2000 AAAP ANNUAL MEETING Symposium I
Substance Abuse in Native American Populations
Substance use disorders are a substantial problem for the Native American population of the U. S. There are several potential explanations for this including unique genetic, psychosocial, and socio-economic issues. Awareness of cultural issues is critical to the understanding of drug and alcohol abuse in the Native American populations and of great importance in de-signing and implementing effective treatments. Dr. Walker presented data from a prospective, longitudinal study of substance use in American-Indian adolescents. Dr. Fleming reviewed what is known about American-Indian children of alcoholics. Dr. Westermeyer presented data on comorbid psychiatric disorders among Native Americans with addictive disorders.
Symposium Chair: Hugh Myrick, M.D., Medical University of South Carolina, Charleston, SC
American Indian Substance Use: Prevalence, Risk, and Protection
R. Dale Walker, MD, Oregon Health Sciences Center, Portland, OR
This presentation will include a background on prevalence and a look at one longitudinal study following 750 American Indian families who live in the Northwest over an 11-year period with 9 years of data.
There are 41 non-Canadian or Alaskan tribes in the Pacific Northwest that have been there for 15,000 years. For this presentation American Indians (AIs) are defined as people who are descendants of pre-Columbus inhabitants of North America. There are over 550 tribal groups in the U.S. and over 1000 languages for 2.2 million people. Although many are of Asian origin there may have been European and Polynesian migrations as well.
The problems reported by AIs to the Indian Health Service include: lowest life expectancy of any group of people in the Western hemisphere, 6 times the alcoholism, 6 times the tuberculosis, 3.5 times the diabetes, 3 times the accidents, 72 physicians/ 100,000 (U.S.242/100,000), and 60% over 65 live in poverty (U.S. 27%). Additionally, AI adolescent problems include develop-mental disabilities, depression, suicide, anxiety, alcohol/substance abuse, low self esteem, alienation, high rates of running away and school dropout compared to a non-AI sample.
Essentially, AIs have the same disorders as the general population with greater prevalence, greater severity, much less access to treatment, more cultural relevance, and the social context is quite disintegrated within the family.
The study described here began with a sample of 522 youth and 278 women, 248 of whom were the biological mothers of the youth. There is a special focus on 224 family dyads, a two generational prospective longitudinal study of mothers and their children with a normative sample of 5th and 6th graders. The children were 11.5 years-old at the beginning. Eight years later many of the children had moved away from the family. Thirty-four percent of the participants were found to have a history of lifetime alcohol dependence in the mother and 44% in the father.
Prevention with these Indian families should start no later than 5th-6th grades. The concept of gateway drugs is absent in this sample. Use of alcohol and drugs starts at the same time.
Lifetime substance abuse in female adults in this study shows above average alcohol, marijuana and stimulant use and dependency compared to the U.S. general population. AI women drink much like AI men, not like other women. Treatment and harm reduction are strategies to address substance abuse with AI women. In addition, the psychiatric diagnoses in these women include lifetime depression that is dramatically high, and panic disorder that is quite elevated.
Treatment is a multidimensional process including tribes, community, family, and peers. The cultural approach to treatment is broad-based and holistic with inclusion of the unconscious. Useful tools include group therapy, psychopharmacology and "Indian Is" groups—talking about what it means to be an Indian. Cultural sensitivity of the therapist is extremely important in a culturally responsive treatment strategy.
American Indian Children of Alcoholics
Candace M. Fleming, PhD, University of Colorado Health Sciences Center, Denver, CO
There has been a strong focus on the drinker, but the spouse, children, parents, and other family members have long been ignored. I was a child raised in a community that organized itself around the consumption and abuse of alcohol. Although, my parents did not drink, I was exposed to it in my Indian community. I have been able to overcome some deeply felt negative feelings so I am able to work better with my own Indian people.
Rates of alcohol-specific mortality in Indian communities is substantially higher than U.S. averages. But not all American-Indian (AI) communities are the same, e.g., Indian rates of abstinence in some communities exceed U.S. averages. There is also consider-able variation within tribes. Rates of fetal alcohol syndrome (FAS) and alcohol-related birth defects vary among native communities. For example, Navajo: 1.6/1,000; Southwestern Plains: 10.7/1,000 compared to 1.95/1,000 for all U.S. races. Alaskan Natives: 2.1/1,000 – 3.8/1,000. South Dakota Natives: 3.9/1,000. There is some re-cent optimism about FAS due to a national FAS prevention training program for Indian communities targeting school children, women pregnant for the first time, and community members. This training showed a knowledge gain and ease in trans-mission of knowledge to others in the community. However, actual behavior change still needs to be studied. Another example of optimism was a dramatic decline of FAS in a Southwestern Plains community after a change in tribal policy that stopped per capita payments from mineral royalties.
There are some studies that describe experiences of children of alcoholics (COAs). They found that COAs were significantly more likely to come from homes with parental alcohol abuse, divorce, a single parent, and a chaotic family. However, alcohol is not necessarily the cause or the only factor. One study presented evidence of alcohol abuse in 85% of neglect cases and 63% of abuse cases. Another indicated that 52% of the control families’ homes (no evidence of child abuse or neglect) were reported as also alcohol abusing, showing multiple factors at work.
Studies of COAs who witnessed domestic violence showed that alcohol dependence is a significant risk factor for both perpetrators and victims of domestic violence in a Navajo sample. AI women in a New Mexico study were shown to be significantly more likely to be victims of domestic violence homicide than women of other ethnic groups. Studies in the general population have documented that
COAs are at increased risk of developing alcohol problems. Although there are no studies with AIs, it is also likely to be true for them.
There are a different group of protective factors applicable to AI children compared to children from other groups. The family appears to have much more enduring influence for AI youth rather than peers. So, interventions should focus on both family and peers, but with an emphasis on family.
Some studies with AI adult children of alcoholics (COAs) showed that drinking parents can be fun in good times. However, in bad times violent conflicts result in fear and anger, children left to care for themselves, and children taking on adult responsibilities at an early age. Studies describe conditions in which children do not develop a healthy sense of self in relationship to others, and their sense of power and dependency become skewed.It is also important to look at the clinical literature on COAs, although very little has been written for AIs. Some twelve-step work has been done and there is a slow movement toward the integration of mental health and substance abuse. Ten years ago the National Association of Native American Children of Alcoholics (NANACOA) was founded. Also, the concept of the dysfunctional family seems to resonate with some Indian groups. Other factors to address are loss and grieving and the concepts of family roles and boundaries. In addition, factors such as trauma and stress are family and tribe-specific and need to be considered in that context.
Policy implications for Indian COAs include: 1) addressing basic research about what Indian COAs need, 2) increasing treatment options for the family, 3) examining and debating the issue of criminalization of drinking during pregnancy, 4) placing children in foster care with extended family members who are not abusing, 5) meaningfully involving Indian culture in prevention and intervention, and 6) increasing tribal support of sobriety and responsible drinking.
In recent years there has been an increase in the celebration of native resiliency. There is a healing and wellness movement abroad, which breeds hope for the future of increasing health in Indian communities.
Comorbid and Other Psychiatric Disorders Among Native Americans
Joseph J. Westermeyer, MD, PhD, VA Medical Center, Minneapolis, MN
Background: In the last decade the early census data suggests there has been a 30% increase in the number of American Indian (AI) people in the U.S. The average age three decades ago was in the low 40’s, now it is in the low 60’s and the education level is improving. However, new or formerly unrecognized problems are now occurring. Fetal alcohol syndrome (FAS) is one of them. There are enough instances of FAS and other consequences of alcohol that the leadership of tribes at least in the Upper Midwest is focusing on solutions. One way is going back to abstinence, an ethic that is beginning to develop. Another is religion, which like disulfuram, provides an excuse not to consume alcohol in response to the considerable pressure to drink. Other solutions involve some political and community changes which bear watching and describing. Also, more young AI people are serving as positive role models. Information is spreading regarding alcoholism as a disease and what can be done to treat and prevent it.
Method: The study being presented involves the mainly Woodlands people. Most were the people the English called Chippewa; the French called them Ojibway; and they refer to themselves as Anishinabe. Others in the group were called Sioux by the French and called themselves Lakota or Dakota. All of the people in the study were veterans. The study was funded by the Veterans Administration (VA) and started with an open ended set of questions asked in community settings, rather than in the VA. The idea was to find out why they were or weren’t using the VA. A previous national study had shown that the rates of post traumatic stress syndrome and alcoholism were high, but the veterans were not actively seeking treatment. Interview, paper and pencil questionnaires, and computer-based algorithmic questionnaires were used.
Findings: Three groups of veterans, totaling 668, were compared as follows:
Half were rural and half urban. Those with lifetime SUD or current SUD had high scores on the Michigan Alcohol Screening Test (adapted to include drugs). In all three groups rates of PTSD were high. Major depression and anti-social personality disorder occurred more often among those with lifetime SUD or current SUD. Many of these veterans with lifetime (but not current) SUD have success-fully sought and used treatment. However, among those with current SUD, many had used some form of treatment in the last year (seldom the VA) but it appears that many are not actually recovering despite treatment.Study findings that undermine old stereotypes include:
Sober pow-wows, AI half-way houses, and other treatment designed for AI people (e.g., traditional sweat lodges) are now available.
The veterans in this study described barriers to using the VA that included too many forms, complicated bureaucracy, and distrust. They also recommended that there be outreach to people by an AI person they know and trust and emphasis on getting people into treatment before they have lost their family and jobs.
Recommendations: These are based on experiences with AI patients in the North Central area of the U.S. and include facilitating early access to treatment; hiring AI staff in majority programs; providing halfway houses for AI men with access to work and AI women with facilities for children; maintaining AIs in care may be enhanced by presence of AI staff; recognizing psychiatric comorbidity by using interview and evaluation; using special cultural modalities as warranted, e.g., sage, sweat lodge, American Indian Church, sober pow-wows, healing ceremonies, vision quest, "Indian AA"; and reducing stigma of psychiatric evaluation/care.
2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP