Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives

Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation

INTRODUCTION

American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care.

METHODS

The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research.

RESULTS

Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance.

CONCLUSIONS

Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

American Indian and Alaska Native substance use treatment: Barriers and facilitators according to an implementation framework

INTRODUCTION

Substance use disorder (SUD) and overdose deaths are higher in the American Indian and Alaska Native (AIAN) population than in other racial/ethnic groups. Multi-level gaps hinder SUD treatment for AIAN patients. Few studies have engaged front-line clinicians and administrators of SUD treatment programs serving AIAN patients to identify barriers and facilitators to improve the implementation of effective treatment.

METHODS

We conducted key informant interviews with a diverse sample of providers and administrators of SUD treatment programs across California regarding barriers and facilitators to treatment for AIAN patients. An AIAN-majority community advisory board (CAB) guided the development of an interview guide and helped to recruit respondents from five types of SUD programs statewide. Using ATLAS.ti, the research team coded interviews and classified emergent themes as barriers and facilitators related to Outer, Inner, and Individual domains of the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Representatives of 13 of 15 invited SUD treatment programs participated and 9 of the 13 interviewed self-identified as AIAN. Related to Outer Setting barriers from coded interviews, a dominant barrier was policies that defund or underfund SUD treatment, especially detoxification centers. Outer Setting facilitators included consistent Indian Health Service (IHS) eligibility criteria, judicial system connections for direct treatment access, and community programs advocating SUD treatment. Key themes related to barriers for the Inner Setting were limited bed capacity, poor coordination of intake and care, and lack of telehealth technology. Facilitators integrated mental health, linkage to external resources, and culturally centered care. Individual-level barriers were negative attitudes such as SUD stigma, distrust of governmental programs, and lack of transportation while individual engagement was facilitated by programs addressing negative attitudes and providing telemedicine for remote care.

CONCLUSION

The public health threat of SUD for the AIAN population mandates the implementation of interventions and policies that facilitate care. This qualitative study with primarily AIAN clinical leaders of SUD treatment highlights opportunities to improve care at multiple CFIR levels, focusing on capacity, coordination, culturally congruent care, and community initiatives to promote engagement.

Exploring recovery: Findings from a six-year evaluation of an American Indian peer recovery support program

OBJECTIVES

We aimed to identify correlates of short-term recovery among American Indians who participated in the Transitional Recovery and Culture (TRAC) Program, a Peer Recovery Support (PRS) program. Research aims (As) were A1. How do recovery capital resources and indicators of recovery differ between TRAC participants who completed a six-month follow-up and those who did not? A2. How much did recovery capital resource measures change between intake and six-month follow-up? A3. Which recovery capital resources are associated with balanced recovery?

METHODS

We used the medicine wheel evaluation framework. Each concept within the framework - spiritual, emotional, mental, and physical health - was incorporated into a composite recovery outcome variable. TRAC enrolled 422 American Indians from 2014 to 2019 living in Montana and Wyoming. Six-month change was examined among 214 program participants that completed the six-month program.

RESULTS

We observed significant change for the following recovery capital resources: stable housing, being occupied, attending recovery groups, interacting with family and friends, past substance use activity, and self-reported health status. Logistic regression results for balanced short-term recovery showed that improving or maintaining occupation (AOR = 6.73, p = 0.0026), interacting with family or friends (AOR = 4.66, p = 0.0050), and still receiving services at follow-up (AOR = 2.25, p = 0.0487) were associated with significant increased odds of higher balanced short-term recovery scores.

CONCLUSION

PRS helps American Indian people achieve short-term recovery. Future efforts should focus on how to retain peers in PRS programs, and the recovery capital needed to sustain long-term recovery.

The Imperative for Research to Promote Health Equity in Indigenous Communities

Health disparities exact a devastating toll upon Indigenous people in the USA. However, there has been scant research investment to develop strategies to address these inequities in Indigenous health. We present a case for increased health promotion, prevention, and treatment research with Indigenous populations, providing context to the recent NIH investment in the Intervention Research to Improve Native American Health (IRINAH) network. We discuss the disproportionate costs and consequences of disparities borne by Indigenous groups, the limited evidence base on effective intervention for this population, how population uniqueness often makes transfer of existing intervention models difficult, and additional challenges in creating interventions for Indigenous settings. Given the history of colonial disruption that has included genocide, forced removal from lands, damaging federal, state and local policies and practices, environmental contamination, and most recently, climate change, we conclude research that moves beyond minor transformations of existing majority population focused interventions, but instead truly respects Indigenous wisdom, knowledge, traditions, and aspirations is needed, and that investment in intervention science to address Indigenous health disparities represent a moral imperative.

Transforming through leadership: a qualitative study of successful American Indian Alaska Native behavioral health leaders

BACKGROUND

Effective leadership is vital in the struggle to decrease the behavioral health disparities between the US population and American Indian Alaska Native (AIAN) communities. AIAN communities have a pre-colonization history of highly effective leadership, yet some AIAN leadership traditions have been eradicated through decades of trauma and genocidal efforts. There is a paucity of research on AIAN public health leadership, and most existing research relies on samples of individuals holding leadership positions rather than individuals purposely selected because of their effectiveness. The aim of the study was to investigate the experiences of successful AIAN behavioral health leaders and present an emerging AIAN public health leadership model.

METHODS

Thirty-eight public health leaders in the Substance Abuse and Mental Health Service Administration (SAMHSA) funded Circles of Care project were observed over the course of their three-year leadership role. Stringent criteria for successful community participatory leadership resulted in the selection of 11 of the 38 leaders for inclusion in the study. Ultimately eight leaders (21% of the population of observed leaders) participated in the study. Semi-structured, one-on-one qualitative interviews were conducted. The methods were informed by phenomenology and the data were analyzed using a thematic content analysis approach.

RESULTS

The analysis resulted in ten themes: Hopeful Vision for the People, Cultural Humility, Awareness of Historical Context, Purpose Driven Work Behavior, Cultural and Bi-Cultural Knowledge, Trusting a Broader Process, Caring Orientation, Holistic Supervision, Community Centered, and Influence Through Education. Respondents were strongly motivated by a desire to help future generations. They described their success in terms of the application of traditional AIAN values such as cultural humility and community orientation, but also relied heavily on task orientation. An emerging AIAN leadership model is presented.

CONCLUSIONS

It is important to encourage AIAN public health leaders to employ leadership research and models conducted or developed in the context of AIAN communities. The emerging model presented in this study could serve as an initial basis for AIAN leadership training. Given the challenging context of AIAN leadership, the lessons taught by these successful leaders could be adapted for use by leaders in non AIAN settings.

Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?

This study focused on (1) whether disparities in timely receipt of substance use services can be explained in part by the characteristics of the community in which the clients reside and (2) whether the effect of community characteristics on timely receipt of services was similar across racial/ethnic groups. The sample was composed of adults receiving publicly funded outpatient treatment in Washington State. Treatment data were linked to data from the US census. The outcome studied was "Initiation and Engagement" in treatment (IET), a measure noting timely receipt of services at the beginning of treatment. Community characteristics studied included community level economic disadvantage and concentration of American Indian, Latino, and Black residents in the community. Black and American Indian clients were less likely to initiate or engage in treatment compared to non-Latino white clients, and American Indian clients living in economically disadvantaged communities were at even greater risk of not initiating treatment. Community economic disadvantage and racial/ethnic makeup of the community were associated with treatment initiation, but not engagement, although they did not entirely explain the disparities found in IET.

How do providers serving American Indians and Alaska Natives with substance abuse problems define evidence-based treatment?

Rates of substance abuse remain high in American Indian and Alaska Native (AI/AN) populations. While there are many evidence-based treatments (EBTs) for substance use problems, no studies exist describing how directors of treatment programs serving AI/ANs perceive and use EBTs. Twenty-one key informant interviews with program administrators and 10 focus groups with clinicians were conducted at 18 treatment programs for AI/ANs with substance use problems. Demographic data were not collected to protect participant privacy. Transcripts were coded to identify relevant themes. A majority of participants correctly defined an EBT using the key terms "effective" and "research" found in standard definitions of the phrase. More detailed descriptions were uncommon. Prevalent themes related to attitudes about EBTs included concerns about cultural relevance, external mandates to use EBTs, and their reliance on western conceptualization of substance abuse. While most administrators and clinicians who treat AI/AN clients for substance abuse had a basic understanding of what constitutes an EBT, there was little consensus regarding their relevance for use with AI/ANs. Recognizing that broad geographic and tribal diversity among AI/AN populations may impact conclusions drawn about EBTs, several factors may enhance the abilities of program staff to identify EBTs most appropriate for local implementation. These include gaining a more detailed understanding of how an EBT is developed and how to assess its scientific grounding, as well as utilizing definitions of EBTs that include not only research evidence, but also clinical expertise and judgment, and fit with consumer choice, preference, and culture.

Challenges to providing quality substance abuse treatment services for American Indian and Alaska Native communities: perspectives of staff from 18 treatment centers

BACKGROUND

Substance abuse continues to exact a significant toll, despite promising advancements in treatment, and American Indian and Alaska Native (AI/AN) communities remain disproportionately impacted. Understanding the challenges to providing quality substance abuse treatment to AI/AN communities could ultimately result in more effective treatment interventions, but no multi-site studies have examined this important issue.

METHODS

This qualitative study examined the challenges of providing substance abuse treatment services for American Indian and Alaska Native (AI/AN) communities. We conducted key informant interviews and focus groups at 18 substance abuse treatment programs serving AI/AN communities. Seventy-six service participants (21 individuals in clinical administrative positions and 55 front-line clinicians) participated in the project. Interview transcripts were coded to identify key themes.

RESULTS

We found that the challenges of bringing effective substance abuse treatment to AI/AN communities fell into three broad categories: challenges associated with providing clinical services, those associated with the infrastructure of treatment settings, and those associated with the greater service/treatment system. These sets of challenges interact to form a highly complex set of conditions for the delivery of these services.

CONCLUSIONS

Our findings suggest that substance abuse treatment services for AI/AN communities require more integrated, individualized, comprehensive, and longer-term approaches to care. Our three categories of challenges provide a useful framework for eliciting challenges to providing quality substance abuse treatment in other substance abuse treatment settings.

Critical cultural awareness: contributions to a globalizing psychology

The number of psychologists whose work crosses cultural boundaries is increasing. Without a critical awareness of their own cultural grounding, they risk imposing the assumptions, concepts, practices, and values of U.S.-centered psychology on societies where they do not fit, as a brief example from the 2004 Indian Ocean tsunami shows. Hermeneutic thinkers offer theoretical resources for gaining cultural awareness. Culture, in the hermeneutic view, is the constellation of meanings that constitutes a way of life. Such cultural meanings-especially in the form of folk psychologies and moral visions-inevitably shape every psychology, including U.S. psychology. The insights of hermeneutics, as well as its conceptual resources and research approaches, open the way for psychological knowledge and practice that are more culturally situated.

Client and provider views on access to care for substance-using American Indians: perspectives from a Northern Plains urban clinic

In addition to disparities in rates of substance use problems, American Indians (AIs) report multiple barriers to receiving treatment services. The present study utilized intake questionnaire data and focus groups to gain perspectives from 152 clients (65% male, 35% female; mean age 30 years) and 6 female providers on access to treatment for Northern Plains AIs in an urban, non-Native program. AI clients acknowledged the need for treatment more often than did substance users in general, but faced greater resource barriers. Both clients and providers offered specific recommendations for improving access to substance use treatment for AI populations in the Northern Plains.

A framework for conducting a national study of substance abuse treatment programs serving American Indian and Alaska native communities

BACKGROUND

Because of their broad geographic distribution, diverse ownership and operation, and funding instability, it is a challenge to develop a framework for studying substance abuse treatment programs serving American Indian and Alaska Native communities at a national level. This is further complicated by the historic reluctance of American Indian and Alaska Native communities to participate in research.

OBJECTIVES AND METHODS

We developed a framework for studying these substance abuse treatment programs (n ≈ 293) at a national level as part of a study of attitudes toward, and use of, evidence-based treatments among substance abuse treatment programs serving AI/AN communities with the goal of assuring participation of a broad array of programs and the communities that they serve.

RESULTS

Because of the complexities of identifying specific substance abuse treatment programs, the sampling framework divides these programs into strata based on the American Indian and Alaska Native communities that they serve: (1) the 20 largest tribes (by population); (2) urban AI/AN clinics; (3) Alaska Native Health Corporations; (4) other Tribes; and (5) other regional programs unaffiliated with a specific AI/AN community. In addition, the recruitment framework was designed to be sensitive to likely concerns about participating in research.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This systematic approach for studying substance abuse and other clinical programs serving AI/AN communities assures the participation of diverse AI/AN programs and communities and may be useful in designing similar national studies.

Rethinking cultural competence: insights from indigenous community treatment settings

Multicultural professional psychologists routinely assert that psychotherapeutic interventions require culturally competent delivery for ethnoracial minority clients to protect the distinctive cultural orientations of these clients. Dominant disciplinary conceptualizations of cultural competence are "kind of person" models that emphasize specialized awareness, knowledge, and skills on the part of the practitioner. Even within psychology, this approach to cultural competence is controversial owing to professional misgivings concerning its culturally essentialist assumptions. Unfortunately, alternative "process-oriented" models of cultural competence emphasize such generic aspects of therapeutic interaction that they remain in danger of losing sight of culture altogether. Thus, for cultural competence to persist as a meaningful construct, an alternative approach that avoids both essentialism and generalism must be recovered. One means to capture this alternative is to shift focus away from culturally competent therapists toward culturally commensurate therapies. Indigenous communities in North America represent interesting sites for exploring this shift, owing to widespread political commitments to Aboriginal cultural reclamation in the context of postcoloniality. Two examples from indigenous communities illustrate a continuum of cultural commensurability that ranges from global psychotherapeutic approaches at one end to local healing traditions at the other. Location of culturally integrative efforts by indigenous communities along this continuum illustrates the possibility for local, agentic, and intentional deconstructions and reconstructions of mental health interventions in a culturally hybrid fashion.

Use of the evidence base in substance abuse treatment programs for American Indians and Alaska Natives: pursuing quality in the crucible of practice and policy

BACKGROUND

A variety of forces are now shaping a passionate debate regarding the optimal approaches to improving the quality of substance abuse services for American Indian and Alaska Native communities. While there have been some highly successful efforts to meld the traditions of American Indian and Alaska Native tribes with that of 12-step approaches, some American Indian and Alaska Natives remain profoundly uncomfortable with the dominance of this Euro-American approach to substance abuse treatment in their communities. This longstanding tension has now been complicated by the emergence of a number of evidence-based treatments that, while holding promise for improving treatment for American Indian and Alaska Natives with substance use problems, may conflict with both American Indian and Alaska Native and 12-step healing traditions.

DISCUSSION

We convened a panel of experts from American Indian and Alaska Native communities, substance abuse treatment programs serving these communities, and researchers to discuss and analyze these controversies in preparation for a national study of American Indian and Alaska Native substance abuse services. While the panel identified programs that are using evidence-based treatments, members still voiced concerns about the cultural appropriateness of many evidence-based treatments as well as the lack of guidance on how to adapt them for use with American Indians and Alaska Natives. The panel concluded that the efforts of federal and state policymakers to promote the use of evidence-based treatments are further complicating an already-contentious debate within American Indian and Alaska Native communities on how to provide effective substance abuse services. This external pressure to utilize evidence-based treatments is particularly problematic given American Indian and Alaska Native communities' concerns about protecting their sovereign status.

SUMMARY

Broadening this conversation beyond its primary focus on the use of evidence-based treatments to other salient issues such as building the necessary research evidence (including incorporating American Indian and Alaska Native cultural values into clinical practice) and developing the human and infrastructural resources to support the use of this evidence may be far more effective for advancing efforts to improve substance abuse services for American Indian and Alaska Native communities.

The red road to wellness: cultural reclamation in a Native First Nations community treatment center

This article explores how Native American cultural practices were incorporated into the therapeutic activities of a community-controlled substance abuse treatment center on a "First Nations" reserve in the Canadian north. Analysis of open-ended interviews with nineteen staff and clients-as contextualized by participant observation, program records, and existing ethnographic resources-yielded insights concerning local therapeutic practice with outpatients and other community members. Specifically, program staff adopted and promoted a diverse array of both western and Aboriginal approaches that were formally integrated with reference to the Aboriginal symbol of the medicine wheel. Although incorporations of indigenous culture marked Lodge programs as distinctively Aboriginal in character, the subtle but profound influence of western "therapy culture" was centrally evident in healing activities as well. Nuanced explication of these activities illustrated four contributions of cultural analysis for community psychology.