As a psychiatric mental health nurse practitioner at Family HealthCare, Whitney Fear fights for equity in her treatment of those with substance use disorders. In North Dakota, where alcohol is the most abused substance in the state, Whitney uses trauma-informed care with her patients, an approach that factors in adverse childhood events or other experiences that could affect their experience with addiction. In “Who Cares,” we learn that Whitney used this person-centered approach to help Damon, a former patient, with his alcohol use disorder.

With substance abuse, sometimes it’s not about getting people to quit using altogether if they’re not ready. Instead, it’s about helping your patients feel better. This is a harm reduction approach that’s more productive than pushing people to quit, says Whitney, who notes that recommended guidelines are just that — guidelines. Sometimes they’re not meant for every patient. Instead of an approach like abstinence, she asks her patients: “What are some things that you would like to see improve that don’t involve quitting drinking altogether?”

Behind every addiction is a person with a story. Studies show that the social determinants of health — including where patients live, their race, any adverse childhood experiences, their resources, and their ability to access quality healthcare — play a significant role in their experience with a substance use disorder.

For instance, individuals living in rural communities are more likely to struggle with some form of addiction. This may be due to a variety of factors, such as fewer educational and job opportunities, limited access to medical care, and higher poverty levels. In 2020, 49.5 percent of North Dakota residents reported that they lived in rural areas — 35.4 percent higher than the average U.S. rate. And in these rural parts of North Dakota, individuals were more likely to report that alcohol use was a serious problem.

For many people in rural areas, finding help can be yet another battle on top of their addiction. As many as 13 percent of North Dakotans ages 18-25 needed treatment for alcohol use disorder in a specialty facility but could not receive treatment. And across all age groups, a higher percentage of people in North Dakota needed treatment for alcohol use disorder than the rest of the United States. Lack of Medicaid funding continues to be an issue for those seeking treatment programs throughout the state.

A North Dakota 2020 public health report showed how cultural perceptions and social norms can also influence a community’s continued use of substances. Ease of accessibility to alcohol continues to be a risk factor for many North Dakotans. Compared to states like Virginia — with one bar for every 64,773 people — North Dakota has the highest number of bars per capita, with one bar for every 1,809 people. This makes it that much easier to access alcohol in areas like Fargo.

Evidence suggests that all of this contributes to a generational public health issue in North Dakota. According to a 2021 study, it’s estimated that within a month, 34.1 percent of adults in North Dakota engaged in binge drinking (five or more drinks in two hours), compared to the U.S. average of 26.5 percent. In fact, 90.8 percent of adults in North Dakota believe that alcohol is consumed excessively within their community.

COVID-19 has aggravated everyday stressors, leading to an increase in alcohol consumption on a national level. Recent findings report that as many as 60 percent of individuals increased their alcohol intake during the pandemic lockdowns. Research suggests that stress-related drinking is often more dangerous, as those who use substances to cope are more likely to develop alcohol use disorder. The rise of addiction across the country has led to an even greater need for patient-centered treatment for substance use disorders.

In “Who Cares,” Whitney shares her personal experience with alcohol, both individually and in her community on the Pine Ridge Reservation, a place where substance use disorders contribute to lower life expectancies. This helps inform her person-centered approach to care and gives her empathy for those she treats. For more insight, listen to her episode on SHIFT Talk and explore the resources below.

Discussion Questions

  1. Think about how any personal experience with substance use informs the way you approach patients. Does it lead to greater empathy or greater stigma? Why is that?
  2. What did you think of the way Whitney spoke with her patient Damon about his alcohol use? How do you approach patients who have substance use disorders?
  3. Think about your own community. How is Fargo, North Dakota, similar — or different? What factors might lead to an increase in substance use — or limit access to care?
  4. What are the factors in a patient’s personal story to consider when providing them with resources or approaching a conversation about substance use?
  5. What are some ways that you can be an agent for change in how the healthcare system treats and interacts with patients in your community who have substance use disorders?

For Further Reading

Here’s a list of additional resources and to learn more about substance use disorders.

  1. “Harm Reduction: Compassionate Care of Persons with Addictions,” MEDSURG Nursing. 2013 Nov-Dec.
  2. “Addiction Nursing Competencies: A Comprehensive Toolkit for the Addictions Nurse,” JONA: The Journal of Nursing Administration. 2021 Sep.
  3. “Ethnicity and Health Disparities in Alcohol Research,” National Institute on Alcohol Abuse and Alcoholism (NIAAA).
  4. “Patient Communication In Substance Abuse Disorders,” National Center for Biotechnology Information (NCBI). 2021 July 26.
  5. “Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions,” S. Preventative Services Task Force. 2018 Nov 13.
  6. “Screening and Assessment Tools Chart,” National Institute on Drug Abuse (NIDA). 2022 Mar 21.
  7. “Chapter 2—Screening for Substance Use Disorders,” Substance Abuse and Mental Health Administration (SAMHSA).
  8. “Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices,” Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. 2014.

Resources and Organizations to Make a Difference

The following is a compilation of resources on substance use disorders for Native Americans and North Dakota residents:

  1. “Excessive Alcohol Consumption,” Community Preventive Services Task Force, The Community Guide. Accessed 2018 Oct 1.
  2. “Preventing Excessive Alcohol Use: What Public Health Can Do,” Public Health Grand Rounds, Hosted by the Centers for Disease Control and Prevention.
  3. The National Harm Reduction Technical Assistance Center
  4. Indian Health Service: Alcohol and Substance Abuse Program (ASAP)
  5. North Dakota Behavioral Health Human Services: Addiction Treatment Resources
  6. North Dakota Behavioral Health Human Services: Free Through Recovery
  7. Family Healthcare: Behavioral Health Services
  8. North Dakota Behavioral Health Human Services: Shared Community Resources
  9. Alcoholics Anonymous: Fargo-Moorhead Intergroup
  10. North Dakota Al-Anon and Alateen: Meetings