Alcohol use among Native Americans compared to whites: Examining the veracity of the 'Native American elevated alcohol consumption' belief

Culturally tailoring a secondary suicide prevention intervention for American Indian and Alaska Native people in substance use treatment

BACKGROUND

Substance use treatment programs are ideal places for suicide prevention interventions. People who misuse substances are at elevated risk for suicide compared to the general population. However, most treatment programs do not incorporate suicide prevention, and none have been adapted for American Indian and Alaska Native (AI/AN) people. Preventing Addiction Related Suicide (PARS) is a suicide prevention module developed for use with people in treatment for substance misuse. A previous study demonstrated increased suicide help-seeking among this population.

OBJECTIVE

Culturally adapt PARS for use with AI/AN communities.

METHODS

We conducted focus groups and interviews with stakeholders in three Tribal health systems. We elicited feedback on PARS content, structure, and implementation. Data were analyzed using constant comparison. Results were used to adapt PARS and member checking was used to refine it.

RESULTS

Participants unanimously endorsed using PARS in their health systems. Suggested adaptations included shortening the module, using community-specific information, removing jargon and stigmatizing language, and emphasizing cultural connectedness.

DISCUSSION

This community-based, qualitative study adapted the PARS module for use with AI/AN communities. Research is needed to evaluate the clinical effectiveness of the adapted module. If found effective, this would represent the first evidence-based suicide prevention intervention among AI/AN individuals in treatment for substance misuse.

Provider perspectives on the impact of COVID-19 on treatment of substance use and opioid use disorders among American Indian and Alaska Native adults

Introduction

American Indian/Alaska Native (AI/AN) communities are more likely to suffer negative consequences related to substance misuse. The COVID-19 pandemic exacerbated the opioid poisoning crisis, in combination with ongoing treatment barriers resulting from settler-colonialism, systemic oppression and racial discrimination. AI/AN adults are at greatest risk of COVID-19 related serious illness and death. In collaboration with an Indigenous community advisory board and Tribal leadership, this study explored AI/AN treatment provider perceptions of client-relatives' (i.e., SUD treatment recipients) experiences during the pandemic from 2020 to 2022.

Methods

Providers who underwent screening and were eligible to participate (N = 25) represented 6 programs and organizations serving rural and urban areas in Washington, Utah, and Minnesota. Participants engaged in audio-recorded 60-90 min semi-structured individual interviews conducted virtually via Zoom. The interview guide included 15 questions covering regulatory changes, guidance for telemedicine, policy and procedures, staff communication, and client-relatives' reactions to implemented changes, service utilization, changes in treatment modality, and perceptions of impact on their roles and practice. Interview recordings were transcribed and de-identified. Members of the research team independently reviewed transcripts before reaching consensus. Coding was completed in Dedoose, followed by analyses informed by a qualitative descriptive approach.

Results

Five main domains were identified related to client-relative experiences during the COVID-19 pandemic, as observed by providers: (1) accessibility, (2) co-occurring mental health, (3) social determinants of health, (4) substance use, coping, and harm reduction strategies, and (5) community strengths. Providers reported the distinctive experiences of AI/AN communities, highlighting the impact on client-relatives, who faced challenges such as reduced income, heightened grief and loss, and elevated rates of substance use and opioid-related poisonings. Community and culturally informed programming promoting resilience and healing are outlined.

Conclusion

Findings underscore the impact on SUD among AI/AN communities during the COVID-19 pandemic. Identifying treatment barriers and mental health impacts on client-relatives during a global pandemic can inform ongoing and future culturally responsive SUD prevention and treatment strategies. Elevating collective voice to strengthen Indigenous informed systems of care to address the gap in culturally-and community-based services, can bolster holistic approaches and long-term service needs to promote SUD prevention efforts beyond emergency response efforts.

Negative Affect and Drinking among Indigenous Youth: Disaggregating Within- and Between-Person Effects

Negative affect (depression/anxiety) and alcohol use among Indigenous youth in Canada remain a concern for many communities. Disparate rates of these struggles are understood to be a potential outcome of colonization and subsequent intergenerational trauma experienced by individuals, families, and communities. Using a longitudinal design, we examined change in alcohol use and negative affect, and reciprocal associations, among a group of Indigenous adolescents. Indigenous youth (N = 117; 50% male; Mage=12.46-16.28; grades 6-10) from a remote First Nation in northern Quebec completed annual self-reported assessments on negative affect (depression/anxiety) and alcohol use. A Latent Curve Model with Structured Residuals (LCM-SR) was used to distinguish between- and within-person associations of negative affect and alcohol use. Growth models did not support change in depression/anxiety, but reports of drinking increased linearly. At the between-person level, girls reported higher initial levels of depression/anxiety and drinking; depression/anxiety were not associated with drinking. At the within-person level, drinking prospectively predicted increases in depression/anxiety but depression/anxiety did not prospectively predict drinking. When Indigenous adolescents reported drinking more alcohol than usual at one wave of assessment, they reported higher levels of negative affect than expected (given their average levels of depression/anxiety) at the following assessment. Our findings suggest that when Indigenous youth present for treatment reporting alcohol use, they should also be screened for negative affect (depression/anxiety). Conversely, if an Indigenous adolescent presents for treatment reporting negative affect, they should also be screened for alcohol use.

Fatal Firearm Violence Among American Indians and Alaska Natives

There is a dearth of population-based studies regarding firearm-related deaths and years of potential life lost among American Indians and Alaska Natives (AI/AN). Using the Centers for Disease Control and Prevention's (CDC) We Based Injury Statistics Query and Reporting System (WISQARS) data for the three most recent years (2018-2020), we analyzed the demographic characteristics of AI/ANs who succumbed to firearm violence. AI/ANs averaged almost 500 firearm-related deaths per year. The majority of these deaths were observed among individuals 20-39 years of age (53%), males (84.4%), and in the West (55.3%). A plurality of these firearm-related deaths were suicides (48.9%) followed by homicides (43.5%). During the 3-year study period, the age-adjusted firearm death rate increased almost 5 times the growth of the AI/AN population. Also, a staggering 67,050 years of potential life were lost before the age of 80 years (YPLL80) during this period. Firearm suicides were responsible for the largest proportion of YPLL80s (48.5%). Traditional legal interventions [e.g., child access prevention (CAP) laws and extreme risk protection orders (ERPO)], if expanded to more states could potentially help reduce AI/AN firearm mortality. None of the 10 states with the highest firearm mortality of AI/AN have ERPOs and 8 of the 10 do not have CAP laws. Also, a renewed focus on cultural continuity and indigenous protective factors is essential to ameliorate the level of firearm violence in AI/ANs.

Development and Feasibility Pilot Study of Indigenous Recovery Planning: A Community-Engaged Approach to Addressing Substance Use in a Native Community

Although Native (American Indian and Alaska Native [AI/AN]) populations have high rates of abstinence from alcohol, health problems associated with substance use remain a pressing concern in many AI/AN communities. As part of a longstanding community-based participatory research (CBPR) project involving five years of relationship building and three preliminary studies, our team of academic and community co-researchers developed a culturally grounded intervention to facilitate recovery from substance use disorders among tribal members from a rural AI reservation. Our Indigenous Recovery Planning (IRP) intervention consists of six weekly sessions and aims to provide inroads to existing resources in the community, affirm and enhance Native identity, address culturally relevant risk factors, and build upon strengths. Results from a feasibility pilot study (N = 15) suggest that IRP is feasible to implement and acceptable to the community. Although there was insufficient statistical power to conduct hypothesis testing, there were changes between pretest and posttest scores in the expected directions. Future directions and limitations of this research are discussed.

Using Geographic Disaggregation to Compare Tuberculosis Epidemiology Among American Indian and Alaska Native Persons-USA, 2010-2020

BACKGROUND

American Indian and Alaska Native (AIAN) populations are frequently associated with the highest rates of tuberculosis (TB) disease of any racial/ethnic group in the USA. We systematically investigated variation in patterns and potential drivers of TB epidemiology among geographically distinct AIAN subgroups.

METHODS

Using data reported to the National Tuberculosis Surveillance System during 2010-2020, we applied a geographic method of data disaggregation to compare annual TB incidence and the frequency of TB patient characteristics among AIAN persons in Alaska with AIAN persons in other states. We used US Census data to compare the prevalence of substandard housing conditions in AIAN communities in these two geographic areas.

RESULTS

The average annual age-adjusted TB incidence among AIAN persons in Alaska was 21 times higher than among AIAN persons in other states. Compared to AIAN TB patients in other states, AIAN TB patients in Alaska were associated with significantly higher frequencies of multiple epidemiologic TB risk factors (e.g., attribution of TB disease to recent transmission, previous diagnosis of TB disease) and significantly lower frequencies of multiple clinical risk factors for TB disease (e.g., diagnosis with diabetes mellitus, end-stage renal disease). Occupied housing units in AIAN communities in Alaska were associated with significantly higher frequencies of multiple measures of substandard housing conditions compared to AIAN communities in other states.

CONCLUSIONS

Observed differences in patient characteristics and substandard housing conditions are consistent with contrasting syndromes of TB epidemiology in geographically distinct AIAN subgroups and suggest ways that associated public health interventions could be tailored to improve efficacy.

The criminal justice system in alcohol use treatment: a nationwide analysis of racial disparities in treatment referral and completion

BACKGROUND

Alcohol use and the criminal justice (CJ) system have long been integrally connected in the United States and have both disproportionally impacted Communities of Color. Despite this connection, scholarly literature has largely focused on substance use as a whole, and little literature has examined the influence of race on CJ referral to alcohol treatment and treatment outcomes.

METHODS

A total of 749,349 cases from the treatment episodes dataset discharge were used in the current study. A series of ANOVA and logistic regression analyses were conducted to examine the impact of race on (i) likelihood of referral to alcohol treatment by the CJ system and (ii) the association between CJ referral and treatment completion.

RESULTS

Results revealed significant disparities in both who is referred to alcohol treatment by the CJ system and the association of that referral to treatment completion. Notably, American Indian/Alaska Native people were significantly more likely than people of all other races to be referred by the CJ system. However, American Indian/Alaska Native people showed the smallest association between CJ referral and treatment completion.

CONCLUSIONS

Contrary to previous literature, findings showed that referral of and positive association between CJ referral and treatment completion are not equal across people of different races. Taken together, these results highlight continued racial inequities in the role of the CJ system in alcohol treatment and the unique potential for non-CJ-related treatment to best serve people combatting alcohol use disorder.

Alcohol Use Disorder Visits and Suicide Ideation Diagnosis: Racial/Ethnic Differences at Emergency Departments

INTRODUCTION

Nationally, suicide ideation prevalence is comparable among White, American Indian/Alaska Native, Black, and Hispanic adults experiencing alcohol use disorder. This study examines whether such comparability extends to the probability of receiving a suicide ideation diagnosis when presenting with alcohol use disorder at emergency departments. The probability of hospitalization following such diagnosis is examined as well.

METHODS

National Emergency Department Sample (2019) data were used. Logistic and multilevel logistic regression analyses were performed in 2022-2023 with suicide ideation diagnosis and subsequent hospitalization as the outcome variables. Control variables included demographics, payor, alcohol use disorder level, comorbidities, and emergency department facility. Adjusted probabilities were computed.

RESULTS

Age-adjusted probabilities of suicide ideation diagnoses for American Indian/Alaska Native, Black, and Hispanic patients with alcohol use disorder were 5.4%, 6.7%, and 4.9% (95% CIs=3.7, 7.1; 6.0, 7.4; 4.4, 5.4), respectively; all less than that for White counterparts (8.7%; 95% CI=8.2, 9.2). Among patients with alcohol use disorder plus suicide ideation diagnoses, the age-adjusted probability of hospitalization for American Indians/Alaska Natives (32.4%; 95% CI=20.9, 44.0) was less than that for Whites, Blacks, and Hispanics (49.8%, 52.3%, and 49.9%; 95% CIs=46.7, 52.8; 47.1, 57.5; and 43.9, 55.8, respectively). In regressions with multiple control variables, the racial/ethnic differences remained statistically significant (p<0.05).

CONCLUSIONS

Diagnosis of suicide ideation, a key step in emergency department suicide prevention care, occurred significantly less often for patients of color with alcohol use disorder than for White counterparts. American Indians/Alaska Natives, the racial/ethnic group known to have the nation's highest suicide rate, had the lowest probability of being hospitalized after a diagnosis of alcohol use disorder plus suicide ideation.

An Updated Narrative Review on the Role of Alcohol Among Indigenous Communities

Purpose of Review

The role of alcohol varies considerably among Indigenous Peoples and is the backdrop of persistent stereotypes despite decades of research. This paper provides an updated narrative review on the alcohol literature among Indigenous communities, highlighting recent studies published since 2017.

Recent Findings

We examined published literature involving alcohol use rates, including abstinence; risk and protective factors; treatment; and recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities.

Summary

Evidence-based alcohol use prevention, intervention, and recovery strategies with Indigenous communities are outlined. Recommendations are provided for researchers, health providers, and public policy advocates to address and better understand alcohol use, treatment, prevention, and recovery among Indigenous Peoples. Specific recommendations include using community-based participatory research strategies and harm reduction approaches to prevent and treat alcohol use problems with Indigenous communities. Future research is needed to elucidate mechanisms of resilience and recovery from Alcohol Use Disorder and possible shifts in perceptions of alcohol use for Indigenous Peoples.

Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Lessons learned and future directions: A scoping review of American Indian and Alaska Native participants in the National Drug Abuse Treatment Clinical Trials Network

INTRODUCTION

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by substance use disorders (SUDs) and related health disparities in contrast to other ethnoracial groups in the United States. Over the past 20 years, substantial resources have been allocated to the National Institute on Drug Abuse Clinical Trials Network (CTN) to disseminate and implement effective SUD treatments in communities. However, we know little about how these resources have benefitted AI/AN peoples with SUD who arguably experience the greatest burden of SUDs. This review aims to determine lessons learned about AI/AN substance use and treatment outcomes in the CTN and the role of racism and Tribal identity.

METHOD

We conducted a scoping review informed by the Joanna Briggs framework and PRISMA Extension for Scoping Reviews checklist and explanation. The study team conducted the search strategy within the CTN Dissemination Library and nine additional databases for articles published between 2000 and 2021. The review included studies if they reported results for AI/AN participants. Two reviewers determined study eligibility.

RESULTS

A systematic search yielded 13 empirical articles and six conceptual articles. Themes from the 13 empirical articles included: (1) Tribal Identity: Race, Culture, and Discrimination; (2) Treatment Engagement: Access and Retention; (3) Comorbid Conditions; (4) HIV/Risky Sexual Behaviors; and (5) Dissemination. The most salient theme was Tribal Identity: Race, Culture, and Discrimination, which was present in all articles that included a primary AI/AN sample (k = 8). Themes assessed but not identified for AI/AN peoples were Harm Reduction, Measurement Equivalence, Pharmacotherapy, and Substance Use Outcomes. The conceptual contributions used AI/AN CTN studies as exemplars of community-based and Tribal participatory research (CBPR/TPR).

CONCLUSION

CTN studies conducted with AI/AN communities demonstrate culturally congruent methods, including CBPR/TPR strategies; consideration/assessment of cultural identity, racism, and discrimination; and CBPR/TPR informed dissemination plans. Although important efforts are underway to increase AI/AN participation in the CTN, future research would benefit from strategies to increase participation of this population. Such strategies include reporting AI/AN subgroup data; addressing issues of cultural identity and experiences of racism; and adopting an overall effort for research aimed at understanding barriers to treatment access, engagement, utilization, retention, and outcomes for both treatment and research disparities for AI/AN populations.

A comparison of alcohol and commercial tobacco use in populous American Indian/Alaska Native states

BACKGROUND

Modern research suggests that the racial influence on smoking and drinking behaviors may not be as prevalent as once thought. This study utilizes national survey data to compare binge drinking and commercial cigarette smoking behaviors between American Indians/Alaskan Natives (AI/AN) and non-Hispanic Whites in the five most populous AI/AN U.S. states.

METHODS

Data were analyzed from the Behavioral Risk Factor Surveillance System (BRFSS) from 2018 to 2022; White (n=79,405), AI/AN (n=11,007). Data analyses include frequency statistics, followed by two model evaluations comparing main effects of race/ethnicity and sex for both binge drinking and commercial cigarette smoking behaviors, and subgroup estimates of race/ethnicity by sex. An ANOVA was utilized to evaluate differences by race/ethnicity, sex, and race/ethnicity by sex subgroups by states.

RESULTS

Males were over twice as likely to engage in binge drinking, with no significant differences found between people identifying as AI/AN and White individuals. Both White and AI/AN males were twice as likely to engage in binge drinking, compared to their White female counterparts. AI/AN individuals were over twice as likely to engage in commercial cigarette smoking compared to their White counterparts.

CONCLUSIONS

Results showed no significance differences in AI/AN versus White individuals in binge drinking (controlling for sex, age, and income), while there were significant differences by sex (controlling for race/ethnicity, age, and income). People identifying as AI/AN were significantly more likely to engage in commercial cigarette smoking compared to White individuals, signifying the importance of racial/ethnical and covariate considerations when establishing public health interventions.

Racial and ethnic disparities in monthly trends in alcohol-induced mortality among US adults from January 2018 through December 2021

Background: Historically, American Indians/Alaska Natives (AIANs), Blacks, and Hispanics have experienced higher alcohol-induced mortality rates. Given a disproportionate surge in unemployment rate and financial strain among racial and ethnic minorities and limited access to alcohol use disorder treatment during the COVID-19 pandemic, it is essential to examine monthly trends in alcohol-induced mortality in the United States during the pandemic.Objectives: This study estimates changes in monthly alcohol-induced mortality among US adults by age, sex, and race/ethnicity.Methods: Using monthly deaths from 2018-2021 national mortality files (N = 178,201 deaths, 71.5% male, 28.5% female) and census-based monthly population estimates, we calculated age-specific monthly alcohol-induced death rates and performed log-linear regression to derive monthly percent increases in mortality rates.Results: Alcohol-induced deaths among adults aged ≥25 years increased by 25.7% between 2019 (38,868 deaths) and 2020 (48,872 deaths). During 2018-2021, the estimated monthly percent change was higher for females (1.1% per month) than males (1.0%), and highest for AIANs (1.4%), followed by Blacks (1.2%), Hispanics (1.0%), non-Hispanic Whites (1.0%), and Asians (0.8%). In particular, between February 2020 and January 2021, alcohol-induced mortality increased by 43% for males, 53% for females, 107% for AIANs, the largest increase, followed by Blacks (58%), Hispanics (56%), Asians (44%), and non-Hispanic Whites (39%).Conclusions: During the peak months of the pandemic, the rising trends in alcohol-induced mortality differed substantially by race and ethnicity. Our findings indicate that behavioral and policy interventions and future investigation on underlying mechanisms should be considered to reduce alcohol-induced mortality among Blacks and AIANs.

Co-occurring suicidal ideation and alcohol-related problems: An intersectional analysis of Native American and White adults with minoritized sexual identities

BACKGROUND

Disparities in suicidal ideation (SI) and alcohol use disorder (AUD) are evident in both Native American and minoritized sexual identity groups, relative to non-Hispanic White and heterosexual groups. However, Native Americans report lower drinking and binge drinking rates than White adults. Persons with intersecting identities, specifically Native Americans with minoritized sexual identities, may be at greater risk for SI and drinking, binge drinking, and AUD than White and Native American heterosexual adults.

METHODS

Five years (2015-2019) of National Survey of Drug Use and Health data were combined (N = 130,157). Multinomial logistic regressions tested racial (Native American vs White) and sexual identity (lesbian/gay/bisexual vs heterosexual) differences in odds of SI, drinking, and co-occurring SI + drinking, versus neither SI/drinking. Subsequent analyses examined SI + binge drinking, and SI + AUD.

RESULTS

Compared to White heterosexual adults, Native American heterosexual adults reported lower co-occurring SI + drinking odds, whereas Native American sexual minoritized adults reported higher odds. Native American sexual minoritized groups showed greater co-occurring SI + binge drinking odds and greater co-occurring SI + AUD odds compared to White heterosexual adults. Native American sexual minoritized adults showed greater SI only compared to White sexual minoritized adults. Sexual minoritized Native Americans showed higher odds of co-occurring SI + drinking, binge drinking, and AUD than White heterosexual adults.

CONCLUSIONS

Native American sexual minoritized groups showed higher likelihood of co-occurring SI + drinking, binge drinking, and AUD relative to both White and Native American heterosexual adults. Disparities warrant outreach for suicide and AUD prevention for Native American sexual minoritized adults.

Feasibility and Acceptability of Using Ecological Momentary Assessment to Evaluate Alcohol Use with American Indian Women

BACKGROUND

Ecological momentary assessments (EMA) are one way to collect timely and accurate alcohol use data, as they involve signaling participants via cell phones to report on daily behaviors in real-time and in a participant's natural environment. EMA has never been used with American Indian populations to evaluate alcohol consumption. The purpose of this project was to determine the feasibility and acceptability of EMA for American Indian women.

METHODS

Eligible participants were American Indian women between the ages of 18 and 44 who were not pregnant and had consumed more than one drink within the past month. All participants received a TracFone and weekly automated messages. Self-reported measures of daily quantity and frequency of alcohol consumption, alcohol type, and context were assessed once per week for four weeks. Baseline measurements also included the Drinking Motives Questionnaire-Revised (DMQ-R) and the Interpersonal Support Evaluation List (ISEL).

RESULTS

Fifteen participants were enrolled in the study. All but one participant completed all data collection time points, and drinking patterns were consistent across the study period. A total of 420 records were completed across 86 drinking days and 334 non-drinking days. Participants reported drinking an average of 5.7 days over the 30-day period and typically consumed 3.99 drinks per drinking occasion. Sixty-six percent of participants met gender-specific cut-points for heavy episodic drinking, with an average of 2.46 binge drinking occasions across the four week study period.

CONCLUSIONS

This proof-of-concept project showed that EMA was both feasible and acceptable for collecting alcohol data from American Indian women. Additional studies are necessary to fully implement EMA with American Indian women to better understand the drinking motives, contexts, patterns, and risk factors in this population.

The role of culture in the association between racial discrimination and alcohol use among North American Indigenous adolescents reporting recent drinking

BACKGROUND

North American Indigenous (NAI) communities have identified alcohol use as a primary health concern. Experiences of racial discrimination are associated with greater alcohol use, but findings are mixed regarding the role of culture in this relationship. The goal of the present study was to examine the role of culture in the association between racial discrimination and alcohol use.

METHODS

Across two studies (Study 1: N = 52; Study 2: N = 1743), NAI adolescents living on or near NAI reservations who reported recent alcohol use completed self-report measures of racial discrimination, cultural affiliation, and alcohol use (e.g., frequency).

RESULTS

Bivariate correlations revealed a significant positive association between racial discrimination and alcohol use (Study 1: r = 0.31, p = 0.029; Study 2: r = 0.14, p < 0.001) but not between cultural affiliation and alcohol use. Racial discrimination and cultural affiliation were significantly positively correlated in Study 1 (r = 0.18, p < 0.001), but not in Study 2. Across both studies, the interactions between racial discrimination and cultural affiliation significantly predicted alcohol use in unadjusted models (Study 1: b = 0.70, SE = 0.32, p = 0.033, 95% CI [0.06, 1.33]; Study 2: b = 0.01, SE = 0.01, p = 0.041, 95% CI [0.001, 0.03]), such that the association between racial discrimination and alcohol use was stronger for adolescents reporting high (vs. low) levels of cultural affiliation. In adjusted models controlling for age and sex, the interaction between racial discrimination and cultural affiliation remained significant in Study 2 (b = 0.01, SE = 0.01, p = 0.0496, 95% CI [0.00002, 0.03]) but was no longer significant in Study 1.

CONCLUSIONS

Findings speak to the need to reduce racial discrimination against NAI youth and to consider youths' different needs based on level of cultural affiliation to reduce subsequent alcohol consumption.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

The Cultural Adaption of a Sobriety Support App for Alaska Native and American Indian People: Qualitative Feasibility and Acceptability Study

BACKGROUND

Despite high rates of alcohol abstinence, Alaska Native and American Indian (ANAI) people experience a disproportionate burden of alcohol-related morbidity and mortality. Multiple barriers to treatment exist for this population, including a lack of culturally relevant resources; limited access to or delays in receiving treatment; and privacy concerns. Many ANAI people in the state of Alaska, United States, live in sparsely populated rural areas, where treatment access and privacy concerns regarding peer-support programs may be particularly challenging. In addition, prior research demonstrates that many ANAI people prefer a self-management approach to sobriety, rather than formal treatment. Taken together, these factors suggest a potential role for a culturally adapted smartphone app to support ANAI people interested in changing their behavior regarding alcohol use.

OBJECTIVE

This study was the first phase of a feasibility and acceptability study of a culturally tailored version of an off-the-shelf smartphone app to aid ANAI people in managing or reducing their use of alcohol. The aim of this qualitative needs assessment was to gather insights and preferences from ANAI people and health care providers serving ANAI people to guide feature development, content selection, and cultural adaptation before a pilot test of the smartphone app with ANAI people.

METHODS

From October 2018 to September 2019, we conducted semistructured interviews with 24 ANAI patients aged ≥21 years and 8 providers in a tribal health care organization in south-central Alaska.

RESULTS

Participants generally endorsed the usefulness of a smartphone app for alcohol self-management. They cited anonymity, 24/7 access, peer support, and patient choice as key attributes of an app. The desired cultural adaptations included ANAI- and land-themed design elements, cultural content (eg, stories from elders), and spiritual resources. Participants considered an app especially useful for rural-dwelling ANAI people, as well as those who lack timely access to treatment services or prefer to work toward managing their alcohol use outside the clinical setting.

CONCLUSIONS

This needs assessment identified key features, content, and cultural adaptations that are being implemented in the next phase of the study. In future work, we will determine the extent to which these changes can be accommodated in a commercially available app, the feasibility of implementation, and the acceptability of the culturally adapted version of the app among ANAI users.

Culturally tailored substance use interventions for Indigenous people of North America: a systematic review

Purpose–

The purpose of the current study is to conduct a systematic review of peer-reviewed work on culturally tailored interventions for alcohol and drug use in Indigenous adults in North America. Substance use has been reported as a health concern for many Indigenous communities. Indigenous groups experienced the highest drug overdose death rates in 2015, the largest percentage increase in the number of deaths over time from 1999 to 2015 compared to any other racial group. However, few Indigenous individuals report participating in treatment for alcohol or drug use, which may reflect the limited engagement that Indigenous groups have with treatment options that are accessible, effective and culturally integrative.

Design/methodology/approach–

Electronic searches were conducted from 2000 to April 21, 2021, using PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed. Two reviewers classified abstracts for study inclusion, resulting in 18 studies.

Findings–

Most studies were conducted in the USA (89%). Interventions were largely implemented in Tribal/rural settings (61%), with a minority implemented in both Tribal and urban contexts (11%). Study samples ranged from 4 to 742 clients. Interventions were most often conducted in residential treatment settings (39%). Only one (6%) intervention focused on opioid use among Indigenous people. Most interventions addressed the use of both drugs and alcohol (72%), with only three (17%) interventions specifically intended to reduce alcohol use.

Originality/value–

The results of this research lend insight into the characteristics of culturally integrative treatment options for Indigenous groups and highlight the need for increased investment in research related to culturally tailored treatment across the diverse landscape of Indigenous populations.

Measuring Attitudes About Alcohol Misuse and Dependence Among Alaska Native People Within a Tribal Health Care System

OBJECTIVES

Attitudes about alcohol misuse and dependence influence alcohol use and help-seeking behavior. Alaska Native and American Indian (AN/AI) people have higher rates of alcohol-related morbidity and mortality but engage in treatment at lower rates than the general population. No validated instruments exist to assess attitudes of AN/AI people about alcohol misuse and dependence to inform treatment and prevention efforts. This study aimed to develop an instrument to assess public attitudes among AN/AI people of alcohol misuse and dependence.

METHODS

This multiphase, mixed-methods study was conducted at Southcentral Foundation, a tribally owned health system serving 65,000 AN/AI people in Alaska. We conducted focus groups and interviews with health system users, providers, and leaders to adapt the Public Attitudes About Addiction Survey. The adapted instrument was piloted with 200 people. Cognitive interviews and exploratory and confirmatory factor analyses were used to refine the instrument, which were then administered to 777 AN/AI people.

RESULTS

Initial exploratory factor analysis identified 5 factors, including 3 from the original Public Attitudes About Addiction Survey (moral, disease, nature), a combined psychology and sociology factor (psychosocial), and a new factor (environment). A final 4-factor model (psychosocial, moral, disease, nature) with 14 items had good fit with root mean square error of approximation (0.035; comparative fit index = 0.977; Tucker-Lewis index = 0.970; standardized root mean residual = 0.040) and loadings ranging from 0.41 to 0.80.

CONCLUSIONS

This study developed the first instrument to assess AN/AI attitudes about alcohol misuse and dependence. This instrument has potential to inform alcohol-related treatment in AN/AI communities. Future research is warranted to adequately measure place-based contributors salient to AN/AI people.

Diverse rural caregivers for individuals with Alzheimer's disease or related dementias: analysis of health factors at the individual, interpersonal, and community level

Objectives: Approximately 6.2 million Americans aged 65 or older have Alzheimer's disease or related dementias (ADRD). Unpaid family members and friends provide the bulk of caregiving for these individuals. Caregiving in rural areas adds unique challenges, particularly for ethnically/racially diverse caregivers. This study provides a profile of diverse, rural ADRD caregivers with an emphasis on multi-level factors that influence physical and mental health.Methods: A cross-sectional survey was conducted with 156 diverse rural ADRD caregivers.Results: 65% of participants identified as White/Non-Hispanic (WNH; n = 101) and 35% identified as ethnically/racially diverse (ERD; n = 55). The majority of participants reported economic deprivation. More ERD caregivers were uninsured and had at least one chronic health condition. Higher proportions of ERD caregivers smoked cigarettes, consumed alcohol regularly, and had not seen or talked to a doctor in the previous year. There were no ethnic/racial group differences in stress, anxiety, depressive symptoms, subjective health, or sleep quality.Conclusion: Rural caregivers, regardless of ethnicity/race, may benefit from extra supports in order to maintain optimal health. Further research is needed to disentangle the complex relationship between culture, caregiving, and health.

Recovery from alcohol among urban Alaska Native and American Indian people

Alaska Native and American Indian (ANAI) people experience dramatic alcohol-related health disparities compared to the general US population. Although the majority of ANAI people reside in urban settings (>70%), data are sparse on alcohol abstinence among urban ANAI people with alcohol use disorder (AUD). We conducted a qualitative study using a phenomenological approach to examine the experiences of 20 urban ANAI adults recovering from AUD. Participants' narratives had their own unique dimensions but shared a clear, interrelated trajectory of pre-alcohol recovery, a turning point, and ongoing alcohol recovery. All participants reported a combination of external and internal motivation to stop using alcohol.

Alcohol consumption and pregnancy in American Indian and Alaska Native women: A scoping review of the literature

American Indian and Alaska Native communities have diverse cultures, histories, and contemporary experiences. Grouping them together masks the differences in health and lifestyle behaviors, chronic disease rates, and health outcomes among them. This is particularly true for data on drinking during pregnancy among American Indian and Alaska Native women. The goal of this article is to describe how generalizing findings from data gathered from often small, geographically specific samples, combined with inferior research methodologies, has led to misunderstandings about drinking among preconceptual and pregnant American Indian and Alaska Native women. We conducted a scoping review using PubMed and the "PCC mnemonic" (population, concept, and context) as our guide. Our search terms included the population (American Indian and Alaska Native women), concept (alcohol), and context (immediately before or during pregnancy) and focused on PubMed articles in the United States. Using these search terms, we uncovered a total of 38 publications and eliminated 19, leaving 19 for review. Methodologically (i.e. how data were collected), we found most previous research on prenatal or preconceptual alcohol use with American Indian and Alaska Native women used retrospective data collection. We also assessed who data were collected from and noted two groups: studies that sampled higher-risk women and those that focused on American Indian and Alaska Native women in specific geographic areas. Restricting data collection to higher-risk American Indian and Alaska Native women or conducting small studies in specific geographic areas has generated an incomplete and inaccurate picture of American Indian and Alaska Native women as a whole as well as those who consume alcohol. Data from select groups of American Indian and Alaska Native women may overestimate the true prevalence of drinking during pregnancy among this population. Updated and accurate data on drinking during pregnancy are urgently needed to inform the development of interventions and prevention efforts.

Indigenous participation in pediatric Indigenous health research in Canada: a systematic review

For health inequities to be successfully addressed through health research, it is necessary for researchers to strive for genuine engagement with stakeholders. Indigenous people provide critical perspectives in Indigenous health research. The objective of this review was to systematically review the existing pediatric Indigenous health research in Canada to determine the prevalence of Indigenous participation. Embase, MEDLINE, Cochrane Library were searched on April 15, 2017 and updated on July 16, 2020. A total of 798 studies focused on the health of Indigenous children ≤18 in Canada were included, of 17,752 abstracts screened in English and French. A total of 46.1% of articles indicated Indigenous participation, increasing over time. Organization/government was the most common form of Indigenous participation (62.8%) and Indigenous researcher as author was least common (10.9%). Participation by child age, geography and topic area varied. The most common category of topic researched was nutrition, lifestyle and anthropometrics. Indigeneity of researchers was determined by self-identification in the papers and may be an underestimate. Although improving over time, less than half of studies about Indigenous children in Canada included Indigenous participation in their execution. Journals and funding bodies must ensure fulsome participation of Indigenous people in research focused on Indigenous children. IMPACT: Indigenous participation in pediatric Indigenous health research is critical to producing ethical relevant and actionable results. This review describes the status of Indigenous participation in this body of work in Canada. This review highlights areas of concern and strength to improve the practices and ethics of medical researchers in this area, thereby increasing relevance of pediatric Indigenous health research to communities.

Trends in Deaths Fully Attributable to Alcohol in Minnesota, 2000-2018

OBJECTIVE

Overall trends in rates of fully alcohol-attributable mortality may mask disparities among demographic groups. We investigated overall, demographic, and geographic trends in fully alcohol-attributable mortality rates in Minnesota.

METHODS

We obtained mortality data from Minnesota death certificates and defined fully alcohol-attributable deaths as deaths that would not occur in the absence of alcohol. We calculated age-adjusted death rates during 2000-2018 using 5-year moving averages stratified by decedents' characteristics and geographic location.

RESULTS

Chronic conditions accounted for most of the alcohol-attributable deaths in Minnesota (89% during 2014-2018). Alcohol-attributable mortality rates per 100 000 population increased from an average rate of 8.0 during 2000-2004 to 12.6 during 2014-2018. During 2000-2018, alcohol-attributable mortality rates were highest among males (vs females), adults aged 55-64 (vs other ages), and American Indian/Alaska Native people (vs other racial and ethnic groups) and lowest among people aged ≤24 years and Asian or Pacific Islander people. During 2014-2018, the alcohol-attributable mortality rate among American Indian/Alaska Native people was more than 5 times higher than the overall mortality rate in Minnesota.

CONCLUSIONS

Results from this study may increase awareness of racial and ethnic disparities and continuing health inequities and inform public health prevention efforts, such as those recommended by the Community Preventive Services Task Force, including regulating alcohol outlet density and increasing alcohol taxes.

Homicides Involving American Indian and Alaska Native Individuals

This Viewpoint discusses homicide rates among American Indian and Alaska Native individuals and the importance of utilizing existing strategies tailored to the needs of American Indian and Alaska Native communities to prevent violence and reduce these rates.

Harm reduction acceptability and feasibility in a North American indigenous reserve community

AIMS

The present study assessed community and culturally specific alcohol-related harm among North American Indigenous (NAI) individuals, as well as the acceptability and feasibility of harm reduction approaches in one reserve-based NAI community.

METHODS

Participants lived on or near a NAI reserve in Canada. Semi-structured focus groups were conducted with health care workers (N = 8, 75% NAI) and community members (N = 9, 100% NAI). Self-report questionnaires were administered that measured acceptability and feasibility of harm reduction strategies.

RESULTS

Conventional content analysis revealed loss of culture as culturally specific alcohol-related harm. Health care workers rated harm reduction approaches to be acceptable and feasible, while community participants were more mixed. Majority of participants felt that some harm reduction strategies could provide opportunities for individuals who use alcohol to connect to Indigenous culture and traditions. However, there were mixed findings on whether harm reduction strategies are consistent with Indigenous cultural traditions and values.

CONCLUSION

Future research is needed to evaluate potential utility of harm-reduction approaches for NAI communities.

Opioid use in indigenous populations: indigenous perspectives and directions in culturally responsive care

In this work, we outline the necessary components for culturally responsive treatment to opioid use disorders in Indigenous communities. First, we examine the context of historical trauma faced by Indigenous groups in the U.S. and how this context may affect successful implementation of treatment. We then outline the strategies of Penobscot Nation and Little Earth in developing holistic treatment regimens for Indigenous peoples, and list policy interventions suited to improve outcomes for Indigenous groups related to opioid use disorders. We conclude with suggestions for future directions in anticolonial strategies for addressing opioid use in Indigenous communities. The combination of culturally responsive treatment, tribal sovereignty in the treatment of opioid use disorders, and effective resource allocation is necessary to affect positive change in Indigenous substance use trajectories.

The Generational Impact Of Racism On Health: Voices From American Indian Communities

Structural racism toward American Indians and Alaska Natives is found in nearly every policy regarding and action taken toward that population since non-Natives made first contact with the Indigenous peoples of the United States. Generations of American Indians and Alaska Natives have suffered from policies that called for their genocide as well as policies intended to acculturate and dominate them-such as the sentiment from Richard Henry Pratt to "kill the Indian…, save the man." The intergenerational effect is one that has left American Indians and Alaska Natives at the margins of health and the health care system. The effect is devastating psychologically, eroding a value system that is based on community and the sanctity of all creation. Using stories we collected from American Indian people who have experienced the results of racist policies, we describe historical trauma and its links to the health of American Indians and Alaska Natives. We develop two case studies around these stories, including one from a member of the Navajo Nation's experiences during the COVID-19 pandemic, to illustrate biases in institutionalized structures. Finally, we describe how the American Indian and Alaska Native Cultural Wisdom Declaration can help policy makers eliminate the effect of systemic racism on the health of American Indians and Alaska Natives-for instance, by lifting constraints on federal funding for American Indian and Alaska Native initiatives and allowing payment to traditional healers for their health services.

Dual Diagnosis and Alcohol/Nicotine Use Disorders: Native American and White Hospital Patients in 3 States

INTRODUCTION

Nationally, mental illness prevalence is comparable among Native Americans and Whites experiencing alcohol and nicotine use disorders. However, authors are concerned that mental illness in Native Americans with substance use disorders may be disparately underdiagnosed in medical settings. For 3 states with large Native American populations, this study compares the prevalence of mental illness diagnoses among Native Americans and Whites hospitalized with alcohol/nicotine use disorders.

METHODS

In 2021, hospital discharge data were used to compare non-Hispanic Native Americans with non-Hispanic Whites in Arizona and New Mexico (2016-2018) and (regardless of Hispanic ethnicity) Native Americans with Whites in Oklahoma (2016-2017). Differences in any mental illness, mood, and anxiety diagnoses were assessed using multilevel regressions (adjusted for demographics, payor, comorbidities, facility). Adjusted predicted probabilities were constructed.

RESULTS

Among alcohol-related discharges, probabilities of non-Hispanic Native Americans and non-Hispanic Whites receiving any mental illness diagnoses in Arizona were 18.0% (95% CI=16.1, 19.9) and 36.8% (95% CI=34.1, 39.5), respectively; in New Mexico, they were 24.5% (95% CI=20.7, 28.3) and 43.4% (95% CI=38.7, 48.1). Oklahoma's probabilities for Native Americans and Whites were 30.7% (95% CI=27.4, 34.0) and 36.8% (95% CI=33.5, 40.2), respectively. Among nicotine-related discharges, any mental illness diagnosis probabilities for non-Hispanic Native Americans and non-Hispanic Whites in Arizona were 21.2% (95% CI=18.9, 23.5) and 33.1% (95% CI=30.3, 35.9), respectively; in New Mexico, they were 25.9% (95% CI=22.7, 29.1) and 37.4% (95% CI=33.8, 40.9). Oklahoma's probabilities for Native Americans and Whites were 27.3% (95% CI=25.1, 29.6) and 30.2% (95% CI=28.0, 32.4), respectively. Mood and anxiety diagnoses were also significantly lower for non-Hispanic Native Americans in Arizona/New Mexico and Native Americans in Oklahoma.

CONCLUSIONS

Findings suggest disparate underdiagnosis of mental illness among Native Americans hospitalized with alcohol/nicotine use disorders in the examined states.

Health-Related Behavioral Risk Factors and Obesity Among American Indians and Alaska Natives of the United States: Assessing Variations by Indian Health Service Region

INTRODUCTION

Health-related behavioral risk factors and obesity are linked to high risk for multiple chronic diseases. We examined the prevalence of these risk factors among American Indians and Alaska Natives (AI/ANs) compared with that of non-Hispanic Whites and across Indian Health Service (IHS) regions.

METHODS

We used 2017 Behavioral Risk Factor Surveillance System data from participants in 50 states and the District of Columbia to assess 4 behavioral risk factors (current cigarette smoking, heavy drinking, binge drinking, and physical inactivity) and obesity. We analyzed disparities in these risk factors between AI/AN and non-Hispanic White participants, nationwide and by IHS region, by conducting log-linear regression analyses while controlling for potential confounders.

RESULTS

Nationwide, crude prevalence of current smoking, physical inactivity, and obesity were significantly higher among AI/AN than non-Hispanic White participants. After adjustment for sociodemographic characteristics, AI/AN participants were 11% more likely to report current smoking (P < .05) and 23% more likely to report obesity (P < .001) than non-Hispanic White participants. These patterns persisted in most IHS regions with some exceptions. In the Southwest region, AI/AN participants were 39% less likely to report current smoking than non-Hispanic White participants (P < .001). In the Pacific Coast region, compared with non-Hispanic White participants, AI/AN participants were 54% less likely to report heavy drinking (P < .01) but 34% more likely to report physical inactivity (P < .05). Across IHS regions, AI/AN participants residing in Alaska and the Northern Plains regions had the highest prevalence of current smoking and binge drinking, and those in the Southwest and Pacific Coast regions had the lowest prevalence of current smoking. AI/AN participants in the Southwest region had the lowest prevalence of physical inactivity, and those in the Southern Plains region had the highest prevalence of obesity.

CONCLUSIONS

The findings of this study support the importance of public health efforts to address and improve behavioral risk factors related to chronic disease in AI/AN people, both nationwide and among IHS regions, through culturally appropriate interventions.

Determinants of Relapse and Opportunities for Growth: Perspectives on Substance Use among American Indian Community Members

Resulting from generations of historical oppression and systemic racism, American Indian and Alaska Native (AI/AN) communities experience serious health disparities associated with substance use disorders (SUDs). As part of a longstanding community-based participatory research intervention development project, our partnership of academic and community co-researchers conducted seven focus groups (N = 35) to understand community stakeholders' perspectives on substance use, relapse, and recovery on a rural AI reservation. Participants included cultural leaders (n = 10), SUD treatment providers (n = 5), people with SUD (n = 10), and affected family members (n = 10). Cultural leaders viewed relapse as symptomatic of historical oppression, whereas other stakeholder groups attributed relapse to individual and interpersonal risk factors such as peer influence, lack of family support, and traumatic stress. All participant groups recognized relapse as a normative aspect of recovering from SUD that presents new opportunities for learning and growth. Specifically, regaining humility, learning to ask for help, recognizing one's triggers, and strengthening commitment to change were identified as learning outcomes for people with SUD. For family members, relapse provided the opportunity to practice forgiveness and compassion, two important cultural values. All groups emphasized the importance of grounding interventions in cultural values and traditions.

'You want to deal with power while riding on power': global perspectives on power in participatory health research and co-production approaches

INTRODUCTION

Power relations permeate research partnerships and compromise the ability of participatory research approaches to bring about transformational and sustainable change. This study aimed to explore how participatory health researchers engaged in co-production research perceive and experience 'power', and how it is discussed and addressed within the context of research partnerships.

METHODS

Five online workshops were carried out with participatory health researchers working in different global contexts. Transcripts of the workshops were analysed thematically against the 'Social Ecology of Power' framework and mapped at the micro (individual), meso (interpersonal) or macro (structural) level.

RESULTS

A total of 59 participants, with participatory experience in 24 different countries, attended the workshops. At the micro level, key findings included the rarity of explicit discussions on the meaning and impact of power, the use of reflexivity for examining assumptions and power differentials, and the perceived importance of strengthening co-researcher capacity to shift power. At the meso level, participants emphasised the need to manage co-researcher expectations, create spaces for trusted dialogue, and consider the potential risks faced by empowered community partners. Participants were divided over whether gatekeeper engagement aided the research process or acted to exclude marginalised groups from participating. At the macro level, colonial and 'traditional' research legacies were acknowledged to have generated and maintained power inequities within research partnerships.

CONCLUSIONS

The 'Social Ecology of Power' framework is a useful tool for engaging with power inequities that cut across the social ecology, highlighting how they can operate at the micro, meso and macro level. This study reiterates that power is pervasive, and that while many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances in participatory research partnerships, in order to contribute to improved equity and social justice outcomes.

Belief in the myth of an American Indian/Alaska Native biological vulnerability to alcohol problems among reservation-dwelling participants with a substance use problem

BACKGROUND

Belief in the myth of an American Indian/Alaska Native (AIAN)-specific biological vulnerability (BV) to alcohol problems is associated with worse alcohol outcomes among AIAN college students who drink, despite also being associated with greater attempts to reduce drinking. This study examined the association of belief in a BV with alcohol use among reservation-dwelling AI adults with a substance use problem.

METHODS

Participants (n = 141) who drank alcohol in the past 90 days were selected from a larger AI sample who self-identified as having a substance use problem. Moderated-mediation analyses examined whether belief in a BV was positively associated with alcohol- and substance use-related consequences and whether self-efficacy and craving mediated the association of belief in a BV with alcohol use.

RESULTS

Among participants who reported using alcohol but not hard drugs (e.g., methamphetamine, opioids), greater belief in a BV was associated with more drinking days, which in turn was associated with greater alcohol-related consequences. Among participants who used alcohol only, belief in a BV was also significantly associated with greater craving, and in turn with more drinking days. Among individuals who used both alcohol and hard drugs, greater belief in a BV was associated with fewer drinking days, but was not significantly associated with substance use-related consequences. No association was found between belief in a BV and self-efficacy to avoid alcohol or drug use.

CONCLUSIONS

Among individuals who use only alcohol, belief in a BV may contribute to more drinking days and greater alcohol-related consequences through its association with greater craving. This study provides further evidence of the potential harm of internalizing the belief that being AIAN contributes to the risk for alcohol problems, a notion that lacks scientific evidence despite decades of research. The findings highlight the importance of combating societal myths regarding AIAN peoples and the internalization of these stereotypes.

Contributors to reduced life expectancy among Native Americans in the Four Corners States

To assess trends in life expectancy and the contribution of specific causes of death to Native American-White longevity gaps in the Four Corners states, we used death records from the National Center for Health Statistics and population estimates from the U.S. Census Bureau from 1999–2017 to generate period life tables and decompose racial gaps in life expectancy. Native American-White life expectancy gaps narrowed between 2001 and 2012 but widened thereafter, reaching 4.92 years among males and 2.06 years among females in 2015. The life expectancy disadvantage among Native American males was primarily attributable to motor vehicle accidents (0.96 years), liver disease (1.22 years), and diabetes (0.78 years). These causes of deaths were also primary contributors to the gap among females, forming three successive waves of mortality that occurred in young adulthood, midlife, and late adulthood, respectively, among Native American males and females. Interventions to reduce motor vehicle accidents in early adulthood, alcohol-related mortality in midlife, and diabetes complications at older ages could reduce Native American-White longevity disparities in the Four Corners states.

Unveiling an 'invisible population': health, substance use, sexual behavior, culture, and discrimination among urban American Indian/Alaska Native adolescents in California

Objectives: There are limited public health data on urban American Indian/Alaska Native (AI/AN) populations, particularly adolescents. The current study attempted to address gaps by providing descriptive information on experiences of urban AI/AN adolescents across northern, central, and southern California.Design: We describe demographics and several behavioral health and cultural domains, including: alcohol and other drug (AOD) use, risky sexual behavior, mental and physical health, discrimination experiences, involvement in traditional practices, and cultural pride and belonging. We recruited 185 urban AI/AN adolescents across northern, central, and southern California from 2014 to 2017 who completed a baseline survey as part of a randomized controlled intervention trial.Results: Average age was 15.6 years; 51% female; 59% of adolescents that indicated AI/AN descent also endorsed another race or ethnicity. Rates of AOD use in this urban AI/AN sample were similar to rates for Monitoring the Future. About one-third of adolescents reported ever having sexual intercourse, with 15% reporting using alcohol or drugs before sex. Most reported good mental and physical health. Most urban AI/AN adolescents participated in traditional practices, such as attending Pow Wows and learning their tribal history. Adolescents also reported discrimination experiences, including being a victim of racial slurs and discrimination by law enforcement.Conclusions: This study describes a select sample of California urban AI/AN adolescents across several behavioral health and cultural domains. Although these adolescents reported numerous discrimination experiences and other stressors, findings suggest that this sample of urban AI/AN teens may be particularly resilient with regard to behavioral health.

Assessing the Predictive Validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) in Alaska Native and American Indian People

OBJECTIVES

The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder.

METHODS

The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates.

RESULTS

After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates.

CONCLUSIONS

Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native Communities: A Randomized Clinical Trial

Importance

Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders.

Objective

To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

Design, Setting, and Participants

This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020.

Interventions

Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period.

Main Outcomes and Measures

Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL).

Results

Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03).

Conclusions and Relevance

The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174315.

Historical trauma and substance use among American Indian people with current substance use problems

OBJECTIVE

In the United States, American Indian and Alaska Native (AI/AN) people suffer health inequities associated with alcohol and other drug use and also experience historical trauma symptoms resulting from colonization. Research suggests that historical trauma may be associated with substance use among AI/ANs.

METHOD

As part of a Community-Based Participatory Research project with tribal partners from a rural AI reservation, our team collected cross-sectional survey data from 198 tribal members who self-identified as having substance use problems. We examined associations between historical trauma thoughts, historical trauma symptoms, and substance use outcomes. We also examined historical trauma symptoms, current trauma symptoms, awareness of systemic discrimination, and ethnic identity as moderators of the associations between historical trauma thoughts and substance use variables.

RESULTS

Historical trauma thoughts, controlling for symptoms, were associated with greater abstinent days, fewer heavy alcohol use days, fewer drinks per drinking day, and fewer drug use days; historical trauma symptoms, controlling for thoughts, were associated only with fewer abstinent days. Moderation analyses showed that historical trauma thoughts were associated with better substance use outcomes when historical trauma symptoms were low, current trauma symptoms were low, awareness of systemic discrimination was high, and ethnic identity was high.

CONCLUSION

When distressing trauma symptoms are low, historical trauma thoughts may act as a protective factor or as a marker for other factors associated with better substance use outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Variations in risk and promotive factors on substance use among urban American Indian youth

Although roughly 70% of the American Indian and Alaska Native (AI) population live in urban areas, research is scarce regarding this population. As a consequence, there is limited understanding about the salient socioenvironmental factors that aid in preventing substance use among urban AI communities. This study utilized a statewide, cross-sectional, school-based survey of urban AI adolescents (N = 2,375) to (a) examine the associations between substance use and risk and promotive factors within the family and peer group, and (b) explore how these associations vary by subgroups (gender, racial/ethnic background, and grade level). Results suggest that risk factors-familial substance use and antisocial peer affiliation-were associated with higher alcohol, cigarette, and marijuana use. However, these findings varied by subgroup. For males, involvement with antisocial peers was associated with greater marijuana use. Involvement with antisocial peers was also positively associated with alcohol and marijuana use for multiracial/multiethnic AI adolescents and those adolescents in 10th and 12th grades. The promotive factors-supportive family environment and prosocial peer affiliation-were not universally associated with lowered substance use by subgroup. This study advances understandings of the risk and promotive factors important in reducing and preventing substance use among urban AI adolescents. Experiencing familial substance use and affiliating with antisocial peers were the salient factors associated with increased substance use, particularly for urban AI adolescents who are older, male, and with multiracial/multiethnic AI backgrounds.

Culturally tailored evidence-based substance use disorder treatments are efficacious with an American Indian Southwest tribe: an open-label pilot-feasibility randomized controlled trial

BACKGROUND AND AIMS

Many evidence-based treatments (EBTs) for substance use disorder (SUD) exist, yet few are tailored to Indigenous patients. This trial tested the efficacy of a culturally tailored EBT that combined Motivational Interviewing and the Community Reinforcement Approach (MICRA) versus treatment as usual (TAU).

DESIGN

A mixed efficacy/effectiveness randomized controlled trial of MICRA (n = 38) and TAU (n = 41) using a parallel design with follow-up assessments at 4-, 8-, and 12- months post baseline.

SETTING

United States, reservation-based outpatient, addiction specialty care treatment program.

PARTICIPANTS

79 (68% male) American Indian and Alaska Native (AI/AN) Tribal members meeting criteria for SUD and seeking SUD treatment.

INTERVENTIONS

MICRA (individual therapy sessions beginning with MI for 2-3 sessions) compared with TAU (individual and group counseling sessions in a didactic style with Twelve-Step philosophy and elements of relapse prevention).

MEASURES

Demographics, percent days abstinent (PDA; the primary outcome at 12months assessed by Form 90D), Inventory of Drug Use Consequences, Alcohol and Drug Use Self-Efficacy Scale, Native American Spirituality Scale, and SCID-DSM-IV-TR.

FINDINGS

There was no evidence for the benefit of MICRA over TAU (MICRA PDA = 72.63%, TAU = 73.62%, treatment effect: B = -4.04 (SE = 5.47); 95% CI = -14.941, 6.866; BF = 3.44) in the primary outcome. Both groups showed improvements in PDA, SUD severity, and negative consequences from baseline to the 12-month follow-up. Neither self-efficacy nor spirituality were significant mediators of MICRA.

CONCLUSIONS

There were no treatment group differences between culturally tailored evidence-based treatments for substance use disorder and treatment as usual in this randomized controlled trial with American Indian and Alaska Native participants. Nonetheless, participants improved over time on several substance-related outcomes.

Conjoint adolescent developmental trajectories of alcohol and marijuana use and early adult outcomes among North American Indigenous people

OBJECTIVE

The current study examined the developmental interrelationships between alcohol and marijuana use trajectories from ages 10 to 18 years in a sample of North American Indigenous adolescents. Distinct co-use groups were formed to create profiles of young adult outcomes.

METHOD

Dual group-based trajectory models of marijuana and alcohol frequency were estimated using data from a longitudinal community-based participatory study of Indigenous adolescents from the upper Midwest and Canada. Joint probabilities were used to create co-use groups, and profiles were created using early adult (Mean Age - 26.28 years) outcomes.

RESULTS

Four joint trajectory groups were identified: 1) no marijuana and no/low alcohol use (34.4%), 2) mid-onset alcohol only (14%), 3) mid-onset co-use starting at age 13 (24%), and 4) early-onset co-use starting at age 11 (22%). High probabilities existed that adolescents would use marijuana early if they began drinking alcohol at the youngest ages, and that adolescents would not use marijuana if they drank infrequently or delayed drinking until mid-adolescence. Adult outcomes were poorer for the early- and mid-onset co-use groups, but there were few differences between the no/low use and alcohol-only groups.

CONCLUSION

Co-use of marijuana and alcohol was associated with poorer outcomes in early adulthood, particularly for the group with an earlier age of onset. Abstaining from either substance in adolescence was associated with better outcomes.

Protective factors against tobacco and alcohol use among pregnant women from a tribal nation in the Central United States

Identifying social determinants of tobacco and alcohol use during pregnancy is critical to improving health outcomes for the next generation. This is especially important on a rural Tribal Nation where influences such as isolation, cultural barriers, and historical trauma have made it uniquely challenging to prevent substance use during pregnancy. The purpose of this study is to identify population-specific factors that are protective against smoking and drinking during pregnancy. We used data from 421 pregnancies collected as a part of the Safe Passages study from a rural Tribal Nation in the central United States. Pregnant women were classified as women who did not smoke (n = 84), women who quit during pregnancy (n = 23), women who smoked during pregnancy (n = 314), and women who both smoked and drank alcohol during pregnancy (n = 149). Demographic data revealed that 28.8% of the mothers were currently employed, and 91.8% of mothers reported a household income of less than $3,000 per year. Substance use rates were higher than national averages: 74.6% smoked during pregnancy and 35.4% of the women both smoked and drank alcohol during pregnancy. Five factors were identified as being protective against substance use during pregnancy: 1) living with someone (81% less likely to smoke and 92% less likely to smoke and drink), 2) having at least 12 years of education (128% less likely to smoke, and 126% less likely to smoke and drink), 3) having over 12 years of education (235% less likely to smoke, and 206% less likely to smoke and drink), 4) being employed (158% less likely to smoke, and 111% less likely to smoke and drink), and 5) not being depressed (214% less likely to smoke, and 229% less likely to smoke and drink). These social determinants should be considered for intervention research to decrease rates of substance use during pregnancy.

Examining adverse childhood experiences among Native American persons in a nationally representative sample: Differences among racial/ethnic groups and race/ethnicity-sex dyads

BACKGROUND

Existing research using nationally representative samples has provided valuable information regarding the prevalence and context of childhood adversity, but Native American persons have largely been absent from these studies.

OBJECTIVE

We examined adverse childhood experiences (ACEs) among persons identifying as White, Black, Asian, Hispanic, and Native American in the NESARC, a longitudinal study (Wave 1: 2001-2002; Wave 2: 2004-2005) using a nationally representative sample from the United States.

METHODS

Means tests and negative binomial regression were used to examine the prevalence and variety of ACEs across racial/ethnic groups and race/ethnicity-sex dyads.

RESULTS

Native American persons reported the greatest average number and variety of ACEs than persons from any other racial/ethnic group, and reported the highest rates of physical abuse, sexual abuse, parental substance abuse, and witnessing violence than members of any other racial/ethnic category. Native American females reported the greatest rates of emotional abuse, while Native American males reported the greatest rates of physical neglect; the highest rates of parental substance use among the race/ethnicity-sex dyads were reported by both Native American females and males. Significantly higher rates of sexual violence were reported by Native American females compared to other groups; almost 1 in 4 Native American females reported sexual violence.

CONCLUSIONS

Future research should make a concerted effort to broaden examinations of ACEs to include Native American respondents and to include measures of historical trauma and racial discrimination. Broader support for system change as well as increased development and use of culturally responsive prevention and intervention programming is likely necessary to reduce ACEs among Native American persons.

The Validity of the Short Inventory of Problems and Drinking Intensity among Urban American Indian Adults

BACKGROUND

American Indian (AI) adults have both high prevalence rates of alcohol abstinence and alcohol use disorders compared to non-Hispanic White adults. We investigated the applicability and validity of the Short Inventory of Problems (SIP) among AI urban adults and the moderating effect of biological sex.

METHODS

AI adults from three Alcoholics Anonymous samples (n = 124) provided baseline, 3-, 6- and 9-month data. Measures included Form 90 and the SIP, which includes 5 domains of alcohol-related negative consequences including interpersonal, intrapersonal, physical, impulse control and social. Drinking frequency and intensity were assessed by percent days abstinent (PDA) and drinks per drinking day (DPDD).

RESULTS

Cronbach alphas of the SIP were similar between urban AI adults and the mainstream treatment-seeking population reported in the SIP manual. DPDD was a significant and positive predictor of all five SIP scales collected 9-months later. Higher PDA was significantly and negatively associated with later consequences, and all 5 SIP scales. Moderation tests indicated that the association between consequences and drinking intensity was stronger for AI females with fewer drinking days resulting in significantly fewer consequences for AI males relative to AI females.

CONCLUSIONS

Findings highlight the acceptability of SIP as a measure to assess drinking related consequences among AI urban adults, with clinical implications related to alcohol use and sex. Further research is warranted to examine differential drinking related outcomes among AI men and women in addition to adaptations of the SIP that more fully capture the range of negative drinking consequences.

Health Disparities Research with American Indian Communities: The Importance of Trust and Transparency

American Indian and Alaska Native (AI/AN) communities experience notable health disparities associated with substance use, including disproportionate rates of accidents/injuries, diabetes, liver disease, suicide, and substance use disorders. Effective treatments for substance use are needed to improve health equity for AI/AN communities. However, an unfortunate history of unethical and stigmatizing research has engendered distrust and reluctance to participate in research among many Native communities. In recent years, researchers have made progress toward engaging in ethical health disparities research by using a community-based participatory research (CBPR) framework to work in close partnership with community members throughout the research process. In this methodological process paper, we discuss the collaborative development of a quantitative survey aimed at understanding risk and protective factors for substance use among a sample of tribal members residing on a rural AI reservation with numerous systems-level barriers to recovery and limited access to treatment. By using a CBPR approach and prioritizing trust and transparency with community partners and participants, we were able to successfully recruit our target sample and collect quality data from nearly 200 tribal members who self-identified as having a substance use problem. Strategies for enhancing buy-in and recruiting a community sample are discussed.

Racial and ethnic differences in alcohol-, opioid-, and co-use-related deaths in Washington State from 2011 to 2017

BACKGROUND

Few studies exist examining alcohol and opioid co-use mortality rates among racially and ethnically diverse communities, presenting a critical gap in understanding the contribution of alcohol on opioid-related deaths and strategies for prevention. The purpose of the study was to assess whether alcohol and opioid-related deaths differ by race/ethnicity subgroups and if there has been an increase in alcohol and opioid-related deaths between 2011 and 2017.

DESIGN

Secondary data analysis of publicly available alcohol and opioid mortality data among non-Hispanic Whites, Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native individuals in Washington State.

MEASUREMENTS

The primary outcomes were alcohol-only, opioid-only, and alcohol-opioid co-use mortality, 2011-2017. Alcohol and/or opioid-related deaths were assigned an International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for the underlying or multiple cause of death.

FINDINGS

Between 2011 and 2017, alcohol-only mortality rates increased among non-Hispanic White (P = 0.003) and Hispanic individuals (P = 0.008). Opioid-only mortality rates increased among American Indian/Alaska Native (P = 0.004) and Hispanic individuals (P = <0.001). American Indian/Alaska Native individuals had the highest alcohol-only, opioid-only, and co-use-related mortality rates when looking at between-group incidence rates.

CONCLUSIONS

Although the opioid epidemic has been characterized as a public health crisis that predominantly impacts non-Hispanic White individuals, racial and ethnic minorities are increasingly impacted by fatal and non-fatal overdose related to co-occurring substance use. Our findings using data from Washington State, align with existing data and signal a dire need to address alcohol and opioid misuse through targeted interventions to prevent overdose and poisoning, with special considerations for American Indian/Alaska Native communities.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.