Evidence-Based Assessment of Substance Use Disorder

The current review describes updated information on the evidence-based assessment of substance use disorder. We offer an overview of the state of the science for substance-related assessment targets, instruments (screening, diagnosis, outcome and treatment monitoring, and psychosocial functioning and wellbeing) and processes (relational and technical) as well as recommendations for each of these three components. We encourage assessors to reflect on their own biases, beliefs, and values, including how those relate to people that use substances, and to view the individual as a whole person. It is important to consider a person's profile of symptoms and functioning inclusive of strengths, comorbidities, and social and cultural determinants. Collaborating with the patient to select the assessment target that best fits their goals and integration of assessment information in a holistic manner is critical. We conclude by providing recommendations for assessment targets, instruments, and processes as well as recommendations for comprehensive substance use disorder assessment, and describe future directions for research.

Culturally tailored digital therapeutic for substance use disorders with urban Indigenous people in the United States: A randomized controlled study

INTRODUCTION

Indigenous people experience health disparities, including higher rates of substance use disorders (SUDs). Digital therapeutics are a growing platform for treatment services and have the potential to expand access to culturally responsive interventions for Indigenous people. As one of the first randomized controlled trials for SUDs for American Indian and Alaska Native (AI/AN) adults, the aim of this study was to pilot test the efficacy of a culturally tailored intervention among urban Indigenous adults.

METHODS

The study used a randomized controlled parallel design of 12 weeks of treatment-as-usual (TAU) (n = 26) versus TAU + Therapeutic Education System-Native Version (TES-NAV) (n = 27) with follow-up assessments at end of treatment and week 24 in an urban outpatient addiction treatment program for Native American adults. TAU consisted of individual/group counseling and cultural activities. The TES-NAV arm comprised TAU + 26 self-directed culturally tailored digital skills-based modules grounded in the community reinforcement approach with contingency management for abstinence and module completion. Primary outcome was longest consecutive weeks of abstinence from drugs and heavy drinking measured using self-report (Timeline Followback) and urine alcohol and drug toxicology screen during 12 weeks of treatment. Secondary outcomes were percent days abstinence during and posttreatment, coping strategies, social connectedness, and substance use and sexual risk behaviors.

RESULTS

The study enrolled fifty-three (52.8 % male) AI/AN adults seeking treatment for a SUD. Although the study did not detect a benefit of TAU+TES-NAV over TAU on the primary outcome (Median = 2 consecutive weeks of abstinence for both arms) at end of treatment (treatment effect: Z = -0.78, p = 0.437), TAU+TES-NAV participants did demonstrate significantly greater percent days of abstinence at the week 24 follow-up (69.3 % versus 49.0 % for TAU; t = 2.08, p = 0.045) and significantly greater change in social connectedness mean score, baseline to week 12 (Z = -2.66, p = 0.011), compared to TAU. The study detected no differences between treatment arms for coping strategies or risk behaviors.

CONCLUSION

The addition of TES-NAV to TAU did not significantly improve consecutive weeks of abstinence from drugs or heavy drinking; however, several secondary findings suggest promise for a culturally tailored digital therapeutic SUD intervention among urban Indigenous people.

CLINICAL TRIALS

GOV REGISTRATION: #NCT03363256.

Psychostimulant Misuse Among American Indian, Alaskan Native, or Native Hawaiian College Students in the U.S. From 2015 to 2019

Introduction

This study examines factors associated with psychostimulant misuse, including polysubstance use and social factors, among the understudied American Indian/Alaska Native/Native Hawaiian (AI/AN/NH) college student population.

Methods

Data were from the 2015 to 2019 American College Health Association-National College Health Assessment IIc (ACHA-NCHA IIc) survey. Multivariable logistic regression models and odds ratios were used to estimate associations between psychostimulant misuse and potential risk and protective factors among AI/AN/NH college students, including licit and illicit substance use, social support, relationship factors, exposure to violence or abuse, mental health symptoms, drug and alcohol education, and sample demographics.

Results

Opioid misuse among AI/AN/NH college students significantly increased the odds of using psychostimulants. Specifically, for cocaine use, the adjusted odds ratio (aOR) was 3.17 with a 95% confidence interval (C.I.) of 2.17 to 4.63; for methamphetamine use, the aOR was 38.87 (95% C.I. 19.24-78.52). For amphetamine misuse among non-Tobacco users, the aOR was 5.47 (95% C.I. 3.49-8.55), while among Tobacco users, the aOR was 2.65 (95% C.I. 2.07-3.41). For cocaine and other stimulant misuse, the aOR was 3.64 (95% C.I. 2.30-5.67). Additionally, the use of other types of licit and illicit substances was associated with greater odds of psychostimulant use and misuse. Conversely, factors such as age, living on campus, and residing in parental/guardian housing were linked with lower odds of psychostimulant use and misuse.

Conclusion

Substance use prevention and treatment interventions targeting AI/AN/NH college students should address polysubstance use, including the combined use of opioids and psychostimulants. Substance use interventions should not be siloed to focus narrowly on single substances but rather should leverage potential protective factors against substance use, such as promoting supportive campus and family living conditions and other social support networks, in broad efforts to reduce multiple forms of substance use among AI/AN/NH students.

Effectiveness and feasibility of a motivational interviewing intake (MII) intervention for increasing client engagement in outpatient addiction treatment: an effectiveness-implementation hybrid design protocol

BACKGROUND

Client discontinuation from outpatient addiction treatment programs is common, and the initial intake is the service delivery point with the highest attrition rate. Replacing the comprehensive intake assessment with a person-centered Motivational Interviewing (MI) intervention is a potential solution to address provider and client concerns about the disengaging, time-intensive nature of the typical initial intake. It remains unclear whether the use of an alternative to the standard intake at the initial visit can fit within typical organizational reporting requirements, whether it decreases attrition, and whether implementation of person-centered intake procedures within outpatient addiction treatment programs is feasible, acceptable, and can be sustained.

PURPOSE

To describe the methods and design of an effectiveness-implementation hybrid type 1 trial of a Motivational Interviewing at Intake (MII) intervention using the Consolidated Framework for Implementation Research (CFIR).

METHODS

The study will determine the effectiveness of two intake conditions: (1) standard comprehensive intake assessment (intake-as-usual [IAU]), and (2) MII consisting of a person-centered discussion between provider and client about the client's desire and intent to enter treatment. Although both interventions are focused on understanding client presenting complaints and needs for treatment, the delivery differs as the IAU uses a semi-structured assessment guide, while MII applies the theory of MI to have a conversation about treatment engagement. Adults seeking outpatient addiction treatment services will be randomly assigned to the MII condition (n = 75) or the IAU condition (n = 75). Primary outcomes will be client engagement (i.e., treatment entry, attendance, and completion) obtained from the electronic medical record. Secondary outcomes (client motivation and therapeutic alliance) will be putative mechanisms of client engagement assessed immediately before and after the intake. The trial also will explore determinants of effective, sustainable implementation using assessments of organizational readiness and capacity to change, as well as interviews on MII implementation feasibility.

CONCLUSION

This trial of an MII intervention will investigate the feasibility of a motivational intervention as an initial contact with substance use treatment-seeking clients as well as indicators of intervention effectiveness within the systems where it is employed. Trial registration Clinicaltrials.gov identifier: NCT05489068.

Coming together for something good: recommendations from a scoping review for dissemination and implementation science to improve indigenous substance use disorder treatment

Introduction

Dissemination and Implementation (D&I) science is growing among Indigenous communities. Indigenous communities are adapting and implementing evidence-based treatments for substance use disorders (SUD) to fit the needs of their communities. D&I science offers frameworks, models, and theories to increase implementation success, but research is needed to center Indigenous knowledge, enhancing D&I so that it is more applicable within Indigenous contexts. In this scoping review, we examined the current state of D&I science for SUD interventions among Indigenous communities and identified best-practice SUD implementation approaches.

Methods

PubMed and PsycINFO databases were queried for articles written in English, published in the United States, Canada, Australia, and New Zealand. We included key search terms for Indigenous populations and 35 content keywords. We categorized the data using the adapted and extended Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework that emphasizes equity and sustainability. RE-AIM has also been used as a primary model to consistently identify implementation outcomes.

Results

Twenty articles were identified from the original unduplicated count of over 24,000. Over half the articles discussed processes related to Reach, Adoption, and Implementation. Effectiveness was discussed by 50% of the studies (n = 10), with 25% of the articles discussing Maintenance/sustainability (n = 4). Findings also highlighted the importance of the application of each RE-AIM domain for meaningful, well-defined community-engaged approaches.

Conclusion

Finding indicated a need to prioritize Indigenous methods to culturally center, re-align and adapt Western treatments and frameworks to increase health equity and improve SUD treatment outcomes. Utility in the use of the modified RE-AIM and the continued modification for Indigenous communities was also noted.

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.

A Systematic Review of Trauma and Substance Use in American Indian and Alaska Native Individuals: Incorporating Cultural Considerations

INTRODUCTION

Disproportionate rates of psychiatric disorders, like substance use and posttraumatic stress disorders (SUD and PTSD), exist among American Indian and Alaska Native (AI/AN) individuals. This review examines substance use and trauma in existing AI/AN literature and utilizes an AI/AN-specific model to culturally inform the relationship between these factors and provide recommendations for future research.

METHODS

We searched three databases through April 2021 for peer-reviewed articles that examined substance use and trauma in AI/AN individuals.

RESULTS

The search identified 289 articles and of those, 42 were eligible for inclusion, including 36 quantitative and 6 qualitative studies. Rates of lifetime trauma exposure varied from 21 to 98% and were correlated with increased rates of SUDs. A dose response of traumatic events also increased the likelihood of an SUD among reservation-based AI populations. Factors from the Indigenist Stress Coping model included cultural buffers such as traditional healing and cultural identity, which aided in recovery from SUD and trauma, and social stressors like boarding school attendance, discrimination, and historical loss.

CONCLUSIONS

SUD and trauma are highly correlated among AI/AN individuals though rates of PTSD are lower than might be expected suggesting resilience. However, this pattern may not be consistent across all AI/AN groups and further research is needed to better explain the existing relationship of SUD and PTSD and relevant historical and cultural factors. Further research is needed to culturally tailor, implement, and validate PTSD and SUD assessments and treatments to ameliorate these health inequities.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

Sexual Assault, Psychological Distress, and Protective Factors in a Community Sample of Black, Latinx, and White Lesbian and Bisexual Women

Intersectionality and minority stress frameworks were used to guide examination and comparisons of psychological distress (depression, anxiety, posttraumatic stress disorder symptoms) and protective factors (religiosity, spirituality, social support) among 673 Black, Latinx, and White lesbian and bisexual women with and without histories of sexual assault. Participants were from Wave 3 of the 21-year longitudinal Chicago Health and Life Experiences of Women (CHLEW) study. More than one-third (38%) of participants reported having experienced adolescent or adult sexual assault (i.e., rape or another form of sexual assault) since age 14. Confirmatory factor analysis, structural equation modeling, and multivariate analyses of covariance were used to analyze the data. Results revealed that levels of religiosity/spirituality and psychological distress varied by race/ethnicity and by sexual identity (i.e., Black lesbian, Black bisexual, Latinx lesbian, Latinx bisexual, White lesbian, White bisexual). Black lesbian women reported the highest level of religiosity/spirituality whereas White lesbian women reported the lowest level. White bisexual women reported the highest level of psychological distress whereas White lesbian women reported the lowest level. We found no significant differences in reports of sexual assault or in social support (i.e., significant other, family, friend, and total social support). However, White lesbian women had higher friend, significant other, and total social support relative to the other five groups of women with minoritized/marginalized sexual identities. Future work should examine whether religiosity, spirituality, and social support serve as protective factors that can be incorporated into mental health treatment for lesbian and bisexual who have experienced sexual assault to reduce psychological distress.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Epidemiological trends in opioid-only and opioid/polysubstance-related death rates among American Indian/Alaska Native populations from 1999 to 2019: a retrospective longitudinal ecological study

OBJECTIVES

The rate of drug overdose deaths in the USA has more than tripled since the turn of the century, and rates are disproportionately high among the American Indian/Alaska Native (AI/AN) population. Little is known about the overall historical trends in AI/AN opioid-only and opioid/polysubstance-related mortality. This study will address this gap.

DESIGN

This is a retrospective longitudinal ecological study.

SETTING

US death records from 1999 to 2019 using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research.

PARTICIPANTS

US non-Hispanic AI/AN people age 12 years and older.

MEASURES

The primary outcomes, identified via the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes, included overdose deaths due to (1) opioids only, opioids in combination with any other substance, all-opioid related overdoses; (2) combinations of opioids and alcohol, opioids and methamphetamine, opioids and cocaine, opioids and benzodiazepines; and (3) specific types of opioids.

RESULTS

From 1999 to 2019, opioid-only mortality rates increased from 2.8 to 15.8 per 100 000 (p<0.001) for AI/AN women and 4.6 to 25.6 per 100 000 (p<0.001) for AI/AN men. All opioid-related mortality rates increased significantly (p<0.001) from 5.2 to 33.9 per 100 000 AI/AN persons, 3.9 to 26.1 for women and 6.5 to 42.1 for men. AI/AN also exhibited significant increases in mortality rates due to opioids and alcohol, opioids and benzodiazepines, opioids and methamphetamine, and AI/AN men experienced substantial increases in mortality due to opioids and cocaine. Mortality rates by individual opioid types increased significantly over time for heroin, natural and semi-synthetic (prescription), and synthetic opioids (fentanyl/fentanyl analogues) other than methadone.

CONCLUSIONS

These findings highlight magnification over time in opioid-related deaths and may point to broader systemic factors that may disproportionately affect members of AI/AN communities and drive inequities.

The mediation and moderation effect of social support on the relationship between opioid misuse and suicide attempts among native American youth in New Mexico: 2009-2019 Youth Risk Resiliency Survey (NM-YRRS)

BACKGROUND

Suicide attempt and opioid misuse continue to be major behavioral health challenges among American Indians and Alaska Natives (AI/AN). The aim of the study is to evaluate the mediating and moderating role that social support (SS) plays in their association among AI/AN high-school students in New Mexico (NM).

METHODS

An aggregated NM Youth Resiliency and Risk Survey (NM-YRRS, 2009-2019: odd years) dataset was used. Multivariable logistic regression modeling and mediation analysis were conducted while adjusting for confounding variables.

RESULTS

Overall, 12.0 and 14.0% of AI/AN students reported opioid misuse and suicide attempt, respectively. The adjusted odds ratio of suicide attempt in students with high SS relative to low SS who misused opioids was 0.43 (p-value = 0.007). The effect of high SS relative to low SS among males who misused opioids was more pronounced (AOR = 0.24, p-value < 0.0001) compared to females (AOR = 0.43, p-value = 0.007). Relative to low SS, high SS was protective for suicide attempt among AI/AN students who misused opioids and attended school in off-reservation (AOR = 0.42, p-value = 0.012) communities, rural communities (AOR = 0.44, p = 0.040), and in communities that are both rural and off-reservation (AOR = 0.39, p = 0.035). Overall, 23.64, and 41.05% of the association between opioid misuse, and suicide attempt was mediated and moderated by SS, respectively. The mediation effect of SS was lowest for rural, on-reservation schools.

CONCLUSION

More resources need to be allocated to rural on-reservation schools to enhance social support. The study highlights key insights into the significant role SS plays in promoting health and mitigating the association between opioid misuse and suicide attempt.

A trend analysis of the prevalence of opioid misuse, social support, and suicide attempt among American Indian/Alaska native high school students in New Mexico: 2009-2019 Youth Risk Resiliency Survey (YRRS)

BACKGROUND

American Indian and Alaska Native (AI/AN) youth face stark inequities in opioid misuse, social support, and suicide attempt. This study examined trends in these behavioral measures among AI/AN students in New Mexico (NM).

METHODS

Using the NM oversampled Youth Resiliency and Risk Survey (NM-YRRS, 2009 - 2019: odd years), prevalence estimates of opioid misuse, social support (SS), and suicide attempt for AI/AN high school students were generated. Trends over time were assessed via linear regression of weighted proportions according to Peter Armitage. Stratified trends by demographics were also employed.

RESULTS

While the prevalence of suicide attempt did not change significantly over time, it was consistently higher among females (2011-2019), those who misused opioids, received low social support, had a mother with less than high school education, had a C, D, or F for academic performance, and non-straight students relative to their counterparts. In particular, the prevalence of suicide attempt among AI/AN students who reported opioid misuse in 2009 was significantly higher by 25.4% than their counterparts who did not report opioid misuse (35.8% vs. 10.4%.) A significant decreasing trend over time (2009-2017) was observed for opioid misuse (16.1%↓8.8%, p-value = 0.0033), including when stratifying by sex (males: 15.9%↓9%, p-value = 0.002; females: 16.2%↓8.6%, p-value = 0.012). Youth with high maternal education exhibited significant decline in opioid misuse (13.5%↓6.7%, p-value = 0.019; 2011-2017.) Opioid misuse increased significantly from 2017 to 2019 (8.8%↑12.9%, p-value < 0.0001.) For instance, in 2019 among AI/AN students who reported low social support, opioid misuse was roughly doubled (18.9% vs. 8.5%, p < 0.0001), and suicide attempt was tripled (21.3% vs. 7.0%, p < 0.0001) compared to students with high social support.

CONCLUSION

No significant trend was observed for suicide attempt. We observed a significant decreasing trend in opioid misuse between 2009 through 2017 but a significant increase from 2017 to 2019. A higher level of maternal education (college or above), and an A or B school grade performance were protective against both opioid misuse and suicide attempt.

Changes in pain during buprenorphine maintenance treatment among patients with opioid use disorder and chronic pain

OBJECTIVE

Opioid use disorder (OUD) and chronic pain frequently co-occur. Little is known about changes in pain during buprenorphine/naloxone (BUP/NX) maintenance and whether outcomes vary by pain levels. The present study examined changes in pain intensity and pain interference over 12 weeks of BUP/NX maintenance among participants with OUD and chronic pain (N = 194). Differences in outcomes were assessed during BUP/NX maintenance (Week 12) and 2 months following a BUP/NX taper (Week 24).

METHOD

Data from Phase 2 of the Prescription Opioid Addiction Treatment Study (POATS) were used. Two latent transition models were conducted to characterize profiles and transitions between profiles of pain intensity or pain interference (estimated separately).

RESULTS

Each model identified a high and low profile. In the pain interference model, the majority were classified in the low profile at baseline. In the pain intensity model, the majority were classified in the high profile at baseline. In both models, patients were more likely to remain in or transition to the low profiles by Week 12. Worse depression was associated with membership in the high pain interference profile at both timepoints. Women were more likely to be in the high pain intensity profile at baseline. Those in the high pain intensity and high pain interference profiles at Week 12 reported worse mental health quality of life (MH-QOL) at Week 12, as well as high pain intensity and high pain interference at Week 24.

CONCLUSIONS

For a subgroup of patients, high pain intensity and high pain interference remains unchanged during BUP/NX maintenance treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Associations between opioid misuse and social relationship factors among American Indian, Alaska Native, and Native Hawaiian college students in the U.S

BACKGROUND

Despite declining overall rates of opioid misuse among college students, racial and ethnic differences in percentage and correlates of opioid misuse among student populations remains unclear. This study seeks to estimate percentages of opioid misuse among American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students and determine whether problems in social bonds affect AI/AN/NH opioid misuse.

METHODS

Guided by social relationship factors associated with substance use in the Social Development Model, we used 2015-2019 data from the American College Health Association-National College Health Assessment survey in multivariable logistic regression models to examine the role of social bonds with peers and family in opioid misuse (prescription and non-prescription) among AI/AN/NH college students across the U.S.

RESULTS

The percentage of opioid misuse was highest among AI/AN/NH college students (7.12 %) relative to other race/ethnicity groups. AI/AN/NH college students who reported experiencing loneliness (aOR: 1.68; 95 % CI 1.33-2.12; P < .0001), difficult social relationships (aOR: 1.27; 95 % CI 1.04-1.55; P = 0.0196), family problems (aOR: 1.32; 95 % CI 1.07-1.63; P = 0.0097), and intimate partner violence (aOR: 1.92; 95 % CI 1.56-2.36; P < .0001) were significantly more likely to misuse opioids than students who did not report experiencing these relationship problems.

CONCLUSIONS

Relationship problems with peers and family increase AI/AN/NH college student risk for opioid misuse, indicating opportunities for colleges to support programs addressing healthy social relationships as a means to reduce opioid misuse among AI/AN/NH students.

Culturally tailored evidence-based substance use disorder treatments are efficacious with an American Indian Southwest tribe: an open-label pilot-feasibility randomized controlled trial

BACKGROUND AND AIMS

Many evidence-based treatments (EBTs) for substance use disorder (SUD) exist, yet few are tailored to Indigenous patients. This trial tested the efficacy of a culturally tailored EBT that combined Motivational Interviewing and the Community Reinforcement Approach (MICRA) versus treatment as usual (TAU).

DESIGN

A mixed efficacy/effectiveness randomized controlled trial of MICRA (n = 38) and TAU (n = 41) using a parallel design with follow-up assessments at 4-, 8-, and 12- months post baseline.

SETTING

United States, reservation-based outpatient, addiction specialty care treatment program.

PARTICIPANTS

79 (68% male) American Indian and Alaska Native (AI/AN) Tribal members meeting criteria for SUD and seeking SUD treatment.

INTERVENTIONS

MICRA (individual therapy sessions beginning with MI for 2-3 sessions) compared with TAU (individual and group counseling sessions in a didactic style with Twelve-Step philosophy and elements of relapse prevention).

MEASURES

Demographics, percent days abstinent (PDA; the primary outcome at 12months assessed by Form 90D), Inventory of Drug Use Consequences, Alcohol and Drug Use Self-Efficacy Scale, Native American Spirituality Scale, and SCID-DSM-IV-TR.

FINDINGS

There was no evidence for the benefit of MICRA over TAU (MICRA PDA = 72.63%, TAU = 73.62%, treatment effect: B = -4.04 (SE = 5.47); 95% CI = -14.941, 6.866; BF = 3.44) in the primary outcome. Both groups showed improvements in PDA, SUD severity, and negative consequences from baseline to the 12-month follow-up. Neither self-efficacy nor spirituality were significant mediators of MICRA.

CONCLUSIONS

There were no treatment group differences between culturally tailored evidence-based treatments for substance use disorder and treatment as usual in this randomized controlled trial with American Indian and Alaska Native participants. Nonetheless, participants improved over time on several substance-related outcomes.

The Condom Use Self-Efficacy Scale in Substance Use Disorder Treatment-Seeking American Indian Adults

American Indians (AIs) experience substance use disorder and sexual risk related inequities with elevated rates of sexually transmitted infections, unintended pregnancy, and fetal alcohol spectrum disorders. Substance misuse is associated with risky sexual behaviors including condomless sex. Objectives: The current study aimed to test the validity of the Condom Use Self-Efficacy Scale (CUSES) and the relationship between self-efficacy and condom use behaviors in AI individuals with substance use disorders (SUDs). Exploratory analyses also examined changes in condom use self-efficacy across SUD treatment. Methods: As part of a larger randomized controlled trial, AI individuals (N = 79) seeking SUD treatment completed baseline measures of condom use self-efficacy and sexual risk behaviors. Results: Confirmatory factor analysis (CFA) indicated that a 3-factor, 10-item version of the CUSES was a reliable and valid measure in this population. Condom use self-efficacy was associated with condom use behavior and increased during SUD treatment. Conclusions: Overall, it appears that the CUSES is a valid measure in AI individuals, is related to condom use behavior, and increases with SUD treatment. There is a need for future research to integrate these findings into AI cultural values. Addressing sexual risk behaviors in SUD treatment may be an important target and future research is needed to understand predictors of condom use self-efficacy and determine potential intervention targets to reduce sexual risk behaviors and related health inequities.

The Validity of the Short Inventory of Problems and Drinking Intensity among Urban American Indian Adults

BACKGROUND

American Indian (AI) adults have both high prevalence rates of alcohol abstinence and alcohol use disorders compared to non-Hispanic White adults. We investigated the applicability and validity of the Short Inventory of Problems (SIP) among AI urban adults and the moderating effect of biological sex.

METHODS

AI adults from three Alcoholics Anonymous samples (n = 124) provided baseline, 3-, 6- and 9-month data. Measures included Form 90 and the SIP, which includes 5 domains of alcohol-related negative consequences including interpersonal, intrapersonal, physical, impulse control and social. Drinking frequency and intensity were assessed by percent days abstinent (PDA) and drinks per drinking day (DPDD).

RESULTS

Cronbach alphas of the SIP were similar between urban AI adults and the mainstream treatment-seeking population reported in the SIP manual. DPDD was a significant and positive predictor of all five SIP scales collected 9-months later. Higher PDA was significantly and negatively associated with later consequences, and all 5 SIP scales. Moderation tests indicated that the association between consequences and drinking intensity was stronger for AI females with fewer drinking days resulting in significantly fewer consequences for AI males relative to AI females.

CONCLUSIONS

Findings highlight the acceptability of SIP as a measure to assess drinking related consequences among AI urban adults, with clinical implications related to alcohol use and sex. Further research is warranted to examine differential drinking related outcomes among AI men and women in addition to adaptations of the SIP that more fully capture the range of negative drinking consequences.

Commentary on the impact of the COVID-19 pandemic on opioid use disorder treatment among Indigenous communities in the United States and Canada

This commentary focuses on how some Indigenous communities in the United States (U.S.) and Canada are addressing the opioid epidemic within the context of the COVID-19 pandemic, from the perspective of the co-authors as researchers, clinicians, and pharmacists working within or among Indigenous communities in three eastern Canadian provinces and two western U.S. states. The pandemic has likely exacerbated opioid use problems among Indigenous communities, especially for individuals with acute distress or comorbid mental illness, or who are in need of withdrawal management or residential services. In response to the pandemic, we discuss first how greater prescription flexibility has facilitated and even increased access to medications for opioid use disorder. Second, we describe how Indigenous-serving clinics have expanded telemedicine services, albeit not without some challenges. Third, we note challenges with restricted participation in traditional Indigenous healing practices that can be helpful for addiction recovery. Fourth, we mention providers' worries about the pandemic's impact on their patients' mental health and safety. We argue that certain treatment transformations may be helpful even after the pandemic is over, through enhancing access to community-grounded treatment, decreasing stigma, and promoting patient self-efficacy.

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COVID-19 pandemic has challenged opioid use treatment for Indigenous peoples.

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Treatment has been aided through expanded telemedicine and prescription flexibility.

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These adjustments may expand future treatment access to Indigenous communities.

Education and Training in Substance Use Disorders and Addictions: The University of New Mexico Integrated Training Model

This paper describes SUD/addictions training at the University of New Mexico. Coordinated and integrated academic, research, and clinical training resources are described, with an emphasis on the integration of resources across multiple training domains. Academic training resources in the Psychology Department include core clinical courses, basic science courses, and opportunities for students to develop expertise in health or quantitative psychology. Other academic resources come from affiliated departments and colleges such as Sociology, the College of Population Health, the College of Education, and Health Sciences. Research training resources are available within the Psychology Department, affiliated Departments and Colleges, and specialized research centers including the Center on Alcoholism, Substance Abuse, and Addictions, and the Mind Research Network. A network of community partners provides additional research sites. Clinical training resources are provided through a specialized alcohol treatment clinic and a diversity clinic within the Department, opportunities for students to serve as research clinicians, and community practicum sites supervised by on-site doctoral level psychologists or Departmental faculty. The UNM training program provides one model for graduate training in SUD/addictions. Keys to the program are the presence of multiple SUD/addictions clinical faculty member with active research programs, willingness to mentor students in research and clinical work, and basic science faculty whose research is relevant to addictive behaviors. Other critical elements include systematic development of clinical training opportunities, effective collaborations with community agencies for research and clinical training, meaningful research partnerships with other academic departments and specialized research centers, and external funding for training activities.

Substance Use Research with Indigenous Communities: Exploring and Extending Foundational Principles of Community Psychology

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.

Native Americans resolve alcohol use disorder: "Whatever it takes or all that it takes"

OBJECTIVES

There is a growing awareness of the prevalence of abstinence and rates of remission from alcohol problems among Native Americans (NAs). Past NA remission research has included epidemiological studies, treatment outcomes, and qualitative inquiry. In this study, we sought to qualitatively examine how NAs resolved moderate to severe alcohol use disorder (AUD) and maintained long-term sobriety.

METHOD

Recruitment via newspaper advertisements, flyers, and word-of-mouth yielded 55 NA participants (56% male). Face-to-face semistructured interviews lasted about 1 hr. We transcribed the audio recordings and analyzed data with NVivo software using an iterative process of thematic analysis and consensus building.

RESULTS

Two major coding categories were used: motivating factors and actions used to resolve AUD. Each of these categories consisted of subcodes (8 and 13, respectively).

CONCLUSIONS

NAs resolved AUD via multiple methods and efforts. What worked for one individual did not necessarily work the first time or for another individual. Although some motivators or actions were unique to NAs, others were similar to findings in the general population. Because multiple and varied motivations and actions may be required to resolve AUD, individuals with AUD and their loved ones should persevere in their efforts to make positive changes. Future research should examine other NA tribal regions and NA remission from drug use disorder. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives

The U.S. is experiencing an alarming opioid epidemic, and although American Indians and Alaska Natives (AI/ANs) are especially hard hit, there is a paucity of opioid-related treatment research with these communities. AI/ANs are second only to Whites in the U.S. for overdose mortality. Thus, the National Institute on Drug Abuse convened a meeting of key stakeholders to elicit feedback on the acceptability and uptake of medication assisted treatment (MAT) for opioid use disorders (OUDs) among AI/ANs. Five themes from this one-day meeting emerged: 1) the mismatch between Western secular and reductionistic medicine and the AI/AN holistic healing tradition; 2) the need to integrate MAT into AI/AN traditional healing; 3) the conflict between standardized MAT delivery and the traditional AI/AN desire for healing to include being medicine free; 4) systemic barriers; and 5) the need to improve research with AI/ANs using culturally relevant methods. Discussion is organized around key implementation strategies informed by these themes and necessary for the successful adoption of MAT in AI/AN communities: 1) type of medication; 2) educational interventions; 3) coordination of care; and 4) adjunctive psychosocial counseling. Using a community-based participatory research approach is consistent with a "two eyed seeing" approach that integrates Western and Indigenous worldviews. Such an approach is needed to develop impactful research in collaboration with AI/AN communities to address OUD health disparities.

Low rates of alcohol and tobacco use, strong cultural ties for Native American college students in the Southwest

INTRODUCTION

College attendance is associated with an increased risk for substance use yet we know little about substance use among Native American college students and its regional variation. This study examined alcohol, tobacco, and drug use and their relation to gender, institution, age, and cultural involvement among Native American college students in the Southwest.

METHODS

Native American community college and university students in a large Southwest city (N = 347) completed an online survey about past-month and lifetime substance use and involvement in cultural activities.

RESULTS

Cultural involvement was related to less past-month substance use. In the past month, 43% drank alcohol, 27% binge drank, 20% used drugs, and 13% were current smokers. Males, community college students, and older individuals were more likely to have a positive CAGE-AID and have used drugs more than 100 times. Younger individuals were more likely to use marijuana in the past month.

CONCLUSIONS

These findings highlight cultural strengths and comparatively low rates of tobacco and alcohol use among Native American college students in the Southwest.

Descriptive drinking norms in Native American and non-Hispanic White college students

OBJECTIVE

College students tend to overestimate how much their peers drink, which is associated with higher personal alcohol use. However, research has not yet examined if this phenomenon holds true among Native American (NA) college students. This study examined associations between descriptive norms and alcohol use/consequences in a sample of NA and non-Hispanic White (NHW) college students.

METHOD

NA (n=147, 78.6% female) and NHW (n=246, 67.8% female) undergraduates completed an online survey.

RESULTS

NAs NHWs showed similar descriptive norms such that the "typical college student," "typical NA student," and "typical NHW student" were perceived to drink more than "best friends." "Best friends" descriptive norms (i.e., estimations of how many drinks per week were consumed by participants' best friends) were the most robust predictors of alcohol use/consequences. Effect size estimates of the associations between drinking norms and participants' alcohol use were consistently positive and ranged from r=0.25 to r=0.51 across the four reference groups. Negative binomial hurdle models revealed that all descriptive norms tended to predict drinking, and "best friends" drinking norms predicted alcohol consequences. Apart from one interaction effect, likely due to familywise error rate, these associations were not qualified by interactions with racial/ethnic group.

CONCLUSIONS

We found similar patterns between NAs and NHWs both in the pattern of descriptive norms across reference groups and in the strength of associations between descriptive norms and alcohol use/consequences. Although these results suggest that descriptive norms operate similarly among NAs as other college students, additional research is needed to identify whether other norms (e.g., injunctive norms) operate similarly across NA and NHW students.

Pilot Outcome Results of Culturally Adapted Evidence-Based Substance Use Disorder Treatment with a Southwest Tribe

Introduction

Although American Indians/Alaska Natives (AI/ANs) have exhibited high rates of alcohol and drug use disorders, there is a paucity of substance use disorder treatment outcome research. In addition, there exists controversy about whether evidence-based treatments (EBTs) are culturally appropriate given that they were derived mainly by and for non-Hispanic White populations and do not explicitly include aspects of AI/AN culture and worldview.

Methods

In this pilot study, we collaboratively culturally adapted two EBTs, Motivational Interviewing and Community Reinforcement Approach (MICRA), and evaluated substance use and psychological outcomes at 4- and 8-months post-baseline assessment. In preparation for a larger randomized clinical trial (RCT), eight tribal members (75% male) participated in this pilot treatment study. Measures included substance use, urine screens, self-efficacy, psychological distress, and hopelessness. All participants completed follow-up assessments at 4- and 8-months. Due to small sample size, effect sizes were calculated to evaluate outcomes pre- and post-treatment.

Results

Despite high rates of abstinence at baseline, percent days abstinent (PDA) increased at the 8-month time point for the most commonly used substances (alcohol, Hedges's g = 0.59, and marijuana, g = 0.60) and for all substances combined (excluding tobacco, g = 0.56). Improvements in psychological distress (g = − 0.66) and 5 of the 7 Addiction Severity Index domains (range of g = − 0.42 to − 0.98) also emerged.

Conclusions

Results suggest that culturally adapted EBTs yield significant improvements in alcohol use, psychological distress, and legal problems among AI/ANs. Future research using RCT methodology is needed to examine efficacy and effectiveness.

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A pilot study of evidence-based treatment outcomes with American Indians with 8-month follow-ups

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Medium to large effect sizes for increased percent days abstinent at 4- and 8-month follow-ups

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Medium to large effect sizes for improvements in psychological distress and 5 of 7 ASI domains.

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Small effect size for improvement in self-efficacy

Cultural adaptation, psychometric properties, and outcomes of the Native American Spirituality Scale

Spirituality is central to many Native Americans (NAs) and has been associated with recovery from substance use disorders (SUDs). However, no published questionnaire uniquely taps tribal-specific spiritual beliefs and practices. This hinders efforts to integrate traditional NA spirituality into SUD treatment and track spiritual outcomes. As part of a randomized controlled trial examining SUD treatment for NAs, we adapted the Daily Spiritual Experience Scale (DSES) in collaboration with members of a Southwest tribe to create the Native American Spirituality Scale (NASS) and measured changes in the NASS over the course of treatment. The 83 participants (70% male) were from a single Southwest tribe and seeking SUD treatment. They completed the NASS at baseline, 4, 8, and 12 months. Exploratory factor analysis of the NASS was conducted and its temporal invariance, construct validity, and longitudinal changes in the factor and item scores were examined. The NASS yielded a 2-factor structure that was largely invariant across time. Factor 1 reflected behavioral practices, while Factor 2 reflected more global beliefs. Both factors significantly increased across 12 months, albeit at different assessment points. At baseline, Factor 1 was negatively related to substance use and positively associated with measures of tribal identification while Factor 2 was unrelated to these measures. Given the importance of tribal spirituality to many NAs, the development of this psychometrically sound measure is a key precursor and complement to the incorporation of tribal spirituality into treatment, as well as research on mechanisms of change for SUD treatment among NAs and assessment of NA spirituality in relation to other aspects of health.

Longitudinal study of urban American Indian 12-step attendance, attrition, and outcome

OBJECTIVE

Strong opinions have been voiced about the "fit" between 12-step treatment, community-based 12-step practices, and American Indian beliefs and values. Little is known, however, about the relative benefit of 12-step programs for urban American Indians, although they are the most widely accessed type of treatment by American Indians. This study investigated rates of 12-step attendance, attrition, and substance use outcomes for American Indians for 9 months relative to non-Hispanic White participants.

METHOD

This study compared urban American Indian (n = 63) and non-Hispanic White (n = 133) 12-step attendance, attrition, and substance use over 9 months. The sample was formed by merging data from two prospective single-group longitudinal studies investigating behavior change in community-based 12-step programs. Participants were interviewed at baseline and at 3-, 6-, and 9-month follow-ups. No intervention was provided. Participants were recruited from Alcoholics Anonymous meetings in the community and as they presented for outpatient substance use disorder treatment. Substance use and patterns of 12-step attendance were measured using the Form 90 calendar-based interview, and the General Alcoholics Anonymous Tools of Recovery was administered to assess the adoption of prescribed 12-step practices and beliefs.

RESULTS

Trajectories in 12-step meeting attendance over 9 months did not differ between American Indian and non-Hispanic White participants. However, American Indian participants discontinued 12-step attendance significantly less often than non-Hispanic White participants. Higher rates of 12-step attendance predicted increased alcohol abstinence and decreased drinking intensity for both American Indian and non-Hispanic White participants. Twelve-step attendance was unrelated to later illicit drug use for both American Indian and non-Hispanic White participants.

CONCLUSIONS

Community-based 12-step program attendance is associated with drinking reductions among urban American Indians.

Drum-Assisted Recovery Therapy for Native Americans (DARTNA): results from a pretest and focus groups

Drum-Assisted Recovery Therapy for Native Americans (DARTNA) is a substance abuse treatment intervention for American Indians/Alaska Natives (AI/ANs). This article provides results from 1) an initial pretest of DARTNA provided to 10 AI/AN patients with histories of substance use disorders, and 2) three subsequent focus groups conducted among AI/AN DARTNA pretest participants, substance abuse treatment providers, and the DARTNA Community Advisory Board. These research activities were conducted to finalize the DARTNA treatment manual; participants also provided helpful feedback which will assist toward this goal. Results suggest that DARTNA may be beneficial for AI/ANs with substance use problems.

"I'm not one of them": barriers to help-seeking among American Indians with alcohol dependence

The majority of people with alcohol use disorders do not seek formal treatment. Research on barriers to help-seeking have only recently focused on ethnic minority populations. The present study investigated the extent to which an adult American Indian (AI) sample experienced similar and/or unique barriers to help-seeking as have been reported in the literature. Using both qualitative and quantitative methods, 56 (54% male) AIs with lifetime alcohol dependence completed a semistructured face-to-face interview and a self-administered written survey. Interviews were tape recorded, transcribed, and coded for four major themes: personal barriers, pragmatic barriers, concerns about seeking help, and social network barriers. Quantitative data provided percentage endorsing each survey item and strength of each barrier, which were categorized according to the four major themes. In previous research, most barriers questionnaires have not queried for cultural concerns or how the specific type of help may be a mismatch from the client's perspective. Given the rapidly changing racial/ethnic demography in the United States, further research addressing cultural and spiritual concerns as well as more common barriers is indicated. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

The impact of depression on abstinence self-efficacy and substance use outcomes among emerging adults in residential treatment

A large proportion of emerging adults treated for substance use disorder (SUD) present with symptoms of negative affect and major depressive disorder (MDD). However, little is known regarding how these comorbidities influence important mechanisms of treatment response, such as increases in abstinence self-efficacy (ASE). This study tested the degree to which MDD and/or depressive symptoms interacted with during-treatment changes in ASE and examined these variables' relation to outcome at 3 months' posttreatment. Participants (N = 302; 74% male) completed measures at intake, midtreatment, end-of-treatment, and at 3-month follow-up. ASE was measured with the Alcohol and Drug Use Self-Efficacy (ADUSE) scale; depressive symptoms were assessed with the Brief Symptom Inventory 18 (BSI 18) Depression scale; and current MDD diagnoses were deduced from the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Random coefficient regression analyses focused on during-treatment changes in ASE, with BSI 18 scores and MDD diagnosis included as moderators. At intake, individuals with MDD or high levels of depressive symptoms had significantly lower ASE, particularly in negative affect situations. No evidence for moderation was found: ASE significantly increased during treatment regardless of MDD status. There was a main effect of BSI 18 Depression scores: those with lower BSI 18 scores had lower ASE scores at each time point. MDD and BSI 18 Depression did not predict 3-month outcome, but similar to previous findings ASE did predict abstinence status at 3 months. Treatment-seeking emerging adults with MDD merit particular clinical attention because of their lower reported self-efficacy throughout treatment.

American Indian methamphetamine and other drug use in the Southwestern United States

To investigate the extent of methamphetamine and other drug use among American Indians (AIs) in the Four Corners region, we developed collaborations with Southwestern tribal entities and treatment programs in and around New Mexico. We held nine focus groups, mostly with Southwestern AI participants (N = 81) from three diverse New Mexico communities to understand community members, treatment providers, and clients/relatives views on methamphetamine. We conducted a telephone survey of staff (N = 100) from agencies across New Mexico to assess perceptions of methamphetamine use among people working with AI populations. We collected and analyzed self-reported drug use data from 300 AI clients/relatives who completed the Addiction Severity Index (ASI) in the context of treatment at three diverse addiction treatment programs. Each focus group offered a unique perspective about the effect of drugs and alcohol on each respective community. Though data from the phone surveys and ASIs suggested concerning rates of methamphetamine use, with women more adversely affected by substance use in general, alcohol was identified as the biggest substance use problem for AI populations in the Southwest. There appears to be agreement that methamphetamine use is a significant problem in these communities, but that alcohol is much more prevalent and problematic. There was less agreement about what should be done to prevent and treat methamphetamine use. Future research should attend to regional and tribal differences due to variability in drug use patterns, and should focus on identifying and improving dissemination of effective substance use interventions.

Conducting research with racial/ethnic minorities: methodological lessons from the NIDA Clinical Trials Network

BACKGROUND

Multiple studies in the National Institute on Drug Abuse Clinical Trials Network (CTN) demonstrate strategies for conducting effective substance abuse treatment research with racial/ethnic minorities (REMs).

OBJECTIVES

The objectives of this article are to describe lessons learned within the CTN to (1) enhance recruitment, retention, and other outcomes; (2) assess measurement equivalence; and (3) use data analytic plans that yield more information.

METHOD

This article includes background information and examples from multiple CTN studies on inclusion, measurement, and data analysis.

RESULTS AND CONCLUSIONS

Seven recommendations are included for conducting more effective research on REMs.

Exploring racial/ethnic differences in substance use: a preliminary theory-based investigation with juvenile justice-involved youth

Background

Racial/ethnic differences in representation, substance use, and its correlates may be linked to differential long-term health outcomes for justice-involved youth. Determining the nature of these differences is critical to informing more efficacious health prevention and intervention efforts. In this study, we employed a theory-based approach to evaluate the nature of these potential differences. Specifically, we hypothesized that (1) racial/ethnic minority youth would be comparatively overrepresented in the juvenile justice system, (2) the rates of substance use would be different across racial/ethnic groups, and (3) individual-level risk factors would be better predictors of substance use for Caucasian youth than for youth of other racial/ethnic groups.

Methods

To evaluate these hypotheses, we recruited a large, diverse sample of justice-involved youth in the southwest (N = 651; M age = 15.7, SD = 1.05, range = 14-18 years); 66% male; 41% Hispanic, 24% African American, 15% Caucasian, 11% American Indian/Alaska Native). All youth were queried about their substance use behavior (alcohol, marijuana, tobacco, illicit hard drug use) and individual-level risk factors (school involvement, employment, self-esteem, level of externalizing behaviors).

Results

As predicted, racial/ethnic minority youth were significantly overrepresented in the juvenile justice system. Additionally, Caucasian youth reported the greatest rates of substance use and substance-related individual-level risk factors. In contrast, African American youth showed the lowest rates for substance use and individual risk factors. Contrary to predictions, a racial/ethnic group by risk factor finding emerged for only one risk factor and one substance use category.

Conclusions

This research highlights the importance of more closely examining racial/ethnic differences in justice populations, as there are likely to be differing health needs, and subsequent treatment approaches, by racial/ethnic group for justice-involved youth. Additionally, this study highlights the need for timely, empirically supported (developmentally and cross-culturally) substance abuse interventions for all justice-involved youth.

Helping Clients Feel Welcome: Principles of Adapting Treatment Cross-Culturally

Empirically supported interventions (ESIs) for treating substance problems have seldom been made available to or tested with minority populations. Dissemination of ESIs may help reduce the disproportionate health disparities that exist. However, ESIs may require some adaptation to be effective with minority populations. One ESI, motivational interviewing (MI), appears to be particularly culturally congruent for Native American communities. We worked with Native American community members and treatment providers to adapt MI for Native communities. Reflecting their feedback and suggested amendments, we created and disseminated an intervention manual to improve the accessibility of MI within Native communities. To help guide practitioners working with Native American clients, we used focus-group methodology to explore communication patterns for negotiating change. Native American treatment providers expressed comfort with and enthusiasm for integrating MI into their current practices. Recommendations for adaptations ranged from simple to complex changes. The unique value and challenges of collaboration between academic and community members are presented from each author's perspective. This culturally adapted MI manual will likely improve the accessibility and adoption of MI practices as well as encourage controlled, clinical trials with Native communities.

American Indian/Alaska Native alcohol-related incarceration and treatment

American Indian/Alaska Natives have high rates of alcohol-related arrests and are overrepresented in justice systems. To understand the relationship between alcohol dependence, treatment, and alcohol-related incarceration, this study queried American Indian/Alaska Natives currently in remission from alcohol dependence. Participants reported receiving 0 to 43 treatment experiences. Moreover, participants had a significantly greater number of alcohol-related incarcerations than all other treatments combined. These findings underline the importance of making alcohol treatment available within criminal justice settings.

Testing of an orthogonal measure of cultural identification with adult mission Indians

The Orthogonal Cultural Identification Scale (OCIS; Oetting & Beauvais, 1990-91) has been validated among Native American youth, but not adults. The present study sought to test the reliability (internal consistency) and validity (construct and factorial) of the OCIS among an adult Native American sample consisting of 389 Mission Indians (61% female). Participants were recruited from reservations using a venue sampling strategy. The OCIS was completed as part of a self-assessment packet of questionnaires. Internal consistency for OCIS subscale scores ranged from 0.76 to 0.91. Both concurrent and discriminant validity were demonstrated. Confirmatory factor analysis revealed 2 factors: (1) Anglo American Identification and (2) Native American Identification. These results indicate the OCIS is a reliable and valid instrument for use with adult Native Americans.

Natural history of alcohol dependence and remission events for a Native American sample

OBJECTIVE

Examining the progression of a disorder cross- culturally may help distinguish elements common to addictions from those that are differentially shaped by culture. This study sought to construct a combined sequence of both problem emergence and recovery efforts with Native Americans.

METHOD

In a cross-sectional sample, 44 adult Native Americans (61% men) who had resolved alcohol dependence completed face-to-face interviews at a research center. The Alcohol Related Behaviors Survey and the Change Effort Card-sorts along with measures of alcohol involvement and current quality of life were administered.

RESULTS

This sample's sequence of alcohol-related events was compared to that reported for Jellinek's historical white male sample (r(s) = .46, p = .001), a recent Navajo sample (r(s) = .33, p = .024), and a recent Mission Indian sample (r(s) = .28, p = .24). This sample's sequence of change efforts was compared to that in the Navajo sample (r(s) = .33, p = .182).

CONCLUSIONS

Despite the small sample size precluding generalizability, there was greater concordance between this intertribal sample and Jellinek's white male sample than between this sample and a Mission Indian sample, indicating both cross-cultural and intracultural variation. In addition, change efforts begin during the development of alcohol problems rather than waiting until the person "hits bottom," as suggested by previous research. Integrating the pathology of substance- use disorders with the process of resolving those disorders extends our understanding of the course of alcohol dependence.

Course of recovery from alcoholism

This article represents the proceedings of a symposium at the 2005 Research Society on Alcoholism meeting in Santa Barbara, California, organized and chaired by Kamilla L. Venner. This symposium integrated current empirical research on the course of recovery from alcoholism from multiple perspectives, an aim that is consistent with NIAAA's new focus on the process of recovery. The presentations and presenters were as follows: (1) The Role of Community Services and Informal Support on 7-Year Drinking Outcomes in Treated and Untreated Drinkers, by Helen Matzger; (2) The Sequence of Recovery Events in a Native American Sample, by Kamilla L. Venner; (3) Transformational Change in Recovery, by Alyssa A. Forcehimes; (4) Social Settings and Substance Use: Contextual Factors in Recovery, by Rudolf H. Moos; and (5) A Broader View of Change in Drinking Behavior, by discussant Mark L. Willenbring. A theme connecting the presentations was that treatment is but one discrete aspect to recovery and that sustained recovery is often influenced by an individual interaction with others within a social context. Collectively, presentations underscored the need to think more broadly about factors contributing to the remission of alcohol dependence.

Progression of alcohol problems in a Navajo sample

OBJECTIVE

This study tested the cross-cultural applicability of Jellinek's progression in a sample of Navajo men and women. Jellinek (1952) described a predictable progression of alcoholism that continues to be used widely in treatment, but it is unclear whether this pattern is consistent across cultures and genders.

METHOD

The sample consisted of 99 Navajo (67 men and 32 women) who were undergoing detoxification in a secure facility. Participants were asked about the quantity and frequency of their drinking as well as other drinking experiences. Their level of cultural identification was also assessed.

RESULTS

Of the 46 events established by Jellinek, the order of progression for the Navajo sample was modestly correlated (r(s) = .41, p = .005, 17% shared variance) with that for Jellinek's white men. The correlation of Jellinek's sample with the Navajo men was slightly larger (r(s) = .48, p = .001, 23% shared variance) than that of the whole sample; however, the comparison with Navajo women resulted in a near zero correlation (r(s) = .06, p = .705, 4% shared variance).

CONCLUSIONS

In the context of studies from other cultures, these data suggest convergence decreases as the studied sample deviates culturally from Jellinek's sample of U.S. white men. These data question the cross-cultural applicability of this popular model of progression of alcoholism.