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.

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.

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.

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

BACKGROUND: 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.

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).

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.

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.

Study Protocol for the Opioid and Pain Treatment in Indigenous Communities Trial: A Systems Level Intervention for Enhanced Screening and Brief Intervention and Referral for Co-Occurring Chronic Pain and Opioid Use Disorder.

American Indian/Alaska Native (AI/AN) individuals have the highest rates of opioid overdose mortality and chronic pain (CP) compared to other racial/ethnic groups in the United States. These individuals also report higher rates of pain anxiety and pain catastrophizing, which are both associated with poorer outcomes and risk for opioid misuse (OM) and opioid use disorder (OUD) among individuals with CP. Yet, no prior studies have examined rates of comorbid pain and OUD among AI/AN adults. This commentary describes an implementation research partnership of 3 AI/AN-serving clinics and a university team that utilizes an implementation hybrid type III design to examine the impact of implementation strategies on adoption and sustainability of evidence-based screening and brief intervention for CP and OM/OUD among AI/AN clients. As part of our community-engaged approach, we embrace both AI/AN models and Western models, and a collaborative board of 10 individuals guided the research throughout. We hypothesize that our culturally centered approach will increase rates of screening and brief intervention and improve identification of and outcomes among AI/AN clients with CP and OUD who receive treatment at participating sites. Each site convenes a workgroup to evaluate and set goals to culturally center screening and brief interventions for CP and OM/OUD. Data collected include deidentified electronic health records to track screening and brief interventions and rates of CP and OUD; provider and staff surveys beginning prior to implementation and every 6 months for 2 years; and a subset of clients will be recruited (N = 225) and assessed at baseline, 6, and 12 months to examine biopsychosocial and spiritual factors and their experiences with culturally centered screening and brief intervention. Cultural adaptations to the measures and screening and brief intervention as well as barriers and facilitators will be addressed. Recommendations for successful Tribal health clinic-university partnerships are offered.

Quantifying the Burden of Opioid Use Disorder and Non-fatal Opioid Overdose in American Indian and Alaskan Native Populations Using the Cerner Real-World Data™ Database.

OBJECTIVE: This study evaluated the prevalence and incidence of opioid use disorder (OUD), rates of opioid overdose (OD), and rates of non-fatal (NF) OD in American Indian/Alaskan Native (AI/AN) populations. METHODS: We used de-identified patient data from Oracle Cerner Real-World Data™. Rates were estimated over time, and stratified by sex, age, marital status, insurance, and region. Mann-Kendall trend tests and Theil-Sen slopes assessed changes over time for each group while autoregressive modeling assessed differences between groups. RESULTS: The study identified trends in OUD and OD among 700,225 AI/AN patients aged 12 and above. Between 2012 and 2022, there was a significant upward trend in both OUD and OD rates (p < 0.05) , with OUD diagnosed in 1.75% and OD in 0.38% of the population. The Western region of the US exhibited the highest rates of OUD and OD. The 35-49 age group showed the highest rates of OUD, while the 12-34 age group had the highest rates of OD. Marital status analysis revealed higher rates of OUD and OD among separated, widowed, or single patients. Additionally, individuals with Medicare or Medicaid insurance demonstrated the highest rates of OUD and OD. CONCLUSION: Results show that rates of OUD, OD, and NF OD continue to rise among AI/AN individuals, with some regional and demographic variation. Our study provides foundational estimates of key AI/AN populations bearing greater burdens of opioid-related morbidity that federal, state, and tribal organizations can use to direct and develop targeted resources that can improve the health and well-being of AI/AN communities.

Provider perspectives on the impact of COVID-19 on treatment of substance use and opioid use disorders among American Indian and Alaska Native adults.

Introduction: American Indian/Alaska Native (AI/AN) communities are more likely to suffer negative consequences related to substance misuse. The COVID-19 pandemic exacerbated the opioid poisoning crisis, in combination with ongoing treatment barriers resulting from settler-colonialism, systemic oppression and racial discrimination. AI/AN adults are at greatest risk of COVID-19 related serious illness and death. In collaboration with an Indigenous community advisory board and Tribal leadership, this study explored AI/AN treatment provider perceptions of client-relatives' (i.e., SUD treatment recipients) experiences during the pandemic from 2020 to 2022. Methods: Providers who underwent screening and were eligible to participate (N = 25) represented 6 programs and organizations serving rural and urban areas in Washington, Utah, and Minnesota. Participants engaged in audio-recorded 60-90 min semi-structured individual interviews conducted virtually via Zoom. The interview guide included 15 questions covering regulatory changes, guidance for telemedicine, policy and procedures, staff communication, and client-relatives' reactions to implemented changes, service utilization, changes in treatment modality, and perceptions of impact on their roles and practice. Interview recordings were transcribed and de-identified. Members of the research team independently reviewed transcripts before reaching consensus. Coding was completed in Dedoose, followed by analyses informed by a qualitative descriptive approach. Results: Five main domains were identified related to client-relative experiences during the COVID-19 pandemic, as observed by providers: (1) accessibility, (2) co-occurring mental health, (3) social determinants of health, (4) substance use, coping, and harm reduction strategies, and (5) community strengths. Providers reported the distinctive experiences of AI/AN communities, highlighting the impact on client-relatives, who faced challenges such as reduced income, heightened grief and loss, and elevated rates of substance use and opioid-related poisonings. Community and culturally informed programming promoting resilience and healing are outlined. Conclusion: Findings underscore the impact on SUD among AI/AN communities during the COVID-19 pandemic. Identifying treatment barriers and mental health impacts on client-relatives during a global pandemic can inform ongoing and future culturally responsive SUD prevention and treatment strategies. Elevating collective voice to strengthen Indigenous informed systems of care to address the gap in culturally-and community-based services, can bolster holistic approaches and long-term service needs to promote SUD prevention efforts beyond emergency response efforts.

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.

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.

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.

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.

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.

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.

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.