February 2020, Volume XXXIII, No 11

  Public Health

Reducing Native American opioid deaths

Culture-based research

orth America is struggling through an opioid overdose epidemic that has cut across all dividing lines: race, gender, age, socioeconomic status, and culture. Native American Nations suffer this grief and loss along with all other American communities. It is no secret that the Minnesota Native American drug overdose death rate in recent years is six times higher than the state’s overall average. Medical providers who care about and treat Native American people need context and connection with the healing priorities that these individuals value.

Background and methodology

In 2019, the White Earth Ojibwe/Anishinaabe Nation, in Northern Minnesota, teamed with the University of Minnesota Medical School, Duluth Campus, on a culture-based research project to address this painful, needful issue. Their study, Reducing Opioid Overdose Deaths in Minnesota: Insights from One Tribal Nation (https://tinyurl.com/mp-opioid-research)—funded by the National Drug Early Warning System—was the first known Native American methodology opioid fatality review (OFR) study in North America. White Earth Nation participants considered the process as much a healing ceremony as a scientific data collection initiative.

The Minnesota Native American drug overdose death rate ... is six times higher than the state’s overall average.

In the spring of that year, White Earth Nation’s Overdose Response Committee, under the leadership of Clinton Alexander, MPH, an enrolled White Earth Nation member, teamed with a University of Minnesota Medical School, Duluth Campus research group headed by Dr. Brenna Greenfield, an assistant professor and licensed clinical psychologist. Their project explored White Earth Reservation Ojibwe citizen views on healing the wounds of the opioid epidemic. The White Earth Nation study was conceived as part of the White Earth Ojibwe opioid crisis response Tribal Action Plan, and was built on a national review model established by the work of Erin Russell, Chief of Maryland’s Center for Harm Reduction Services.

The research team chose to expand the public health fatality review model into an indigenous methodology research, inviting participating White Earth Nation community members to set their own healing research agenda in a culturally and spiritually informed manner. The work respected the lives, stories, positive community contributions, and cultural/spiritual identities of community members lost to opioid overdose—not merely treating them as “fatality statistics.” The research team formed community focus talking-circle groups, comprised of White Earth citizens from all walks of life, to discuss their impressions of the OFR methodology, risk, and protective factors for opioid overdose losses in White Earth Nation.

Also, an OFR team, comprised of White Earth Nation healing professionals from multiple disciplines, shared in talking-circle reviews of emergency care records, hospital records, autopsy records, behavioral health and human services issues, social media posts, and personal perspectives regarding five individuals who died of opioid overdose in White Earth communities over the previous several years. Each of the lost community members was known to one or more of the review team members. The privacy, confidentiality, and grief work of White Earth families and communities were respected. The team placed cultural, historical trauma, and spiritual input at the center of their review process.

“The richness of the White Earth team’s results is due to the infusion of the case review process with respect, dignity, and a strengths-based approach unique from any other team I have worked with,” said Russell, who has supported the launch of OFR in Maryland and across the nation. “The work respected the lives, stories, positive community contributions, and cultural/spiritual identities of community members lost to opioid overdose—not merely treating them as ‘fatality statistics.’”

The opioid fatality review project was about one tribal nation’s creative and innovative strategies to address the opioid crisis at the local level. The goal of the study was to identify factors that may contribute to these deaths and provide recommendations about ways to address them, with the ultimate goal of reducing opioid overdose deaths and health inequities. The White Earth Nation focus groups and fatality review team found it was not adequate to simply share autopsy and post-mortem drug-testing statistics.

In their own words

To understand the meaning of this research study, one must hear the incisive, practical, and compassionate thoughts of focus group participants, which may reflect misconceptions regarding Native Americans:

What are the circumstances that are actually around their death? They just didn’t OD and die ... so I would say you need to investigate their actual deaths ... (not) just assuming that oh, it’s just another Indian with a needle in their arm, OD. And not bother. [Community focus group participant]

There’s that whole laundry list of things, adverse childhood experiences, lack of social economic status, multi-generational dysfunction, behaviors, you go through all those. I think one of the deeper issues is ... I don’t think we’ve done enough to strengthen cultural identity and draw on cultural resiliency of our families. [OFR team member focus group participant]

The death certificates say that these people died of overdoses, but ... I’d say 90% died of broken hearts. ... [I]t’s the trauma that our people go through. [Community focus group participant]

How many times have they reached out for services? Follow up on how they were treated. When we first started doing the harm reduction of clean needle exchange, I had a woman who brought in another woman... And she goes ... “You were right. She is different.” “What do you mean?” “You don’t shame me.” ... We need to stop shaming our people. They’ve been shamed enough. [Community focus group participant]

It was not adequate to simply share autopsy and post-mortem drug-testing statistics.

I think that we will probably see some version of something a patient once said to me that made me smile and then shocked the hell out of me. The patient said, you know, you really helped me ... but not on the days you thought you were helping me. So, I think that we will see that shelter, food, respect, and compassion are going to turn out to be very important factors ... helping them to trust in the help you’re offering. [OFR team member focus group participant]

While the opioid epidemic has magnified grief and tragedy among communities throughout the United States, resilience and hope were clearly braided among the comments of the Native community and fatality review members:

There’s a lot of community strengths and the fact that we’re actually still here, we survived genocide, we are very much a resilient people. We are intelligent, we are caring, and we are loving, and we’re always coming up with solutions to find what’s going on and try to respond to what’s happening within our communities. [Community focus group participant]

Helping break the stigma ... The police department is implementing community policing and getting familiar with Good Samaritan laws. Programs are hosting community picnics while offering services. Having an overdose prevention officer that goes out on calls and offers services is unique and shows what kind of direction we are taking on substance abuse ... five years ago that idea would seem crazy. When programs started reaching out to the community the number of overdoses decreased significantly. [Community focus group participant]

We have our culture. We have our revitalization and restoration of our language, our ceremonial practices. ... and the other part is our humor. It is the cornerstone of healing. [Community focus group participant]

Findings

Key findings identified by the overdose fatality review team members through their review of five Native American overdose deaths included: 1) hesitation or refusal to call for assistance, 2) lack of coordination with other substance use disorder treatment programs, 3) unaddressed medical and mental health needs, 4) movement between reservations and to urban areas, and 5) poor data accuracy and availability.

The focus group members identified the following risk factors for overdose deaths among Native American study participants: 1) implications of historical loss, 2) historical and contemporary trauma, 3) shame and stigma, 4) effects on children, and 5) jurisdictional issues and rurality.

Protective factors identified from the focus groups: 1) innovative solutions, 2) naloxone availability, 3) community collaborations, and 4) culture.

Interventions and hope

Opioid overdose death inequities among American Indians in Minnesota and the participating tribal nation have multiple contributing factors that offer an opportunity for intervention. There is a particular need for community involvement, multidisciplinary collaboration, continued naloxone outreach, additional funding for multiple services (e.g., recovery-based housing, mental health treatment, cultural programming, and transitional reentry support services), and improving reliability and access of pertinent data.

The White Earth Ojibwe Nation and the University of Minnesota Medical School, Duluth Campus research team hope that the release of their published research report will inspire other communities—including other North American Native Nations/Tribes—to take up the challenge, in their own cultural/spiritual context, of thinking and talking about opioid fatality losses and ways to find meaningful healing wisdom and balance from and for each other.

Carson Gardner, MD, is a board-certified family physician with over 40 years of rural Minnesota family practice experience, including 20 years working with the White Earth Indian Health Service clinic and as medical director of the White Earth Nation Tribal Health Department.

Clinton Alexander, MPH, is a public health professional with the White Earth Health and Behavioral Health Divisions with over a decade of experience in developing harm reduction programming that includes being a founding member of the White Earth Harm Reduction Coalition. He previously played an instrumental role in developing a community-driven harm reduction program with peer-delivered syringe exchange and overdose prevention services.

Brenna Greenfield, PhD, LP, is a licensed clinical psychologist and assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. Her research focuses on substance use disorder treatment and recovery, prevention of opioid overdose deaths, behavioral health interventions, and American Indian health equity. 

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Brenna Greenfield, PhD, LP, is a licensed clinical psychologist and assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. Her research focuses on substance use disorder treatment and recovery, prevention of opioid overdose deaths, behavioral health interventions, and American Indian health equity.