Success Story: Northwest Portland Area Indian Health Board

49 days of ceremony

Any visitor to the Northwest Portland Area Indian Health Board's (NPAIHB) website is greeted with this statement: "We know that there is much work to be done to improve the health status in Indian Country, but we do not shy away from the challenge."

This motto drives NPAIHB's innovation and leadership along with their 43 federally recognized Tribes of Oregon, Washington, and Idaho. Their work on opioid overdose prevention in Tribal communities is among the portfolio of projects and initiatives that demonstrate NPAIHB's commitment to addressing challenges. Tribal communities in the Pacific Northwest have been impacted by the drug overdose epidemic, like so many others across the country. Historically, treatment options have relied on abstinence-only messaging and other morally based programs that reinforced internal and external stigma towards individuals with a substance use disorder. In 2017 the Board prioritized a response to the drug overdose epidemic that incorporated culturally appropriate behavioral health programming and Traditional Indigenous Knowledge (TIK) to prevent negative health outcomes.

NPAIHB developed their Tribal Opioid Response National Strategic Agenda by collaborating with community members and partners. The agenda highlights key action areas and recommendations for Tribal communities including integrated care models and harm reduction strategies. The agenda also incorporates the concept of culture as prevention into all strategy areas. According to Behavioral Health Program Director Dr. Danica Brown, "we were not just encouraged to integrate... it was a mandate from our delegates to incorporate Traditional Indigenous Knowledge, Tribal best practices, and culture into the development of our programs."

Staff at NPAIHB delved deeper into what TIK means and how to indigenize knowledge to make evidence-based treatments, such as treatment with medications for opioid use disorder (MOUD), more accessible to communities. They leaned into oral traditions and the story of the "Trickster" as an Indigenous framework for understanding substance use disorders. The work culminated in a framework called the 49 Days of Ceremony which was developed with the Alaska Native Tribal Health Consortium (ANTHC) and Tribal elders. The 49 Days of Ceremony is an Indigenous health promotion framework that incorporates seven components of wellbeing: mental, emotional, physical, spiritual, Mother Earth (or connection to all living beings), Father Sky (or connection to ancestors), and the Sacred Fire- Volition (or one's will to live). This holistic perspective aims to address root causes of health conditions, such as substance use disorder, by helping individuals understand ancestral knowledge, connect to community, and reclaim their overall health and wellbeing.

NPAIHB is using this framework to develop two curricula, "Auntie and Uncle Society" that will train elders as facilitators and "Being a Healthy Human Being" that will guide participants through a project-based, experiential learning intervention focused on a community-based project, such as a canoe journey or sweat lodge building. The collaborative learning process of "Being a Healthy Human Being" is broken down into four main stages. It begins with building trust among the facilitator, participants, and larger community. Once this groundwork is built, the group works together to prepare for the activity logistically, physically, and emotionally. During the journey, participants work through challenges and successes presented by their chosen experiential learning activity. Reflection and prayer are intentionally integrated during and after the activity for participants to think about their experiences, lessons learned, and applications to their everyday lives. Throughout the entire process, individuals are given opportunities to connect to their inner selves, their environment, and their community to begin healing personal and historical trauma.

Now, four years in to putting the strategic agenda into action, communities' views about substance use disorder are changing and people are recognizing the healing power of reconnecting with each other and their own Indigenous identities. In two years, the Swinomish Indian Tribal Community transformed from a community fixed on abstinence-only messaging without evidence-based treatment with medication to building their own wellness center with a fully integrated MOUD treatment program. Even the development process of the 49 Days of Ceremony framework has been transformative for the Advisory Committee, which includes NPAIHB staff, ANTHC staff, Tribal elders, and Indigenous consultants. Partners were able to strengthen relationships with each other and reconnect to their own identities through conversations centered around TIK.

Many Tribal communities have also started expressing interest in using the 49 Days of Ceremony framework to promote healing in their own settings. The challenge for NPAIHB now is to ensure the integrity and sustainability of the work as communities begin to adapt and implement their own 49 Days of Ceremony projects. The Advisory Committee is overseeing pilot projects to ensure fidelity of the work and to further refine development of the "Being a Healthy Human Being" and "Auntie and Uncle Society" curricula. In May 2021, NPAIHB piloted a 49 Days of Ceremony canoe building project with an Alaska Native community. Lessons learned from this pilot and feedback from participants will inform future iterations of the intervention and the development of Indigenous formative and outcome evaluations of the intervention.

According to Dr. Brown, working with communities and sharing the idea of an Indigenous response to the drug overdose epidemic has allowed NPAIHB to "take this very complex human condition and reframe it so that Tribal communities can be more open to understanding other ways of addressing substance misuse." Shifting community norms and building a new approach to health education and promotion is no small feat, yet NPAIHB's progress in doing so makes clear their commitment to embracing challenges and creating opportunities for the communities they serve.

Acknowledgements: Special thanks to Danica Brown and the 49 Days of Ceremony Advisory Committee for their contributions to this story.