disorders in new and innovative ways.

Changes are underway – changes that will result in improved coordination of SAMHSA services to tribal communities.  Ultimately the result will be healthier tribal communities – communities where lives are full and where native language, culture and traditions including native healing approaches can flourish. SAMHSA continues to look forward in assisting each of you in any way we can.  Thank you.

Last revised: June 18, 2013