At the Turtle Mountain Band of Chippewa Indians, their opioid-related work is divided between work funded by the CDC, and work funded by other resources such as Health Resources and Services Administration (HRSA), and SAMHSA. 

Their current CDC funding is used to host and provide training and educational events on cultural connectedness activities; this includes presenters on herbal medicines, traditional healing, historical trauma, as well as hands-on craft creation (ribbon shirts and skirts, medicinal earrings, moccasin making). Jodi expresses, “Attendees will get the teachings along with the crafts and learn how healing is connected to the crafts, and learn about culture is prevention; for example, learn why someone would wear a ribbon skirt. Community mentors are brought into the events to share their beliefs and how they create these crafts, so the community is sharing and learning from each other.”

The goal of these events is to provide community members with an opportunity to reconnect to culture. “Culture is prevention, it’s the healing of facing traumas, realizing why we are who we are, being proud of things we are still able to do such as cultural connectedness programming. People want to teach the youth too. There is interest in these types of cultural connectedness programming.”

Part of “facing traumas” is the acknowledgement of how historical trauma impacts the present. “It’s why we are who we are, it’s not our fault. We want to help Tribal community members understand this, and understand where we want to be, through reclaiming identity and healing.”

Jodi started working at TMBCI in February 2024, and previously worked for public health at the state and county level. “This is a dream job, now being able to incorporate the culture, working directly with the people where I live. Now I get to work for my people where I grew up. She knew her name was tied to prevention services in the area, as people reached out to her wanting Narcan training when she started. Jodi stated, “We will include Narcan training and supplies in our Year 2 funding application, and more of the craft sessions, including expanding to drum making. A lot of these things are important because we’re meeting our community where they’re at now.” 

These services operate out of the 5^th Generation Healing Center, “a tribally run Alcohol and Other Drug service program which serves the Turtle Mountain Chippewa Indian Reservation with a continuum of care in the prevention, intervention, and treatment of the disease of alcoholism and other drug abuse for individuals, families, and communities.” Other CDC-funded projects include general disease prevention and a mobile health unit (“to try to provide services to rural areas to reduce barrier of transportation”), which carries Narcan. 

One of TMBCI’s non-CDC-funded projects involves building their public health workforce capacity. At Turtle Mountain Community College, they have a 9-month public health leadership certificate, with 15 graduated students so far, in addition to an Associate of Applied Science degree in Public Health Leadership. The public health department has grown in the last 3-4 years, with a lot of capacity building that began during COVID: “We brought on a state health director, Dr. Terry Dwelle, and a Tribal epidemiologist; we think we’re a rare case to be able to have our own Tribal Epidemiologist. Through CDC Foundation, we also brought on 5 field staff.” These staff assist in disease testing (COVID, RSV, flu, monkeypox) and communications (“someone to share the status of health issues”). TMBCI also has a small grant to partner with local educational systems (Turtle Mountain Community School System, St John School District, Ojibwa Indian School, and Dunseith Day School) to emphasize the importance of public health in schools. Another school-based partnership involved bringing in the North Dakota Public Health Training Network which was provided to school administrators and staff.

“We’re trying to secure and strengthen partnerships, that in itself can be a component for overdose prevention. In the community, many rely on the county public health department, and Turtle Mountain Public Health is trying to increase visibility and show the community what resources are available; we are there for them.”

Transportation issues remain a barrier to public health access due to TMBCI’s rural location near the Canadian border. “We hear a lot that we’re doing a lot of healing. Our Tribal community is very large (80% of county is Native American people), but there’s a large population that hasn’t been reached. How do we reach the people, how do you get those resources to the people, to the housing sites where people are?” The rural location also struggles with lack of cell phone service to call in for support.

Jodi and colleagues also acknowledge insufficient necessary resources to support overdose prevention, like behavioral health services, treatment and recovery centers—this creates a backlog of referrals, where even if they refer to the behavioral health branch, there’s no availability for appointments.” “This creates a Revolving Door Effect: people come in and don’t address the underlying issue. For example, they’ve been to treatment several times, but never addressed ADHD or specific traumas.” They’re excited their next round of funding will include a Licensed Clinical Social Worker to focus on and treat mental health concerns, as well as address trauma.

Another source of excitement within the public health department is upcoming tobacco control work for North Dakota. “We’re offering tobacco training from Mayo Clinic in October for staff at the Public Health Department and Recovery Center. It will help educate the staff on addiction, especially the peer support specialists. This is important, as 40% of respondents in our 2022 Community Health Assessment indicated smoking.”

“With public health, I want to save the world. I have to remind myself it’s about reducing rates. We want to heal everyone, but we have to start by reducing rates.”

The California Tribal Epidemiology Center (CTEC) was established in 2005 to assist in collecting and interpreting health information for American Indians and Alaska Natives (AIAN) in California (from website). While Snesha and Priyanka are primarily involved in Opioid Response, the team works on a variety of health issues; for example, to address the burden of HIV, STIs, gaps in prevention.”

Within the Tribal Opioid Overdose Program, CTEC has 2 main goals: to build a local opioid surveillance system and implement ODMAP. “ODMAP is kind of a novel thing, you record data right as overdose is happening. With other data sets, you must rely on state-level information, which can take a long time to access.” They note, “ODMAP is something that’s a game-changer, because we’re getting real-time data and immediate response. We met with tribal communities that are excited to be able to access overdose data quickly.”

“A lot of people don’t know about this tool. With ODMAP, you can set up a spike alert, and learn where the burden is highest from state to state. One of the tribal health programs told us that previously, they waited 2 years to receive data on overdoses. We were surprised when we heard that from them. Now, they’re one of our tribal health programs that is going to implement ODMAP.”

Implementing ODMAP is a new grant project for CTEC, so they are still working on recruitment, though “a lot of tribal health programs have reached out. We’re looking forward to connecting with more communities.” To publicize their ODMAP recruitment, they are holding informational webinars for recruitment, and outreach. “We’re trying to get as many tribal health programs involved as possible for opioids, as opioids are one of the major issues in our community.”

During the informational webinars, CTEC mainly covers methodological procedures, to strengthen the surveillance program, and evaluation, to ensure Tribal programs are assessing information in the same way.” In addition, “it’s a snapshot of what the project will be, meaning the deadlines and deliverables. Then, the tribal health programs apply to us if they would like funding.” From the applications they’ve already received, the CTEC team has “learned a lot from them directly about what they’re planning to do. As the projects roll out and we gather more information, then we’ll have better insight into what’s been working in the field.” 

They continue, “Through these projects, we’re trying to collect as much data as possible, as we currently rely on state-level data. For example, we’d like to know if there are other agencies where opioids are being prescribed much more frequently.”

Regarding challenges with their work, CTEC expressed, “I think one of the most challenging things is the response rate is on the lower side. There are a lot of reservations where the internet is not great, so it takes longer for messages to get to them.” They’ve also noted that many Tribes struggle with infrastructure and staffing requirements, as “some tribes may not have the infrastructure to staff a first responder to go out and collect the data.”

To other Tribal Epidemiology Centers doing this work, CTEC recommends “Start early as possible, because it takes time to communicate information the Tribes need before they apply.”

For the Eastern Band of Cherokee Indians, opioid prevention and harm reduction efforts flow through many areas of their public health prevention. “We started a Syringe Services Program (SSP) here in 2018, mainly because we had high rates of overdose deaths, and at the time, high rates of Hepatitis C as well. It’s controversial to start an SSP, and as public health professionals we had to persuade the Tribal Council to start one.” Over time, “we were able to hire peer support specialists teach on nasal naloxone; I think it genuinely made a huge difference in our communities over the years.”

Sheena attributed much of their success to their Tribal Health Improvement Plan (THIP), which is based on their Tribal Health Assessment (THA) conducted by Public Health and Human Services (PHHS) at EBCI every five years; one of the three core health areas in the THIP to address is substance abuse. Of the plan, “It’s been really community driven, to create a plan to save lives and reduce overdose deaths, to get people into recovery, and to reduce stigma.” One activity EBCI focused on in the past year was revamping their Cherokee Rally for Recovery, an event to promote the wellness and support of those recovering from substance abuse; “Our goal was to have 100 people and almost 500 people came. We were able to track how many people there were in active recovery, new to recovery, or supporters of those in recovery.” 

“I can’t say enough about the THIP. It’s all these pieces working together, breaking those barriers so people can get help, come forward and make lifestyle changes.”

EBCI launched their new project, public health vending machines, in October of 2023. The vending machine includes hygiene projects, safe sex supplies, nasal naloxone, fentanyl test trips, bug spray for encephalitis, and more. The items in the vending machines are fully funded by grant dollars and are set outside public buildings. The vending machines allow the public health team to access the data on when people use the supply and what time of day. To date, the vending machines have dispensed almost 19,000 products, including 300+ units of naloxone.

“We wanted to increase access, it’s all about access. The community loves them, we have not heard one negative thing about them. People don’t have to sign up for the program, they just type their [Tribal] enrollment number in the machine. Some products have limitations (for example, deodorant is limited to once per week per person), but naloxone and test strips don’t. I think it’s worked incredibly well.”

EBCI began the process of implementing the vending machines by looking up other sites in the country that were using them, then presented the idea to their community council: “we love it, we think that the community could benefit from it, but do you love it or want it?” Thankfully, the council was receptive. “They were so well received that soon we spoke with our community clubs, and they all wanted one.”

“We’re finally starting to see data from our Overdose Mapping and Application Program (ODMAP) that our overdoses are going down drastically. It’s full circle when you see that data, that our efforts are paying off; it’s very powerful and refreshing to see the progress.”

Regarding changes in the community, Sheena expressed, “I feel like there’s been a paradigm shift. Some people have tried to understand [harm reduction] better. For example, with SSP, people thought we were just giving needles out and saturating the community with needles. We had to educate that people have to return needles to get more, that was important; now, our return rate is 95%. We also have large receptacles that we painted red for people to deposit needles. We originally put those out for people who use substances, but now people with diabetes use them too. We’ve educated people on how the receptacles benefit everyone’s health.” 

“Stigma reduction has been a major part. People didn’t really understand how addiction changes the brain; you also have the flip side of families reaping the ramifications of people using substances.”

Overall, EBCI recommends to their peers in this work to “be open minded with strategies to help. Always include culture in what you’re doing, who you are as a person and who you are as a nation.”