Dr. Kay Foland Introduces Section 1 Concepts Substance abuse is one of this nation’s leading health problems.

More people die, become ill or disabled by abusing alcohol, tobacco, and illegal drugs than from any other preventable behavior. 

Because of that, preventing substance abuse is a high priority – and a great challenge – for our society. 
 

For additional information on prevention of substance abuse from the Native American perspective, surf to 
The Healthy Nations Initiative.

Alcohol, the most abused substance in America, is almost always the drug of choice for Native American elders. 

Native Americans have experienced a long history of social disadvantage and their disproportionate substance abuse and psychiatric problems have been well documented. 

Alcohol-related mortality and hospitalization for alcoholism are more prevalent in Native Americans than in the United States general population. 

Although much has been written about the problem of alcohol and other drug abuse in elders as well as the problem of alcohol abuse among Native Americans, surprisingly little information is available specifically on substance abuse among Native American elders.

Clearly, substance abuse has taken a severe toll on the health of Native Americans. 

In Module 3, Sections 1 and 2, we will be addressing the issues of substance abuse in Native American elders, with a focus on alcohol abuse.

Of all Indian deaths, 3.2% are diagnosed as being caused by alcoholism. 

This is four times higher than the national average and many people consider that to be a conservative estimate. 

Additionally, one of the leading causes of death in the Native American population is accidents and unfortunately, an estimated 75% of all accidental deaths of Native people are alcohol related. 

Also, the fourth leading cause of death within this population is Cirrhosis, accounting for 6% of all deaths. 

By comparison, Cirrhosis only accounts for 1.7% of deaths in the general population.

So you can see that this is a very serious problem among Native people. 

And finally, the rates of suicide and homicide are also significantly higher in the Indian population and it is estimated that 80 to 90% of these fatalities are alcohol related. These are staggering numbers.

When you compile all of these problems, you can see that alcohol is a factor in many, many more Indian deaths.

For additional statistical information, surf to Alcoholism and Native Americans by John M. Stevenson.

Obviously, the survival of Indian people today continues to be challenged by the abuse of alcohol. 

To help you understand the cause and high rate of alcohol abuse in Native American elders, view the PowerPoint Presentation that looks at three possible explanations.

Genetic differences, diet and stress were thought to contribute to a particular Indian response to alcohol. 

Several studies have been conducted with varying results.

Officially, the Indian Health Service Task Force on Alcoholism came to a conclusion. They found that there was no valid evidence to prove Indians differ in any way from other ethnic groups either in their physiological or constitutional response to alcohol. 

However, the debate continues. In fact, some recent research concluded that Native Americans might absorb and metabolize alcohol faster than Caucasians. So clearly, further studies are necessary. 

On the other hand, we do know that alcoholism does tend to run in families and this familial nature of alcoholism has been confirmed by numerous reports in the modern scientific literature.

Let’s hear from Madonna Blue Horse Beard and Hap Carlin as they reminisce about how important drinking was to their families as a social activity.

So, now let’s talk about some other Social and Cultural Factors which contribute to alcohol use among Native Americans:

First, alcohol is used for a number of reasons, among them are:
 

• enjoyment and the attainment of a psychoactive high…

• to demonstrate generosity in the form of “giveaways” at drinking events…

• and frankly, at times simply to get drunk.

Another contributing factor in alcohol abuse can be Socioeconomic Conditions.

For example, using alcohol to cope with painful life circumstances, such as unemployment, poverty, inadequate education, poor health, or low self-esteem.

The forced cultural alteration from the original Native ways into the dominant white society has also contributed significantly to stress and low self-esteem among Native Americans.

In addition, here are some factors that Native Americans believe contribute to their excessive drinking:

• Drinking can be viewed as an expression of defiance against prohibition…

• Or the often heard phrase: “To be Indian is to drink”…

• Alcohol also seems to relieve the boredom caused by unemployment, a life without purpose, and the lack of religious traditions…

• Drinking can seem to liberate repressed emotions, especially for men who are taught not to express them…

Drinking today in Indian country is both habit, (“We’ve always done it this way” or “It’s Indian to drink”), and social acknowledgment (“Come, friend, and drink with me”). 

Regrettably, many people of all cultures still believe that Indians are genetically different and will thus react differently to alcohol…once again, the firewater myth. 

But drinking can also be a result of the addictive properties of alcohol and it’s become so closely associated with the reservation life-style that it’s hard to see any alternatives. 

Unfortunately, drinking itself has become a metaphor for hopelessness, helplessness, defeat, and escape from the historic circumstances that are often poorly understood by both Indians and whites alike. 

To get a Native perspective, let’s listen to Madonna Blue Horse Beard and Hap Carlin again as they talk about some additional personal experiences with alcohol and addictions in their Native American culture. 

I’d like to thank Madonna and Hap for sharing their life stories with us. They have provided a very necessary insight into the problems Native Americans struggle with every day. 

It is important to remember, though, that individual differences do exist within the Native American culture and therefore stereotypes are not necessarily valid. 

To generalize about Indian drinking would be a mistake, because American Indians are not a homogeneous group. 

Although we cannot generalize about Indian drinking, an understanding of some of the general cultural changes and theories of etiology can assist nurses in providing more individualized care. 

It’s important to remember that people age 65 years and older are the fastest growing segment of the American population. By the year 2030, older adults will represent approximately 22% of the entire U.S. population. 

A significant number of those elders chronically abuse alcohol, which is associated with (or is the basis for) many health-related problems. 

The sad truth, however, is that health professionals frequently do not recognize alcohol and drug dependence in older adults even though the prevalence of substance abuse disorders is 2 to 3% among older women and perhaps as high as 10% among older men. 

And in hospital settings the prevalence is actually much higher. 

Among elders aged 65 and older who come into the emergency room, the rate of alcohol dependence is 15% or more. 

By miss-diagnosing these disorders, the core problem is not being dealt with which simply perpetuates the duration of the abuse.

A number of age-related risk factors can contribute to elders’ vulnerability to alcoholism, drug abuse and medication misuse. 

To help you as a health professional understand the age-related factors that affect Native American elders, view the PowerPoint Presentation that looks at these areas of vulnerability

Well, despite screening problems that may occur certain conditions or clinical assessments of substance misuse and abuse should prompt the nurse into further investigation.

• There is a history of previous misuse or abuse. 

So relapsing and drinking again is very common in addiction disorders. 

And obviously, elders who have abused before are at risk of returning to that coping behavior.

• Loss and loneliness can contribute to the use and abuse of alcohol. 

Nurses should consider that the stress of loss and loneliness or increased leisure time and access to alcohol in social settings may all lead to abuse.

• Noncompliance with health regimens. 

• Mental or physical problems that may be treated with psychoactive substances. 

• Inadequate access to leisure activities. 

Therefore, the relationship between loneliness or boredom and the use of any potentially addictive substances to self medicate should always be considered.

• Negative self-concept that can come with aging. 

• Denial is a major component of addictive disorders, and therefore it is particularly strong in the elderly population. 

As a nurse, you should also consider the possibilities of substance abuse when elders have otherwise unexplained difficulty with following directions or unusually prolonged wound healing. 

Some of the possible warning signs of alcohol or other drug abuse are: 

• Housing problems

• Falls / accidents

• Poor nutrition

• Lack of exercise

• Inadequate self-care

• Social isolation

• Changes in cognition

• Mood swings

• Confusion

• Sleep disturbances

• Chronic pain

• Gastrointestinal disturbances

• Depression

• or even an unexpected reaction to medication 

Behaviors such as memory loss, poor balance, sleeping more than usual, and tremors may be overlooked because of the notion that they are nothing more than the normal consequences of aging. 

When that happens, taking a history can be very complicated because routine screening tools are not reliable when memory loss is present. 

Also, denial of the problem by elders and their families can often occur because many people automatically fear the stigma of disapproval when you mention the problem of alcohol abuse. 

And don’t forget that even without memory loss and denial, traditional cut-off levels of drinking are inaccurate because of the decreased tolerance known to occur with aging.

Now, before we close this session, I’d like you to consider just a few other factors that can contribute to the incidence of alcohol use or abuse in the elderly. 

For example, elders may hide a drinking problem and families may tolerate alcoholism in a mis-guided attempt to help make that elder’s life more tolerable.

Another factor is that alcoholism may get misdiagnosed as senility or as a physical disorder.

Unfortunately, that happens more often than it should.

And sometimes, it’s difficult to detect that elders are drinking from boredom and isolation.

It also could be the result of multiple losses that may be too complicated for them to discuss.

And finally, poor health and inadequate income can also contribute to depression, which is often the first step on the path to alcoholism.

I’d like to mention one last thing that so often gets overlooked...their respect for elders may (at times) make young clinicians uncomfortable with posing questions to confirm alcohol as the underlying etiology of medical problems.

But that respect should never replace a nurse’s commitment to finding the truth because only then can the elder truly be served.

Well, with that, we have come to the end of this Module.

This ends Section 1 of Module 3.  To review, we have defined and elaborated on the following concepts.
 

Other online resources regarding Native American Elders and Substance Abuse can be found at the following sites:

Moving Forward with your Life! Leaving Alcohol and other Drugs Behind (RealPlayer Audio Message)

Healthy People 2010
Against the Odds: American Natives Endure Increased Health Risks and Diminished Care.

Thank you for participating in Section 1 of Module 3. 

And next, Section 2 in Module 3 of this Series will address the Interventions and Screening Tools that can be used when working with Native American Elders.

Thank you for your time and attention.  Please be sure
to take the Post-Test for Section 1.

Proceed to Section 2