WHITE EARTH, Minn. -- Clinton Alexander has a large poster on the wall of his office in the White Earth Nation’s public health center. It's designed to be used for presentations at an academic conference, and it lists the key findings from a recent review of opioid overdose deaths on the reservation.
But layered under the scientific data on the background of the poster are the boarding school records of Alexander’s great-grandmother. She was one of thousands of American Indian children who were sent away to the schools in an effort to eliminate their language and culture.
"When we look at this opioid epidemic and we look at the overdose fatality review, we can't be looking at this without that context being ever present,” Alexander said. “You can't have that without remembering these things."
Alexander works on opioid overdose response for White Earth’s public health department. He’s a co-author of the report. The urgency of his work is relentless. Even as he sat down to discuss the report findings, he was checking a new message on his phone. Another overdose. Another death.
White Earth is not alone.
American Indians in Minnesota have the highest opioid overdose death rate of American Indians anywhere in the country.
In a search for solutions, White Earth officials and university researchers have collaborated on what they are calling a groundbreaking review of opioid overdose deaths that looks deep into the medical histories and the personal lives of a handful of people who died as a result of opioid overdose on the White Earth Reservation.
What their pilot project found are some deep-seated risk factors driving opioid addiction — and a framework for efforts to prevent future deaths.
Generational trauma a key risk factor
Past trauma, which continues to affect Native people today, emerged as a primary risk factor for opioid use in Indian Country.
"Many people I've talked to in tribal communities feel like this is one of the drivers of opiate use; it's like this kind of psychic wound or spiritual pain," said Brenna Greenfield, an assistant professor at the University of Minnesota Duluth medical school and lead author of the report.
"Opioids are a painkiller, and that's a reason for a lot of people using in the first place, so without addressing those underlying issues, it's going to be hard to address opioid use overall."
Opioid fatality reviews are a way to examine what led to an overdose death, and an effort to learn how to prevent future deaths. Some states use them to focus on places they consider “hot spots” — areas where overdose deaths are unusually high. In this case, researchers at the National Drug Early Warning System reached out to Greenfield, because the American Indian population in Minnesota is considered a “hot spot” for overdose deaths.
The project was funded by the National Institutes of Health through the Center for Substance Abuse Research at the University of Maryland, which operates the Drug Early Warning System.
Reviewing a death through the lens of a life
Opioid overdose fatality reviews usually include a look at medical records, autopsy reports and police files, but researchers took a unique approach at White Earth.
White Earth tribal officials wanted the deaths of each of the five people to be reviewed as a life, not a statistic.
“We decided we wouldn't just write people off that we were reviewing as another overdose death,” Greenfield said, “but really to honor their lives and we did that by talking about the strengths of the individual."
The review team, mostly based on the reservation, included public health and substance abuse treatment experts, mental health and crisis response team members and White Earth cultural and spiritual advisers.
Many of those on the multi-disciplinary team knew personally the people whose deaths they were studying. They began each review by talking about the person’s strengths — and examined obituaries and social media posts to understand the individual behind the medical records.
Greenfield struggles to talk about that part of the study. Her voice breaks and a tear rolls down her cheek as she explains the importance of personalizing people who are often seen as statistics.
"I just felt a lot of sadness for the family members -- for their lost loved ones and how it continues to affect them,” she said. “So I think that reinforced the importance of the work and continuing to find ways to respect people who are deceased, and find ways to prevent future deaths."
Looking beyond the medical records was the most challenging part of the work, but also the most important, said Dr. Carson Gardner, the White Earth reservation’s medical director, and chair of the White Earth research review board, which approved a permit for this project.
"Believe me, that was emotional, tear-filled, and sometimes frustration-filled,” Gardner said. “We looked at each other and said, 'Why didn't we know this?' We discovered the social media posts in this modern world are a look into the heart and mind of an individual who's struggling."
The cases they reviewed, Gardner said, point to the need for non-judgmental support, respect and friendship as protection against overdose deaths.
In addition, community focus groups identified several top risk factors that can prevent people struggling with addiction from seeking help: the effects of generational trauma; contemporary trauma, which includes high rates of sexual violence and trafficking of Native women; community stigma against drug abuse; and public shaming.
The two-year-long project identified five key issues people already recognized as barriers to preventing overdose deaths. Top among them: a reluctance to call for help.
People are reluctant to call for emergency help when there’s an overdose, Greenfield said, as they often fear legal trouble, or that children will be taken away.
Second, the review found there’s often a disconnect between reservation treatment programs and off-reservation programs -- and that can be exacerbated by the fact that many people move among tribal nations, and between rural reservations and the Twin Cities.
In addition, many of those addicted to opioids also have unaddressed medical or mental health issues.
Amid the crisis, the White Earth Nation has already developed several innovative programs to address the opioid epidemic. Emergency responders all carry naloxone, the antidote to opioid overdose and about 2,000 local residents are trained to administer naloxone.
Tribal officials say that’s saved dozens, perhaps hundreds, of lives.
White Earth declared a public health emergency around opioid abuse in 2011, one of the first tribal nations in the country to take that action.
Tribal treatment programs were early adopters of using medication to help treat opioid addiction.
White Earth’s civil commitment program, run through the tribal courts, can be used to force members who refuse help into a treatment program.
And the White Earth Nation also runs a treatment program designed specifically for pregnant women with drug addictions.
Alexander believes all of those efforts have made a difference. But the opioid crisis persists. He thinks there are still systemic barriers to getting help for those who are addicted.
“Our services are not set up, necessarily, in the best way to help somebody who is struggling with drug use get the help they need,” he said. “We oftentimes put the cart before the horse and say, 'You've got to stop using before we start working with you.’”
Some minor issues, like a breakdown in communication among programs, were resolved during the review process itself simply by having people from many different programs sit around the same table and talk about barriers that prevent people from getting help. But Alexander thinks more needs to be done to ensure those at risk of opioid overdose receive unconditional help.
“I think that fundamental idea of meeting people where they're at is at the heart of what we need to do, and I think that's why fatality review, for us, really gives us that context to see: Where were those things that we that we missed the boat on?” said Alexander.
‘They died of a broken heart’
In addition to its research on individual deaths, the review team asked community focus groups about the key causes of drug addiction.
They identified several risk factors. At the top of that list was historical and contemporary trauma.
“The focus group member who said, ‘These people didn't die of drug overdoses, they died of a broken heart,’ that's a broad and deep philosophical, spiritual and cultural comment,” said Gardner.
“So how can we prevent the heart from breaking, and how can we offer healing for the broken hearts? Those are the practical things that need to come out of this work.”
The next step at White Earth is engaging the community in trying to answer those questions, said Alexander.
There was a debate among the review team about whether or not to release the results of the opioid overdose fatality review, over a fear the information would be used to perpetuate negative stereotypes. But they felt that the findings of the White Earth research can help other communities if it’s shared.
Alexander thinks this work will be a catalyst for efforts to find ways for individuals and communities to heal from the psychic wounds of historical and contemporary trauma.
“I think what it does is it provides a foundation for us to look at how do we start to heal, It's always easier said than done, but I know that we're moving in that direction,” said Alexander. “We have a traditional value of a strong heart, having courage, and as difficult as some of these cases were to review there was that commitment to want to change things for our community.”