A Conversation About Drug Use and Addiction for American Indians and Alaska Natives

Dr. David R. Wilson, director of the NIH Tribal Health Research Office, and Dr. Nora D. Volkow, director of the NIH National Institute on Drug Abuse, discuss the latest research on drug use and addiction for American Indian and Alaska Native communities. Recorded November 2021

Video length: 20:39

Transcript

[DR. DAVID WILSON SPEAKING]

My name is Dr. David Wilson. I am the Director of the NIH Tribal Health Research Office. I’m also a member of the Navajo Nation and today I am joined by my colleague, Dr. Nora Volkow, who is the Director of the National Institute on Drug Abuse. Or as many refer to it as NIDA, which is also part of the NIH.

The mission of NIDA is to advance the science that better understands the causes and consequences of drug use and addiction and to be able to apply that knowledge to improve individual and public health. So welcome, Dr. Volkow.

[DR. NORA VOLKOW SPEAKING]

Thanks very much for having me, Dr. Wilson. Can I call you David? 

[DR. DAVID WILSON SPEAKING]

Absolutely, absolutely. So, we’re here today to have a special discussion on drug use and addiction, which are really tremendous areas of concern, not only in any country, but I think we’re seeing a lot of challenges throughout the United States. So, I’d like to start off with a couple of questions. 

Dr. Volkow, the COVID-19 pandemic has fueled a tragic situation, with deadly consequences, specifically around drug use and addiction. Can you share what you’re seeing, not only on a national scale, but what’s happening specifically among American Indian and Alaskan Native communities?

[DR. NORA VOLKOW SPEAKING]

Yes, and I know unfortunately what you’re saying is correct. We’ve seen an acceleration of the number of deaths associated with overdoses with the COVID pandemic. So, during the 12 months that ended up in April of 2021 the CDC just released data that tells us that more than 100,000 people died during that year. 

And so, everyone has been affected and it reflects very much the challenges that we have all been facing as a society with the uncertainty, the stress, the loss of loved ones. That actually are associated with behaviors that leave people sometimes greater likelihood of taking drugs and taking drugs in ways that are more dangerous.

At the same time we’ve seen that the illicit drug market is actually has been loaded with very, very dangerous drugs, like fentanyl and methamphetamine that have very high fatality rates. And within these very major challenges we have also seen tragically that there are some groups that are affected more than others. For example, we have noted in the past four or five years, that among American Indians and Alaskan Natives, there has been an increase in overdose there from opioids but importantly from methamphetamine. 

So, methamphetamine has been devastating American Indian communities, Alaskan Natives in ways that no other community has seen. And unfortunately, again, this has been exacerbated by the pandemic. Other aspect of work that actually makes the issue so very challenging is that we have seen that at least 75% of the overdose deaths from methamphetamine were associated with drug combinations. 

Methamphetamine that was contaminated with fentanyl. So, when people that are taking methamphetamine consume it, they don’t really know that it may have fentanyl and they have no tolerance to opioids. Fentanyl is among the most potent opioids that we know of, so that increases the risk of overdoses.

[DR. DAVID WILSON SPEAKING]

Wow, there’s just so many things to think about. So, you mentioned a lot of different things that have worsened the trajectory of these conditions that were specifically related to the pandemic. 

Are there any other things aside from the isolation and is there a challenge of people having access to resources, where they can seek care? Where they can seek support for those who are suffering from addiction in American Indian and Alaskan Native communities?

[DR. NORA VOLKOW SPEAKING]

Well, there are treatments and actually support systems have been expanded over the past two or three years, because of the significant increases in overdose deaths. However, during the COVID pandemic, access to those services has been curtailed enormously, because for example, the healthcare system was overwhelmed with COVID cases, and it couldn’t actually have the capacity to accommodate other their needs. 

And that affected very negatively the outcomes on people that were taking drugs, because that’s a place where they could go and get initiated in treatment or get the treatment, they were referred to special assist centres. The treatments that are, apart from the healthcare system’s specialty treatment for substance use disorder, for example, also suffered during the COVID pandemic.

Many of them closed their doors or decreased their staff that were able to take care of patients. They were much harder to access because of difficulties in transportation. And so, it became very, very challenging for everyone, including the American Indians and Alaskan Natives, that to start with, had a much harder access to some of these treatments.

Some of the tribes are actually in rural areas and they are not nearby treatment facilities that can provide access to support systems necessary for stopping taking drugs and for achieving recovery. So, all of that negatively impacted actually so, in the one hand, as you are commenting, the stresses, the social isolation leading people to take more drugs. But then the systems that would protect them and help them get out of the dangers of drug use and addiction were curtailed by the pandemic.

[DR. DAVID WILSON SPEAKING]

It really sounds like there’s been a swell or a building wave of challenges that have just added to the complexity of dealing with drug use and drug addiction. So, you’re so close to these issues. And as an expert, a leader, a researcher and an advocate for American Indian and Alaskan Native communities, what do you see as strategies to help us address this overdose crisis?

[DR. NORA VOLKOW SPEAKING]

Well, it is, I mean, we use science. Our main tool is actually to develop knowledge that can help optimize treatment outcomes for people with substance use disorders and prevent them. We’ve also, through this science, what has become very clear, is that there’s not an intervention that works for everyone. And what is also very clear is that there are enormous strengths among American Indians and Alaskan Natives.

And I would say perhaps the strongest one that they have and I bring it up because we should take advantage of it for prevention and treatment, is that of social networks. And there’s a very strong tradition among American Indians and Alaskan Natives, of the value of others, of the value of nature, of that spiritual communication of that we’re more than who we are. That we belong to or are part of something greater. And having respect for that. And that is extraordinary powerful and I think that in a way, the loss of that sense of being part of something bigger, is what makes people very hopeless and distressed and puts them at the higher risk of taking drugs. So, what we are learning is how can we empower scientists that come from American Indians and Alaskan Natives, that know that culture. So that they can develop models that are sensitive to these traditions. More importantly, take advantage of the strength of these traditions to implement and provide resilience. 

So, through grants and various mechanisms, we’re actually, on the one hand, trying to increase and expand the very limited number of scientists that we have from American Indian and Alaskan Native communities. Because we need to have a much greater representation of them on the creation of knowledge. 

But at the same time, create partnerships in the meantime that can actually deploy therapeutic interventions. Deploy prevention interventions that are likely to be particularly viable, that are cultural sensitive to American Indians and Alaskan Natives. I learnt from that, because we should all take lessons that are positive and apply them even to other communities. 

[DR. DAVID WILSON SPEAKING]

I really appreciate that. I think something that really resonated with me was the community approach to healing and I think that that’s something that we can all learn that many tribal communities actually embrace. It’s more the community approach over the individual approach. So, it’s not only the individual, but it’s coming together as a community and how we heal everybody, because they all play an integral role in each of our communities. So can you tell us more about the research that NIDA is doing to support tribal communities specifically, or studies that you are particularly excited about in the area of this research?

[DR. NORA VOLKOW SPEAKING]

Yes, there are several ones that I’m very excited about. One of them, is again, taking advantage ultimately of resources that exist that are placed, for example, through SAMSA or through CDC. There’s been some grants that have been given to American Indians and Alaskan Natives in tribal communities to try to actually deploy treatment and prevention efforts.

So, we have, through NIDA, supplementing those researchers to actually take advantage to gain information about what works from those interventions and therapy and prevention such that then they can be applied in a very targeted ways.

We also have, I’m also very excited about another initiative, also targeted to American Indians and Alaskan Natives, to take advantage of social networks which are so extraordinarily important to address the notion of substance use. What we’ve known all along, is that particularly among American Indians and Alaskan Natives, there have been always major challenges in terms of substance use, with alcohol use disorders. That’s one and the other one we’ve also known that American Indians and Alaskan Natives there are relatively very high rates of suicide and we have started to see the significant increases now on methamphetamine use and also opioid use. 

So, the notion is within these constraints that are part of the diseases of distress, that in a way reflect trauma and a sense of lack of resources and empowering that American Indians and Alaskan Natives have lived through their history. But they have that against them, but on the other hand they have the strength of community. So, this research is going to be focussing on that power of the networks to try to maximize how do we use it for prevention and treatment. And also, how to use it as an early signal of distress. 

So, in a network that is communicating properly and that has that support system, you should be able to screen and intervene early on when you see someone suffering. As opposed to what happens very much when people are in that situation, or in isolation, which again increases the risk of very negative outcomes. So, I am very, very excited about these projects. 

We also have a project that maximizes that, again, saying, we are [inaudible], we are the scientists in a way, right? What science and knowledge can be derived in different ways. So, we are asking the younger people living in these communities to actually use symbols through other ways of expression. To communicate to us what they think is meaningful in terms of passing the message that use of drugs is actually a negative trajectory. And how do they communicate that in a meaningful way to other young people that are of the same culture? And again, empowering the voices because they were born there. They are part of this community. We have been basically as much as we want to understand it, we are outside it. We don’t have that sensitivity that they do, so again, we’re trying to use ways to expand that so that we can gain knowledge in optimal communications as strategies that may be effective to them.

[DR. DAVID WILSON SPEAKING]

Wow, that’s a really wonderful example and I think what you just highlighted is a really good example of community-based participatory research. Bringing in many different communities who share different types of knowledge to help achieve a common goal. So that’s wonderful. I’m really happy to hear about that and I’m glad that we’re also seeing a trend across the agency in terms of recognizing that it’s really important to think about the community when thinking about research.

Whether we’re thinking about drug addiction, or drug abuse, or we’re thinking about mental health issues, so I’m glad that this is a growing conversation. And you very much will have early on recognized this, because of your extensive engagement with tribal communities so we really appreciate that. 

Can you briefly talk about something that’s emerging and has a tremendous amount of potential? But I just don’t think our audience really knows a lot about it. And that is in terms of precision medicine and how could this actually be used as another tool to help tribes better understand addiction in their communities? Specifically, I’m thinking along the lines of pharmacogenomics but I think that you could be able to provide a lot more examples.

[DR. NORA VOLKOW SPEAKING]

Yes, no and I think I mean obviously precision medicine and pharmacogenomics has the potential of improving the way that we treat anyone, whether it’s American Indian, Alaskan Native, or Hispanic, or Black American. Because it actually identifies potential genes that may modify the way that we respond to our treatment. Or may modify or increase the risk or resilience to a disease. 

As we’re dealing with substance use disorders. And addiction, including addiction, what we need to be mindful is that the main country where there’s right now, in terms of that impact, that these drugs are creating in our communities at this point is not genetics. This point is social and economic factors that are driving people to despair and that are also pushing an illicit market that is very profitable. So, these are major impact factors. 

Genetics certainly makes you more higher risk, so genetics are going to make you more or less vulnerable to adverse or resilient circumstances. They are going to model like that response. But when you have not addressed the main source of the harms from addiction, you’re not ready to take advantage of… You’ll ultimately, with the tailoring of that intervention. I think that right now the urgency is to address the factors that are making people so vulnerable to taking drugs. To address the factors that have made American Indians and Alaskan Natives so very vulnerable to right now, the rising methamphetamine and fentanyl. And also, that has made them so very vulnerable to suicide and again, we have to say, that there have been an enormous amount of historical suffering and in a way unfairness. 

There was a way that we have dealt in the past with them and I think… Which is also when I speak of them, I mean we also have to recognize that it’s an extremely diverse group of incredible richness of culture. So, it’s not like we can even put them in just in one category, but of a richness that historically, we have not been able to appreciate.

And I think that this is the time, with COVID, that it has forced us into thinking that these priorities are untenable and that it’s hurting everybody. And in the case of addiction, yes, I’d love to see the day when we can look at genetics and tailor the intervention accordingly for treating substance use disorders. But right now, it is a crisis. My perspective is we need to address the social and economic determiners that are driving many people to situations of despair.

[DR. DAVID WILSON SPEAKING]

Absolutely, very, very important. Well, we are almost running out of time, so I’d like to ask you one more really important question. What is your advice to someone who maybe is struggling with addiction themselves, or may have a loved one that they see struggling with addiction?

[DR. NORA VOLKOW SPEAKING]

I would, basically my first message to them, is addiction can be treated. This is disease like many others. It is a chronic disease, so it’s like if you have diabetes, I mean it would be great if we could give you a treatment, like an antibiotic that cures you. But we don’t have that. What we can do is actually give you treatments that allow you to live your life perfectly normal.

The same thing with addiction. It can be treated. It requires long-term treatment, the [inaudible] to which can be decreased the longer the period that you have been in recovery. But recovery is achievable and with that recovery is basically a return to life, to a normal life, to a productive life. And that basically is what we aim to do when we’re speaking about treating substance use disorders and ultimately achieving recovery.

What has happened is that people don’t, when they are in the midst of the distress from addiction and they relapse and they relapse and they relapse, so many times they lose hope and say, I’m never going to be able to get out of it. And the reality that is the relapse stay is part of the addiction cycle and it does not mean that it cannot be treated. It means you have to restart treatment. 

So, the same thing if you hypertension and you know, you’re controlling your blood pressure, you’re taking your meds and then it goes up again. And you go desperate, but you just have to modify that treatment intervention and you can control it very, very well. So that is my message. Seek treatment. Do not be afraid to seek help. There is nothing that they know as weakness or being embarrassed or shame about being addicted. They are like any other disease. You don’t chose to have it.

[DR. DAVID WILSON SPEAKING]

Wow, thank you so much, Dr. Volkow for being here today to discuss these urgent issues surrounding drug use and addiction. It’s so critical for the NIH to continue to focus its work on strengths, resiliency and the assets of American Indian and Alaskan Native people.

And I really appreciate you spending some time with us today to talk about this, again, a critically important issue. And thank you for listening.

[DR. NORA VOLKOW SPEAKING]

No, thanks very much for having me and thanks very much for representing the American Indians and Alaskan Natives.