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Spillane NS, Schick MR, Kirk-Provencher KT, Nalven T, Goldstein SC, Crawford MC, Weiss NH. Trauma and Substance Use among Indigenous Peoples of the United States and Canada: A Scoping Review. TRAUMA, VIOLENCE & ABUSE 2023; 24:3297-3312. [PMID: 36197078 DOI: 10.1177/15248380221126184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Substance use has been identified by Indigenous populations as contributing to health disparities facing their communities. Rates of trauma exposure and post-traumatic stress disorder are higher in Indigenous, compared to non-Indigenous, populations and have been linked to substance use. Historical trauma is thought to be one mechanism underlying substance use and related disorders. The purpose of the present study is to summarize the current state of the literature focusing on the association between trauma (historical and lived) and substance use among Indigenous populations in the United States and Canada. Databases were systematically searched using the preferred reporting items for systematic reviews and meta-analyses statement. The search strategy initially yielded 4,026 articles. After exclusion of ineligible articles, 63 articles remained for synthesis. Results of the present review provide evidence for a positive link between substance use and both historical trauma (i.e., 86.4% of studies) and lived trauma (i.e., 84.7% of studies). Indigenous participants reported that historical trauma and pain related to loss of cultural identity contributed to substance use in their communities. Indigenous participants also consistently described an association between lived trauma and substance use. Despite heterogeneity among Indigenous communities, findings suggest a significant association between trauma and substance use across many different tribes and settings (e.g., reservation/reserve, rural/urban). Indigenous participants identified healing from trauma and reconnecting with culture as necessary components for reducing substance use and maintaining sobriety. With this, the development and implementation of interventions should partner with Indigenous communities in a manner that promotes and enhances cultural values for healing.
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Affiliation(s)
| | - Melissa R Schick
- University of Rhode Island, Kingston, USA
- Yale School of Medicine, New Haven CT, USA
| | - Katelyn T Kirk-Provencher
- University of Rhode Island, Kingston, USA
- University of Colorado Anschutz Medical Campus, Aurora, USA
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Gonzalez VM, Skewes MC. Association of racism and substance use treatment with belief in the myth of an American Indian/Alaska Native biological vulnerability to alcohol problems. CULTURAL DIVERSITY & ETHNIC MINORITY PSYCHOLOGY 2023; 29:339-347. [PMID: 37227852 PMCID: PMC10330333 DOI: 10.1037/cdp0000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Belief in an American Indian/Alaska Native (AIAN) specific biological vulnerability (BV) to alcohol problems is associated with worse alcohol outcomes among AIANs. Despite a notable lack of evidence that biogenetic factors play a greater role in the development of alcohol problems among AIANs than other groups, many people still believe this myth. Consistent with theory and evidence that greater experiences with discrimination leads to the internalization of stereotypes and oppression, we hypothesized that greater perceived racial discrimination (racism) would be associated with greater BV belief, but that having a stronger ethnic identity would weaken this association. We also examined whether previous substance use treatment as well as participation in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) was associated with BV belief. METHOD Participants were 198 reservation-dwelling AI adults with a substance use problem who completed a survey as part of a larger community-based participatory study. RESULTS A multiple regression analysis revealed that greater systemic racism was associated with greater belief in a BV; this association was not moderated by ethnic identity. Greater interpersonal racism was also associated with greater BV belief-but only among those low in ethnic identity. A regression analysis revealed that previous treatment, AA, and NA participation were not associated with BV belief. CONCLUSIONS Greater systemic and interpersonal racism were associated with belief in a BV, and greater ethnic identity buffered the association between interpersonal racism and BV belief. This suggests that both combatting racism and fostering positive ethnic identity may help to lessen BV belief. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Goldstein SC, Spillane NS, Nalven T, Weiss NH. Harm reduction acceptability and feasibility in a North American indigenous reserve community. JOURNAL OF COMMUNITY PSYCHOLOGY 2022; 50:3607-3624. [PMID: 35420216 PMCID: PMC9464673 DOI: 10.1002/jcop.22859] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Silvi C Goldstein
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Nichea S Spillane
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Tessa Nalven
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Nicole H Weiss
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
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Skewes MC, Gameon JA, Grubin F, DeCou CR, Whitcomb L. Beliefs about causal factors for suicide in rural Alaska Native communities and recommendations for prevention. Transcult Psychiatry 2022; 59:78-92. [PMID: 33161888 PMCID: PMC8105422 DOI: 10.1177/1363461520963869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rural Indigenous communities in Alaska suffer staggeringly high rates of suicide. In close-knit Alaska Native villages, each suicide leaves a trail of affected family and community members in its wake. This research aimed to understand community perceptions of what causes suicide in rural Alaska Native villages and generate recommendations for prevention strategies. In-depth interviews were conducted with 25 Alaska Native university students who moved from rural villages to an urban area to attend college. All had been profoundly affected by others' suicides and shared their beliefs about causal factors and recommendations for prevention efforts. Perceived causes included resistance to seeking help or discussing personal problems, loss of culture, traumatic experiences, geographical and social isolation, lack of opportunity, substance abuse, and exposure to others' suicides. Participants believed that suicide is preventable and recommended multi-level approaches to address suicide disparities. They provided recommendations for potentially effective and culturally appropriate prevention strategies, including increasing cultural and social connections, educating community members about mental health, and increasing accessibility of counseling services/reducing barriers to mental health services utilization.
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Affiliation(s)
| | - Julie A. Gameon
- Department of Psychology, Montana State University, Bozeman, MT
| | - Fiona Grubin
- Johns Hopkins School of Public Health, Baltimore, MD
| | - Christopher R. DeCou
- Department of Psychiatry and Behavioral Sciences and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA
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Woods C, Kim B, Guo K, Nyguen T, Taplayan S, Aronowitz T. Factors That Influence Substance Use Among American Indian/Alaskan Native Youth: A Systematic Mixed Studies Review. J Am Psychiatr Nurses Assoc 2022; 28:37-57. [PMID: 34396829 DOI: 10.1177/10783903211038050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The American Indian/Alaskan Native (AI/AN) mortality rate from illicit drug use was 22.7%, double that of the general population between 2007 and 2009. Fifteen percent of AI/AN youth reported receiving treatment for substance use compared with 10% of non-AI/AN peers. OBJECTIVE The purpose was to explore the factors that influence substance use among AI/AN youth. METHOD We performed a systematic review using a results-based convergent synthesis design. Eight electronic databases were searched for articles published between 2014 and 2019 using the search terms "Native American youth," "Native American adolescent," "Native Youth," "substance use," "substance misuse," and "substance abuse." The Mixed Methods Appraisal Tool was used to appraise the studies. RESULTS Forty-seven studies met the inclusion criteria (44 quantitative, one qualitative, and two mixed-methods studies). The results were organized using the ecological systems model and included evaluation of both protective and risk factors related to AI/AN youth substance use. Three system levels were found to influence substance use: individual, micro- and macrosystems. The individual systems-level coping mechanisms played a key role in whether AI/AN youth initiated substance use. Family, school, and peer factors influence the microsystem level. At the macrosystem level, community environmental factors were influential. CONCLUSION The major factor linking all the systems was the influence of a connected relationship with a prosocial adult who instilled future aspirations and a positive cultural identity. Findings of this systematic mixed studies review will assist in intervention development for AI/AN youth to prevent substance misuse.
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Affiliation(s)
- Cedric Woods
- Cedric Woods, PhD, University of Massachusetts Boston, Boston, MA, USA
| | - BoRam Kim
- BoRam Kim, BSN, RN, University of Massachusetts, Boston, MA, USA
| | - Kristine Guo
- Kristine Guo, University of Massachusetts, Boston, MA, USA
| | - Tuyet Nyguen
- Tuyet Nugyen, University of Massachusetts Boston, MA, USA
| | - Sarin Taplayan
- Sarin Tapalyan, BSN, University of Massachusetts, Boston, MA, USA
| | - Teri Aronowitz
- Teri Aronowitz, PhD, APRN, FNP-BC, FAAN, University of Massachusetts Boston, Boston, MA, USA
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Gonzalez VM, Skewes MC. Belief in the myth of an American Indian/Alaska Native biological vulnerability to alcohol problems among reservation-dwelling participants with a substance use problem. Alcohol Clin Exp Res 2021; 45:2309-2321. [PMID: 34837658 PMCID: PMC8642279 DOI: 10.1111/acer.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022]
Abstract
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.
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Larimer ME, Parker M, Lostutter T, Rhew I, Eakins D, Lynch A, Walter T, Egashira L, Kipp BJ, Duran B. Perceived descriptive norms for alcohol use among tribal college students: Relation to self-reported alcohol use, consequences, and risk for alcohol use disorder. Addict Behav 2020; 102:106158. [PMID: 31830672 DOI: 10.1016/j.addbeh.2019.106158] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 01/31/2023]
Abstract
This research addressed gaps in the literature by testing relationships between perceived descriptive alcohol use norms and individual's own alcohol use and consequences among tribal college and university (TCU) students. Survey data were collected from 3239 tribal college students in 22 TCUs across the United States in 2015 and 2016, of whom 3174 provided usable data on the variables of interest for the current manuscript. Results indicated students misperceived the descriptive norms for alcohol use at their TCU, on average estimating students at their college drank more frequently, more per occasion, and more total drinks per week relative to the observed averages on these outcomes. Participants' own drinking was significantly related to their perceived norms, with higher perceived norms related to more drinking. In addition, higher perceived norms were associated with greater alcohol-related negative consequences and lower likelihood of being a non-drinker. These findings extend research with students at majority-serving colleges and universities, indicating normative misperceptions exist and have similar relationships to alcohol use and consequences among TCU students nationwide. These findings support adaptation of normative feedback interventions for use with TCU students to emphasize healthy alcohol norms and correct misperceptions that support the stereotype that all students drink to excess.
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Affiliation(s)
- Mary E Larimer
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States.
| | - Myra Parker
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Ty Lostutter
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Isaac Rhew
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Danielle Eakins
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Alex Lynch
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Theresa Walter
- Center for the Study of Health & Risk Behaviors, Department of Psychiatry & Behavioral Sciences, University of Washington, United States
| | - Leo Egashira
- Indigenous Wellness Research Institute, School of Social Work, University of Washington, United States
| | | | - Bonnie Duran
- Indigenous Wellness Research Institute, School of Social Work, University of Washington, United States
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Wendt DC, Hartmann WE, Allen J, Burack JA, Charles B, D'Amico EJ, Dell CA, Dickerson DL, Donovan DM, Gone JP, O'Connor RM, Radin SM, Rasmus SM, Venner KL, Walls ML. Substance Use Research with Indigenous Communities: Exploring and Extending Foundational Principles of Community Psychology. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2019; 64:146-158. [PMID: 31365138 PMCID: PMC6777961 DOI: 10.1002/ajcp.12363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Many Indigenous communities are concerned with substance use (SU) problems and eager to advance effective solutions for their prevention and treatment. Yet these communities also are concerned about the perpetuation of colonizing, disorder-focused, stigmatizing approaches to mental health, and social narratives related to SU problems. Foundational principles of community psychology-ecological perspectives, empowerment, sociocultural competence, community inclusion and partnership, and reflective practice-provide useful frameworks for informing ethical community-based research pertaining to SU problems conducted with and by Indigenous communities. These principles are explored and extended for Indigenous community contexts through themes generated from seven collaborative studies focused on understanding, preventing, and treating SU problems. These studies are generated from research teams working with Indigenous communities across the United States and Canada-inclusive of urban, rural, and reservation/reserve populations as well as adult and youth participants. Shared themes indicate that Indigenous SU research reflects community psychology principles, as an outgrowth of research agendas and processes that are increasingly guided by Indigenous communities. At the same time, this research challenges these principles in important ways pertaining to Indigenous-settler relations and Indigenous-specific considerations. We discuss these challenges and recommend greater synergy between community psychology and Indigenous research.
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Affiliation(s)
- Dennis C Wendt
- Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - William E Hartmann
- School of Interdisciplinary Arts and Sciences, University of Washington-Bothell, Bothell, WA, USA
| | - James Allen
- Memory Keepers Medical Discovery Team - American and Rural Health Equity, Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth Campus, Duluth, MN, USA
| | - Jacob A Burack
- Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Billy Charles
- Center for Alaska Native Health Research, Institute for Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA
| | | | - Colleen A Dell
- Department of Sociology, School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada
| | - Daniel L Dickerson
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dennis M Donovan
- Department of Psychiatry and Behavioral Sciences, Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Joseph P Gone
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anthropology, Harvard University, Cambridge, MA, USA
| | - Roisin M O'Connor
- Department of Psychology, Concordia University, Montreal, QC, Canada
| | - Sandra M Radin
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Stacy M Rasmus
- Center for Alaska Native Health Research, Institute for Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA
| | - Kamilla L Venner
- Department of Psychology and Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Melissa L Walls
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth Campus, Duluth, MN, USA
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Gonzalez VM, Bravo AJ, Crouch MC. Endorsement of the "firewater myth" affects the use of protective behavioral strategies among American Indian and Alaska Native students. Addict Behav 2019; 93:78-85. [PMID: 30703666 PMCID: PMC6488417 DOI: 10.1016/j.addbeh.2019.01.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 01/01/2023]
Abstract
Belief in an American Indian/Alaska Native (AI/AN) specific biological vulnerability (BV) to alcohol problems (aka the "firewater myth") has been found to be associated with worse alcohol outcomes among AI/AN college students who drink, despite also being associated with greater attempts to reduce drinking. In the current study, we examined the associations of belief in a BV and belief that AI/AN people have more alcohol problems with the use of alcohol protective behavioral strategies (PBS) among AI/AN college students. PBS examined, as measured by the Protective Behavioral Strategies Scale-20, included manner of drinking, limiting/stopping drinking, and serious harm reduction strategies. Participants were college students who identified being AI/AN (n = 137) and had drank in the past month, and were selected from a larger multi-site study on PBS. Mediation models revealed that greater belief in a BV and belief that AI/AN people have more alcohol problems were both negatively associated with manner of drinking, which in turn was associated with greater past month alcohol use and alcohol consequences. These beliefs were not significantly associated with other PBS. Consistent with prior research with other student populations, both manner of drinking and limiting/stopping drinking were associated with less alcohol use and all three domains of PBS were directly associated with fewer alcohol consequences. The results suggest that these beliefs regarding AI/AN people and alcohol negatively affect the use of strategies aimed at avoiding drinking behavior that can lead to rapid drinking and a higher blood alcohol content, contributing to alcohol consequences.
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Affiliation(s)
- Vivian M Gonzalez
- Department of Psychology, University of Alaska Anchorage, 3211 Providence Drive, Anchorage, AK 99508, United States.
| | - Adrian J Bravo
- Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, 2650 Yale Blvd SE, Albuquerque, NM 87106, United States.
| | - Maria C Crouch
- Department of Psychology, University of Alaska Anchorage, 3211 Providence Drive, Anchorage, AK 99508, United States.
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DiBello AM, Miller MB, Carey KB. Self-Efficacy to Limit Drinking Mediates the Association between Attitudes and Alcohol-Related Outcomes. Subst Use Misuse 2019; 54:2400-2408. [PMID: 31434546 PMCID: PMC6883163 DOI: 10.1080/10826084.2019.1653322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Personal attitudes toward alcohol consumption are reliable predictors of alcohol use and related problems, with emerging work suggesting that one's favorable attitude toward limited drinking (i.e., at levels below the threshold for heavy episodic drinking) is a buffer against alcohol use and binge drinking. However, little work has examined the specific mechanism(s) through which one's personal attitude toward limited drinking is associated with alcohol use and related problems. One such mechanism may be an individual's self-efficacy to limit their alcohol use. The current study aimed to evaluate whether self-efficacy to limit one's alcohol use mediates the association between one's personal attitude toward limited drinking and actual alcohol use and related problems over time. Participants were mandated students (n = 568; 28% female) who violated campus alcohol policy and received a brief motivational intervention. Mediation models were used to test (a) self-efficacy to limit one's alcohol use as a traditional mediator of the attitudes-drinking quantity association and (b) self-efficacy and drinking quantity as serial mediators of the attitudes-alcohol-problems link. Favorable attitudes toward limiting drinking at baseline were positively associated with self-efficacy to limit drinking at 1 month, which was associated with a reduction in drinking quantity at 3 months; this, in turn, was associated with a reduction in alcohol-related problems at 5 months. These findings provide a rationale for incorporating attitudes and self-efficacy in the development and refinement of intervention strategies.
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Affiliation(s)
- Angelo M DiBello
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Psychology, City University of New York, Brooklyn College, Brooklyn, New York, USA
| | - Mary Beth Miller
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kate B Carey
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
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