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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: This research was completed in connection with two CTN studies: CTN-0096 and CTN-0118. 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. Related protocols: CTN-0096, CTN-0118

Abstract:

Background: Incorporating American Indian and Alaska Native (AI/AN) traditional practices and knowledge into healthcare can support AI/AN health. Drug overdose deaths disproportionately impact AI/AN communities due to colonization, genocide, historical trauma, discriminatory policies, and under-resourced healthcare. Medications for opioid use disorder (MOUD; e.g., buprenorphine, methadone, naltrexone) are considered the most effective treatment for reducing mortality. Integrating AI/AN cultural practices with MOUD may increase acceptability and uptake of MOUD within AI/AN communities.

Methods: National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) Protocol #0096 (Tribal MOUD) is a two-phase community-based participatory research (CBPR) trial to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities (N = 4 sites). A Collaborative Board (CB) guided intervention development (Phase I completed). A stepped wedge design (two sites/step) allows intervention implementation at all sites and improvements across sites (Phase II ongoing). The primary implementation outcome is the number of consumers with OUD who initiate MOUD in the six months pre-intervention vs. implementation periods; secondary outcomes are MOUD screening and retention (de-identified electronic medical record data). Additional data include organizational predictors (staff surveys) and moderators (consumer assessments) of implementation outcomes; and MOUD intervention acceptability (staff/consumer qualitative interviews).

Conclusions: This is the first study to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities. Implementation science and CBPR are complimentary for co-developing strategies with AI/AN communities to integrate Indigenous and Western best practices, which may ultimately reduce opioid-related mortality among AI/AN peoples and enhance Indigenous community wellness.

Related protocols: CTN-0096

Abstract:

This presentation was delivered as part of a symposium at the 2024 CPDD conference entitled, “Two-Eyed Seeing for Opioid Use Disorder Treatment and Recovery with American Indian and Alaska Native Communities,” moderated by Aimee Campbell and Carmen Rosa. In this section of the symposium, Dr. Patten discussed the development and testing of a novel, moderated, private Facebook group intervention to support AI/AN women in opioid use disorder recovery. The intervention was developed through feedback from key partners and beta tested and refined with AI/AN women in recovery.

Related protocols: CTN-0123

Abstract:

COVID-19 exacerbated the opioid-related poisoning crisis among many American Indian/Alaska Native (AI/AN) communities. There is a lack of research examining the extent of the impact of the pandemic on the delivery of treatment for opioid use disorder (OUD) in this population. In collaboration with an Indigenous Collaborative Board, Tribal leadership and administration, this study, part of CTN-0118, explored AI/AN SUD-serving treatment providers’ experiences delivering treatment for OUD from 2020-2022. Eligible providers (N=25) represented 6 programs and organizations serving Tribal and urban areas primarily in the Pacific Northwest. Two members of the research team independently reviewed transcripts before reaching consensus on a finalized codebook and analysis was informed by a qualitative descriptive approach. Findings indicated providers viewed the changes to telemedicine, medication dosing, and the introduction of mobile services as a positive and increased access to care. Barriers remained, however, including when programs discontinued services and reverted to pre-pandemic policy (e.g., no longer mailing prescriptions). This study highlights the impact of the COVID-19 pandemic and what was perceived as effective in the delivery and sustainment of telemedicine, medications, as well as the continued necessity to provide a menu of treatment and social service options to meet the unique needs of AI/AN communities. Study results may inform future programmatic and organizational systems change among AI/AN communities to enhance access and SUD service engagement beyond emergency response efforts.

Related protocols: CTN-0118

Abstract:

Introduction: American Indian/Alaska Native (AI/AN) communities are more likely to suffer negative consequences related to substance misuse. The COVID-19 pandemic exacerbated the opioid poisoning crisis, in combination with ongoing treatment barriers resulting from settler-colonialism, systemic oppression and racial discrimination. AI/AN adults are at greatest risk of COVID-19 related serious illness and death. In collaboration with an Indigenous community advisory board and Tribal leadership, this study, supported by CTN-0118, explored AI/AN treatment provider perceptions of client-relatives’ (i.e., SUD treatment recipients) experiences during the pandemic from 2020 to 2022.

Methods: Providers who underwent screening and were eligible to participate (N = 25) represented 6 programs and organizations serving rural and urban areas in Washington, Utah, and Minnesota. Participants engaged in audio-recorded 60-90 min semi-structured individual interviews conducted virtually via Zoom. The interview guide included 15 questions covering regulatory changes, guidance for telemedicine, policy and procedures, staff communication, and client-relatives’ reactions to implemented changes, service utilization, changes in treatment modality, and perceptions of impact on their roles and practice. Interview recordings were transcribed and de-identified. Members of the research team independently reviewed transcripts before reaching consensus. Coding was completed in Dedoose, followed by analyses informed by a qualitative descriptive approach.

Results: Five main domains were identified related to client-relative experiences during the COVID-19 pandemic, as observed by providers: (1) accessibility, (2) co-occurring mental health, (3) social determinants of health, (4) substance use, coping, and harm reduction strategies, and (5) community strengths. Providers reported the distinctive experiences of AI/AN communities, highlighting the impact on client-relatives, who faced challenges such as reduced income, heightened grief and loss, and elevated rates of substance use and opioid-related poisonings. Community and culturally informed programming promoting resilience and healing are outlined.

Conclusion: Findings underscore the impact on SUD among AI/AN communities during the COVID-19 pandemic. Identifying treatment barriers and mental health impacts on client-relatives during a global pandemic can inform ongoing and future culturally responsive SUD prevention and treatment strategies. Elevating collective voice to strengthen Indigenous informed systems of care to address the gap in culturally-and community-based services, can bolster holistic approaches and long-term service needs to promote SUD prevention efforts beyond emergency response efforts.

Related protocols: CTN-0118

Abstract:

American Indian and Alaska Native (AI/AN) communities experienced a disproportionate increase in opioid-related poisonings during COVID-19. Availability of treatment, such as medications for opioid use disorder (MOUD) within AI/AN communities, is therefore imperative. We completed qualitative interviews with substance use disorder treatment providers providing services to AI/AN adults to assess the impact of COVID-19 related regulatory changes (e.g., medication dosing) and transitions in services (i.e., telemedicine) that aimed to enhance access to care. This project was supported by CTN-0118.

Related protocols: CTN-0118

Abstract:

The COVID-19 pandemic exacerbated the drug poisoning crisis in American Indian/Alaska Native communities, in combination with ongoing substance use disorder (SUD) treatment barriers resulting from settler-colonialism, systemic oppression and racial discrimination. For similar reasons, AI/AN adults also experienced increased risk of COVID-19 related serious illness and death. In collaboration with an AI/AN Collaborative Board and Tribal leadership and administration, this study, supported by CTN-0118, explored AI/AN SUD treatment providers’ perception of client-relatives’ (i.e., SUD treatment recipients) experiences (e.g. substance use) during the height of the pandemic (2020-2022).

Related protocols: CTN-0118

Abstract:

The purpose of this study, NIDA Clinical Trials Network protocol CTN-0123 was to develop a culturally-tailored American Indian/Alaska Native (AI/AN) women’s Facebook group supporting opioid recovery as an adjunct to medication. Participants were AI/AN women in Minnesota in opioid recovery, interested parties, and a Community Advisory Committee (CAC) of AI/AN women with lived experience, health care providers, and community members.

For the intervention, the study team developed evidence-based content focusing on stress/trauma and substance use, mindfulness, responding to triggers, and supportive community resources. Additional content centered on AI/AN culture was also selected.

Interviews were conducted by two women, then transcribed and coded using content analysis with NVivo software. Results were presented to CAC for further content refinement.

CAC members (n = 10) guided study methods, intervention development, and dissemination activities. 14 AI/AN women (mean age 36.4 years; mean 6.7 months opioid abstinence) and 12 interested parties (7 men, 5 women) were receptive to an AI/AN gender-specific Facebook group, preferring content with AI/AN people and/or text resonating with AI/AN culture (e.g., Native traditions, family, personal stories, historical trauma). Recommendations included (1) protect confidentiality, (2) retain positivity, (3) incorporate resources and exercises to build coping skills, and (4) moderators should be authentic and relatable to build trust.

Conclusions: This approach provides a model for developing culturally tailored, appealing and effective social media interventions to support AI/AN women in recovery from opioid use disorder.

Related protocols: CTN-0123

Abstract:

This is the primary outcomes article for Aim 1 of CTN-0123.

The ongoing opioid misuse epidemic has had a marked impact on American Indian/Alaska Native (AI/AN) communities. Culture- and gender-specific barriers to medically assisted recovery from opioid use disorder (OUD) have been identified, exacerbating its impact for AI/AN women. Wiidookaage’win is a community-based participatory research study that aims to develop a culturally tailored, moderated, private Facebook group intervention to support Minnesotan AI/AN women in medically assisted recovery from OUD. The current study, NIDA Clinical Trials Network study CTN-0123, assessed the preliminary feasibility and acceptability of the intervention in a beta-test to inform refinements before conducting a pilot randomized controlled trial (RCT).

The intervention was beta-tested for 30 days. Moderators were trained prior to delivering the intervention. Study assessments were conducted at baseline and post-intervention. The post-intervention assessments included substance use (self-report and urine drug screen), treatment acceptability, mental health, and spirituality outcomes. We examined intervention engagement patterns using Facebook metrics and qualitatively explored common topics that emerged in participant posts and comments.

Ten AI/AN women taking medication for OUD (MOUD) were recruited (age range 25–62 years). Participants had been in opioid recovery a mean of 15.2 months (SD = 16.1; range = 3–60). The study participation rate (accrued/eligible) was 91%. Nine participants completed the post-intervention survey assessment and eight completed a UDS. Acceptability was high based on the mean treatment satisfaction score (M = 4.8, SD = 0.2 out of a possible 5.0), Facebook group engagement, and positive qualitative feedback. All participants retained at post-intervention continued their MOUD treatment, and none had returned to opioid use.

Conclusions: The beta-test indicated that the Facebook platform and study procedures generally worked as intended and that the intervention was largely acceptable to study participants. The results of this study phase provided valuable insights to inform refinements prior to conducting a pilot RCT to further assess the feasibility, acceptability, and potential efficacy of the intervention.

Related protocols: CTN-0123

Abstract:

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization. The objective of this study, part of CTN-0117, was to examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status.

This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age =18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023.

Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined.

Among the 19 648 participants in the pre–COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days).

Conclusions: In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

Related protocols: CTN-0117

Abstract:

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by substance use disorders (SUDs) and related health disparities in contrast to other ethnoracial groups in the United States. Over the past 20 years, substantial resources have been allocated to NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) to disseminate and implement effective SUD treatments in communities. However, we know little about how these resources have benefitted AI/AN peoples with SUD who arguably experience the greatest burden of SUDs. This review aims to determine lessons learned about AI/AN substance use and treatment outcomes in the CTN and the role of racism and Tribal identity.

The authors conducted a scoping review informed by the Joanna Briggs framework and PRISMA Extension for Scoping Reviews checklist and explanation. The study team conducted the search strategy within the CTN Dissemination Library and nine additional databases for articles published between 2000 and 2021. The review included studies if they reported results for AI/AN participants. Two reviewers determined study eligibility.

A systematic search yielded 13 empirical articles and six conceptual articles. Themes from the 13 empirical articles included: (1) Tribal Identity: Race, Culture, and Discrimination; (2) Treatment Engagement: Access and Retention; (3) Comorbid Conditions; (4) HIV/Risky Sexual Behaviors; and (5) Dissemination. The most salient theme was Tribal Identity: Race, Culture, and Discrimination, which was present in all articles that included a primary AI/AN sample (k = 8). Themes assessed but not identified for AI/AN peoples were Harm Reduction, Measurement Equivalence, Pharmacotherapy, and Substance Use Outcomes. The conceptual contributions used AI/AN CTN studies as exemplars of community-based and Tribal participatory research (CBPR/TPR).

Conclusions: CTN studies conducted with AI/AN communities demonstrate culturally congruent methods, including CBPR/TPR strategies; consideration/assessment of cultural identity, racism, and discrimination; and CBPR/TPR informed dissemination plans. Although important efforts are underway to increase AI/AN participation in the CTN, future research would benefit from strategies to increase participation of this population. Such strategies include reporting AI/AN subgroup data; addressing issues of cultural identity and experiences of racism; and adopting an overall effort for research aimed at understanding barriers to treatment access, engagement, utilization, retention, and outcomes for both treatment and research disparities for AI/AN populations.

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 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the 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 strength-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.

Related protocols: CTN-0096

Abstract:

This is the Results Article for CTN-0044-A-2.

Longstanding disparities in substance use disorders and treatment access exist among American Indians/Alaska Natives (AI/AN). Computerized, web-delivered interventions have the potential to increase access to quality treatment and improve patient outcomes. National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0044 established the efficacy in lowering drop-out rates and increasing abstinence of an interactive, web-based version of the Community Reinforcement Approach (CRA) intervention plus incentives, the Therapeutic Education System (TES). However, TES has not been tested among AI/AN populations. This mixed method acceptability study was conducted at two urban outpatient substance abuse treatment programs affiliated with the Clinical Trials Network; one in the Northern Plains region, the other on the Pacific Northwest. The sample consisted of 40 urban AI/AN, and results found TES acceptable across seven indices (range 7.8-9.4 on 0-10 scales with 10 indicating highest acceptability). Clients gave the highest ratings of acceptability to TES modules that included HIV/STI information, as well as managing triggers that can lead to risky sexual or drug using behavior. Modules receiving lower ratings tended to be those completed earlier; lower rating may reflect features of TES functionality, such as getting comfortable with the interface and answering questions to demonstrate learning to be able to move from one module to the next. Initial, lower acceptable rates, and the relatively low use of the internet of the population at baseline, may indicate that web-based interventions need more comprehensive introduction in this population.

Conclusions: Overall, findings suggest that core TES content is acceptable among a diverse population of AI/AN clients in outpatient substance use treatment. Qualitative interviews suggest adaptation of the TES content specific to AI/AN culture could improve adoption. Additional efforts to adapt TES and conduct a larger effectiveness study are warranted.

Related protocols: CTN-0044-A-2

Abstract:

Community-university teams investigated substance use, abuse, and dependence (SUAD) and related concerns, needs, strengths, and resources in four Washington State Tribal communities as part of National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0033-Ot-3.

One hundred and fifty-three key community members shared their perspectives through 45 semi-structured interviews and 19 semi-structured focus groups. Qualitative data analysis revealed robust themes: prescription medications and alcohol were perceived as most prevalent and concerning; family and peer influences and emotional distress were prominent perceived risk factors; and SUAD intervention resources varied across communities. Findings may guide future research and the development of much needed strength-based, culturally appropriate, and effective SUAD interventions for American Indians, Alaska Natives, and their communities.

Related protocols: CTN-0033-Ot-3

Abstract:

This is the Results Article for CTN-0033-Ot-1 and CTN-0033-Ot-5.

American Indians and Alaska Natives (AI/ANs) experience significant disparities in health status and access to care. Furthermore, only limited data are available on substance use, mental health disorders, and treatment needs for this population. Addressing such disparities and developing culturally relevant, effective interventions for AI/AN communities require participatory research. The Western States Node of the National Drug Abuse Treatment Clinical Trials Network (CTN) partnered with two American Indian substance abuse treatment programs as part of protocol CTN-0033-Ot-5: an urban health center and a reservation-based program to assess client characteristics, drug use patterns, and treatment needs. Data collected by staff members at the respective programs from urban (n=74) and reservation (n=121) clients were compared. Additional sub-analysis examined patients reporting regular opioid use and mood disorders. Findings indicate that urban clients were more likely to report employment problems, polysubstance abuse, and a history of abuse. Reservation-based clients reported having more severe medical problems and a greater prevalence of psychiatric problems. Clients who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems.

Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessments of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AI/AN clients seeking treatment for substance use disorders. In addition to more details about the epidemiology of alcohol and drug use disorders among AI/ANs, there is also the need for more information about the treatment system this population has access to.

Related protocols: CTN-0033-Ot-1, CTN-0033-Ot-5