Substance Abuse and Effective Treatment for Adult American Indians and Alaska Natives

1. Substance Abuse and Effective Treatment for Adult American Indians and Alaska Natives Michele Henson, B.S., C.H.E.S. MPH Candidate, University of Arizona

2. Abstract • From a life-course perspective, adults play an important role in shaping proximal environments • Adult AIANs face a number of health disparities • Substance abuse has a bi-directional relationship with health disparities • Substance abuse rates vary greatly among AIAN communities • Overall substance abuse rates have not changed in decades • Many have concluded that the lack of culture in substance abuse treatment is a downfall in current treatment regimes

3. Gone and Calf Looking (2011) state, “statistics fail to convey the decimation that substance use disorders have wrought in these close-knit (AIAN) communities… (AIAN) access to efficacious treatment is imperative and urgent”

4. Methods • Literature search of PubMed Central using the search term “adult American Indian Alaska Native substance abuse treatment programs” • Inclusion criteria were: • (1) written in English • (2) discuss substance abuse treatment • (3) population of interest is adult American Indians and/or Alaska Natives • (4) peer reviewed publications between 1970-2013

5. Results A total of 26 articles met all criteria and were included in this literature review

6. Results: 4 Main Themes Emerged from a Nominal Classification • Persistent Challenges • Protective/Recovery Factors • Current Trends in Treatment • Culture in Treatment • Culture as Treatment

7. Persistent Challenges • Difficulties accessing treatment • Financial barriers • Transportation barriers • Lack of treatment options conducive to tribal culture and worldview • High rates of comorbidities • High rates of mental distress • Historical trauma • Present-day trauma • High-risk environments • High rates of poverty and unemployment are more conducive to substance abuse than recovery- Gone and Calf Looking (2011)

8. Protective/Recovery Factors • Positive family relationships • Enculturation • Biculturalism

9. Protective/Recovery Factors • Positive family relationships • High degree of social support and spiritual involvement • Brave Heart, 2011 • More likely to recover if: • Married • Gilder et al., 2010 • Have children • Torres Stone et al., 2005

10. Protective/Recovery Factors • Enculturation • Degree to which a person participates in and identifies with his/her traditional culture on a spiritual level • “…Enculturation serves as a resiliency factor that may protect against alcohol misuse or serve as an important curative factor in alcohol treatment programs” • Torres Stone et al. (2006) • Those with low traditional culture orientation were 4+ times more likely to drink heavily • Herman Stahl et al. (2003)

11. Protective/Recovery Factors • Biculturalism • Feeling comfortablein identifying with both traditional culture and the majority culture • The lowest rates of substance abuse were found in AIANs who processed healthy biculturalism • Blume & Escobedo (2005) • Szlemko et al. (2006)

12. Trends in Current Treatment • General requirement for the use of Evidence-Based Treatments (EBTs) • Required for grant funding and IHS and Medicaid reimbursement • Typically 30 to 120 days of residential treatment and/or cognitive behavioral therapy using the12-step Alcoholics Anonymous (AA) framework • AIANs are typically not included in study population of the evaluation of EBTs • Sklemko et al. (2006); Novins et al. (2011)

13. Trends in Current Treatment • Problems with the use EBTs in the AIAN population: • Culturally inappropriate • Naquin et al. (2008); Hartmann & Gone (2011); Novins et al, (2011); Wexler (2011) • Feelings of incompatibility and lack of comfort • Walls et al. (2006); Hartmann & Gone (2011); Novins et al, (2011); Wexler (2011) • “No room” for culture in EBTs • Sklemko et al. (2006); Novins et al., (2011) • Many AIANs have stated preference for cultural (non-EBT) treatment that is rooted in traditional healing and indigenous knowledge • Walls et al. (2006); Hartmann & Gone (2011)

14. Culture in Treatment • Inherent within AIAN culture are traditional ways of healing and ways of knowing • Cultural traditions are “very much alive” in AIAN reservations/villages • In urban AIAN communities the use of ‘pan-Indian’ cultural healing has shown to be effective • Many AIANs who have successfully recoveredattribute that success to a return to his or her tradition culture • Torres Stone et al. (2006); Walls et al. (2006); Gone and Calf Looking (2011)

15. Culture in Treatment • AIANs identify with their traditional cultures in different ways and to different degrees • AIANs may not want to abandon the use of Euro-American models of treatment completely • Appropriate treatment will depend on degree of personal cultural identification • Choices between or integrating both healing methods is preferred and necessary

16. Culture as Treatment • High substance abuse rates are due to a loss of traditional beliefs and culture • Szlemko et al. (2006) • Brave Heart(2011) • Culture revitalization has the potential to create health benefits beyond sobriety including: • Ability to relieve stress and treat co-morbidities • Root causes of substance addiction • Strengthen AIAN families • Create healing effects on entire AIAN communities • Trauma (a root cause of substance abuse) is shared by AIAN populations and communities • Brave Heart (2011); Gone and Calf Looking (2011)

17. Successful Treatment Recommendation • Increase the capacity to incorporate culture into treatment • Bicultural skills training • Shift community social norms (passive acceptance)

18. Resilience in AIANs in regards to Substance Use • Remission rates of AIAN substance abusers have been reported to be as high as 75% • Sobriety movements: • Eskimo Spirit Movement (Inupiaq Ilitqsat) • Handsome Lake Movement • Red Road Sobriety movement • AIAN communities self-determining alcohol policies • Many AIAN communities report higher rates of abstinence than the general population

19. Discussion • Two of the articles listed prevention as the best way to reduce alcohol and substance abuse • May (2005): Tribes enforcing stricter alcohol policies • Brave Heart (2011): Alleviating the effects of historical trauma • 35% listed the lack of accessible health care and substance abuse treatment as a major barrier to reducing substance abuse rates • 58% outlined the efficacy of culture incorporation in AIAN substance abuse treatment • 38% made the claim that EBTs are not improving but limiting the successful outcomes of substance abuse treatment

20. Discussion- Where do we go from here? • EBTs are not the best treatment method for everyone • EBT requirement are limiting innovative treatment practices • If the EBT requirement is to remain, some have suggested testing cultural healing and substance treatment practices

21. Discussion- Where do we go from here? • Problems with ‘testing’ cultural substance abuse treatment methods: • Some AIAN communities may not feel comfortable ‘testing’ their sacred healing methods • Differences/uniqueness of cultures

22. Recommendation • Reevaluate the EBT requirement for funding and reimbursement for AIAN substance abuse treatment regimes • Move from ‘Evidence-based’ to ‘Practice-based’ • Enables AIANs to access treatment that works for them • Allows for further AIAN self-determination • Seek out those who have successfully recovered from addiction and identify factors that contributed to recovering • Give voice to those who have recovered in peer-reviewed literature

23. Contact Info and Special Thanks Michele Henson michelehenson@email.arizona.edu Special thanks to the Center for American Indian Resilience This work was supported by the Center for American Indian Resilience (CAIR) a NIH-NIMHD P20 Exploratory Center of Excellence (1P20MD006872) awarded to Northern Arizona University with subcontracts to University of Arizona and Dine College

24. Sources Blume, A.W., Escobedo, C.J. (2005). Best Practices for Substance Abuse Treatment Among American Indians and Alaska Natives: Review and Critique in Best Practices in Behavioral Health Services for American Indians and Alaska Natives. One Sky National Resource Center For American Indian and Alaska Native Substance Abuse Prevention and Treatment Services, 77-94 Brave Heart, M. Y. H. (2011). The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: A Lakota Illustration. Journal of Psychoactive Drugs 35 (1), 7-13. Gilder, D.A., Lau, P., Corey, L., Ehlers, C. (2008). Factors Associated with Remission from Alcohol Dependence in an American Indian Community Group. American Journal of Psychiatry 165(9), 1172-1178. Gone, J.P., Calf Looking, P.E. (2011). American Indian Culture as Substance Abuse Treatment: Pursing Evidence for a Local Intervention. Journal of Psychoactive Drugs 43(4), 291-296 Hartmann, W.E., Gone, J.P. (2012). Incorporating Traditional Healing Into an Urban American Indian Health Organization: A Case Study of Community Member Perspectives. Journal of Counseling and Psychology 59(4), 542-554. May, P.A. (2005). History and Challenges in Substance Abuse Prevention Among American Indian Communities in Best Practices in Behavioral Health Services for American Indians and Alaska Natives. One Sky National Resource Center For American Indian and Alaska Native Substance Abuse Prevention and Treatment Services, 1-24.

25. Sources Naquin, V., Manson, S.M., Curie, C., Sommer, S., Daw, R., Maraku, C., Lallu, N., Meller, D., Willer, C., Deaux, E. (2008). Indigenous Evidence-Based Effective Practice Model: Indigenous Leadership in Action. The International Journal of Leadership in Public Services 4(1), 14-24. Novins, D. K., Aarons, G.A., Conti, S.G., Dahlke, D., Daw, R., Fickenscher, A., Fleming, C., Love, C., Masis, K., Spicer, P. for the Centers for American Indian and Alaska Native Health’s Substance Abuse Treatment Advisory Board (2011). Use of the evidence base in substance abuse treatment programs for American Indians and Alaska natives: pursing quality in the crucible of practice and policy. Implementation Science 6(63). 1-12. Szlemko, W. J., Wood, J.W, Thurman, P.J. (2006). Native Americans and Alcohol: Past, Present, and Future. The Journal of General Psychology 133(4), 435-451. Torres Stone, R., Whitbeck, L.B., Chen, X., Johnson, K., Olson, D.M. (2006). Traditional Practices, Traditional Spirituality, and Alcohol Cessation Among American Indians. Journal of Studies on Alcohol 67(2), 236-244. Walls, M.L., Johnson, K.D., Whitbeck, L.B., Hoyt, D.R. (2006). Mental Health and Substance Abuse services Preferences among American Indian People of the Northern Midwest. Community Mental Health Journal 42(6), 521-5356. 3 Wexler, L. (2011). Behavioral Health Services “Don’t Work for Us”: Cultural Incongruities in Human Services Systems for Alaska Native Communities. American Journal of Community Psychology 2011(47), 157-169.

26. Questions?