Screening and Brief Intervention for Hazardous Alcohol Use and Aboriginal Populations

1. Screening and brief intervention for hazardous alcohol use and Aboriginal populationsDr. John F. Anderson, Senior Research Fellow, Centre for Addictions Research of BCPresentation to: 3rd Conference of INEBRIALisbon, Portugal26th October 2006

2. Acknowledgement of Territory“I would like to acknowledge, withrespect, the history, customs, andculture of the Coast Salish and StraitsSalish peoples on whose traditionallands the University of Victoria resides.”“Also, I acknowledge that my CAR-BC office at the University of Victoria is located in the Traditional Territory of the Lekwungen Peoples.”

3. Personal AcknowledgementsMaggie BradyJodi SturgeMiranda Kelly

4. Two ThemesTheme One: Some musings of a non-Aboriginal community medicine researcher on relationship between hazardous alcohol use among Aboriginal drinkers and alcohol-related harms including potential impact of SBI in reducing harms.Theme Two: The importance of considering cultural and historical issues when conducting alcohol research within Aboriginal populations.

5. First Nations Regional Longitudinal Health Survey (RHS) 2002/0310,962 adults (18+) interviewed in 238 First Nations communities across CanadaCanadian Addiction Survey 200413,909 adults (15+) from 10 provinces responded to telephone interview

7. ConclusionsMore abstainers in Aboriginal populationFewer regular monthly and weekly drinkersMore monthly and weekly binge drinkersAs age increases, greater reduction in drinking overall including rate of regular drinking but lesser reduction in rate of binge drinking.

8. Regional analysis of health statistics for status Indians in British Columbia 1992-2002: British Columbia Vital Statistics Agency:Source for alcohol-related deaths (ASMR)The costs of substance abuse in Canada 2002: Canadian Centre on Substance Abuse:Source for alcohol-related disease categories

9. Alcohol-Related Death Ratios by Alcohol Related Disease CategoryLiver cirrhosis – 5.7 XMotor vehicle accidents – 3.8 XSuicides/self-inflicted injuries – 2.6 XOesophageal cancer – 1.4 X (Est.)Cardiac arrythmias – 1.8X

10. ConclusionIn British Columbia, alcohol related mortality rate among status Aboriginals is 4-6 X greater than in the general population.

11. Areas of InquiryThe relationship between rates and patterns of Aboriginal drinking and alcohol-related mortality.The impact of reducing the rate of binge drinking on alcohol-related mortality.SBI for hazardous alcohol use as a means to reduce binge drinking among Aboriginal drinkers.

12. Stockwell T, et al. Total versus hazardous per capita alcohol consumption as predictors of acute and chronic alcohol-related harm. Contemporary Drug Problems 1996; 23(3):441-64.“There is increasing evidence that binge-drinking patterns contribute to the risk of a variety of physical and social harms over and above crude volume of consumption. [The] time…will come to measure and target specifically the substantial amounts of alcohol that are consumed by communities in a hazardous or high-risk fashion.”

13. Crude consumption volume and alcohol-related risk (AHD)

14. Rate of binge drinking and alcohol-related mortalityAboriginal drinkers 2-3 X more likely to binge drink with a 4-6 X greater alcohol-related mortality

15. Rate of binge drinking and alcohol-related mortality

16. SBI for hazardous Aboriginal drinking and the research literature

17. Brady M, Dawe S, Richmond R. (1998). Expanding knowledge among Aboriginal service providers on treatment options for excessive alcohol use. Drug Alcohol Rev. Mar;17(1):69-76.“178 agencies throughout Australia were interviewed, and findings are presented from the 29 agencies in this sample which provided services primarily for Aboriginal people. Approximately half offered a variety of approaches including brief interventions, with goals of moderation; the other half were entirely abstinence-orientated.”However, many Aboriginal addiction treatment services providers under-value the role of harm minimization; much of the attitude expressed is consistent with cultural determinism and involves the notion that Aboriginal people are unable to drink in a controlled, low-risk manner because predisposing genetic and cultural factors have become destabilized by colonialism.

18. Sibthorpe BM, et al. (2002). The demise of a planned randomized controlled trial in an urban Aboriginal medical service. Medical Journal of Australia; 176:273-6.‘RCTs involving inevitably complex study protocols may not be acceptable or sufficiently adaptable to make them viable in busy, Indigenous primary health care settings.’‘Decisions about appropriate interventions will often have to be based on qualitative assessment of appropriateness and evidence from other populations and other settings.’

19. Brady M, Sibthorpe B, Bailie R, et al. (2002). The feasibility and acceptability of introducing brief intervention for alcohol misuse in an urban Aboriginal medical service. Drug and Alcohol Review; 21:375-80. SBI is culturally appropriate but potential barriers to expanded implementation include lack of provider time and the complexity of health issues within the patient population.

20. The meaning of alcohol in Aboriginal culture and SBI for hazardous drinking Wing DM, Thompson T, Heleshaya. The meaning of alcohol to traditional Muscogee Creek Indians. Nursing Science Quarterly 1996; 9(4):175-80. “…unearthing the meaning of alcohol among high risk cultural groups could challenge the way in which contemporary health care systems approach alcoholism treatment.”

21. Wing DM, Thompson T, Heleshaya. The meaning of alcohol to traditional Muscogee Creek Indians. Nursing Science Quarterly 1996; 9(4):175-80. Categories of Meaning Drinking to feel accepted (by the dominant culture) Alcohol as an evil (that detracts from living a traditional life) Drinking (as a disease) that causes irresponsible behaviour Alcohol (as a dominant cultureimposition) to control Aboriginals

22. Drinking to feel accepted and to be perceived as ‘normal’ Brady M. (1995). Culture in treatment, culture as treatment. A critical appraisal of developments in addictions programs for indigenous North Americans and Australians. Social Science and Medicine; 41(11):1487-98. e.g., the fringe camps surrounding Alice Springs and Darwin in Australia are populated by Aboriginal drinkers whose excessive drinking is a ‘normal’ feature of a hermetically sealed cultural environment. The cultural homogeneity among drinkers shelters them from external threat but also sustains the alcohol commodity as the prime medium of exchange and reinforces damaging drinking as a normal feature of their society.

23. Drinking to feel accepted and to be perceived as ‘normal’ Rothe JP. Towards a better understanding of First Nations communities and drinking and driving. Int J Circumpolar Health 2005 Sep;64(4):336-45. “Living in First Nations communities is socially complex, highly emotionally charged, and peer-pressured. Drinking and driving and alcohol abuse amongst First Nations people reflect the community social structure, daily pressures and norms of behavior. Hence, to reduce drinking and driving casualties amongst First Nations young people, intervention strategies must address systemic issues, namely local people's social realities, norms, as well as local and peer relationships.”

24. Accepting drinking to respect autonomy Brady M. (1995). Culture in treatment, culture as treatment. A critical appraisal of developments in addictions programs for indigenous North Americans and Australians. Social Science and Medicine; 41(11):1487-98. “aspects of ‘traditional culture' may hinder the process of counteracting alcohol and drug abuse. One example of this is the ideal of personal autonomy among Aboriginal people and an associated antipathy to being told what to do. Australian Aborigines in tradition-oriented communities subscribe to a pervasive belief in the right of others to conduct themselves as they wish. There are strong disincentives to interfere in other peoples' business, even in the case of excessive and dysfunctional drinking which is damaging to the individual or to others in the community.”

25. Evil Drinking (Sin) or Irresponsible Drinking (Disease) Chanteloup FN. (2002). Considering the myth of the drunken Indian. PhD dissertation. Ottawa: Carlton University. The Firewater or Drunken Indian Myth from the perspective of non-Aboriginals: The Aboriginal drinker as one possessing both a deficit and an excess of individualism thus producing an archetype of the alcoholic who is both a moral failure and diseased.

26. Drinking as a means of controlling others Encore Chanteloup FN. (2002). The Firewater or Drunken Indian Myth from the perspective of Aboriginals (RCAP transcripts): Aboriginal drinking patterns are imbedded in a pathological relationship between Aboriginal and non-Aboriginal societies triggered by the historic process where Europeans gained control over Aboriginal lands through the use of deceit, unethical behaviour and alcohol. The net outcome was the loss of both Aboriginal land and identity. Hence, alcohol has become enshrined within a ‘Lost’ metaphor, i.e., Land/Aboriginal, and is therefore a potent symbol of lost Aboriginal culture and values. Further assimilation policies, e.g., residential schools, reserve system, have reinforced and perpetuated the dysfunctional relationship and sense of external locus of control.

27. Questions: How do you screen and intervene with hazardous drinkers if the culture reinforces minding your own business? Or, if alcohol is perceived as evil and detracting from living a traditional way of life or if alcohol use per se creates havoc and causes disease, how do you advocate for controlled drinking? [as per R. Room (1992), within a culture of temperance, it is difficult to argue a neutral position for alcohol where acceptable patterns and levels of drinking are balanced against social and health costs.] Also, SBI for hazardous drinking is highly dependent on establishing consensus about community norms, i.e., safe/acceptable drinking patterns and levels - How do you establish an acceptable community norm when the existing norms are so extreme, e.g., abstinence versus binge drinking? Moreover, what is most likely to motivate hazardous drinkers to change, e.g., negative individual health consequences versus impaired community function?

28. On the other hand… If alcohol is a symbol of a disrupted relationship between and within communities and if hazardous alcohol use is at least partially the result of dominant culture assimilation policies, then is a community intervention like screening and brief intervention for hazardous alcohol use a useful approach? If the goals are to repair negative relationships, heal intergenerational dysfunction, restore Aboriginal identity in order to begin to re-build First Nation communities, then are population health interventions that improve overall rather than individual health outcomes more congruent with an Aboriginal interpretation of the past and future role of alcohol in Aboriginal society?

29. But wait!!!There are other key factors to consider when researching hazardous drinking in Aboriginal communities.Ref: Schnarch B. Ownership, control, access, and possession (OCAP) or self-determination applied to research: a critical analysis of contemporary First Nations research and some options for First Nations communities. Ottawa: National Aboriginal Health Organization, 2004.

30. Some food for thought?Community health research pertaining to hazardous alcohol use among Aboriginal drinkers is a complex issue!Research requires consultation and collaboration with Aboriginal communities.Research must cope with a sometimes confusing conflict between ethical principles, e.g., utility and autonomy.

31. Consultation The gathering of information and its subsequent use are inherently political. In the past, Aboriginal people have not been consulted about what information should be collected, who should gather that information, who should maintain it, and who should have access to it. The information gathered may or may not have been relevant to the questions, priorities and concerns of Aboriginal peoples. (RCAP, April 1992-December 1993)

32. Consultation Community involvement, participation and collaboration are required. This includes collaboration on all aspects of any research project including: development, sponsorship, assessment of benefits and risks, methodology, reporting and dissemination plans, data ownership. The research relationship should be negotiated perhaps with a written contract or MOU.

33. Consultation Some practical steps forward: Understanding and acknowledging traditional research methodologies to facilitate research collaboration, e.g., within Inuit culture, the importance of data gathering and analysis in order to achieve consensus about a hunt or a camp, e.g., Nanuvut (Keewatin) circa 1979. Meaningful capacity development for Aboriginals should be incorporated into the research project including the support of aboriginal researchers, e.g., LE,NONET Project, University of Victoria.

34. Utility / Autonomy Community interests should be supported with potential benefits maximized and harm reduced or avoided. Community priorities should be respected, i.e., reducing alcohol-related community despair/disruption resulting from assimilation policies may supersede reducing individual alcohol-related health risks (Brunen, 2000). Community leaders may prefer to take action on problems as opposed to only studying them, e.g., informal surveys of drug user groups to rapidly identify affected users requiring intervention.

35. Next Steps: Anderson JF. Screening and brief intervention for hazardous alcohol use and Indigenous populations: culturally congruent concept or wanton wishful whim? Addiction Research and Theory 2006: accepted for publication. Anderson JF. Firewater and other drunken Indian myths: boon or barrier to implementation of harm minimization strategies for hazardous alcohol use in Aboriginal populations? Social Science and Medicine 2006: awaiting final editorial decision.

36. Next Steps: In collaboration with aboriginal partners and stakeholders, establish a provincial monitoring system to: Measure and study ongoing trends in alcohol use among Aboriginals. Increase precision at quantifying harms associated with Aboriginal drinking. Ensure that interpretation of results reflect an Aboriginal perspective on the impact of hazardous alcohol use on Aboriginal society.

37. Next Steps: In collaboration with Aboriginal partners and stakeholders, produce a best evidence review paper on the prevention of harms associated with Aboriginal alcohol use. The paper can be used as a platform knowledge base to inform future research as well as implementation and modification of existing interventions for hazardous drinking.

38. Next Steps: In collaboration with aboriginal partners and stakeholders: Develop and implement a community health pilot(s) that examines and responds to hazardous alcohol use in aboriginal communities