... High rates of SUD in AIAN youth, including lifetime opioid misuse, in both urban and rural areas have been linked to numerous risk factors, including poverty, poor social conditions, exposure to use in others, community norms, community stressors such as violence and discrimination, antisocial peer groups, lower school performance, trauma exposure, and significant life stress (Beauvais & LaBoueff, 1985;Dickerson et al., 2016;Fisher et al., 1998;LeMaster et al., 2002;Nalven et al., 2020;Oetting et al., 1988;Sarche & Spicer, 2008;Rutman et al., 2008), parental use, younger age at initiation of use, initiating use with another drug, adolescent conduct problems, sexual abuse, witnessing family trauma, or experience of a traumatic event (O'Connell et al., 2007), and psychological distress and high risk behavior (Hawkins et al., 2004). Mental health disparities may also demonstrate a significant contributor to risk for SUD; AIAN youth are at disproportionately high risk for depression, anxiety, trauma-related stress, attention deficit hyperactivity disorder (ADHD), conduct disorder, and suicide rates four times the national average (American Psychiatric Association, 2017; Beals et al., 1997Beals et al., , 2005Costello et al., 1997;Moncher et al., 1997;Sarche, 2011;Stiffman et al., 2003;Whitbeck et al., 2008;Yoder et al., 2006;Zvolensky et al., 2001). Further, research suggests that traumatic exposure is highly prevalent in AIAN communities and associated with increases in mental health issues and SUD (Ehlers et al., 2013). ...