July 9, 2009

Substance Abuse Treatment Facilities Serving American Indians and Alaska Natives

Substance abuse disorders disproportionately affect minority populations, particularly the American Indian and Alaska Native (AI/AN) population. In 2007, over 1 in 8 American Indians and Alaska Natives aged 12 or older were classified with substance dependence or abuse in the past year (13 percent) compared with less than 1 in 10 (9 percent) of the total population the same age.¹ Because this is a particularly vulnerable population, examining the resources that can be marshaled to address its substance abuse treatment needs is crucial.

American Indians and Alaska Natives have an especially large population at risk for substance abuse, yet not all who receive substance abuse treatment do so in clinics designated specifically for AI/AN use. Only 55 percent of American Indians or Alaska Natives rely on the federally funded Indian Health Service (IHS) or tribally operated clinics/hospitals for any health care,² meaning a large proportion of the population relies on other publicly and privately funded facilities for such services.

Data on facilities offering substance abuse treatment services specifically for American Indians or Alaska Natives are collected by the National Survey of Substance Abuse Treatment Services (N-SSATS). In 2007, a total of 13,648 facilities were included in N-SSATS. Of those, 259 served the AI/AN population specifically, with 189 operated by a Tribal government, 41 operated by IHS, and 29 from a list³ (provided by IHS) of facilities serving the AI/AN population that were operated neither by IHS nor a Tribal government. For another 76 facilities, the indication that they served the AI/AN population was that they offered treatment services in an AI/AN language—a key component of culturally competent substance abuse treatment for this population. Of these 76 facilities, 52 were private non-profit facilities, 18 were private for-profit facilities, and 6 were operated by the local, community, State, or Federal government. These 76 facilities may serve other populations as well as the AI/AN population.

This report examines the characteristics of these 335 identified facilities serving the AI/AN population in 2007. For this report, facilities operated by a Tribal government will be referred to as “TG facilities,” and facilities operated by IHS will be referred to as “IHS facilities.” In addition, the 29 facilities operated neither by a Tribal government nor by IHS (e.g., operated by a private organization; a community, local, or State government; or a non-IHS Federal government agency) but identified by IHS as serving the AI/AN population will be referred to as “IHS-ID facilities,” and the 76 facilities not included in any of the previously mentioned groups but offering substance abuse treatment services in an AI/AN language will be referred to as “mixed client facilities.” Of the 335 AI/AN facilities, 56 percent were TG facilities, 12 percent were IHS facilities, 9 percent were IHS-ID facilities, and 23 percent were mixed client facilities (Figure 1).

The AI/AN population is more likely than other Americans to live in rural areas, but a growing majority live in urban areas. In 2000, 61 percent of the AI/AN population lived in urban areas (vs. 79 percent of all Americans⁴) compared with only 38 percent in 1970.⁵ However, in 2007, only 40 percent of all AI/AN substance abuse treatment facilities were located in urban areas (i.e., in counties where the U.S. Census Bureau defined a Metropolitan Statistical Area) and 60 percent were located in rural areas (all other areas) (Table 1). The majority of TG and IHS facilities were located in rural areas (73 and 63 percent, respectively), while more than half of IHS-ID and mixed client facilities were located in urban areas (62 and 64 percent, respectively). Within the urban areas, nearly twice as many AI/AN facilities were in small urban areas with fewer than 1 million residents (86 facilities) as in large ones with more than 1 million residents (48 facilities).

While urban IHS substance abuse treatment facilities were about evenly divided between small and large urban areas, other urban AI/AN facilities showed contrasting patterns. Urban IHS-ID facilities were less likely to be in small than large urban areas (24 vs. 38 percent). Urban TG and mixed client facilities, by contrast, were more than twice as likely to be in small urban areas as in large urban areas (TG: 20 vs. 7 percent; mixed client: 43 vs. 21 percent).

Among the four types of AI/AN treatment facilities, the proportion offering the major types of care—outpatient, hospital inpatient, or non-hospital residential—did not differ substantially in 2007 (Table 2). Among all of the AI/AN facilities, outpatient-only care predominated (72 percent), followed by facilities offering both outpatient and non-hospital residential care (13 percent), and then by facilities offering only non-hospital residential care (9 percent). Overall, 89 percent of AI/AN facilities offered outpatient care, either by itself or in combination with other types of care.

IHS-ID and mixed client facilities—by definition more likely than other AI/AN facilities to be privately operated—were more likely to offer two or more types of care (27 percent each) than IHS (19 percent) or TG (13 percent) facilities. By contrast, TG facilities were more likely than IHS, IHS-ID, or mixed client facilities in general to offer only outpatient treatment (80 percent vs. 69 percent, 63 percent, and 52 percent, respectively).

Only a small proportion (4 percent) of AI/AN facilities provided opioid treatment programs (OTPs), that is, programs that dispense methadone or buprenorphine to treat addiction to opiates. Mixed client facilities were more likely to offer OTPs (11 percent) than IHS (2 percent), TG (2 percent), or IHS-ID facilities (none).

Among all AI/AN substance abuse treatment facilities, 21 percent were small (fewer than 15 clients), 44 percent were medium-sized (15-59 clients), and 35 percent were large (60 clients or more) (Table 3).⁶ IHS facilities were more likely to be small (39 percent) than were TG (20 percent), mixed client (17 percent), or IHS-ID (11 percent) facilities. Conversely, IHS-ID facilities and mixed client facilities (41 percent each) were more likely to be large facilities than TG (33 percent) or IHS facilities (28 percent). However, it is important to note that mixed client facilities may also serve non-AI/AN clients, which may contribute to their size.

AI/AN substance abuse treatment facilities offered services in a total of 31 AI/AN languages—a sign of culturally competent substance abuse treatment for clients speaking these AI/AN languages. Overall, 43 percent of AI/AN facilities offered services in one or more AI/AN languages (nearly 33 percent offered services in just one language and another 11 percent offered services in two or more languages). Specifically, 19 percent of AI/AN facilities offered treatment services in Navajo; the next most common languages spoken at AI/AN facilities were Lakota (8 percent), Hopi (5 percent), and Yupik (2 percent) (Table 4). About one in four (25 percent) of all AI/AN facilities offered treatment services in AI/AN languages other than Navajo, Lakota, Hopi, or Yupik.

By definition, the 76 mixed client facilities offered treatment services in AI/AN languages and were the most likely to offer each of the languages specifically queried in N-SSATS—Navajo (57 percent), Lakota (25 percent), Hopi (13 percent), and Yupik (5 percent). Over two fifths (43 percent) of mixed client facilities offered substance abuse treatment services in other AI/AN languages.

Nearly all AI/AN substance abuse treatment facilities provided individual counseling (98 percent), most provided group counseling (83 percent) or family counseling (76 percent), and more than half provided marital/couples counseling (52 percent) (Table 5). In addition to the types of counseling offered, all AI/AN facilities (100 percent) reported providing substance abuse counseling sometimes or often as a clinical/therapeutic approach;⁷ the next two most common approaches were relapse prevention (99 percent) and 12-step approach (92 percent) (Table 6). While the majority of AI/AN facilities used contingency management (60 percent) or trauma-related counseling (76 percent) sometimes or often, of the queried approaches, these were the two clinical/therapeutic approaches used least often by AI/AN facilities.

There was no substantial variation among the AI/AN groups in their likelihood to use most counseling approaches. Contingency management was an exception; while only 48 percent of IHS-ID facilities reported using this approach sometimes or often, 67 percent of IHS facilities, 65 percent of mixed client facilities, and 59 percent of TG facilities reported that they did.

Understanding the services available to the AI/AN population provides valuable information for funding and planning future AI/AN substance abuse treatment programs.

Since most of the AI/AN population lives in urban locations, it is particularly noteworthy that AI/AN facility groups had different distributions in this respect. While TG and IHS facilities were predominantly rural, IHS-ID and mixed client facilities were most often found in urban locations.

Facility size also varied by AI/AN facility type: IHS facilities were predominantly small, and TG and IHS-ID facilities were predominantly medium or large in size. Finally, these results also show that selected facilities outside the formal AI/AN treatment network of IHS and TG facilities are helping to fill needs for substance abuse treatment in specific AI/AN languages.

¹ The findings refer to “not Hispanic or Latino American Indian or Alaska Native” (respondents reporting two or more races analyzed separately) in Table 5.4B of the following report: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: Detailed tables. Retrieved March 23, 2009, from http://www.oas.samhsa.gov/NSDUH/2k7nsduh/tabs/2k7tabs.pdf
² Culture Card, A Guide to Build Cultural Awareness: American Indian and Alaska Native. (2007, December). Rockville, MD: Substance Abuse and Mental Health Services Administration.
³ These facilities are from a list provided by IHS and are operated neither by IHS nor a Tribal government but by another type of organization (e.g., private for-profit; private non-profit; and local/community/county, State, or non-IHS Federal government agency).
⁴ U.S. Census Bureau. (2005). Table 27. Urban and rural population by State: 1990 and 2000. In Statistical Abstract of the United States: 2006 (p. 31). Washington, DC: Author.
⁵Reported AI/AN percentages are of “AI/AN alone” from the following report: Castor, M. L., Smyser, M. S., Taualii, M. M., Park, A. N., Lawson, S. A., & Forquera, R. A. (2006). A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations
living in select urban counties. American Journal of Public Health, 96, 1478–1484. .
⁶ Facility size is the sum of inpatient, residential, and outpatient client counts; in this report, inpatient, residential, and outpatient N-SSATS facility client counts used for classifying facility size were reported for March 30, 2007.
⁷ N-SSATS collects data from facilities about whether nine specific clinical/therapeutic approaches are used in treatment: substance abuse counseling, relapse prevention, 12-step approach, brief intervention, cognitive-behavioral therapy, motivational interviewing, anger management, trauma-related counseling, and contingency management.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (July 9, 2009). The N-SSATS Report: Substance Abuse Treatment Facilities Serving American Indians and Alaska Natives. Rockville, MD.

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