Community perspectives on drug/alcohol use, concerns, needs, and resources in four Washington State Tribal 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.

Measurement Invariance and Application of an Alcohol-Related Consequence Scale for American Indian Adolescents

American Indian (AI) adolescents experience disproportionate alcohol-related consequences. The present study evaluated the psychometric properties and application of the American Drug and Alcohol Survey (ADAS™) alcohol-related consequence scale for AI adolescents through a secondary analysis of a large population-based sample of adolescents living on or near AI reservations. We found support for the ADAS alcohol-related consequence scale as a one-factor model, invariant discretely across race, sex assigned at birth, and age, and with good internal consistency. Evidence for construct validity was found through significant positive correlations between frequency of past 12 months of drinking, frequency of past 12 months of intoxication, and lifetime alcohol-related consequences. AI adolescents were significantly more likely to report more alcohol-related consequences than their non-Hispanic White peers. Race significantly interacted with frequency of drinking in predicting alcohol-related consequences such that these associations were stronger for AI adolescents. However, race did not significantly interact with frequency of intoxication in predicting alcohol-related consequences. Results from this study demonstrate the utility of the ADAS alcohol-related consequence scale for use across demographic groups with little risk of measurement bias.

A realist review of best practices and contextual factors enhancing treatment of opioid dependence in Indigenous contexts

OBJECTIVES

The objective of this study was to examine international literature to identify best practices for treatment of opioid dependence in Indigenous contexts.

METHODS

We utilized a systematic search to identify relevant literature. The literature was analysed using a realist review methodology supported by a two-step knowledge contextualization process, including a Knowledge Holders Gathering to initiate the literature search and analysis, and five consensus-building meetings to focus and synthesize relevant findings. A realist review methodology incorporates an analysis of the complex contextual factors in treatment by identifying program mechanisms, namely how and why different programs are effective in different contexts.

RESULTS

A total of 27 sources were identified that met inclusion criteria. Contextual factors contributing to opioid dependence described in the literature often included discussions of a complex interaction of social determinants of health in the sampled community. Twenty-four articles provided evidence of the importance of compassion in treatment. Compassion was evidenced primarily at the individual level, in interpersonal relationships based on nonjudgmental care and respect for the client, as well as in more holistic treatment programs beyond biophysical supports such as medically assisted treatment. Compassion was also shown to be important at the structural level in harm reduction policies. Twenty-five articles provided evidence of the importance of client self-determination in treatment programs. Client self-determination was evidenced primarily at the structural level, in community-based programs and collaborative partnerships based in trust and meaningful engagement but was also shown to be important at the individual level in client-directed care. Identified outcomes moved beyond a reduction in opioid use to include holistic health and wellness goals, such as improved life skills, self-esteem, feelings of safety, and healing at the individual level. Community-level outcomes were also identified, including more families kept intact, reduction in drug-related medical evacuations, criminal charges and child protection cases, and an increase in school attendance, cleanliness, and community spirit.

CONCLUSIONS

The findings from this realist review indicate compassion and self-determination as key program mechanisms that can support outcomes beyond reduced incidence of substance use to include mitigating systemic health inequities and addressing social determinants of health in Indigenous communities, ultimately healing the whole human being.

Gender-based differences in abstention and desistance from drug use among American Indian adolescents

Informed by the social control theoretical perspective, this study intends to identify the factors more likely to differentiate American Indian (AI) adolescents who never used illicit drugs (abstainers) and those who used drugs in the past but did not report recent drug usage (desisters) from their peers who reported lifetime and recent drug usage (persisters). This secondary analysis is based on data from a multi-site study conducted between 2009 and 2013. It is based on a gender-balanced sample (N = 3,380) of AI adolescents (50.50% male; Mean age = 14.75; SD = 1.69) representing the major AI languages and cultural groups in the U.S. Half of the AI adolescents reported lifetime drug use (50.40%), 37.50% never used drugs, and 12.10% stopped using drugs. When controlling for the variables included in the analysis, AI boys were significantly more likely than AI girls to desist from drug use. Both boys and girls who never used drugs tended to be younger, were less likely to have delinquent friends and a lower level of self-control, had stronger bonds to school, but lower levels of family attachment, and reported increased parental supervision. Compared to drug users, desisters associated significantly less with delinquent peers. While school attachment, self-control, and parental monitoring did not differentiate female desisters from female drug users, adolescent boys who desisted from drug use were more likely to report higher levels of school attachment and parental monitoring and their level of self-control was less likely to be low.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study

PURPOSE

Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation.

METHODS

Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation.

FINDINGS

Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described.

CONCLUSIONS

The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: A systematic scoping review

BACKGROUND

American Indian/Alaskan Native (AI/AN) communities are second only to White Americans in mortality from opioid use disorder (OUD), while the smallest racial/ethnic minority population group in the USA. Those in rural communities experience significant health care disparities, including poorer treatment access for substance use disorder. This systematic scoping review aimed to trend the emerging evidence on opioid use disorder (OUD) management among rural AI/AN communities as well as workforce training needs.

METHOD

We searched the Medline, Embase, PsycInfo, SSCI, and Digital theses databases for empirical study publications on OUD management among AI/AN rural communities across the continuum of prevention, treatment and care. Eight studies met the following criteria: (a) focused on OUD; (b) sampled rural AI/AN members; (c) investigated prevention, treatment and/or care perspectives and/or practices or health provider preparation; and (d) published during the period 2009-2020. Included studies met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) quality control standards.

FINDINGS

Six of eight of the studies (75%) were surveys with community members and other stakeholders on OUD management within rural AI/AN communities rather than active interventions within this population. Moreover, five of eight of the studies (63%) reported a preference for culturally grounded health and wellness interventions with rural AI/AN, involving families, and community interventionists, utilizing community reinforcement approaches. Three of eight studies (37.5%) reported need for the cultural adaption of medication-assisted treatments (MAT) and use of culturally informed recovery care approaches. One of eight studies (12.5%) proposed to use culturally adapted contingency management behavioral approaches for OUD treatment and recovery care.

CONCLUSION

The evidence is trending to endorse culturally adapted OUD management with rural AI/AN communities, prioritizing prevention education, and use of MAT with cultural adaptation and whole person approaches to sustainable recovery care. Mental health care should be a part OUD prevention, treatment and recovery care in rural AI/AN rural communities.

Perceptions of alcohol misuse among Alaska native health care system stakeholders: A qualitative exploration

Although alcohol misuse is a priority for health care systems serving Alaska Native and American Indian (ANAI) people, stakeholders' perceptions of misuse are understudied. Patients (n = 34), providers (n = 20), and leaders (n = 16) at a Tribally owned and operated health care system reported that alcohol misuse results from the interaction of factors, including colonization, structural factors, social alienation, social norms about overdrinking introduced at the time of colonizing contact, coping with emotions, and beliefs about ANAI people and alcohol. Childhood exposure to alcohol misuse leads some ANAI people to avoid alcohol altogether, shedding light on the high levels of abstinence observed in ANAI communities.

Transforming responses: Exploring the treatment of substance-using African American women

This article explores how intrapersonal and structural oppression may impact treatment and the recovery process of 23 self-identified African American women with histories of incarceration and substance use. Using a critical consciousness (CC) framework and content-based thematic analysis, researchers systematically coded and extracted themes and patterns from focus group data to evaluate how marginalizing processes-such as race-based discrimination-impact treatment, the therapeutic relationship, and service provision. Results indicate that participants' health and treatment were negatively impacted by oppressive factors, specifically the oppressive process of silencing. The authors discuss research and practice implications.

La Cultura Cura: Latino Culture, Shared Experiences, and Recovery in Northern Californian Anexos

This article examines the anexo's use of Latino culture and shared experiences to promote recovery and its appeal to 1.5- and second-generation Latinos. Anexos are grassroots recovery groups with origins in Mexico that offer a residential Alcoholics Anonymous program in Latino communities. Data were gathered from a two-year (2014-2016) ethnographic study of anexos in Northern California and were analyzed thematically. Despite having access to publicly funded treatment, many 1.5- and second-generation Latinos accessed anexos based on cultural familiarity, shared experiences, and a desire to recuperate cultural practices lost during their substance use.

Mental, Physical and Social Dimensions of Health Equity and Wellness among U.S. Indigenous Peoples: What is Known and Next Steps

This special issue and introduction focuses on promoting health equity and addressing health disparities among Indigenous peoples of the United States (U.S.) and associated Territories in the Pacific Islands and Caribbean. We provide an overview of the current state of health equity across social, physical, and mental health domains. In Part 1 of the special issue, we trace promotive, protective, and risk factors related to Indigenous health equity. Part 2 of the special issue describes interventions that address and promote wellness, providing promising pathways to achieving and transcending health equity.

Effectiveness and appropriateness of culturally adapted approaches to treating alcohol use disorders in Indigenous people: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to investigate the effectiveness and appropriateness of culturally adapted approaches for treating alcohol use disorders in Indigenous peoples in Canada, New Zealand, Australia, and the USA.

INTRODUCTION

Poor and disadvantaged people, particularly those who are Indigenous, suffer more health effects due to alcohol misuse and are therefore subject to more law enforcement actions. Analyses have identified strategies for improving health services for Indigenous people; chief among these is culturally safe care specifically tailored to the context. Alcohol addiction is a chronic relapsing condition that usually requires ongoing treatment, so it is vital that treatment therapies are appropriate, meaningful, and effective. Many evidence-based therapies for substance abuse have not been specifically designed for or tested in Indigenous and First Nations communities. This absence of cultural considerations may be a contributor to the failure of these programs to engage with clients and successfully influence their behavior.

INCLUSION CRITERIA

This review will consider qualitative and quantitative studies of any methodology, published in any language after 1998. Studies including adult and/or adolescent participants in inpatient or outpatient alcohol treatment programs described as being adapted to meet cultural needs will be considered.

METHODS

This review will use the convergent segregated approach to mixed methods reviews. A range of databases will be searched, including MEDLINE, CINAHL, Embase, and PsycINFO. Two reviewers will critically appraise and extract data from studies meeting the inclusion criteria. Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach, and quantitative studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. The JBI convergent segregated approach to mixed methods reviews will be followed.

One size does not fit all: A NIDA CTN inspired model for community engaged cultural adaptation

The NIDA National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) is devoted to the development of effective interventions for people who use substances across a variety of populations. When positive outcomes of a particular intervention do not generalize to other groups, adaptation may improve effectiveness for a different target group. However, currently limited information is available for involving community participation in cultural adaptation. The current paper illustrates the evolution of our methodology for community engaged cultural adaptation by describing a series of sexual health and substance use interventions. We highlight the transition from minimal community involvement (the Delphi process), to moderate community involvement (theater testing), to full community engagement in cultural adaptation. Ultimately, the results of these three projects led to the development of Community Collaborative Cultural Adaptation, a novel and concrete approach to cultural adaptation. This approach emphasizes the advantage of establishing academic/community partnerships for cultural adaptation to increase the effectiveness and sustainability of interventions.

Health-Related Participatory Research in American Indian and Alaska Native Communities: A Scoping Review

A scoping review was conducted to assess the state of the literature on health-related participatory research involving American Indian and Alaska Native communities. Online databases were searched for relevant articles published between 1/1/2000 and 5/31/2017. 10,000+ data points relevant to community-level engagement in and regulation of research, community research capacity and cultural adaptation were extracted from 178 articles. Community engagement varied across study components: 136 (76%) articles reported community participation in research-related meetings and other events and 49 (27%) articles reported community involvement in initiation of research. 156 (88%) articles reported use of community-level tools to guide or regulate research. 93 (52%) articles reported that community members received research-related training. 147 (82%) articles described some type of cultural adaptation. Across all articles, data points on community engagement were not reported in 3061 (40%) out of 7740 cases. Findings suggest a need for increased community engagement in early stages of the research process and for reporting guidelines for participatory research involving American Indian and Alaska Native communities. There is also need to further existing research on the impact of different components of participatory research on process and outcome measures and to develop funding mechanisms that account for the time and resource intensive nature of participatory research.

“One Out of Ten Ain’t Going to Make It”: An Analysis of Recovery Capital in the Rural Upper Midwest

Substance use and associated fatalities are disproportionately experienced by rural communities. This study used consensual qualitative research methodology to analyze focus group data from individuals in short- and long-term recovery in rural Michigan and Minnesota. Coding was conducted within a recovery capital framework to improve understanding of the resources and barriers participants experienced in their recovery. Key findings included barriers related to transportation, as well as access to and availability of sober meetings and sober living activities. Participants perceived connections to culturally appropriate treatment as particularly important. A reconstruction of social networks from those promoting addiction to those supporting recovery was also prominently emphasized. Recovery capital appears to be a useful framework for assessing how rural communities are experiencing substance use crises, in addition to identifying areas of low capital and high need in supporting long-term recovery.

A Culturally Informed Systematic Review of Mental Health Disparities Among Adult Indigenous Men and Women of the USA: What is known?

Related to a broader context of historical oppression, Indigenous peoples of the USA are overburdened with the mental health challenges that social workers tend to treat, including post-traumatic stress disorder (PTSD), depression, suicide and substance use disorders (SUD). The purpose of this systematic review is to use the Framework of Historical Oppression, Resilience and Transcendence (FHORT) to identify empirical research on risk and protective factors related to mental health and SUD amongst these populations. This systematic review includes peer-reviewed quantitative and qualitative research articles from 1980 to 2017 focusing on the mental health of US Indigenous adults. A total of thirty-eight peer-reviewed empirical articles met inclusion criteria. Results reveal adults within Indigenous populations are at a high risk for mental health outcomes, including PTSD, depression, suicide, SUD and comorbidity across these outcomes. Underlying risk factors across outcomes included historical oppression and loss, family problems and SUD. Protective factors tended to include family and social support and engagement with tribal cultural activities. Significant variability was identified based on gender and geographic regions. Given that protective factors tended to include cultural, familial and community tenets, holistic approaches are the most promising programmes for social workers to work towards.

"They Gave Me Life": Motherhood and Recovery in a Tribal Community

OBJECTIVE

This study explored factors related to substance misuse and recovery among Native mothers in a Pacific Northwest tribe, focusing on motherhood as a motivating factor in seeking treatment and sustaining recovery.

METHOD

Using a community-based participatory research approach, we conducted a thematic analysis of 20 in-depth interviews and one focus group (N = 12) with Native women 18 years and older living on or near the reservation.

RESULTS

Qualitative findings highlighted challenges, motivations and strategies for seeking treatment and recovery in four major themes: (a) the close relationship between interpersonal violence and substance misuse; (b) traditional healing in recovery; (c) community-specific challenges to recovery; and (d) the motivating role of motherhood in seeking treatment and successful recovery.

CONCLUSIONS

A central finding of this work is that pregnancy and motherhood may be underexplored factors in Native women's substance use. Results support previous work suggesting that Native women are at high risk of interpersonal trauma and that trauma contributes to substance misuse. Findings offer several rich implications for treatment and recovery among Native mothers in tribal communities including the necessity of trauma-informed treatment, community and culturally-based interventions, more integration of treatment services with Child Protective Services, and drawing on motherhood as a motivation for seeking and succeeding in recovery.

Assessment of culture and environment in the Adolescent Brain and Cognitive Development Study: Rationale, description of measures, and early data

Neurodevelopmental maturation takes place in a social environment in addition to a neurobiological one. Characterization of social environmental factors that influence this process is therefore an essential component in developing an accurate model of adolescent brain and neurocognitive development, as well as susceptibility to change with the use of marijuana and other drugs. The creation of the Culture and Environment (CE) measurement component of the ABCD protocol was guided by this understanding. Three areas were identified by the CE Work Group as central to this process: influences relating to CE Group membership, influences created by the proximal social environment, influences stemming from social interactions. Eleven measures assess these influences, and by time of publication, will have been administered to well over 7,000 9-10 year-old children and one of their parents. Our report presents baseline data on psychometric characteristics (mean, standard deviation, range, skewness, coefficient alpha) of all measures within the battery. Effectiveness of the battery in differentiating 9-10 year olds who were classified as at higher and lower risk for marijuana use in adolescence was also evaluated. Psychometric characteristics on all measures were good to excellent; higher vs. lower risk contrasts were significant in areas where risk differentiation would be anticipated.

Native Transformations in the Pacific Northwest: A strength-based model of protection against substance use disorder

This paper presents findings from the Native Transformations Project, an exploratory community-based participatory research study that aims to identify sources of strength and protection against substance use disorder in three tribal communities in the coastal Pacific Northwest. Preliminary results from the study describe the specific settings, acts, and behaviors that build strengths and provide protection at the family, community, individual, and spiritual levels within coastal Pacific Northwest local tribal cultures. Findings from this study give voice to stated community preferences for grassroots Native intervention programs based in local cultural knowledge, worldviews, values, and theories of change, that operate at the local level on their own terms.