An Updated Narrative Review on the Role of Alcohol Among Indigenous Communities

Abstract

Purpose of Review

The role of alcohol varies considerably among Indigenous Peoples and is the backdrop of persistent stereotypes despite decades of research. This paper provides an updated narrative review on the alcohol literature among Indigenous communities, highlighting recent studies published since 2017.

Recent Findings

We examined published literature involving alcohol use rates, including abstinence; risk and protective factors; treatment; and recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities.

Summary

Evidence-based alcohol use prevention, intervention, and recovery strategies with Indigenous communities are outlined. Recommendations are provided for researchers, health providers, and public policy advocates to address and better understand alcohol use, treatment, prevention, and recovery among Indigenous Peoples. Specific recommendations include using community-based participatory research strategies and harm reduction approaches to prevent and treat alcohol use problems with Indigenous communities. Future research is needed to elucidate mechanisms of resilience and recovery from Alcohol Use Disorder and possible shifts in perceptions of alcohol use for Indigenous Peoples.

Introduction

To understand the complex role of alcohol in an Indian Country, it is imperative to define American Indian/Alaska Native (AI/AN)/Indigenous Peoples as distinct, thriving populations and to discuss social and health inequities within historical and contemporary contexts. Many names are used to describe the original inhabitants of the North American continent, also known as Turtle Island [1], including American Indian, Native American, Alaska Native, First Nations, Native Peoples, Aboriginal, Métis, Inuit, and Indigenous Peoples. Whenever possible in this paper, we use the term “Indigenous” [2] as an inclusive descriptor that represents the original inhabitants of specific areas while acknowledging that most of the literature in this review focuses on Indigenous Peoples in North America. For example, some literature included in this review refers to First Nations Peoples in what is now Canada and AI/AN Peoples in what is now the USA. Future research is needed to better understand the relations with alcohol across Indigenous Peoples globally.

There are currently 3.7 million individuals (1.1% of the US population) in the USA who exclusively identify as AI/AN [3]; however, this number increases to 9.7 million individuals (2.9% of the US population) when allowing for multiracial identification [3]. These numbers can also vary when accounting for tribal citizenship or who is eligible for federal health services [4]. For example, 2.6 million AI/ANs are currently eligible for health services through the Indian Health Service (IHS) [5]. To date, there are 574 federally recognized tribes, or tribal nations, in the USA [4, 6]. Federally recognized tribes are sovereign nations recognized by the federal government through treaties and federal policies [7], and as such, each tribe determines their own citizenship eligibility criteria as an exercise of tribal sovereignty. AI/AN Peoples are citizens or descendants of tribal nations, including federally recognized tribes, tribes recognized by state governments yet not recognized by the federal government, and other tribes that exist as cultural entities without federal or state recognition.

Prior to colonization, fermented substances were virtually absent from Indigenous communities in North America [8]. European colonizers introduced alcohol and modeled binge drinking to Indigenous communities as a form of violence to coerce tribes into unfair trades and treaties [9]. This resulted in problems related to alcohol misuse among some Indigenous individuals, which ultimately led to negative stereotype depictions of AI/ANs who used alcohol, such as the “drunken Indian” [10] and the “firewater myth,” or the belief that Indigenous Peoples are more susceptible to the effects of alcohol and more vulnerable to alcohol use problems due to genetic or biological differences [10, 11]. Such stereotypes persist and are internalized among some Indigenous individuals [12, 13], despite no clear evidence of genetic predisposition to alcohol addiction for AI/ANs [14]. In 1832, the US Congress passed a law prohibiting the sale of liquor to AI/AN individuals, which was in effect until 1953 when the US Congress granted tribes control over alcohol policies [15]. Importantly, the 1887 Dawes Act required AI/AN individuals to prove ½ or greater degree of Indian blood to qualify for an allotment of their own tribal estate; the Dawes Act was used as a tactic to revoke political status through intergenerational invisibility and erasure of Indigenous Peoples [7, 16]. To summarize, the US Congress simultaneously prohibited the sale of alcohol to Indigenous individuals while purposefully excluding some Indigenous individuals as US citizens, thus, contributing to the historical dehumanization and contemporary inequities of Indigenous Peoples.

Much of the previous alcohol literature with Indigenous communities has been deficits focused e.g., [17, 18]. In general, this narrative is overly concerned with “risk behaviors,” usually positioning Indigenous Peoples’ health as a problem to be solved while promoting the pathologizing views of Indigenous Peoples as being more prone to negative health outcomes and in need of intervention [19]. Such deficit approaches are often deeply racialized and produced through ongoing settler-colonial relations that position Whiteness as the “norm;” Western forms of knowledge are prioritized and viewed as superior to Indigenous ways of knowing and being [19]. To combat these deficit-focused and stereotypic narratives, Bryant and colleagues [19] suggest using sociocultural approaches, which view strengths as sociocultural relations, collective identities, and practices. This type of approach allows for better capturing Indigenous ways of knowing and being and provides a strong basis to build meaningful interventions [19], which we apply to our discussion on the role of alcohol among Indigenous communities.

The purpose of this updated review is to provide a current picture on the role of alcohol among Indigenous communities by including recent literature on alcohol use rates, including abstinence; risk and protective factors associated with alcohol use; alcohol use treatment; and alcohol use recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities. We also highlight research conducted with Indigenous communities by Indigenous researchers. While public health consequences of problematic alcohol use are heightened in some Indigenous communities, and thus, deserve empirical, policy, and practice attention, we also want to highlight research on alcohol abstinence and alcohol recovery among Indigenous Peoples from a harm reduction approach, as well as sociocultural frameworks that may help guide future alcohol prevention and intervention efforts with Indigenous communities. One such sociocultural framework is the adapted National Institute of Minority Health and Health Disparities (NIMHD) Research Framework [20] for AI/AN Peoples [21], which we discuss further below.

Method

For this updated narrative review, we examined published literature, primarily focusing on recent literature (i.e., published since 2017, within the past 5 to 6 years at the time this paper is written) involving alcohol use rates, including abstinence; risk and protective factors associated with alcohol use; alcohol use treatment; and alcohol use recovery among Indigenous communities, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities. We first decided a priori to include alcohol use rates among Indigenous Peoples, either exclusively or across ethnic/racial groups, from federally funded surveys with representative samples of the US population, including: the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC) and the National Survey on Drug Use and Health through Substance Abuse and Mental Health Administration (SAMHSA).

Next, we used an adapted version of the National Institute of Minority Health and Health Disparities (NIMHD) Research Framework [20] for AI/AN Peoples [21] to guide our literature search in contextualizing cultural factors associated with alcohol use, treatment, recovery, and future research directions for Indigenous communities. The NIMHD Research Framework integrates genetic, biological, environmental, social, political, and cultural influences to identify factors that are dynamically related and work synergistically to influence health disparities across the lifespan among minoritized individuals and populations [20]. The adapted NIMHD Research Framework for AI/AN nations identifies influences that are particularly relevant for understanding the health and wellbeing of Indigenous Peoples, such as spirituality; collective resilience; traditional constructions of illness and healing; historical trauma, boarding/residential schools; and unique financial and healthcare infrastructures, including tribal sovereignty and major federal Indian policies [21]. This framework was selected to guide this review because such determinants fall within these dimensions of influence of alcohol-related health inequities, and can be readily operationalized, measured, and analyzed in ways analogous to their conceptual counterparts for other populations. We then searched the English-language literature using the PsycINFO database beginning with the year 2017. These PsycINFO searches employed a combination of keywords such as, “drinking” and “alcohol” along with terms used to represent Indigenous ethnic/racial identification, such as “American Indian,” “Alaska Native,” “Native American,” and “Indigenous.”

Lastly, we reviewed our team’s prior peer-reviewed journal articles related to alcohol use among Indigenous communities e.g., [22–25] and our edited, published book chapters related to these topics e.g., [26, 27]. We then selected papers for inclusion based on the following criteria: (1) Peer-reviewed, (2) published since 2017, (3) samples comprised exclusively of Indigenous Peoples or samples across racial/ethnic groups with representation of AI/AN Peoples, and (4) content related to the focus of the review (i.e., alcohol use rates, including abstinence; risk and protective factors associated with alcohol use; alcohol use treatment; and alcohol use recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities). We cross-referenced our literature search results with our team’s prior work, as well as cross-referenced these identified articles with those included in systemic reviews to ensure there were no duplicate articles represented in the current review. Additionally, we summarize the key articles identified, which are presented alphabetically by the author, followed by year of publication, in Table 1.

Table 1.

Recent peer-reviewed articles on alcohol among Indigenous communities (i.e., published in 2017 to 2022)

Authors (year)	Topic of interest	Study design	N = Sample size of Indigenous participants, or number of articles reviewed (if applicable)	Key outcomes
Andersen et al. (2021) [28••]	Approaches to treating Indigenous Peoples with AUD	Systematic Review	19 eligible articles	Research supports traditional, community-driven approaches to reducing drinking. Web-based brief interventions, motivational interviewing, and Naltrexone are also supported.
Brave Heart et al. (2020) [29••]	Evaluation of Historical Trauma and Unresolved Grief Intervention for depression, trauma, and grief	Randomized-Controlled Trial (RCT)	N = 52	Qualitatively, compared to the control group (Interpersonal Psychotherapy only), participants were more engaged in treatment for depression/trauma/grief when the intervention included cultural history, values, and practices
Clifford & Shakeshaft (2017) [30•]	Peer-reviewed articles on substance use among Indigenous Peoples from Australia, New Zealand, Canada, and the U.S. published between 1993–2014 were identified	Review	1046 total eligible articles; 176 focused on alcohol	The number of data-based publications on substance use among Indigenous Peoples statistically increased over this time period; however, studies on measurement and intervention did not significantly increase over time, suggesting increased research is needed.
Cunningham et al. (2022) [31••]	Prevalence of any mental illness diagnosed among patients hospitalized with AUD	Cross-sectional	N = 23,380	AI/AN patients hospitalized with AUD were significantly less likely to be diagnosed with a comorbid mental illness than non-Hispanic White patients.
Dale et al. (2019) [32••]	Addiction recovery mutual support groups	Systematic Review	4 eligible articles	All support groups studied were part of Alcoholics Anonymous. Varying study designs were found. Research should continue to expand knowledge of mutual support groups for AI/AN Peoples.
Doty-Sweetnam & Morrissette (2018) [33•]	Addiction recovery among First Nations and Aboriginal women	Qualitative	N = 7	Themes such as guilt, shame, resilience, social support, tradition, and spirituality were commonly endorsed.
Fish et al. (2017) [34•]	Prevalence of interpersonal and dating violence and substance use	Cross-sectional	N = 2103	AI/AN college students reported lower rates of past-month drinking (59.9%) than NHW college students (68.7%).
Gameon & Skewes (2021) [35••]	Associations of historical trauma thoughts/symptoms and drinking outcomes	Cross-sectional	N = 198	Historical trauma thoughts were negatively associated with drinking, especially when historical trauma symptoms were low.
Goldstein et al. (2022) [36••]	Acceptability and feasibility of harm reduction	Mixed methods	N = 8 (75% Indigenous) health care workers; N = 9 (100% Indigenous) community members	Health care workers rated harm reduction approaches as acceptable and feasible and community members were more mixed.
Greenfield et al. (2018) [37•]	Prevalence of past-month drinking, cultural engagement	Cross-sectional	N = 347	43% of AI/AN college students reported past-month drinking; involvement in cultural activities was negatively associated with past-month drinking
Greenfield et al. (2021)2 [38••]	Prevalence of high-intensity drinking; childhood trauma and family alcohol use as risk factors	Cross-sectional	N = 434	NHWs had twice the odds of current drinking than AI/AN Peoples.
Henson et al. (2017) [39•]	Protective factors for health promotion	Systematic Review	18 eligible articles	Authors identified nine categories of protective factors (e.g. family connectedness, positive social norms) that promote healthier drinking outcomes.
Ignacio et al. (2022) [40••]	Alcohol and other drug prevention needs assessment among Indigenous youth ages 13–17	Qualitative	N = 10	Four constructs of Indigenous relationality: 1) youth understand the harms of alcohol and other drug use, 2) youth appreciate non-abstinence-based education, 3) youth need safe spaces to talk about the impacts of alcohol and drug use, and 4) youth desire to prevent alcohol and other drug use harms for others and themselves.
John-Henderson et al. (2020) [41••]	Historical trauma as a predictor of stress during the COVID-19 pandemic	Prospective cohort	N = 205	Historical trauma thoughts before the pandemic were positively associated with greater increases in stress during the pandemic among those with low social support.
Kelley et al. (2019) [42••]	Tribal best practices in preventing substance abuse	Systematic Review	4 eligible articles	Tribal best practices are consistently used in AI youth prevention services and should be better represented in research and dissemination.
Lee et al. (2018) [43••]	The role of alcohol availability in risky drinking	Qualitative	N = 31	Oppressive structural barriers exacerbate negative consequences of risky drinking for both individuals and communities.
Liddell & Burnette (2017) [44•]	Evidence-based, culturally-informed substance use treatment for Indigenous youth	Systematic Review	14 eligible articles	Though varied approaches to substance use treatment have been successful, research of these treatments is still underrepresented for Indigenous youth.
Lillie et al. (2021) [45••]	Addiction recovery	Qualitative	N = 20	Phases of recovery included Pre-Recovery (e.g., awareness of problem, hope), Turning Point (e.g., readiness, motivation), and Ongoing Recovery (e.g., peer or professional support, lifestyle changes, cultural activities).
Looby et al. (2017) [46•]	Prevalence of drinking in the past 6 months; positive alcohol expectancies	Cross-sectional	N = 43	AI/AN college students drank half as much as NHW students. NHW (but not AI/AN) race was positively associated with positive alcohol expectancies, which in turn, was positively associated with drinking.
Luczak et al. (2017) [47•]	Prevalence of AUD across ethnic/racial groups	Systematic Review	20 eligible articles	Authors found higher rates of AUD among AI/AN populations compared to other ethnic groups, though rates of AUD within AI/AN Peoples varied widely.
Purcell-Khodr et al. (2020) [48••]	The role of primary care in risky drinking	Systematic Review	28 eligible articles	Brief interventions were most represented in research. Cultural and bicultural factors were valued by providers and patients. Naltrexone as a treatment for drinking yielded promising results.
Skewes & Blume (2019) [49••]	Relationship between racial trauma and substance use	Qualitative	N = 25	Participants reported stress from racism and historical are key factors of risky substance use.
Soto et al. (2022) [50••]	Identify risk and protective factors of addictive behaviors among AI/AN Peoples	Systematic Review	69 eligible articles	Risk factors: historical trauma, socioeconomic challenges, family/friends modeling risky use Protective factors: cultural connectedness, family/friends modeling sobriety
Toombs et al. (2021) [51••]	Best practices for substance use treatment with Indigenous Peoples	Systematic Review	31 eligible articles	Research mostly studied residential (versus non-residential) treatment programs. Approaches varied widely, with no conclusive “best format” for treatment.
Trinidad et al. (2020) [52••]	Perceptions of factors leading to alcohol misuse	Qualitative	N = 34 patients, 5 providers, and 10 leaders	Participants reported colonization, systemic barriers, isolation, social norms, drinking to cope, and negative stereotypes of drinking contribute to alcohol misuse.
Vaeth et al. (2017) [53•]	Prevalence of AUD; correlates of drinking and AUD; and treatment needs, access, and utilization examined across ethnic/racial groups	Critical Review	140 eligible articles	Authors found higher rates of AUD and alcohol-related consequences among AI/AN populations compared to other ethnic/racial groups.
Venner et al. (2019) [54••]	Addiction recovery, maintenance of long-term sobriety	Qualitative	N = 55	Motivational factors (e.g., social support, self-reflection, performance at work) and action steps (e.g., seeking treatment, helping others, spiritual practice) helped many with addiction recovery.
Weatherall et al. (2020) [55••]	Prevalence of alcohol dependence; assessment methods	Systematic Review	11 eligible articles	Range of alcohol dependence varied from 3.8 to 33.3% of Indigenous participants. No assessment tools were culturally-specific, but 2 out of 8 tools were validated with Indigenous populations.
Zephier Olson & Dombrowski (2020) [56••]	Indian boarding school attendance and family discord as risk factors of substance use	Systematic Review	27 eligible articles	Family discord in AI/AN families should be contextualized within the culture-wide history of Indian boarding school attendance when discussing it as a correlate of risky substance use.

¹Papers of particular interest, published recently have been highlighted as: • Of importance: •• Of major importance

²While this article by Greenfield and colleagues was published in 2021, the data presented in this article came from four National Alcohol Surveys collected during 2000–2015

Results

The following themes of results for this narrative review emerged from using a bottom-up (i.e., data driven) approach. The yielded themes were also guided by the NIMHD Research Framework [20] and the adapted NIMHD Research Framework for AI/AN nations [21], which consider levels of influence (individual, interpersonal, community, and societal) and domains of influence over the life course (biological, behavioral, physical/built environment, sociocultural environment, and health care systems) that impact Indigenous health inequities, and we relate to the role of alcohol. Specifically, our identified themes include: Historical Trauma and Contemporary Alcohol-Related Health Inequities, Alcohol Use Rates, Low Alcohol Use Rates and Abstinence, Risk Factors Influencing Alcohol Use, Barriers to Alcohol Use Treatment, Protective Factors Against Alcohol Misuse and Negative Drinking Consequences, Alcohol Use Prevention, Alcohol Use Treatment, and Alcohol Use Recovery.

Historical Trauma and Contemporary Alcohol-Related Health Inequities

The effects of colonization and culture-wide events experienced by Indigenous Peoples in the past remain impactful today and relate to contemporary health inequities associated with alcohol use (e.g., cirrhosis, motor vehicle accidents, and suicide deaths) among Indigenous Peoples [17, 18]. Furthermore, the ongoing psychological and emotional processes and responses to historically traumatic events are termed “historical trauma” [57]. A recent systematic review stated that historical trauma is often assessed as a risk factor for substance misuse among Indigenous Peoples, though empirical studies that have examined the relation between historical trauma and substance misuse among Indigenous Peoples have yielded mixed results [50••]. Studies continue to examine components of historical trauma and their differential associations with alcohol use. For example, one study explored interactions between historical trauma thoughts (i.e., frequency of thoughts about losses of land, life, and culture) and historical trauma symptoms (i.e., frequency of emotional and behavioral responses, such as anxiety, isolation, and avoidance of historical trauma thoughts) in a sample of American Indian adults from one reservation in the Northern Plains who self-identified as having substance use problems [35••]. Findings from this study indicated that historical trauma thoughts, controlling for symptoms, were associated with greater days abstinent, fewer heavy alcohol use days, and fewer drinks per drinking day [35••]. Soto and colleagues [50••] encouraged working towards clarifying and consistently operationalizing historical trauma as a construct to fully understand the intricacies of its relationship with alcohol use. Historical trauma should further inform other individual, family, and community-level risk factors of alcohol misuse among Indigenous Peoples. For example, historical trauma has been linked to common correlates of alcohol misuse such as post-traumatic stress disorder (PTSD), depression, adverse childhood experiences (ACEs), and poorer quality of family and community relationships [29••, 41••, 56••]. Considering sociocultural history and contemporary contexts may contribute to improve prevention and intervention efforts for alcohol misuse in Indigenous communities.

Historical and socioeconomic contexts give way to system-level inequities, such as inequities in income, employment, and access to education; all of which are associated with worse drinking outcomes for Indigenous youth and adults [50••]. Racism and negative stereotypes against Indigenous Peoples are other known systemic risk factors for alcohol misuse. In a sample of AI/AN Peoples hospitalized for Alcohol Use Disorder (AUD), patient records across hospitals in Arizona, New Mexico, and Oklahoma revealed that AI/AN patients hospitalized for AUD were 51.1% less likely to receive a diagnosis of any comorbid mental illness compared to non-Hispanic White (NHW) patients [31••]. The authors discuss this inequity of underdiagnosed mental health comorbidities as a barrier to receiving appropriate, comprehensive care for AUD, which may stem from negative alcohol-related stereotypes and mistrust between AI/AN patients and Westernized medical providers [31••].

Alcohol Use Rates

National, cross-sectional surveys with diverse ethnic/racial group representation consistently find that Indigenous individuals are less likely to consume alcohol compared to all other ethnic/racial groups; however, some research indicates that among Indigenous individuals who consume alcohol, they are more likely to drink larger quantities and to binge drink compared to the general population [58–60]. For example, data from the 2012–2013 U.S. National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) indicated that AI/AN Peoples had higher rates of AUD (20.2%) relative to NHW people (14.2%) [61]. More recently, the 2020 National Survey on Drug Use and Health revealed that Indigenous Peoples 18 years and older reported greater rates of past-month heavy alcohol use (defined as 5 or more binge-drinking episodes in the past month; 9.1%) than NHW people (7.8%) and the total population (7.0%) [62]. Other research has demonstrated similar results with rates of AUD, as previous systematic reviews, with data spanning 1994 to 2016 and 2000 to 2017, respectively, have indicated overall greater rates of AUD among Indigenous Peoples compared to other ethnic/racial groups [47•, 53•]. Furthermore, Cunningham and colleagues [31••] examined hospital discharge data from 2016 to 2018 and found that AI/AN patients hospitalized for AUD or nicotine use disorder (NUD) in Arizona, New Mexico, and Oklahoma were younger compared to NHW patients, and rates of alcohol dependence (rather than alcohol abuse) were slightly higher for AI/AN patients (65.5%) compared to NHW patients (63.7%) in New Mexico.

Though some research has found greater rates of drinking-related problems and AUD among Indigenous Peoples than the general population, a systemic review on alcohol dependence among Indigenous Peoples in Australia, New Zealand, Canada, and the USA from 1989 to 2020 found that these results vary based on factors, such as sampling methodology (e.g., national versus community sampling), assessment measures, and drinking outcomes (e.g., past-month drinking versus AUD [55••]. Additionally, Walls and colleagues [25] identified higher rates of lifetime SUD, including AUD, in retrospective reports among a large, longitudinal sample of Indigenous Peoples from 2002–2010 to 2017–2018; however, past-year rates of AUD were comparable to non-Indigenous Peoples. The authors indicate that past-year rates of alcohol abuse were nearly identical when comparing Indigenous and non-Indigenous young adults using NESARC estimates, which suggests a high rate of recovery among Indigenous young adults despite early-onset SUD in adolescence among some [25]. Taken together, these findings suggest that longitudinal assessment is important to understanding accurate prevalence and trajectories of mental health problems among Indigenous Peoples and other communities.

Importantly, national data should be interpreted with caution, as Indigenous Peoples are commonly misclassified as other ethnic/racial groups [63]. Moreover, recent research has called for a shift away from between-group comparisons (e.g., AI/AN versus NHW) to examine health disparities [64]. This between-group approach restricts understanding of the mechanisms through which adverse social determinants of health (SDOH) contribute to health inequities, and results in ethnology distortion wherein underrepresented populations, who are largely excluded from clinical trials and interventions, are not adequately described [64].

Low Alcohol Use Rates and Abstinence

While high rates of binge drinking, AUD, and negative alcohol-related consequences remain a public health priority for many Indigenous communities, empirical research also demonstrates that Indigenous Peoples consume less alcohol, or entirely abstain from alcohol at higher rates, compared to other populations [e.g., [34•, 37•, 58]]. Specifically, findings from the 2018 National Survey on Drug Use and Health revealed that the percentage of people who reported any alcohol use in the past month was higher in the general population (54.3%) compared to AI/AN young adults (44.7%) [65]. Further, Greenfield and colleagues [38••] examined data from four National Alcohol Surveys from 2000 to 2015, and adjusted models demonstrated that NHW individuals had twice the odds of current drinking compared to AI/AN Peoples and individuals from other ethnic/racial backgrounds. Furthermore, apparent differences in high intensity drinking (i.e., defined in this study as consuming 8 or more drinks for women, and 10 or more drinks for men, per drinking day in the last 12 months) between NHW Peoples and AI/AN Peoples were eliminated by adjusting for sociodemographic factors (e.g., childhood trauma, family problem drinking) [38••]. Another national survey collected between 2008 and 2010 with AI/AN college students indicated that up to 60% of AI/AN students reported past-month drinking compared to 68.7% of NHW students [34•]. Additional studies with AI/AN college students, with data from 2013 to 2018, indicated that AI/AN students engage in less binge drinking and lower drinking overall compared to their NHW counterparts [37•, 46•, 65]. Further, epigenetic research has demonstrated that AI/AN individuals do not have a greater genetic predisposition to develop AUD compared to individuals from other ethnic/racial backgrounds [14]. Collectively, these findings are important to combat negative stereotype depictions of any alcohol use among AI/AN Peoples.

Risk Factors Influencing Alcohol Use

Alcohol misuse and negative drinking consequences among Indigenous communities must be considered in the context of larger systemic risk factors, such as historical trauma, poverty, family history of AUD, and acculturative stress [60]. Previous qualitative work by Brown Trinidad and colleagues [66] demonstrated that multiple interacting risk factors — including colonization, structural oppression, social exclusion, and stereotypes of Indigenous people — contribute to alcohol use problems in Indigenous communities. In a study about intergenerational historical trauma impacts, the authors concluded by indicating that many Indigenous Peoples exposed to historical trauma remain healthy, which suggests that future research is needed to explore factors related to maintaining health in the face of historically traumatic events [67].

Barriers to Alcohol Use Treatment

Barriers to obtaining treatment also contribute to alcohol-related health inequities among Indigenous communities. Venner and colleagues [68] conducted a mixed-methods study to examine barriers AI/AN Peoples face in seeking help for AUD. Results indicated that unique cultural barriers to alcohol use treatment included a “lack of cultural interventions” (e.g., traditional healing) and potential differences in ethnicity/race of the patients and treatment providers [68]. Scholars such as Skewes and Blume [49••] have also reported on barriers to receiving help for an alcohol use problem in Indigenous communities specifically, singling out stress from racism as a main factor. Importantly, experiencing distress from racism and discrimination prevents many Indigenous Peoples from accessing health care in general e.g., [69]. Furthermore, qualitative work by Lee and colleagues [43••] demonstrated that socialstructural determinants of health magnified alcohol impacts. In other words, structural issues (e.g., lack of affordable housing) may amplify the negative effects of drinking throughout the community even if only a few individuals have an alcohol use problem.

Protective Factors Against Alcohol Misuse and Negative Drinking Consequences

Even amidst the effects of colonization and culture-wide traumatic events, Indigenous Peoples are highly resilient and possess many strengths that can serve to protect against alcohol use-related negative outcomes. Mohatt and colleagues [70] used grounded theory (i.e., examining themes that emerge from the data) to transcribe and analyze life histories of more than 100 Alaska Native Peoples, including those who had recovered from alcohol use problems or those who never had a drinking problem; this latter group encompassed both non-problem drinkers and lifetime abstainers. Their multilevel model described the following four interactive and reciprocal protective processes: (1) individual, family, and community characteristics; (2) trauma and trauma responses; (3) experimental substance use and one’s social environment; and (4) reflective processes associated with a life decision or turning point related to recovery [70]. The authors further elaborated on this conceptual model and the importance of cultural factors mediating these processes. For non-problem drinkers, resilience was drawn from individual stories of self-confidence, self-efficacy, and self-mastery in relation to coping with stress and/or trauma [70]. For the lifetime abstainers, efficacy was described in social terms and understood as “communal mastery,” which is a concept describing that one best masters situations by joining others. Implications of this study suggest that alcohol use prevention and intervention efforts with Indigenous communities should simultaneously focus on individual, family, and community levels to build resilience and protective factors at all levels [70].

Protective factors against alcohol use exist at the individual, family, and community levels, in which qualitative and mixed-methods researchers have been crucial in identifying [33•, 45••, 54••]. One particularly prevalent multi-level protective factor is cultural connectedness through understanding and identification with traditional cultural practices, language, and spirituality [39•, 50••]. Previous systematic reviews have identified a host of individual protective factors, including possessing current or future life aspirations, such as being a role model for others or attending college [71, 72]. Allen and colleagues [71] identified positive self-image, or believing in oneself, as protective against alcohol use with Alaska Native communities. Related to having a positive self-image, self-efficacy, defined as that the ability to problem solve and self-regulate, has also been demonstrated to be protective against alcohol and other substance use in both American Indian and Alaska Native communities [39•, 50••]. In a recent study with AI/AN adolescents living in urban areas in California, those who self-identified as AI/AN reported better mental health, less alcohol and marijuana use, lower rates of delinquency, and increased happiness and spiritual health [66].

Community and family factors that can serve to protect against alcohol use and dependence are vast. Similar to individual cultural connectedness, surrounding oneself with others who are strongly connected to their culture can serve as a protective factor against alcohol use [50••]. Previous research has cited the importance of having positive role models and continuous positive parental involvement in the prevention of alcohol use; further, having greater opportunities for positive experiences (e.g., extracurricular activities, volunteering) has been cited as protective against alcohol use [71–74].

Alcohol Use Prevention

There are currently several culturally relevant substance use prevention programs available for Indigenous youth, including Project HAWK [75], Think Smart [76], and the Cherokee Talking Circle school-based intervention program [77]. While evidence-based prevention practices can be effective when utilized with Indigenous populations, prior literature has suggested that culturally relevant methods and/or tribal best practices (TBPs) may be most efficacious for alcohol use prevention among Indigenous populations [42••, 78]. A systematic review by Kelley and colleagues [42••] revealed several TBPs for three Northern Plains tribes (i.e., the Creator’s Game, basketball, and drumming) that are consistently implemented in efforts to reduce youth substance use on the reservation; however, the authors also noted the dearth in discussions of TBPs and discrepancies in the communication and dissemination of TBPs in the literature. It is crucial to expand the knowledge base regarding TBPs and culturally relevant prevention methods to prevent negative alcohol use-related outcomes among Indigenous populations.

Alcohol Use Treatment

Early attempts in researching alcohol use treatment among Indigenous communities lacked cultural adaptations and Indigenous representation within the research team [79]. At the turn of the twenty-first century, a paradigm shift was observed — increased Indigenous representation among researchers, which likely allowed for improved research practices and integration of traditional cultural healing modalities, such as talking circles and sweat lodge ceremonies. Two randomized controlled trials (RCTs) support a pharmacological intervention that utilizes naltrexone to target alcohol use and dependence for Indigenous individuals; however, this type of intervention on its own may be less acceptable to Indigenous populations given the history of abuses by researchers and general distrust of White or Western methodologies [28••, 48••, 78]. Previous studies have aimed to assess treatment outcomes for residential versus nonresidential alcohol treatment programs for Indigenous Peoples and have had mixed findings; currently, findings are inconclusive regarding the best treatment intervention format for Indigenous Peoples [51••]. There are currently several culturally informed interventions targeting alcohol use among Indigenous populations, many of which lack research investigating their efficacy. This complicates researchers’ ability to compare these interventions with other treatments as well as develop strong evidence-based interventions and is an urgent need [44•].

Treatment of AUD for Indigenous Peoples should utilize a holistic, community-based approach, as opposed to a Western, individualistic approach. Evans-Campbell [80] emphasized the importance of relationality and including family and community within health interventions for Indigenous Peoples. A large component of understanding the benefits of cultural- and community-based treatment is to understand the values, activities, and spirituality of the individual tribe. Additionally, connecting to culture is viewed as medicine that possesses protective benefits from traumatic events [81]. Activities, such as engaging in ceremonies, learning traditional language, consuming traditional foods, and holding traditional values have been shown to be cultural healing practices [81]. Further, “culture as treatment” has been identified as a critical mechanism to produce positive health outcomes [82, 83].

There is limited published outcome research on substance use interventions developed for Indigenous Peoples despite some research suggesting higher frequencies of binge drinking, AUD, and negative alcohol-related consequences among these populations [84]. While non-Indigenous treatment methods have been employed, they have been shown to be less effective and particularly destructive to Indigenous individuals [85–87]. Therefore, culturally tailored and culturally derived (i.e., developed with communities via CBPR research methodologies) interventions are necessary and have the potential to increase treatment engagement for community members, which also have potential for sustainability within behavioral health [88, 89]. For example, Venner and colleagues [84] conducted a pilot study to culturally adapt two evidence-based treatments (i.e., Motivational interviewing and the Community Reinforcement Approach) to evaluate substance use and psychological outcomes with Indigenous adults with a SUD diagnosis from a Southwest tribe in the USA. Substance use and psychological outcomes were assessed 4 months and 8 months after baseline, and results indicated significant reductions in psychological distress and in alcohol use and other substances [84]. Findings from this pilot study suggest that culturally tailored interventions are promising for reducing alcohol and other substance use among Indigenous Peoples.

Harm reduction is another promising intervention approach to reduce the disproportionate alcohol-related harm experienced by Indigenous communities [36••]. Harm reduction approaches represent compassionate and pragmatic strategies applied to policy, populations, communities, or individuals that aim to minimize alcohol-related harm and enhance quality of life without requiring or advising abstinence or use reduction [90, 91]. Results of a recent mixed-methods, community-based participatory study with community health care providers and Indigenous community members from one rural reserve in Eastern Canada revealed that health care providers rated alcohol harm reduction approaches as acceptable and feasible while community participants were more mixed [36••]. Specifically, most community member participants felt that some harm reduction strategies could provide opportunities for individuals who use alcohol to connect to Indigenous culture and traditions; however, findings were mixed regarding whether harm reduction strategies fit with Indigenous cultural traditions and values [36••]. Building on this work, a recent qualitative, community-based participatory study examined the perceptions of alcohol and other drug (AOD) use, harm reduction, and culture among Indigenous youth ages 10 to 17 years old living in the Pacific Northwest [40••]. Findings revealed the following four key themes; all of which involve relationality: (1) youth understand the harms of AOD use (people); (2) youth appreciate alternatives to abstinence-based education (ideas); (3) youth need safe spaces to talk about the impacts of AOD (place); and (4) youth desire to help prevent AOD harms for themselves and others (cosmos) [40••]. Results of this study provide a theoretical foundation to guide AOD prevention and treatment for Indigenous youth [40••]. Collectively, these findings suggest that CBPR and harm reduction approaches may be particularly beneficial in treating alcohol and other substance use problems among Indigenous communities.

Alcohol Use Recovery

There is a need for increased empirical studies on alcohol use recovery among Indigenous populations, and we also recognize that certain communities have developed and implemented their own Tribal-specific alcohol use recovery programs (i.e., “Tribal Best Practices” or TBPs), some of which may be unpublished and unavailable to the public for various valid reasons [42••]. A recent systematic review by Dale and colleagues [32••] identified just four studies investigating the effects of mutual support groups among Indigenous Peoples recovering from alcohol use or AUD and concluded that there is an overwhelming lack of empirical knowledge regarding the utility of mutual support groups in alcohol use recovery for Indigenous Peoples. Further, it was concluded that there is an urgent need and desire for culturally relevant mutual support groups; these support groups would likely need to be highly specialized depending on the tribe(s) participating in the recovery programs, as AI/AN tribes are vastly heterogeneous [32••].

Community engaged practices are a promising form of alcohol use prevention, intervention, and recovery, as community is essential for sustaining public health within the Indigenous worldview. The White Bison “Well-briety” movement in the USA is one such community-engaged alcohol use intervention that culturally modifies and delivers the Alcoholics Anonymous (AA) recovery program to Indigenous populations across the country in efforts to facilitate culturally based healing [92, 93]. While this is a nationally available community-based resource, there is an urgent need to increase the number of Indigenous community mental health workers on tribal lands to address health inequities such as alcohol use [94]. Increasing representation in the community mental health workforce on tribal lands is hypothesized to have numerous benefits, including familiarity with traditional knowledge (e.g., importance of community, interconnection between all life forms, interconnection of physical, mental, and spiritual health), understanding of the tribe’s history and culture, and honor of tribal sovereignty [94].

Future Directions for Research

Future research is needed to further elucidate mechanisms of resilience and recovery from Alcohol Use Disorder or possible shifts in perceptions of alcohol use across generations of Indigenous Peoples. Previous longitudinal research has demonstrated that consuming alcohol in moderation was associated with lower alcohol dependence, fewer alcohol-related problems, and lower reward value at 1-year follow-up e.g., [95], though most of this research has been conducted with non-Indigenous Peoples. Future research with Indigenous Peoples on this topic is warranted. From a harm reduction perspective, breaking down barriers and stigma for non-abusive relationships with alcohol (i.e., infrequently, or occasionally, consuming low to moderate amounts of alcohol without developing alcohol use problems) among Indigenous Peoples if they choose to partake may help to combat stereotypic narratives while promoting self-determination of health behaviors.

Involvement of communities is essential in Indigenous research to avoid further harm and correct prior wrongs and harm done by scholars and academic institutions e.g., [96]. Community-based participatory research (CBPR) is the recommended methodology when working with Indigenous communities [97], which involves developing and cultivating ongoing relationships with the goal of positive outcomes. By involving the community, community members can guide the researchers in a reciprocal relationship with the goal of healing from colonization and related socio-political harms. Community members can participate as partners, collaborators, and researchers in identifying the concerns and strengths of their community [98–100]. This approach has begun to address the gap in adequate and culturally appropriate treatment for those with a SUD. To date, multiple CBPR projects within an Indian Country have been shown to address substance use using strengths-based and culturally appropriate interventions [36••, 40••, 82].

Conclusions

While the fundamental roots of alcohol and related problems for Indigenous communities lie within the backdrop of colonization, historical trauma, and ongoing oppression and marginalization [101], research on the role of alcohol among Indigenous communities has evolved. Research in this area began with stereotypes, such as the “drunken Indian” and “firewater myths” [10, 11], which remain internalized among some Indigenous Peoples [12, 13] and persist despite no clear evidence of genetic predisposition to alcohol addiction for Indigenous Peoples [14] and high abstinence rates in some Indigenous communities [34•, 37•, 58]. Alcohol use research with Indigenous communities in the late 1900s–early 2000s was largely pathology-based and deficits-focused [17–19]. This focus began to shift in the early 2000s–2010s, as cultural adaption research became increasingly available e.g., [102], and more researchers began examining SDOH, such as historical trauma [67], as contributors to health inequities. Indigenous scientists also developed and studied models of adaptive mental health coping and substance use recovery [103], which have significantly contributed to these research shifts. Most recently, Indigenous scientists and researchers partnering with Indigenous communities have recommended culturally grounded, community- and strengths-based research approaches (e.g., CBPR) for alcohol prevention and intervention efforts [36••, 40••, 82, 97]. However, research on the role of alcohol with Indigenous communities still has room for growth, such as through increasing the number of Indigenous scientists and health care providers [94] and funded training pathway programs to support them e.g., [104].

The public health consequences of AUD are heightened in some Indigenous communities, and thus, deserve empirical, policy, and practice attention, particularly in the form of culturally grounded, community-driven interventions and treatment approaches. Such solutions are found within Indigenous communities themselves in terms of Indigenous wisdom, cultural reclamation, healing, and revitalization wherein Indigenous Peoples assert the power of culture as medicine and healing [105]. From a harm reduction perspective, we suggest that Indigenous Peoples can have a normative relationship with alcohol (i.e., infrequently, or occasionally, consuming low to moderate amounts of alcohol without developing alcohol use problems) if they choose to partake, which may help to combat the stereotypic narratives while promoting self-determination of health behaviors. Future research is needed to further elucidate mechanisms of resilience and recovery from AUD or possible shifts in perceptions of alcohol use across generations of Indigenous Peoples.