Despite only representing 2% of the U.S. population, American Indians and Alaskan natives (AI/AN) experience higher rates of alcohol abuse compared to other ethnic groups.1,2 Stereotypes often depict Native Americans as binge drinkers, and although alcohol remains the most-abused substance (29.6% of the population reports binge drinking), illicit drug use is also steadily on the rise.2 Problems with substance abuse in this community are associated with violence, social issues, economic despair, and widespread health problems.
Research suggests that North American indigenous tribes have been altering their mental states, often through spiritual rituals, for centuries. In the past, AI/AN individuals achieved these altered states through a variety of non-medicinal methods, including sleep deprivation, fasting, and self-inflicted pain, such as burning. Additionally, psychotropic substances, including peyote and tobacco, were commonly used in association with spiritual experiences and for shamanic use.3
Before European colonization, many tribes did produce fermented beverages, although the alcohol content in these drinks was reportedly much weaker and underdeveloped than the alcohol people drink today. The rate of excessive alcohol use within the indigenous AI/AN communities during this period is largely unknown, but it’s believed that drinking alcohol may have been mainly used for ceremonial and spiritual practices.3
However, among early European colonists, alcohol was consumed on a regular basis, often as a substitute for contaminated water or to treat various medical ailments. Europeans made distilled spirits and viewed drinking as socially acceptable.
Historical research suggests that the infiltration of European influence on American soil, coupled with the indigenous AI/AN communities’ unexpected and rapid introduction to alcohol consumption, may have contributed to their initial drinking problems. Demand for product increased quickly; at this time, both colonists and the AI/AN community used alcohol as means of trade and money.3,4 In this way, alcohol played a pivotal role in the political and economic shaping of early America.
Attitudes toward drinking began to shift as alcohol use progressed within the AI/AN community. Social consumption and group drinking increased as alcohol began to represent a bonding experience. Like the English colonists, binge drinking became more widely acceptable and common.3
Financial despair also represents an overarching issue contributing to drinking rates, with 15% of AI/AN people living below the poverty line at any given time.1 In addition to economic and educational concerns, it must be noted that acculturation struggles may have a strong influence on AI/AN substance use. The loss of culture or the simultaneous integration with a larger European-influenced culture can be a struggle for modern-day AI/AN individuals and their families.3 In fact, a developing study proposed that AI/AN drinkers may fall into 2 categories: anxiety drinkers and recreational drinkers. These categories are described in the following way:4
Regarding alcohol use, many AI/AN individuals report a sense of ambivalence around their drinking, often viewing it as a social mechanism that increases bonding. On the other hand, some also believe that they are essentially prone to abusing alcohol or illicit substances because of their genetics. In this sense, they view their culture as “dooming” them to an addiction.4
Contemplating or achieving abstinence from alcohol is often associated with fear of alienation or isolation from the community.3 Hence, the destructive cycle of addiction can appear to be a self-fulfilling prophecy.
Today, AI/AN individuals have disproportionately high rates of alcohol-related incarcerations compared to many other racial groups. In fact, between 70% and 95% of all AI/AN arrests are alcohol-related crimes (e.g., public drunkenness, DWI, underage drinking).5
There is a direct relationship between the severity of alcohol dependence and the number of alcohol-related incarcerations, meaning the most problematic drinkers are most likely to face more jail time.6 While historic research suggests that this population has frequent contact with federal and tribal justice systems, treatment remains relatively scant, with only 45% of AI/AN receiving formal (e.g., specialized substance abuse rehabilitation) or informal care (e.g., Alcoholics Anonymous meeting attendance).6
As a result, regardless of the origin for this overrepresented incarceration trend, people are more likely to be involved with courts and penal systems than they are with treatment settings. In fact, the criminal justice system is the most common referral source for treatment in this population. When stabilization does occur, it is often in the form of medical hospitalization, which may be a forced and ineffective initial intervention for recovery, since it does not require acknowledging that alcohol use has become problematic.6
The incarceration epidemic is associated with perpetuated social issues: those who have felonies on their record are significantly less likely to secure employment, stable housing, and access to social and economic resources.5 Thus, the ones who need the most transitional assistance tend to be the least likely to actually receive it.
The AI/AN population appears to have an exacerbated risk of developing physical, mental, and social health problems. This means that, in addition to elevated addiction rates, AI/AN are also more likely to have co-occurring disorders, such as anxiety and depression.7
These risks are most troubling among AI/AN youth who display the highest rates of depressive episodes compared to any other ethnic group; suicide represents the second-leading cause of death for males within this demographic.8 And less than half of all adolescents graduate from high school, compared to the national average of 71%.9
Subsequently, AI/AN youth are far more likely to struggle with addiction rates than any of their peers. Nearly 75% of AI/AN youth in treatment reported alcohol as their substance of abuse.8 Among AI/AN 8th graders, more than 56% have tried marijuana; and the use of opioids, including heroin, is 2 to 3 times higher than the national average.9 As it stands today, nearly 15% of the AI/AN population meets criteria for a substance use disorder compared to 4.6% for Asians, 7.4% among blacks, and 8.4% among Caucasians.8
Multigenerational transmission of alcohol problems may be a leading factor for continued problems in the modern AI/AN community. For example, young people in today’s community are likely to have first been exposed to substance use by their parents or from elsewhere within their families. In their early childhood experiences, drinking and illicit substance use may be normalized and highly accepted. Other environmental issues, such as earlier age of onset use, exposure to trauma, and acculturation hardship also contribute to inherent risk.
While there does not seem to be a significant disparity among addiction rates seen in male and female youth, the prevalence of substance use disorders for adult men is twice that of women. To date, alcohol accounts for 26.5% of all male deaths.4
Tribal location also appears to play a role in addiction statistics. In terms of geography, literature analyses have found that northern reservations have higher rates of substance use disorders than southern reservations.7
Furthermore, modern research continues to explore the biopsychosocial framework of addiction to understand how genetic risk factors may predispose for addiction. Even if genetic factors do impact the likelihood of developing substance abuse behaviors and chronic addiction issues, they are not inevitable outcomes—the direction toward preventive measures and better treatment access could potentially offset any heritable influence.10
Even though AI/AN adults tend to be more in need of treatment than what the national average suggests, pervasive stigmas attached to mental illness and recovery approaches may pose a significant barrier preventing those from seeking help.1,3
It is important to note that different tribal groups within the AI/AN community have different perceptions and definitions of mental disorders. Some see mental illness as having no distinction from physical illness, following the idea that the physical body has no separation from the mental and spiritual spheres. Others discredit Western methods of assessing, diagnosing, and treating mental illness, often distrusting “white” medicine.11
Still other tribal points of view may consider mental illness as expressions of demonic possession, as spiritual gifts, or as terminal losses of the soul.11 As a whole, treatment providers can best support this population by adopting a culturally competent approach in understanding various frameworks and understandings of mental illness.
Effective AI/AN treatment incorporates cultural sensitivity with evidence-based practices, including medically assisted detox, residential care, and support groups. Depending on the person’s needs, treatment planning for long-term care—such as inpatient treatment, sober living, and individual and family therapy—is recommended.
In recovery practices, clinical teams should consider specific interventions related to honoring tribal culture, such as healing circles, sweat lodges, and dancing rituals. Within the AI/AN population, balancing both medical and holistic care appears to be an essential feature of successful recovery.7