SUBSTANCE ABUSE PREVALENCE AND TREATMENT UTILIZATION AMONG AMERICAN INDIANS RESIDING ON-RESERVATION

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1 SUBSTANCE ABUSE PREVALENCE AND TREATMENT UTILIZATION AMONG AMERICAN INDIANS RESIDING ON-RESERVATION Mindy Heman-Stahl, Ph.D., and Jenny Chong, Ph.D. Abstact: Ameican Indians esiding on-esevation wee inteviewed egading thei substance use and teatment utilization. One-thid had a cuent substance abuse poblem. Pedictos included gende, tibe, age, employment status, household income, and educational attainment. Almost two-thids of those with substance abuse poblems had eceived no teatment within the past yea. A combination of fomal and infomal teatment was the most common appoach. Teatment utilization was pedicted by gende, age, and insuance coveage. Planning fo substance abuse pevention and teatment sevices among Ameican Indians living on esevation is a fomidable task. While numeous steeotypes of Ameican Indian dinking pattens have polifeated, actual eseach has lagged behind in suppoting o efuting these assumptions (May, 1994). Anecdotal infomation attests to seious alcohol abuse poblems on esevations. In a suvey of ove 60 Ameican Indian esevations, 70% ated substance abuse poblems among the top thee health pioities (McKenzie, 1994). Howeve, little empiical evidence exists about the tue level of need among this population. In the absence of up-to-date studies, public health specialists have elied on measues of motality and mobidity. These measues indicate that alcohol abuse is a majo facto in five of the ten leading causes of death among Ameican Indians, and data suggest that 17% to 19% of all Ameican Indian deaths ae alcohol-elated. Ameican Indians suffe dispopotionately fom alcohol-elated accidents, cihosis of the live, homicide, and suicide (Indian Heath Sevice [IHS], 1996). Analysis of Indian Health Sevice (IHS) sevice aea data indicate that the Ameican Indian age-adjusted motality as compaed to all othe aces was 465% geate fo alcoholism, 184% geate fo accidents, 46% geate fo suicide, 1

2 2 VOLUME 10, NUMBER 3 and 39% geate fo homicide (IHS, 1996). While these data ae alaming, they should not be used to popagate moe steeotypes of Ameican Indian dinking. May (1994) assets that the motality ate also may be inceased by chaacteistics of ual living such as highe-isk envionments, distance to medical cae, less fequent use of seatbelts, and lowe access to health sevices. In fact, seveal studies have shown that the popotion of nondinkes is highe among Ameican Indian adults than the geneal population (May, 1989). Howeve, among Ameican Indians who do dink, the popotion of poblem dinkes appeas to be much geate than the geneal population, and Ameican Indian dinkes ae moe likely than non-indian dinkes to dink lage quantities, suffe blackouts, and expeience a highe popotion of alcohol-elated poblems (May, 1994). This is tue fo Ameican Indian youth as well, who have been found to initiate dug use ealie, dink heavie, and suffe fom moe negative consequences fom dinking (Beauvais, Oetting, & Edwads, 1985). Conducting lage-scale, epesentative suveys of Ameican Indians esiding on esevation is difficult. The few that have been published ae quite dated (Roy, Choudhui, & Ivine, 1970; Sampath, 1974; Shoe, Kinzie, Hampson, & Pattison, 1973). Howeve, in 1988 a eplication of one of the oiginal psychiatic epidemiologic suveys was conducted (19 yeas afte the oiginal study) by Shoe and colleagues in the same Ameican Indian village (Kinzie, et al., 1992; Leung, Kinzie, Boehnlein, & Shoe, 1993). Although ates of alcohol abuse and dependence as well as othe psychiatic impaiments had fallen ove the yeas, the pevalence of alcohol use disodes was still stikingly high with thee-quates of the men (ove age 20) and 39.4% of the women having a lifetime alcohol use disode. Lifetime pevalence ates fo alcohol use disodes wee moe than 3 times highe than those fo the geneal population found in the Epidemiologic Catchment Aea (ECA) study (Regie et al., 1988). Point pevalence estimates fo alcohol wee 36.4% fo men and 7.0% fo women. Rates wee similaly high in a study of almost 2,500 Ameican Indians esiding on nine diffeent esevations in South Dakota: appoximately 30% wee found to be in need of substance abuse teatment (Bay, Dalbeth, Heman-Stahl, Walke, & Sanchez, 1999). A coss-sectional study compaing the CAGE to the Diagnostic and Statistic Manual Thid Edition-Revised (DSM-III-R) found that 85% of men and 53% of women had lifetime diagnoses of alcohol dependence as assessed by the DSM-III-R (Saemi et al., 2001). Anothe epidemiologic suvey on alcohol abuse and dependence found that 51% of Ameican Indians living in thee diffeent esevation communities (including Pueblo, Plains, and Plateau cultues) had poblems with alcohol. Men, young adults, and the unmaied had the highest ates of alcohol poblems. Beeaved individuals and those expeiencing high degees of stess wee also moe pone to alcohol disodes (Manson, Shoe, Baon, Ackeson, & Neligh, 1992).

3 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 3 While alcoholism among Ameican Indians has been much discussed, little attention has been paid to emeging dug poblems. Data on dug poblems among Ameican Indian adults is scant, although thee is available infomation on the pevalence of illicit dug use among adolescents. Beauvais and Oetting and thei colleagues at the Ti-Ethnic Cente fo Pevention have extensively studied the pattens of alcohol and dug use among Ameican Indian youth (Beauvais, 1992a). They found that dug use was highe among Ameican Indian youth than thei non- Indian countepats. Rates of lifetime use wee paticulaly high fo maijuana (83% vs. 35%), cocaine (23% vs. 6%), stimulants (37% vs. 12%), and hallucinogens (27% vs. 4%) (National Institute on Dug Abuse [NIDA], 1995). These data highlight the potential poblems of dug use on esevations but do not povide any accuate indication of the numbe of adults who have dug abuse poblems. Because ates of alcohol-elated poblems appea highe among Ameican Indians, infomation egading access to teatment, paticulaly fo those living on geogaphically isolated esevations is citical. Thee ae numeous baies to accessing and eceiving qualified substance abuse sevices on esevation. Results fom the National Medical Expenditue Suvey demonstate that Ameican Indians encounte longe tavel and waiting times and thus make fewe appointments fo health cae sevices in geneal (Beauegad, Cunningham, & Conelius, 1991). Resouce constaints, managed cae, distance, and convesion to tibal compacting have all complicated the sevice delivey system (Manson, 2000; Noen, Kindig, & Spenge, 1998). Common baies identified in a suvey of Native Ameican Health Pogams (McKenzie, 1994) included limited access, limited availability of specialty consultation, cultually insensitive sevices, inadequate data systems, confusion egading eligibility, and incomplete infastuctue development. Moeove, Ameican Indians esiding in uban aeas with no cultually competent teatment pogams often etun to esevations thus daining the esouces available fo those esiding on-esevation (Cente fo Substance Abuse Teatment [CSAT], 1999). The types of teatments sought by Ameican Indians may diffe as many seek a moe holistic appoach to teatment that incopoates taditional values, beliefs, ceemonies, and pocesses (CSAT, 1999). Taditional healing is an impotant mental health esouce and many Native heales ae active in Ameican Indian communities although utilization of heales is geneally a pivate matte (Abbott, 1998; Nelson, McCoy, Stette, & Vandewagen, 1992). The pupose of this study is two-fold: (a) to povide igoous data egading the level and coelates of substance abuse poblems among Ameican Indians on esevation in Aizona; and (b) to examine the fequency, chaacteistics, and coelates of substance abuse teatment

4 4 VOLUME 10, NUMBER 3 utilization among esevation-based Ameican Indians. Ameican Indian s utilization of both fomal and infomal teatment, including taditional methods of healing will be assessed. Method Backgound In an effot to impove the quality of infomation used in planning state substance abuse teatment sevices, the Cente fo Substance Abuse Teatment (CSAT) initiated a seies of equest fo poposals (RFP) to povide funding and technical assistance to state public health officials inteested in collecting igoous data to infom substance abuse policy and planning decisions. In Septembe 1994, the Aizona Depatment of Health Sevices eceived funding to conduct studies thoughout the state to detemine the pevalence of substance abuse and dependence and the need fo teatment. Ameican Indians compise 5-6% of the total population in Aizona and thee-quates of them live on esevation land. Resevations located in counties with high indicatos of substance abuse (e.g., alcoholelated motality, mobidity, and taffic accidents) wee selected to paticipate. These poxy indicatos wee used since thee wee no esevation-specific indicatos available. Befoe the study was conducted, appoval was obtained fom tibal councils, as well as tibal health depatments and esevation-based substance abuse teatment centes. Pesentations to the tibal councils egading the pupose and benefits of the study, as well as the citical need fo such infomation on the esevation wee made. The tibal councils of all thee esevations appoved paticipation. The next step was to fom community-planning committees involving pesons fom vaious agencies connected to issues of substance abuse in ode to ensue that the study was conducted in a cultually sensitive fashion and addessed issues of pimay concen to the community. Data Collection Data wee collected by tained community membes on each esevation. All inteviewes wee Ameican Indian and accepted membes of the community. Inteviewes wee ecuited though seveal methods: ecommendations by membes of the planning committee, advetising though wod of mouth, and ecommendations by othe eseaches who had tained and employed Ameican Indians fo othe studies conducted on the esevations. All inteviewes conducted face-to-face suveys using laptop computes. Seveal days of taining wee conducted to teach

5 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 5 inteviewes compute-assisted pesonal inteviewing (CAPI) and to incease thei knowledge of substance abuse and teatment and efeal issues. Inteviewes wee fully tained on potection of confidentiality since fea of lack of confidentiality was thought to be the majo eason inhibiting paticipation. No infomation about compomised confidentiality was eve tansmitted back to the eseaches o, to ou knowledge, the tibal council o paticipating agencies. Futhemoe, no inteviewes wee dismissed fom the study due to inappopiate o unethical actions. Taines monitoed inteviewes within the fist seveal weeks of taining to povide constuctive feedback and ensue quality contol. Monitoing continued thoughout the data collection peiod. The majoity of inteviews (90%) wee conducted in English although seveal inteviewes wee bilingual (to thei Native language) and in some cases, paticulaly when inteviewing eldes, inteviewes switched between English and the Native language (8.6%). Ten inteviews (1.4%) wee conducted pedominantly in the Native language. Key wods wee tanslated and povided to inteviewes to pomote standadization in cases whee Taditional language was inseted. Sampling Because substance abuse poblems did not appea to concentate in specific aeas of the esevations, households wee selected using skip pattens fom andom stating points. Household (o house lot) maps of evey village o distict wee obtained fom the elevant tibal agencies. Using an estimated 25% pevalence ate of substance abuse, an alpha set at 0.05, an estimated efusal ate of 10%-20%, and 80% powe, the total numbe of house lots to be tageted on each esevation was detemined. The popotion of ineligible households (e.g., Non-Ameican Indian, nonesidential) and vacant o unoccupied house lots wee based on Census data o infomation povided by othe agencies such as HUD o emegency sevices. Refusal ates wee detemined by speaking with expets who had conducted o wee knowledgeable about conducting household suveys on the esevation. Seven pecent of homes wee vacant o unoccupied in Tibe A and two houses wee ineligible because esidents wee not enolled Ameican Indians. Thity-thee pecent of lots wee vacant in Tibe B. Within Tibe C, 25% of house lots wee vacant and 5% tuned out to be businesses. Once a home was tageted, inteviewes dopped off mateial about the study at the home including an aticle discussing the study published in the local newspape and a copy of the tibal esolution suppoting the study. Only adults 18 yeas of age and ove who wee enolled membes of the tibe wee invited to paticipate. Individuals with the most ecent bithday wee selected in ode to educe selection bias. Paticipants wee compensated fo thei time by payment of $19.00 o a vouche woth $19.00 fo use at the local supemaket. To minimize bias, all

6 6 VOLUME 10, NUMBER 3 eligible households wee contacted up to 10 times to ensue that the hadto-each wee not systematically missed. No aggessive effots wee made to convet efusals, although inteviewes wee tained on techniques of gentle pesuasion. The suvey was caied out between 1996 and A total of 725 completed suveys wee obtained, with the esponse ate calculated at 92% (the numbe of paticipating households/total eligible households contacted). Five individuals efused to paticipate fom Tibe A, eight pesons efused to be suveyed fom Tibe B, and 25 pesons efused at Tibe C. Reasons fo efusal included disbelief in the usefulness of suveys, dissatisfaction with the Health Depatment, unwillingness to answe pesonal questions, inconvenient times, and disinteest. No infomation is available fo compaing diffeences between those who ageed vesus efused to paticipate in the suvey. The low efusal ate was likely due to epeated attempts by inteviewes to contact homes combined with the stong emotions elicited by the topic among community membes who felt compelled to do something to help addess the destuction caused by alcohol and dug use in thei communities. Instuments Data wee collected using a suvey designed by the National Technical Cente fo substance Abuse Needs Assessment at Havad Univesity. Diagnoses of substance abuse and dependence wee made using a modified vesion of the Substance Abuse Module of the Diagnostic Inteview Schedule (DIS-SAM) (Robbins, Cottle, & Babo, 1990) with diagnostic citeia fom the fouth edition of the Diagnostic and Statistical Manual fo Mental Disodes (DSM IV) (Ameican Psychiatic Association, 1994). Diagnoses fo the following substances wee calculated based on the pesence and duation of symptoms: alcohol, maijuana, hallucinogens, cocaine, opiates, stimulants, depessants, and inhalants. This instument has shown adequate eliability and validity in minoity populations and has been successfully used with Ameican Indians (Manson et al., 1992). The instument was pilot tested at a Ameican Indian esidential teatment facility. Mino adaptations wee made to the instument to ensue that it was cultually elevant and addessed issues gemane to esevation life. Individuals wee sceened into the diagnostic potion of the inteview if they epoted using alcohol o dugs within the past 18 months (ceemonial use of peyote was excluded duing sceening). Those who qualified fo a lifetime abuse o dependence diagnosis and who expeienced one o moe symptoms in the past 12 months wee detemined to have a substance abuse poblem and wee consideed in need of teatment. Socio-demogaphic infomation was captued using single desciptive items. Respondents wee asked whethe they had any of the

7 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 7 following types of insuance: pivate health insuance, Medicaid o AHCCCS (i.e., Aizona Health Cae Cost Containment System Aizona s Medicaid pogam), Medicae, veteans o militay benefits, Indian Health Sevice (IHS) 1, othe, o no health insuance. Employment was assessed by asking individuals which of the following descibed thei situation: employed fulltime; employed, but on family leave o on leave fo some othe eason; employed pat-time; unemployed; seasonal woke; full-time homemake; o self-employed. Income was assessed by asking espondents whethe thei income was ove o unde $15,000 and then eading choices within $5,000 incements (e.g., 0-$5,000, $5,001-$9,999, etc.). Educational attainment was measued by asking espondents how much school they had completed (no school, 1 st 8 th gade, some high school but no diploma, high school gaduate o equivalent like GED, some college but no degee, associate degee, college degee, o advanced degee). All espondents who epoted use of alcohol o dugs within the past 18 months wee asked if they had eve eceived teatment fo thei alcohol o dug use. Respondents wee asked specifically about thei use of the following types of teatment sevices: detoxification (in a hospital; non-hospital, esidential facility, o an outpatient pogam); esidential ehabilitation (in a hospital, a esidential facility which lasted longe than 30 days, o a esidential facility which lasted fewe than 30 days); halfway o ecovey house; outpatient o nonesidential teatment (intensive vesus less intensive); outpatient methadone teatment; self-help goups; theapy fom a psychiatist, psychologist, social woke o counselo outside of a fomal dug o alcohol pogam; talking to a eligious o taditional leade, medicine peson, o village elde; using altenative teatments like acupunctue, hypnosis, o vitamins o hebs; o paticipating in a pogam that used sweat lodges, talking cicles o othe taditional Ameican Indian pactices. We defined fomal teatments as those that occued in a stuctued pogam and wee povided by licensed o cedentialed pofessionals such as esidential ehabilitation, methadone teatment, pivate hospital pogams, and outpatient counseling. Infomal o othe ecovey sevices wee defined as those sevices individuals seek outside of stuctued pogams including Alcoholics Anonymous (AA) o othe ecovey goups, speaking with eldes o spiitual leades, altenative theapies such as hebs, acupunctue, o use of taditional heales. Results The esults section focuses on the desciptive and explanatoy analyses concening substance abuse and teatment utilization. We begin by poviding desciptive infomation about the paticipants fom the thee tibes. The pevalence of substance abuse poblems by age and gende is pesented fo the whole sample and then by tibe. Desciptive infomation

8 8 VOLUME 10, NUMBER 3 about utilization of fomal and infomal teatment is also povided. In ode to assess the association between socio-demogaphic chaacteistics (explanatoy vaiables) and substance abuse and teatment utilization (esponse vaiables) in a multivaiate setting, Logistic Regession analyses wee pefomed. Finally, Logistic Regessions wee eun adding inteaction tems to examine whethe the elationships between socio-demogaphic chaacteistics and the outcomes vaied by tibe. Results ae based on combined analyses fom all thee paticipating Tibal Nations. Seven hunded and twenty-five pesons completed the suvey. Because the Tibal Nations equested anonymity, no identifying o desciptive infomation about the tibes ae pesented. Howeve, some esults ae pesented by tibe in ode to examine whethe poblem ates ae homogeneous acoss esevations. The data wee weighted such that they epesented the adult population age and gende distibution of each tibe. Foty pecent of the sample was ecuited fom Tibe A, 25% fom Tibe B, and 35% fom Tibe C (Table 1). Thee wee no significant diffeences in the pecentage of females, the age distibution, o insuance coveage by tibes. Tibes did diffe significantly on the following demogaphic and socioeconomic chaacteistics: unemployment (X 2 = 33.98, df = 8, p <.001), maital status (X 2 = 16.46, df = 6, p <.01), income (X 2 = 75.14, df = 8, p <.001), and educational achievement (X 2 = 86.05, df = 4, p <.001). Tibe C had the lowest unemployment ate and the highest educational and income level. Tibe C also had the lowest numbe of individuals epoting alcohol use within the past 18 months (X 2 = 16.16, df = 2, p <.0001). One-thid of Ameican Indians esiding on esevation had an alcohol o dug poblem (Table 2). Alcohol abuse o dependence disodes wee much moe common than dual alcohol and dug poblems o dug only poblems. Males wee moe likely to have an alcohol only and dual alcohol and dug poblem than females. Males and females wee equally likely to have dug only poblems. The pevalence of alcohol poblems was consistent acoss young and middle-age goups and did not dop until afte age 45. Eighty-eight pecent of 46 to 55 yea olds and 95.1% of individuals 56 yeas and olde wee fee of substance abuse poblems compaed to 59.1% of 18 to 25 yea olds, 64.1% of 26 to 35 yea olds, and 68.5% of 36 to 45 yea olds. Dual alcohol and dug disodes deceased with age fom 14.5% of 18 to 25 yea olds to 10.4% of 26 to 35 yea olds, to 4.1% of 36 to 45 yea olds. No instances of co-mobid alcohol and dug poblems wee found among esevation esidents ove the age of 45. Dug only poblems wee vey uncommon, with geneally less than 1% of the population abusing o being dependent on illicit substances in the absence of an alcohol use disode. Substance abuse vaied significantly acoss tibes (see Table 3). Tibe B had the highest ates of alcohol o dug abuse poblems and Tibe C the lowest. Among all tibes, alcohol only poblems wee the most

9 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 9 pevalent. Dug only poblems wee only epoted in Tibe A (the most uban esevation). Females in Tibe C had paticulaly low ates of substance abuse poblems. Substance abuse poblems wee geate among males in all tibes. Alcohol poblems tended to pesist though middle age fo membes of Tibes A and B, while the popotion of adults with substance abuse poblems in Tibe C geneally deceased with age. Howeve, among those in Tibe C, the popotion of adults with dual alcohol and dug poblems was consistent among 18 to 55 yea olds, but deceased moe substantially afte age 35 fo membes of Tibes A and B. Among those with a substance abuse poblem, 64.5% did not eceive any teatment in the past 12 months; 7.1% utilized fomal teatment sevices only (e.g., outpatient, inpatient, detox); 13.6% used both fomal and infomal teatment sevices; while 15.2% used infomal sevices only such as AA o Native healing (e.g., sweat lodges, medicine men) (See Table 4). Among those who used infomal teatment, use of Native healing pactices was moe common than use of AA (27.4% vs. 14.3%, espectively). Significant diffeences in the types of teatment accessed wee found by age (X 2 = 20.69, df = 9, p <.01) and income (X 2 = 20.83, df = 12, p <.05). Eldes wee least likely to eceive teatment, while individuals between the ages of 18 and 25 wee most likely to use fomal sevices and those aged 26 to 35 wee most likely to use infomal o combined appoaches to teatment. Multivaiate Logistic Regession analyses wee conducted to examine the associations between socio-demogaphic chaacteistics and substance abuse poblems. Vaiables significantly associated with substance abuse poblems included gende, tibal affiliation, age, employment, income, and educational achievement. As shown in Table 5, males wee 3.05 times moe likely than females to have a substance abuse poblem. Pevalence ates also vaied by tibe with adults in Tibe A and Tibe B being 1.94 and 2.50 times moe likely to have an alcohol o dug abuse disode than adults in Tibe C. Young and middle-aged adults wee moe likely to have substance abuse poblems than olde adults: 18 to 25 yea olds wee 7.01 times moe likely than adults ove age 55 to have poblems, individuals 26 to 35 yeas wee 8.47 times moe likely to have a substance abuse disode than individuals ove age 55, and adults aged 36 to 55 yeas wee 7.06 times moe likely than those ove 55 to have a cuent substance abuse poblem. Those whose employment status was othe (e.g., homemakes, etied) wee less likely to have substance abuse poblems than those who wee employed. A high income was potective such that those with highe household incomes wee less likely to have substance abuse poblems. Educational achievement was also potective: individuals who did not gaduate fom high school wee 2.55 times moe likely to have a substance abuse poblem than those with moe than a high school education, and individuals with a high school degee wee 2.19 times moe likely than those with moe than a high school education to

10 10 VOLUME 10, NUMBER 3 Table 1 Sample Chaacteistics by Tibe (weighted) (n=725) Tibe A Tibe B Tibe C Total Sample size % Female 54.3% 53.1% 51.1% 52.8% yeas 27.5% 15.6% 18.0% 21.8% yeas 25.7% 34.4% 26.6% 26.5% yeas 19.2% 25.0% 20.4% 20.0% 56+ yeas 29.5% 25.0% 35.0% 31.7% Unemployed 14.7% 16.1% 4.3% 10.1% Employed 51.5% 58.1% 68.6% 59.5% Othe 33.7% 25.8% 27.0% 30.4% % Maied/Living Togethe 48.2% 56.3% 62.2% 54.8% Sepaated/divoced/widowed 22.6% 18.8% 19.8% 21.2% Single (neve maied) 29.1% 25.0% 18.0% 24.0% % with Household Income <$15, % 54.6% 54.1% 58.0% Pivate Health Insuance 27.3% 29.0% 24.3% 26.0% Govenment-povided Health Insuance 69.7% 61.3% 73.1% 70.8% No Health Insuance 3.0% 9.7% 2.7% 3.2% % with less than a high school education 46.3% 28.1% 20.9% 34.3% % with high school degee o equivalent 30.1% 40.6% 22.8% 27.3% % with geate than a high school education 23.6% 31.3% 56.3% 38.4% % sceened into alcohol diagnostic model 64.9% 68.8% 50.5% 58.6% based on use within past 18 months Note: Unemployed excludes those who ae not seeking wok o who ae etied and disabled. Othe employment includes homemakes o those etied o disabled. High school education includes a GED.

11 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 11 Table 2 Type of Substance Abuse Poblem by Gende and Age (n=725) No Substance Alcohol Alcohol Dug Total Alcohol Abuse Only and Dug Only and/o Dug Poblem (%) (%) (%) (%) Poblem (%) Males Females ys ys ys ys Total Table 3 Type of Substance Abuse Poblem by Gende and Age and Tibe (n=725) No Substance Alcohol Only Alcohol and Dug Only Abuse Poblem (%) Dug (%) (%) (%) Tibe A Tibe B Tibe C Tibe A Tibe B Tibe C Tibe A Tibe B Tibe C Tibe A Tibe B Tibe C Males Females ys ys ys Total

12 12 VOLUME 10, NUMBER 3 Table 4 Teatment Utilization by Those with Cuent Substance Abuse Poblems Within the Past 12 Months by Demogaphic Chaacteistic and Type of Substance Abuse Poblem (n=196) No Fomal Fomal and Infomal Teatment Sevices Infomal Sevices Sevices (%) Only (%) Sevices (%) Only (%) (n=127) (n=15) (n=35) (n=51) Tibe A Tibe B Tibe C Male Female yeas yeas yeas yeas Employed Othe Unemployed Maied Divoced/sepaated/widowed Single, neve maied % income below $15, % income above $15, % less than high school degee % with high school degee o equivalent % with geate than a high school degee Pivate Health Insuance Govenment-povided health insuance No health insuance Total Note: Unemployed excludes those who ae not seeking wok o who ae etied and disabled. Othe employment includes homemakes o those etied o disabled. High school education includes a GED.

13 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 13 Table 5 Adjusted Odds Ratios and 95% Confidence Intevals (CI): Demogaphic Coelates of Substance Abuse Poblems (n=725) Odds Ratio Lowe CI Uppe CI Male vs. female 3.05* Tibe A vs. C 1.94* Tibe B vs. C 2.50* yeas (vs. 56+ yeas) 7.01* yeas (vs. 56+ yeas) 8.47* yeas (vs. 56+ yeas) 7.06* Othe vs. employed 0.59* Unemployed vs. employed Sepaated/divoced/widowed vs. maied Single (neve maied) vs. maied Income continuous 0.85* Less than high school education vs. 2.55* geate than high school education High school education vs. geate 2.19* than high school * p <.05 Note: Unemployed excludes those who ae not seeking wok o who ae etied and disabled. Othe employment includes homemakes o those etied o disabled. High school education includes a GED.

14 14 VOLUME 10, NUMBER 3 have an alcohol o dug poblem. Inteaction tems wee added to detemine whethe these elationships vaied by tibe. Tibal inteactions wee found fo education level, maital status, and age (not shown). The odds of a divoced, sepaated, o widowed adult having a substance abuse poblem (as compaed to a maied adult) was highe in Tibe C than Tibe A. The odds atio of an individual without a high school education having a substance abuse poblem (compaed to an individual with moe than a high school education) was geate fo adults in Tibe A as compaed to Tibe C. Finally, the odds of younge and middle age adults having a substance abuse poblem (as compaed to adults ove age 55) was geate in Tibe A than in Tibe C. The next table (Table 6) examines coelates of past yea teatment utilization. Males wee 2.91 times moe likely than females to eceive teatment. Adults in Tibe A wee moe likely to eceive teatment than those in Tibe C. Adults aged 26 to 35 wee the most likely to utilize teatment sevices in the past yea. Inteestingly, those with insuance (pivate o govenment-povided) wee less likely to eceive cae. Employment, maital status, income, and educational achievement wee not significant coelates of past yea teatment utilization. Inteactions between tibe and the othe socio-demogaphic vaiables wee not significant. Discussion A substantial potion of Ameican Indians on Aizona esevations suffe fom substance abuse poblems, paticulaly alcohol abuse o dependence. Despite the high pevalence of alcohol use disodes in the population, it is impotant to note that a lage numbe of Ameican Indians ae nondinkes: 41.5% of those suveyed epoted no alcohol use at all in the past 18 months. The popotion of the adult population abstaining fom alcohol is much highe among Ameican Indians than the geneal population (less than 20% of the adult household population nationally abstains fom alcohol) (Substance Abuse and Mental Health Sevices Administation [SAMHSA], 2000). May (1989) notes that thee ae two kinds of nondinkes those who ae lifelong abstaines and those who ae fome dinkes who have quit. Consistent with othe studies (Leung et al., 1993), alcohol use appeas to be bi-modally distibuted in the community with lage popotions of individuals abstaining and lage popotions dinking heavily. It has been hypothesized that economic depivation and lack of oppotunity ae significant contibutos to alcohol poblems on esevation (Beauvais, 1998). Consistent with this hypothesis, we found that the Tibal Nations with the highest level of education and household income had the lowest levels of poblem alcohol and dug use. Both education attainment and income wee significantly associated with substance abuse poblems even afte contolling fo gende, age, and tibal affiliation, although

15 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 15 Table 6 Adjusted Odds Ratios and 95% Confidence Intevals (CI): Demogaphic Coelates of Past Yea Teatment Utilization (n=725) Odds Ratio Lowe CI Uppe CI Male vs. female 2.91* Tibe A vs. C 2.59* Tibe B vs. C yeas (vs. 56+ yeas) 3.30* yeas (vs. 56+ yeas) 5.80* yeas (vs. 56+ yeas) 3.92* Othe vs. employed Unemployed vs. employed Sepaated/divoced/widowed vs. maied Single (neve maied) vs. maied Income-continuous Less than high school education vs geate than high school education High school education vs. geate than high school education Pivate insuance vs. no insuance 0.18* Govenment insuance vs. no insuance 0.35* * p<.05 Note: Unemployed excludes those who ae not seeking wok o who ae etied and disabled. Othe employment includes homemakes o those etied o disabled. High school education included a GED. Note: 31 individuals who wee not diagnosed as needing teatment eceived teatment within the past 12 months. supisingly unemployment was not. It is possible that the way employment categoies wee coded disguised significant contasts. Fo example, many of the people inteviewed wee self-employed as atisans, while othes woked pat-time o seasonal jobs (e.g., fiefighting in the national foests duing the summe when dy conditions ae common). Thus, standad categoization systems fo employment may not be effective fo esevation populations whose wok status may be in a state of flux. Povety was ampant in this sample, with 54% epoting a household income of less than $15,000 and an unemployment ate of 10.1%. Clealy economic vitalization and autonomy ae cental to maintaining a healthy lifestyle among esevation esidents.

16 16 VOLUME 10, NUMBER 3 Substance abuse poblems ae moe common among males and young to middle age adults. Concuent with othe eseach, ou study found that high poblem ates pesist until about 45 yeas of age when ates begin to dop off (Bay et al., 1999; Leung et al., 1993; Manson et al., 1992). Rates may be lowe among olde adults because of high levels of alcoholelated motality o because individuals eventually age-out of heavy o poblematic dinking (Quinteo, 2000). Mail and Johnson (1993) epot that many men eventually quit dinking as they begin to take on esponsibilities associated with being an elde, and heavy dinking females epot quitting substance use aound the age of 35 to 40 when they see thei behavio is inconsistent with the expectations they endose fo thei childen. Although males wee 2 to 3 times moe likely to have alcohol o dug poblems than females, the popotion of females epoting substance abuse poblems is much lage than the Aizona geneal population (18% vs. 6%) o the U.S. female population as a whole (Aizona Depatment of Heath Sevices [ADHS], 1998; Kessle et al., 1994). In addition, females had ates of dug-only poblems that wee equivalent to males. The popotion of female poblem dinkes in ou study is highe than that found by Leung et al. (1993), but simila to ates found by Bay and colleagues (1999). It is difficult to make diect compaisons to othe studies due to diffeences in methodologies and definitions of what constitutes a substance abuse poblem. Pathways to alcohol abuse may diffe fo women: Women may be moe likely to develop poblem use while in elationships with substance abusing men o to tun to alcohol in an effot to elieve the negative affect associated with victimization, gief, and loss. Many Ameican Indian women pesenting fo substance abuse teatment have a histoy of tauma including child sexual abuse and domestic violence (Bindis et al., 1995). Futue eseach should seek to delineate the diffeences in substance use etiology fo Ameican Indian men and women. Although poblems with alcohol geatly outnumbe poblems with dugs, the popotion of adults with dug poblems is still much highe than the Aizona and U.S. non-esevation household population (ADHS, 1998, Kessle et al., 1994), paticulaly among those who aleady have poblems with alcohol. Wheeas alcohol has been the pimay dug of addiction, Mail and Johnson (1993) epot a gowing concen among Tibal Nations fo illicit dug use and poly-dug use. Expeimentation with illicit dugs appeas to stat ealie fo Ameican Indian youth (Beauvais & LaBoueff, 1985), and ealy and excessive use may geatly incease the pobability of futue substance abuse poblems. As such, teatment and pevention povides should focus on the ole of illicit dugs both in the pathways to addiction and in the teatment of concomitant disodes. Appoximately two-thids of individuals with a substance abuse poblem had not eceived cae in the past yea. Women and eldes wee the least likely to eceive cae. Responsibilities such as taking cae of childen may make women less available to seeking cae. Women also

17 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 17 may be less likely to come into contact with systems that can identify, efe, o mandate substance abuse teatment such as the ciminal justice o employment systems. Because substance use is less common among eldes, thee may be moe stigma associated with seeking teatment. Attitudes towad teatment o wold-views of illness and healing may also impact teatment-seeking behavio of olde Ameican Indians (Manson, 2000). The ual and isolated natue of many esevations pesents special challenges fo both the outeach and povision of cae. Most people who eceived teatment used infomal sevices whethe alone o in conjunction with fomal sevices. Use of infomal sevices may esult fom poo access to fomal pogams as well as a desie to incopoate taditional aspects of healing and spiituality into ecovey. In this study 27.4% of people with a substance abuse poblem epoted use of taditional healing pactices including sweat lodges, taditional ceemonies, consultation with village eldes, o use of medicine men. What little eseach thee is on teatment effectiveness among Ameican Indians suggests that cultually divese teatments that include taditional foms of healing and use ethnically matched counselos may incease teatment success (May & Moan, 1995; Weibel-Olando, 1989). The use of AA was less fequent: 14.3% of those with a substance abuse poblem epoted use of this sevice. Ameican Indians on esevation may assume that AA is incompatible with thei belief system, although use seems to be inceasing as the taditional Twelve Step philosophy is being expanded to include tibal values and beliefs (Abbott, 1998; CSAT, 1999; Womack, 1996). Pivate insuance coveage was low in the population; howeve, insuance coveage did not facilitate access to teatment in this study. Many insuance plans povide inadequate coveage fo substance abuse teatment. Futhemoe, even if substance abuse teatment is coveed unde insuance, access o availability may be limited. Moe health sevices eseach is needed to undestand the stuctual baies to substance abuse teatment among Ameican Indians including the association between payment systems and access to health cae. Moeove, given the populaity of taditional healing among this population, futue eseach should exploe ationales fo selecting types of teatment as well as the effectiveness of taditional healing. It is impotant to ecognize that thee is a geat deal of divesity in the cultual, geogaphical, and economic chaacteistics of Tibal Nations (Weisne, Weibel-Olando, & Long, 1984). Ou study did find diffeences in substance use and teatment seeking behavio by tibe. Substance use may be affected by a numbe of contextual o cultual chaacteistics including the histoical context of alcohol intoduction, tibal histoy of political and economic oppession, migation, adheence to taditional cultue, cultual pespectives on substance use (e.g., ceemonial use, vision quests) as well as community attitudes, noms, and policies egading alcohol

18 18 VOLUME 10, NUMBER 3 (Beauvais, 1998; Weisne, Weibel-Olando, & Long, 1984). As such, eseaches need to take into account the maco level chaacteistics associated with substance use acoss diffeent esevations. Seveal limitations to this study should be noted. Data wee collected fom a epesentative household sample of thee esevations in the State of Aizona. The esultant sample had a highe popotion of female paticipants than would be expected by chance (esults wee weighted to the population to coect fo this), thus we cannot be cetain that the individuals within households wee andomly selected as intended. Paticipation of the adult ove the age of 18 with the most ecent bithday was equested, but it is possible that whoeve answeed the doo oveode this equest and selected the peson with the lowest substance use to paticipate. Similaly, attitudes towad eseach o sevice utilization could have influenced self-selection fo paticipation. The sample consists of Ameican Indians fom only thee esevations and these esevations wee selected due to high county-level indicatos of alcohol-elated motality and mobidity. Because thee is a geat deal of divesity among Tibal Nations, we cannot genealize findings fom these thee Nations to all Ameican Indians esiding on esevation in Aizona o the United States. Fea of lack of confidentiality o social desiability may have motivated some espondents to undeestimate thei substance use; thus, these data ae limited by use of a single epote. Validation of substance use by multiple epotes o methods may stengthen futue eseach in this aea. Nevetheless, the ates of substance misuse found in this population ae consistent with those of othe epidemiologic studies of Ameican Indians (Bay et al., 1999; Kinzie et al., 1992). The Diagnostic Inteview Schedule has been used woldwide and can be used effectively with Ameican Indians (Manson, Walke, & Kivlahan, 1987); howeve, futhe effots to continue to assess the coss-ethnic and coss-language equivalence of this and othe diagnostic measues ae needed. In ou study, 72 individuals conducted thei inteview in thei Native language o in a mix of English and thei Native language. Although key tems wee tanslated and infomation about the need fo standadization in tanslation was discussed in taining, we cannot assue standadization acoss all inteviews. Finally, this study did not include off-esevation Ameican Indians and moe eseach is needed to compae alcohol and dug use between those esiding on and off-esevation. Conclusion Many Ameican Indians on esevation abstain fom alcohol use and many othes have poblems esulting fom excessive and out-of-contol use. Given this exteme distibution of dinking pattens, moe eseach is needed to undestand moe modeate o contolled pattens of dinking. Damatic diffeences exist within and between Tibal Nations and acoss

19 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 19 people. Thus, a deepe undestanding of the intepesonal and contextual influences on excessive substance use is cucial. Rathe than focusing solely on estimating psychopathology in Ameican Indian communities, eseach should focus on undestanding issues of esilience such as identifying factos associated with esistance to substance use initiation o successful ecovey. Undestanding the coelates and pedictos of substance use and abuse among Ameican Indians is impotant fo the development of empiically gounded and cultually sensitive pevention and teatment models (Beauvais, 1992b; May & Moan, 1995; Stubben, 1997). Only though compehensive, community-diven, and cultually sensitive effots can the myiad poblems associated with substance abuse in Ameican Indian communities be combated. Mindy Heman-Stahl, Ph.D. Reseach Psychologist RTI Intenational 3040 Conwallis Road P.O. Box Reseach Tiangle Pak, NC Refeences Abbott, P. J. (1998). Taditional and westen healing pactices fo alcoholism in Ameican Indian and Alaska Natives. Substance Use and Misuse, 33, Ameican Psychiatic Association. (1994). Diagnostic and statistical manual of mental disodes (4 th edition). Washington, DC: Autho. Aizona Depatment of Health Sevices (ADHS). (1998). Substance abuse in Aizona (Contact No ). Phoenix, AZ: Autho. Beauegad, K., Cunningham, P., & Conelius, L. (1991). National Medical Expenditue Suvey Reseach Findings 9 (AHCPR Pub. No ). Rockville, MD: Agency fo Health Cae and Policy Reseach. Beauvais, F. (1998). Ameican Indians and alcohol. Alcohol Health and Reseach Wold, 22, Beauvais, F. (1992a). Compaison of dug use ates fo esevation Indian, nonesevation Indian, and Anglo youth. Ameican Indian and Alaska Native Mental Health Reseach, 5, Beauvais, F. (1992b). An integated model fo pevention and teatment of dug abuse among Ameican Indian youth. Jounal of Addictive Diseases, 11,

20 20 VOLUME 10, NUMBER 3 Beauvais, F., & LaBoueff, S. (1985). Dug and alcohol abuse intevention in Ameican Indian communities. The Intenational Jounal of the Addictions, 20, Beauvais, F., Oetting, E. R., & Edwads, R. (1985). Tends in dug use of Indian adolescents living on esevations Ameican Jounal of Dug and Alcohol Abuse, 20, Bay, R. M., Dalbeth, B. T., Heman-Stahl, M., Walke, J. A., Sanchez, R. P. (1999). Substance use and need fo teatment: Findings fom the South Dakota Native Ameican suvey. Reseach Tiangle Pak, NC: Reseach Tiangle Institute. Bindis, C., Bekowitz, G., Peteson, S., Boadnax, Y., Clayson, Z., Gandhi, S., Handley, M., & Tung, P. (1995). Evaluating the effectiveness of alcohol and substance abuse sevices fo Ameican Indian/Alaska Native women. Phase 2 final epot. (DHHS Contact Numbe ). Univesity of Califonia at San Fancisco: Cente fo Repoductive Health Policy Reseach, Institute fo Health Policy Studies. Cente fo Substance Abuse Teatment. (1999). Cultual issues in substance abuse teatment. U. S. Depatment of Health and Human Sevices, Substance Abuse and Mental Health Sevices Administation (DHHS Publication No. SMA ). Rockville, MD: Autho. Indian Health Sevice. (1996). Tends in Indian health. U. S. Depatment of Health and Human Sevices, Indian Health Sevices, Office of Planning, Evaluation, and Legislation, Division of Pogam Statistics. Autho. Kessle, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H., & Kendle, K. S. (1994). Lifetime and 12-month pevalence of DSM III-R psychiatic disodes in the United States: Results fom the National Co-mobidity Study. Achives of Geneal Psychiaty, 51, Kinzie, J. D., Leung, P. K., Boehnlein, J., Matsunaga, D., Johnson, R., Manson, S., Shoe, J. H., Heinz, J., & Williams, M. (1992). Psychiatic epidemiology of an Indian village: A 19-yea eplication study. Jounal of Nevous and Mental Disease, 180, Leung, P. K., Kinzie, J. D., Boehnlein, J. K., & Shoe, J. H. (1993). A pospective study of the natual couse of alcoholism in a Native Ameican village. Jounal of Studies on Alcohol, 54, Mail, P. D., & Johnson, S. (1993). Boozing, sniffing, and toking: An oveview of the past, pesent, and futue of substance use by Ameican Indians. Ameican Indian and Alaska Native Mental Health Reseach, 5, Manson, S. M. (2000). Mental health sevices fo Ameican Indians and Alaska Natives: Need, use, and baies to effective cae. Canadian Jounal of Psychiaty, 45,

21 SUBSTANCE ABUSE PREVALENCE AND TREATMENT 21 Manson, S. M., Shoe, J. H., Baon, A. E., Ackeson, L., & Neligh, G. (1992). Alcohol abuse and dependence among Ameican Indians. In J. E. Helze & G. J. Canino (Eds.), Alcoholism in Noth Ameican, Euope, and Asia (pp ). New Yok: Oxfod Univesity Pess. Manson, S. M., Walke, R. D., & Kivlahan, D. R. (1987). Psychiatic assessment and teatment of Ameican Indians and Alaska Natives. Hospital and Community Psychiaty, 38, May, P. A. (1989). Alcohol abuse and alcoholism among Ameican Indians: An oveview. In T. D. Watts & R. Wight (Eds.), Alcoholism in minoity populations (pp ). Spingfield, IL: Chales Thomas Publishe. May, P. A. (1994). The epidemiology of alcohol abuse among Ameican Indians: The mythical and the eal popeties. Ameican Indian Cultue and Reseach Jounal, 18, May, P. A., & Moan, J. (1995). Pevention of alcohol misuse: A eview of health pomotion effots among Ameican Indians. Ameican Jounal of Health Pomotion, 9, McKenzie, D. (1994). Dialogue on aboiginal substance use. In D. McKenzie (Ed.), Aboiginal Substance use eseach issues (pp ). Ottowa: Canadian Cente fo Substance Abuse. National Institute on Dug Abuse. (1995). Dug use among acial/ethnic minoities. U.S. Depatment of Health and Human Sevices (NIH publication no ). Rockville, MD: Autho. Nelson, S. H., McCoy, G. F., Stette, M., & Vandewagen, W. C. (1992). An oveview of mental health sevices fo Ameican Indians and Alaska Natives in the 1990s. Hospital and Community Psychiaty, 43, Noen, J., Kindig, D., & Spenge, A. (1998). Challenges to Native Ameican health cae. Public Health Repots, 113, Quinteo, G. (2000). The lizad in the geen bottle : Aging out of poblem dinking among Navajo men. Social Science Medicine, 51, Regie, D. A., Fame, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd., L L., & Goodwin, F. K. (1988). Comobidity of mental disodes with alcohol and othe dug abuse: Results fom the Epidemiologic Catchment Aea (ECA) study. Jounal of the Ameican Medical Association, 19, Robbins, L. N., Cottle, L. B., & Babo, T. (1990). The Diagnostic Inteview Schedule Substance Abuse Module (DIS-SAM). St. Louis: Depatment of Psychiaty, Washington Univesity School of Medicine. Roy, C., Choudhui, A., & Ivine, D. (1970). The pevalence of mental disodes among Saskatchewan Indians. Jounal of Coss-Cultual Psychology, 1, Sampath, B. M. (1974). Pevalence of psychiatic disodes in a southen Baffin Island Eskimo settlement. Canadian Psychiatic Association Jounal, 19,

22 22 VOLUME 10, NUMBER 3 Substance Abuse and Mental Health Sevices Administation, SAMHSA. (2000). National household suvey on dug abuse: Main findings Depatment of Health and Human Sevices. Rockville, MD: Autho. Saemi, A., Hanson, R. L., Williams, D. E., Roumain, J., Robin, R., Long, J. C., Goldman, D., & Knowle, W. C. (2001). Validity of the CAGE questionnaie in an Ameican Indian population. Jounal of Alcohol Studies, 62, Shoe, J. H., Kinzie, J. D., Hampson, D., & Pattison, M. (1973). Psychiatic epidemiology of an Indian village. Psychiaty, 36, Stubben, J. (1997). Cultually competent substance abuse pevention eseach among ual Native Ameican communities. In E. B. Robetson, Z. Sloboda, G. Boyd, L. Beatty, & N. Kozel (Eds.), Rual substance abuse: State of knowledge and issues (pp ). Rockville, MD: NIDA Reseach Monogaph 168 (NIH Publication No ). Weibel-Olando, J. (1989). Teatment and pevention of Native Ameican alcoholism. In T. Watts & R. Wight (Eds.), Alcoholism in minoity populations (pp ). Spingfield, IL: Chales Thomas Publishes. Weisne, T. S., Weibel-Olando, J. C., & Long, J. (1984). Seious dinking, White man s dinking and teetotaling : Dinking levels and styles in an Uban Ameican Indian population. Jounal of Studies on Alcohol, 45, Womack, M. L. (1996). The Indianization of Alcoholics Anonymous. Monogaph of the Native Ameican Reseach and Taining Cente, Univesity of Aizona. Tucson, Aizona. Autho s Notes Funding fo this poject was made possible though the Behavioal Health Sevices, Aizona Depatment of Health Sevices by contact # unde the States System Development Pogam administeed by the Division of State Pogams, Cente fo Substance Abuse Teatment, Substance Abuse and Mental Health Sevices Administation. The Human Subjects Committee (Institutional Review Boad) of the Univesity of Aizona authoized the appoval of this poject though the expedited eview pocedue, with the condition(s) that subjects anonymity be maintained. We gatefully acknowledge the assistance of Chistina Dye, Aizona Depatment of Health Sevices; Steven Chang, Univesity of Aizona; the Tibal Councils and Tibal Health Depatments and membes of the planning committee who suppoted and guided this eseach, specifically Teesa Wall, Veonica Pastano, Linda Havatone, Leon Nuvayestewa, Geogia Masayesva, Ph.D., Kaen Honanie, Taylo Satala, and Heman Honanie. We ae paticulaly indebted to all of the suvey inteviewes fo thei had wok and commitment, and to the espondents fo thei kind paticipation. We also thank the anonymous eviewes fo thei insightful comments.