Virtual Culturally Grounded Interventions for Substance Use in Urban American Indian and Alaska Native Emerging Adults: A Randomized Clinical Trial.

Importance: American Indian and Alaska Native individuals report higher rates of substance use disorders and psychological distress compared with individuals from other racial and ethnic groups. However, few evidence-based, culturally grounded programs address substance use and mental health for urban American Indian and Alaska Native emerging adults. Objective: To test 2 culturally grounded virtual interventions for substance use among urban American Indian and Alaska Native emerging adults. Design, Setting, and Participants: In this randomized clinical trial, participants were recruited across the US from December 1, 2020, to October 27, 2023. Participants completed an online screening questionnaire. Eligibility criteria included (1) age 18 to 25 years; (2) living in an urban area in the US (not a rancheria or a reservation); (3) self-identification as American Indian or Alaska Native; (4) no opioid use disorder; and (5) English speaking. The participants completed baseline surveys, were randomized to 1 of 2 culturally grounded virtual interventions, and completed 3-, 6-, and 12-month surveys. Follow-up was completed January 28, 2025. Analysis was based on intention to treat. Interventions: Participants received either 3 Traditions and Connections for Urban Native Americans (TACUNA) workshops and a wellness circle, or an opioid education health and wellness cultural (HWC) workshop (usual care). Main Outcomes and Measures: Surveys focused on opioid, alcohol, and cannabis use (primary outcome) and consequences of alcohol and other drug use, mental health, cultural connection, and peer influence (secondary outcomes). Results: Among the 541 randomized participants (451 [83.2%] female; mean [SD] age, 22.1 [2.2] years), the TACUNA and HWC groups both reported decreased frequency of cannabis use (B [SE],  -0.44 [0.20] and -0.54 [0.21], respectively) and decreased rates of positive screens for alcohol (B [SE], -0.03 [0.01] and -0.02 [0.01], respectively) and cannabis (B [SE], -0.02 [0.01] and -0.03 [0.01], respectively) use disorders. Rates of time spent with peers who use alcohol and prescription opioids, clinical depression and anxiety, alcohol and cannabis consequences, and peer norms around alcohol, cannabis, prescription opioids, and heroin use improved in both groups. Only TACUNA participants reported decreases in frequency (B [SE], -0.51 [0.20]) and quantity (B [SE], -0.25 [0.09]) of alcohol use and quantity of cannabis use (B [SE], -0.07 [0.03]). In addition, TACUNA participants reported greater decreases in time spent around peers using cannabis and heroin and greater decreases of anxiety compared with HWC participants. Conclusions and Relevance: In this randomized clinical trial of 2 virtual culturally grounded interventions for substance use, virtual recruitment and intervention successfully reached urban American Indian or Alaska Native emerging adults with decreased access to resources. Both groups reduced consequences and cannabis use; however, only TACUNA participants reported decreases in quantity of alcohol and cannabis use and time spent around peers using cannabis and heroin and greater decreases in anxiety. These findings emphasize the role of bringing American Indian and Alaska Native emerging adults together to discuss ways to reduce alcohol and other drug use and socially connect with their tribal communities in the urban environment in a virtual setting. Trial Registration: ClinicalTrials.gov Identifier: NCT04617938.