Continuing Education Activity

Alaskan Natives and American Indians comprise a diverse population with a distinct variation in alcohol and substance abuse rates due to geographic location and tribal affiliation. Alcohol and substance abuse leads to increased morbidity and mortality rates, so prevention and early identification and treatment by healthcare professionals are imperative. This activity describes the etiology and epidemiology of substance and alcohol abuse in Alaskan Natives and American Indians and highlights the importance of treatment by the interprofessional healthcare team.

Objectives:

• Identify both risk and protective factors pertaining to alcohol and substance abuse among Alaskan Natives and American Indians.
• Review the epidemiology of alcohol and substance abuse among Alaskan Natives and American Indians.
• Describe the management of alcohol and substance abuse among Alaskan Natives and American Indians.
• Review how interprofessional healthcare teams can coordinate with other important stakeholders to improve patient outcomes in the Alaskan Native and American Indian populations.

Introduction

Alaskan Natives and American Indians constitute both a diverse and heterogeneous community. Based on the 2010 consensus, this population represents over 560 federally recognized tribes and compromises over 2.9 million people.[1] Additionally, if we include Alaskan Natives and American Indians that also identify with another race, this encompasses over 5.2 million individuals.[1] For centuries, it has been commonly thought that Native Americans have higher rates of alcohol consumption compared to whites.[2] In a statement from the U.S. government report, ethnologist H.R. Schoolcraft declared, “It is strange how all the Indian nations, and almost every person among them, male and female, are infatuated with the love of a strong drink. They know no bounds to their desire”.[2]

One of the shortcomings of many of these statements is examining Alaskan Natives and American Indians as an entire population. In reality, Alaskan Natives and American Indians exhibit many differences within their population, with many tribes having distinct languages, cultures, and customs. These differences also include vastly different alcohol and substance abuse levels, which vary by geographic location and tribe.[1] Thus, studying subgroups of Alaskan Natives and Native Americans and applying data to the entire population is easily susceptible to misinterpretation and overgeneralization.

Etiology

In Alaskan Natives and American Indian populations, environmental and genetic risk factors contribute to substance and alcohol use disorder. Genetically, in respect to alcohol use disorder, some populations of Alaskan Natives and American Indians are less likely than other ethnic groups to carry the protective variation of genes that produce the enzymes to metabolize alcohol, including alcohol dehydrogenase and acetaldehyde dehydrogenase.[3] 

These protective genes are located at specific alleles, including ADH1B, ADH1C, and ALDH2.[3] This causes individuals who consume alcohol to have increased levels of acetaldehyde in their blood. The increased acetaldehyde levels cause increased blood flow, increased heart rate, dizziness, sweating, and nausea, or what is commonly known as a “flushing response.”[3] 

These individuals are often protected from excess alcohol ingestion due to these undesirable side effects that occur with the initial consumption. Alaskan Natives and American Indians are susceptible to the same environmental risk factors for alcohol and substance abuse found in all populations, including a family history of substance abuse, specific personality characteristics, psychiatric comorbidities, gender, and trauma exposure.[1] However, they also experience additional risk factors that are unique to their population. These include the historically documented emotional and psychological trauma that resulted from cultural genocide and the elimination of a cultural group's foundation and core.[1] 

Another factor influencing the rates of alcohol and drug abuse within the American Indian and Alaskan Native populations is their community’s acceptance of recreational substances. Many reservations often capitalize on selling cigarettes and alcohol at a lower cost due to the lower tax rates found on tribal reservations.[1] This allows easier availability and access to these products, decreasing the success rates among individuals who attempt to quit smoking and drinking. Some tribes have enacted strict laws that prohibit the possession and/or sale of alcohol on the reservation to counter this. Another strong protective factor unique to the Alaskan Native and American Indian populations is their deep-rooted sense of family, tribal affiliation, and spirituality. These factors can significantly increase the success rate of substance abuse prevention and treatment.

Epidemiology

Epidemiological data regarding the alcohol and substance abuse rates among Alaskan Native and American Indian populations demonstrate a complex pattern with great variation between the studies. Today, the majority of Alaskan Native and American Indians reside in urban or suburban areas.[1] 

Due to the federal government efforts in the mid-twentieth century, which forced Alaskan Native and American Indian assimilation, many tribes are now dispersed. This makes research and sampling among Alaskan Native and American Indian populations very complicated. The commonly used national probability samples based on U.S. residential patterns have led to skewed results. As a result of this challenge, much of the research performed among Alaskan Native and American Indians is conducted on tribal reservations. It thus is capturing only a small portion of the entire population.[1] 

According to the Tri-Ethnic Center, Alaskan Native and American Indian adolescents demonstrate higher rates of tobacco, alcohol, drug use, and earlier initiation when compared to other adolescents in the United States.[1] The highest rates were documented in those who had dropped out of school and lived within a reservation.[1] In contrast, another study that examined four Alaskan Native and American Indian reservations reported increased thirty-day use of substances among adolescents. However, the increased use was eliminated when the results were stratified by geographic location.[1]

In Alaskan Native and American Indian adults, the same picture of variation between tribal communities and geographic location exists. A joint study published by National Longitudinal Alcohol Epidemiologic Study and American Indian Service Utilization, Psychiatric Epidemiology, and Risk and Protective Factors Project showed Alaskan Native and American Indians who lived in urban or suburban areas consumed alcohol more frequently than those who lived on a reservation. Another study showed that alcohol use rates were lower in Alaskan Native and American Indian adults than other Americans, but among those Alaskan Native and American Indian who did drink, there was heavier episodic use. In Alaskan Native and American Indian adults, tobacco use rates were higher, and drug use rates were found to be equivalent to other American adults.[1]

History and Physical

The history and physical exam findings identified among the Alaskan Native and American Indian populations are similar to the findings among other ethnic groups. Primary care physicians utilize screening tools to identify individuals who may already have an alcohol or substance abuse disorder or individuals who are at increased risk. Two commonly used screening tools are Alcohol Use Disorders Identification Test (AUDIT) and the CAGE-AID questionnaire.[4] 

Screening every individual is necessary because selective screening can result in missed opportunities for intervention. Physical exam findings of substance and alcohol use disorder can be absent or very subtle.[4] Although screening tests are a useful tool, they rely on truthful and accurate reporting from the patient. Subjective screening questions include a history of alcohol and substance use, how often and how much is consumed, any negative health or personal consequences relating to alcohol and substance use, and the impact on their friends and family and other personal and professional relationships. Physical signs and symptoms of excessive or problematic substance use may include a recent weight loss or weight gain, frequent falls or accidents, psychological disturbances, and sleep disturbances.[4] 

Alcohol withdrawal symptoms including tremors and shakes, psychosis, and seizures. Other adverse effects of alcohol abuse can include pancreatitis, fatty liver, and in later stages jaundice, ascites, hepatomegaly, spider angiomas, gynecomastia, and cirrhosis. Specifically, in adolescents, some risk factors that should prompt further evaluation and assessment of alcohol and substance abuse disorder include a drastic change in physical appearance, marked personality change, decreased performance in school or a job, engaging in criminal behavior, or severe psychological instability.[4]

Evaluation

Laboratory testing can help to determine the existence and extent of alcohol and substance abuse. These include urine, blood, saliva, hair, and breath tests to detect substance use. Similarly, physicians can order serum alcohol levels, ethyl glucuronide in the urine, and phosphatidyl ethanol levels in the blood. There is also a myriad of testing options that can help suggest a history of drug or alcohol use.

Chronic alcohol use can cause an increase in liver enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT), with a 2:1 characteristic pattern, respectively. Macrocytic anemia, elevated gamma-glutamyl transferase levels (GGT), and increased prothrombin time are other commonly associated findings associated with alcohol abuse. Health care professionals can use the  Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria to evaluate whether an individual meets the criteria for alcohol and substance use disorders.

Treatment / Management

Alcohol and substance use disorder can have many adverse effects on American Indian and Native American’s health, relationships, and even employment status. American Indian and Alaskan Natives, when compared with non-Hispanic whites, were found to be 41% more likely to seek treatment for alcohol abuse.[5] Motivational Interviewing is an evidence-based treatment that has shown to be effective in treating alcohol and substance use disorders.[6] Motivational interviewing is a patient-focused technique that consists of both a relational and technical approach.[6] 

The relational segment consists of the interviewer establishing a rapport with the patient through compassion, empathy, and accentuation of patient autonomy. The technical approach is designed to allow the patient to discuss their individual motivation for change and reinforce their decision. Motivational Interviewing has been used to treat alcohol and substance abuse disorders because it aligns with Alaskan Native and American Indian culture and values.[6] Other options available for treating alcohol and substance use disorder include cognitive behavioral therapy, group therapy, and various pharmacological therapies specific to the substance being used.

Differential Diagnosis

• Bipolar disorder
• Panic disorder 
• Generalized anxiety disorder 
• Psychosis 
• Mania

Prognosis

Among Alaskan Natives and American Indians who entered an alcohol detoxification treatment facility, seventy-five percent of individuals had successful completion. Alaskan Natives and American Indians who exhibited an older age of onset with first alcohol consumption and longer length of stay in the treatment facility were more likely to achieve successful detoxification. 

Individuals treated for alcohol use disorder who also had a substance use disorder were 50% less likely to complete the detoxification treatment. After detoxification facilities, only 36% of Alaskan Natives and American Indians accepted a referral to another inpatient or outpatient substance treatment program. When comparing genders, women were 38% percent less likely to accept. However, individuals who were facing legal issues were twice as likely to accept a referral. After accepting a referral, only 58% of individuals entered substance abuse treatment programs.[7]

Complications

Many adverse related health events develop due to alcohol and substance abuse. Alaskan Natives and American Indians both experience higher mortality rates from alcohol, chronic liver disease, and drugs when compared to all other races.[1] Premature death rates are also 90% higher for Alaskan Natives and American Indians than for all other ethnic groups in the United States, primarily due to alcohol use.[1] 

Alcohol use disorders among Alaskan Natives also contribute to higher cirrhosis rates, dementia, suicide, homicide, and non-intentional injuries.[8] The leading cause of death for Alaskan Native men is alcohol abuse, and it is ranked the sixth leading cause of death in Alaskan Native women.[8] The alcohol-related death rate was 16.1 times higher among Alaskan Natives than Whites in the United States, according to a study conducted by the Alaska Native Tribal Health Consortium.[8] 

Similar to the variability of alcohol and substance use rates observed among different tribes and geographic locations, there is also variability among the death rates. Indian Health Service areas reported alcohol-related death rates from as low as 18.3/100,000 observed in the Eastern United States to as high as 86.4/100,000 in North and South Dakota.[1]

Deterrence and Patient Education

Alaskan Natives and American Indians can utilize their strong support system, including their family, friends, peers, and the entire tribal community, to help them adhere to their treatment plan. By maintaining a supportive environment and continued dedication to their treatment plan, Alaskan Natives and American Indians can avoid the negative health consequences of drug and alcohol use and decrease relapse risk.

Enhancing Healthcare Team Outcomes

Alcohol and substance abuse is a very complex problem within both the American Indian and Native American populations. One key strategy to reducing alcohol and substance abuse and improving health care outcomes is to develop strong partnerships between interprofessional healthcare team members, tribes, tribal leaders, and academic researchers.[9] 

Through this collaboration, alcohol and substance-related health care disparities can be reduced by future research projects and health care initiatives. Another successful strategy healthcare providers can implement the development of preventative and treatment plans that are culturally based and designed specifically for the unique culture of a particular tribe. Finally, an effort to reduce the cultural and social stigma associated with alcohol and substance abuse is vitally important to helping Native Americans, and American Indians feel comfortable seeking treatment and driving optimal outcomes. [Level 5]