Content Analysis of Preferred Recovery Pathways Among Urban American Indians and Alaska Natives Experiencing Alcohol Use Disorders

Abstract

Approximately three fourths of the American Indian and Alaska Native (AI/AN) population lives in urban areas, and urban AI/ANs are disproportionately affected by alcohol-related morbidity and mortality. Although no studies have documented alcohol use disorder (AUD) treatment outcomes specific to urban AI/ANs, studies in other Native communities highlight concerns about the cultural acceptability of directive, abstinence-based approaches, such as cognitive behavioral therapy and 12-step programs. Understanding this population’s desired recovery pathways in their own words may help providers create more culturally appropriate, patient-centered, and effective approaches. Participants ( N = 31) were urban AI/ANs who screened positive for AUD using the AUDIT-C. They participated in semi-structured interviews eliciting their experiences in AUD treatment to date and suggestions for redesigning AUD treatment in their own vision. Conventional content analysis was used to create a thematic description. Findings indicated that intrinsic motivation and not extrinsic pressure (e.g., mandated treatment) was associated with positive treatment engagement and outcomes. Participants appreciated feeling safe and supported in AUD treatment, but also felt AUD treatment could be institutional and oppressive. Participants preferred compassionate counselors with lived experience who could provide insights into recovery; they largely did not appreciate a “tough love” approach or power struggles with counselors. Native-led treatment centers providing access to cultural practices were preferred. Moving forward, participants suggested AUD treatment providers should help patients meet basic needs, prioritize patient-driven versus provider-driven goal-setting, support patients’ reconnection with meaningful activities, facilitate access to a supportive community network, and recognize cultural activities as important recovery pathways.

Commentary: Similarities and Differences Between Harm-Reduction and Substitute Addiction-- Implications for the Health Professions

“…That said, quantitative and qualitative research has indicated that many of these sufferers will simply not present for abstinence-based treatment, even when facing external coercion (Center for Behavioral Health Statistics and Quality, 2022; SAMHSA, 2019). Alternatively, they may attend but are turned away by providers due to intoxication, or can't engage authentically in treatment programming that requires commitment to abstinence, will leave treatment early, and/or complete treatment but relapse shortly thereafter (Collins et al, 2012(Collins et al, , 2016Crabtree et al, 2018;Nelson et al, 2023;Orwin et al, 1999), compounding medical risks such as the worsening "kindling effect" observed in the case of alcohol withdrawal (Becker, 1998). In contrast, for those providers who work primarily with nontreatment-seekers who are severely impacted by substance-related harm (e.g., people experiencing homelessness in community-based settings such as shelters), only 5% of whom are interested in abstinence (Fentress et al, 2021), providers must partner with these potential service users ("meet them where they are at") if they hope to be helpful.…”

A pilot study of virtual Harm Reduction Talking Circles for American Indian and Alaska Native adults with alcohol use disorder

“…AI/AN people have reported experiencing structural (e.g., lack of time and transportation) and motivational (e.g., not wanting to stop drinking) barriers to treatment (Haeny et al, 2021; Venner et al, 2012). Research has also highlighted concerns about the cultural acceptability of directive, Western, abstinence‐based approaches and the corresponding need for more research on lower‐barrier, patient‐centered and culturally grounded (i.e., derived from the beliefs and values of a specific culture) AUD treatments (Blume, 2021; Donovan, 2015; Nelson, Collins, et al, 2023; Venner et al, 2019).…”

“…In phase 1, our research team conducted (a) interviews with 31 urban AI/AN patients with AUD, (b) key informant interviews with six management and traditional health professionals, and (c) five staff and provider focus groups. In these forums, we asked participants about AUD treatment they had experienced or administered to date, suggestions for its revisioning, perceptions of harm reduction, interest in Talking Circles as a means of community‐led and culturally grounded healing, and ideas to tailor the HaRTC and AUD treatment more broadly to meet the needs of AI/AN patients (Nelson et al, 2022; Nelson, Collins et al, 2023).…”