Alcohol and Substance Abuse Evaluation and Treatment in American Indians and Alaska Natives

Etiology

In Alaska Native and American Indian populations, environmental and genetic risk factors contribute substantially to substance and alcohol use disorder. Genetically, concerning alcohol use disorder, some populations of Alaska 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.[6] These protective genes, found at specific alleles such as ADH1B, ADH1C, and ALDH2, lead individuals who consume alcohol to experience elevated levels of acetaldehyde in their bloodstream.[6] The increased acetaldehyde levels cause increased blood flow, increased heart rate, dizziness, sweating, and nausea, or what is commonly known as a "flushing response," which may be interpreted as a warning sign.[6][7] The individuals lacking these genes are often, then, less protected from the undesirable adverse effects that occur with the initial alcohol consumption.

Alaska Natives and American Indians are susceptible to the same environmental risk factors for alcohol and substance use disorders found in all populations: a family history of substance abuse, specific personality characteristics, psychiatric comorbidities, gender, and trauma exposure.[1] However, they also experience additional risk factors 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 beliefs.[1] 

Economic factors, such as poverty and unemployment rates higher than the national average, contribute to stressors that may lead to substance use as a coping mechanism. Moreover, historical and cultural ties to the land and traditional practices can influence substance use patterns, with some communities experiencing higher rates of alcohol-related issues due to factors like isolation, lack of economic opportunities, and historical trauma.

Another factor influencing the rates of alcohol and substance use disorders within the American Indian and Alaska 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. A strong protective factor unique to the Alaska 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 use disorder prevention and treatment.[4]

Epidemiology

Epidemiological data regarding the alcohol and substance use disorder rates among Alaska Native and American Indian populations demonstrate a complex pattern with significant variation between studies. Today, the majority of Alaska Native and American Indians reside in urban or suburban areas.[1] Due to the federal government efforts in the mid-twentieth century, which forced Alaska Native and American Indian assimilation, many tribes are now dispersed. This makes research and sampling among Alaska Native and American Indian populations very complicated. The commonly used national probability samples based on United States (US) residential patterns have led to skewed results. As a result of this challenge, much of the research performed among Alaska Native and American Indians is conducted on tribal reservations. Thus, it captures only a small portion of the entire population, not a representative sample.[1] 

According to the Tri-Ethnic Center, Alaska Native, and American Indian adolescents demonstrate higher rates of tobacco, alcohol, and substance use and earlier initiation when compared to other adolescents in the US.[1][4] The highest rates were documented in those who had dropped out of school and lived on a reservation.[1]  In contrast, another study that examined 4 Alaska Native and American Indian reservations reported increased 30-day use of substances among adolescents. However, the increased use was eliminated when the results were stratified by geographic location.[1] Alaska Natives and American Indians both provide community support for impaired adolescents with targeted programs.[8][1]

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

History and Physical

The history and physical examination findings identified among Alaska Native and American Indian populations are similar to findings among other ethnic groups. Primary care physicians utilize screening tools to identify individuals who may already have an alcohol or substance use disorder or individuals who are at increased risk for developing such a disorder. Two commonly used screening tools are the Alcohol Use Disorders Identification Test (AUDIT) and the CAGE-AID questionnaire.[9] 

Screening every individual is necessary because selective screening can result in missed opportunities for intervention. Physical exam findings of substance and alcohol use disorders may be absent or very subtle.[9] 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.[9] 

Alcohol withdrawal symptoms can include tremors, shakes, psychosis, and seizures.[10] Other adverse events of long-term alcohol use 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 use disorders include a drastic change in physical appearance, marked personality changes, decreased performance in school work or job performance, engaging in criminal behavior, or severe psychological instability.[9]

Evaluation

Laboratory testing can help to determine the existence and extent of alcohol and substance abuse. These tests include urine, blood, saliva, hair, and breath analysis to detect substance use. Similarly, physicians can order serum alcohol levels, ethyl glucuronide levels in the urine, and phosphatidyl ethanol levels in the blood. There are also a myriad of testing options that can help detect 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 (GGT) levels and increased prothrombin time are other commonly associated findings associated with alcohol abuse. Healthcare 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. Additionally, evaluating the presence of co-occurring disorders such as anxiety, depression, or trauma is crucial, as these often intersect with substance abuse. 

Treatment / Management

Alcohol and substance use disorders can have many adverse events that affect American Indian and Native American’s health, relationships, and even employment status. American Indians and Alaska Natives, when compared with non-Hispanic White individuals, were found to be 41% more likely to seek treatment for alcohol abuse.[11] The treatment of alcohol and substance use in Alaska Natives and American Indians requires culturally sensitive and community-specific approaches that respect traditional healing practices. Effective treatment strategies often involve a combination of behavioral therapies, medical interventions, and peer support programs tailored to meet the diverse needs and cultural backgrounds of these populations. Various pharmacological therapies specific to the substance being used can also be utilized.

Motivational interviewing has been used successfully to treat alcohol and substance use disorders in these populations because it aligns with Alaska Native and American Indian culture and values. Motivational interviewing, an evidence-based treatment, is a patient-focused technique that consists of both a relational and technical approach.[12] The relational segment consists of the interviewer establishing a rapport with the patient through compassion, empathy, and accentuation of patient autonomy. The technical approach allows patients to discuss their motivation for change and reinforce their decision.[12] (B3)

Healthcare professionals must collaborate closely with tribal leaders, community elders, and culturally competent counselors to ensure that interventions respect indigenous values and beliefs. By fostering trust and understanding within the community, treatment programs can enhance engagement and improve outcomes, supporting individuals and families in their journey toward recovery and wellness. Geography significantly influences alcohol and substance use among Native Americans, shaping both access to resources and patterns of use. Remote and rural communities often face limited access to healthcare facilities, including substance abuse treatment centers, which can hinder timely intervention and support for Native individuals struggling with addiction. Future treatment models must address access to care in all geographical areas.

Differential Diagnosis

Included in the work-up and differential diagnosis of alcohol and substance use disorders are these co-occurring disorders, which can exist in the same patient independently but can mimic, as well as be exacerbated by substance and alcohol use disorders. These conditions include the following:

• Bipolar disorder
• Depression 
• Panic disorder 
• Generalized anxiety disorder 
• Psychosis 
• Mania
• Post-traumatic stress disorder
• Schizophrenia
• Schizoaffective disorders, bipolar or depressive type

Stimulant usage is especially known to exacerbate or initiate psychosis, delusions, and hallucinations in patients with no previous history of mental health diagnoses. 

Prognosis

Among Alaska Natives and American Indians who entered an alcohol detoxification treatment facility, 75% of individuals had successful completion. Alaska Natives and American Indians with an older age at onset of first alcohol consumption and longer length of stay in the treatment facility were more likely to achieve successful detoxification. Those with co-occurring psychiatric diagnoses and alcohol use disorder were less likely to have long-term remission after treatment programs.[13]

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 Alaska 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. In contrast, individuals facing legal issues were twice as likely to accept a referral. After accepting a referral, only 58% of individuals entered substance abuse treatment programs.[14]

Complications

Many adverse related health events are complications of alcohol and substance use disorders. Alaska Native and American Indian populations experience higher mortality rates from alcohol, chronic liver disease, and drug use sequelae when compared to all other races.[1] Premature death rates are also 90% higher for Alaska Natives and American Indians than for all other ethnic groups in the US, primarily due to alcohol use disorder.[1][15]

Alcohol use disorders among Alaska Natives also contribute to higher cirrhosis rates, dementia, suicide, homicide, and unintentional injuries.[16] The leading cause of death for Alaska Native men is alcohol use disorder, and it is ranked the sixth leading cause of death in Alaska Native women.[16] The alcohol-related death rate was 16.1 times higher among Alaska Natives than White individuals in the US, according to a study conducted by the Alaska Native Tribal Health Consortium.[16] 

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]