ATTC Messenger October 2016 Expanding Access to Medication-assisted Treatment in Native Communities
Expanding Access to Medication-assisted Treatment in Native Communities
Traci Rieckmann, PhD
Director, Northwest ATTC
Robin Baker, MS
Doug Novins, PhD
Laurie Moore, PhD
Health providers in the United States underutilize one of the best available tools for the treatment of substance use disorders (SUDs). Medication-assisted treatment (MAT), the use of medications that have been shown in research to reduce the likelihood of individuals with SUDs to experience a relapse, is well documented as an effective means of helping SUD patients.
The high rates of SUDs among American Indians and Alaska Natives (AI/ANs) is a longstanding concern (SAMHSA, 2012). Almost three times as many AI/ANs were classified with substance dependence or abuse compared to Caucasian Americans (21.8% and 8.7%; (SAMHSA, 2013)) and the percentage of AI/ANs who require treatment for alcohol or illicit drug use is almost twice that of other races/ethnicities in the United States (17.5% and 9.3%, respectively (SAMHSA, 2012). AI/ANs also have the highest rate of alcohol-related deaths among ethnic groups in the United States (Beals, et al., 2005, Ehlers, et al., 2008), with age-adjusted rates reported as three times greater than among Caucasians (Landen, et al., 2014). AI/ANs commit suicide at a 60% higher rate than all other races/ethnicities, and 47% of these are associated with alcohol and drug use (Landen, et al., 2014). These problems are not only individually devastating, but also crippling to AI/AN communities that struggle with lingering historic cultural trauma, high rates of poverty (CDC, 2014), greater prevalence of mental and chronic health disorders (Nelson & Nelson, 2013), and limited access to quality health care (Novins, et al., 2011).
Multiple factors—historical, political, and economic—underlie these high rates. Approximately half of all AI/ANs earn less than 200% of the federal poverty level compared with one-quarter of Caucasians (James, Schwartz, & Berndt, 2009). Socioeconomic disparities influence quality of life, educational attainment, health status, and health care choices, creating a significant challenge for many AI/ANs. Other contributing factors include limited access to skilled, culturally competent providers and comprehensive services (Brooks et al., 2013; Hoge et al., 2013). Finally, AI/AN communities are impacted by cross-generational emotional and psychological trauma from colonization, forced assimilation, relocation, genocide, and ongoing discrimination, which can contribute to dependence and addiction (Gone & Trimble, 2012).
The need for culturally appropriate evidence-based practices
The National American Indian and Alaska Native ATTC
The National American Indian and Alaska Native ATTC September 2016 newsletter focuses on the opioid epidemic in tribal communities. Click here to access the newsletter.
The National American Indian and Alaska Native ATTC strengthens and promotes systematic behavioral health practice changes that both honor and contribute to the health and well-being of AI & AN communities, tribes, and individuals.
For more information,visit the
National American Indian and Alaska Native ATTC website.
In considering these troubling statistics, it is important to note that AI/AN communities are not monolithic. Rates of SUD occurrence vary across tribes and between urban and reservation geographic locations (Radin et al., 2015).The majority of AI/AN communities and reservations are located in rural areas with limited access to specialized services and physicians with cultural competency training (Brooks et al., 2013). Yet although both rural and urban AI/AN communities struggle with inadequate access to and funding for mental health and SUD services, the challenges often are more acute in rural and reservation communities that lack qualified health care professionals. And the strong sense of kinship obligations that many AI/ANs feel for others in their communities (Gone & Trimble, 2012) means that in some of these communities virtually everyone is affected by the tragic impacts of SUDs. Complicating this is that the treatments available in many AI/AN communities are perceived as ineffective, prompting many AI/AN communities and researchers to question the efficacy of western approaches to treatment in AI/AN settings. Evidence-based practices, such as MAT, could potentially improve services, but AI/AN treatment programs and researchers have raised concerns regarding the cultural appropriateness and even applicability of evidence-based practices to AI/AN populations.
Indeed, research suggests that successful treatment and recovery should include accessible, person- and family-centered care with skilled and compassionate providers working in programs that embrace traditional tribal culture (Radin et al., 2015).The cultural trauma and the strong kinship obligation in many AI/AN communities make it imperative that interventions be culturally adapted to foster a reattachment to traditional AI/AN values that can serve to simultaneously address cultural trauma and treat alcohol and other drug dependence and abuse. Unfortunately, how to blend these approaches with evidence-based treatments, including MATs, is not well studied.
Medication-assisted Treatment (MAT)
Several medications are available to help patients achieve abstinence and prevent relapse (Comer, et al., 2006; Krupitsky, et al., 2011; Minozzi, et al., 2006; O’Malley, et al., 2007; Syed & Keating, 2013; Rosner, et al., 2010). The most common medications for treatment of opioid use disorders are methadone, buprenorphine, and naltrexone. Methadone and buprenorphine both mimic the effects of endorphins (opiods that we naturally produce) and reduce cravings and withdrawal symptoms without producing feelings of euphoria (Amato et al., 2011; Barnett et al., 2001). Naltrexone blocks the opioid receptors in the brain and prevents opioids from attaching to the receptors, which reduces the pleasurable effect of opioid drugs.
Research suggests that successful treatment and recovery should include accessbile, person- and family-centered care with skilled and compassionate providers working in programs that embrace traditional tribal culture (Radin et al., 2015).
The most common medications for treatment of alcohol dependence and abuse are naltrexone, acamprosate, and disulfiram. Just as it does for opioids, naltrexone blocks the effects of alcohol and has been shown to reduce heavy drinking days. Acamprosate reduces the physical and emotional distress that may occur in the weeks and months after alcohol consumption stops. Disulfiram interferes with metabolizing alcohol, resulting in adverse side effects such as flushing, nausea, chest pain, breathing difficulty, headache, confusion, and blurred vision, which occur if an individual drinks while taking this medication (NIAAA, 2008). Cost varies across these different medications and must be considered when weighing treatment options. Nevertheless, MAT in combination with therapy and other supports is considered the gold standard in the treatment of substance dependence and abuse. Indeed, both policy documents (ASAM, 2014; CMS, 2014) and treatment guidelines (ASAM, 2015; SAMHSA, 2009; WHO, 2009) emphasize the importance of providing access to MAT for individuals in SUD treatment.
Barriers to greater use of MAT
Despite the evidence that MATs are an efficacious treatment option for substance dependence and abuse (Ducharme, Fraser, & Gill, 2007; Jan, Gill, & Borawala, 2011), utilization is limited in the U.S. Economic pressures, both in terms of individual access to care (coverage, transportation, time, and knowledge of treatment needs and options) and systems-level resources and infrastructure (available providers, clinics, and services) prevent many individuals from accessing care. Stigma also serves as a barrier to greater use of MATs (White, 2012). Individuals, family, friends, and caregivers are potential sources of stigma, but these biases are most problematic when they arise from providers (Wu, et al., 2011). Some physicians hold negative views towards the use of MAT because of their specialty training or their misperceptions about how well MATs work (Knudsen, Abraham, & Roman, 2011). In such cases, patients might not receive any information from their providers regarding MAT options (Woods & Joseph, 2012). A lack of qualified physicians and highly trained substance abuse professionals generally only exacerbates the situation (Abraham et al., 2013). Research also suggests that counseling staff members who have attained higher education levels (such as a master’s degree or higher) are more supportive of using MAT (Rieckmann, et al., 2014; Abraham, et al., 2010).
Unfortunately, very little research has been conducted on the use of MAT in AI/AN communities, and there is a total paucity of literature regarding best implementation strategies for MAT in AI/AN communities. Examining, documenting, and sharing experiences of clinics serving AI/AN persons would be a valuable next step for the field.
MAT utilization in AI/AN communities
While there are barriers for MAT utilization across the nation, barriers that limit uptake in AI/AN communities are often even more difficult to overcome (Hoge, et al., 2013; SAMHSA, 2007). The University of Colorado and Oregon Health and Science University partnered on a three-phase project that involved an expert advisory board review, qualitative program case studies, and a national survey of AI/AN substance abuse treatment programs. Specific aims included describing the use of specific evidence-based treatments in substance abuse treatment programs serving AI/AN communities; describing the factors associated with the implementation of evidence-based treatments in these programs; and identifying methods for more effective dissemination of evidence-based treatments to substance abuse treatment programs serving AI/AN communities. Analysis of data from the national survey of treatment programs that serve AI/AN communities indicated that only a quarter of them offered MAT (Rieckmann, et al., 2016).
Limited resources in rural communities, a history of marginalization, and a lack of interventions for substance abuse that are designed by AI/AN community members have served as barriers to accessing evidence-based treatments. This is especially relevant in the use of MAT where the empirical support for the treatment is profound but the use with AI/AN clients is limited. Based on the literature the following recommendations could increase access to MAT in programs serving AI/AN communities.
- Providers, investigators, and staff in behavioral health settings should be informed about the impact of cross-generational cultural trauma.
- Researchers and providers should also collaborate with tribal leaders to ensure that the programs embrace and support traditional tribal values. Allowing tribal advisers to embrace MAT independently based on evidence would create a sense of ownership in the program and prevent resentment for having been forced to adopt new treatment practices.
- Trainers and providers should engage in outreach and disseminate information about MAT and the role it can play in supporting and facilitating recovery.
- Administrators, providers and investigators should seek to hire staff and providers who identify as AI/AN and ensure that all are trained in how to support substance abuse treatment programs in delivering culturally informed care.
Further research on the effectiveness and adoption of MAT in AI/AN communities that experience high levels of SUDs is critical. Researchers should be encouraged to partner with programs serving AI/AN communities as well as tribal leaders and individual AI/ANs. In the meantime, programs on the ground should seek to increase access to the most promising practices in addiction treatment, balancing the importance of evidence-based practices such as MAT with the importance of ensuring that treatments options are culturally informed.
The National American Indian and Alaska Native ATTC
Upcoming webinars from the National American Indian and Alaska Native ATTC:
One important resource is the National American Indian and Alaska Native Addiction Technology Transfer Center (ATTC). This group of researchers and trainers is dedicated to bolstering behavioral health changes that honor and contribute to the health and well-being of AI/AN communities, tribes, and individuals. Situated at the University of Iowa, the National American Indian and Alaska Native ATTC provides webinars and training for behavioral health and addiction treatment specialists in a way that draws upon the diverse and unique cultures, ceremonies, customs, and teachings of AI/ANs. For more information, visit the National American Indian and Alaska Native Addiction Technology Transfer Network website.