Delivering Opioid Use Disorder Treatment among American Indian and Alaska Native Adults During the COVID-19 Pandemic and Beyond: Facilitators and Barriers to Care

Abstract

Background:

American Indian and Alaska Native (AI/AN) communities experienced a disproportionate increase in opioid-related fatal and non-fatal poisonings during the COVID-19 pandemic. Access to treatment, such as medications for opioid use disorder (MOUD), became even more critical, although research among this population is limited. We completed qualitative interviews with substance use disorder (SUD) treatment providers (i.e., MOUD prescribers, non-prescribing clinicians, non-clinical support staff) to assess the impact of COVID-19 on MOUD care among AI/AN adults.

Methods:

Sixty-minute semi-structured interviews were completed with providers working in SUD treatment (N=25). Eligible providers represented 6 programs serving rural Tribal and urban areas primarily in the Pacific Northwest United States. Transcripts were independently reviewed and analyzed for themes based upon the research aims.

Results:

Nineteen female and six male providers completed interviews. Four themes were identified: 1) Beneficial policy changes for MOUD delivery; 2) Telehealth as the biggest policy shift; 3) Addressing complexity, and 4) Cultural services. Findings indicated providers viewed the introduction of telehealth, implementation of mobile services, and expanded take home dosing as positive and leading to increased treatment access. However, barriers related to the internet, transportation, and reimbursement of telehealth remain.

Conclusions:

Providers highlighted the utility in the expansion and sustainment of telehealth. Flexible policies for MOUD were particularly beneficial during the height of COVID-19 to maintain and increase access to treatment. Providing a menu of treatment options, emphasizing cultural engagement and social support were deemed necessary to enhance AI/AN community driven solutions in curbing the opioid poisoning public health crisis.

1. Introduction

The US is currently in the fourth wave of the opioid epidemic with American Indian and Alaska Native (AI/AN) populations particularly impacted (Ciccarone, 2021). Unfortunately, the opioid public health crisis and the COVID-19 pandemic intersected with devastating consequences among AI/AN communities (Zhu et al., 2022). Among AI/AN people, the mortality rate for COVID-19 infection was almost two times higher than non-Hispanic Whites (Arrazola et al., 2020), while the rate of fatal drug poisonings increased 39% between 2019 and 2020 among AI/AN people (Kariisa et al., 2022). AI/AN communities addressed these challenges with strengths-based and resilient approaches leading to some of the highest COVD-19 vaccination rates in the country (Haroz et al., 2022), flexibility in health service delivery (Palzes et al., 2023), and innovative SUD harm reduction strategies (Kelley et al., 2024).

Over the last two decades, medications for opioid use disorder (MOUD; e.g., buprenorphine, methadone) have become standard of care for OUD across diverse populations (Blanco & Volkow, 2019; Wakeman et al., 2020). However, AI/AN people have always faced barriers in OUD treatment access (Venner et al., 2018). For AI/AN communities, lower engagement in MOUD has been associated with an overall lack of availability of prescribers (Riedel et al., 2021), the need to integrate MOUD within a larger holistic healing paradigm that is low-barrier and culturally congruent (Nelson et al., 2025), and the potential for stigma and distrust of Western medicine (Venner et al., 2018). Other barriers to MOUD have included justice involvement and geographic location (Krawczyk et al., 2021). Increased risk of discontinuing MOUD is also correlated with polysubstance use and younger age (Lillie et al., 2021). Continued evaluation of the factors that enhance MOUD engagement among AI/AN communities are recommended.

Federal regulatory and policy changes to SUD and MOUD care delivery during the COVID-19 pandemic offered an opportunity to examine impact on access and health outcomes (Parker et al., 2023). Some of the regulatory changes were sustained including telehealth expansion and increased take home doses of methadone (Department of Health and Human Services & Substance Abuse and Mental Health Services Administration, 2024). Research among providers serving non-AI/AN communities highlighted the benefits of these policy changes which included decreased experiences of stigma by seeking care through telehealth services, national changes to funding telehealth, increased treatment engagement, and positive outcomes related to the relaxed policy in medication dosing (Lott et al., 2023; Treitler et al., 2022; Wendt et al., 2021). More research is needed to assess the experiences and potential implications of long-term service delivery among providers serving AI/AN communities during the height of COVID-19 (Wendt et al., 2021).

In the present study, we interviewed 25 providers (i.e., MOUD prescribers, non-prescribing clinicians and non-clinical support staff) working in American Indian-serving outpatient substance use disorder programs to assess the facilitators and barriers to providing MOUD and substance use disorder treatment during COVID-19. Longer-term policy and regulatory impacts were also examined alongside culturally informed treatment and cultural services. This study helps to inform enhancements necessary to providing effective OUD treatment among AI/AN people. While the study was framed and completed within the context of a global public health emergency, implications for services stretch beyond the pandemic with continued creative solutions needed to improve care among AI/AN communities.

2. Methods

2.1. Community-based Participatory Research & Positionality

The research was completed in connection with two NIDA Clinical Trials Network studies (Hirchak et al., 2023; Richardson et al., 2024). Community-Based Participatory Research (CBPR) has previously demonstrated improved intervention engagement and health outcomes (Wallerstein et al., 2018, 2019; Wallerstein & Duran, 2010), with the present study design guided by CBPR. For example, a national Collaborative Board (CB), consisting of over 25 members from across the country, was involved in the study in many ways. Members included AI/AN researchers, MOUD providers, and people with living (i.e., still currently using illicit opioids) and lived experience (i.e., in recovery for OUD), to name a few. Through the collaboration and integration of the CB, they assisted in the qualitative interview question development, recruitment, and data interpretation. Based on CB guidance and continued dialogue with the authors, we framed the research within a relational lens, referring to the people that the providers serve in this study as “client-relatives.” Other key CBPR principles included 1) the development of relationships with Tribal leadership to build trust and respect sovereignty through fully executed data-sharing agreements; 2) reflexivity in the study design and interview question development process; 3) fostering relationships with behavioral health providers; and 4) partnering with practitioners at American Indian-serving organizations and treatment centers across the US to enhance recruitment efforts, but primarily focused in the Pacific Northwest.

In alignment with reflexivity and the spirit of CBPR, the authors include a statement about their positionality (Thambinathan & Kinsella, 2021). KH is a descendant of the Eastern Shoshone Tribe/mixed European ancestry. She has partnered with AI/AN communities on SUD treatment research for 15 years. KB is a descendant of immigrants and Filipino ancestry. She has worked with AI/AN communities for over 4 years. MR is a citizen of the Haliwa-Saponi Tribe and Asian Indian of Indo-Fijian descent. She has worked alongside AI/AN communities to provide health and human services and centering Indigenous informed research practices for more than 8 years. RS is a Cowlitz Tribal member descending from Chief Scenewa. FK is of mixed European background. KAO is White of mixed European ancestry. ANCC is White of mixed European ancestry and has partnered with AI/AN communities on SUD research for 15 years. KV is Athabascan (Chitina Village Tribe) and mixed European ancestry and has partnered with AI/AN communities for 30 years.

2.2. Participants & Procedures

Prospective participants were screened for the following inclusion criteria: 1) willing and able to provide informed consent; 2) employed at an AI/AN-serving program offering addiction treatment services (e.g., opioid treatment program, outpatient addiction program); 3) having direct client-relative contact administrative (e.g., program directors due to their knowledge of program operations) or clinical; 4) 18 years of age or older; and 5) fluent in English. Interviews assessed changes in client-relatives substance use (e.g., opioid, alcohol, cannabis, heroin, and methamphetamine) along with SUD treatment modality and service delivery. Barriers to access along with barriers and facilitators to changes in treatment delivery was explored, such as telehealth. Questions also included cultural activities offered or integrated into treatment services. The final semi-structured interviews included 15 base questions. For example, we asked, “Describe the policy changes, if any, that were adopted by your program (e.g., temporary, emergency revision to the delivery of medications, telehealth, etc.)?” For a complete list of interview questions please see the appendix.

This study was approved by the Washington State University (#18604) and Northwest Portland Area Indian Health Board Institutional Review Boards (#1743728-3). Fully executed data sharing agreements were also completed with Tribes. Participants reviewed a consent form and were provided an opportunity to ask questions. Once consented, the interviews lasted approximately 60-90 minutes and were conducted via video conference (i.e., Zoom). Participants were offered a $100 Tango gift card as compensation for time and effort which was sent directly to their email.

2.3. Data Analysis

Twenty-five percent of the total transcripts were independently coded by two members of the research team. A finalized codebook was subsequently reached through iterative discussions and agreement of codes by the coders, senior researchers on the team, and preliminary presentations to the CB. All interview transcripts were then uploaded and coded by two research team members in Dedoose. The coding procedure and frequency of applied codes indicated saturation and while the application of codes was assessed across coders, no further intercoder reliability checks were completed. For the present study, 6 primary and 43 secondary codes were extracted from the original codebook to undergo further applied thematic analysis by the lead author (Guest et al., 2012).

To increase the proportional value of these data between urban and rural providers, the frequency of codes applied was calculated using the normalization function in Dedoose, a common feature within the software. This process involves applying a weight of ‘1’ to the largest group of members within a code. The subsequent weights were then calculated based on the ratio of members in the largest group to the number in the subsequent groups. These weights are then used to adjust (“normalize”) the number of raw counts to accomplish ratio equivalence (Arthur & Clark, 2021). Code Application Frequency was then calculated using the adjusted (“normalized”) counts (please see appendix for additional details). Preliminary results and data interpretation were presented to the CB for further data analysis refinement.

3. Results

3.1. Participant Characteristics

Twenty-five providers participated representing six American Indian-serving addiction treatment centers primarily in urban areas (88%) in Washington state, with other programs located in Oregon, Utah, and Minnesota. The sample was majority female (76%), with ages ranging from 30-60 years old. Most of the providers were in clinical roles (e.g., nurse practitioners, licensed mental health counselors, licensed clinical social workers) with the remaining sample including roles such as care coordinators (Table 1).

Table 1.

Sample Characteristics

Demographics	Providers
	N = 25
Age	43.2 (8.1)
Sex
Female	19 (76.0%)
Male	6 (24.0%)
Self-Defined Location
Rural	4 (16.0%)
Urban	21 (84.0%)
Provider Type
Clinician (prescribers and non-prescribers)	22 (88.0%)
Non-Clinical Support Staff (with direct client-relative contact)	3 (12.0%)
Treatment Providers in Washington State	22 (88.0%)

Table 2 summarizes the overarching themes with the total application of codes and weighted by geographic region demonstrating similarities in provider experiences across themes. Overarching themes of provider experiences during COVID-19 included: 1) Beneficial policy changes for MOUD delivery; 2) Telehealth as the biggest policy shift; 3) Addressing complexity; and 4) Cultural services.

Table 2.

Provider Themes & Code Application Frequency

Overarching Theme	Weighted % of Codes Urban	Weighted % of Codes Rural	Total Raw Count of Codes Applied
Beneficial policy changes for MOUD delivery	47.0%	53.0%	662
Telehealth as the biggest policy shift	58.8%	41.2%	722
Opportunities and challenges to providing treatment	47.7%	52.3%	237
Cultural services	44.7%	54.8%	63

3.2. Beneficial Policy Changes for MOUD Delivery

Providers discussed many changes to service delivery during the height of COVID-19 that were perceived as generally positive, especially around medications. Changes were mainly related to home medication inductions (e.g., for buprenorphine) and medication distribution extended carries (e.g., meeting criteria to take methadone home). Providers appreciated curbside dosing where client-relatives would receive their medications from within their vehicle and “mobile services” where staff delivered medications to client-relatives. In one community, due to inclement weather and road closures, providers even delivered the medications by boat.

Additionally, extended medication carries were implemented and were viewed favorably. Providers highlighted how extended carries (e.g., 14 day take homes versus daily dosing at the clinic) allowed client-relatives to continue working or attending to family matters, while also reducing COVID-19 transmission risk. Medication adherence remained a concern for providers, although no provider directly mentioned this within the context of medication diversion. Mailing prescriptions came up less frequently and came with its own set of challenges, for example missing medication due to delayed delivery (see Table 3), making it a less favorable option for many providers. Transportation was also expanded during this time and provided by many of the participating clinics (i.e., transportation to the clinic or pharmacy).

Table 3.

Beneficial Policy Changes for MOUD Delivery

Subtheme	Exemplar Quote
Extended Carries	…. medication also got little bit longer. If they’re stable, we—I will tend to give them, like, a month worth of medication. If they’re not stable, still wanna see ’em every two weeks. But definitely, the medication doses has increased…. They used to come in to get a medication before [the] pandemic. Since [the] pandemic started, we don’t store the medication in our-in our cabinet anymore—our medication room anymore…. [clients] have to go to the community clinic. (1019)
Pandemic within an Epidemic	And we just weren’t able to provide those services as often as we-as we were before. People were more engaged. So, the culture changed where we don't like to be—w-we're like wraparound services. We really, believe in the-the therapeutic—or the-the holistic and the—just all the services matter. Mental health…Our transportation, we have child watch. We have, we try to remove barriers and COVID-19 just, I mean, it added that barrier to all of those things. So, some people got more carries…. Kinda weighing what the pros and the cons were of that. Because we're also in a—not only in a…pandemic with COVID. We're also [having] the opiate crisis, and fentanyl… Positive for alcohol, or benzodiazepine, or continued fentanyl. That was more on the heightened…less carries. (1016)
Medication Adherence & Compliance	They weren't coming here for treatment. They were just getting their prescription…. They did have to come in, from time to time to do UAs and things like that. They weren't very happy about that, of course, because you have to have a driver come pick 'em up…. Probably 50 percent of our people that actually didn't even have Suboxone in them. So, we've had to communicate with them and let them know that, you know, this has to change. You're getting a prescription, and you're not taking it. Something's not going right. (1006)
Challenges to Mailing Prescriptions	The mail-in prescriptions, we were getting complaints about, you know, people, having to go to their post office to pick up their meds and post office closing at a certain time and them missing their meds. And we had to send them a—like, an emergency prescription to a local pharmacy just to carry 'em over until the post office opened again….. Some patients were kind of couch surfing and, they would move somewhere else, and we didn't know, but their meds were sent to their other address, and they might've had issues with that person that lived there…. Post office required a signature, and so, if they weren't home, it would be returned to the post office…. We had issues with FedEx. (1014)
Sustained Outreach	They were like, ‘I really need to, really need to do this, but I don’t know if they’re gonna accept me or what’s goin’ on.’ I think once they started seeing us out there, in the streets, doing outreach, they-they kind of were like, ‘Okay, well, we-we know for sure that <Clinic> is gonna help us.’ So, it was kind of just, after that, I feel like things became easier for folks who, were looking for help because they weren’t sure if it was available until they saw, all of us doing our outreach out there. So, we would partner with…pretty much all of the places that you can think of here in <city> that are associated with the Native community. We had-we had Naloxone on hand always… Face-to-face type of things, we put a stop to our harm reduction street outreach for a little bit, but then we started up again…. We started going out in the community again and handing out safe harm, safe use kits and stuff like that. But we had pretty much everything available…. (1008)

Another area of consideration was harm reduction, which was conceptualized by providers as building client-relatives’ safety and trust with them and their organization alongside sustained outreach. Strategies were mentioned in many contexts including poisoning-reversal medications (e.g., naloxone), needle exchange programs, and drug safety checks. All these strategies were considered beneficial and in some instances the harm reduction activities were led by the provider themselves. Providers from one of the urban programs also discussed how outreach continued to be an important part of their work during the COVID-19 pandemic. They described how providing these services reminded people that help was available which enhanced trust and strengthened overall treatment engagement that continued post-pandemic (Table 3).

3.3. Telehealth as the Biggest Policy Shift

As highlighted in Table 4, the integration of telehealth was perceived as the biggest service delivery policy shift as none of the providers had previously utilized telehealth. Many programs experienced challenges getting telehealth systems up and running but worked to rapidly implement telehealth to meet client-relatives’ needs. Programs provided tablets, devices to connect to virtual conferencing, and data plans funded through the CARES Act, Tribal program funds, and donations. Client-relatives were allowed to keep the devices; this was seen as positive outcome by the providers, although challenges related to the internet or loss of devices remained a barrier and led to overall loss of contact with some client-relatives.

Table 4.

Telehealth as the Biggest Policy Shift

Subtheme	Exemplar Quote
Telehealth Benefits	I think for the most part, people are okay with how things are running right now. Like I say, they’re welcome to schedule an appointment and come in at this point. But most of ’em are preferring to still keep ’em virtual just because of—they have other things that they have going on in their lives. And it’s more convenient for them now that they’ve figured out how to work it. (1020)
Make Telehealth Permanent	I think they should be able to offer those telehealth services to community members out of the area, out of state. You know, they were able to do it during the pandemic. And now, telehealth has become something that a lotta people are leaning on. It's—whether it's more convenient, they can squeeze it in between things, or they don't have transportation. Or it's just so many different factors involved. But being out of state is one of those. And I feel like virtual—if they were able to make that exception during the pandemic, why not continue that? Or reevaluate that, and continue that so people can get that care? It felt awful to call this person and tell them, ‘You know, I know you're a community member, and that you need support right now. But unfortunately, we're stuck.’ Luckily, we do have executive leadership and a health board director. I was told that they are still doing the leg work to investigate this further because they feel that this person should be able to get telehealth services. (1036)
Continue Hybrid Treatment Approaches	I mean, it makes it easier for clients. That's definitely true. They don't have to coordinate transportation or find ways to come in. So, clients are actually happier to do it. But there are some clients that just need that in-person support. And a lot of providers do go out there and see their clients, you know, and maintain social distancing and just, have that face-to-face interaction.” (1026)

One of the most important implementation supports was virtual conferencing technical assistance for client-relatives as most had never used this type of technology. Telehealth was also described as a shift in how care was provided and none of the providers mentioned having specific training on delivering care in this way. The providers described the initial shift as “overwhelming,” and “bumpy,” but once implemented, generally positive. Telephone counseling was the most common form of telehealth and favored by most. When telephone counseling was no longer reimbursable at some programs, providers thought that was unfortunate. Providers also spoke of personal preferences and variable skill at delivering services telephonically or through video. Some preferred to deliver services in-person, finding it very difficult to engage people virtually while others felt they provided excellent services through virtual visits.

Providers also noted the social support and connections made in an in-person group session that were not the same in a virtual setting. While telehealth expanded access and availability (e.g., people no longer had to take time off work to attend group), it was not considered a panacea or even a substitute for face-to-face service delivery. Some programs continued to have client-relatives come into the office but would have them sit in a room by themselves and have their visit with the provider, who in some cases may have been in an office down the hall or at home. Providers did not directly discuss how the potential conflict between their perception of the need for in-person services and the client-relatives' desire for flexibility might be resolved. Ultimately, providers felt that while telehealth should continue to be offered, it came down to personal choice of the client-relative and their needs around in-person services versus telehealth.

3.4. Addressing Complexity

Providers also identified regulatory and policy shifts to maintain as part of services moving forward. While mentioned within the context of the COVID-19 pandemic, providers appreciated some of the flexibility in how care was delivered while also noting areas for continued enhancements to better serve client-relatives. For example, programs already experienced workforce challenges and meeting needs with small teams only intensified during the height of COVID-19. As another example, even with the transition to telehealth, transportation remained a significant barrier. Providers from urban areas were more likely to report transportation challenges as rural programs had often already known this was a service that would be needed.

3.5. Cultural Services

Cultural activities were a prominent feature of all but one of the programs long before the pandemic. Providers described the impact of COVID-19 on cultural engagement for the people they served as “devastating.” Prior to COVID-19, holistic approaches to health were common, including social, spiritual, or cultural activities. Providers mentioned Elder “coaches” sharing teachings (e.g., outdoor plant gathering, harvesting, processing), other knowledge keepers providing healing for client-relatives (e.g., sweat lodges), and traditional master carvers, beaders, or other artists providing routine services. Community dinners, smokehouse activities, and weekly family-friendly culture nights were also essential features at some organizations.

Providers highlighted specific barriers to facilitating cultural services during COVID-19 beyond the obvious. As one example, opening and closing a group session by smudging (i.e., burning medicines such as cedar and cleansing oneself). When people attended virtually, there was no longer the ability to help people receive that medicine and be cleansed in that way, making providers fearful of how that might leave client-relatives vulnerable after a difficult session.

Although not directly linked to culture, providers emphasized factors that impacted client-relatives well-being that could be considered related, such as the Indigenous determinants of health (M. Parker et al., 2023; Reading & Wien, 2009). For example, providers described having conversations about genocide, historical trauma and colonization and how the federal health policy approach during the COVID-19 pandemic was a reminder to client-relatives of these past assaults (e.g., sterilization of American Indian women without their consent by Indian Health Service up until the 1980s; Lawrence, 2000). Structural or interpersonal racism related to George Floyd’s murder and national protests that ensued, which also occurred during the first year of the pandemic, were mentioned as “triggers” for client-relatives.

Most of the providers discussed the need for cultural engagement as an important part of treatment and healing and this was especially true during the COVID-19 pandemic. Some of these cultural activities offered during that time took the form of implementing or expanding virtual Medicine Wheel or Wellbriety classes (e.g., culturally informed Alcoholics Anonymous [AA], family focused activities). Other cultural outreach was more tangible including drum making kits or traditional foods (e.g., smoked fish) sent or personally delivered to client-relatives’ homes (Table 6). While services had to shift due to closures and a major move to telehealth, seeing the need, providers in no way stopped creating cultural touchpoints when and where appropriate and felt that this should always be available to interested client-relatives.

Table 6.

Cultural Services

Subtheme	Exemplar Quote
Create Family and Community Cultural Connections	We have the kids help make a list for the summer, when school’s out, to outdoor activities we can do safely. Community journey is gonna happen. Usually trying to embrace any outlets that we have. The Tribe has been amazing with food deliveries. You know, any kind of cultural stuff that they can do down at the ballpark. They actually did cedar weaving and beading down in the big tent set up down there… Trying to engage, as best we can with cultural aspect. (1028)
Provide Cultural Engagement Opportunities	I mean in a Tribal health clinic, I—we pro—try to provide that culturally-competent care, but in addition, we try to also provide like-like, community…cultural events…we have a garden where they—people can learn about Indigenous, like, plants and, you know, medicines that were made by Indigenous people, just really specific things that I think help…They just—there’s a lack of community, and there’s the urban Indian phenomenon where people are just spread out—don’t feel connected, and then there’s this pandemic. Anything that we can do to kind of provide cultural, like, activities. (1032)
Offer Cultural Materials	Art supplies, those things were mailed out, which we hadn’t done before. Journals were mailed out; we hadn’t done before. Smudging supplies (1033)

4. Discussion

In the present study, we completed interviews with providers working in American Indian-serving treatment programs to assess their experiences delivering MOUD during the COVID-19 pandemic. Our findings highlighted how providers appreciated the flexibility in dosing and observed a need for continued telehealth. Findings were unique in that the providers described cultural services that were offered as part of treatment before and during the pandemic. Providers underscored the overall importance of continuing the new treatment modalities and expanded services to build upon these efforts to increase the holistic health of American Indian people in OUD recovery.

Providers were proponents of the relaxed regulations related to flexible medication dosing. Extended take home doses were more consistently favored, and providers supported the policy of medication initiation without an in-person visit. Providers discussed extended carries based upon the criteria set forth in the regulations and who they thought might gain the most from the continued policy. Based upon our findings, clearer criteria for extended take home dosing and additional strategies for application of criteria may be necessary so that treatment inequities are not inadvertently exacerbated (e.g., stigma; Harris et al., 2023). Providers also noted additional challenges related to mailing prescriptions, making this policy less beneficial due to client-relatives unstable housing or barriers related to mail carriers (e.g., the requirement to sign for packages with identification).

Across providers, there was a commitment to sustained outreach, including harm reduction, which was discussed as client-relative safety. Harm reduction described by providers emphasized a value of many AI/AN communities: the importance of revitalizing the role of caretaking (Killsback, 2020). Some providers demonstrated this belief by leading initiatives in the distribution of drug poisoning reversal medications, fentanyl test strips, lockboxes, syringe exchange and outreach to unhoused community members. Providers also discussed accountability and concern for client-relatives’ safety with extended carries. Research conducted outside of AI/AN communities has noted provider concerns related to diversion (Abadie & Fisher, 2024). In our sample, this was not explicitly stated. Additionally, in alignment with the providers’ perspectives in this study, diversion has not been associated with take home doses as initially feared (Amram et al., 2022).

Unlike prior studies with other provider populations, none of the programs included in our sample offered telehealth as part of services before COVID-19 (Chen et al., 2023; Lott et al., 2023). Consistent with prior research, providers discussed the need for quick implementation and the importance of technical assistance for successful telehealth initiatives (Chen et al., 2023; Lin et al., 2022). Telehealth was perceived as the most impactful change in policy for them. While our findings similarly highlighted the importance of telehealth (Riedel et al., 2021), providers in our sample had mixed feelings of how well it increased treatment engagement. Social connection and social support were consistently emphasized as not the same when visits and groups were conducted virtually (Richardson et al., 2024). However, the sentiment across providers was that telehealth should be permanently offered to increase accessibility when appropriate (Riedel et al., 2021), with additional considerations for improved internet access to decrease disparities (Rodriguez & Betancourt, 2021).

Internet continued to be a challenge as noted elsewhere in the literature (Chen et al., 2023), underscoring the importance of sustained efforts to address this social need among AI/AN communities (Lin et al., 2022; Lott et al., 2023). While telephone services were helpful to overcome internet challenges during the COVID-19 pandemic, they were no longer reimbursable afterward within some programs, a policy change that was noted by a few providers. In addition, providers thought keeping telehealth services across state lines was important to reach Tribal members who lived out of state, so this may be another policy area to consider keeping as a permanent feature (Health Resources and Services Administration, n.d.). Our findings also underscored another treatment access challenge, transportation. Surprisingly, barriers were mainly described by providers in urban areas, underlining that transportation is a broader issue for AI/AN communities and remains so after the COVID-19 pandemic.

All but one program in our sample had been offering their cultural traditions alongside Western approaches before the pandemic, confirming the critical role of framing MOUD treatment within an overarching holistic lens (Hirchak et al., 2023; Venner et al., 2018). Our findings also align with other urban AI/AN communities that have identified spirituality and community strengths as integral to healing (Zeledon et al., 2020). Providers described cultural services that have been previously noted in the literature, including activities led by Elders-in-Residence, Wellbriety curriculum (i.e., culturally responsive AA that includes additional family and healing activities), ceremonies (e.g., sweat lodges), beading, singing, and drumming (Dickerson et al., 2012; Zeledon et al., 2020). Trust between providers and client-relatives was also reported to be high. This feeling of trust may be due in part to provider’s treatment philosophy, as well as the fact that participating programs were primarily operated by their respective Tribal Nations, yet another important factor in Tribal sovereignty and self-determination that contributes to AI/AN whole health and well-being (Rainie et al., 2015; Venner et al., 2020). Overall, the importance of the community coming together for social support and cultural connection, and the necessity to find creative ways for this to continue despite multiple public health emergencies, could not be overstated (Herron & Venner, 2023; O’Keefe et al., 2021; Wakhlu et al., 2024).

Limitations must be noted alongside several strengths of the study. While study recruitment was national, ultimately our network was more successful in the Northwest. Partnerships with two Tribal Nations increased the total provider sample to one that is relatively large for qualitative substance use research with AI/AN communities. However, it does limit the ability to generalize findings to AI/AN communities outside of Washington State. Additionally, the sample was primarily urban based, though weighted results were presented to show commonalities and differences between the rural and urban areas. Future work may want to specifically focus on rural communities.

5. Conclusion

Our study highlighted the importance of community voices to understand the impacts of the COVID-19 pandemic on treatment delivery among AI/AN adults during two intersecting public health emergencies. Strengths were highlighted in the programs, primarily trust and community-driven strategies to solve the opioid epidemic. Several policy recommendations were also noted including continued audio-only telehealth, providing telehealth across state lines, more training on delivering quality care through telehealth, and the development of clearer criteria for extended take home medication doses at the federal level. Future policy efforts might continue to assess these factors in improving the total health of AI/AN people beyond the COVID-19 pandemic.

Table 5.

Addressing Complexity

Subtheme	Exemplar Quote
Stay Creative	There was a little exemption of the March before last when COVID broke out. Over the summer, the option was you could meet clients outside if you maintain a six-foot distance. So, a number of us therapists, we had to be super creative, and so we were seeing people in the park. We were going on hikes with clients. (1005)
Privacy Concerns & Considerations	…The other issues of people with kids or pets or other household members. That's another big thing that came up is, you know, you have someone who's attending services and they can't find a private room. Or there's nowhere they can go to have confidentiality or kids, childcare. They're trying to have a session, and they have an infant or whatever it may be. And so just all that stuff, as you probably can imagine, with telehealth, that pops up, I think we've seen just about all of it…” (1025)
Internet Always a Barrier	Some people, the Internet out in the county where they live, they live remotely, and they get horrible Internet. So, if they join on camera, then it’s breaking up, and we can’t hear what they say, and they can’t hear. So, then, for those people, we’ve just elected to have them call in because then it's easier. They can hear everything. We can hear them. …So, having high-speed, reliable Internet for everyone would be a huge, huge thing that would allow better engagement. Because that kind of break up—when your connection’s unstable, it takes a lot of time out of a group, and it makes it really hard to have a fluid conversation and discussion where people feel like they can jump in and give their, like, ‘Well, when I tried this breathing technique, it really helps me when I have a trigger.’ It’s hard to have that, kind of, back and forth when Internet is just really shoddy. (1023)