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Considering the opioid epidemic’s adverse and disproportionate consequences on Indigenous American communities across the nation, United States federal agencies (i.e., Indian Health Service, the Bureau of Indian Affairs, and the White House Office of National Drug Control Policy) and Tribal nations are urgently calling for more substance use treatment and prevention efforts. Problem-solving courts (PSCs) are a well-known innovation for treating individuals with substance use disorders (SUDs) and those who have committed non-violent offenses. However, very little is known about these courts in indigenous communities and how they address substance use disorders. Drawing on a small sample of court coordinators (n=5), this pilot study contributes unique insights into emerging literature on Indigenous American communities and their use of Tribal Healing to Wellness courts to provide substance treatment services using culturally responsive practices. In addition, the findings inform future research directions aimed at understanding the nuances of developing and implementing treatment programs within high-risk, high-need, and high-poverty Tribal communities.
Keywords: Medication-assisted treatment, opioid use disorder, Indigenous Americans, Healing to Wellness, Tribal courts
Considering the opioid epidemic’s adverse and disproportionate consequences on Indigenous American communities across the nation, federal agencies (i.e., Indian Health Service, the Bureau of Indian Affairs, and the White House Office of National Drug Control Policy) and Tribal nations are urgently calling for more substance use treatment and prevention efforts. Problem-solving courts (PSCs) are a well-known innovation for treating individuals with substance use disorders (SUDs) who have committed non-violent offenses (Mitchell et al., 2012; Haskins, 2019). Unlike traditional criminal courts, PSCs are designed to provide participants with customized treatment services and recurring judicial monitoring of the participant’s progress within a collaborative court context (Kaiser & Holtfreter, 2016). Different types of PSCs address various types of offending-related behaviors that are rooted in underlying social issues, such as substance misuse, homelessness, or mental health disorders (Berman, 2002; Marlowe, Hardin, & Fox, 2016) or circumstances that exist among special populations such as veterans, individuals reentering society from prison, or Indigenous Americans experiencing substance use issues within Tribal communities. Within problem-solving courts is a subset of Tribal Healing to Wellness courts1 designed to serve Indigenous American (IA) populations. These courts provide a culturally relevant and responsive approach to the needs of indigenous communities through their court processes, including their treatment, testing, and graduated problem-solving responses. There is much to learn about these courts in Indigenous communities and how they address substance use disorders. This pilot study seeks to provide context surrounding the gap in available knowledge by using a small sample of court coordinators (n = 5) who were interviewed about their PSCs for IA participants with SUDs, including alcohol and opioid use disorders. Thus, we contribute important considerations for conversations about emerging literature on IA communities and their use of Tribal Healing to Wellness courts for providing substance treatment services using culturally responsive practices.
The opioid epidemic has disproportionately impacted the 2.7 million people living in Tribal communities (Horwitz et al., 2020; Vestal, 2016 and 2019). Although Indigenous Americans (IAs) comprise less than two percent of the national population, from 2006 to 2014, they were nearly 50 percent more likely to die of an opioid overdose than non-natives (Horwitz et al., 2020; Vestal, 2016 and 2019). IAs remain a vulnerable population as Tribal communities’ overdose mortality rates persist above the national average and have risen since 2000 (Centers for Disease Control (CDC), 2022). These communities continue to face persistent inequities in access to healthcare on and off reservations, often resulting in little to no access to mental health and substance use services. One in 28 IAs (3.5%) receives some SUD treatment, even though 13 percent of Native people would benefit from said services (Kaliszewski, 2022).2 By comparison, among the general population in the United States, one in 65 (1.5%) people 12 and older received SUD treatment in 2017, while 7.6% needed it (Substance Abuse and Mental Health Services Administration (SAMHSA), 2021). While these numbers generally show the large gap between the need for and receipt of SUD treatment in both the IA and general population, they obscure that SUD is more prevalent in the IA population, and there is a disproportionate impact that a lack of access to SUD treatment has on indigenous communities.
Tribal Healing to Wellness courts is a crucial mechanism to treat substance use and mental health disorders for people in indigenous communities. In 2014, there were a recorded 72 operating “Healing to Wellness” courts (Tipps, Buzzard, & McDougall, 2018). These courts are part of a Tribal justice system and implement the original drug court concept to address the local community’s treatment needs (U.S. Department of Justice, 2014). The drug court model is the oldest and most common type of problem-solving court that facilitates access to behavioral substance use therapies for people with non-violent, drug-related crimes (Marlowe, Hardin, & Fox, 2016). Drug courts and other types of PSCs subscribe to the same ten key practice components developed by the National Association of Drug Court Professionals (NADCP). These components include authorizing supervised treatment programming, conducting drug testing to monitor abstinence, using frequent court check-ins for judicial monitoring, and using incentives and sanctions to ensure compliance of participants (see U.S. Department of Justice, 2014 for a complete discussion of these ten components). The original jurisdiction of Tribal courts provides the authority for Tribal Healing to Wellness Courts to implement problem-solving practices or healing-to-wellness practices as the courts see fit. Consequently, the design and structure of treatment programs vary significantly from one IA community to the next and reflect each community’s context-specific circumstances and capacities (Tipps, Buzzard, & McDougall, 2018).
While there are ten Tribal Key Components included in these courts’ development and implementation, the IA courts often mirror PSCs that serve non-indigenous individuals (U.S. Department of Justice, 2014). The IA specific guiding principles for courts include: 1) leveraging community healing resources within the Tribal justice process to help participants achieve physical and spiritual healing and to improve the community’s well-being; 2) referring participants to substance use treatment programs and protecting their due process rights; 3) using legal and clinical screenings to identify eligible participants for substance use disorder treatment and promptly placing participants in a treatment program; 4) providing access to culturally informed “holistic, structured, and phased, substance abuse treatment and rehabilitation services” (U.S. Department of Justice, , 2014, pg. 28); 5) providing supervised treatment and monitoring for participants’ progress through frequent and random drug and alcohol testing; 6) offering progressive sanctions and rewards to motivate participants to comply with the requirements of their treatment plan; 7) creating opportunities for judicial and staff involvement with participants; 8) assessing the court’s progress and efficacy through monitoring and evaluation; 9) providing interdisciplinary education (e.g., training and development efforts) opportunities, which foster effective Tribal Healing to Wellness court planning, implementation, and operation; and 10) establishing and sustaining ongoing communication, coordination, and cooperation among court team members, the local community, and treatment providers, which is fundamental for the court program’s success.
Tribal Healing to Wellness courts infuses substance use treatment with culturally responsive treatment requirements and services. For instance, sanctions may include Tribal community service hours, helping elders or storytellers, or partaking in community-based conflict resolution sessions (e.g., peacemaking, family conferences, elders’ panels) (U.S. Department of Justice, 2014). Culturally responsive incentives may include receiving community recognition through a formal award ceremony or community celebration (U.S. Department of Justice, 2014). In providing culturally responsive treatment, Tribal Healing to Wellness courts collaborate with traditional healers (e.g., medicine men) to integrate traditional healing practices that focus on Indigenous American principles of family, harmony, accountability to the community, and a redirecting away from the crime to the cause of it (Krueger-Gutierrez, 2015). Traditional healing practices are tribe-specific and can include various healing components, including “traditional healing ceremonies, talking circles, peacemaking, sweats, sweat lodge, visits with a medicine man, sun dance, and vision quest.” (U.S. Department of Justice, 1999, p. 10). This holistic approach attempts to heal the person so that they reach a physical and spiritual state of wellness. Unfortunately, research on Tribal Healing to Wellness courts remains very limited, with a few case studies of individual Native communities and no details on the extent of treatment service implementation. In addition, there is no firm understanding of the treatment processes operating in IA courts, specifically whether they address the rising opioid epidemic amongst the IA population.
Evidence-based practices and their use for SUD treatment in indigenous communities are widely understudied (Legha et al., 2014), as is the use of Medication-Assisted Treatment (MAT) (Rieckmann et al., 2017). The term Medication-Assisted Treatment (MAT)3 is frequently used to refer to medications for alcohol and illicit drugs. However, some prefer the term medications for opioid use disorder (MOUD) or medications for alcohol use disorder (MAUD). In this paper, we will use the term MAT. MAT is an evidence-based treatment with federal approval for Disulfiram, Acamprosate, and Naltrexone for treating alcohol use disorder (AUD) and Methadone, Buprenorphine, and Naltrexonefor treating opioid use disorders. Despite the well-documented effectiveness of MAT in reducing substance misuse and recidivism (Amato et al., 2005; Bankole, 2008), it remains a widely underutilized treatment option, especially in justice settings (National Academies of Sciences, Engineering, and Medicine, 2019). MATs are associated with a reduction in substance use, aligning with harm reduction principles (Lenton & Single, 1998; Brinkley-Rubinstein et al., 2017). However, national and local drug policy has historically promoted the end of illicit substance use rather than the reduction of harms caused by substance use (Marlatt & Witkiewitz, 2010).
Consequently, MATs may seem in opposition to that longstanding abstinence agenda. However, as MATs continue to show efficacy and national and global drug policy incorporate harm reduction principles, the adoption and implementation of MATs in justice settings have been on the rise (Berg, 2019; Global State of Harm Reduction, 2020). Unfortunately, there remains a significant lack of research on MAT utilization within Tribal communities; it is unknown to what extent MAT is used among IAs (Rieckmann et al., 2017). Given this significant gap in research, little is known about how and to what extent Tribal Healing to Wellness courts use MAT for IA populations and to reduce high overdose mortality rates within Tribal communities (Tipps, Buzzard, & McDougall, 2018). While MAT is widely supported by national (including numerous federal) organizations4, there is still a lag in the uptake of MAT medications as an evidence-based treatment for managing and decreasing opioid misuse in criminal legal settings, especially in rural communities. Nearly 60% of rural counties in the U.S. do not have any eligible prescribers of buprenorphine in office-based settings (Andrilla et al., 2019). This same trend is likely to exist in Tribal nations, many of which are in rural areas. More research is necessary to understand the availability of MAT for IA people attempting to manage their substance use disorders under the supervision of Tribal Healing to Wellness courts.
The present qualitative pilot study was conducted from 2019 to 2020 to supplement a more extensive study of MAT utilization in PSCs (Farago, Blue, Smith, et al., 2022). An interviewer with Tribal membership conducted telephone interviews with a sample of Tribal Healing to Wellness court coordinators who were working in courts that primarily serve Indigenous Americans. The pilot study aimed to explore how Tribal Healing to Wellness courts use and administer MAT as a treatment for indigenous peoples with SUDs. Five coordinators were interviewed by telephone to learn how these courts serve IAs with SUDs, especially concerning their access to MAT. Two research questions guided the present study. First, how is MAT implemented within Tribal Healing to Wellness courts? Second, in what ways is MAT being utilized to treat IA participants within Tribal Healing to Wellness courts?
Sixty potential research participants were identified based on the results of an online search for problem-solving courts serving IAs. Using this list of participants, the interviewer invited potential participants to participate in an interview for research purposes. Most respondents have yet to respond to the request for an interview. Seven court coordinators agreed to participate in the study; however, one participant chose to discontinue the interview halfway through. As a result, six court coordinators were interviewed. Another interview was explicitly unrelated to IA communities as the court served primarily non-IA constituents and thus was excluded from the present analysis. Therefore, this pilot study is based on interviews with five court coordinators from Healing to Wellness courts serving IA people (see Table 1). Upon approval from the university’s Institutional Review Board, data was collected through semi-structured interviews that typically lasted 45 minutes to an hour. The interview guide was developed from the more extensive study; the survey contained the following thematic sections: 1) introduction; 2) court coordinator role; 3) problem-solving court; 4) staffing and training of staff; 5) treatment services offered; 6) assessments and screening; 7) treatment collaboration; 8) factors affecting participants; 9) coordinator perceptions and attitudes; 10) MAT attitudes and perceptions; and 11) demographics. Some of the interview prompts included: “What has been your experience at your court?”; “How would you describe your problem-solving court and its participants?”; and “Please describe the staff involved in your problem-solving court and their training related to Medication-Assisted Treatment.” Unlike the more extensive study, one qualitative data collection instrument (i.e., interview guide) was developed for collecting data from Healing to Wellness court coordinators. Tribal Healing to Wellness courts were difficult to engage in the research study. Since there was no reliable directory or contact list of such courts, the researchers had to develop a list of active courts with the aid of their coordinators. Most wellness PSCs did not have a website, and in the cases where one exists, it often contained outdated and/or inaccurate contact information. Other barriers to recruitment included coordinators’ concerns about or discomfort with the interview questions and lack of interest and/or knowledge about MATs.
After each telephone interview, transcripts were generated and checked for accuracy by typing them into Word documents and reading them extensively, line-by-line, while listening to the audio recordings as a reference. A qualitative data management software, Atlas.ti, aided in the coding process and facilitated the management of the generated transcripts (Muhr, 1991). The interview data were analyzed through a systemic coding process that consisted of an inductive and deductive approach to coding. Open coding was used to identify initial patterns in the data and create codes that summarized text passages (Corbin & Strauss, 2008). Two researchers independently identified around 50 codes related to substance use treatment, MAT usage, court operations, and culturally responsive practices. Open coding was followed by closed coding, whereby a handful of the most relevant and previously identified codes were applied to all transcripts through line-by-line coding (Corbin & Strauss, 2008). For this article, we focused on the most relevant codes that spoke to the following themes: MAT Service Availability & Acceptability, Integrating Culturally Responsive Services into PSCs, and Barriers and Facilitators for Treatment Program Participation.
The interviewer, the initial analyst who began making sense of the collected data throughout the transcription process, has a positionality as an Indigenous American (Diné (Navajo)/Southern Ute) woman with legal and clinical psychology training. Her positionality was vital in the quality and content of the interviews with Tribal court coordinators. Although she identifies as Indigenous American and is enrolled in a federally recognized tribe, she was not raised traditionally or spoke her tribe(s)’s language(s). Thus, she acknowledges herself as an outsider when researching within Indigenous American communities. However, she has prior professional knowledge of the functioning of Tribal courts from her previous experience as a coordinator of residential treatment for court participants when she worked at a reservation-based substance use treatment facility. The interviewer’s prior knowledge and legal background supported her ability to recruit participants for the study. She also acknowledges that her philosophical lens is rooted in humanistic existentialism. As such, she believes in the dignity of others and the freedom of choice, even when it comes to substance use. However, she also recognizes the societal context and the authority of the legal system on the lives of individuals who become physically dependent on substances or whose use of substances results in justice system involvement. Considering these potential barriers to wellness, dignity, and freedom, her motivation for this research is to support system changes that prioritize individuals rather than the economization of services.
The second analyst is a non-indigenous woman who is a first-generation immigrant to the U.S. As such, she participated in the study as an outsider to the Indigenous American community. The social constructivist paradigm underpinned her epistemological approach to this study. Accordingly, her philosophical assumptions about the ever-changing and profoundly subjective nature of reality, as constructed through social interactions, played a role in how she analyzed the data. Additionally, her sociological training influenced coding because it attuned her to macro-, meso-, and micro-levels of analysis in understanding the broader social issue of addiction and the opioid epidemic. She coded under the assumption that substance use and treatment attitudes and practices in IA communities are deeply subjective, multifaceted, and socially situated in local, state, and national contexts. Accordingly, as a coder, her objective was to understand the culturally relevant meaning of substance use treatment in IA communities and to analyze the data so that it could reveal a complex array of views and meanings about how these communities approach substance use treatment.
Providing an overview of the interview data from five court coordinators, Table 1 shows the scope of five Tribal Healing to Wellness courts.
Table 1: Five Tribal Healing to Wellness Court Characteristics
Type/s of SUD Among Court Participants
Offers MAT Program?
Healing to Wellness
Adults; federally recognized Tribal members only
Heroin, alcohol, and meth; co-occurring meth and opiate SUD
Yes, an established program with its own MAT clinic that is in walking distance of the court.
Healing to Wellness
Adults; local Tribal members and non-Tribal member residents
Any formally diagnosed SUD (details unknown)
Yes, an established program that collaborates with another tribe to administer MAT.
Healing to Wellness
Youths; federally recognized Tribal members only
No, MAT is not offered since court serves youths with AUD. However, the court is considering opening an adult drug court program because of apparent rise in SUD among adult Tribal members.
Healing to Wellness
Adults and Youths; federally recognized Tribal members and their descendants
Co-occurring SUD involving mostly alcohol, marijuana, meth, and/or opiates
Will soon be offering MAT since the tribe recently received a grant and is now developing a brand-new MAT program.
Healing to Wellness
Adults only; Any local resident
Meth; co-occurring SUD with meth and heroin
Yes, an established MAT program is offered and the court refers participants to treatment providers.
In these courts, court participants tended to be male and completed the SUD treatment program in approximately 16 months. Per federal funding regulations, all five courts excluded people from court participation if they had committed a violent offense. Additionally, people who committed sex offenses were excluded from the programs.
Court coordinators tended to be female (80%), working for five years or less (60%), and occupied the role of case managers or program managers. Their duties included any combination of managing the court docket, scheduling hearings, acting as participant advocates, managing general administrative duties, collaborating with community stakeholders (e.g., Tribal leaders, community members) along with treatment providers, reviewing and updating court policies (e.g., eligibility requirements) or the policy handbook, managing grant seeking and writing to sustain court funding and grow the court program over time. Interviewees emphasized the importance of attending the annual NADCP and other Healing to Wellness court training (e.g., Tribal consortium and Tribal enhancement training); however, coordinators also expressed that annual training was costly and highly dependent on the availability of court funds. At the same time, three out of five (60%) interviewees did not cite MAT-specific education as a typical component of their annual training activities.
As shown in Table 1, courts were at different stages of MAT utilization: three courts authorized MAT through well-established programs (i.e., Courts 1, 2, and 5), while two others were developing MAT programs (i.e., Courts 3 and 4). Among the courts that had established treatment programs, only one court coordinator (from Court 1) confirmed that their court authorized buprenorphine/naloxone and naltrexone. The other interviewees either chose not to disclose this information or stated that they do not know what types of MAT their treatment staff uses as the court only refers people to them but does not directly manage their treatment decisions. Across the courts with established MAT programs, there was variation in how the treatment services were offered. For example, one IA community had its own MAT clinic across the street from the courthouse. Another court partnered with a nearby Tribe to provide MAT services, especially Methadone treatment, which the neighboring Tribe offered through their treatment clinic. In each Tribal community, the availability of MAT was linked to the IA leaders’ and other community members’ general acceptance of it as a treatment option. For instance, a coordinator from Court 1 shared the following:
I think that in order for us to have started the opioid treatment program, the community as a whole had to give approval; they would not have pushed through with it otherwise. So, most of the community is on the same page because so many of them have been impacted by overdoses, chronic jail and incarceration, losing family members, or having their family members destroyed, and they're able to see the difference in that.
Other court coordinators (i.e., Courts 2 and 4) reflected on additional factors that contributed to the acceptance and availability of MAT, such as the county context in which the court was located, existing federal requirements for providing MAT services in grant-funded PSCs, or the presence of a designated MAT advocate on the court’s board of directors. For example, the court coordinator from Court 2 shared:
I would say [MAT is] very welcomed, and even for some clients, it is encouraged. The [redacted] county drug court doesn’t allow MAT. So having a drug court program in the area, I think, is a really big positive with our [Tribal] community. I don’t know that we would be successful if we did not allow it. I do believe that it was part of our [federal] grants that we had to require, or we had to accept MAT. I do know that the board also has an advocate for our board of directors; I believe there was an advocate for Medication Assisted Treatment. So, if [the board of directors] didn't allow it, I don't think we would have a big enough support from the tribe.
In contrast to coordinators from Courts 1 and 2, the coordinator from Court 5 oversaw both IA-serving Healing to Wellness courts in addition to seven different courts that served a diverse population of county residents (i.e., IA and non-IA), also known as a State Court Coordinator. This coordinator observed that various stakeholders were very accepting of MAT, including for treatment of pregnant women with a SUD:
So, I would say that from my judges to my attorneys, to social services and the family drug court, to my staff, and the case managers who are making referrals for MAT, I have experienced no bias, no ill feelings about having pregnant women on MAT or anything like that.
Additionally, the State Court Coordinator described how the court’s funding and provision of MAT changed over time as a new federal healthcare policy was implemented:
And since I started in April of 2013, our drug courts have paid for medically assisted treatment and referred people for medically assisted treatment for anyone that needed it. That was before Medicaid covered it in our county, pre-Obamacare. We had contracts with the MAT providers, which was really just methadone. So, we had contracts with the methadone providers, and we paid out of pockets, out of the collaborative courts’ budget for anybody that needed methadone.
The above quotation suggests that there are meaningful relationships to consider between healthcare reforms and MAT availability, specifically, how national healthcare reforms may facilitate access to MAT for court participants who would not be able to afford it otherwise.
Two courts offered culturally responsive incentives or treatment services to serve IA participants better and gain their trust in the treatment process. The coordinator from Court 1 shared how the court integrated cultural responsivity into its incentives and sanctions:
So that if a client is in full compliance, we have a drawing, and they’re able to choose something that they might need. We do that, and we just started, when I came on board, kind of changed the core process so that we do it in a circle, we do medicine, but medicine down, sage and sweetgrass. So, we try to be very cultural, which I think has made clients more open to the process as well. [For sanctions, we offer] community service and doing it in a way that you can give back to your community, pay homage to the elders, and do something for elders. So, we try to make the whole thing a learning process. And with trying to be consistent in our responses, still make them something that will hopefully get the client to change their behavior if it is about missing groups or relapses. We look at that as a therapeutic response, or maybe it is just an issue of increase your level of care and treatment. So, we have really tried hard to incorporate white bison; we had a white bison as one of the mandatory [requirements]. We do that as part of the healing processes.
Meanwhile, the coordinator from Court 2 mentioned healing rooms as a critical, culturally responsive treatment resource:
The healing rooms that we have, we really try to push that and have that as a resource for them. When they go to inpatient, we’ll try to arrange housing, have it set up by the time they’ve done an inpatient, so they have somewhere to go. And that really seems to work. Whether they have a bed at an Oxford house or they’re doing laundry for another [inaudible 00:24:58] housing, or even if it is just getting in contact with family members to make sure they have a safe place to stay.
Offering “healing rooms” is one way treatment programs can foster a culturally responsive ethos for their IA clients and further support their recovery by helping them transition from inpatient to outpatient care and a safe environment. Fostering a connection between participants and their respective traditional IA healing practices can be an important way for an individual reconnects with their community and begins “to walk in balance and harmony,” thereby making progress toward a pivotal treatment goal of Healing to Wellness courts (SAMHSA, 2018, p. 6).
A lack of transportation and housing were critical barriers to adult participants’ engagement with a Tribal Healing to Wellness court’s treatment program. Transportation is a central barrier to court-authorized treatment participation for high-poverty participants. Many must travel 20 to 40 miles to the nearest court without a personal vehicle or access to a local transportation system. These conditions put Tribal Healing to Wellness court participants at increased risk of dropping out of their treatment program. The coordinator from Court 1, which has an established treatment program complete with a MAT clinic across from the court, explained why this was a unique challenge on a reservation:
So, if you live at the other end of the reservation, and there’s no bus transportation, and you don't have a car or a license, which is the majority of my clients, that has a huge impact on their ability to fully participate. Because what ends up happening is they’ll get somewhere too late to engage, they won't be able to make it in at all.
The coordinator from Court 4, which is in the process of developing a brand-new MAT program, also expressed transportation concerns and related funding shortages that could be particularly challenging when engaging those participants in SUD treatment who lived in remote parts of the reservation:
Our reservation is a pretty wide area, and there’s not a lot of resources here for us to cover [the needs of remotely located residents], especially with us having transportation issues too. There’s not a lot of funding in our tribe to get work or transportation for our officers. So, it is hard to reach out to these outlying communities. Sometimes they’re 30, 40 miles away, and it is hard, especially if we have participants in those communities, to get here. And actually, all of the treatment facilities and staff are right here in our central location in town, like our agency. So, it is really hard for them to get here and us to get to them. Especially weather issues; we have really hard winters here.
The coordinator’s insight from Court 4 suggests that it is vital to consider the Tribal Healing to Wellness court’s geographic context and how it may compound transportation shortages and pose unique, context-specific challenges to providing access to SUD treatment programs for IAs living on a reservation or in nearby rural areas.
Concerning housing, interviewees cited that their communities were experiencing severe shortages. Coordinators expressed their concerns for participants without housing, noting that they needed a safe and supportive environment to rely on that could foster their SUD recovery. Additionally, coordinators acknowledged that participants without a safe and stable home environment faced more barriers to accessing and adhering to their treatment program. For example, the coordinator from Court 2, who collaborates with a nearby Tribe to administer MAT, explained:
Housing is our biggest barrier right now, I would say. We have a lot of sober housing in the area, but unfortunately, in our areas, there’s a huge drug epidemic, [so] they’re all full. And we found that when our participants don’t have clean and sober housing, it really makes it hard for them to succeed [in the treatment program].
In another community, the housing shortage was exacerbated by the intersection between SUD and punitive housing policies, as explained by the coordinator from Court 4:
…the housing department has to evict a lot of families because of drug use. So, methamphetamine is one of the big things. The houses actually have to be condemned until they can get a hazmat crew to come in and clean it up. So, there’s a lot of boarded-up houses here, and there's not just enough houses going up to keep families in them. So, housing and homelessness is a huge issue here.
In contrast to adult participants, IA youths faced different types of barriers to treatment participation and SUD recovery. Lack of family support for SUD treatment, including parents’ struggles with SUD, were some of the main challenges IA youths faced during their court participation. The coordinator from Court 4 highlighted this sentiment:
So, our juvenile project, I’d say the biggest barrier is the parents are usually also addicted or suffering some kind of substance disorder. And they were really young parents, so they don’t have a strong connection with their kids. They need the skills for parenting, for one thing. So, it’s hard because the juvenile program restricts age. We don't actually have family wellness support. So, if one participant can come in, we try to rope in the family, but there’s no way for us to actually make the parent do something that they need to be doing. So, it is kind of like the juvenile's doing it all by themself most of the time.
Relatedly, a supportive family was also acknowledged as a significant factor in facilitating IA youths’ success in a treatment program. One court coordinator from Court 3 explained, “We have seen those individuals that have excelled or have graduated from our drug court program when the family support system is there; it really helps.” Given that a robust family support system is crucial for supporting IA youths’ SUD recovery, it is imperative to find new and additional ways to integrate SUD treatment of IA youths with family support services and to continually recognize within the court’s practices that IA youth’s recovery is interlinked with and dependent upon their family’s well-being.
The interviews revealed several themes about MAT service availability and acceptability, integrating culturally responsive services into Tribal Healing to Wellness courts, and barriers and facilitators for treatment program participation. The data shows that the acceptance and availability of MAT are greatly influenced by the local community context in which the court is located. Adoption of MAT practices tend to lag in rural and remote communities mainly due to delays in research dissemination and policy reform (University of Michigan Behavioral Health Workforce Research Center, 2019). Thus, the misperceptions of MATs as “just another drug” or the perception of risk for increased medication diversion persist (Richard et al., 2020). A strategy for addressing these misperceptions is through training. The data support the value of training for court staff to clarify the benefits of and evidence supporting MAT implementation. Like other harm-reducing practices, such as needle exchanges and safe injection sites, community buy-in is preceded by a goal in policy shifting from abstinence to harm reduction (Marlatt & Witkiewitz, 2010; Hawk et al., 2015). Existing federal requirements for authorizing MAT services, including eligibility criteria for accessing treatment, impact the availability and use of MAT in court-authorized treatment programs. Such circumstances help explain the noticeable variation in MAT uptake and implementation across Tribal communities. While some Tribal communities offer established SUD treatment programs, inclusive of a MAT clinic on the reservation, others must collaborate closely with neighboring Tribes and other local agencies to provide court participants with access to such treatments. However, the data also suggests that without safe and stable housing and reliable and affordable transportation, participants can face significant barriers to adhering to their program’s treatment requirements. For example, certain types of MAT treatment, such as methadone, which is one of the most used forms of MAT in the U.S. (Harm Reduction International, 2020), require regular in-person visits to a licensed treatment provider, and this is particularly difficult to comply with when living in a rural area without reliable public transportation. Additionally, lack of access to a sober home environment can increase one’s risk for relapse to substance misuse, even if they are receiving MAT. Nonetheless, while this small sample of data does not yield any substantive conclusions, it suggests that coordinators in these understudied and little-understood Tribal Healing to Wellness courts may hold favorable attitudes and perceptions of MAT and that Tribal leaders see the benefits of expanding access to MAT services as a necessary form of SUD treatment for IAs.
Several considerations must be met to offer and successfully provide the SUD treatment services IAs need. First and foremost, it should be expected that justice and healthcare professionals consider the diversity of cultures within IA populations and the subsequent variety of needs in approaching treatment and service (Zeledon et al., 2020). It has been suggested that MAT services should be tailored to Tribal communities to reduce barriers to access for IAs (Harm Reduction International, 2020). To do so, treatment providers working with Tribal communities must be effectively trained to honor the native emphasis on “spirituality, holistic healing, and wellness” (Venner et al., 2018, pgs. 111). For example, to accomplish this while implementing MAT in Tribal communities, healing frameworks must be integrated to close the gap between Western medicine approaches and traditional Native wellness practices (Venner et al., 2018). In this way, cultural competency is necessary to serve the substance use treatment needs of Tribal nations more effectively.
The present data suggest that courts are incorporating various culturally responsive practices into their treatment processes, including healing rooms, white bison, smudging with sage and sweetgrass, conducting group sessions in the shape of a circle, and paying homage to elders. Such culturally responsive practices garner participants’ trust and cooperation in the treatment process. In the broader literature, some evidence indicates that culturally sensitive SUD treatment (e.g., talking circles, addressing historical trauma, sweat lodges, and drumming ceremonies) can positively contribute to participants’ SUD recovery process (see review by Greenfield & Venner, 2012). However, integrating IA cultural values and worldviews into typically Westernized medical SUD treatment practices is relatively rare, and related research on its outcomes is sparse (Greenfield & Venner, 2012). Future research should address these gaps in knowledge and investigate the extent to which infusing such cultural practices into SUD treatment results in improved recovery outcomes for IAs across various Tribal nations. This is especially important since researchers do not know the extent of the available evidence, its benefits, or whether it is generalizable to IAs (Venner et al., 2018). In building this knowledge, non-IA scholars must conduct research collaboratively and integrate various research and ethical considerations into their efforts. Examples of such considerations include co-conducting studies with Tribal members (e.g., community-based participatory research), reflecting on the study’s potential community-level risks and benefits, and incorporating IA worldviews and values into the research design and process (i.e., indigenization) (Greenfield et al., 2021; Harding et al., 2012; Rasmus, 2014).
The present qualitative pilot study has three main limitations. While the collected data yields some exploratory insights on how MAT is used and implemented in Tribal Healing to Wellness courts, the sample size is insufficient for developing substantive conclusions about MAT utilization among IA communities. The sample is small because recruiting and finding willing research participants was particularly challenging, a common issue in research on problem-solving courts. Outdated websites and contact information, including inactive phone lines, made identifying IA-serving courts and locating contact information much more complicated than expected. Additionally, some research participants’ hesitancy and uncertainty about being interviewed further reduced the number of willing participants. For example, one participant initially consented to the interview but withdrew their consent because they felt concerned about answering questions about the Tribal government’s involvement/support for the court treatment program. To mitigate such participant recruitment challenges, future studies could draw upon a more network-driven recruitment strategy that enlists the help of key professional organizations and personnel (e.g., Tribal leaders) to help legitimize the study in coordinators’ eyes and encourage their participation. For example, in our parent survey study (see Farago et al., 2022), the National Association of Drug Court Professionals (NADCP) sent a letter to state coordinators, facilitating access to surveying local court coordinators. In the context of Tribal Healing to Wellness Courts, similar efforts to reach out to Tribal Leaders and court judges could yield better results for accessing court coordinators. The study’s second limitation is reliance on court coordinators’ self-selective participation. Most of the research participants reported that their program either had an established MAT program or was in the process of establishing one. Thus, the current pilot study does not present the perspectives of court coordinators or courts that do not have a MAT program or lack knowledge of MAT services. Lastly, while discussing how MAT utilization and acceptability varies by medication type is vital to understand the nuances of how Tribal Healing to Wellness courts authorize this type of treatment option, only one of our interviewees could provide information on the specific type of MAT (e.g., buprenorphine, naltrexone) available through the court’s treatment providers. Hence, this study’s findings help inform overarching discussions of MAT authorization among these particularly understudied courts. Future studies should advance the literature by examining the nuances of MAT utilization and acceptability in the context of Tribal Healing to Wellness Courts.
The present pilot study offers some exploratory findings on substance use disorder treatment through Tribal Healing to Wellness courts serving Indigenous American communities. This research topic remains notably under investigated. Nevertheless, these findings inform future research directions to understand the nuances of developing and implementing SUD treatment programs within high-risk, high-need, and high-poverty Tribal communities. Future qualitative studies should capture additional details about providing and receiving SUD treatment in Tribal communities by conducting more in-depth analyses with larger samples of court personnel, court participants, and Tribal community members. To do so effectively, researchers must be culturally aware of their position, values, biases, and the historical context of the indigenous people they seek to engage in research. Furthermore, researchers should collaborate with other stakeholders (e.g., Tribal leaders, members, and treatment practitioners) to support the design and implementation of programs and services that meet indigenous peoples’ treatment needs. Given Tribal communities’ context-specific needs, challenges, and resources for providing and implementing SUD/MAT programs, it is also essential to conduct more studies that aim to 1) identify factors/circumstances that explain Tribal communities’ unique needs within certain states and regions of the U.S., and 2) support the development of more effective regional and state-level facilitators of SUD/MAT services that are more responsive to indigenous communities’ diverse treatment needs across the nation.
Addressing pervasive social barriers to participating in treatment programs must accompany any effort to improve SUD treatment services for IA communities, namely shortages in safe housing, the unavailability of public transportation, and the absence of a supportive family network (especially for youths recovering from SUD). For participants living in high-poverty, high-need, rural communities, such factors are essential for ensuring participants’ successful recovery and completion of their treatment programs. The barriers found in the present pilot study reflect ones found in related literature and highlight the need for increased federal, state, and court-based support for connecting participants with system-level resources, such as transportation to and from SUD services and access to a sober home environment (Zeledon et al., 2020). Addressing these needs is fundamental to supporting Indian Country’s recovery from the opioid crisis.
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Fanni Farago is a doctoral student and research assistant at George Mason University and holds an M.A. in Sociology from the University of Houston. She contributes to qualitative and quantitative research projects within the broader areas of health, immigration, and education. She contributed to the current project as a Graduate Research Assistant for the Center for Advancing Correction Excellence! (ACE!).
Lindsay R. Smith is a doctoral candidate in the Criminology, Law, and Society department at George Mason University. She works as a Graduate Research Assistant at the Center for Advancing Correctional Excellence! (ACE!). Her research areas of interest include gender-based violence, community corrections, and co-occurring disorders.
Violette Cloud is from the four corners region of the Southwest (CO, AZ, NM, UT). She is an enrolled member of the Navajo Nation and a descendant of the Southern Ute Tribe. Violette holds a Master of Science (M.S.) in Clinical Psychology and a Juris Doctorate (J.D.) from the University of New Mexico.
Michael Gordon is a Senior Research Scientist at the Friends Research Institute and has expertise in developing, implementing, and evaluating innovative substance abuse treatment interventions for criminal justice populations (prisoners, parolees, probationers) with histories of opioid addiction. Dr. Gordon has been Principal Investigator or Co-Investigator on six major studies that have contributed to the field of substance abuse, HIV and criminal justice: (1) methadone maintenance for prisoners, (2) buprenorphine for prisoners, (3) long-acting naltrexone for prisoners, (4) long-acting naltrexone for probationers and parolees, (5) rapid HIV testing for criminal justice populations, and 6) criminal justice drug abuse treatment studies.
Faye S. Taxman is a Professor at the Schar School of Policy and Government and the founding director of the Center for Advancing Correctional Excellence! (ACE!), which conducts collaborative and creative research to bring evidence-based practices and treatment to practitioners and policymakers in the criminal justice and health fields. Taxman, a health services criminologist, is an expert in implementation and intervention sciences. She has conducted various experiments to determine which processes will improve access to treatment and retention, and to formulate and assess new models of probation that are consistent with current evidence-based practices.