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Assessing the Impact of American Indian Peer Recovery Support on Substance Use and Health

  • Allyson Kelley & Associates PLLC


Peer Recovery Support (PRS) is emerging as a key intervention for communities and individuals as they address high rates of substance abuse and limited recovery resources. American Indian populations were among the first people to use concepts of PRS through abstinence-based revitalization movements and ceremonies. The present study examined the impact of PRS on substance use, emotional and psychological problems, and social connections among urban and reservation American Indian peers involved in a 3-year PRS program. A total of 224 individuals, 110 male and 114 female completed baseline GPRA. Of these, 65 peers completed baseline and 6-month follow-up GPRAs. Involvement in PRS decreased substance use significantly among peers. Peer attendance at voluntary self-help groups and support from family and friends increased as a result of PRS.
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Journal of Groups in Addiction & Recovery
ISSN: 1556-035X (Print) 1556-0368 (Online) Journal homepage:
Assessing the Impact of American Indian Peer
Recovery Support on Substance Use and Health
Allyson Kelley, Dyani Bingham, Erika Brown & Lita Pepion
To cite this article: Allyson Kelley, Dyani Bingham, Erika Brown & Lita Pepion (2017) Assessing
the Impact of American Indian Peer Recovery Support on Substance Use and Health, Journal of
Groups in Addiction & Recovery, 12:4, 296-308, DOI: 10.1080/1556035X.2017.1337531
To link to this article:
Published online: 08 Dec 2017.
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, VOL. , NO. , –./X..
Assessing the Impact of American Indian Peer Recovery
Support on Substance Use and Health
Allyson Kelleya, Dyani Binghama, Erika Browna, and Lita Pepionb
aAllyson Kelley and Associates PLLC, Sandia Park, New Mexico, USA; bRocky Mountain Tribal Leaders
Council, Billings, Montana, USA
American Indian; peer
recovery support; substance
use; urban and reservation
Peer Recovery Support (PRS) is emerging as a key intervention
for communities and individuals as they address high rates of
substance abuse and limited recovery resources. American Indian
populations were among the rst people to use concepts of PRS
through abstinence-based revitalization movements and cere-
monies. The present study examined the impact of PRS on sub-
stance use, emotional and psychological problems, and social
connections among urban and reservation American Indian peers
involved in a 3-year PRS program. A total of 224 individuals, 110
male and 114 female completed baseline GPRA. Of these, 65 peers
completed baseline and 6-month follow-up GPRAs. Involvement
in PRS decreased substance use signicantly among peers. Peer
attendance at voluntary self-help groups and support from fam-
ily and friends increased as a result of PRS.
This is a story. It is written in a manner that reects a western scientic paradigm.
This paradigm is often the choice of treatment providers, researchers, academic
journals, and funding agencies. We respect this paradigm and at the same time
we honor the people, communities, tribes, and families involved in the Transi-
tional Recovery and Culture Program (TRAC). There is a spiritual aspect of healing
(recovery) that is dicult to measure by western scientic standards. To begin,
we want you the reader to know who we, the storytellers, are. We want you to
understand our relationship to recovery and to the American Indian communities
involved in this healing journey.
I support sustainability and coalition building eorts through writing and research. The
best part is working with authentic people who believe in recovery and share values of
honesty, trust, hard work, acceptance and spirituality. I am inspired by the resilience and
strength of peers. Through their stories and journey, I have learned how to support people
in recovery and live a more balanced life. Allyson Kelley, Evaluator
CONTACT Allyson Kelley Allyson Kelley and Associates PLLC, PO BOX  Sandia
Park, NM .
©  Taylor & FrancisGroup, LLC
I spend time with people recovering from substance use disorders, providing support,
encouragement, motivation, information and direction as they feel they need. This entails a
number of dierent activities—usually something the Peer enjoys doing—walking, eating,
having coee, visiting, and sometimes things they don’t enjoy so much such as completing
on-line forms, applications for assistance, going to court or seeing their Parole ocer. - Lita
As TRAC program director I have come to understand my own recovery better. I once felt
alone struggling with addictions and trauma; now I am proud to be part of the recovery
movement. The best part of recovery is being centered in spirituality, healing and accep-
tance. Dyani Bingham, Project Director Blackfeet/Assiniboine/Little Shell/Gros Ventre
I am fortunate to have had the opportunity to support the TRAC program as an
AmeriCorps VISTA member during 2016. I seek to advocate for integrating culture-based
programming wherever traditional Western techniques and approaches fall short of
providing holistic, culturally-responsive services for indigenous people. I am grateful to
have been able to serve the TRAC program and for being given the opportunity to witness
the powerful and important impact of this work. Erika Brown, TRAC AmeriCorps
VISTA Member
The term American Indian has been used throughout this article, but it is impor-
tant to note that this term does not reect the unique tribal status of the 566 feder-
ally recognized tribes in the United States. We selected this term because it encom-
passes the tribes from the Northern Plains who participated in this program. Also,
the eects of peer recovery support (PRS) may be dierent based on the unique cul-
reservation environments and how PRS is delivered.
An estimated 50% of adults or 25 million people in the United States with substance
use disorders (SUD) are in recovery (White, 2012). Recovery from SUD is a process
of change through which individuals improve their health and wellness, live a self-
directed life, and strive to reach their full potential. Recovery includes four primary
dimensions: health, home, purpose, and community (Substance Abuse and Mental
Health Services Administration [SAMHSA], 2012). Community-based PRS services
are emerging as a key intervention for communities and individuals as they address
high rates of substance abuse and limited recovery resources. PRS (coaching) is a
nonclinical approach that includes mentoring, education, and support services pro-
vided by individuals with the lived experience of recovery to individuals with SUD
or co-occurring substance use and mental disorders (Reif et al., 2014). Individuals
provide PRS in a variety of community and institutional settings, either as volunteers
or paid workers. PRS is eective because it emphasizes social support, empathy, and
therapeutic relationships (White, 2009)—all of which predict successful recovery.
Adults and youth with SUD benet from PRS and services may occur before, after,
or in lieu of treatment (Loveland & Boyle, 2005).
The success of PRS is largely based on the exibility of the approach and the
peer-based mutual help component (Laudet, 2007). However, documenting these
successes has been dicult because the very nature of PRS requires autonomy, self-
directed recovery processes, and exibility. Peer recovery coaching has not been
rigorously evaluated. In one clinical trial involving peer coaches, SUD treatment,
and child welfare services, results demonstrated improved family reunication rates
compared with families who did not receive peer recovery coaching (Ryan, Marsh,
Test a, & L o ud e rm a n, 2006). In another study of PRS, authors report that recovery
coaching and recovery supports were strongly associated with successful outcomes
among drug court participants (Mangrum, 2008). Studies support recovery coach-
ing as an eective intervention for SUD and co-occurring substance use and mental
disorders (Reif et al., 2014; Solomon, 2004). In the meta-analysis of PRS related
studies conducted by Reif and colleagues, there were two randomized control trials,
four quasi-experimental studies, and four pre-/poststudies (2014). None of these
studies targeted American Indian populations and communities (Kelley, Snell, &
Bingham, 2015).
American Indian populations were among the rst people to use concepts of
PRS through abstinence-based revitalization movements and ceremonies including
the Native American Church (Coyhis & White, 2006), societies, kinship systems,
collectivism, and living values that support recovery. Despite widespread assim-
ilation and destruction eorts, many American Indian people and communities
remain resilient and know their language, traditions, stories, ceremonies, and cul-
ture (Gone & Calf Looking, 2011).
Culture is an important concept in recovery because it is the essence of individuals
and communities (Frierson, Hood, & Hughes, 2002). Culture is a cumulative body
of learned and shared behavior, values, customs, and beliefs common to a particular
of treatment for SUD (Gone & Calf Looking, 2011). Aspects of culture that may
facilitate healing and recovery within PRS include a balance of physical, emotional,
spiritual, and mental supports. For example, talking circles, sweat lodge, prayer, and
smudging are unique to American Indian populations and are integrated into PRS.
Understanding what recovery support looks like for American Indian popula-
tions disproportionately impacted by SUD (Urban Indian Health Institute, 2011)is
an important rst step in addressing this public health epidemic. American Indian
or Alaska Native people are more likely to need treatment and recovery supports for
illicit drug or alcohol use than any other racial or ethnic group (SAMHSA, 2012).
However, the recovery process for American Indian populations is unique. First,
recovery among American Indian populations often includes the entire community
or family as opposed to the individual (Jilek-Aall, 1981). Second, unlike their Euro-
pean American counterparts, American Indian populations are less likely to enter
treatment for SUD and more likely to enter a natural recovery, meaning they quit
using drugs or alcohol without treatment. In one longitudinal study that compared
European Americans and Navajos, the Navajos were more likely to quit drinking
at an earlier age and report that treatment did not help them quit (recover; Kunitz,
Levy, & Andrews, 1994). Most Navajos in this study cited family support, religion,
and spirituality as the key factors in supporting long-term sobriety. Enculturation
is a key factor for American Indian people in their recovery (Stone, Whitbeck,
Chen, Johnson, & Olson, 2006). Third, previous studies have consistently found
that participation in cultural activities, traditional activities, and spiritual practices
are protective against alcohol misuse (Hazel & Mohatt, 2001;Stoneetal.,2006),
although it is not clear how enculturation actually protects against SUD. New
research focusing on the connections between traditional spirituality and healing
may provide much-needed answers to the role of enculturation and healing for
individuals in recovery (Owen, 2014). We could not locate similar PRS studies
in other indigenous populations (Canada, Mexico, Australia); however, PRS has
worked well in other settings and is a viable option for American Indian populations
because it incorporates culture, spirituality, and connection.
A key dierence in PRS and other peer-based recovery programs like Alcoholics
Anonymous (AA) is that peer mentors provide a variety of recovery options and
support services. AA may be one type of service oered to peers to explore. Another
dierence between PRS and AA is that PRS does not prescribe a set of actions to be
undertaken to achieve and maintain sobriety, such as the AA 12 steps. PRS begins
with a relationship between a peer mentor with the lived experience of recovery and
a peer who seeks recovery. These relationships are advantageous for individuals who
may not be comfortable in group settings like AA. Another dierence between PRS
bers whereas PRS is not as structured. The exibility inherent in PRS allows the peer
mentor to support the peer in tailoring an approach to achieving and maintaining
sobriety that suits the unique needs of the individual.
In the present study, we compared 6-month change rates for drug and alcohol
use, depression, anxiety, suicide attempts, psychological and emotional impacts,
attendance at voluntary self-help groups, and support from family and friends
among American Indian peers enrolled in the TRAC. Briey, depression may exac-
erbate alcohol abuse (Kishoe, Gopalkrishnan, Bery, & Ghulam, 2015)andanxiety
is often reported by individuals in recovery (Friedmann, Saitz, & Samet, 1998).
Alcohol and drug use are strongly associated with suicide and suicide attempts
(Wojnar et al., 2008; Wilcox, Conner, & Caine, 2004) and individuals in recovery
often report psychological and emotional problems. Voluntary self-help groups and
social support provide a buer between the stresses of everyday life and sustained
long-term recovery.
TRAC is a community-driven PRS approach conceptualized in August 2012 after
tribal leaders voiced concerns about substance abuse and the need for more eec-
tive recovery supports (Kelley et al., 2015). The goals of the TRAC program are to
improve sobriety rates in each community, increase community awareness of sub-
stance abuse problems and the need for supporting recovery, and increase commu-
nity support for eorts to create sober communities. A tribal consortium located
in Billings, Montana, received funding in October 2013 from the SAMHSA Center
for Substance Abuse and Treatment. The consortium partnered with tribal Chemi-
cal Dependency Program Directors and tribal leaders to identify communities that
would be willing to pilot the TRAC program. This resulted in a culturally tai-
lored, tribal-specic PRS that was preferred over a Pan-Native American Recovery
approach that fails to recognize the unique traditions, language, and history of a
given tribe (Owen, 2014). Six peer mentors (coaches) provided PRS in three com-
munities, one reservation recovery program and two urban settings. Peer mentors
in this program also served as cultural leaders, elders, healers, advisors, and spiri-
tual teachers. A community advisory board supported the program and included
community representatives from substance abuse/recovery supporting organiza-
tions, cultural programs, traditional knowledge keepers and elders, public and tribal
schools, social service organizations, law enforcement, juvenile justice, community-
based organizations, and others.
PRS in practice
TRAC peer mentors provided diverse recovery support activities that highlight the
self-directed nature of PRS and the concept of many paths to recovery. Peers are
American Indian and most are from Northern Plains Tribes. Peers represent diverse
backgrounds and histories, some grew up in urban settings and others live on reser-
vations. Many peers have experienced trauma in their lifetime. Peer mentors sup-
ported their peers using a variety of recovery support activities: sweat lodge, weekly
talking circles, weekly Wellbriety meetings, wellness and physical tness, spiritual
gatherings, church, cedaring, feeding and outreach, employment and education
guidance, sober housing support, food and necessities support, spiritual and cul-
tural support, and transportation. Most peer mentors met with peers in-person or
over the phone over a 6-month period.
All study procedures were approved by the Rocky Mountain Tribal Institutional
Review Board. The study hypothesis is as follows: Involvement in PRS decreases
substance use, depression, anxiety, suicide attempts, psychological and emotional
impacts while increasing attendance at voluntary self-help groups and support from
family and friends.
We used a holistic approach based on the medicine wheel framework (Atlantic
Council for International Cooperation, n.d.) to examine outcomes, including work-
ing with peers to review and validate results and enlisting cultural reviewers to
ensure the results were culturally responsive to the unique status of American Indian
populations and their healing process. The medicine wheel framework (Atlantic
Council for International Cooperation, n.d.) served as a guide to implement the
program and interpret the data. The medicine wheel includes four domains: spiri-
tual, mental, emotional, and physical.
Sample and procedure
Peers were recruited from tribal chemical dependency programs, tribal health pro-
grams, community social service agencies, and through self-referral. Potential peers
were contacted by a member of the TRAC team via telephone. Verbal consent
was obtained for screening to determine eligibility. Written informed consent was
obtained by the peer mentor before peers completed baseline intake using the Gov-
ernment Performance and Results Act (GPRA) tool. The GPRA tool is a federally
mandated data collection and performance tool that all SAMSHA grantees must use
Peers met with peer mentors over a 6-month period, at the end of which time
the 6-month GPRA follow-up was administered. Peers who completed the 6-month
follow-up assessment received a $25 gift card. All peers discharged from the pro-
gram were encouraged to continue to attend recovery support groups and maintain
positive social connections to support their recovery. GPRA baseline and follow-up
by a member of the program team. Analyses were conducted by the lead evaluator
and rst author at the end of the 3-year program.
A retrospective review of GPRA data was conducted by the lead evaluator. These
data were collected from participants (N=224) entering the program between
September 2013 and April 2016. Of these, 65 peers completed baseline and 6-month
GPRA interviews. All interviews were anonymous.
The GPRA includes seven sections: record management/demographics, drug and
alcohol use, family and living conditions, education, employment and invoice, crime
recovery, and social connectedness. An example GPRA question is, “In the past
30 days, not due to your use of alcohol or drugs, how many days have you: a) expe-
rienced serious depression, b) experienced serious anxiety or tension, c) attempted
suicide?” Response options are a number between 0 and 30, “refused to answer, or
don’t know. To document the impact of PRS in this study, we selected GPRA ques-
tions with the medicine wheel framework in mind, including drug and alcohol use
(physical domain), depression (emotional domain), anxiety (emotional and mental
domains), suicide (emotional and spiritual domains), psychological and emotional
impacts (emotional, spiritual, and mental domains), attendance at voluntary self-
help groups (physical and spiritual domains), and support from family and friends
(physical and mental domains).
Depression can exacerbate alcohol abuse and many people in recovery report
depressive symptoms (Kishoe et al., 2015). Peers were asked, In the past 30 days, not
due to your use of alcohol or drugs, how many days have you experienced serious
depression? Response options were a number between 0 and 30.
Individuals in recovery may experience anxiety which may precipitate relapse
(Friedmann et al., 1998). Results from the National Epidemiologic Survey on Alco-
hol and Related Conditions show strong associations between drug use disorders
and anxiety disorders (Grant & Dawson, 2006). Peers were asked, “In the past
30 days, not due to your use of alcohol or drugs, how many days have you expe-
rienced anxiety or tension? Response options were a number between 0 and 30.
Suicide attempts
Alcohol and drug use are strongly associated with suicide and suicide attempts
(Wojnar et al., 2008; Wilcox et al., 2004). Peers were asked, “In the past 30 days, not
due to your use of alcohol or drugs, how many days have you attempted suicide?”
Response options were a number between 0 and 30.
Psychological and emotional impacts
The psychological and emotional eects of drug and alcohol addiction and recovery
may include mood swings, depression, decrease in pleasure in everyday life, and
complications of mental illness (Croft, 2016). Peers were asked, “How much have
you been bothered by psychological or emotional problems in the past 30 days?”
Response options were based on a 5-point Likert scale ranging from 1 (not at all)to
Voluntary self-help groups and social support
Informal social networks provide critical support for individuals in recovery. Previ-
ous studies report that social support, spirituality, and self-help groups buer stress
and enhance the quality of life for individuals in recovery (Buckman, Bates, & Mor-
genstern, 2008). Peers were asked, “In the past 30 days, how many times did you
attend voluntary self-help groups? Responses options were a number between 1
and 99. Family and friends play a critical role in supporting long-term recovery and
healing. Peers were asked, In the past 30 days, did you have interaction with fam-
ily and or friends that are supportive of your recovery? Response options were yes
or no.
Data preparation and analyses
All statistical analyses were performed using SPSS version 21.0. Descriptive frequen-
cies and means for all variables of interest were computed. Bivariate analyses were
of substance use. Paired samples t-tests were used to examine dierences between
baseline and 6-month follow-up data from the GPRA for all measures. Changes in
continuous data (alcohol use, binge drinking, illegal drug use, combined alcohol
and drug use, depression, anxiety, suicide attempts, and emotional impacts from
substance use) were explored and dierences from baseline and 6-month GPRA
reports are outlined in the results section.
Tab l e . Demographic characteristics baseline and -month GPRA follow-up (n=).
Interview Baseline Follow-up Change
Housed   .%
Employed (full time/part time)   .%
Monthly income average $. $. .%
Health status (excellent or very good) .% .% .%
A total of 224 individuals, 110 male and 114 female completed baseline GPRA
intakes throughout the 3-year program. Of these, 65 peers completed baseline and
6-month follow-up GPRAs. The mean age of peers completing 6-month follow-
up GPRA was 36.15 years (SD =13.54), 32 were male and 33 females, and three
were veterans. The follow-up rate was 29.5% and this is signicantly lower than
the SAMSHA required follow-up rate of 80%. SAMHSA requests that all grantees
maintain an 80% follow-up rate and if grantees are unable to maintain this, they can
request technical assistance, additional training, and support. Peers could decline
answering any GPRA question and this accounts for the dierences in total response
rates in the tables that follow. Chi-square analysis revealed no signicant dierences
by gender or age.
Peers reported increased housing (133.3%), increased employment (75%) and
improved health status (71%) from baseline report data. The only characteristic
that decreased at the 6-month GPRA was monthly income ($226.37 vs. $193.75;
see Table 1 ).
Alcohol and drug use
The mean and standard deviations of peer alcohol and drug use in the past 30 days
is presented in Tab le 2. Results show decreases in drug and alcohol use from intake
to 6-month follow-up. Signicant dierences were observed for past 30-day alco-
hol use, M=3.30, SD =8.5, t(64) =3.13, p=.003; illegal drug use days, M=
2.32, SD =7.29, t(64) =2.56, p=.01] and alcohol and drug use days, M=1.09,
SD =4.53, t(64) =1.94, p=.05. Alcohol and drug use days reect responses to
the GPRA question, “During the past 30-days, how many days have you used both
drugs and alcohol on the same day?” There was not a signicant dierence in past
30-day binge drinking days, M=.67, SD =4.05, t(64) =1.34, p=.18.
Tab l e . Alcohol and drug use over the past -days, (n =).
Alcohol use, mean
days (SD)
Alcohol binge, mean
days (SD)
Illegal drug use, mean
days (SD)
Alcohol and drug use,
mean days (SD)
Intake . (.) . (.) . (.) . (.)
-monthfollow-up .(.)∗∗ . (.) . (.) . (.)
p<.. ∗∗p<..
Tab l e . Anxiety, depression, emotional impact, and suicide attempts (n=).
Interview Anxiety, mean days (SD)
Depression, mean
days (SD)
Emotional impact,
mean score (SD)
Suicide attempts,
mean days (SD)
Intake . (.) . (.) . (.) . (.)
-month follow-up . (.) . (.) . (.) ∗∗ . (.)
p<.. ∗∗p<..
Psychological and emotional impacts
The mean and standard deviations of anxiety, depression, emotional impacts, and
suicide attempts are presented in Tab l e 3. Six-month GPRA follow-up data show a
signicant increase in how much Peers are bothered by psychological or emotional
problems, M=−2.12, SD =2.17, t(64) =−7.85, p=.00. There was not a signicant
dierence in depression, M=.94, SD =10.5, t(64) =.73, p=.47]; anxiety, M=.55,
SD =11.1, t(64) =.41, p=.69, or suicide attempts, M=.02, SD =.12, t(64) =1.0,
Six-month GPRA follow-up data show slight increases in attendance at voluntary
self-help groups, M=3.20, SD =6.1 vs. M=4.2, SD =6.2, and the number of
peers reporting interactions with family and friends in the past 30 days, M=.74,
SD =.62 vs. M=1.12, SD =1.2.
This study was designed to examine the impact of PRS on substance use, emo-
tional and psychological problems, and social connections among American Indian
peers involved in the TRAC program. The study’s hypothesis—Involvement in
PRS decreases substance use, depression, anxiety, suicide attempts, psychological
and emotional impacts while increasing attendance at voluntary self-help groups
and support from family and friends—was partially accepted. Involvement in PRS
decreased substance use signicantly. Involvement in PRS reduced depression and
anxiety, but the decrease was not statistically signicant. Suicide attempts did not
dance at voluntary self-help groups and support from family and friends increased
as a result of PRS.
Overall, PRS was eective in this study. This is consistent with previous that found
recovery coaching as an eective intervention for SUD and co-occurring substance
use and mental disorders (Reif et al., 2014; Solomon, 2004). The eectiveness of PRS
TRAC adds new information to the literature about PRS and American Indian
populations. Peers reported gains in stable housing, employment, and improved
health during the 6-month TRAC program. An area that requires further review is
during the 6-month period. Peers completing the 6-month TRAC program report
signicant reductions in alcohol and illegal drug use. There were reductions in
binge drinking and combined drug and alcohol use, although not statistically
signicant. A possible reason for this includes limited frequency at intake (e.g.,
M=1.6daysatintakevs.M=1.0 days at follow-up). Anxiety and depression
also decreased although peers were more bothered by psychological or emotional
problems. To understand more about the emotional impacts reported by peers, the
team asked peer mentors for possible explanations. One peer mentor said, “They are
no longer numbing. it’s very stressful to build a life with no money, support, clue
or help. I feel for the folks I work with—they are true Warriors who ght a battle
of survival each and every day. Results show that peers’ attendance at voluntary
self-help groups and meeting with family and friends increased over the 6-month
period. These results are encouraging because both group and healthy relationships
provide support for peers in recovery beyond the PRS model and TRAC program.
However, challenges remain. First, retention of peers is a major challenge. TRAC
served 224 peers over a 3-year period in six communities; of these, only 65 (29%)
completed the program and 6-month follow-up GPRA. However, attrition rates are
a challenge reported by previous authors. In one U.S. study, 75% to 80% of indi-
viduals seeking recovery left at various stages in the referral, intake, and treatment
processes (Loveland & Driscoll, 2014). In a meta-analyses of psychosocial interven-
tions for SUD, nearly one-third of participants left before completing their treat-
ment (Dutra et al., 2008). Possible reasons for attrition in TRAC include the tran-
sient nature of peers, incarceration, relapse, and inconsistent communication due to
lack of resources. The transient nature of peers is often part of the recovery process
as many peers are in transition between locations and experience unstable hous-
ing situations. Peers may be moving back to the reservation or to an urban center.
Some peers are awaiting sentencing and during the 6-month period are incarcer-
ated. Relapse may also contribute to high attrition rates. Alternately, some peers do
not have access to a phone, computer, or transportation that facilitates meetings
and communication with peer mentors and follow-up. Barriers to follow-up will be
explored in future work.
Strengths and weaknesses
A major strength of this study is that it was facilitated by a tribal consortium and
PRS was oered by American Indian people with the lived experience of recovery to
nection, and belonging that is dicult to nd in many recovery/treatment settings
(Gone & Calf Looking, 2011).TRACistherstpilotprogramtoimplementPRSand
rst step in documenting the types of recovery support that are needed and how
PRS can successfully implemented and achieved in American Indian contexts.
The main weakness of this study, as mentioned previously, relates to attri-
tion and small sample size. Another limitation is that the types of PRS supports
and services delivered to peers were not documented because of the conden-
tial nature of PRS and the exploratory nature of this pilot program. It is possible
that peers were involved in other recovery programs and services that supported
their successes along with the TRAC program. Future work should consider how to
document the kinds of PRS that peers receive, the frequency/duration of PRS, and
the impact of PRS on recovery outcomes.
Previous studies have reported on the eectiveness of PRS (Reif et al., 2014). How-
ever, this is the rst study that documents the impact of PRS in American Indian
populations. American Indian populations were among the rst to utilize concepts
of PRS through kinship systems, values, and support for those in need. Future stud-
ies with American Indian populations may consider evaluating strength-based fac-
tors including resilience, spirituality, identity, and kinship systems that are unique
to American Indian populations.
This is the rst study that quanties the impact of PRS on recovery and key recov-
ery outcomes for American Indian people. Extending PRS to both urban and reser-
vation American Indian peers and peer mentors, rather than focusing on one popu-
lation or the other, increased access to PRS that was not previously available. Future
research should explore the impact of PRS on family relationships, cultural connect-
edness, and community readiness to support recovery. The end goal of PRS is an
improvement in key areas of life that were impacted by substance use. Results from
the TRAC program give hope for individuals and communities who need recovery
resources and promise for future work.
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... Of the 18 peer-reviewed interventions, the vast majority were located in the USA (n = 16; 88.89%). Eight (44.44%) interventions were located in the West region of the USA (Dickerson et al., 2012;Edwards, 2003;Gone and Calf Looking, 2015;Kelley et al., 2017Kelley et al., , 2018Pearson et al., 2019;Saylors, 2003;Wright et al., 2011), three (16.67%) were located in the Alaska (Naquin et al., 2006;Ray et al., 2020;Running Bear et al., 2014) and three (16.67%) ...
... Fewer (n = 5; 27.78%) took place strictly in urban contexts (Dickerson et al., 2012;Edwards, 2003;Saylors, 2003;Tonigan et al., 2020;Wright et al., 2011), and two (11.11%) interventions took place in both urban and rural contexts (Kelley et al., 2017;Pearson et al., 2019). Notably, all but one intervention that included urban contexts (n = 6) were located in the West in the USA (Dickerson et al., 2012;Edwards, 2003;Pearson et al., 2019;Saylors, 2003;Tonigan et al., 2020;Wright et al., 2011). ...
... The sample size of the studies ranged from 4 to 742, with the average number of participants being approximately 213 individuals. Though the majority (n = 13; 72.22%) of interventions serviced male and female participants (Burduli et al., 2018;Dickerson et al., 2012;Edwards, 2003;Kanate et al., 2015;Kelley et al., 2017Kelley et al., , 2018Naquin et al., 2006;Ray et al., 2020;Running Bear et al., 2017;Tonigan et al., 2020;van der Woerd et al., 2010;Venner et al., 2021;Wright et al., 2011), a few (n = 4; 22.22%) served women exclusively (Gray et al., 2010;Hanson and Pourier, 2015;Pearson et al., 2019;Saylors, 2003) and one (5.55%) serviced only male participants (Gone and Calf Looking, 2015). ...
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Purpose The purpose of the current study is to conduct a systematic review of peer-reviewed work on culturally tailored interventions for alcohol and drug use in Indigenous adults in North America. Substance use has been reported as a health concern for many Indigenous communities. Indigenous groups experienced the highest drug overdose death rates in 2015, the largest percentage increase in the number of deaths over time from 1999 to 2015 compared to any other racial group. However, few Indigenous individuals report participating in treatment for alcohol or drug use, which may reflect the limited engagement that Indigenous groups have with treatment options that are accessible, effective and culturally integrative. Design/methodology/approach Electronic searches were conducted from 2000 to April 21, 2021, using PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed. Two reviewers classified abstracts for study inclusion, resulting in 18 studies. Findings Most studies were conducted in the USA (89%). Interventions were largely implemented in Tribal/rural settings (61%), with a minority implemented in both Tribal and urban contexts (11%). Study samples ranged from 4 to 742 clients. Interventions were most often conducted in residential treatment settings (39%). Only one (6%) intervention focused on opioid use among Indigenous people. Most interventions addressed the use of both drugs and alcohol (72%), with only three (17%) interventions specifically intended to reduce alcohol use. Originality/value The results of this research lend insight into the characteristics of culturally integrative treatment options for Indigenous groups and highlight the need for increased investment in research related to culturally tailored treatment across the diverse landscape of Indigenous populations.
... In 2015 the TRAC team published a qualitative study on considerations for implementing PRS in AI reservation communities (Kelley et al., 2015). In 2017 the TRAC team published a second study on the impact of PRS on substance use and health with 224 individuals involved in the first three years of the TRAC program (Kelley et al., 2017). Building on TRAC's previous work, this evaluation aimed to identify key factors of successful short-term recovery among AIs who participated in the TRAC program over a six-year period. ...
... TRAC peer mentors are American Indian, primarily from the Northern Plains Tribes, and adhere to the idea that there are "many paths to recovery" by providing flexible client-driven support. Peer mentors represent diverse background and experiences, and utilize many recovery support strategies to assist their peers, including talking circles, Wellbriety meetings, spiritual gatherings, sweat lodges, physical fitness, housing assistance, food assistance, education and employment assistance, transportation, and spiritual and cultural support (Kelley et al., 2017). Peer mentors obtained quantitative data for each TRAC peer via interviews at intake, and at a six-month follow-up visit, using the Government Performance and Response Act (GPRA) measures. ...
... We also found that unstable housing is a significant correlate of high balanced short-term recovery scores among TRAC peers, which was unanticipated. This is not consistent with previous evaluations (Kelley et al., 2017;Jason et al., 2006) where sober and supportive housing were found to help individuals maintain their recovery. It may be that the peers' previous living environments included individuals who continued to use substances and therefore posed risks to the peers' own recovery; such complexity is not captured in the GPRA measures. ...
Objectives We aimed to identify correlates of short-term recovery among American Indians who participated in the Transitional Recovery and Culture (TRAC) Program, a Peer Recovery Support (PRS) program. Research aims (As) were A1. How do recovery capital resources and indicators of recovery differ between TRAC participants who completed a six-month follow-up and those who did not? A2. How much did recovery capital resource measures change between intake and six-month follow-up? A3. Which recovery capital resources are associated with balanced recovery? Methods We used the medicine wheel evaluation framework. Each concept within the framework – spiritual, emotional, mental, and physical health – was incorporated into a composite recovery outcome variable. TRAC enrolled 422 American Indians from 2014 to 2019 living in Montana and Wyoming. Six-month change was examined among 214 program participants that completed the six-month program. Results We observed significant change for the following recovery capital resources: stable housing, being occupied, attending recovery groups, interacting with family and friends, past substance use activity, and self-reported health status. Logistic regression results for balanced short-term recovery showed that improving or maintaining occupation (AOR = 6.73, p = 0.0026), interacting with family or friends (AOR = 4.66, p = 0.0050), and still receiving services at follow-up (AOR = 2.25, p = 0.0487) were associated with significant increased odds of higher balanced short-term recovery scores. Conclusion PRS helps American Indian people achieve short-term recovery. Future efforts should focus on how to retain peers in PRS programs, and the recovery capital needed to sustain long-term recovery.
... Two focused on American Indian/Alaska Native populations. Kelley et al. (2017) assessed peer recovery support and found at the six-month follow-up, there was no significant difference in suicide attempts or binge drinking compared to baseline; however, a significant decline in alcohol use in the past 30 days was noted. Cwik et al. (2016) assessed the impact of the White Mountain Apache Suicide Surveillance and Prevention System, a multi-faceted suicide prevention program that included dissemination of resources as well as educational workshops such as Applied Suicide Intervention Skills training. ...
... Cwik et al., 2016) the other did not (e.g. Kelley et al., 2017). This may be due to the fact that suicide is a relatively rare outcome. ...
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Suicide remains a leading cause of death worldwide, with an estimated 700,000 suicide deaths per year. The World Health Organization identifies reducing alcohol use as one component of comprehensive approaches to suicide prevention. This paper conducted a rapid review of the evidence on alcohol-related suicide prevention interventions. PubMed, Embase and Web of Science were searched for articles related to alcohol, suicide, prevention, and policies, published between 1990 and 2020. 5293 articles were identified; after deduplication, 2567 studies were screened at the title and abstract level. 402 articles underwent full-text review. 69 articles were ultimately included and underwent data extraction. Interventions were categorized as policy interventions, community-based interventions, and clinical interventions. While there is evidence that policy interventions targeting alcohol may be associated with lower suicide rates, more evidence using stronger study designs is needed. The evidence for community interventions was mixed and supported the need for further research on these types of interventions. Pharmaceutical and therapy-based clinical interventions also showed some promise, with more research needed. Overall, despite evidence of alcohol’s role in suicide attempts and deaths, few interventions have been developed with the purpose of addressing alcohol-related suicide. More research is needed to identify effective interventions to prevent alcohol-related suicide.
... A key issue with Western behavioral health theories and treatment models is that they are developed based on a general population profile and lack cultural specificity or context when applied to unique populations like AIs. Among AI populations, researchers have found that support from family and friends, culture, spirituality, and involvement in voluntary selfhelp groups facilitate recovery (Kelley et al., 2017). Others report that enhancing self-efficacy, coping skills, motivation, and social network changes (Kelly et al., 2009) support recovery. ...
... In the present evaluation, we identified homelessness, fear of relapse, and the importance of social support as contextual factors that support recovery. This is consistent with previous studies in this population where social support and housing were facilitated through PRS services (Kelley et al., 2017). At the same time, this evaluation pointed to the importance of grant-funded programs and their flexibility compared with other PRS programs that require extensive paperwork to meet third-party billing requirements. ...
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Objectives: This qualitative evaluation was guided by two questions: 1) How does peer recovery support (PRS) support American Indian (AI) people in recovery from substance use disorders? and 2) What makes PRS effective? Methods: We utilized a descriptive qualitative study design to explore the essence of PRS. Semi-structured interviews were conducted with six AI peers to explore the perceptions and lived experiences of recovery from one urban Montana location. Data analysis involved coding all the transcripts using the priori codes developed, then identifying key themes from the coded data. Results: Themes and interview data helped us explore how PRS supports recovery and potential reasons why it is effective for AI populations. Peers indicated that the program helped them maintain their recovery, and the role of peer mentors was critical to their success. Themes of belonging, connection, and compassion were common among peers interviewed. They also felt that recovery is a spiritual process. The peers had limited recommendations for improving the program, except the need for funding sustainability. Conclusions: Understanding how people recover is the first step in addressing the current substance misuse epidemic facing our nation. This evaluation outlined the qualitative impacts of PRS, the spiritual nature of PRS, the context of PRS, and recommendations from peers involved in the program. More work is needed to explore how to sustain PRS programs and integrate PRS into existing community-based settings, like churches, social services, urban AI centers, and other locations.
... 101 Additionally, an American Indian community-driven program has shown that attendance at voluntary self-help groups and support from family and friends increased as a result of PRSS. 102 Service users also reported gains in important components of recovery, including stable housing, employment, and improved health during the 6-month participation in this program. 102 The community recovery maintenance program, PROSPER, encompasses an array of peer-to-peer social support activities for people in recovery who have been incarcerated. ...
... 102 Service users also reported gains in important components of recovery, including stable housing, employment, and improved health during the 6-month participation in this program. 102 The community recovery maintenance program, PROSPER, encompasses an array of peer-to-peer social support activities for people in recovery who have been incarcerated. It showed excellent results for participants who had increased self-efficacy, perceived social support, quality of life, and decreased perceived stress. ...
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Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.
... A review examining the effectiveness of PRC-delivered interventions found that of the small number of studies that had systematically evaluated treatment outcomes, PRCs appeared to have a positive effect on important treatment outcomes, including reducing substance use across a variety of populations (Bassuk et al., 2016;Eddie et al., 2019). Moreover, peer-delivered recovery services appeared to promote retention in follow-up treatment following discharge after acute substance use-related hospitalizations (Tracy et al., 2011), which is associated with reduced rates of relapse (Kelley et al., 2017) and improvements in long-term outcomes (Chinman et al., 2014;Eddie et al., 2019). ...
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The peer recovery workforce, including individuals in sustained recovery from substance use, has grown rapidly in the previous decades. Peer recovery coaches represent a scalable, resource-efficient, and acceptable approach to increasing service delivery, specifically among individuals receiving substance use services in low-resource communities. Despite the potential to improve access to care in traditionally underserved settings, there are a number of barriers to successfully integrating peer recovery coaches in existing recovery services. The current study presents results from two focus groups composed of peer recovery coaches. Findings suggest that peer recovery coaches report discordance between their perceived role and their daily responsibilities and experience both inter- and intrapersonal challenges that impact their own recovery processes. These results point to several promising policy and structural changes that may support and enhance this growing workforce.
... Initial findings suggest that recovery coaching has potential for improving people's treatment and recovery outcomes (Bassuk et al., 2016;Eddie et al., 2019). A growing body of research indicates that peer recovery coaching helps linking people to substance use treatment (Kleinman et al., 2021;Scott et al., 2020), promotes harm reduction approaches (Ashford et al., 2018;Samuels et al., 2018Samuels et al., , 2019, improves retention in treatment while helping people address barriers to care (James et al., 2014), increases engagement in outpatient and recovery support services following treatment discharge (Byrne et al., 2020;O'Connell et al., 2017;Smelson et al., 2013), reduces recidivism and improves drug court engagement (Belenko et al., 2021), and generally improves quality of life factors, such as achieving stable housing, employment, and more social support (Haberle et al., 2014;Hansen et al., 2020;Kelley et al., 2017). ...
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Many people being treated for substance use disorders leave emergency departments (EDs) without being connected to the appropriate care, resulting in increased risk of overdose, death, and recidivism. Providing recovery coaching services in the ED has been identified as a promising strategy to link people to the appropriate follow-up care and supports. We present a brief history of recovery coaching and describe the Emergency Department Recovery Coaching Program offered by the Connecticut Community for Addiction Recovery. Some of the lessons learned from this model include providing financial compensation to the recovery coaches, building a professional support network within and outside the organization, and investment of resources in ED staff education, relationship building, and buy-in. Future research should seek to learn from the programs that are being implemented in real-world settings and explore the feasibility and acceptability of integrating recovery coaching into existing services, simultaneously to observing its effectiveness.
... Searches of the literature did not locate PRC treatment programs specific to any cultural groups other than AIs (Kelley et al., 2017). Many AI cultures may be particularly well suited for PRC work for several reasons. ...
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Background Peer recovery coaches (PRCs) have become a critical tool in addiction treatment in many areas of the world. Despite this fact, no identified research has examined the process or impact of PRC training. Furthermore, no scales were identified to measure trainee confidence in various PRC techniques. The goal of this article is to analyze the process and immediate impact of PRC training of twelve American Indians (AIs) in a culturally-specific program. We focus most specifically on trainee confidence levels. Methods No written consent was obtained and completion of the assessment was considered consent. Trainees completed self-assessments before and after the training. The self-assessment examined nine areas ranging from understanding the role of PRCs to knowledge of effective PRC techniques. Paired t -tests were used to assess for changes in individual trainee responses between the pre- and post-assessments. Results Pre-training responses ranged from moderate to high. Questions with the lowest average confidence levels address PRC activities or specific techniques to facilitate recovery. All nine questions showed statistically significant mean improvements in the post-training self-assessments. Questions regarding specific PRC activities and techniques showed the greatest improvement. Questions relating to helping people more generally showed the smallest improvement. Average post-training responses fell within a very narrow range indicating relatively consistent confidence levels across skills. Analysis indicates participants were possibly over-confident in certain areas (i.e., maintaining boundaries). This small pilot represents an initial attempt to measure confidence levels of PRC trainees. The findings may inform future training by identifying certain areas where emphasis might be most helpful for trainees. In addition, it is hoped that this work will encourage more systematic analysis of the impact of PRC training on individuals.
... There were no suicide attempts after interventions in both arms in the RCT by Sareen et al. 15 In an uncontrolled before-after study, a peer support intervention with traditional activities with AI, 23 suicide attempts decreased by 0.02 mean days at 6-month followup (Cohen's d=0.23). Suicide attempts decreased in five uncontrolled before-after studies. ...
Objective Suicide rates are often higher in Indigenous than in non-Indigenous peoples. This systematic review assessed the effects of suicide prevention interventions on suicide-related outcomes in Indigenous populations worldwide. Methods We searched CINAHL, Embase, PubMed, PsycINFO, ProQuest Dissertations & Theses and Web of Science from database inception to April 2020. Eligible were English language, empirical and peer-reviewed studies presenting original data assessing the primary outcomes of suicides and suicide attempts and secondary outcomes of suicidal ideation, intentional self-harm, suicide or intentional self-harm risk, composite measures of suicidality or reasons for life in experimental and quasi-experimental interventions with Indigenous populations worldwide. We assessed the risk of bias with the Cochrane Risk of Bias Tool and the Risk of Bias Assessment for Non-randomised Studies. Findings We included 24 studies from Australia, Canada, New Zealand and the USA, comprising 14 before–after studies, 4 randomised controlled trials (RCTs), 3 non-randomised controlled trials, 2 interrupted time-series designs and 1 cohort study. Suicides decreased in four and suicide attempts in six before–after studies. No studies had a low risk of bias. There was insufficient evidence to confirm the effectiveness of any one suicide prevention intervention due to shortage of studies, risk of bias, and population and intervention heterogeneity. Review limitations include language bias, no grey literature search and data availability bias. Conclusion For the primary outcomes of suicides and suicide attempts, the limited available evidence supports multilevel, multicomponent interventions. However, there are limited RCTs and controlled studies.
Introduction: The Peer Recovery Expansion Project (PREP) was designed to expand outreach and deliver enhanced treatment services via peer-recovery coaches for individuals with substance use disorder (SUD) and limited access to healthcare. Methods: PREP was implemented in low-socioeconomic areas with historic challenges to accessing SUD treatment. Services were provided to 153 clients through tailored cultural responsiveness, use of peer-based recovery coaching, and development of a Recovery Support Network. Outcome data were collected using the Government Performance and Reporting Act tool at intake and at 6-month follow-up for coaches and clients. Results: The vast majority of peer-recovery coaches were satisfied with the overall quality of the training and their training experience (96.8%). Around 95% agreed that the training enhanced their skills in the topic area and 93% agreed that the training was relevant to substance use disorder treatment at the 6-month post training survey. Majority of clients were from low-income, minority demographics that had a high prevalence history of incarceration, homelessness, and inconsistent employment. At 6-month follow-up, they reported a 22% increase in stable housing and a 25% increase in full-time/part-time employment/training program enrollment. They also demonstrated a significant decline in reported depression, anxiety, and prescribed medication use at 6-month follow-up when compared to baseline. Conclusions: Clients enrolled in a tailored evidence based peer-led program decreased their psychiatric symptoms and increased their housing stability and employment. Study outcomes support the use of an integrated peer-led support for increasing engagement in care for adults experiencing substance use disorders.
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This article reviews Native American ritual practices, frameworks and key concepts employed by several substance abuse treatments centres in the U.S. and Canada. It also examines the way Alcoholics Anonymous’ Twelve Step programme has been modified to attract and serve the needs of Native Americans and First Nations and its potential impact on the ritual practices. Native concepts of wellbeing are highlighted and linked to the idea of living in “balance”.
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Peer recovery support (PRS) offers significant benefits for individuals in recovery from substance abuse disorders. This research describes the experiences of the first 12 months of a tribally led, American Indian community-based PRS project in two American Indian communities. An intrinsic qualitative case-study design was used to answer the research question, “What are some considerations for implementing PRS services in an American Indian reservation community?” Results showed PRS services fill a much-needed gap in American Indian communities where recovery support resources are limited and substance abuse is pervasive.
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Engaging individuals who have a substance use disorder (SUD) in treatment continues to be a challenge for the specialty addiction treatment field. Research has consistently revealed high rates of missed appointments at each step of the enrollment process: 1. between calling for services and assessment, 2. between assessment and enrollment, and 3. between enrollment and completion of treatment. Extensive research has examined each step of the process; however, there is limited research examining the overall attrition rate across all steps. A single case study of a specialty addiction treatment agency was used to examine the attrition rates across the first three steps of the enrollment process. Attrition rates were tracked between August 1, 2011 and July 31, 2012. The cohort included 1822 unique individuals who made an initial request for addiction treatment services. Monthly retrospective reviews of medical records, phone logs, and billing data were used to calculate attrition rates. Attrition rates reported in the literature were collected and compared to the rates found at the target agency. Median time between request for treatment and assessment was 6 days (mean 7.5) and between assessment and treatment enrollment was 8 days (mean 12.5). An overall attrition rate of 80% was observed, including 45% between call and assessment, 32% between assessment and treatment enrollment (another 17% could not be determined), and 37% left or were removed from treatment before 30 days. Women were less likely to complete 30 days of treatment compared to men. No other demographics were related to attrition rates. One out of every five people who requested treatment completed a minimum of 30 days of a treatment. The attrition rate was high, yet similar to rates noted in the literature. Limitations of the single case study are noted. Attrition rates in the U.S. are high with approximately 75% to 80% of treatment seekers disengaging at one of the multiple stages of the enrollment and treatment process. Significant changes in the system are needed to improve engagement rates.
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Alcohol and other drug abuse is a major problem for children and families involved with public child welfare. Substance abuse compromises appropriate parenting practices and increases the risk of child maltreatment. A substantial proportion of substantiated child abuse and neglect reports involve parental substance abuse. Once in the system, children of substance-abusing families experience significantly longer stays in foster care and significantly lower rates of reunification. To address these problems, child welfare systems are developing service integration models that incorporate both substance abuse and child welfare services. This study provides an initial examination of the effectiveness of one service integration model that emphasizes the provision of intensive case management to link substance abuse and child welfare services. The authors used an experimental design and focused particular attention on two outcomes: access to substance abuse services and family reunification. The findings indicate that the families assigned to the experimental group used substance abuse services at a significantly higher rate and were more likely to achieve family reunification than were families in the control group.
The articles included in this issue of Alcohol Research & Health represent only a small sample of the research that has been conducted using the 2001-2002 NESARC, but they demonstrate the range and dimensions of its data and some of the important issues to which these data may be applied. With the completion of Wave 2, NESARC will represent an unprecedented source of information on the natural history and comorbidity of AUDs and associated disabilities which will continue to set the standard for survey methodology, statistical analysis, and psychiatric epidemiology.
A history of Navajo drinking longitudinal studies of alcohol use alcohol-related mortality - changing period effects survival patterns of the original study groups Navajo drinking careers a family history of alcohol use Navajo mortality in its regional context alcohol treatment and the bureaucratization of tradition.
OBJECTIVE Peer recovery support services are delivered by individuals in recovery from substance use disorders to peers with substance use disorders or co-occurring mental disorders. This review describes the service and assesses its evidence base. METHODS Authors searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts for outcome studies of peer recovery support services from 1995 through 2012. They found two randomized controlled trials, four quasi-experimental studies, four studies with pre-post service designs, and one review. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS The studies met the minimum criteria for moderate level of evidence. Studies demonstrated reduced relapse rates, increased treatment retention, improved relationships with treatment providers and social supports, and increased satisfaction with the overall treatment experience. Methodological concerns included inability to distinguish the effects of peer recovery support from other recovery support activities, small samples and heterogeneous populations, lack of consistent or definitive outcomes, and lack of any or appropriate comparison groups. CONCLUSIONS Peer recovery support providers aim to help individuals achieve and maintain recovery, yet studies to date have not tested the key mechanisms of this intervention. To better demonstrate the effectiveness of peer recovery support, researchers should isolate its effects from other peer-based services. Additional research should solidify its place within the substance use treatment continuum for adults with substance use disorders.
Culture and spirituality have been conceptualized as both protecting people from addiction and assisting in the recovery process. A collaborative study, utilizing focus group and survey methods, defined and examined cultural and spiritual coping in sobriety among a select sample of Alaska Natives. Results suggest that the Alaska Native worldview incorporates a circular synthesis and balance of physical, cognitive, emotional, and spiritual processes within a protective layer of family and communal/cultural beliefs and practices embedded within the larger environment. Cultural-spiritual coping in sobriety is a process of appraisal, change, and connection that leads the person toward achieving an overarching construct: a sense of coherence. Cultural and spiritual processes provide important areas for understanding the sobriety process as well as keys to the prevention of alcohol abuse and addiction. © 2001 John Wiley & Sons, Inc.