Centering Culture in the Treatment of Opioid Use Disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board

Abstract

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

1. Introduction

For more than twenty years the opioid overdose epidemic has been a major public health crisis among many American Indian and Alaska Native (AI/AN) communities. Past year rates of opioid misuse were similar between AI/AN 12 years of age or older and non-Hispanic Whites (NHWs; 5.8% AI/AN adult v 4.0% NHWs; SAMHSA, 2018), however, the proportion of opioid overdose (OD) deaths among AI/AN populations is higher than NHWs and variable by state and region (Oluwoye, Kriegal, Alcover, Hirchak & Amiri, 2020). State differences include higher AI/AN adult OD fatality compared with NHWs in Minnesota, Washington, Alaska, and Oklahoma. Additionally, AI/AN adults have higher mortality rates compared with NHWs in both urban (22.1 vs 21.4/100,000) and rural areas (19.8 vs 19.2/100,000; Mack, 2017). AI/AN communities have implemented policy changes and sought better prevention and treatment methods to address the opioid epidemic, including integrating medications for opioid use disorder (OUD).

FDA-approved medications for opioid use disorder (MOUD; e.g., methadone, buprenorphine-naloxone [Suboxone], and naltrexone) are considered best practice treatment (ASAM, 2019; Blanco & Volkow, 2019; McCarty, Priest & Korthuis, 2018). Medications have been shown to effectively reduce all-cause mortality and fatal OD (Larochelle et al., 2018; National Academies of Sciences, Engineering, and Medicine, 2019). Access to MOUD was expanded outside of traditional addiction specialty programs with the availability of buprenorphine and naltrexone in primary care settings.

Recently, AI/AN communities have employed a holistic approach and cultural re-centering of medication-based treatment to increase acceptability among providers and patients (Parkhurst, Burke, Montiel, Davis, & Ritchey, 2018; Tipps, Buzzard & McDougall, 2018). Holistic healing integrates the emotional, physical, spiritual, and mental aspects of each individual instead of taking a primarily biological approach to health and wellbeing (McCabe, 2008). Implementation efforts have highlighted that while research to develop culturally grounded treatments generated from within and by the community based in traditional knowledge, culture, and holistic healing are increasing (Walters et al., 2020), the more common process of culturally re-centering interventions is also necessary and beneficial (Dickerson et al., 2020). Re-centering interventions places the existing evidence-based treatment within the cultural framework, representation, knowledge, or worldviews to increase engagement, acceptability, and positive treatment outcomes among diverse communities (Venner et al., 2022).

In alignment with this approach, Venner and colleagues (2018) highlighted the need to tailor MOUD delivery with AI/AN communities in a culturally responsive manner, based on the integration of Indigenous and Western worldviews, and framed by a healing tradition. For example, if causal models of addiction are different in AI/AN communities, then the treatment model needs to address those causes as well or it will likely be insufficient and invalidating. Some Tribal communities have successfully implemented their own MOUD programs based upon these principles (e.g., Swinomish Tribe’s didgwálič Wellness Center that reduced opioid overdose among tribal members by 50% in one year; https://www.didgwalic.com/), but the need to increase MOUD adoption, implementation and uptake among AI/AN communities remains.

Academic researchers, community partners, and federal funders have increasingly employed community-engaged strategies to address health inequities, such as OUD and OD, among AI/AN communities. Community based participatory research (CBPR) is one example of a best-practice framework for Tribal communities that is collaborative and strengths-based. Use of CBPR has led to improved health and social equity outcomes among AI/AN communities by integrating important conversations and processes around context, partnership, and research methods (Rasmus, 2019; Wallerstein et al., 2010; 2018; 2019). CBPR builds trust between partners, honors multiple ways of knowing, includes reflexive power-sharing, and bi-directional learning (LaVeaux & Christopher, 2009). Principles of CBPR formed the foundation of this research project funded by the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN), a protocol through the Southwest Node.

This project aims to develop an implementation strategy to support the cultural centering of the delivery of MOUD within four geographically diverse partnering AI/AN primary care and addiction specialty organizations in both urban and reservation areas. The research team is comprised of university researchers from various backgrounds including AI/AN and non-AI/AN. During the intervention development phase of the study, a Collaborative Board (CB) was convened to 1) identify key components of a culturally centered implementation intervention, 2) introduce and tailor implementation science strategies, and 3) build partnership with our academic research team for bi-directional learning in achieving the study aims.

In the present paper, we report the proceedings of the first national community engaged collaboration to discuss topics related to culturally re-centering the implementation process intervention (Aim 1) via an initial two-day meeting that brought together the national CB. This extends the literature by identifying areas important to cultural re-centering of the delivery of MOUD with AI/AN clients, as well as methods to engage a CB in this work. Topics discussed during the meeting included: understanding the etiology of addiction from an AI/AN perspective; concepts of wellness, pain, and recovery; best practices for engagement, treatment delivery, and recovery; and integration of traditional practices into healthcare settings. Information gathered during the meeting formed the foundation for ongoing intervention development as the study progressed. Findings may also inform future implementation science for the process of integrating Western and Indigenous knowledge into practice. The components of CBPR identified here to culturally center MOUD among AI/AN may also improve policy for addiction treatment with AI/AN communities, as well as how AI/AN knowledge and practice can expand public health initiatives more broadly.

2. Methods

2.1. Participants and Positionality

The CB was convened to guide the development of a culturally re-centered implementation intervention to increase the delivery of MOUD, as well as inform study methods. Recruitment of the CB occurred over a three-month period. The lead and co-investigators of the study reached out to individuals with diverse experience via personal and professional networks across the U.S. and invited them to become members of the CB. Final membership (N=26) included physician prescribers, behavioral health providers (both AI/AN and non-AI/AN), AI/AN people knowledgeable in traditional healing and worldviews, AI/AN adults who have resolved OUD (e.g., in recovery, lived experience), Elders, AI/AN ethnobotanists, NIDA CTN representatives, AI/AN researchers, and experts in implementation of MOUD and related services with AI/AN adults.

An initial in-person meeting comprised of the CB and research team was conducted over two days at the Indian Pueblo Cultural Center in Albuquerque NM, in October 2019. The university research team was comprised of both AI/AN researchers and non-AI/AN researchers. The core research team facilitated the activities during the two-day event. Although not community members of the areas from which the CB members were drawn, the research team included individuals with many decades of experience in building Tribal partnerships, engaging in Indigenous and health equity research, and CBPR. Some of the CB members had experience with conducting research in partnership with AI/AN communities, CBPR and implementation science, while others did not have a research background. The study was not considered human subjects research by the University of New Mexico IRB and informed consent was not obtained.

2.2. Procedures

The two-day meeting began with an opening song from one of the CB members and was followed by group introductions. The first day included a study overview by the research team and presentations by the Co-Investigators on CBPR methods and members experiences with CBPR, on culturally grounded versus culturally re-centering AI/AN intervention models, and an introduction to implementation science. In alignment with the use of creative facilitated discussion methods employed with Indigenous people (Kading et al., 2019), the World Café method was identified as the best approach to facilitate discussion and presented to members as a “Rez Café.” The World Café is a qualitative facilitation method that allows for a flexible approach to collaborative dialogue, sharing of knowledge, and exploration of opportunities for action-oriented research (Coghlan & Brydon-Miller, 2014). It is a culturally congruent collaborative process that allows for meaning making together, with an invitation for participation through discussion, writing and illustrations. The Rez Café took place on Day 1 and Day 2. On both days, round tables were set up with flipcharts, markers, and voice recorders. Members were split up into eight groups of about 4-5 people each and given 15 minutes to discuss each core question (See Table 1 for a list of guided questions). All tables were assigned a voice recorder as well as a notetaker/host who remained at the same table as CB members rotated to different tables. After each question was read and discussed among members, the meeting facilitator reassigned members to another table/topic initiating exploration of a new question.

Table 1.

Guiding Questions

Q1	What causes people to develop OUD?
Q2	What are AI/AN strengths?
Q3	How can we present traditional ideas of holistic health to people with OUD?
Q4	How can traditional healing practices be integrated into diverse treatment settings?
Q5	What helps people with OUD get better?
Q6	How might traditional ideas around pain be integrated into OUD/chronic pain treatment?
Q7	How can AI/AN people incorporate medications into a holistic approach to wellness?
Q8	How can we best engage people with OUD into treatment?

Mindmaps, a guided discussion process where the question or theme is presented in the center of the flipchart with the ideas generated from the discussion branching out, were utilized to capture responses. AI/AN communities have utilized this facilitated discussion method as a non-linear, culturally appropriate manner for capturing group discussions (Coyhis & Simonelli, 2008); a CB member recommended the method. The process took 60 minutes for four questions on each day. At the end of the Rez Café on the first day, notetakers reported responses to each question to the whole CB. The second day ended with an overview of the Rez Café accomplishments and a summary of discussions paying close attention to the context, connections, patterns, and perspectives shared across questions. The CB meeting concluded with a facilitated discussion regarding CB communication strategies, next steps, and a closing prayer.

Transcribed audio recordings of the discussion were compared with detailed notes and observations to ensure that members’ ideas were accurately and completely documented. A research team member independently reviewed and coded the transcripts and identified initial themes and sub-themes (KS). Themes were shared first with the PIs and university research team and then with the full CB to verify accuracy and discuss interpretation. There were no significant disagreements around the identified themes and sub-themes. After the initial round of review from members of the university research team and the full CB, three additional members of the research team and one CB member then reviewed the transcripts to finalize codes and themes based upon the discussion. At the same time, the three members of the research team and the one CB member identified the most appropriate quotes within each theme and sub-theme (KH, AHV, AV and MN). Final themes were then presented again to the full CB to solicit feedback and confirm interpretation and use of quotes. There were no significant changes requested during the presentation or when the paper was submitted to each CB member for final review. The coding process and the information obtained during it were incorporated into the interpretation and drafting of the results to strengthen ecological validity.

3. Results

3.1. Complex causes of OUD among AI/AN adults

The CB highlighted personal and external factors contributing to OUD, including mental health and the healthcare system structures. At the individual level, stress, depression, and low self-esteem were believed to be the primary factors leading to misuse of opioids (as one CB Member stated, “stress, anxiety, probably…mental disorders…having a mental health comorbidity could be a trigger”). A history of adverse childhood experiences, and trauma generally, were also believed to be primary contributors leading to stress and depression that can then lead to opioid misuse, as well as a lack of social support or loneliness. The CB specifically noted historical and intergenerational trauma as external factors leading to opioid misuse. Members suggested that family cohesion and traditional family practices were eroded by colonization, forced relocation, and other systematic forms of oppression, that could lead to potential impaired functioning. The CB also discussed the impact of stereotyping related to addiction for AI/AN communities. Stereotyping was believed to have resulted in medical professionals targeting and labeling AI/AN people as “addicts.” These stereotypes are stigmatizing and can become internalized and lead to more use. On the other end of the spectrum, it was theorized that drugs have been normalized as a coping behavior in some AI/AN families.

The role of the healthcare system was highlighted as another external factor impacting OUD. It was argued that providers do not deliver adequate information to clients and, once on opioid medications, do not manage clients well. One member described how physical injuries initially treated with opioids may lead to longer term substance use disorders:

I think a lot of people get into it. They’ll have an accident of some kind. They’ll get a pain prescription…oftentimes little bit excessive, or it extends too long. And then I think sometimes the provider realizes…the pain should be…minimum right now, and they either will just abruptly discontinue or not taper. Then people go through withdrawal, and a lot of times people will then either buy pills to try to manage their pain or the withdrawals or turn to heroin…. I think people are often set up for opioid use disorders.

Another common belief is that opioids are viewed as an “acceptable drug” that is not harmful because they are prescribed by medical professionals. A CB member suggested,

The misunderstanding of…dependence that can develop from opiates…some people…feel like if it’s a prescription, that it’s safe. That if it…is from a bottle, it’s not going to become dependent or you’re not going to be as harmed as you’re—as opposed to buying it on the street or from heroin. They’ll take a bunch of pills, not knowing that could actually lead to overdose as well. So, I think it goes back to that…misunderstanding about and the safety of medication.

The CB concluded that physicians have been prescribing opioids with a “one size fits all” attitude, and this in combination with a lack of client knowledge around the addictive nature of opioids has been lethal. Although historically providers may have been over-prescribing opioids to patients, more recent efforts have been made to curtail this at Indian Health Service and other healthcare facilities. The CB believed that continued vigilance around healthcare professionals’ training and attitudes were important to provide quality treatment. A compassionate workforce that does not shame or stigmatize and maintains confidentiality and trust would better engage individuals in treatment.

The initial contact an individual has with a healthcare organization was described as crucial to bridging the potential gap between provider and client (e.g., a client not returning to treatment after the first visit). This includes approaches that might be seen as more client centered, that is accommodating people when they are ready for treatment by allowing walk-ins and flexible schedules. Further, personalization of treatment goals could allow providers to tailor activities (e.g., understand the individuals’ treatment goals both short- and long- term) and increase rapport and collaboration. In addition, the CB emphasized the importance of providers taking the time to learn from programs that are models of care (e.g., successful Tribal treatment programs, medical home model, having a customized menu of options, providing medications on site).

3.2. AI/AN cultural strengths and integration of healing traditions, practices, and holistic approaches to wellness in MOUD

The CB identified many cultural strengths (Figure 1. Mindmap of Cultural Strengths). Family support was described as a unique and specific strength among AI/AN communities, and an additional strength because of ties to clan systems. The CB also identified the individual strengths of men, women, and those who are two-spirited (i.e., both masculine and feminine spirit; same-gender loving). It was suggested that each person has a particular role to play in leadership, family and community connectedness, spirituality, providing resources to their families and relatives, and providing diverse knowledge to the next generation. One CB member stated, “Familial…like knowing about other family members that went through the same thing, or how they survived a similar ordeal, whether it’s addiction to drugs or else alcohol.” Another member stated, “From an individual’s strength to the traditional strengths, spiritual strengths, family, clan, community, tribe, location, any kind of strengths that we can bring to help them in maybe the program aid people better in recovery.” And, finally, someone else summarized: “Broadly: family, social, kind of community networking, religion, spirituality, language, cultural identity.” This highlights the importance for providers to integrate the family as well as individual and community resilience when treating individuals with OUD.

Figure 1.

Mindmap of Cultural Strengths

In addition to strengths to draw from when providing MOUD to AI/AN adults, the CB also discussed a cultural grounding to appreciate and integrate traditional ideas of holistic health with people with OUD. Elders, family, friends, and community may provide support to engage or re-engage with culture. By providing traditional healing practices, forgiveness and humility are shared and allow the nourishment of the “Native spirit.” Spirituality is one cultural connection point. For this to take place, it is important for the person to understand the meaning (e.g., drumming, songs, talking circles): “A spiritual foundation must first be built in order for the context of treatment to be understood and accepted.” Taking the time to sit (e.g., talking circles), drink traditional teas (e.g., cedar water), and discuss what is on someone’s mind help reduce anxiety and promote healing. The incorporation of sweat lodges was provided as another example of a traditional practice that could be integrated: “When you’re sitting in like the lodge…I can’t go into too much detail…that’s what it’s about. Like you are publicly—it’s almost like a form of meditation. There are songs. There are prayers. They have long talks.”

Members pointed out the importance of asking what holistic health means to the individual so that traditional healing methods might be delivered in a way that is specific to the individual. Along with providing opportunities to practice traditional healing, celebrating treatment milestones was encouraged and were remarked on as important dates to celebrate as a rite of passage. Upon the success of these milestones, cultural ceremonies and celebration should occur. Ceremonies and celebrations would vary from community-to-community, so they would need to be contextual and tailored.

The CB was also asked to reflect upon traditional conceptualizations of pain and how this might become a part of treatment. Along with their mainstream clinical treatment, the CB reasoned that by providing a menu of holistic health options within treatment facilities would be a way for AI/AN people to utilize cultural services and enhance the traditional meaning of endurance and pain. If a facility has a space dedicated to traditional healing, this may increase client success in meeting important milestones in their recovery.

One CB member explained it this way: “Through this form of meditation and these long ceremonies you are experiencing pain. You’re facing that pain. Then you’re facing it with people to support you, ‘You’re not going through this alone.’” In addition, people seeking to treat their pain with AI/AN traditional healing practices must believe this form of medicine will work. The Rez café groups discussed the importance of making traditional healing knowledge available in their communities, especially among their youth. It was reasoned that with this process put in place, the belief in and efficacy of traditional healing to combat pain would be high, and as a result, pain could be better managed. There was consensus that Western-based medicines (i.e., opioid analgesics) over emphasized relieving pain and some members viewed this as unsustainable (e.g., increases tolerance). One member stated,

I think pain has been recognized as part of the human experience, and it—and different cultures have different ways of experiencing and expressing that and addressing that. And in the client population that I see, some people feel like pain is something just to be endured, with suffering. Where others are kind of in this learned helplessness where, everything needs a medication for it. So, it’s a wide, very diverse understanding and tolerance of pain.

3.3. Similarities and differences across treatment perspectives

CB members often referred to MOUD as MAT (i.e., medication-assisted treatment). We have therefore included the mindmaps with MAT to remain consistent with what was captured during the discussions. When addressing the question, “How can AI/AN people incorporate medications into a holistic approach to wellness?” the default placement of MAT was at the center of the mindmap. After some discussion between members of one of the breakout groups, a decision was made to place Holistic Wellness in the center of the mindmap (see Figure 2. Mindmap of Centering Wellness in MAT). When the second breakout group started, they placed MAT back at the center (see Figure 3. Mindmap of Centering MAT in Wellness). Subsequent breakout groups continued to add to both versions of the mindmap. This shifting of the placement of Holistic Wellness and MAT resulted in different conceptualizations of treatment. When Holistic Wellness was placed at the center, numerous other concepts were integrated into the center and some of the individual branches became cyclical in nature. Elders, spirituality, teachings and culture were integrated as part of holistic wellness rather than branching out. The Holistic Wellness map was also absent of words that have a more negative connotation (e.g., shame, judgement, stigma).

Figure 2.

Mindmap of Centering Wellness in MAT

Figure 3.

Mindmap of Centering MAT in Wellness

The MAT-centered map highlighted the importance of education and information sharing whereas the Holistic Wellness map highlighted the importance of traditional teachings. The MAT map comprised diverse stakeholders such as Elders, youth, health board, tribal council, key leadership, and the community overall. The Holistic Wellness map highlighted the importance and centrality of Elders and involvement of the family. Although both maps included Elders, culture, spirituality, and Native evidence-based practices, these concepts were either integrated or more centralized on the Holistic Wellness map. Overall, the Holistic Wellness map resulted in more concepts (n=28) being mapped compared to the MAT map (n=17). One of the CB members emphatically summarized the similarities and differences by stating:

There’s no way MAT is going to really work in Native communities in the long-term unless we center it culturally. There’s no way. There’s just no way. Unless we incorporate ceremony and traditional medicine in the form of like plants or whatever, whatever is relevant to those communities, there’s no way it’s going to work for them. I mean that’s my firm belief. [Laughter].

4. Discussion

In this paper, we report the proceedings from a 2-day face-to-face meeting of a national Collaborative Board (CB) which included Elders, cultural leaders, providers, individuals with lived experience, and researchers from over 25 communities, organizations, and universities who were tasked with starting to identify key components to culturally re-center and implement MOUD among AI/AN communities. The research expands implementation science by identifying the process for integrating Western and Indigenous knowledge and practice among AI/AN communities. The CB highlighted many important pieces to consider when culturally centering MOUD among AI/AN communities, primary care, and addiction treatment programs. The quality of the relationship between the provider and client was deemed crucial to enhance trust and reduce stigma. A cultural grounding of MOUD in traditional practices, spirituality, strengths, and a holistic conceptualization of pain were highlighted to further support AI/AN individuals seeking treatment. A broad conceptualization of family was identified as essential to the treatment process to support individuals in their long-term recovery. Addressing trauma and external factors caused by colonization, such as intergenerational trauma, were also noted.

The project utilized an adapted World Café (i.e., Rez Café) methodology to facilitate discussion (Coghlan & Brydon-Miller, 2014). The Rez Café is a unique qualitative facilitation approach that supports CBPR and transformational and collaborative dialogue for action-oriented research. In the present study, it provided an initial landscape for key issues to consider around MOUD and areas that programs might need to focus on. Using this method also highlighted the relationship between key constructs and components (e.g., medicines and medications, family and treatment, areas of stigma and ways that those can be addressed, engaging AI/AN clients). This process outlined the framework in which to develop the implementation intervention. It can be replicated in other research projects to support cultural re-centering of programs among AI/AN communities by identifying areas of importance for cultural adaptation, creating a relaxed and safe space for participation and sharing of ideas among people from diverse backgrounds, and increasing the rigor of the findings through the rich analysis and interpretation of the data from all participants.

The CB participation highlighted the importance of the core tenants of community psychology when conducting research with Indigenous people, including sociocultural competence, empowerment, and reflexive practice. For example, focusing on strengths and enhancing trust between providers and individuals with OUD to increase treatment engagement and retention was emphasized as an important part of cultural tailoring and implementation work. Many AI/AN individuals have a general distrust of Western medicine because of historical trauma and discrimination (Call et al., 2006; Guadagnolo et al., 2009; Simonds, Goins, Krantz, & Garroutte, 2014). This distrust may reduce engagement of stakeholders, affecting retention and access to needed addiction care and services (Dickerson et al., 2010; Evans, Spear, Huang, & Hser, 2006).

In addition to potential mistrust, another barrier to engagement with MOUD may be that traditional AI/AN knowledge and approaches to treating OUD are different from Western medical approaches (Venner et al., 2018). This might be due to Western medicine’s focus on the individual versus the collective, secular versus spiritual, and reductionistic versus holistic types of treatment (Calabrese, 2008). Our results seem to underscore this point, with the importance of family and community and connections to traditional practices and culture consistently mentioned as central to the treatment process. Employing Western evidence-based treatments wholesale has been described as a form of acculturation and assimilation representing further colonization. Therefore, understanding ways in which traditional culture and knowledge can be centered, and delivery of Western medications integrated into AI/AN cultural practices, may help to promote cultural revitalization (Gone & Calf Looking, 2011; 2015).

Another key recommendation from the CB was to make the organizational and service delivery environment welcoming and judgement free (for further ideas in relationship to this see Venner, Felstein, & Tafoya, 2006). Providers need to get to know the individual client and build connections. Considerations around the cultural identity of individuals, for example their interest level in traditional healing, are necessary to avoid a one-size-fits all approach to healthcare delivery (Hernandez-Vallant, Herron, Fox, & Winterowd, 2021). Additionally, decreasing stigma in services was identified as important and has been recommended for improving treatment services elsewhere (Cooper & Nielson, 2017; Crapanzano, Hammarlund, Ahmad, Hunsinger, & Kullar, 2019; Lefebvre et al., 2020). As expressed by the CB, traditional views on pain would be helpful for providers and clients to discuss as a way to de-emphasize opioid analgesic treatment and increase coping focused traditional practices to improve functioning.

To engage people with OUD into treatment, CB members also recommended to include traditional ceremonies such as the sweat lodge or community level healing and spiritual ceremonies. The CB recommended the introduction and use of herbs and traditional medicines to help AI/AN individuals with OUD heal. They highlighted the value of traditional herbs made into teas for pain as well as the social connection these activities create, which help individuals to cope with pain, as well as regain social connections. Recovery celebrations and honoring individuals in their journey was also advised.

Our findings are also in alignment with other efforts to include a holistic approach to MOUD (Indian Health Service, ND). The CB focused MOUD through a holistic wellness lens, underscoring the importance of traditional teachings, the inclusion of elders and involving family. Family was highlighted as a key in the process of healing from OUD. Members talked about the value of family participating in recovery alongside the person with OUD. In AI/AN communities, family is often not limited to the nuclear family but is broadened to extended family and may include people who are not blood relatives (Haozous, Strickland, Palacios & Solomon, 2014). Furthermore, many AI/AN peoples have specific ties to clan systems which may identify a broader scope of relations and social support. Options for integrating family can be as simple as adding a family night to more comprehensive treatment, like family therapy or the Community Reinforcement and Family Training approach (Smith & Meyers, 2007; Venner et al., 2021; Campbell et al., 2015), as well as mutual help groups such as Wellbriety Circles (Wellbreity Movement, 2017).

In addressing the root causes and external factors that have contributed to OUD, the CB specifically and repeatedly mentioned historical trauma and colonization and how these assaults on culture have resulted in AI/AN people feeling disconnected from cultural ways and worldviews, possibly contributing to OUD (Brave Heart & DeBruyn, 1998). The CB identified cultural connection as necessary to address the negative impact of trauma and colonization. Over the past couple of years, the American Public Health Association and the director of the Center for Disease Control and Prevention declared racism as a public health crisis (American Public Health Association, 2020; CDC, 2020). In meetings following the initial gathering, the CB later identified racism as another external factor needing to be directly addressed. It is possible that the CB’s initial remarks around historical trauma and colonization encompassed concepts such as discrimination and racism, but it was not explicitly mentioned in these terms.

The government-to-government relationship between Tribal nations and the federal government also places AI/AN communities in a unique political status, one that is more akin to nationality than racial categorization (Getches, Wilkinson, & Williams, 2004). This is an additional layer of nuance related to sovereignty and ethnicity among AI/AN people that may influence perceptions of race. The recent national mainstream recognition of structural racism as contributing to health inequities among communities of color, may have also helped bring the impacts of racism on health into focus for the CB (Bailey, Feldman & Bassett, 2021).

As part of future directions to address racism within the intervention, we have begun to identify ways to integrate discussion of structural racism into implementation strategies as part of the intervention. The CB has recommended provider education and trainings to destigmatize and improve the understanding of addiction, but also to include information on the history of AI/AN communities and how to be an effective ally. Similar to previous research, increasing cultural humility was suggested by the CB as an important way to build trust and address trauma and racism within organizations and communities, especially as many providers do not identify as AI/AN people (Goforth, 2016; Wendt et al., 2019).

There were limitations of this research that should be noted. The CB members were not representative of the partnering research sites or all tribes, so their recommendations may not reflect the local service ecology or needs of a specific tribal community or urban AI/AN organization. However, CB members were convened from across the US to increase generalizability. Although qualitative methods were utilized to analyze the data, this was not a formal qualitative research study; additional research is warranted. Future research should therefore continue to assess and define ways to center culture when integrating Western interventions with AI/AN communities.

5. Conclusion

The CB identified cultural factors that impact the uptake of MOUD among AI/AN adults in hopes of improving treatment and informing public health and policy. This work contributes an additional lens for our understanding of how MOUD services can be integrated within AI/AN-serving organizations. These results are currently being used to guide the development of a culturally centered implementation intervention to increase the uptake and integration of MOUD across four clinical sites predominantly serving AI/AN clients. The CB’s recommendations also have implications for future implementation studies conducted in partnership with AI/AN communities.