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Table 1 Context mechanism outcome table

From: A realist review of best practices and contextual factors enhancing treatment of opioid dependence in Indigenous contexts

References

Location

Study design

Study sample

Context: program description

Mechanism: compassion

Mechanism: control

Outcomes

Beckstead et al. [31]

USA

Questionnaire

American Indian/Alaska Native (AI/AN) youth (n = 229) from 39 tribes

Dialectical Behavior Therapy (DBT) evidence-based treatment integrated with traditional models of healing within a AI/AN youth residential treatment centre (average length of stay 120 days)

Mindfulness, a core skill taught in DBT which can include traditional models of healing such as ceremony, talking circles and smudging; program considers individual needs for quality of life (e.g. employment) alongside substance misuse treatment

Consultation with tribal leaders; local spiritual leader provided weekly spiritual practices and explained the relationships between traditional practices and the mindfulness skills taught in DBT

Treatment outcomes: 96% either recovered or improved using Youth Outcome Questionnaire-Self Report edition pre and post-treatment (clinically significant change criteria)

Benoit et al. [19]

Canada: Downtown Eastside Vancouver

Participant observation, semi-structured interviews, and focus groups

Aboriginal women living in Vancouver’s Downtown Eastside (DTES) (n = 12); 25 interviews with staff and health professionals (n = 61)

Vancouver Native Health Society (VNHS), an integrated and holistic (e.g. food bank) service provision and primary care setting based on integrating traditional and western approaches; Sheway, VNHS partner with a model of care based on harm reduction

Free healthcare, non-judgmental primary care and establishing trust before initiating health care; providers aim to make a connection first, work on healing

Though service providers are primarily non-Indigenous, the clinic has recruited Indigenous volunteers to support agency; participants also noted gaps in traditional healing practices

Patient perspectives: Women primarily indicated a need for a Healing Place, integrated and holistic health care based in respect and influence over decisions and services that impact their healing

Black et al. [32]

Australia: Winnunga Nimmityjah community

Survey

Aboriginal adult opioid dependent patients (n = 21)

Opioid replacement pharmacotherapy for Aboriginal patients in the Winnunga Nimmityjah Aboriginal Health Service, a community controlled primary care setting

Programs include social supports and comprehensive care within a “supportive framework” that ensures stability for patients

Community-controlled health service houses the program; community leadership in education to garner support for opioid replacement therapy and peer outreach

Treatment outcomes: Comparable to outcomes in mainstream programs (81% retention; no significant change in self-reported heroin use)

Campbell et al. [37]

USA: Northern Plains Region and Pacific Northwest

Surveys and Interviews conducted 1-week post intervention

American Indians and Alaska Natives (AI/AN) (n = 40)

The Therapeutic Education System, a web-based community reinforcement approach for substance misuse treatment completed onsite at two urban outpatient programs

Training included learning to manage negative thinking and improve self confidence

Not evident

Participant outcomes: 37 completed at least one module; Patient perspectives: Participants indicated less interest in western approaches and a desire for more culturally specific communication styles and traditional practices including spirituality

Dooley et al. [33]

Canada: NW Ontario

Retrospective chart review

Mothers and infants (n = 2743)

The Integrated Pregnancy Program at the Sioux Lookout Meno Ya Win Health Centre that integrates prenatal and addiction care, including OAT and tapering in the third trimester

Male partners are involved in the program and offered additional addiction treatment; respect for patient; family-centered care; postpartum care is coordinated with community-based programs to ease transitions

Includes traditional healing practices along with OAT to encourage community involvement; the authors attribute the decrease in neonatal abstinence syndrome to the local community initiatives

Treatment outcomes: Significant decrease in neonatal abstinence syndrome between 2009 and 2015 (p = 0.001); observed positive community-wide changes

Duvivier et al. [20]

USA: Southwest, Midwest, and Great Lake regions

Program description

Indian Health Service pharmacists

The Prescription Drug Abuse Workgroup, Pharmacy-based interventions including responsible prescribing practices and improved access to medication-assisted treatment, comprehensive services, pharmacist-developed training for first responders

Advocate respect for the patient including supportive and nonjudgmental relationships; individualized and comprehensive treatment procedures; expansion of more comprehensive services beyond dispensation

Collaborations with local governing bodies

Care provider outcomes: pharmacists have pledged to reduce stigma, screen for opioid use disorder, support safe prescribing, and increased access to naloxone and committed to expanding medicated assisted therapies

Gray [43]

USA

Literature Review and case study

American Indian Adolescents

Two-month, 12-step based, in-patient treatment program with weekly trauma and loss treatment groups

Trauma-informed treatment, psychological and emotional wellness to prevent relapse; safe environment for grief support; holistic healing including spirituality, cultural connection, empowerment and internal strength; family-based care (adult family members invited to attend the final week)

Traditional healing practices and individual empowerment

Paper conclusions: treatment must include focus on trauma and loss, connection with culture and spirituality, and healthy coping skills

Gray et al. [44]

Australia, New Zealand, Canada, and US

Editorial

Indigenous populations

N/A

Harm reduction policies; solutions that address structural drivers of health inequities; partnerships between Indigenous and non-Indigenous organizations require trust

Indigenous people must guide or be involved at all stages of research and interventions

Key lessons: Research and interventions must be community-based, in collaboration with communities; appropriate research, evaluation and policy (including harm reduction) must be community defined; broader structural interventions

Jumah et al. [21]

Canada: NW Ontario

Provider workshop

Service providers in Indigenous communities

Service provider workshop for care of women with opioid dependence while pregnant and postpartum, in rural and remote settings

Recommendations included increased provider education on SDOH, trauma-informed care; improved transitions between services; family-based care including keeping families intact; improved access to medicated assisted therapy to reduce risks in transporting

Recommendations included Indigenous-led programs/ partnerships with Indigenous-led programs; integration of Indigenous best practices with ‘gold standard’ medicine; funding models that encourage collaboration rather than competition between communities

Care provider outcomes: providers committed to Indigenous-led interventions, improved transitions in care, trauma-informed care based in Indigenous worldviews and holistic health and wellbeing, and improved access to treatment (including stable funding for Indigenous programming)

Kanate et al. [34]

Canada: NW Ontario, North Caribou Lake First Nation

Community statistics 1 year before and 1 year after the program initiation

Community-wide data

Community-based, outpatient program that integrates buprenorphine-naloxone opioid substitution and counseling from traditional healers as well as other modes of holistic healing

Community acceptance and celebration of individuals attending treatment; holistic healing; sense of community purpose

Program is managed by community nurses and healthcare providers; First Nation counselors and healers deliver culturally based and land-based healing programs

Treatment outcomes: Community-wide healing: Decrease in drug-related medical evacuations (-30%), criminal charges (-66.3%), child protection cases (-58.3%); increase in school attendance (33.3%); observed increase in community spirit and sense of purpose

Katt et al. [35]

Canada: N Ontario, Nishnawbe Aski Nation communities

Urine toxicology screening

FN community members aged 16–48 (n = 22)

Community-based 30 day suboxone tapered off or to low dose maintenance program with community-based aftercare

Aftercare programs included overall health and spiritual support

Treatment in community health centre; collaboration between off-site addiction specialists and on-site care providers

Treatment outcomes: 95% completed the program, 88% had no evidence of prescription opioid use in their urine toxology on day 30

Katzman et al. [38]

USA

Pre/post intervention survey

Indian Health Service clinicians (n = 1079)

5-h virtual education sessions for clinicians on safe prescribing and appropriate pain management

Not evident

Not evident

Care provider outcomes: significant increase in knowledge, self-efficacy, attitudes (p < 0.001)

Kiepek et al. [22]

Canada: Ontario, Sioux First Nation

Program overview

Sioux First Nations

Inpatient medical withdrawal support service for patients seeking abstinence in the Sioux Lookout Meno Ya Win Health Centre (SLMHC)

Holistic care (integrates physical, emotional, interpersonal, contextual factors), recognition that individual health stems from community health; trusting and responsive relationships, emphasis on patient goals and additional supports from establishing a daily routine to community leadership; follow-up care

Community-based program; integrates traditional healing including Elders in residence; individual patient goals are prioritized

Treatment outcomes: All but two patients successfully completed the program between December 2011 and June 2012

Landry et al. [23]

Canada: New Brunswick, Elsipogtog First Nation

Semi-structured focus groups

Three groups: professional (methadone maintenance treatment program management and delivery) group, patient group, community group (n = 22)

Elsipogtog methadone maintenance treatment program in the Elsipogtog Health & Wellness Centre

Holistic healing, based in traditional medicine and spiritual beliefs, including life skills such as parenting practices

Community-based program, services offered in Mi'kmaq, Indigenous staff, Elders are available

Participant perspectives:Program considered effective at the Individual level (improved parenting practices), with some positive community impacts outlined (cleanliness, safety) but patients experienced stigma, marginalization and discrimination within the community (e.g. spiritual centers, employers) and family conflict demonstrating misinformation within the community

Lee et al. [39]

Australia: Sydney

Semi-structured interviews and surveys

Aboriginal female clients (n = 24) and staff (n = 21)

Weekly Aboriginal women's support group at an inner-city outpatient alcohol and other drug treatment service including opioid substitution treatment; format ranges from educational to informal conversation or recreational (e.g. art)

Topics vary, including treatment options and broader healing, skill building; group described as non-judgemental, offering skills-based training and broader health education including navigating systems; children welcome to attend the program; program emphasis on coming together and relaxing, providing opportunities for peer support and relationships with staff

Program encouraged client ownership of the group

Participant perspectives: Group members reported feeling safe, respected, supported and valued, gaining new skills, improved self-esteem and identity, more connected to services; both staff and patients reported a desire to interact more informally with each other

Mamakwa et al. [36]

Canada: NW Ontario, Sioux Lookout region

Medical record review including buprenorphine-naloxone prescribing and urine drug screening

6 First Nation communities (n = 526)

Community-based buprenorphine-naloxone treatment combined with traditional healing; 4 weeks of daily treatment and aftercare

Inductions are in groups of 10–20 within a community-wide celebration; programs are viewed as a "welcoming back" of patients; treatment facilities are used as meeting places for healing circles; healing includes spirituality (Elder-guided, land-based aftercare)

Programs were community designed, implemented and administered; healing circles and traditional activities over formal programs

Treatment outcomes: Retention rates were high (72% at 18 months); urine drug screening showed high rates of negative results for illicit opioids (84–95%); Community outcomes: Decline in suicides in six communities; one community had declines in drug-related medical evacuations, criminal charges and child protection cases, and increase in school attendance

Marquina-Marquez et al. [24]

Canada: N Ontario

Open-ended interviews and oral story telling

Oji-Cree reserve residents, recruited through medical facilities (n = 35)

Community-based healing movement, including nature-based therapeutic initiatives, traditional healing methods and physical spaces for healing, often outdoors and informal

Emphasis on personal reconnection to land (place attachment integral to wellbeing), spiritual world, and identity, healing from personal traumas, maintaining family ties, love and respect for community

Grassroots movement based in culture; informal and self-paced

Participant perspectives: Traditional practices support healing and family/community reconnection; the grassroots/community-based nature was important for holistic healing; the informal nature allowed for individuals to engage at their own pace

Momper et al. [25]

USA: Midwestern Indian Reserva- tion

Eight Talking circles

AI adults and youth (n = 49)

No specific program

Not evident

One tribal council passed a resolution prohibiting OxyContin prescriptions except in terminal cases

Participant perspectives: Reported barriers to treatment: need for group support; worries that returning the same environment would result in relapse; lack of adequate and accessible treatment options

Radin et al. [26]

USA: 4 Washington state tribal communities

Semi-structured interviews and focus groups

Community members (n = 153)

General substance use, abuse, and dependence (SUAD) programs and resources across the four communities

Valued program aspects included community support for struggling individuals, family involvement in treatment, sense of identity, attention to “whole person”, life skills, and providers who are supportive

Need to address prescription drug misuse with better communication between community and healthcare providers; valued aspects of available programs included culturally-based and community driven prevention, treatment and aftercare; individualized treatment

Participant perspectives: valued community support, 'supportive' care providers; need for family/community wellness, adequate transition housing more supportive of recovery; need for greater community- provider collaboration, community-based and culturally-based care and healing centres; Former patient perspectives highlighted the need for compassion, holistic treatment (including trauma treatment), and the desire to keep families intact an important motivator

Russell et al. [45]

Canada

Scoping Review

Aboriginal

Multiple, includes a section on the National Native Drug Abuse Program (NNADAP) and community-based suboxone programs

Not evident

Scoping review focused on the successes of community-based and culturally-integrative treatment

Paper conclusions: Community-based treatment models have promising outcomes (high completion rates, improved abstinence, community-level improvements); more contextually and culturally appropriate treatment needed

Saylors et al. [40]

USA: San Francisco Bay Area

Program overview, staff and interviews and clinical data

Native American Women clients (n = 742)

Women's Circle project of the Native American Health Center, focused on integrating western and Indigenous healing, holistic health;

Women’s group provides nonthreatening entry into health programs; emphasizes respect for patient/patient comfort, trauma-informed care; a nurse case manager facilitates transitions between services; holistic healing and skills training (e.g. family functioning); meeting the patient 'where they're at'

Healers from diverse communities brought in to support traditional healing for culturally diverse clients; incorporation of spirituality into counselling is guided by the patient; emphasis on Native staff

Treatment outcomes: Heroin use decreased by 93%; women who were using nonprescription methadone stopped after intervention; self-reported improvement in health, living conditions, increase in school attendance, decrease in involvement with criminal justice system; increase in importance of culture to participants

Srivastava et al. [27]

Canada: Ontario, Sioux Lookout First Nation

Physician interviews

Family physicians in Sioux Lookout (n = 18)

Sioux Lookout Zone Physicians initiated an education program to reduce physician anxiety about prescribing opioids, improve the management of chronic pain, and limit the risk of addiction

Educate patients on harm reduction strategies

Physician to develop treatment agreements with patient

Physician outcomes: Increased awareness of addictive potential of opiates; started titrating lower potency medications for chronic pain; improved physician confidence in opioid prescribing and identification of patients with opioid dependence; increased use of treatment agreements with patients

Teasdale et al. [28]

Australia: Sydney

Interviews and focus groups

Indigenous patients and Indigenous and non-Indigenous staff (n = 63)

The Drug Health Service of Sydney South West Area Health Service, Eastern Zone, provides drug-related services including opioid maintenance pharmacotherapy with medication dispensed daily or every other day at the treatment centre

Staff provided after-hours support for family and community; aimed at providing therapeutic, non-authoritarian care

Priority assessment for Aboriginal clients; broad and flexible dosing hours; collaboration with Aboriginal Medical Services

Participant perspectives: Clients reported misinformation about methadone's health impacts, and culturally-based concerns; non-Aboriginal staff indicated a lack of cultural awareness training and appropriate care for holistic health challenges particularly to help with child protection services, heavy burden of after-hours support; paper conclusions: tighter partnerships with the Aboriginal community and a less formal and more welcoming service

Thomas et al. [41]

Canada: British Columbia

Semi-structured interviews and surveys including follow-up

First Nation community members (n = 12)

“Working with Addiction and Stress” 4-day retreat with ayahuasca-assisted group therapy

NOW AN ILLICIT SUBSTANCE – REMOVE?

Primary aim was to release pain and heal through participation in ceremony and personal reflection

Involvement of local First Nations spirit-keeper

Treatment outcomes: Opioid use (one participant) had no change

Uddin et al. [29]

Canada: N Ontario, Eabametoong FN

Physician reflection

N/A

Northern Ontario Suboxone Support program, community-based programs; partnership between community and addiction specialists

Holistic healing in aftercare, compassionate staff

Community design and ownership is key to the program’s success

Paper conclusion: patients report the program has made a positive difference in their lives; author argues that Suboxone should be dispensed in the community by community nurses and trained laypeople

Venner et al. [30]

USA

Stakeholder Meeting

AI/AN Community members and AI/AN and non-AI/AN healthcare providers and agencies

National Institute on Drug Abuse stakeholder meeting to elicit feedback on medication assisted treatment in the community

Program needs outlined included holistic healing, traditional healing, patient desires to be medication free, and address systemic barriers (lack of resources in community, discrimination and inadequate care experienced outside of community)

Program needs outlined included need for better resources in community, more AI/AN care providers

Paper conclusions: must integrate medicated assisted therapy into traditional healing approaches and train providers to honor Indigenous ways of knowing

Williams et al. [42]

Australia: Adelaide

Discussions and electronic records

Nunga Australians (n = 226)

The 'Way Out' program, a holistic health program including opioid substitution

Holistic health focus on individual needs and trauma, family-based support, patient advocacy; reconciliation displays in the centre; access within a health centre to provide confidentiality; strong links with correctional services to ensure seamless transitions between services

Initiated by community, strong partnership with Aboriginal health programs in development and implementation; community members are relied upon to raise awareness about the program and ensure its success; community-based activities; Aboriginal staff; flexible appointments

Treatment outcomes: Program is attracting and maintaining more Indigenous clients than any previous program in the region; of those who ever accessed opioid substitution treatment, 40% are in current substitution, 10% have successfully completed, 16% transferred out, and 34% have defaulted (19% before stabilization, 15% after)