Opioid use in indigenous populations: indigenous perspectives and directions in culturally responsive care

Abstract

In this work, we outline the necessary components for culturally responsive treatment to opioid use disorders in Indigenous communities. First, we examine the context of historical trauma faced by Indigenous groups in the U.S. and how this context may affect successful implementation of treatment. We then outline the strategies of Penobscot Nation and Little Earth in developing holistic treatment regimens for Indigenous peoples, and list policy interventions suited to improve outcomes for Indigenous groups related to opioid use disorders. We conclude with suggestions for future directions in anticolonial strategies for addressing opioid use in Indigenous communities. The combination of culturally responsive treatment, tribal sovereignty in the treatment of opioid use disorders, and effective resource allocation is necessary to affect positive change in Indigenous substance use trajectories.

Over 450,000 individuals have died from opioid overdoses since 1999, making opiates a leading cause of injury-related death in the United States (Hedegaard et al., 2020). Though Indigenous individuals in North America have the highest rates of abstinence from drugs and alcohol (Cunningham et al., 2016), the opioid epidemic has been particularly devastating among Indigenous¹ communities; the Centers for Disease Control (CDC) reported that Indigenous groups had the highest drug overdose death rates in 2020, at 42.5 deaths per 100,000, and experienced a sharp 39% increase in the number of deaths in 2020 (Hedegaard et al., 2021). Government organizations such as the National Institutes of Health (NIH) and Substance Abuse and Mental Health Services Administration (SAMHSA) have recently allocated hundreds of millions of dollars in funding, $350 million (2019) and $123 million (2021), respectively, to address the growing problem and invest in prevention and treatment programs and develop treatment schedules for individuals struggling with opioid addiction (National Institutes of Health, 2019; SAMHSA, 2021). Despite this unprecedented investment, there continues to be a rise in opioid-related fatalities; there were over 75,000 opioid overdose deaths in the 12-month period ending in April 2021, an over 33% increase from 56,064 the previous year (Centers for Disease Control and Prevention, 2021). These figures present a complex problem related to investment, resource distribution, and outcomes as Indigenous groups have been largely excluded in relation to culturally-specific opioid use disorder treatment and prevention.

In part, opioid use disorders have experienced increased attention because they have plagued white² communities. This has led to the development of policy and programming that disproportionately services this population (Hansen & Netherland, 2016), and has caused disparities in effective treatment protocols for nonwhite opioid users who benefit most from treatment that is community-centered and culturally responsive (Lau, 2006). Because individuals who belong to racial and ethnic groups that have been minoritized have experienced increasing rates of opioid use disorder and death (Hedegaard et al., 2021), there is a need to invest resources in interventions that are developed and rooted in these communities. For Indigenous groups specifically, culturally responsive treatment is not just preferable–it is necessary to center experiences of historical trauma, decolonize traditional treatment regimens, and allow tribal sovereignty in addressing the needs of their specific communities.

In this work, we outline the necessary components for culturally responsive reactions to opioid use disorders in Indigenous populations and provide examples of effective efforts. First, we describe the extent to which opiates have pervaded Indigenous communities. Next, we examine the context of historical trauma faced by Indigenous groups in the U.S., and how this context may affect the outcomes of prevention and intervention efforts. Additionally, we outline the success of two Indigenous groups – Penobscot Nation and Little Earth – in developing holistic treatment regimens for Indigenous peoples. These case studies serve as models for culturally focused programs that acknowledge the role of historical trauma in opioid substance use disorders. We also outline a list of policy interventions that may facilitate program development and resource allocation to improve outcomes for Indigenous groups. Finally, we conclude with suggestions for future directions in anti-colonial strategies for addressing opioid use in Indigenous communities, and provide direction for social workers and treatment programs.

Opioid use in Indigenous communities

Indigenous groups comprise one of the fastest growing populations in regard to opioid-related fatalities (Centers for Disease Control and Prevention, 2021). Opioid-related overdose deaths have increased by five times between 1999 and 2015 in Indigenous populations, equating to 22 deaths per 100,000 in metropolitan areas and almost 20 deaths for 100,000 in non-metropolitan areas (Mack et al., 2017). Further, these figures may undercount Indigenous opioid fatality by as much as 35% due to racial misclassification on death certificates (Mack et al., 2017). In part, opioid use and fatality is driven by increased access to prescription opiates (DuPont, 2010); Indigenous young adults are at a higher risk of abusing prescription drugs, with approximately one in ten individuals age 12 or older reporting using prescription painkillers for nonmedical reasons, compared with one in 20 among Non-Hispanic Whites and one in 30 among Black youth (Calcaterra et al., 2013).

Though Indigenous groups have higher rates of opioid use disorders, they are less likely to access Medication for Opioid Use Disorder (MOUD) or other forms of drug treatment. In a 2016 survey, only one percent of Indigenous adults reported the receipt of treatment for illicit drug use in the prior year (Center for Behavioral Health Statistics and Quality, 2018). Structural racism, stigma, medical mistrust, poverty, lack of health insurance, and lack of access to culturally tailored treatments among other social determinants of health continue to be major barriers for accessing and engaging in MOUD (Acevedo et al., 2012). Improving the accessibility and efficacy of opioid treatment programs invariably requires addressing these social determinants of health, with a particular focus on historical trauma on opioid substance use disorders and disengagement from Anglo-centric treatment regimens.

The treatment of historical trauma

Prominent scholars have examined the extent to which Indigenous people experience significant intergenerational effects of colonization (Barker et al., 2019; Brave Heart et al., 2011; Ehlers et al., 2013; Gone et al., 2019; Hartmann et al., 2019; Nelson & Wilson, 2017; Treloar & Jackson, 2015). Specifically, sovereign Indigenous nations have been forcibly removed from their original homelands, mandated to attend culturally repressive boarding schools, and have experienced extreme levels of physical, sexual, and spiritual violence since first contact with settlers in the early 1500ʹs (Gone et al., 2019). These horrific experiences have manifested in a set of psychological effects across generations of Indigenous families that are consistent with firsthand experiences of trauma. This phenomenon, which has been understood and defined as historical trauma, has been used to explain disparities in behavioral health outcomes for Indigenous people, including drug and alcohol use (Brave Heart, 2003).

Given that Indigenous groups have unique experiences of trauma, it follows that they are unique in their experiences of the internalization and externalization of this trauma and require specialized prevention and intervention efforts (Brave Heart et al., 2011). According to Hartmann et al. (2019), the greatest challenge to addressing historical trauma with Indigenous groups is engaging individuals without ‘pathologizing Indigeneity, reifying social narratives of victimhood, and obscuring attention to recurrent settler-colonial arrangements’ (p. 11). Thus, interventions that mirror the values and power dynamics of the settler-colonial state are unable to adequately address the systematic harm enacted upon Indigenous people. Treatments for Indigenous populations need to reflect the values and traditions of their communities in order to facilitate healing and recovery.

In line with this need, it is necessary and critical to center cultural experiences in treatment regimens. Many Indigenous people view culture (e.g., learning and speaking their Indigenous language, accessing and using traditional medicines) as treatment and a preventative tool in substance use (Bassett et al., 2012). Indigenous people often share similar values and orientation to the world; however, their many cultures and languages should not be viewed as a monolith. Further, the degree to which culture is salient will be dependent on the individual (Brady, 1995). Tribes and Native-serving organizations must have the sovereignty and flexibility to imbue cultural perspectives and themes to best serve their own communities.

Two Indigenous-led responses to the opioid crisis incorporate culturally responsive treatment methods to decolonize the standard of care. Penobscot Nation and Little Earth of United Tribes have developed programming that centers the effects of historical trauma and Indigenous identity in their approaches to treatment. These interventions provide models for treatment that recognize and understand the role of historical trauma in substance use etiology while also centering Indigenous culture and strengths, making them model programs in cultural responsivity in the context of opioid treatment.

Case studies in culturally responsive treatment

Penobscot tribal healing to wellness courts

Penobscot Indian Nation, located just outside of Bangor, Maine is a community of just over two thousand, 430 of whom reside on Indian Island. Penobscot Tribal Healing to Wellness Courts (THWC) have expanded to over 92 programs across 26 states (Sekaquaptewa & van Schilfgaarde, 2015). THWCs integrate substance use treatment with the criminal justice system by way of transitional services in a non-punitive setting. These Courts are guided by ten key components including individual and community healing, continuing interdisciplinary and community education, and team interaction (see, Sekaquaptewa & van Schilfgaarde, 2015 for a review of all components). The Penobscot Indian Nation Healing to Wellness Court, launched in 2008, has garnered particular attention because of its repeated success in improving outcomes for constituents.

The Penobscot THWC’s mission is ‘to combine the judicial oversight and powers of the Court with Healing and wellness services to better address any and all underlying or co-occurring substance or mental health issues of court-involved individuals’ (Tipping, 2018, para 1). Intensive case management and counseling, regular drug testing, and progressive rewards and consequences draw similarities with the other adult drug treatment courts in Maine. However, Penobscot presents four phases of treatment and wellness, named after four traditional medicines. Phase I-Tobacco, introduces new beginnings; Phase II-Cedar, confronts personal responsibility; Phase III-Sage, invites cooperation and accountability; finally, Phase IV-Sweetgrass brings completion and continues growth and wellness (Tipping, 2018).

The first THWC component, individual and community healing focus, is evident throughout the Penobscot program. Participants can expect prayer and smudging (burning traditional medicines like sage) at each session. Attendance at Penobscot cultural events like drumming circles and language classes is a program-wide expectation (Conaboy, 2018). At every junction, individual and community wellness are equally important. Further, in response to COVID-19, many THWC teams have modified their services to keep Native communities safe while maintaining consistency in services including the use of telephone sessions, video-conferencing hearings, and connecting participants with virtual community recovery support groups. By integrating traditional perspectives and placing accessibility as a foremost consideration, the Penobscot THWC demonstrates how culturally responsive treatment can be implemented for other Indigenous groups.

Little earth intensive outpatient program

The Little Earth of United Tribes, known as Little Earth, is a community of approximately 1,500 individuals in Minneapolis, Minnesota that represents over 39 different Indigenous tribal groups (Egerstrom, 2018). Little Earth provides a variety of services to its constituents, including educational enrichment, youth interventions, cultural programming, and substance use disorder treatment opportunities for its residents. The Intensive Outpatient Program (IOP) was developed in 2018 to cater to the particular needs of Indigenous members of their community in the areas of trauma-informed and culturally sensitive care (Egerstrom, 2018). Though the IOP services drug use of all kinds, it was explicitly developed in response to Minnesota’s rising opioid overdose death rates in Indigenous communities (Egerstrom, 2018).

Little Earth’s IOP centers the unique experiences of Indigenous people with substance use disorders in several ways. First, the family members of individuals who use drugs are encouraged to engage with IOP programming by attending group cultural teaching, substance use disorder and behavioral health education classes, and by participating in small group counseling sessions to process the effects of traumatic events. Little Earth also provides programming adjacent to traditional methods of healing: urban farming to promote healthy eating exercise regimens and connection with the earth; a joint family program to promote familial connection; and a range of mental health services to be accessed after the IOP such as grief and loss, depression, and anxiety counseling to explore the role of trauma on health and well-being (Egerstrom, 2018). Not only does this approach to recovery encourage desistance from substance use, it also encourages the healing of the family unit through programming that holistically addresses the source of substance use triggers – namely, historical trauma. By engaging with each individual’s unique experience of trauma, encouraging cultural and familial connection, and providing adequate recovery resources, Little Earth’s IOP is a model of culturally responsive care for individuals with opioid use disorders.

Policy developments supporting community-led solutions

In addition to culturally responsive solutions to the opioid crisis, tribes must have sovereignty in tandem with sufficient resources to effectively serve their communities’ needs. Allocation of resources is often aided by federal, state, local, and tribal policy. We highlight three policy developments that social work policy advocates should be apprised of as they may help clear a pathway for Tribal community-led solutions. First, the Native Health Access Improvement Act of 2017 creates a Special Behavioral Health Program for Indian (SBHPI) communities allowing tribes to exercise agency in designing programs in their communities (Indian Healthcare Improvement Act of 2017, 2017). While there has been no movement on this bill since its initial introduction, another amendment was introduced in 2021 in response to the widening health disparities exacerbated by the COVID-19 pandemic. This bill also proposed SBHPI to help Tribes access much-needed resources to address mental health and substance use (Native Behavioral Health Access Improvement Act of 2021, 2021).

Next, the Opioid Response Enhancement Act of 2018 would reauthorize the 21st Century Cures Act Opioid Grant Program of 2017. Fifty percent of each fiscal year funding would be allocated to the ten states and Tribes with the greatest need. This would be the first time there would be a Tribal set-aside funding for this program, at 10% of each fiscal year funding. This legislation has also been referred to a subcommittee with little movement since. Finally, the piece of legislation that capstones the aforementioned acts is President Biden’s January 20, 2021 Executive Order on Advancing Racial Equity in Underserved Communities through the Federal Government which seeks to ensure achieving equity in access to housing, employment, health and social services (Exec. Order No. 13985, 2021). In general, avenues of policy development hold great promise, but their efficacy in affecting meaningful change is dependent on a multi-pronged, holistic approach.

Conclusion and future directions

It is our hope that the U.S. can effectively shift the trajectory of opioid use disorder and death in Indigenous communities through the combination of culturally responsive treatment regimens, tribal sovereignty, and effective resource allocation through effective policy. Social workers are well-positioned to support these ends through client-level work, research, and advocacy. However, the most immediate and consequential need for social workers is awareness and education related to cultural responsivity. It is the goal of this work to serve as an introduction to decolonizing perspectives in opioid use treatment for Indigenous populations.

The interventions reviewed today are culturally responsive insofar as they represent approaches to healing that center culture, highlight the importance of community, and improve accessibility for Indigenous groups. Culturally responsive treatment requires that the needs of each population are addressed in ways that do not exacerbate the underlying causes of substance use disorders (Venner et al., 2018). For social work researchers and practitioners looking to partner with Indigenous communities, this involves recognizing the role of historical trauma in the many aspects of behavioral health and restoring a cultural connection that may have been lost as a result of using patterns and behaviors. Further, culturally relevant treatment is most effective when it is accessible, equitable, and engages all members of a community. Thus, social workers engaging in substance use treatment with Indigenous communities must have an understanding how the persistence of colonialism and Neo-colonialism affect program efficacy and accessibility. Treatment cannot be culturally relevant when it promotes the prevailing narratives of pathologizing Indigeneity and substance use. Education for social work professionals regarding the characteristics of culturally-informed treatment should ideally begin during master and doctoral level social work programs, but can and should continue throughout one’s social work career.

It is important to note that there remains a need for interventions that reach urban-living Indigenous people. Though the majority of resources allocated to Indigenous populations focus on reservation-based communities, most (approximately 71%) Indigenous people live in urban areas in the United States (Yuan et al., 2014). Further, only about 25% of Urban Natives live in counties served by urban Indian health programs authorized and funded through Public Law 94–437, Title V (Indian Health Service, 2018). This means there is a high likelihood that Indigenous people will be seeking substance use disorder services alongside clients from other racial and ethnic backgrounds. To best prepare, social workers and treatment programs should orient themselves with historical trauma and colonialism literature (see above suggestion); hire Indigenous social workers and mental health professionals; hire and compensate Indigenous knowledge keepers, spiritual advisors, and community members to act as consultants; and partner with established culturally-tailored programs such as the ones presented in this work to develop responsive programming and continuing education opportunities for staff. It is the responsibility of social work practitioners to follow and advocate for emerging policies that directly affect Indigenous communities and continuously consult with tribes, tribal organizations, and Indigenous nonprofits throughout the policy development process.