Prescription Opioid Misuse and Heroin Use Among Youth and ...€¦ · Support Program, Matt Keith...

HealthyVoicesHealthyChoices 1

PrescriptionOpioidMisuseandHeroinUseAmongYouthandYoungAdultsinAnchorage,Alaska,NeedsAssessmentHealthyVoicesHealthyChoices&AlaskaInjuryPreventionCenter

HealthyVoicesHealthyChoicesPrescriptionOpioidMisuseandHeroinUseAmongYouthandYoungAdultsinAnchorage,Alaska,NeedsAssessmentApril15,2017Preparedfor

HealthyVoicesHealthyChoicescoalitionVolunteersofAmericaCharlieDanielsPhone:907-265-1912Email:cdaniels@voaak.orgWebsite:www.voaak.org/healthy-voices-healthy-choices

Preparedby

AlaskaInjuryPreventionCenterMarciaHowell,LindseyHajdukandSylviaCraigPhone:907-929-3939Email:Marcia.Howell@alaska-ipc.orgWebsite:www.alaskainjurypreventioncenter.org

Acknowledgements

Thisneedsassessmentwasacollaborativecommunityprocessthatwouldnotbepossiblewithouttheextensiveinvolvement,input,andinsightfromnumerouscommunitymembersimpactedbythesechallengingissues.TheHealthyVoicesHealthyChoicescoalitionwouldliketoextendaheartfeltthankstoallitscoalitionmembersandsupportersfortheoversightandfeedbackthroughouttheneedsassessmentprocess.TheHealthyVoicesHealthyChoicescoalitionwouldliketothanktoallitscoalitionmembersfortheoversightandfeedbackthroughouttheneedsassessmentprocess.Inparticular,wewouldliketothankAmandaLenhardwiththeAmericanLungAssociation,theAlaskaCounterDrugSupportProgram,MattKeithwithGenevaWoods,EydieFlygarewithTutanRecoveryServices,WillHurrwithBoysandGirlsClubsofAlaska,ChrisKosinskiwithAnchorageWaterandWaterwasteUtility,andtheAnchoragePoliceDepartment.Wewouldalsoliketothankourkeyinformantinterviewexperts.WewouldliketothankSouthRestaurant&Cafe,GenevaWoodsMedsetPharmacy,andtheAmericanLungAssociationfortheirgeneroussupportinhostingvariouscommunitymeetings.WewouldliketothankAlaskanAIDSAssistanceAssociationforthecollectionofopen-endedsurveyinformationfromtheirclients.Wewouldalsoliketothankthefollowingagenciesforprovidingprimaryandsecondarydataforthisreport,including:theStateofAlaskaDivisionofBehavioralHealth,theAnchorageSchoolDistrict,AlaskaTraumaRegistry,otherlocalagencies,andVolunteer’sofAmericaAlaska’sPRIMEForLifeprogram.WewouldliketothankAdrieneActiveforsupportontheresourceassessmentandMarnyRiveraforevaluationsupport.ThisneedsassessmentwouldnotbepossiblewithoutthegeneroussupportandinvolvementfromtheHealthyVoicesHealthyChoiceswithVolunteersofAmericaAlaskacoalition,including:CharlieDaniels,LoganDaniels,ZaraSmelcer,TamaraChilds,JayceCarlson,HarryLindsey,DavidCarey,CeylonMitchell,CooperBaldwin,JoyClark,andMorgannJensen.ThisneedsassessmentwasfundedbytheStrategicPreventionFrameworkPartnershipsforSuccessgrantthroughtheStateofAlaskaDepartmentofHealthandSocialServices,DivisionofBehavioralHealth(GrantAwardNo.602-208-1714;July1,2016–June30,2017).

I.TABLEOFFIGURES...........................................................................................................................................6II.TABLEOFTABLES...........................................................................................................................................6III.INTRODUCTION..............................................................................................................................................8

PURPOSEOFASSESSMENT..........................................................................................................................................................8STRATEGICPREVENTIONFRAMEWORK......................................................................................................................................8STAKEHOLDERS.............................................................................................................................................................................9

HealthyVoicesHealthyChoices........................................................................................................................................9AlaskaInjuryPreventionCenter.......................................................................................................................................9

COMMUNITYDESCRIPTION.........................................................................................................................................................9Demographics.......................................................................................................................................................................10Socio-EconomicIndicators...............................................................................................................................................11HealthCareandCoverage...............................................................................................................................................13Governance............................................................................................................................................................................13LegalSystem..........................................................................................................................................................................14

IV.METHODS......................................................................................................................................................15SECONDARYDATA.....................................................................................................................................................................15

YouthRiskBehaviorSurvey.............................................................................................................................................15AlaskaTraumaRegistry....................................................................................................................................................15StateofAlaskaDepartmentofHealthandSocialServices.................................................................................15AlaskaYoungAdultSubstanceUseSurvey................................................................................................................16

PRIMARYDATACOLLECTION....................................................................................................................................................16KeyInformantInterviews.................................................................................................................................................16Open-EndedWrittenSurveys..........................................................................................................................................18VolunteersofAmericaAlaskaPRIMEforLifeData................................................................................................18TelephoneSurvey................................................................................................................................................................18

COMMUNITYREADINESS..........................................................................................................................................................19Tri-EthnicSurveysMethodology....................................................................................................................................19

V.KEYFINDINGS................................................................................................................................................20EXTENTOFTHEPROBLEMINTHECOMMUNITY......................................................................................................................20

CurrentConsumptionPatterns......................................................................................................................................20ConsequencesofOpioidMisuseandHeroinUse....................................................................................................28

COMMUNITYFACTORSASSOCIATEDWITHSOCIALAVAILABILITYOFHEROINANDPRESCRIPTIONPAINRELIEVERS............37AccesstoheroinandprescriptionsopioidsinAnchorage...................................................................................37SafeStorage..........................................................................................................................................................................37HowYouthAccessPrescriptionOpioids.....................................................................................................................39DrugTake-BackEvents......................................................................................................................................................40

COMMUNITYFACTORSTHATCONTRIBUTETORETAILAVAILABILITY....................................................................................40LackofMandatoryPrescriptionDrugMonitoringProgram..............................................................................41Hospital“SatisfactionScores”........................................................................................................................................41PainasaFifthVitalSignCulture...................................................................................................................................42AlternativeorNon-DrugTreatment.............................................................................................................................42

PERCEPTIONSFORRISKOFHARM...........................................................................................................................................43PerceptionofriskofharmamongAnchoragehighschoolstudents..............................................................43PerceptionofriskofharmamongyoungadultsinAnchorage.........................................................................45Studentperceptionofparentalattitudes..................................................................................................................46

HARMREDUCTION....................................................................................................................................................................47

Stigma......................................................................................................................................................................................47Legislation..............................................................................................................................................................................47MedicalCommunity...........................................................................................................................................................48NeedleExchangeProgram..............................................................................................................................................48LackofMedicallyMonitoredDetoxBeds..................................................................................................................48AccesstoNaloxone.............................................................................................................................................................48

OTHERCOMMUNITYFACTORS.................................................................................................................................................49CoordinatedApoliticalAdvocacy..................................................................................................................................49InvolvementofSchools.....................................................................................................................................................50ImprovedAccesstoData..................................................................................................................................................50GrowingCommunityAwarenessThroughtheLocalMedia...............................................................................50CommunityNormsandPerceptions............................................................................................................................50InsufficientCoordinatedEffortstoAddresstheProblem....................................................................................50SyntheticOpioids.................................................................................................................................................................51

COMMUNITYREADINESSASSESSMENT...................................................................................................................................51PerceptionoftheProblemintheCommunity..........................................................................................................58KnowledgeoftheIssue.....................................................................................................................................................59ConcernofPrescriptionOpioidMisuseandHeroinUse.......................................................................................60KnowledgeofEffortstoAddressIssues......................................................................................................................61

COMMUNITYRESOURCEASSESSMENT....................................................................................................................................64Userperceptionsofavailableandneededresources............................................................................................64Resourcesavailabletoaddressinterveningvariables:.........................................................................................65

VI.PRIORITIZATION........................................................................................................................................66PRIORITIZATIONPROCESS.........................................................................................................................................................66

VII.DISCUSSIONANDRECOMMENDATIONS.............................................................................................69REDUCERETAILAVAILABILITY..................................................................................................................................................70REDUCESTIGMA.......................................................................................................................................................................70INCREASESAFEDISPOSAL.........................................................................................................................................................70REDUCEHARM..........................................................................................................................................................................71

VIII.WORKSCITED...........................................................................................................................................73IX.APPENDICES.................................................................................................................................................78

APPENDIXA–SUMMARYOFKEYINFORMANTINTERVIEWS..............................................................................................78APPENDIXB–SUMMARYOFCOMMUNITYREADINESSASSESSMENT...............................................................................97APPENDIXC–COMMUNITYPRIORITIZATIONPROCESS....................................................................................................109APPENDIXD–COMMUNITYRESOURCEASSESSMENT....................................................................................................121APPENDIXE–COMMUNITYRESOURCESASSESSMENTLIST...........................................................................................126APPENDIXF–ANCHORAGERECOVERYAGENCIES...........................................................................................................128APPENDIXG–ANCHORAGEMEDIACOVERAGE..............................................................................................................130APPENDIXH–PRIMEFORLIFESURVEY.........................................................................................................................138APPENDIXI–FOURA’SSURVEY........................................................................................................................................140

I. TableofFiguresFigure1StrategicPreventionModel.............................................................................................8Figure2KeyInformantInterviewSectorRepresentation............................................................17Figure3IntroductiontoOpioidsforRecreationalandMedicalUse............................................20Figure4SummaryofThemesforWhenTakingPrescriptionOpioidsisRisky.............................21Figure5SummaryofThemesforReasonsPeopleBeginOverusingPrescriptionOpioids..........22Figure6AnchorageYouthPrescriptionDrugUse........................................................................23Figure7AnchorageYouthPrescriptionDrugUse........................................................................24Figure8PRIMEForLifeSummaryData.......................................................................................27Figure9SummaryofConsequencesofOpioidMisuseandHeroinUse......................................28Figure10AlaskaHeroinOverdoseDeaths,2009-2015................................................................30Figure11SummaryofAlaskaOverdoseDeathsFromPrescriptionOpioidsandHeroin,2015...30Figure12SummaryofAnchorage2015OpioidERPoisoningDischarges....................................32Figure13SummaryofAnchorage2015HeroinERPoisoningDischarges...................................32Figure14SummaryofWhatPeopledoWithExcessPrescriptionOpioids..................................38Figure15CommunityReadinessScoresforNon-MedicalPrescriptionOpioidMisuseamong12-

17Year-OldsinAnchorage(2017).......................................................................................53Figure16CommunityReadinessScoresforNon-MedicalPrescriptionOpioidMisuseandHeroin

Useamong18-25Year-OldsinAnchorage(2017)...............................................................54Figure17SummaryofthemesfromCommunityReadinessAssessmentgroupinterviews(2017)

.............................................................................................................................................56Figure18SummaryofMessagesFromPrescriberstoPatientsatTimeofPrescription.............60Figure19SummaryofPerceptionsofOpioidUseAmongYouth12-17Years-Olds....................62Figure20SummaryofPerceptionsofOpioidUseAmong18-24YearsOld.................................63Figure21SummaryofPerceptionsofHeroinUseAmongYouth18-24YearsOld......................63

II. TableofTablesTable1AnchorageYouthandYoungAdultPopulationbyAge,2010Census.............................11Table2TopTenAnchorageOccupations.....................................................................................12Table3StagesofCommunityReadinessScale(ColoradoStateUniversity,2014)......................20Table4Past30DayPrescriptionDrugUseWithoutaPrescription,YRBS2015..........................24Table5LifetimePrescriptionDrugUseWithoutaPrescription,YRBS2015................................25Table6LifetimeUseofHeroin,YRBS2015..................................................................................26Table7SubstanceUseandDependenceAmongstYouthbyAgeGroup(2010-2012)................27Table8PrescriptionOpioid-RelatedERDischarges.....................................................................31Table9PrescriptionOpioid-RelatedERDischarges.....................................................................31Table10AmountofDrugsCollectedThroughAnchorageDrugTakeBackEvents......................40Table11Perceptionofriskofharmfromprescriptiondrugmisuseasmoderateorgreater(%)44Table12Perceptionofriskofharmfromtryingtomisuseopioidsonceortwice......................45

Table13Perceptionofriskofharmfromregularmisuseofopioidsonceortwiceaweek........45Table14Perceptionofriskofharmfromtryingheroinonceortwice........................................46Table15Perceptionofriskofharmfromregularlyusingheroinonceortwiceperweek..........46Table16Studentperceptionthatparentsconsiderprescriptiondrugmisuseaswrongorvery

wrong(%).............................................................................................................................47Table17StagesofCommunityReadinessScale..........................................................................51Table18Perceptionofprescriptionopioidmisuseproblemincommunity................................58Table19Perceptionofheroinproblemincommunity................................................................58Table20PercentageofAnchorageAdultsKnowledgeableaboutOpioidAbuseandHeroinUse

(n=382)...............................................................................................................................59Table21PercentageofAnchorageAdultsConcernedaboutOpioidAbuseandHeroinUse(n=

382)......................................................................................................................................60Table22PercentageofAnchorageAdultsKnowledgeableaboutEffortsinCommunityto

AddressOpioidAbuseandHeroinUse(n=382).................................................................61

III. IntroductionTheStateofAlaska’sDepartmentofHealthandSocialServices,DivisionofBehavioralHealth(DBH)issuedtheStrategicPreventionFrameworkPartnershipsforSuccessGrant(SPFPFS)tocoalitionsacrossthestateofAlaskatopreventthenon-medicaluseofprescriptionopioids(NMUPO)among12-25yearoldsandheroinuseamong18-25yearolds.WithinAnchorage,theVolunteersofAmericaAlaska’sHealthyVoicesHealthyChoicescoalition(HVHC)wasawardedfunding.HVHCcontractedwithAlaskaInjuryPreventionCenter(AIPC)toconductthisassessment.

PurposeofAssessment TheDBHtaskedgranteeswithcollectingdatapertainingtoNMUPOamong12-25yearoldsandheroinuseamong18-25yearsolds.Throughtheassessment,granteesweretocollectdatapertainingtothenatureofNMUPOandheroinuseandrelatedconsequences,includinghealthdisparitiesrelatedtoNMUPOandheroinuse.Granteeswerealsoaskedtoassessinterveningandcommunityfactors.Specifically,granteeswererequiredtoassesscommunityfactorsrelatedtosocialandretailavailability,andperceivedriskforharmofNMUPOandheroinuse,andanadditionalinterveningvariablethecoalitionidentifiedinthisprocessisregardingharmreduction.PFSgranteeswereadditionallyaskedtoassessthecommunity’scapacityandreadinesstoaddressNMUPOandheroinuse.

StrategicPreventionFrameworkTheSubstanceAbuseandMentalHealthServices(SAMHSA)fundstheAlaskaSPFPFSgrant.TheDBHrequiresPFSgranteestousetheStrategicPreventionFramework(SPF)toapproachthepreventionofNMUPOandheroinuse.TheSPFisapreventionmodelusedbycommunitycoalitionstoimprovethebehavioralhealthoftheircommunities.

Figure1StrategicPreventionModel

TheSPFtakesacomprehensiveapproachtobehavioralhealthandpreventionandisrootedinprinciplesofpublichealthandcommunityorganizing.StrategiesbasedontheSPFshouldaddressboththeindividualandtheenvironment.TheSPFoutlinesfiveprocessesforimplementation:1)Assessment,2)CapacityBuilding,3)Planning,4)Implementation,and5)Evaluation.TheSPFplacesCulturalCompetencyandSustainabilityatthecoreofthisprocess,meaningthatateachstepoftheSPF,coalitionsshouldworktoensuretheiractionsdemonstrateculturalcompetenceandthattheworkbeingdoneissustainableintothefuture.

Stakeholders

HealthyVoicesHealthyChoicesHVHCisacoalitionwithVolunteersofAmericaAlaska.HVHCbringstogethervariousstakeholderstopromotehealthychoicesthroughpubliceducation,outreach,advocacy,andyouth-ledactivities.ThevisionofHVHCistoeducateandpromotehealthylifestylechoicesrelatedtoourcommunity’syouthandyoungadult’smental,physical,andemotionalwellness.HVHCactivelyadvocatesforacommunitythat:

• Preventsaccesstoalcohol,drugs,andtobaccoproductsbyyouthandyoungadults.• Promotesabstinencefromalcohol,tobacco,andotherdrugsinyouthandyoungadults.• Supportsandpromoteseffectivelifestylechoicesthatbuildandstrengthspositive

assetsinouryouthandyoungadults.

AlaskaInjuryPreventionCenterTheAlaskaInjuryPreventionCenter(AIPC)isanon-profitlocatedinAnchorage,Alaska.AIPC’scorepurposeistopromotewellness,preventinjury,andimprovesafetyinAlaska.AIPChasahistoryofcollectingprimarydataandassessingexistingdatasets.HVHCcontractedwithAIPCtoconducttheassessment.AIPCwillalsoassistHVHCwithdevelopingthelogicmodelandstrategicplan.AIPCisamemberoftheHVHCcoalition.

CommunityDescriptionTheMunicipalityofAnchorage,AlaskaincludesthecommunitiesofAnchorage,Chugiak,EagleRiver,JointBase-ElmendorfRichardson,GirdwoodandcommunitiesalongTurnagainArm.LocatedinSouthcentralAlaska,theAnchoragemetropolitanareasitsinabowlwithCookInlettothewest,andChugachStateParktotheeast.WarmedbyPacificcurrents,thecityhasamildnorthernclimate(AnchorageConvention&VisitorsBureau).Theaveragetemperatureis37F,withanaverage

annualhighof43.7,andaveragelowof30.3F(USClimateData).

DemographicsTheU.S.CensusBureauestimatestheJuly2016populationofAnchoragetobe299,816.Thisisa2.2%increasefrom2010populationestimates(AnchorageEconomicDevelopmentCorporation,2013).Anchorageisthelargestcommunityinthestate,withjustover40%ofAlaska’spopulation.Since2010,Anchoragehasaddedmorethan28,000residentsthroughbirths,lost9,400residentsfromdeaths,andexperiencedanetlossof12,400residentsfromout-migration.Thepopulationpeakedin2013at300,957residents,buthassincehadanetlossof1,920residentssincethattime(AnchorageEconomicDevelopmentCorporation,2017c).In-migrationintoAnchorageisoccurringamongindividualsintheirmid-20’s,oftenfromotherAlaskacommunities.Out-migrationisoccurringamongindividualsintheirlate-teens/early-20’sastheyleavethestateforschoolorwork(AnchorageEconomicDevelopmentCorporation,2017c).PopulationgrowthinAnchoragewillcontinuetobeslowedbyanagingdemographic.AlaskaDepartmentofLaborandWorkforceDevelopmentlong-termprojectionsindicatethepopulationofthoseover65yearsoldareanticipatedtoincreasemorethan30%between2017and2022.Overthatsameperiodthepopulationofresidentsbetweentheages20and64areanticipatedtodecreaseslightly(AnchorageEconomicDevelopmentCorporation,2017c).

RaceandEthnicityAccordingto2015estimatesbasedon2010datafromtheUnitedStatesCensusBureau,theracial/ethnicmakeupofAnchorageisapproximatelyasfollows:

• 65.5%White• 9.6%Asian• 9.1%HispanicorLatino• 8.3%AmericanIndianandAlaskaNative• 7.9%Twoormoreraces• 6.2%BlackorAfricanAmerican• 2.4%NativeHawaiianandOtherPacificIslander

AnchorageishometomoreAlaskaNativepeoplethananyothercityintheUnitedStates(Hunsinger&Sandberg,2013).In2010,26%ofthestate’sAlaskaNativepopulationlivedinAnchorage(Williams,2010).Today,partsofAnchoragearemorethan50%peopleofcolor.AsreportedintheAlaskaDispatchNews,Anchorage’sMountainViewcensusareawasrecentlyidentifiedasthemostraciallydiversecensustractintheentireUnitedStates(McCoy,2013).SeventeenpercentofAnchorageresidentsspeakanotherlanguagethanEnglishintheirhomes.Approximately10%ofAnchorageresidentswerenotUnitedStatescitizensatbirth.

EducationIn2016,theestimatedpopulationat25yearsorolderis192,637.Ofthispopulation,approximately5,244(2.72%)peoplehavebelowa9thgradeeducationlevel;7,482(3.88%)have

agrade9-12educationlevel;46,448(24.11%)haveahighschoollevel;52,940(27.48%)havesomecollege;16,465(8.55%)haveanassociatedegree;41,734(21.66%)haveabachelor’sdegree;and22,324(11.59%)haveagraduatedegree(AnchorageEconomicDevelopmentCorporation,2017b).ThemunicipalityofAnchorageisalsohometotheUniversityofAlaskaAnchorage(UAA),whichisAlaska’slargestpost-secondaryinstitutionandispartoftheAlaska’sstatewideuniversitysystem.UAAservesover14,000studentsandhosts113studentclubs.UAAoffers151degreeprograms,including:associate,certificate,bachelor,masters,anddoctoralprograms(UniversityofAlaska,Anchorage,2017)

GenderIn2015,thepopulationofAnchoragewasapproximately145,703female(48.6%)and154,113male(51.4(UnitedStatesCensusBureau,2015).

AgeTable1providesabriefprofileoftheAnchorageyouthpopulationsbyage.Atthetimeofthe2010census,therewereover65,000youthbetweenages10and24livinginAnchorage.Table1AnchorageYouthandYoungAdultPopulationbyAge,2010Census

Ages NumberofYouth20-24 24,37915-19 21,18710-14 20,4435-9 20,6184andunder 21,961Note.AdaptedfromtheStateofAlaskaDepartmentofLaborandWorkforceDevelopment,ResearchandAnalysis.(2016).DemographicProfileforAnchorageMunicipality.Retrievedfrom:http://live.laborstats.alaska.gov/cen/dppdfs/dem_profile_52.pdf

MilitaryandVeteranPopulationTheAnchoragepopulationalsoincludes5,500militaryandcivilianpersonnelfromthemilitaryJointBaseElmendorf-Richardson(JointBaseElmendorf-Richardson,n.d.).Thereareapproximately29,141veteranslivingwithinAnchorage,basedon2011-2015estimates(UnitedStatesCensusBureau,2015).

Socio-EconomicIndicatorsThemedianAnchoragehouseholdincomebetween2011-2015was$78,326(UnitedStatesCensusBureau,2015).Anestimated8.7%ofpeoplewererecordedaslivingbelowpovertylevel(UnitedStatesCensusBureau,2015),with32,947people125%belowpovertylevel(StateofAlaskaDepartmentofCommerce,Community,andEconomicDevelopment,n.d.)

BetweenOctober1,2013,andSeptember30,2014,therewere7,506peoplerecordedashomelessinAnchorage(AlaskaCoalitiononHousingandHomelessness,2014).Thisincludesfamiliesandindividualsinemergencyshelters,transitionalhousing,andpermanentsupportivehousing.Inthesametimeframe,987childrenwererepresentedunderthesamecategories.Thisdoesnotincludepeopleusing“otherprogramswhoseprimarymissionistoprovideservicestovictimsofdomesticviolence,datingviolence,sexualassault,orstalking,”suchasrapecrisiscentersorbatteredwomen’sshelters(AlaskaCoalitiononHousingandHomelessness,2014).

HousingTheaverageAnchoragehouseholdsizefrom2011-2015was2.77personsperhousehold(UnitedStatesCensusBureau,2015).Oftheestimated115,461Anchoragehouseholdsin2016,66,475wereowner-occupiedand44,830wererenter-occupied(AnchorageEconomicDevelopmentCorporation,2017).In2011,therewere40,575familyhouseholdsand9,910singlemotherhouseholdscontainingpeoplelessthan18yearsofageinAnchorage(AnchorageEconomicDevelopmentCorporation,2013).In2016,theaveragesalespriceofahomeinAnchoragewas$363,932.TherelativecostofhousinginAnchoragehasriseneveryyearsince2009,exceptfor2016witha0.23%decreasefrom2015.TheaveragerentinAnchoragedecreasedfrom$1,312in2015to$1,214in2016foratwo-bedroomapartment.Thelocalvacancyratein2016was3.79%(AnchorageEconomicDevelopmentCorporation,2017c).

EmploymentAsof2011,theAnchoragelaborforcewasestimatedat157,210persons,with147,604peopleemployed(AnchorageEconomicDevelopmentCorporation,2012).Table2showsthetoptenoccupationsinAnchorageasof2012.

Table2TopTenAnchorageOccupations

OccupationsNumberofWorkers Female Male

RetailSalespersons 5,087 2,831 2,256Cashiers 3,290 2,066 1,223OfficeandAdministrativeSupportWorkers,AllOther 2,864 2,238 626CombinedFoodPreparationandServingWorkers,IncludingFastFood

2,627 1,513 1,111

OfficeClerks,General 2,544 1,930 614PersonalCareAides 2,256 1,711 542RegisteredNurses 2,233 2,011 221JanitorsandCleaners,ExceptMaidsandHousekeepingCleaners

2,014 688 1,323

Bookkeeping,Accounting,andAuditingClerks 1,869 1,622 247

OccupationsNumberofWorkers Female Male

GeneralandOperationsManagers 1,114 677 1,137Note. Data retrieved from the State of Alaska Department of Labor and Work Force Development,ResearchandAnalysis:AlaskaLocalandRegionalInformation,AnchorageMunicipality;accessed4/6/15;

CostofLivingAnchorage'soverallcostoflivingindexis130.2%ofthenationalaverage—or30.2%higherthanthenationalaverage—rankingtheAnchoragethe20thmostexpensivecitytoliveinintheU.S.(AnchorageEconomicDevelopmentCorporation,2017).In2013,housingwasthetopitemofexpenditureforAnchorageresidents.Averagedistributionofexpendituresincluded40.6%housing;16.9%transportation;15.5%foodandbeverages;6.6%medicalcare;6.7%recreation;5.7%educationandcommunication;5%clothing;and3.1%othergoodsandservices(Fried,2014).

HealthCareandCoverageAnchorageisrankedthethirdhighestinthenationforhealthcarecosts,precededbytwootherAlaskacities:JuneauandFairbanks.Aphysician’sofficevisitis63.7%higherthanthenationalaverage(AnchorageEconomicDevelopmentCorporation,2017).In2013,theshareofAnchorageresidentswhowereuninsuredwas18.5%.In2012,14.5%ofAnchorageresidentswerenotabletoreceivethecaretheyneededduetothecostofhealthcare.Alsoin2012,41.7%ofAnchorageresidentsreportednothavingaprimarydoctororprovider.In2012,avoidablehospitaladmissions,whicharehospitalizationsduetoconditionsthatcouldhavebeenavoidedwithpreventiveandprimarycareservices,haddecreasedto39.9per1000hospitalizations(ProvidenceMedicalCenter,2015).Anchoragehasfourmajorhospitals,andawiderangeofbehavioralandmentalhealthservicesavailable.TheNationalAllianceonMentalIllnessAnchoragelists15communitymentalhealthserviceprovidersintheAnchoragemetroarea(NAMIAnchorage).TheAnchorageNeighborhoodHealthClinicservesuninsuredandlow-incomeindividualsandfamiliesandprovided$7.8millioninservicestoalmost14,500peoplein2013(AnchorageNeighborhoodHealthCenter,2014).TheAlaskachildren’shealthinsuranceprogramDenaliKidCarepaysforhealthcareforchildrenandteensthroughage18(AlaskaDepartmentofHealthandSocialServices,2016)

GovernanceTheMunicipalityofAnchoragelists34departments,divisions,andoffices,includingtheDepartmentofHealthandHumanServices,OfficeofEmergencyManagement,FireDepartment,PoliceDepartment,ParksandRecreationDepartment,MunicipalLightandPower,

Library,AnchorageMuseumatRasmusonCenter,SolidWasteServices,PortofAnchorage,andPublicTransportation,amongothers(MunicipalityofAnchorage,2015).Thereare38communitycouncilsrepresentingAnchorage’sneighborhoodsthatsereasadvisoriestotheAnchorageAssembly(MunicipalityofAnchorage,2015).Thecommunitycouncilsareprivate,non-profitassociationscomprisedofvolunteercitizenswithinsetgeographicalneighborhoodsdesignatedbytheAssembly(MunicipalityofAnchorage,2015).Asof2013,atotalof344policeofficerswerefulltimelawenforcementemployeesinAnchorage.TheAnchoragePoliceDepartmentisthelargestpolicedepartmentinthestateofAlaska.ItmaintainsaCrisisInterventionTeamofpoliceofficerswhoareeducatedonmentalillness,suicideandcrisisinterventions,activelistening,andde-escalationtechniquessothattheymayrespondtocallsforpersonswithmentalillnesswithempathyandrespect.Morethan90officershavebecomeAPDCrisisInterventionTeammemberssincetheprogram’sinceptionin2011(MunicipalityofAnchorage,2015).

LegalSystemAnchorage’scourtsystemispartoftheStateofAlaskaCourtsystemandiscomprisedoftheAnchorageDistrictCourt,AnchorageSuperiorCourts,andtheAlaskaSupremeCourt(StateofAlaska,2015).Inadditiontothetraditionalcourtsystem,theAnchorageYouthCourt“providestheopportunityforyouthingrades7through12whoareaccusedofbreakingthelawtobejudgedbytheirpeers.Itisacourtinwhichtherolesofattorneys,judges,bailiffs,clerks,andjurorsarefilledbyyouth”(AnchorageYouthCourt,2015).AnchorageYouthCourtallowsyouththeopportunitytoresolvetheirlegalissueswithoutcreatingaformalcriminalrecord.DefendantsaretypicallyfirsttimeoffendersandarereferredtotheAnchorageYouthCourtthroughMcLaughlinYouthCenter’sJuvenileProbationOffice.ThereareeightyouthfacilitiesoperatedbytheStateofAlaska’sDivisionofJuvenileJustice.Anchorage’syouthfacility,McLaughlinYouthCenter,hasthecapacitytodetainorprovidetreatmentfor135youth(StateofAlaska,2015).

IV. MethodsHVHCandAIPCworkedincollaborationtocompletetheassessmentinaccordancewiththeguidancedocumentprovidedbyDBH.ThisassessmentcoveredfourareasofNMUPOandheroinuseincompliancewithDBH’srecommendations.First,HVHCandAIPCassessedconsumptionandrelatedconsequences.Second,thecoalitionassessedinterveningvariablesandcommunityfactorsrelatedtoNMUPOandheroinuse.Thesekeyinterveningvariablesare:socialavailabilityofprescriptionopioidsandheroin,retailavailabilityofprescriptionopioidsthroughproviders,andperceptionsofriskforharm.Third,theassessmentlookedatcommunityresourcesandcommunityreadiness.Fourthandlast,thecoalitionprioritizedcommunityfactorsrelatedtoNMUPOandheroinuse.Acombinationofprimaryandsecondarydatasourcesandtoolswereusedtocaptureandanalyzebothquantitateandqualitativedatasets.Thesevariousdatasetsandcollectionmethodsaredetailedbelow.

SecondaryDataTomeasureNMUPOandheroinconsumptionanditsconsequences,thisassessmentreliedondatafromexistingsources.ThisincludeddatafromtheYouthRiskBehaviorSurvey(YRBS),NationalSurveyonDrugUseandHealth(NSDUH),AlaskaTraumaRegistry(ATR),VolunteersofAmericaAlaska,andtheStateofAlaskaDepartmentofHealthandSocialServices(DHSS).ThesedatasourcesprovidedestimatesofNMUPOuseandheroinuseinAnchorage,aswellasinformationaboutoverdoseandfatality.HVHCandAIPCalsouseddatafromtheAlaskaYoungAdultsSubstanceUseSurvey(YASUS).

YouthRiskBehaviorSurveyTheYRBSisananonymousschool-basedsurveyofhighschoolstudentsthatcoverssixcategoriesofadolescenthealthandsocialbehaviors(AlaskaDivisionofBehavioralHealth,2012).Thesurveyisadministeredeveryotheryearandthemostrecentsurveywasconductedin2015.Inspring2015,1,418studentsfromacrossthestateofAlaskaweresurveyed.TheYRBScontainsquestionspertainingtocurrentandlifetimeprescriptiondruguse(notspecifictoopioiduse/misuse)andheroinuse.DataisavailableatthedistrictlevelfortheAnchorageSchoolDistrict.

AlaskaTraumaRegistryTheAlaskaTraumaRegistrycollectsdatafrom24ofAlaska’sacutecarehospitalsforpatientswithseriousinjuries.AlaskaInjuryPreventionCenterrequesteddatafromtheDivisionofPublicHealthpertainingtoopioidandheroinoverdosefortheappropriateagegroups.

StateofAlaskaDepartmentofHealthandSocialServicesTheDHSShasissuedseveralepidemiologybulletinscoveringtheNMUPOandheroinuseissue.InMarchof2016,theDHSSissuedabulletinwithinformationaboutdrugoverdosedeathsinAlaskafrom2009-2015.ThisbulletinreliedonmortalitydatacollectedbytheAlaskaBureauofVitalStatistics.

AlaskaYoungAdultSubstanceUseSurveyTheCenterforBehavioralHealthResearchandServicesatUniversityofAlaskaAnchorageconductedatelephonesurveytoassessyoungadultsubstanceuseinAlaska(J.D.Barnett,personalcommunication,December23,2016).Specifically,theYASUSaimedtoestablishstate-levelestimatesofopioidandheroinconsumptionandconsequencesamong18-27yearolds.TheYASUSalsocontainedquestionspertainingtosocialavailability,retailavailability,andperceivedriskofharm.Therewereatotalof39questionswithinthesurvey.Atotalof7,130individualswereinvitedtoparticipateandatotalof1,031respondentscompletedthesurvey.Whiletheresearchteamintendedtoonlyinviteparticipantsinthe18-27agerange,someparticipantswereolderthan25.Ofthe1,031respondentstocompletethesurvey,779(75.6%)werewithinthetargetagerangeof18-27.Ofthe7,130participantsinvitedtoparticipate,2,100wereresidentsofAnchorage.Anchorageparticipantsinthe18-27yearrangecompletedatotalof212surveys.TheUAAresearchteamobtainedInstitutionalReviewBoard(IRB)approvalfromtheUniversityofAlaskaAnchorageandtheAlaskaAreaInstitutionalReviewBoardtoconducttheYASUS.PerIRBprotocoltheresearchteamcouldnotproviderawdataforfurtheranalysis,butdidprovidedataanalysisforstatewideandAnchoragedataasawhole,andbyraceandgender.

PrimaryDataCollectionBecauseofthecomplexityofopioidmisuseandheroinuse,HVHCandAIPCjointlydecidedtogatherprimarydata,bothqualitativeandquantitative.Qualitativedatacollectionmethodsallowparticipantstoprovidein-depthexplanationsandrichnarrativeonatopic.SinceNMUPOandheroinpreventionareanemergingissueintheAnchoragecommunity,HVHCandAIPCwantedtocollectasmuchinformationaspossible.GivingcommunitymembersthechancetospeakfreelyontheissueprovidedHVHCandAIPCwithamorecomprehensiveunderstandingoftheissue.HVHCandAIPCconductedinterviewsandopen-endedsurveyswithcommunitymembersandcurrentNMUPOandheroinuserstogathermoreinformationabouttheconsequencesofNMUPOandheroinuseinthecommunity.Atelephonesurvey,conductedbyHaysResearchGroup,collecteddatafromAnchorageresidentsaroundknowledgeoftheproblemofNMUPOandheroinuse,concernabouttheissuesandlevelsofknowledgeofeffortstoaddresstheproblems.

KeyInformantInterviewsTheassessmentteamfirstconsideredconductingfocusgroups.However,duetothesensitivenatureofthetopic,theassessmentteamultimatelydecidedtoconductone-on-oneinterviews.Theassessmentteamchosetoconductone-on-oneinterviewstoensurethatallparticipantsweregivenroomtospeakfreelyonthetopicandtoavoidanydiscomfortanindividualmightfeelsharinginagroup.Thekeyinformantinterviewswerequalitative,in-depthinterviewswithpeoplewhoknowwhatisgoingoninthecommunityregardingnon-medicalprescriptionopioiduseandheroinuse

withinourtargetpopulation.ThekeyinformantsprovidednatureontheinsightofthenatureofthechallengesaroundtheissuesaswellasprovidedrecommendationsforsolutionswithinAnchorage.HVHCandAIPCworkedtogethertoidentifyindividualstointerview.Intervieweesincludedamixofexistingandnewcontacts.AIPCandHVHCchosetointerviewparents,individualsinrecoveryforopioiduse,individualsinrecoveryforheroinuse,activeusers,treatmentproviders,prescribers,militarypersonnel,corrections/law,andcommunitymembersrepresentinghealthcare,education,business,andlocalmedia.Intervieweeswereaskedtoidentifyotherstheythinkmighthavevaluableinputorbeinterestedinparticipatingincoalitionactivities.Figure2KeyInformantInterviewSectorRepresentation

HVHCandAIPCstaffandvolunteersdirectlycontactedrespondentstosolicitparticipation.Respondentswereofferedtheoptiontogothroughthequestionsasanintervieworprovidewrittenresponsestoeachofthequestions.Atotalof22keyinformantswereinterviewedforthisneedsassessment.Responsesweresynthesizedbasedonsectorrepresentation.Afullsynthesisofall22interviewsbysectorisincludedinAppendixAinthisdocument.

Open-EndedWrittenSurveysTocollectdatafromcurrentusers,AIPCdistributedopen-endedwrittensurveystoAlaskanAIDSAssistanceAssociation(FourA’s).FourA’scoordinatesandhousesthecity’sonlysyringeexchangeprogram.AIPCinitiallyprovidedFourA’swith25surveys.Afterreceivingthecompleted25surveysbackfromFourA’sstaff,AIPCprovided25moresurveyswithafewmodificationsbasedonresponsesfromtheinitialsurveydistribution.BothsurveysareincludedintheAppendixIofthisdocument.Intotal,FourA’sstaffdistributedandcollected50surveysfromcurrentusersofeitherheroin,opioids,orboth.Inexchangeforcompletingthesurvey,respondentsreceiveda$25WalMartgiftcard.FourA’sbegandistributingsurveysonFebruary8,2017andhad50surveyscompletedbyFebruary13,2017.

VolunteersofAmericaAlaskaPRIMEforLifeDataVolunteersofAmericaAlaska,incollaborationwiththeAnchorageSchoolDistrict,theBoysandGirlsClubofSouthcentralAlaska,andtheFirstChristianMethodistEpiscopalChurchoffersPRIMEforLifetomiddleandhighschoolstudentsinthegreaterAnchoragearea(VolunteersofAmericaAlaska,2017).PRIMEforLifeisathree-day,alternativetosuspensioncourseforfirst-timedrugandalcoholoffenses.Itcanalsoserveasapreventivecourseforstudentswishingtoavoidsuspension.ThePRIMEforLifeprogramengagesstudentsinself-evaluationoftheirdecisiontousedrugsandalcohol,helpsstudentsseethelife-longconsequencesofdrugandalcoholuse,andequipsstudentswiththeskillsneededtopreventfuturesubstanceuse.VolunteersofAmericaAlaskacoordinatesthePRIMEforLifeprogramandconductssurveyswithparticipants.Thesurveyscontainquestionspertainingtodrugandalcoholuse,includingsocialavailability.AIPCandHVHCanalyzedthedatafromthesesurveysforthisassessment.

TelephoneSurveyTheAlaskaInjuryPreventionCentercontractedwithHaysResearchGroupLLCtoconductatelephonesurveyregardingattitudes,opinions,andbehaviorsrelatedtoseveralbehavioralhealthissuesinAnchorage,Alaska.Questionsaboutopioidandheroinusewereincluded.MarciaHowellofAIPCandAdamHaysofHaysResearchGroupdevelopedthesurveyinstrument.ThetelephonesurveywasconductedfromAugust4,2016toAugust9,2016.Eachsurveyaveragedapproximatelyeightminutesinlength.Atotalof382residentsfromAnchorage,Alaskawereinterviewed.Thesamplewaskeptinproportiontostatepopulationfigureswiththemarginoferrorforagegroupsandgender.HaysResearchGroupteamusedIBMSPSSsoftwaretoanalyzethedata.Theyprovidedfrequencyandcrosstabulationdata.ThoseresultsarepresentedintheKeyFindingssectionofthisreport.

CommunityReadinessAcommunityreadinessassessmentwasconductedfollowingtheTri-EthnicCenterforPreventionResearch'smodelofCommunityReadinessforCommunityChange.(Plested,Jumper-Thurman,&Edwards,2015).Thecommunityreadinessassessmentonthenon-medicaluseofprescriptionopioidsandheroinusemeasuredattitudes,knowledge,resources,andeffortsandactivitiesofcommunitymembersandleadershipinordertoassessthecommunity'sreadinesstoaddressfivekeydimensions:1)Communityknowledgeoftheissues(howmuchdoesthecommunityknowabouttheissues?);2)Communityknowledgeofefforts(Howmuchdoesthecommunityknowaboutcurrentpreventionprogramsandactivities?);3)Communityclimate(Whatisthecommunity’sattitudetowardaddressingtheissues?);4)Leadership(Whatisheleadership’sattitudetowardaddressingtheissue?);and5)Resources(Whataretheresourcesbeingusedorthatcouldbeusedtoaddresstheissue?).

Tri-EthnicSurveysMethodologyAIPCandHVHCdevelopedagroupinterviewprotocoltoevaluatethelevelsofcommunityawareness,understanding,andreadinessofNMUPOandheroinuseinAnchorage.ThecommunityreadinessprotocolisattachedinAppendixB.AselectedgroupofHVHCcoalitionmembersandcommunitymemberswasinvitedtoattendoneortwocommunityreadinessassessmentfocusgroups.Theseparticipantswereidentifiedandselectedaskeyinformantsbasedontheirrepresentationofvarioussectorsinthecommunityaswellastheirknowledgeandexperiencearoundtheissues.Eightparticipantsjoinedthegroupfocusedonnon-medicalprescriptionopioidusefor12-17yearolds.Elevenparticipantsjoinedagroupfocusedonnon-medicalprescriptionopioidandheroinusefor18-25yearolds.Thetotalof19keyinformantsjoinedourtwogroupinterviewsrepresentingthefollowingcommunitysectors:youth-servingorganizations,military,lawenforcement,clinicalservices,medicalservices,youth,parents,NativeAmerican,peopleinrecovery,Hispanic,AlaskaNative,faith,andnon-profitcommunities.Thegroupinterviewswereconducted,captured,scored,andanalyzedbyAIPCandHVHCstaff.Theinterviewdiscussionswereanalyzedforkeythemesrelatingtoprioritycommunityfactorsrelatedtoretailavailability,socialavailability,perceptionofriskforharm,andharmreduction.AllinterviewswereindividuallyscoredonthecommunityreadinessscaleusingtheTri-EthnicCenterCommunityReadinessModel.Everykeyinformantscoredeachcommunityreadinessdimension,andthenthescoreswereaveragedforeachdimensionofreadinessforthetwoissues(non-medicalprescriptionopioidusefor12-17yearolds,andnon-medicalprescriptionopioidandheroinusefor18-25yearolds).Thescoresforeachdimensionwerethenaveragedtoarriveatan“overall”communityreadinessscoreforeachissue.

Table3StagesofCommunityReadinessScale(ColoradoStateUniversity,2014)

StageofReadiness ScoreNoAwareness 1Denial/Resistance 2VagueAwareness 3Preplanning 4Preparation 5Initiation 6Stabilization 7Confirmation/Expansion 8HighLevelofCommunityOwnership 9

V. KeyFindingsExtentoftheProblemintheCommunity

CurrentConsumptionPatterns

Prescriptionopioidmisuse/abuseandheroinuseinAnchoragePrescriptionopioidmisuseandheroinuseareprevalentthroughoutthecommunity.Ourkeyinformantinterviewsrevealedthefarreachtheimpactsofopioidorheroinaddictionhaveonthecommunity,andthatmanypeopleareaffected.

“Mostpeopleknowopioidsaredangerous,thattheyneverwantedlovedonestodoit.Butmanypeopleknowsomeonewhodoes.[…]Manypeopleusingheroindidn’tstartthere.Thecommunityhasmoresympathyforopioidandheroinusersthanotherdrugsbecauseweallknowsomeone.”(KeyInformant,February2017)

Basedonourkeyinformantinterviewswithpeopleinrecoveryandouropen-endedsurveysfromcurrentusers,therewasaroughlyevensplitbetweenpeoplebeinginitiallyintroducedtoopioidsforbothrecreationalandmedicalpurposes.Peoplealsosharedthatiftheywereusingprescriptionopioidstheywouldoftenbothuseandsellthemtoothers.Figure3IntroductiontoOpioidsforRecreationalandMedicalUse

Therewerevaryingopinionsofwhatconstituted“misusingprescriptionopioids.”Somethoughtitwaswhenapersonfirstbeginstousethembeyondmedicalrecommendations,othersbelieveditwaswhentheopioidswerenottreatingpain,andothersbelieveditwasassoonasadependencyisestablished.

“Ithinkitishighlylikelythatsomeonewhoismisusingopioidsrunstheriskofbecomingaddicted.Thisdrugisquicktoclaimitsnextvictim.[…]Childrendon’tunderstandhowthisdrugworksandhowquicklyitcantakeovertheirlives.Oncetheyareinthestagesofneedingit,it’shardtogothroughthewithdrawal.”(KeyInformant,February2017)

Figure4SummaryofThemesforWhenTakingPrescriptionOpioidsisRisky

Onceapersonhasaccesstoprescriptionopioidsthereisariskatbecomingaddicted.Basedonourkeyinformantinterviews,therewerenumerousreasonsthatmayleadpeoplewithinAnchoragetobeginoverusingprescriptionopioids.Figure5SummaryofThemesforReasonsPeopleBeginOverusingPrescriptionOpioids

UseofprescriptiondrugsbyyouthDatafromtheYRBSrevealsseveraltrendsfortheuseofprescriptiondrugsbyyouth12-17yearsofage.ItisimportanttonotethatthequestionontheYRBSsurveydoesnotdifferentiatebetweendifferentkindsofprescriptionsdrugsandmaynotsolelycaptureopioiduse.Figure6showstrendsinprescriptiondrugusewithoutaprescriptionovertimebasedongenderandgradelevel.Basedongender,thereisanear-evenpercentageofmalesandfemalesthatuseprescriptiondrugsatjustunder8%forbothgenders.Basedongradelevel,useofprescriptiondrugsincreasesovergradelevelsandageofyouth.

Figure6AnchorageYouthPrescriptionDrugUse

YouthRiskBehaviorSurveillancedataprovidedbyPFSDETAL.Manyofourkeyinformantsbelievethecommunityhasmorecompassiontowardyouthwhofallvictimtoaddiction.

“Peoplehavetounderstandthatthesekidsdon’tplanontakingthesepillstobecomeaddicts,andiftheycouldgobackandundothefirsttimetheystartedIdon’tknowofanyonewhowouldhavecontinuedtokeeptakingthesepills.”(KeyInformant,February2017)

UseofprescriptiondrugswithoutaprescriptionbyyouthDatafromtheYRBSrevealsseveraltrendsfortheuseofprescriptiondrugswithoutaprescriptionbyyouth.Itisimportanttonotethatthisquestiondoesnotdifferentiatebetweendifferentkindsofprescriptionsdrugsandmaynotsolelycaptureopioiduse.Figure#showstrendsinprescriptiondrugusewithoutaprescriptionovertime.UseofprescriptiondrugswithoutaprescriptionbystudentsinalternativehighschoolsinAlaskawasover40%,in2011,comparedto16.9%forallAlaskanhighschoolyouth(Hull-Jilly&Casto,2011).

Figure7AnchorageYouthPrescriptionDrugUse

YouthRiskBehaviorSurveillancedataprovidedbyPFSDETAL.

30DayUseAnestimated7.5%ofAnchoragehighschoolstudentshadtakenaprescriptiondrugwithoutaprescriptionfromadoctoroneormoretimesduringthepast30days.Ratesofuseinthepast30daysrangefrom4.2%in9thgradetomorethandoublethatin12thgrade(11.0%).Therewasnodifferenceinpast30-dayuseformalesandfemales(7.5%).Forthisassessment,studentswhodidnotidentifyaswhiteorAlaskaNativewerecategorizedas“OtherRaces.”ComparedtowhiteandAlaskaNativestudents,theOtherRacesgroupsawthehighestrate(9.7%)ofprescriptiondrugusewithoutaprescription.Therewerealsodifferingratesofpast30-dayusebyacademicperformance.Approximately12%ofstudentswithprimarilygradesofC,D,orFreportedpast30-dayusecomparedto5.5%ofstudentswithgradesofprimarilyAorB.Thisdatashowsthatthereisagreaterrateofnon-prescriptiondruguseamongstudentsnotidentifyingaswhiteorAlaskaNative,studentsprimarilyreceivinggradesofC,D,andF,andupperclassmen.Table4Past30DayPrescriptionDrugUseWithoutaPrescription,YRBS2015

Estimate 95%ConfidenceIntervalAlaskaTotal 6.4 5.1 8.0AnchorageTotal 7.5 5.7 9.8Sex Male 7.5 5.1 10.8Female 7.5 5.4 10.4

2011 2013 2015

Percen

TrendsinPrescrip\onDrugUseWithoutaPrescrip\onbyYear,YRBS2011-2015

Lifevme

Race/Ethnicity White(Non-Hispanic,SingleRaceOnly) 5.9 3.9 8.8AlaskaNative 7.4 4.0 13.2OtherRaces/Refused/Missing/Unknown 9.7 6.9 12.5Grade 9thGrade 4.2 2.7 6.710thGrade 6.9 4.1 11.611thGrade 8.6 5.3 13.812thGrade 11.0 7.0 17.0AcademicGrades MostlyAsandBs 5.5 3.8 7.9MostlyCs,Ds,andFs 12.1 8.6 16.8

LifetimeUseDatafromthe2015YRBSindicatethat15.0%ofAnchorageSchoolDistrictstudentshadtakenaprescriptiondrugwithoutaprescriptionfromadoctorduringtheirlife.Accordingto2015YRBSdata,theratesforlifetimeusebyfemales(15.6%)wasnotsubstantiallydifferentcomparedtomales(14.3%).Therewaslittledifferenceinprevalenceforlifetimeusewhencomparingracial/ethnicgroups.AlaskaNativeandstudentsnotidentifyingaswhiteorAlaskaNativeeachhadapproximately16%lifetimeuseofprescriptiondrugswithoutaprescription,and13.7%ofwhitestudentsreportedlifetimeuse.Therewasagreaterrateoflifetimeuseforupperclassmencomparedtounderclassmen.Justover10%ofhighschoolfreshmanand12%ofhighschoolsophomoresreportedlifetimeuse.Highschooljuniorshadthehighestlifetimeuseratein2015at19.6%and18.9%ofhighschoolseniorsreportedlifetimeuse.Approximately21.5%ofstudentswithprimarilygradesofC,D,orFreportedlifetimeuseofanon-prescribedprescriptiondrugcomparedto12.4%ofstudentswithgradesofprimarilyAorB.Thisdatashowsthatthereislittledifferenceinlifetimeusebetweenmalesandfemales,orstudentsofdifferentracial/ethnicgroups.Thereare,however,differencesinlifetimeusebygradeyearaswellasbyacademicperformance.Table5LifetimePrescriptionDrugUseWithoutaPrescription,YRBS2015

Estimate 95%ConfidenceIntervalAlaskaTotal 14.6 12.5 17.1AnchorageTotal 15.0 12.6 17.7Sex Male 14.3 11.7 17.4Female 15.6 12.1 19.9Race/Ethnicity White(Non-Hispanic,SingleRaceOnly) 13.7 10.2 18.3AlaskaNative 16.3 11.0 23.4

OtherRaces/Refused/Missing/Unknown 16.1 12.9 19.9Grade 9thGrade 10.3 7.6 13.810thGrade 12.3 8.6 17.111thGrade 19.6 14.6 25.912thGrade 18.9 12.8 26.9AcademicGrades MostlyAsandBs 12.4 9.9 15.5MostlyCs,Ds,andFs 21.5 17.2 26.5

UseofheroinbyAnchorageyouthTheYRBSasksstudentsaboutlifetimeheroinuse.Anestimated1.6%ofstudentsreportedeverhavingusedheroin.Table5showslifetimeuseofheroinforstudentsinAnchoragehighschoolsbysex,race/ethnicity,gradelevel,andacademicgrades.

Table6LifetimeUseofHeroin,YRBS2015

Estimate 95%ConfidenceIntervalAlaskaTotal 2.2 1.3 3.5AnchorageTotal 1.6 .9 2.9Sex Male 2.6 1.4 4.7Female 0.6 0.2 1.8Race/Ethnicity White(Non-Hispanic,SingleRaceOnly) 1.1 0.5 2.6AlaskaNative 0.8 0.2 4.3OtherRaces/Refused/Missing/Unknown 2.6 1.2 5.4Grade 9thGrade 0.8 0.2 2.810thGrade 1.7 0.6 4.711thGrade 3.1 1.3 7.212thGrade 1.1 0.3 3.7AcademicGrades MostlyAsandBs 1.0 0.4 2.1MostlyCs,Ds,andFs 2.9 1.3 6.3

Nonmedicaluseofpainrelieversinthepastyearbyyouthandyoungadults

AccordingtotheNationalSurveyonDrugUseandHealth(NSDUH),therehasbeenanincreaseinthenonmedicaluseofpainrelieversamong18-25yearoldsinAnchorage,from11.79%to

12.35%from2006/2008to2012/2012(Heath,etal.,2015).ReportedratesofusearegreaterinAnchoragethanAlaska’sstatewiderate(11.78inthe2010/2012survey)andgreaterthantheU.S.rate(10.29inthe2010/2012survey).Theratesfor12-17yearoldswere7.2%in2010/2012inAnchorage.ThisisgreaterthattheStatewiderate(6.41)andthenationalrate(5.85)inthe2010/2012survey.Table7SubstanceUseandDependenceAmongstYouthbyAgeGroup(2010-2012)

Behavior* Anchorage Alaska UnitedStatesAges12-17 NonmedicalUseofPainRelievers 7.2% 6.41% 5.85%Ages18-25 NonmedicalUseofPainRelievers 12.53% 11.78% 10.29%Note.TablecreatedfromdataretrievedbyHeathetal.,2015,fromNSDUH.*Referstosubstanceuseordependenceintheyearprecedingsurvey.

WithadditionalinformationgatheredfromPRIMEforLifeparticipantsurveys,itisimportanttonotethatprescriptiondrugsarethethirdmost-usedsubstanceaftermarijuanaandalcohol.ManyoftheyouthparticipatinginPRIMEforLifeself-reportedthattheybeganusingprescriptiondrugsattheaverageageof14. Figure8PRIMEForLifeSummaryData

DataprovidedbyVolunteersofAmericaHealthyVoicesHealthyChoices.

PrescriptiondrugmisuseandabuseatUniversityofAlaskaAnchorageThe2015UAADrugandAlcoholsurveyalsoshowsprescriptiondruguseontheriseoncampus.Ofthe4,000studentswhorespondedtothesurvey,6.6%reportedusingsedativesonceaweekand4.2%reportedusingsedativesthreeormoretimesaweek(Heath,etal.,2015).Lawenforcementdatashowillegaluseofpharmaceuticalsisagrowingconcern,hydrocodoneandOxyContin/oxycodoneabuse,inparticular.

ConsequencesofOpioidMisuseandHeroinUse

CommunityPerceptionsofConsequences

“Idon’tknowanyonewhohasstartedtotakethis[opioid]medicationthatbegantomisuseitbutdidn’tsuffertheconsequencesoftheirhealth,familylife,friendships,school,andfuturedestroyedbythis.”(KeyInformant,February2017)

Figure9SummaryofConsequencesofOpioidMisuseandHeroinUse

MorbidityFrom2004-2013,40hospitalizedpatients,ages9-24,testedpositive,foropiates.Thisrepresents1.3%ofallpatientsinthisagegroupwhoweretestedfordrugs(n=2993)and4.2%(n=954)ofallpatientsinthisagegroupwhotestedpositive.AnEpidemiologyBulletinproducedbytheStateofAlaskarevealedthattherateofhospitalizationsrelatedtoheroinpoisoninginAlaskanearlydoubledfrom2008-2012(Hull-Jilly,Frasene,Gebru,&Boegli,2015).

MortalityDatacollectedfromtheAlaskaBureauofVitalStatisticsmortalitydatabase,showsthatfrom2009-2015,therewere774drugoverdosedeaths.400ofthesedeathswerefromopioidpainrelieversand128wereheroinrelated.Ofthe311thenumberofaccidentalpoisoningdeathsdoubledfrom66in2005to133in2012(Strayer,Craig,Asay,Haakenson,&Provost,2014).Poisoningdeathsinclude,butarenotlimitedto,unintentionaloverdosesfromdrugs.ThenumberofheroinoverdosedeathsinAlaskaincreasedbyafactoroffourfrom2008-2013(Hull-Jilly,Frasene,Gebru,&Boegli,2015).Seventy-fivepercentofallheroin-associateddeathinAlaskafrom2008-2013occurredinAnchorageandtheMatanuskaSusitnaregions(Hull-Jilly,Frasene,Gebru,&Boegli,2015).From2007-2011,Anchoragehad257unintentionallydruginduceddeaths,whichwas49%ofallsuchdeathsintheState.Thisisarateof17.1per100,000andwas25percenthigherthanthenationalaverageof12.9per100,000(Hull-Jilly,Frasene,Gebru,&Boegli,2015).PoisoningwastheleadingcauseofunintentionalinjurydeathsforAlaskaNatives/AmericanIndiansintheAnchorageMat-Suareafrom1992-2011at21%.ThesecondleadingcauseofinjurydeathforAlaskaNatives/AmericanIndiansduringthistimeperiodweremotorvehiclecrashes,meaningthattherewere20%morepoisoningdeathsthanmotorvehicledeathsduringthistimeperiod(Strayer,Craig,Asay,Haakenson,&Provost,2014).

Figure10AlaskaHeroinOverdoseDeaths,2009-2015

http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdfFigure11SummaryofAlaskaOverdoseDeathsFromPrescriptionOpioidsandHeroin,2015

http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdf

RatesofHospitalizationsrelatedtoprescriptionopioidsTable8PrescriptionOpioid-RelatedERDischarges

N %TotalERDischarges 121,232 100.0% PrescriptionOpioid-RelatedERDischarges 568 0.5%Poisonings 29 5.1%OtherERDischarges 539 94.9%Gender Male 271 80.4%Female 297 19.6%Age 12-17YearsOld 7 0.0%18-25YearsOld 101 33.9%OtherAge 460 66.1%Race White 400 70.4%AKNative 100 17.6%AllOtherRaces 55 9.7%Other 13 4.8%Note.AnchorageMunicipalityhealthfacilitiesdischargedataprovidedbyDETAL

Table9PrescriptionOpioid-RelatedERDischarges

N %PharmaceuticalERPoisoningDischarges 458 100.0% PrescriptionOpioidERPoisoningDischarges 29 6.3%Gender Male 10 34.5%Female 19 65.5%Age 12-25YearsOld 8 27.6%OtherAge 21 72.4%Race White 17 58.6%AllOtherRaces 12 41.4%Note.AnchorageMunicipalityhealthfacilitiesdischargedataprovidedbyDETAL

Figure12SummaryofAnchorage2015OpioidERPoisoningDischarges

HospitalfacilitydischargedataprovidedbyPFSDETAL.Figure13SummaryofAnchorage2015HeroinERPoisoningDischarges

HospitalfacilitydischargedataprovidedbyPFSDETAL.

HepatitisCVirusTheHepatitisCvirusinfection(HCV)isthemostcommonchronicbloodborneinfectionintheUnitedStates.HepatitisCisacontagiousliverdiseasethatresultsfrominfectionwiththeHCVandcanrangeinseverityfromamildillnesslastingafewweekstoaserious,lifelongillness.HepatitisCusuallyspreadswhenbloodfromapersoninfectedwiththeHCVentersthebodyofsomeonenotinfected,oftenthroughtheuseofsharingneedlesorotherequipmenttoinjectdrugslikeheroin.ThereisnovaccineforHepatitisCsopreventionisthebestavenuetoavoiditsspread,likeabstainingfrominjectingdrugs(AlaskaDepartmentofHealthandSocialServices,2016).TheStateofAlaska’sSectionofEpidemiology(SOE)reportedatotalof5,888HCVcasesduring2011-2015.ThenumberofHCVcasesroseconsiderablyforallagegroupsinthatperiod,butmostsignificantlyforpeoplebetweentheages18-29(from228to459,a100%increase).Mostcases(55%)weremale,butamongtheagerangeof18-29years,mostcases(53%)werefemale(AlaskaDepartmentofHealthandSocialServices,2016).WithinAnchorage,theoverallrateofpeoplehavingtheHCVis161per100,000people;therateamong18-29year-oldsis221per100,000people,whichisa100%increase(AlaskaDepartmentofHealthandSocialServices,2016).

CostsTheaveragecostforahospitalizedheroinpoisoningwasapproximately$30,000.IncreasesinHepatitisCinfectionsareassociatedwiththesharingofsyringesforheroinorotherintravenousdruguse.ThetreatmentofHepatitisCforonepersoncosts$81,000throughMedicaid(FourA's,2017).

MotorVehicleImpairedDrivingIn2009,justover10%ofDUIcitationsinwhichnon-alcoholrelatedtoxicologytestswereconductedwereissuedduetoopiateuse(AlaskaHighwaySafetyOffice,2009).DrugRecognitionExpert(DRE)evaluationsrevealedthat52driversoutof299impaireddriversin2008wereundertheinfluenceofnarcoticssuchasheroin,oxycontin,orotheropioids(AlaskaHighwaySafetyOffice,2008).TheDREprogramisbeingrevitalized.Itwillbevaluabletogetupdatedinformationwhenitbecomesavailable.

JuvenileDrugOffensesThenumberofjuvenilesarrestedforadrugoffenseincreasedfrom272in2007to353in2011;thismarkeda29%increaseinjuveniledrugoffensearrestsinAlaskaduringthistime(Hull-Jilly,Frasene,Gebru,&Boegli,2015).Keyinformantinterviewsfoundthattherearespecificchallengeswithyouthinthejusticesystemandlinkstodruguse.Someyouthwithinthejuvenilejusticesystemexperiencecognitivedelays,whichthenchallengesthemtounderstandthelong-termconsequencesoftheircurrentactions.Forexample,itmaybechallengingtoconnectthataddictionanditsconsequencescanresultfromtakinganopioidpillforshort-termreliefnow.Thismakesit

challengingforyouthtomakethebestdecisionsforthemselvesspecificallywithinthispopulation.

StatewideSeizures,Charges,andArrestsandCrimeFrom2009to2011arrestsandchargesinAlaskarelatedtoheroinnearlydoubledfrom64to118respectively.Statewide,thepoundsofheroinseizedalsonearlydoubledfrom3.3poundsin2009to6.4poundsin2011(Hull-Jilly,Frasene,Gebru,&Boegli,2015).In2014,theAlaskaStateTroopersreport209arrests/chargesand22.4poundsofheroinseized(AlaskaStateTroopers,2015)In2015therewere233heroinrelatedarrestsinAlaska.In2012,141Hydrocodoneand609OxyContin/Oxycodonedoseswereseized.Thesenumberssawlargeincreasesto796and1183respectivelyin2014(AlaskaStateTroopers,2015).Locally,theAnchoragePoliceDepartmentseized2.78kilosofheroinin2011.Thatnumberincreasedto2.92in2012,5.67in2013and6.9in2014.The2014seizurehadastreetvalueof$3,441,785dollars.In20154.2kilosofheroinwereconfiscatedwithastreetvalueof$1,054,997.APDseized1050Oxycodone,Oxycontin,andhydrocodonedosesinAnchorage,withastreetvalueof$196,900.(AlaskaStateTroopers,2015)Anchoragehasseenanincreaseinallkindsoftheftfrom2014-2015,asreportedbyAnchoragePoliceDepartment.In2014therewere496reportedrobberies,1375burglaries,2768theftsand939reportsofstolenvehicles.In2015,thosenumbersincreasedto621reportsofrobberies,1885burglaries,8962theftsand1154vehiclesreportedstolen.Arrestsforpossessionofnarcoticsrosefrom97in2014to132in2015.(McClure&Monfreda,CrimeinAlaska2015,2015)(McClure&Monfreda,UniformCrimeReportingProgram,2014).

ImpactstoFamiliesBasedonourkeyinformantinterviews,therearemanypersonalchallengesnotonlytoapersonmisusingopioidsorheroin,butalsototheirfamilyandclosefriends.Ourkeyinformantinterviewssharedthemesthatafteraddictionpeoplemaybecomehomeless,jobless,losefamilyandfriendconnections,mayleadtojail,sexualexploitation,ordeath.Onechallengekeyinformantssharedwasthatapersonmaynotknowthefullextentoftheconsequencesuntilitistooclose,includinglosingtheirchildrentotheOfficeofChildren’sServicesorbecominghomeless.Arecentanalysisof2004-2015datafoundthattheincidenceofNeonatalAbstinenceSyndrome(NAS)isincreasingbothnationallyandinAlaska(AlaskaDepartmentofHealthandSocialServices,2016).NASisprimarilyassociatedwithprenatalexposuretoopiates.Prenataluseofopioids,whichincludeheroinandotherprescriptiondrugs,isincreasingnationally,resultinginanassociatedincreaseinNAS.InAlaska,healthcareprovidersareresponsibleforreportingNASinfantstoOCStoassessthesafetyofthehomeenvironmentandpossiblyintervene(AlaskaDepartmentofhealthandSocialServices,2017).

RealConsequencesofNMUPOasdescribedbyactiveusersParticipantswereaskedtoidentifyconsequencesthattheyhadseenfromindividualsusingopioidsbeyondmedicalrecommendations.Consequenceswerevaried,oftenserious,andincluded:addiction,overdose,poorhealth,losingfamilyandfriends,losingjobs,homelessness,lossofnormallife,jail,anddeath.Didyouknowabouttheseconsequencesbeforeyoustartedusing?Afterbeingaskedtoidentifyconsequencestheyhadseenfromprescriptionopioidmisuse,participantsfromthefirstroundofsurveyswereaskediftheyhadbeenawareoftheseconsequencesbeforetheystartedusing.Overhalfofthoseaskedindicatedthattheydidnotknowabouttheconsequences.Ofthosethatsaidyes,theydidknowoftheconsequencesbeforetheystartedusing,severalindicatedthattheydidnotfullyunderstandthedepthandimpactoftheconsequences.Participantsfromthesecondroundofsurveyswereaskedtoidentifywhichconsequencestheyknewaboutbeforetheystartedusing.Justoverhalfofrespondentsknewthatjailandpoorhealthwereconsequencesofusingprescriptionopioidsbeyondmedicalrecommendations.Underahalfofrespondentsknewthatlossofnormallife,losingajob,homelessness,andlosingfriendswerepotentialconsequences.Approximatelyonethirdofrespondentsknewthatlosingfamilycouldbeaconsequenceofmisusingprescriptionopioids.Howlikelydoyouthinkitisthatpeoplewhouseopioidsbeyondrecommendationwillfacetheseconsequences?Almostallrespondentsindicatedthatitisverylikelyorguaranteedthatapersonwhomisusesprescriptionopioidswillfaceconsequences.Whichconsequencesmighthavepersuadedyoutonotstartusing?Themajorityofrespondentsindicatedthatlossoffamilymighthavepersuadedthemfromnotusing.Lossoffriends,jail,andhomelessnesswerealsocommonresponses.Afewsurveyparticipantsmentionedthathavingaccesstomorecommunityevents,parks,andactivitiesandabettercommunityenvironmentmighthavehelpedpreventopioidmisuse.Afewrespondentsalsoindicatedthatbeingmoreeducatedabouttheeffectsofprescriptionopioidsmighthavepreventedthemfrommisusingthem.Somerespondentsindicatedthatnoneoftheconsequencescouldhavepersuadedthemfromnotusing.

RealConsequencesofheroinuseasdescribedbyactiveusersWhatconsequenceshaveyouseenfromheroinuse?

Theconsequencesofheroinuseasdescribedbycurrentuserswereserious.Consequencesincludedlossoffamilyandfriends;loseofjob,homelessness,poorhealth,lossofnormallife,dependency,overdose,anddeath.Whichoftheseconsequencesdidyouknowaboutbeforeyoustartedusing?Theoriginalsurveycontainedaquestionaboutwhichconsequencestheyknewofbeforebeginningtouseheroin.Responsesincludedlossoffamily,lossoffriends,poorhealth,overdose,physicaldependency,abscess,jail,andlossofpossessionsandhome.Themodifiedsurveyprovidedrespondentswithoptionstoselectfrom.Theseoptionsincludedlosingfamily,losingfriends,losingjobs,homelessness,poorhealth,lossofnormallife,andjail.Themajorityofrespondentswereawareofatleastsomeoftheconsequencesofheroinusebeforeinitiatinguse.Roughlyone-fifthofrespondentsfromall50surveyswerenotawareoftheconsequencesofheroinusebeforetheybeganusingheroin.Severalrespondentsindicatedthatwhiletheyhadbeenawarethattherewereconsequencesofheroinuse,theydidnotfullyrealizetheextentoftheconsequencesuntiltheyhadexperiencedthemthemselves.Howlikelydoyouthinkitisthatpeoplewhouseheroinwillfacetheseconsequences?Almostallrespondentsindicatedthatitisverylikelythatapersonwhousesheroinwillfaceconsequencesliketheonesreferencedinthepreviousquestions.Whichconsequencesmighthavepersuadedyoutonotstartusing?Whenaskedwhichconsequencesmighthavepersuadedthemfromnotusingheroin,lossoffamilywasthemostcommonresponse,followedbyjail.Lossoffriends,death,homelessness,andexperiencingwithdrawalwerealsofrequentresponses.Afewrespondentsindicatedthatlossofnormallifemighthavepersuadedthemfromnotusing.Somerespondentsindicatedthatnoneoftheconsequencescouldhavepersuadedthemfromnotusing.Whatotherthingsthatcouldhavepreventedyourheroinuse?Heroinuserswereaskedwhatotherthingsmighthavepreventedthemfromusingheroin.Commonresponsesincludedhavingfamilyandfriendsprovidesupportandoutreachmay

havepreventedthemfromusingheroin.Severalrespondentsalsopointedtopasttrauma,familyinstability,ormentalhealthissuesasleadingthemtoheroinuse.Tworespondentsindicatedthattheytransitionedfromopioidusetoheroinuse.Oneoftheseparticipantsrespondedthatbeingcutoffcoldturkeyfromprescriptionopioidsmadethemseekoutheroin.

CommunityFactorsassociatedwithSocialAvailabilityofheroinandprescriptionpainrelievers

AccesstoheroinandprescriptionsopioidsinAnchorageObtainingPrescriptionOpioidsForcurrentusers,thetwomostfrequentlymentionedmeansforobtainingprescriptionopioidswerethroughthestreetorthroughaprescriptionfromdoctors.Obtainingdrugsfromthestreetwasoftenmentionedasnetworking,orthroughword-of-mouth.Afewrespondentsindicatedfakingscripts.Dealers,friends,andstealingfromfamilyandstrangerswerealsocommonresponses.ObtainingHeroinWhenaskedhowcurrentusersorpeopletheyknewobtainedheroininAnchorage,themajorityrespondedwitheitheradealerorthestreet.Otherresponsesincludedfromfriends,strangers,and,inafewinstances,familymembers.

SafeStorageAthemeemergedfrominterviewswithkeyinformantsthatmanypeopledonotthrowawayunusedprescriptionmedication.Stockpilingofunuseddrugs“foranotherday”isacommonpracticethroughoutAnchorage.Fromacitywidesurvey,nearlyhalf(47%)ofallcommunitymembersreportedthattheystillhavetheirunusedprescriptionopioids.Aquarterofrespondentsreportedthattheydidnothaveanymedicationremainingsodidnothavetodisposeofthem.However,thatleavesaremaining29%ofrespondentsthatdisposedofthemeitherbythrowingtheminthetrash(8%),flushingthemdownatoilet(11%),bringingthemtoa“takeback”(2%),andtheremaindergavethemaway(8%).

Figure14SummaryofWhatPeopledoWithExcessPrescriptionOpioids

DataprovidedbyPFSDETAL.Surveyof212Anchorageresidentsaged18-27.Currentmisusersofprescriptionopioidswhoparticipatedinthesurveysat4’s,discussedwhatsafestoragemeanstothem.Themajorityofrespondentsindicatedthattheyneededtobeinasafeorlockbox.Afewindividualsalsoindicatedthattheyshouldnottellanyonethattheyhaveaprescriptionforopioids.Whenaskedwhattheywoulddoifprescriptionopioidswereunavailable,mostrespondentssaidtheywouldmovetoheroin,anotherdrug,orcontinuetosearchforopioidsuntiltheycouldfindthem.Asmallnumberofsurveyrespondentsindicatedthattheywouldenterdetoxortrytostopusingprescriptionopioidsalltogether.Manyactiveheroinusersarealsomisusersofprescriptionopioids.Whenaskedwhattheywoulddoifprescriptionopioidsweresecurelystored,mostsaidtheywouldseekother

drugs.Severalpointedoutthattheywoulddoanythingtoavoidexperiencingwithdrawal.Asmallnumbersaidtheywoulddetoxandgetclean.Interviewswithkeyinformantsfoundthatadultswerealsonotlikelytobedeterredifopioidsweresimplyunavailable.Many,includingpeopleinopioidrecovery,saidthatiftheywereaddictedandopioidswerenotavailabletheywouldsimply“findsomethingelsetouse”(KeyInformant,January2017).Open-endedsurveyswithactiveusersreinforcedthismessage,thatsomeonewithanaddictionwilldo“whateverittakestonotbesick.”IntheAdultPerceptionsofAnchorageYouth(APAY)asurveyinitiatedbyHVHCandwithDr.MarnyRiveraattheUniversityofAlaskaAnchorageastheprincipalinvestigator,adultsinAnchoragewereaskedquestionsaboutprescriptiondrugsintheirhomeandyouthaccesstotheirprescriptiondrugs.Seventy-fourpercentofadultsinAnchorageindicatedthattheyhaveprescriptiondrugsinthehome.WhilemostAnchorageadultshaveprescriptiondrugsinthehomefifty-fivepercentindicatedthatchildreninthehomedonotknowprescriptiondrugsareinthehomeandanothersixpercentdidnotknowwhetherchildreninthehomeknewtherewereprescriptiondrugs.Themajorityofadults(87%)agreedthatitisnecessaryforparentsorguardianstotakestepstokeepchildrenandyouthfromhavingaccesstoprescriptiondrugsinthehome.AdultsinAnchoragewerealsoaskedaboutseveralstepsthatcouldbetakentoreduceyouthaccesstoprescriptiondrugsinthehome.Lessthanhalfoftheadultsengagedinanyofthefouractivitiestheywereaskedabout.ThemostcommontechniquesusedbyadultsinAnchorageforreducingyouthaccesstoprescriptiondrugsincludedhidingthepills(49%)andkeepingtrackofthenumberofpills(48%).Theleastcommontechniquesusedbyadultsforreducingyouthaccesstoprescriptiondrugsincludedkeepingthepillswiththemwhentheyleavehome(21%)andlockingthepillsup(35%).“Other”methodsforpreventingyouthaccesstoprescriptiondrugssuggestedbysurveyrespondentsincludededucatingyouthaboutprescriptiondruguse,makingprescriptiondrugsinaccessibletoyouth,anddiscardingprescriptiondrugsassoonastheprescriptionhasexpired.Across-tabulationanalysisofAdultPerceptionsofAnchorageYouthsurveydatashowedthatparents(of12-24yearolds)weresignificantlylesslikelythanotheradultsinAnchoragetotakevariousstepstoreduceyouthaccesstoprescriptiondrugsinthehome.Fifty-twopercentofadultshideprescriptionmedicationswhileonly40%ofparentsdid.Whereas35.6%ofadultsreportedthattheylockuptheirpills,only26.2%ofparentsdid.Twenty-threepercentofadultsreportedthattheykepttheirprescriptionmedicationswiththemwhileonly14%ofparentsdid(HVHCdata).

HowYouthAccessPrescriptionOpioidsYouthwhoparticipatedinthePrimeForLifeevaluationsurveyreportaccessingprescriptionopioidsfromafriend,takingthemfromafamilymemberandpayingsomeoneforthem.

Severalmentionedgettingthematschool.Thetwomostcommonresponsesweretakingthemfromafamilymemberandgivingsomeonemoneyforthem.Communityperceptionwasgatheredondruguseandmisuse.HVHC’smemberssurveyed100communitymembersin2015byaskingopenedendedquestions.Questionsaskedincluded“Howdoyouthinkyoungpeopleareaccessingprescriptiondrugsinourcommunity?"Thesurveyfoundthatanswerstothequestion,confirmourassumptionthatyouthareobtainingthemfromsomeonetheyknow,especiallyfriendsandfamilymembers.Themostfrequentlyrecordedanswerwasparents’homefollowedbyfriends,thenfollowedbyparents,siblings,family,andacquaintancesingeneral.

DrugTake-BackEventsPrescriptionDrugTake-BackeffortshaveoccurredinAnchoragewithleadershipprovidedbyHVHC.TheAnchorageDEAisanactiveparticipantintheHVHC’sDrugTakeBackcommittee.TheprescriptiontakebackeffortsthroughoutAlaskahaveresultedinasignificantamountofsafedisposalofdrugs.HVHCandAIPCstaffrecentlymetwithDEAstaffandHVHC'sTakeBackworkgroup.ThereisrenewedinterestandcommitmenttoconductingTakeBackevents.ThenextonewillbeinlateApril,followedbyafallevent.TakeBackeffortsareapowerfulawarenessraisingtool,andwillhelpelevatecommunityrecognitionoftheproblemaswellasreadinesstoplanandimplementpreventionstrategies.Table10AmountofDrugsCollectedThroughAnchorageDrugTakeBackEvents

Eventdate AmountofdrugscollectedinpoundsSeptember25,2010 1336.00April30,2011 1603.60October29,2011 1877.66April28,2012 2722.41September29,2012 1838.00April2013 3931.00Fall2013 2763.00

CommunityFactorsthatContributetoRetailAvailabilityOpioidUseInitiationHalfoftheadultsurveyparticipantswhoareactivelymisusingprescriptionsopioidsindicatedthattheybeganusingprescriptionopioidstogethigh.Theotherhalfrespondedthatusebeganafterreceivingaprescriptionfromadoctorforpost-surgerypain,asportsinjuryoranemergencyroomvisitorfromadentist.

Howdidyoustarttakingopioids?

nRecreationalUse 24Surgery 12SportsInjury 6MedicalCare 4EmergencyRoom 4Dentist 3

FromUsetoMisuseResponsestothequestion“Atwhatpointdoyouthinkusingprescriptionopioids,beyondmedicalrecommendations,becomesdangerous?”werevaried.Manysurveyrespondentsindicatedthattakingprescriptionopioidsatanypointbeyondmedicalrecommendationsisdangerous.Otherrespondentsreferenceddependencyasthepointatwhichitbecomesdangerous.Takingprescriptionopioidswhennotinpainorusingthemrecreationallywerealsoindicatedasdangerous.MisusingPrescriptionCommonresponsesforreasonsformisusingprescriptionopioidswereenjoyingorwantingtoexperiencethehigh,increasedtolerancetoprescriptionopioids,prescribeddosagenotbeingadequateforpain,experiencingpersistentpain,andtheexperienceofphysicalwithdrawalsymptoms.Afewrespondentsalsoindicatedatraumaticexperienceascatalystorunderlyingreasonforabusingprescriptionopioids.

LackofMandatoryPrescriptionDrugMonitoringProgramVoluntaryPDMPparticipationallowsunsupervisedoverprescribing.Inarecentconversation,itwasreportedthatdoctorsaresometimespersuadedtoprescribemorethanthestandardofcareamounttohelpapatientavoidpayingtheco-paytwiceiftheyneedarefill.Keyinformantsstressedthatprescribersmaybeinthechallengingpositionofnotknowinghowmuchprescriptionopioidsapatientistaking,especiallyiftheyareseekingmultipleprescriptionsfromdifferentdoctors.

Hospital“SatisfactionScores”Keyinformantinterviewsalsorevealedthat“hospitalsatisfactionscores”drivemanyprescribers.TheHospitalConsumerAssessmentofHealthcareProvidersandSystemssurvey,orHCAHPS,wasthefirstnational,standardized,andpublicallyreportedsurveyofpatients’perspectivesonhospitalcare.Thesescoreswerefirstusedin2006bytheCentersforMedicareandMedicaidServices(Adams,Bledsoe,&Armstrong,2016).

TheHCAHPSscoresaredesignedtomeasurepatientperceptionsofhospitalexperienceasonesurrogateforhospitalquality.Basedonpatientsatisfaction,manyhavespeculatedthathigherscoresoccurwithpatientsthataremoresatisfiedwiththehospital’streatmentoftheirlevelsofpain.Focuscentersaround:

HCAHPSQuestion14:“Howoftendidthehospitalorproviderdoeverythingintheirpowertocontrolyourpain?”(CentersforMedicareandMedicaidServices,2016).

Manyphysiciansseetheirpatientsatisfactionscoresinpatientsurveysdecreaseasaresultofchangesintheirprescribingpractices,whichaffectcompensationandpromotions.Thequickestsolutiontotreatpainiswithprescriptionopioids.Somefeelthisculturehascontributedtotoday’schallengeswithopioidaddiction,andthatprescribersmayover-prescribetopatientsbydosageandduration.

PainasaFifthVitalSignCultureKeyinformantinterviewswithpharmacistsandprescriberslinkedtoday’sepidemicwithwhattheycall,“painasafifthvitalsign”culture.TheJointCommissionandAgencyforHealthcareResearchandQualitypromotedthemedicalpracticethatnopatientshouldexperiencepain.(Adams,Bledsoe,&Armstrong,2016).Prescribershavetotrusttheirpatientsandprescribeaccordingtothepain;howevertheymaynotknowwhenapatientisaddictedorbreakstrust,puttingtheprescriberintheunwittingpositionofsupportingdangerousbehaviors.

“Weliveinasocietyofinstantfixes,andnobodythink’sit’sOKtoexperiencepainanddiscomfortfromtimetotime,andthat’snottrue.It’sOKtohavethesefeelingsandtofeelthem.I’mjustnotsurewhattheansweris,butwehavetostartdoingsomethingdifferentthanwhatwehavebeendoing.”(KeyInformant,February2017)

AlternativeorNon-DrugTreatmentKeyinformantinterviewswithpharmacistsandprescribersstressedthattherearealternativestoprescribingopioidmedicationthatpotentialpatientshavetherighttobeeducatedonbeforereceivingprescriptionopioids.Variousothertreatmentswereraised,includingmassagetherapy,physicaltherapyoreasternmedicines,suchasacupuncture.Somekeyinformantsalsopointedtotheuseofnon-steroidalanti-inflammatorydrugs(NSAIDs)ratherthanprescriptionopioids.TheseNSAIDsareaclassofdrugsthatprovidesanalgesicandantipyreticeffects,andinhigherdosesalsoprovideanti-inflammatoryeffects.ThesemayincludeIbuprofen,aspirin,andmore.Manycommunitymembersagreetheywouldliketoseeprescriberslookatotheralternativesbeforeprescribingdrugsathigh-riskforaddiction.

“Iwouldliketoseemorenaturalmethodsoftreatment,physicaltherapy,iceorheattreatment,dietandexercisetherapy,andeducationforpeople.[…]Focusontheyoungergenerationtogrowandbuildahealthiergenerationofpeoplewhounderstandthebodyandhowimportantwhatyouputinaffectswhatyougetout.”(KeyInformant,January2017)

PerceptionsforRiskofHarmBasedonopen-endedsurveysofcurrentusers,approximately60%ofyoungadultsviewtryingprescriptionopioidsonceortwiceasrisky.Eighty-sevenpercentofthosesurveyedalsoperceiveregularlymisusingopioidsasphysicallyorotherwiseharmful.Roughly85%ofyoungadultsviewtryingheroinasrisky.Approximately90%ofthosesurveyedalsoviewusingheroinonceortwiceaweekasposingagreatphysicalharmtoanindividual.

Basedonourkeyinformantinterviews,thereisavaryingrangeofwhenpeoplebelievedangerexistsintakingprescriptionopioids.Amongpeopleinrecoveryfromopioidaddiction,somefeltriskexistsassoonasanopioidprescriptioniswritten,whileothersfeelitisonlydangerouswhenapersonusestheprescriptionbeyondthedoctor’sorders.

“Thefirsttimeapersontakesmedicationnotasdirectedtheycrossalineandbecometheirowndoctor,asiftheyknowhowmuchtotake,whichisdangerousbecausetheydon't.”(KeyInformant,January2017)

Interviewswithpeopleinrecoveryforopioidandheroinaddictionsharedsimilarstoriesthatthoughtherisksaregreat,manyfeelknowingtheriskswouldnotdeteruse.Manyfeltthatthedrugusewastreatingasymptomoftrauma,despair,orotherlifechallenges.Manyalsofeltthat,“Peoplethinkitwon’thappentothem”(KeyInformant,January2017).

PerceptionofriskofharmamongAnchoragehighschoolstudentsTheYRBSasksstudentsabouttheirperceptionofriskofharmfromuseofprescriptiondrugswithoutaprescription.Over80%ofstudentsinAnchoragethinkthereisamoderateorgreaterriskofharmfromuseofprescriptiondrugswithoutaprescription.Whenassessedbysex,agreaterpercentageoffemalestudents(85.5%)believethereisamoderateorgreaterriskof

harmascomparedtomales(79.2%).ComparedtoAlaskaNativestudentsandstudentsofOtherRaces,agreaterpercentageofwhitestudentsperceiveamoderateorgreaterriskofharmfromprescriptiondrugmisuse.Between82%and84%of10th,11th,and12thgradestudentsperceivetheriskofharmfromprescriptiondrugmisuseasmoderateorgreat.Incomparison,79.5%of9thgradestudentsperceiveamoderateorgreaterriskofharm.Agreaterpercentage(85.4%)ofstudentswithmostlyA’sandB’sperceivetheriskofharmfromprescriptiondrugmisuseasmoderateorgreatthanstudentswithmostlyC’s,D’s,andF’s(74.6%).Lowgradesshouldnotautomaticallybeassumedtomeanthattheyoutharelessintelligentorhavealwaysbeenlowachievingstudents.Trendsinperceptionmatchtrendsinlifetimeand30-dayprescriptiondrugmisuse.Table11Perceptionofriskofharmfromprescriptiondrugmisuseasmoderateorgreater(%)

PerceptionofRisk Moderateor

GreaterGreat

AlaskaTotal 78.7 54.4AnchorageTotal 82.2 55.8Sex Male 79.2 53.5Female 85.5 58.2Race/Ethnicity White(Non-Hispanic,SingleRaceOnly) 88.9 61.2AlaskaNative 77.8 50.2OtherRaces/Refused/Missing/Unknown 75.2 50.9Grade 9thGrade 79.5 52.310thGrade 83.2 58.411thGrade 84.0 54.212thGrade 82.6 58.4AcademicGrades MostlyAsandBs 85.4 59.0MostlyCs,Ds,andFs 74.6 48.1Ourkeyinformantinterviewsrevealedathemethatpeoplethinkdoctor’sprescriptionsaresafe,especiallyyouthwhomaynothavetheeducationaroundaddictionbrainchemistryandaremisinformed.Youthbelieveinstereotypesthat“addicts”or“heroinusers”arejunkiesandnotsomeonetheyknow.Sinceopioidsarenotillegalbutprescribedbyadoctorthatlendstothemisperceptionthatprescriptionopioidsarenotdangerous.

“Thereisaperceptionthatthosewhoabuseopioidprescriptionsarelosers,ill-educated,unhygienic,cannotholdajob,overallbadpersonratherthan‘regularpersonjustlikeyouandI.’”(KeyInformant,February2017)

Manykeyinformantsalsocitedyoungerpeoplebecomingintroducedtoopioidsthroughsportsinjuriesinmiddletohighschool.Manyalsocitedthatyouthmaybeintroducedtoopioidsas“partydrugs”andmaynotknowwhatpillstheyareexposedto.

PerceptionofriskofharmamongyoungadultsinAnchorageTheYASUScontainedseveralquestionstotheperceptionofriskofharmofopioidandheroinuse.Table13andTable14containdatapertainingtoperceptionofriskfrommisusingopioidsonceortwiceandperceptionofriskofharmfromregularmisuseofopioids.Respondentsrankedthelevelofriskonascalewhere1=noriskand6=greatrisk.Table13showsthatthemajorityofsurveyparticipantsindicatedtherebeingsomelevelofrisktomisusingopioidsonceortwice.Table12Perceptionofriskofharmfromtryingtomisuseopioidsonceortwice

Total AlaskaNative White AllOtherRaces N % N % N % N %1NoRisk 13 6.1 3 10.0 4 3.1 6 11.82 25 11.8 2 6.7 18 13.7 5 9.83 43 20.3 9 30.0 27 20.6 7 13.74 30 14.2 4 13.3 22 16.8 4 7.85 40 18.9 4 13.3 27 20.6 9 17.66GreatRisk 60 28.3 8 26.7 33 25.2 19 37.3Note.TablecreatedusingdatafromHanson,B.L.&Barnett,J.D.(2016)

Table12showsthatjustoverhalf(54.7%)ofyoungadultsaged18-27thatweresurveyedfoundthattheregularmisuseofopioidsonceortwiceariskposedagreatrisk.Table13Perceptionofriskofharmfromregularmisuseofopioidsonceortwiceaweek

Table14andTable15showdatafromtheYASUSonyoungadultsinAnchorageperceptionofriskfromtryingheroinonceortwiceandfromregularlyusingheroin.Whencomparedtodataformisusingopioidsonceortwice,amuchgreaterpercentageofadultsidentifyusingheroinonceortwiceasposingagreatrisk.Similarly,ahigherpercentageofyoungadultsidentifyregularlyusingheroinonceortwiceaweekasposingagreatriskcomparedtothesamequestionforopioidmisuse.Table14Perceptionofriskofharmfromtryingheroinonceortwice

Table15Perceptionofriskofharmfromregularlyusingheroinonceortwiceperweek

Total AlaskaNative White AllOtherRaces N % N % N % N %1NoRisk 7 3.3 3 10.0 1 0.8 3 5.92 5 2.4 1 3.3 2 1.5 2 3.93 5 2.4 0 0.0 3 2.3 2 3.94 10 4.7 1 3.3 4 3.1 5 9.85 24 11.3 3 10. 15 11.5 6 11.86GreatRisk 160 75.5 22 73.3 106 80.9 32 62.7Note.TablecreatedusingdatafromHanson,B.L.&Barnett,J.D.(2016)

StudentperceptionofparentalattitudesAcrossallstudentgroups,between86%and92%ofstudentsfeltthattheirparentsconsiderprescriptiondrugmisuseaswrongorverywrong.

Table16Studentperceptionthatparentsconsiderprescriptiondrugmisuseaswrongorverywrong(%)

PerceptionofParentalAttitudes Estimate 95%ConfidenceIntervalAlaskaTotal 91.1% 88.9 92.9AnchorageTotal 90.3 88.0 92.2Sex Male 89.5 86.4 92.0Female 91.1 88.0 93.4Race/Ethnicity White(Non-Hispanic,SingleRaceOnly) 94.6 92.4 96.2AlaskaNative 86.0 79.1 90.9OtherRaces/Refused/Missing/Unknown 86.3 81.5 90.0Grade 9thGrade 89.2 84.2 92.810thGrade 89.9 84.0 93.711thGrade 90.6 86.6 93.512thGrade 91.6 87.0 94.7AcademicGrades MostlyAsandBs 91.9 89.6 93.7MostlyCs,Ds,andFs 87.0 81.9 90.8

HarmReduction

StigmaTherearemisperceptionsaboutwhousesheroin,andthiscreatesastigma.Stigmamaycauseindividualstonottoseekhelpforthemselves,andforotherstonotrecognizetheneedforhelpinfriendsandfamilymembers.However,heroinaddictioncrossesallethnicandraciallines.

LegislationTheOpioidODDrugsDispensing;ImmunityActbecamelawinAlaskaonMarch15,2016.Opioid/heroinuseandoverdosehascaughttheattentionoflocalpoliticians.In2015,AlaskaStateSenatorJohnnyEllis,representingDowntownAnchorage,Fairview,MountainView,andAirportHeights,introducedSenateBill23tomakeNarcanmorewidelyavailable.ThiswillbeaninvaluabletoolfordecreasingoverdosedeathsbyincreasingaccesstoNaloxoneandimmunityforprescribing,providing,oradministeringopioidoverdosedrugs.Raisingawarenessofthenewlaw,andreducingstigmathatsomemayfeelaskingforaprescriptionforNaloxoneareripeopportunitiesfortheAnchoragecoalitions.

MedicalCommunityTherewere28physiciansinAnchoragecertifiedtotreatopioiddependencewithbuprenorphineasofJanuary6,2016.Buprenorphineisanopioidpartialagonist.Itrelievesopioidwithdrawalsymptoms.Initially,certifiedbuprenorphinephysicianscanonlyhave30activepatientsatatime.After1year,theycanapplyforanincreaseto100patients.ThereisanincreasingnumberoftrainingsbeingprovidedinAnchorageforprescriberstobecomecertifiedtoprescribebuprenorphine.

NeedleExchangeProgramAnchoragehasoneneedleexchangeprogramatFourA’s.Needleexchangeprogramsareaneffectivewaytoreduceconsequencesofneedlesharing,suchasHepatitisCandHIV.Duringthe2016calendaryear,participantscametotheneedleexchangeprogram21,316times.FourA’sdistributed438,578syringesandcollectedandincinerated523,245syringes.GiventheincreaseincasesofpeopleinfectedwiththeHepatitisCvirusbothnationallyandlocallyinAnchorage,manynationaleffortsincludeexpandingsyringeexchangeprogramsaswellasexpandingeffortstoallowaccesstosterilesyringesupplies.

LackofMedicallyMonitoredDetoxBedsAnchoragehasonly13medicallymonitoreddetoxbedsatErnieTurner.Generally,drugtreatmentprogramsrequirethatapersonhasdetoxedpriortoadmission.Medicallymonitoreddetoxisthesafestwaytostopusingheroin.Peoplewithaddictionscanhitanextremelow,generatingadesiretoquitusingandseektreatment.Itiscriticalthatthisoptionbeavailableimmediately.InAnchorage,thewaitisoften30ormoredaysuntilabedisavailable.Thiscreatesasituationwheresomeoneseekingrecoveryservicesmaycontinueusing,andwhentheirnamepopsuponalistforanavailablebed,themomentofdesiringhelphaspassed.Onechallengeourkeyinformantinterviewsrevealedwasthatapersonneedstobesoberinordertoenteradetoxortreatmentprogram.Thatcanbeamajorbarrierforpeopletoreceivethetreatmenttheyneed.Manystressedthatimmediateactionneedstobetakenassoonasapersoniswillingtoseekhelp.Otherwise,thewindowofopportunitymayquicklyclose,especiallyifapersonisdeniedfromaprogram,insurancechallengesthecoverage,orchildcarecannotbesecured.Manykeyinformantsraisedtheneedformorecommunityresourcestosupportacomprehensivetreatmentcenter,includingdetoxbeds,ahospital,in-patientrecoveryservices,jobandlifeskillscoaching,andcoursestoteachindependence.Unfortunately,therewasalsoanacknowledgementatthelackofresourcesandleadershiptomovethisforward.

AccesstoNaloxoneKeyinformantsspokehighlyoftheneedformoreaccesstoNaloxone,sometimesknownasNarcan.Manyrecommendeddistributingthemthroughoutthecommunity.InterviewswithkeyinformantsalsouncoveredthatthereismisinformationabouttheuseofNaloxone.Manypeopledidnotknowthatmedicalcareafteritsusemustbesought.

SomealsofeltthatNaloxoneisgood,butitdoesnottreattherootoftheproblem.SomekeyinformantsalsohadwarningsregardingNaloxone.SomefeltthatofferingNaloxonemayenableuserstoignoreconsequencesofoverdosingandcontinueusing.Withoutadequatedetoxortreatmentfacilities,apersoninrecoveryafteroverdosingandusingNaloxonemayendupinthesamesituation.Onekeyinformantcalledita“veryviciouscycle.”Outofthe504A’ssurveyparticipantswhoarecurrentusersofopioids,justoverhalf(n=29)hadsomeknowledgeaboutNaloxoneorhadheardofit.Fromthe25participantsthatwereaskedabouthowlongNaloxoneremainseffectiveafterbeingadministered,noneoftheparticipantscorrectlyidentifiedthatitlastsroughly30minutes.Responsesvariedfromafewminutestooveramonth.Manyrespondentsdidnotanswerthequestionorwrote“Don’tKnow.”

WhenaskedwhereNaloxoneshouldbedistributed,manyrespondentsindicatedthatitshouldbeavailableattheneedleexchanges.Othersuggestionsincludedinvendingmachines,atlowcostoverthecounter,forfreeatclinics,atalldoctor’soffices,andinEmergencyRooms.

OtherCommunityFactors

CoordinatedApoliticalAdvocacyAnchoragehasastronganddedicatedfieldofpeopleinterestedinreducingdruguseandconsequences.Whiletherearemultiplefactorsthatencourageuseandabuse,thereareevengreateropportunitiestodiscouragethem.Whathasbeenlackingisacentralized,apoliticaland

staffedforcetogatherthestakeholders.ThiswasechoedattheAlaskaHealthSummitduringthesessiondiscussingtheheroinandopioidissuesinFebruary2016.

InvolvementofSchoolsInDecember2015,SouthAnchorageHighSchoolPrincipalDr.KerstenJohnson-Struemplerwrotealettertoparentstitled"PrescriptionDrugs:Pleasetalktoyourstudent."Intheletter,Dr.Johnson-StruemplershedlightonthegrowingissueofillegalprescriptiondruguseatSouthAnchorageHighSchoolandurgedparentstospeakwiththeirchildrenaboutprescriptiondruguseandmonitortheirownmedications.

ImprovedAccesstoDataThereisaneedtoimprovedatacollectionregardingprescriptionopioidandheroinuse.Thisshouldincludeincreasingthenumberoftoxicologytestsdoneforviolentdeathvictims,inmotorvehiclecrashesandtoreinstatesurveillanceofpoisoninginthetraumaregistry.Thiswillprovidemorethoroughdatatofullyunderstandtheseverityoftheheroinandopioidproblemsandassistwithdefiningbaselinesfromwhichtomeasurechange.

GrowingCommunityAwarenessThroughtheLocalMediaInrecentyears,therehasbeenagrowingnationaldiscussionaroundtheincreaseofopioidandheroinoverdosesandrelateddeathsintheUnitedStates.TheAlaskaDispatchNewshasbeencoveringtheriseinopioidandheroinoverdosesanddeathsandtheonlineconversationsonthesearticlesreflectthecommunity'sconcern,levelofawareness,andpersonalconnectionstotheissue.Severalhighprofilefatalitiesrelatedtoopioid/heroinusehavecapturedthelocalmediaandpublic'sattention.AlistoflocalnewsstoriesisdetailedinAppendixG.

CommunityNormsandPerceptionsCommunitynormsareafactorthatdiscouragesriskbehaviors.Alaska’sStrategiestoPreventUnderageDrinkingstatesthat“Individualsandcommunitiesmustmodelpositivebehaviorsinordertopreventfuturegenerationsfromdevelopingsubstanceusedisorders.Thingsassimpleasdiningtogetherasafamilycreatepositivenormsforyouth."HVHCandAYDC/AIPCactivelypartnerpromotinghealthynormsinAnchorage.Researchlocallyandnationallysupportstheconceptthatfamilysupport,monitoringandcommunicationhaveanimpactonyouthalcoholbehaviors.AnchorageSchoolDistrictYRBSanalysisshowedyouthtalkingtotheirparentsnearlyeverydayaboutschoolisasignificantprotectivefactorfor30-dayuseandbingeuseofalcohol.OtherfactorsthatarecorrelatedwithdecreasedsubstanceabusebyAnchorageyouthinclude:Parentandrolemodelbehaviorandcommunitynormsthatdiscouragesubstanceuse,School,home,andcommunityenvironmentsthatdiscouragebothsubstanceuseandalcoholadvertising,Individualsandcommunitiesthatmodelpositivebehaviors,familysupport,monitoringandcommunicationandstrongculturalidentityandsupport.

InsufficientCoordinatedEffortstoAddresstheProblemTherearequiteafeworganizationsinAnchoragewithaninterestintheopioidandheroinproblem.However,theylacktheleadershipincollaborativeinvolvement.ThenewlyformedAnchorageOpioidTaskforcewillalsobeastrongpartnerinthecommunity.

SyntheticOpioidsOurkeyinformantsalsonotednationaltrendsarebeingfeltwithinAnchorage,notingthreewaves:1)opioidpainkillers,2)heroinuse,and3)syntheticopioids.Syntheticopioidsaremorepotent,suchasfentanyl,whichis50-100timesmorepotentthanmorphine.Astheprevalenceofsyntheticopioidsbecomesmoremainstream,theremaybemoreoverdosesanddeaths.

CommunityReadinessAssessmentHVHCandAIPCheldtwogroupkeyinformantinterviewstodeterminethecommunityreadinessinAnchoragetoaddressnon-medicaluseofprescriptionopioidsfor12-17yearolds,andthenon-medicaluseofprescriptionopioidsandheroinusein18-25yearolds.GroupinterviewsfollowedtheTri-EthnicCommunityReadinessAssessmentmodel,developedbyColoradoStateUniversity.Atotalof8individualswereinterviewedinthegroupregarding12-17yearolds,and11individualswereinterviewedinthegroupregardingthe18-25yearolds.Thetotalof19keyinformantsjoinedourtwogroupinterviewsrepresentingthefollowingcommunitysectors:youth-servingorganizations,military,lawenforcement,clinicalservices,medicalservices,youth,parents,NativeAmerican,peopleinrecovery,Hispanic,AlaskaNative,faith,andnon-profitcommunities.TheTri-EthnicCenterforPreventionResearch'smodelofCommunityReadinessforCommunityChangemeasuresfivekeydimensions:1)Communityknowledgeoftheissues(howmuchdoesthecommunityknowabouttheissues?);2)Communityknowledgeofefforts(Howmuchdoesthecommunityknowaboutcurrentpreventionprogramsandactivities?);3)Communityclimate(Whatisthecommunity’sattitudetowardaddressingtheissues?);4)Leadership(Whatisheleadership’sattitudetowardaddressingtheissue?);and5)Resources(Whataretheresourcesbeingusedorthatcouldbeusedtoaddresstheissue?).Everykeyinformantscoredeachcommunityreadinessdimension,andthenthescoreswereaveragedforeachdimensionofreadinessforthetwoissues(non-medicalprescriptionopioidusefor12-17yearolds,andnon-medicalprescriptionopioidandheroinusefor18-25yearolds).Thescoresforeachdimensionwerethenaveragedtoarriveatan“overall”communityreadinessscoreforeachissue.Table17StagesofCommunityReadinessScale

StageofReadiness ScoreNoAwareness 1Denial/Resistance 2VagueAwareness 3Preplanning 4Preparation 5Initiation 6

Stabilization 7Confirmation/Expansion 8HighLevelofCommunityOwnership 9

BasedontheTri-EthnicCommunityReadinessAssessmentmodel,theoverallcommunityreadinessscoreforprescriptionopioidmisusepreventionforages12-17was4.6(onascaleof1to9).Thisindicatesalevelofcommunityreadinessthatisabove"Stage4:Preplanning,"meaningthereissomeconcernandacknowledgementofconcernoftheproblemandstigmaaroundtheissue,butlittleknownoftheissueoroflocalefforts,andthattherearelimitedresourcestofurthertheefforts.Theoverallcommunityreadinessscoreforprescriptionopioidmisuseandheroinusepreventionforages18-25was4.7.Thisalsoindicatesalevelofcommunityreadinessthatisabove"Stage4:Preplanning,"meaningthereissomeconcernandacknowledgementofconcernbutlittleknownoftheissueoroflocalefforts,andthattherearelimitedresourcestofurthertheefforts.

BothcommunityreadinessscoresforbothagegroupsareonthehigherendoftheStage4scale,nearing“Stage5:Preparation,”whichwouldindicatethatmostcommunitymembershaveheardoflocalefforts,leadershipactivelysupportscontinuingandimprovingcurrentefforts,thereisbasicknowledgeabouttheissues,andtherearesomeresourcesidentifiedtofurtherefforts.Theoverallcommunityreadinessscoresareillustratedinthefollowingfigures,aswellasabriefnarrativedescribingsomeofthefindingsbasedoncommunitysectors.

Figure15CommunityReadinessScoresforNon-MedicalPrescriptionOpioidMisuseamong12-17Year-OldsinAnchorage(2017)

CommunityReadinessScoresvariedbasedonsector.Forthekeyinformantsdiscussingnon-medicalprescriptionopioidusefor12-17year-olds,overallcommunityreadinessscoresrangedfrom3.3to5.4acrosssectors.Themilitaryandnon-profitcommunityhadsomeofthelowestreadinessscoresoverallat3.6and3.3respectively.Theclinicalandmedicalservicesectorshadthehighestreadinessscoresforleadershipat7.5and7respectively.TheNativeAmericanyouthrepresentative’sleadershipreadinessscorewas9;however,theremaybelimitationsbasedonhavingonlyonerepresentativefromthisandothersectors.

“Idoseeadvocatesonthisissue,buthavingadvocatesandcommunitymemberleadershiparetwodifferentthings.Folkswouldsaytheysupportexpandedefforts,butwhetheryouhavethepeopletomakethemovementtowardsasolutionisalsotwodifferentthings.”(KeyInformant,April6,2017)

Additionalpolicyrelatedquestionswereaskedregardingpreventioneffortsaroundalternativetreatmenttoprescriptionopioids,safestorageanddisposalofprescriptionopioids,andsocialstigma.Thesectorswiththelowestcommunityreadinessscoresforthesepolicyproposalsweretheclinicalandyouth-servingorganizationswithscoresof2.7and3.7respectively.Both

themilitaryandmedicalsectorshadthehighestcommunityreadinessscoresforthesepoliciesatscoresof6and5.7respectively.

“Ifsomethinghappensclosetoyou,youwanttoworkonsolvingit,butyougetburnedoutwhenyourealizehowbigtheissuesarebeforeyougettothesolution.Alotoftimescommunitymembersknowthereisaproblem,butthere’sstillthatsocialstigmanotonlyonusersbutalsoonfamilyandfriends.”(KeyInformant,April6,2017)

Figure16CommunityReadinessScoresforNon-MedicalPrescriptionOpioidMisuseandHeroinUseamong18-25Year-OldsinAnchorage(2017)

CommunityReadinessScoresvariedbasedonsector.Forthekeyinformantsdiscussingnon-medicalprescriptionopioiduseandheroinusefor18-25year-olds,overallcommunityreadinessscoresrangedfrom3to5.8acrosssectors.TheAlaskaNativeandHispanicrecoveryserviceprovidercommunitieshadsomeofthelowestreadinessscoresoverallat3and3.4respectively.Thelawenforcement(score5.8),clinical(score5.4),andNativeAmericanYouth(score5.4)hadthehighestoverallcommunityreadinessscores.

“InAnchoragethepopulationisinalotofsurvivalmodebecauseofdrinkinganddrugs.Theseissuesimpactfamiliessomuch,butknowingaboutresourcesisdifficult.It’shardtoevenadmitthereisaproblem,especiallyforgrandparentsthatareraisingthegrandkids.Lotsoffamilieshavesecretiveproblems.Thereislotsofhealingtodo.[…]Therearelotsofprograms,buttoknowyoualreadyneedtobelookingforhelpsoyougenerallyhavetobeinalotoftroubletobeginwith.Ifyou’renotintroublepeopledon’ttendtoknowaboutit.”(KeyInformant,April6,2017)

Additionalpolicyrelatedquestionswereaskedregardingpreventioneffortsaroundalternativetreatmenttoprescriptionopioids,safestorageanddisposalofprescriptionopioids,socialstigmaforopioidandheroinuse,andneedleexchanges.ThesectorswiththelowestcommunityreadinessscoresforthesepolicyproposalswerethemedicalandAlaskaNativecommunitieswithscoresof4.4and4.2respectively.Theclinical(score8.8),NativeAmericanYouth(score8.6),andlawenforcement(score8)hadthehighestcommunityreadinessscoresforthesepolicies.Theseoverallscoresareratherhighforthecommunityandmaybeduetotheselectionofkeyinformantswhohaveextensiveexperienceandnetworkingintopreventionefforts.

“Themilitaryisveryreactiveandnotproactive.It’sallcommander-dependent.Thereareafewcommandersthatarevocalaboutthis,andwehavealotofresourcesareavailable,butthey’renotusedunlessthereisaproblem.[…]Ifyouhaveaprescription,noonewillthinktwiceaboutitormakethatbigofadealaboutit.Butuntilsomeonegetsintrouble,that’swhenitbecomesanissue.”(KeyInformant,April6,2017)

Throughthegroupkeyinformantinterviews,themesarosearoundleadershipandcommunitymembers,includingvariousorganizations,understandingandtakingactiononopioidandheroinuse.However,alackofresourcesandenoughfundingtoexpandexistingresourceswasraisedasacommonbarrier.Throughthegroupkeyinformantinterviews,therewerethemesthatarosearoundculturalresponsiveness.Generally,theAlaskaNativeandHispanicpopulationsscoredlowercommunityreadinessscores.Manyofthesechallengescenteredonsocialstigmaholdingfamiliesbackfromseekingsupportservices.Thereisalsoalanguagebarrierthatmayexistineducationeffortsonthedangersofprescriptionopioidaddiction,especiallyfromthemedicalfieldtotheHispaniccommunity.Manyofthethemesfromthegroupkeyinformantinterviewsreinforcedtheprioritycommunityfactorsprioritizedfromcommunitymembers.Thesethemesfromthegroupinterviewsaresummarizedbelow.

Figure17SummaryofthemesfromCommunityReadinessAssessmentgroupinterviews(2017)

IntermediateVariable

PriorityCommunityFactors

CommentsfromCommunityReadinessAssessmentmeetings

"Youth"Group(n=8)

Percent

"YoungAdult"Group(n=11)

Percent

RetailAvailability

Alternativepainmanagementnotcommonlydiscussedwithpatient 6 75 4 36

Alternativeformsofpaincontrolmaycostmorethanopioidsduetoinsurers.

Notmanypeopleknowwhatalternativepaincontrolis,especiallyyouth.

Maybealternativeornon-drugopioidsshouldbepreferencesintreatment.

Doctorstendtoofferprescriptionopioidsasthefirstlineofpaintreatment.

Inadequatepatient/parenteducationattimeofinitialprescription 2 25 6 55

Familiesoftenseekinformationorprogramsaftertheyareseverelyimpactedbyaddictionanditsconsequences.

Thereisnostandardwarningtogivetopatients.

Veryfewprescribersorpharmacieshavepainagreementswithpatientsexplicitlystatingpropermedicationuse.

Themilitarycommunityandculturetendstoacceptuseofprescriptionopioidswithoutquestion.

Languagemayalsobeabarrierincommunicatinginformationaboutprescriptionopioids.

LackofPrescriptionDrugMonitoring(PDMP)participation

6 75 9 82

TheAlaskaNativeMedicalHospitalandSouthcentralFoundationledcommunityonprescriptiondrugmonitoringandpaincontracts.

Therearetoofeweffortstocombatprescriptionopioidmisuse.

TheGovernorisleadingeffortsandhasofferedbillstoaddressprescriptiondrugmonitoringefforts.

SocialAvailability Securestorageandsafedisposal 4 50 7 64

Thereareoveralltoofeweffortstocombatopioidandheroinuse,andtoofewresourcestosupportexistingefforts.

Pharmaciesorprovidersseemtobeunwillingtotakebackallprescriptiondrugs.

Familieswanttoplaytheirparttomakeadifference,buttheymaynotknowthebestpracticesforsafestorage.

Communitymembers,includingthemilitary,donottendtothrowawayprescriptiondrugs.

Socialcircle 2 25 2 18

Grandparentsraisinggrandchildrendonothaveaccurateinformationonopioids,andmaynotuseproperstorageorteachbestbehaviors.

Militarystructureoffersreactive,ratherthanproactive,punishmentofbehavior.

PerceptionofRisk

Lackofunderstandingofwhatopioidsdotothebrainandbodyandhowquicklydependencecanoccur

8 100 11 100

Thereisvastmisinformationaboutopioidaddictioninyouth.

Thereisalackofunderstandingthatmisuseofprescriptionopioidsmayleadtoheroinuse.

Thereisamisconceptionthatdoctorscantellwhowillbeatriskformisuseandabuse.

Peoplebelieveinstereotypesoffamiliessobelieveyouthmayormaynottendtomisuseprescriptionopioids.

Opioidsareprescribedfromadoctorandpresumedtobesafe.Thereislessstigmasurroundingopioidusethanotherdrugssuchasheroin

4 50 2 18

Peoplebelievetherearefewerrisksinprescribedmedication.

Treatingpainasavitalsignhasledtoover-prescribing,andpatientsnowrequestit.

Thereismorepotentialforconversationsaroundstigmafor12-17year-olds,butmaybeharderfor18-25year-olds.

Notunderstandingthevastconsequencesofusingandmisusing 8 100 10 91

Mostyouth-serviceworkersdonotknowhowtoaddressopioidaddictioninyouth.

Thereismisinformationaboutwhocanbecomeaddictedtomisusingprescriptionopioids.

Leadershipinthecommunityarenotactivatedunlesstheconsequencesofaddictionimpacttheirlivesdirectly.

HarmReduction Accesstoneedleexchange N/A 1 9

Thereisalackofunderstandingofhowaneedleexchangeaddressesheroinaddiction.

De-stigmatizeaddiction 4 50 3 27

Familiesarestillsecretivewhenaddictionisimpactingthem.Stigmacanholdthembackfromseekingsupportservices.

Thereisaracialissuethatsomepeopleofcolormightbeatadisadvantageorreceivingtreatment.

Stigmaisprevalentanddifferentinvariouscultures.

Lackofcopingskills 1 13 0 0

Alternativetreatmentcouldinvolvediscussingotherpainmanagementskillswithpatients.

PerceptionoftheProblemintheCommunityTheYASUSaskedsurveyrespondentsabouttheirperceptionoftheproblemofprescriptionopioidmisuseandheroinuseinthecommunity.ThefollowingtwotablesaretheresultsfortheseperceptionsoftheproblemquestionsforAnchorageresidents.Thequestionwasaskedasascalewithonereflectingthattheindividualfoundittobeanotaproblematall,andsixtobeaverylargeproblem.ThetablesshowresultsofthescoresforallAnchorageresidents,AlaskaNativerespondentsonly,Whiterespondents,andrespondentsofallotherraces.Table18Perceptionofprescriptionopioidmisuseproblemincommunity

Total AlaskaNative White AllOtherRaces N % N % N % N %1Notaproblematall 26 12.3% 3 10.0 13 9.9 10 19.62 26 12.3% 4 13.3 18 13.7 4 7.83 51 24.1% 11 36.7 29 22.1 11 21.64 37 17.5% 4 13.3 25 19.1 8 15.75 28 13.2% 4 13.3 18 13.7 6 11.86Averylargeproblem 41 19.3% 3 3.3 27 20.6 11 21.6Table19Perceptionofheroinproblemincommunity

Total AlaskaNative White AllOtherRaces N % N % N % N %1Notaproblematall 31 14.6 3 10.0 18 13.7 10 19.62 28 13.2 7 23.3 17 13.0 4 7.83 42 19.8 6 20.0 25 19.1 11 21.64 25 11.8 1 3.3 18 13.7 6 11.85 30 14.2 7 23.3 19 14.5 4 7.86Averylargeproblem 53 25.0 5 16.7 33 25.2 15 29.4

KnowledgeoftheIssueTheAdultTelephoneSurveyofopioidmisuse/abuseandheroinuseinAnchorageaskedadultsabouttheirknowledgeofopioiduseamongyouthage12-17,youngadultsage18-25,andheroinuseamongyoungadultsage18-25.Theresultsforthosethreequestionsfromthesurveycanbeseeninthetablebelow.Table20PercentageofAnchorageAdultsKnowledgeableaboutOpioidAbuseandHeroinUse(n=382)

Knowledgeaboutopioidabuseamongkids12-17Veryknowledgeable 10%Knowledgeable 10%Somewhatknowledgeable 31%Notknowledgeable 46%Don’tknow 3%Refused 0%Knowledgeaboutopioidabuseamongyoungadults18-25Veryknowledgeable 17%Knowledgeable 13%Somewhatknowledgeable 36%Notknowledgeable 32%Don’tknow 2%Refused 0%Knowledgeaboutheroinuseamongyoungadults18-25Veryknowledgeable 18%Knowledgeable 11%Somewhatknowledgeable 31%Notknowledgeable 39%Don’tknow 1%Refused 0%

Itisalsoclearthatpeoplearenotgivenadequateinformationatthetimeofreceivinganopioidprescription,includingcreatingaplantostop,alternatives,andriskofaddiction.BasedonasurveyofAnchorageresidents,thesummaryisdisplayedinFigure18.

Figure18SummaryofMessagesFromPrescriberstoPatientsatTimeofPrescription

DataprovidedbyPFSDETAL.Surveyof212Anchorageresidentsaged18-27.

ConcernofPrescriptionOpioidMisuseandHeroinUseTheAdultTelephoneSurveyofopioidmisuse/abuseandheroinuseinAnchorageaskedadultsabouttheirlevelofconcernofopioiduseamongkidsage12-17,youngadultsage18-25,andheroinuseamongyoungadultsage18-25.Theresultsforthesethreequestionsareshowninthetablebelow.Table21PercentageofAnchorageAdultsConcernedaboutOpioidAbuseandHeroinUse(n=382)

Concernaboutopioidabuseamongkids12-17VeryConcerned 63%Concerned 15%Somewhatconcerned 15%Notconcerned 4%Don’tknow 1%Refused 0%Concernaboutopioidabuseamongyoungadults18-25VeryConcerned 57%Concerned 16%

Somewhatconcerned 18%Notconcerned 7%Don’tknow 1%Refused 0%Concernaboutheroinuseamongyoungadults18-25VeryConcerned 63%Concerned 16%Somewhatconcerned 13%Notconcerned 6%Don’tknow 1%Refused 0%

KnowledgeofEffortstoAddressIssuesTheAdultTelephoneSurveyofopioidmisuse/abuseandheroinuseinAnchorageaskedadultsabouttheirknowledgeofeffortsinthecommunitytoaddressopioiduseamongkidsage12-17,youngadultsage18-25,andheroinuseamongyoungadultsage18-25.Table22PercentageofAnchorageAdultsKnowledgeableaboutEffortsinCommunitytoAddressOpioidAbuseandHeroinUse(n=382)

Effortsincommunitytoaddressopioiduseamongkids12-17Alot 15%Some 37%Alittle 19%Nothing 11%Don’tknow 16%Refused 1%Effortsincommunitytoaddressopioiduseamongyoungadults18-25Alot 16%Some 35%Alittle 24%Nothing 10%Don’tknow 15%Refused 0%Effortsincommunitytoaddressopioiduseamongyoungadults18-25Alot 19%Some 32%Alittle 21%Nothing 14%Don’tknow 15%Refused 0%

Overall,communitymemberswhowereconcernedorveryconcernedregardingyouthages12-17misuseofprescriptionopioidswas78%.However,theirknowledgeofcommunityeffortsandtheissuewerelower.Peoplewhofelttheyhad“alot”or“some”knowledgeofeffortswas52%ofrespondents.Theirknowledgeoftheissueitselfwaslowerstillat20%.Figure19SummaryofPerceptionsofOpioidUseAmongYouth12-17Years-Olds

DatacollectedbyHaysResearchGroupLLCforAIPC.N-382.Overall,communitymemberswhowereconcernedorveryconcernedforyoungadultsages18-25misuseofprescriptionopioidswas73%.However,theirknowledgeofcommunityeffortsandtheissuewerelower.Peoplewhofelttheyhad“alot”or“some”knowledgeofeffortswas51%ofrespondents.Theirknowledgeoftheissueitselfwasat30%.Overall,communitymemberswhowereconcernedorveryconcernedregardingyoungadultsages18-25forheroinusewasat79%.However,theirknowledgeofcommunityeffortsandtheissuewerelower.Peoplewhofelttheyhad“alot”or“some”knowledgeofeffortswas51%ofrespondents.Theirknowledgeoftheissueitselfwaslowerstillat29%.

Figure20SummaryofPerceptionsofOpioidUseAmong18-24YearsOld

Figure21SummaryofPerceptionsofHeroinUseAmongYouth18-24YearsOld

Figure20and21datacollectedbyHaysResearchGroupLLCforAIPC.N-382.

Thecombinationofhighlevelsofconcern,butlowerlevelsofknowledgeofeffortsandknowledgeofissuewerethemesthroughoutallprimarydatacollection,includinginkeyinformantinterviews.

“Whenwewentdownthispathwedidn’tknowwheretogoorwhototurntoforhelp.[…]Onceyourkidisincrisisit’sassumedit’sbecauseyouareabadparentandthat’sjustnotthecase.Thiscanhappentoanyone.Parentsneedtoknowthewarningsignsbecausetheycanbesoeasilyhiddenandexplainedaway.”(KeyInformant,February2017)

CommunityResourceAssessmentAthree-tieredresourceassessmentwasconducted.First,currentNMUPOandheroinuserswereaskedwhatresourcesareavailableinAnchorageaddressingbothpreventionandtreatment.Treatmentquestionswereincludedknowingthatsuccessfultreatmentwillleadtofewerusers,overdosesandotherharmfulconsequences.Userswerealsoaskedwhatresourcestheywishwereavailable.Secondly,anassessmentwasconductedofresourcesthatcouldprovideassistancewiththeinterveningvariablesprovidedbytheState.ThelistofpotentialpartnersisprovidedasAppendixDandE.AppendixFlinesoutwhichresourcesareavailabletoaddresseachoftheproscribedinterveningvariables.Finally,anassessmentofavailabletreatmentresourcesinAnchoragewasprovided.

UserperceptionsofavailableandneededresourcesSurveyparticipantswhoareactivelymisusingopioidsand/orusingheroinwereaskedabouttheresourcesavailableforthosewhowanthelpwithopioidaddiction.Responsesincludedbothgeneralandspecificresources.Generalresourcesincludedtreatment,detox,counseling,hotlines,rehab,clinics,hospitals,familyandfriends,andchurches.MorespecificresourcesnamedincludedtheErnieTurnerCenter,themethadoneclinic,Suboxone,Vivitrol,NarcoticsAnonymousandAlcoholicsAnonymous,andtheSalvationArmyClitheroeCenter.SeveralrespondentspointedoutinadequacieswiththeresourceoptionsinAnchorage.Criticismsincludedthattherearen’tenoughresources,thatresourcescanbeexpensive,thatthereareoftenwaitlists,andthatthereisalackofempathyforthoseexperiencingopioidaddiction.Afterbeingaskedaboutresourcescurrentlyavailable,surveyparticipantswereaskedaboutresourcesthattheywishedwereavailable.SomeofthemorefrequentresponsesincludedgreateraccesstomethadoneandSuboxone.Therewerealsopleasformoredetoxcentersandrehabswithshorterwaitlists.Afewrespondentsalsowishedforharmreductionresourcessuchasmoreneedleexchangeslocationsandsupervisedinjectionsites.

Resourcesavailabletoaddressinterveningvariables:

OpioidAvailabilitySocialandRetailAvailabilityofPrescriptionOpioidsareinextricablylinked.Areductioninretailavailabilitywillnecessarilyreducesocialaccess.Anchoragehasanumberofagenciesandindividualswhoarewellpoisedtohelpreduceretailavailabilitythrougheducationtopatientsseekingpainrelief,physiciansaboutalternativestoopioidstoreducepainaswellasimprovementstotheAKPDMD.Thelistofresourcesincludespeoplewhoworkorvolunteerinopioidmisusepreventionaswellasprescribersandpharmacists.SeeAppendicesD,E,andF.CurrentlyparticipationintheAlaskanPrescriptionDrugMonitoringProgramisvoluntary.Keyinformantsdescribedthebroadrangeoflevelsinwhichprescribersandpharmacistsareparticipating.Currently,only22%ofstatewidepotentialprofessionalsareregistered.However,implementationofSB74willresultinpositivechanges.TheBillisscheduledtorolloutwithaseriesofmandatesoverthenextfewyears.Ascomponentsbecomecompulsory,retailaccesstoprescriptionopioidswilldecrease.Onceopioidsareprescribedtheyhavethepotentialtobecomesociallyavailable.Anchoragehastwoyear-roundmedicationdroplocationsatProvidencePharmacyandAlaskaNativeTribalHealthConsortium.Additionally,HVHCinconjunctionwithmultiplepartnersincludingtheDEAhosttwoNationalPrescriptionDrugTake-BackDaysinAprilandOctober.Thisisanopportunityforpeopletosafelydisposeofprescriptionmedication.InadditiontoTake-Backevents,safestorageisanothermethodofreducingsocialavailability.HVHCisdistributing“pillpods”toraiseawarenessofsafestorageofallmedication.

HeroinAvailabilityReducingheroinavailabilityisprimarilyalawenforcementfunction.LawenforcementinAnchoragehascontinuallyincreasedtheamountofheroinconfiscatedeachyearandisfullyonboardtocontinuetodoso.However,reducingavailabilityofheroinisnotacure-allfortheultimategoalsofreducingmorbidityandmortalityassociatedwithheroin.Mostactiveheroinuserssaidthatifheroinwerenotavailabletheywouldswitchtoanotherdrug.Simplyreducingaccessisnotaviablestand-aloneoption.Acomplementarycommunitylevelapproachisthereductionofthedesireforheroin.Halfofcurrentheroinuserssaidtheybeganusingopioidswithalegitimateprescriptionforpain.Theythenprogressedtousingheroinwhenprescriptionopioidsbecameunaffordableorinaccessible.Reducingthedesireforheroincanstartwithreducinginitialretailavailabilityofprescriptionopioids.

PerceptionofRiskandHarmReductionResourcesforincreasingtheperceptionoftheriskofbothprescriptionopioidsandheroinandreducingharmfromusecomefrommanyofthesameplaces.AppendicesD,E,andFdescribemultipleorganizationsandindividualswhoareresourcesfortheseissues.Theyfitintotwocategories.Thefirstfallsintotheprimarypreventionscope.Theseareprescriberswhocaneducatepotentialusersaboutthetruerisksofmusingopioidsforpain,aswellasprovidingimprovedinformationaboutwhatconstitutesappropriateuseandhowtotaperoff.The

secondcategoryisthoseorganizationsandindividualswhocanhelpwithharmreduction.ThisincludesprovidingaccesstoandinformationregardingNarcan,cleanneedlesandreferralsandinformationabouttreatmentoptionsandresources.Reducingstigmaregardingaddictionandincreasingwillingnesstoseekhelparetwomoreeffortstheabove-listedresourcescanassistwithproviding.Additionalresourcesfortheseendeavorsincludethenewsmedia,whohavecoveredtheopioidissueswithseveralarticlesamonthforthepasttwoyears.

Communitystrengths,gaps,assets,andweaknessesPartnersinAnchoragehavealonghistoryofworkingtogetheronsubstanceabuseissues.Thisincludestreatmentproviders,membersofmultiplecoalitions,youthservingorganizations,andtheAnchorageSchoolDistrict.Somerelationshipsthatareinthedevelopmentphaseincludemedicalprofessionalsnotinvolvedintreatmentservicesandlawenforcement.Mostcollaborativesubstanceabuseeffortshavebeengearedtowardsunderagedrinking.Inunderagedrinkingpreventionefforts,lawenforcementwasakeypartner.Thenewdirectionofopioidmisuseandheroinusepreventioncanworktore-invigoraterelationshipsfrompriorcollaborativeefforts.Aswithallcollaborativework,relationshipsarethekeystartingpoint.Anchorageisarelativelysmallcommunity,andmanyofthenecessaryrelationshipsarewellformed.Afinalstrength,thatisalsoaweakness,isthatAnchoragenowhasseveralgroupsworkingonthisissue.Worktowardsplanninganddevelopingstrategieswillprovideanopportunityforthevariouspartnersandcoalitionstocometogetherandstrategicallyusetheirstrengthsmovingforward.

VI. PrioritizationPrioritizationProcess

AIPCandHVHCcoordinatedtwoprioritizationmeetingswithmembersoftheHVHCleadershipteam,aswellasmembersoftheHVHCcoalitionasawholeandgeneralcommunitymembers.OnMarch8,2017,theHVHCleadershipteammetfortwohourstonameandprioritizecommunityfactorsrelatedtoNMUPOandheroinusebasedonlocalprimaryandsecondarydatasharedwiththem.Tostarttheprocess,AIPCstaffpresenteddatarelatedtoNMUPOandheroinusetotheleadershipteam.Theleadershipteamthenbrokeoutintogroupsbasedontheirinterestinfourinterveningvariables:retailavailability,socialavailability,perceptionofrisk,andharmreduction.TheDBHrequiredcoalitionstoconsiderretailavailability,socialavailability,andperceptionofrisk.HVHCandAIPCincludedharmreductionasaninterveningvariablebasedonthecommunity’seffortsaroundNarcandistributionandfeedbackfromNMUPOandheroinusers.Throughsmallgroupdiscussions,thegroupsbrainstormedalistofcommunityfactorscontributingtoeachofthefourinterveningvariables.AIPCusedtheCommunityFactor

PrioritizationworksheetprovidedbytheDBHtoguideandframethisprocess.Afterbrainstormingcommunityfactors,thegroupswereaskedtoplacefactorsonachartbasedonwhetherornottherewasthepotentialforchangeonthatfactor,andtheimportanceofthatfactor.AIPCstafffacilitatedeachgroupthroughtheprocessandwasavailabletotakenotesandanswerquestions.Adetailedprotocolfortheprioritizationprocess,worksheets,andsummariesareavailableinAppendixC.Attheconclusionofthefirstprioritizationmeeting,AIPCstaffsummarizedthegroup’swork.AIPCthenmetwithHVHCtofurtherinterpretandorganizethefactorsbrainstormedanddevelopalistofcommunityfactorsforeachinterveningvariable.Belowisthelistofcommunityfactorsdevelopedatthefirstmeeting.

RetailAvailabilityCommunityFactors

• LackofknowledgeofnewpainmanagementrecommendationsfromtheCDC• LackofPrescriptionDrugMonitoringProgram(PDMP)participation• Inadequatepatient/parenteducationattimeofinitialprescription• Alternativepainmanagementnotcommonlydiscussedwithpatient• Needforongoingtrainingforprescribers• Inadequatepatientscreeningforpaincontractsoraddictionrisk• Pharmaceuticalpainmanagementischeaperthanphysicaltherapy

SocialAvailabilityCommunityFactors

• Prescriptiondrugstockpiles• Givingaway,trading,stealing,sellingexcess• Socialstatusofhavingpills• Socialcircle• Inadequatepolicingcapacityandlackofenforcementconsequences• Drugsaren’tstoredsecurely• Socialhost/parent/caregiverenabling

PerceivedRiskCommunityFactors

• Opioidsareprescribedfromadoctorandpresumedtobesafe(evenismisused)• Lessstigmaaroundusingopioidsthanheroin• Trustthatheroinisheroinandnotcutwithfentanyl,etc.• Lackofunderstandingofwhatopioidsdotothebrainandbodyandhowquickly

dependencecanoccur• Notunderstandingvastconsequencesofusingandmisusing• Itwon’thappentome• Riskofmixingsubstancesismisunderstood

HarmReduction

CommunityFactors• AccesstoandknowledgeofNarcan/Naloxone• Accesstoneedleexchange• Lackofcommunityconnectednessandbystanderinvolvement• Interventionavailableatthemomentpeopledecidetheywanttoquitusing• Needtoincreasecopingskills:Reduceneedforquickfixofanyailments,andseeing

opioidsascureall• Needforongoingposttreatment/recoveryservicesandopportunities• De-stigmatizeaddiction

• Perceptionthataddictionisamoralissue• Perceptionthatthedruguseisonlyanissuefor“them”not“us”• Increasehelp-seeking

ThesecondprioritizationmeetingwasopentoallmembersoftheHVHCcoalitionandstakeholdersthroughoutthecommunity.ThatmeetingtookplaceonMarch28,2017.Atthesecondprioritizationmeeting,AIPCstaffagainpresenteddatarelatedtoNMUPOandheroinuse.AIPCstaffthenledthegroupthroughaprioritizationprocessusingthecommunityfactorsbrainstormedbytheHVHCleadershipteamatthefirstprioritizationmeeting.AIPCaskedattendeestoprioritizethevariablesbasedontheirimportanceandchangeability.AIPCplacedseverallargegraphsonthewallsaroundtheroomforeachoftheinterveningvariables.Thegraphsweredrawnwithchangeabilityonthex-axisandimportanceonthey-axis.Participantsweregivenasetofcoloredandnumberedpost-itnotesthatcorrespondedwithacommunityfactorrelatedtotheinterveningvariables.Participantswereaskedtochartthecommunityfactorsaccordingtotheirlevelofimportanceandchangeabilityusingtheircoloredandnumberedpost-itnotes.Attheconclusionofthemeeting,AIPCcollectedthegraphstoassessthegroup’sinputtofurthernarrowthecommunityfactors.SeeAppendixC.Toassessthegraphsanddeterminethefactorsofhighestprioritytothecoalition,AIPCdevelopedamethodtoassignnumericalvaluetoeachfactor’splacementonthegraphs.AIPCtookphotosofeachgraphandprintedthegraphonlinedgraphpaper.AIPCthenassignednumericvaluestoeachhashmarkofthegraphbothonthex-axisandy-axis.Ascorewascalculatedandgiventoeachfactor.Thecommunityfactorswererankedforeachofthefourinterveningvariables.Oncethefactorswereranked,HVHCandAIPCmettoselectahighestprioritycommunityfactorsoffocusforeachoftheinterveningvariables.Basedonthedataandthecoalition’sinput,thefollowingcommunityfactorswereprioritizedforeachinterveningvariable:

RetailAvailabilityPriorityCommunityFactors

• Alternativepainmanagementnotcommonlydiscussedwithpatient• Inadequatepatient/parenteducationattimeofinitialprescription• LackofPrescriptionDrugMonitoring(PDMP)participation

SocialAvailabilityPriorityCommunityFactors

• Securestorageandsafedisposal• Changesinsocialcircle• SafeDisposal

PerceivedRiskPriorityCommunityFactors

• Lackofunderstandingofwhatopioidsdotothebrainandbodyandhowquicklydependencecanoccur

• Opioidsareprescribedfromadoctorandpresumedtobesafe.Thereislessstigmasurroundingopioidusethanotherdrugssuchasheroin.

• NotunderstandingthevastconsequencesofusingandmisusingHarmReductionPriorityCommunityFactors

• Accesstoneedleexchange• De-stigmatizeaddiction• Lackofcopingskills

VII. DiscussionandRecommendationsThroughthedatacollectionandprioritizationprocesses,pathsformakingchangehavebecomeclear.Thishowever,doesnotmeanitwillbeeasy.Thegoodnewsistherearemanyoverlappingissuesandpotentialsolutionsthatwillallowfuturepreventioneffortstomakegreaterimpact.Fourkeyfindingswillassistwithstrategicallymovingforward.

• First,atleasthalfofthecurrentheroinuserswhorespondedtothesurveysstartedusingprescriptionopioidsforpain.Ofthem,manywerenotawareofalternativestoprescriptionopioids,therisksofusingopioids,northeimportanceoftaperinguse.

• Second,misperceptionsandstigmaaroundaddictionresultinmisuseleadingtodependence,adisinclinationtorecognizewhensomeonedevelopsaproblemandanunwillingnesstoseekhelp.

• Third,manypeopleinAnchorageareunwillingtodiscardopioidsandotherunusedmedications.

• Andfinally,onceapersondevelopsanopioiddependence,therearemethodstoreducerisksthatwillreducetheconsequencesofuse.

ReduceRetailAvailabilityReducingretailavailabilityofprescriptionopioidsisoneofthefirststepstotaketopreventbothopioidandheroinaddiction.Thisactionwillreducethenumberofpeoplewhostartusingopioidsnotasprescribed,andwholatermaydevelopdependence.Thedatashowthecommunityisreadytoembarkonmultiplemethodsto

makethishappen.Themedicalprofession,throughnewPDMPmandates,willreceivemoretrainingregardingpainmanagementandengageinmoreconservativeprescribingpractices.Increasingprospectivepatientawarenessofboththerisksofandalternativestoopioiduseforpainmanagementwasrecommendedbythecommunitytodecreaseinitialdemandforopioidprescriptions.Bothoftheseactionswilldecreaseprevalenceofopioiddependenceandhavewidecommunitysupport.

ReduceStigmaInAnchoragetherearestigmasandmisperceptionsregardingopioidaddiction.Theseincludeperceptionsthatopioidaddicts(bothprescriptionandillicitopioids)areprimarilyhomeless,liveinpoverty,andthatitisanAlaskaNativecommunityproblem.Thedatashowthatnoneofthesearethecase.

Opioidaddictionreachesacrossculturesandsocioeconomiclevels.Addictsarealsothoughttobebadpeoplewhorobandstealtoaccessdrugs.Whilethiscanbetrue,whatisoftenmisunderstoodisthatmanypeopleaddictedtoopioidsdonotwanttobeaddictedanddowanthelp.Thestigmasandmisperceptionsresultinfamiliesnotwantingtoadmitthatamemberhasanaddictionissue,andthesubjectishushedandhidden.Membersofthecommunityshowedreadinesstobeginconfrontingthestigmassurroundingaddiction,andbelieveitisanimportantsteptowardsreducingtheharmsofNUMPOandheroinuse.

IncreaseSafeDisposalManypeopleinAnchorageexpressedanunwillingnesstodiscardprescriptiondrugs,includingopioidswhenacourseoftreatmenthasended.Forthosewhoarewillingtodoso,theDrugTake-Backeventsareavaluableservice.Theeventscanalsoserveasanopportunitytoraiseawarenessoftherisksofstockpilingdrugs.

Forthoseunwillingtodiscarddrugs,safestorageiscritical.Usersrecommendedseveraloptions.First,don'tletanyoneknowabouthavingtheprescriptioninthefirstplace.Second,lockthedrugsinasafe,justlikeyouwouldagun.

NMUPOandheroinusersdescribedthedegreestowhichtheywillgotoaccesstheirnexthigh.Theseincludestealingdrugsfromfamilyandfriends.Thepowerofaddictionandthehorrorsofwithdrawalleadtheseactions.Safestoragewillreducesocialavailabilityofprescriptionopioids.Forsome,thiswillhelpreducenonprescriptionuseofprescriptionopioids.Thisisnotacure-all.Itisimportanttonotethatpeoplethatuseheroinandmisuseprescriptionopioidshaveastrongproclivitytoswitchtoadifferentdrugifonebecomesunavailable.

ReduceHarmFinally,anoftenmentionedandmuchneededresourceisincreasedaccesstoin-andout-patientdetoxandtreatmentoptions.Becausethisgrantwillnotsolvethoseissues,harmreductionforuserswasrecognizedasimportant.Harmreductioncomesinvariousflavors.

OneformofharmreductionistheincreasedaccesstoandknowledgeaboutNaloxone(Narcan).MostcurrentheroinuserswerenotfamiliarwithNaloxone.Ofthosewhowerefamiliarwithit,manydidnothaveaccurateunderstandingsabouthowlongitworksforandtheneedformedicalattentionafteronereceivesit.TherewerealsoconcernsthatNaloxonecanleadtopushingthelimitsforahigh.Theseareimportantconsiderationsfortheplanningphase.AnotherharmreductioneffortincludesaccesstotheAlaskanAIDSAssistanceAssociation’s(FourA’s)syringeexchange.Somepeoplewereconfusedbyhowthishelps.Syringeexchangesserveseveralfunctions.One,cleanneedlesprotectagainstmanybloodbornediseasesandinfections,likeHepatitisC.Second,andatleastasimportant,theneedleexchangeisatrustedplacewheremanyusersgotogetinformationabouttreatment,Narcan,HIV/AIDSandmore.Afinalharmreductionideaistoimprovecopingskills,socialandemotionalskills,andlifeskills.Thesearelonger-termrecommendationsbutwilleventuallyhelptoreducetheneedforimmediatereliefofbothphysicalandemotionalpainthroughdrugs.

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IX. AppendicesAPPENDIXA–SummaryofKeyInformantInterviews

SummaryofKeyInformantInterviewsbasedonsectorresponses.KeyInformant-OpioidRecoveryCommunity

1.Whatdrugsdoyouthinkofwhenyouhearaboutprescriptionopioids?

Bothindividualsidentifiedhigherpotentpainmedicationsasprescriptionopioids.

2.Atwhatpointdoyouthinktheusingopioidsbeyondthemedicalrecommendationisdangerous?

Theindividualsdifferedintheirresponses.Oneindividualfeltanytimeanopioidprescriptioniswrittentheriskexists,whiletheotherindividualfeltitisatthepointwhenthepersonbegintousetheprescribeddrugoutsidethedoctor'sorders

3.Howdidyoustarttakingprescriptionopioids?Whatledtoyourusebeyondrecommendations?Thinkingaboutotherpeopleyouknow,howdidtheystartandwhatledtotheirusebeyondrecommendations?

Bothindividualsreferencedhowthedrugsmadethemfeelasthereasonforusingthembeyondwhatthedoctorprescribed,suchastherelieffromchronicpain.

4.Howdo(did)you,orpeopleyouknowobtainprescriptionopioids?

Mostgetopioidsfromdoctor,someforgedprescriptions,stole,orborrowed/boughtfromafriend.

5.Whatconsequenceshaveyouseenfromopioidusebeyondrecommendations?Didyouknowabouttheseconsequencesbeforeyoustartedusing? Bothreferenceddeath."Becominglostinlifeaddicted."

6.Howlikelydoyouthinkitisthatpeoplewhouseopioidsbeyondrecommendationwillfacetheseconsequences?Andwhichonesmighthavepersuadedyoutonotstartusing?

Itdependswithopioidsbecausethereareothernon-lethalusesforthem.Peoplethinkitwon'thappentothem.

7.Whatotherthingsthatcouldhavepreventedorintervened?

Bothareunsure.Onethought"maybe"amotherorfatherfigure.

8.Whataresafewaystostoreopioidsandhowlikelywouldyoubetousethem? Lockedup.Usethemasdirected.

9.Whatwouldyouhavedoneifopioidsweren'treadilyavailable?

Ifusingforpain,usealternativesliketramadoloribuprofen.Ifaddicted,likelyfindsomethingelsetouse.

10.Whatresourcesarethereforpeoplewhowanthelpwithopioidaddiction?

Bothsaidtreatmentcenters,butoneacknowledgedyouhavetobesobertoenterbutthatdoesn'tmakesense.

11.Whatresourcesdoyouwishwereavailable?TellmewhatyouknowaboutNaloxone,sometimesknowasNarcan?Howdoyouthinkitcouldbedistributedtomakeitmorereadilyavailable?

DistributeNarcanthroughsoupkitchensorhomelessshelters.Comprehensivetreatmentcenterwithdetox,hospital,recovery,job/lifeskills,tobeindependentagain.

12.Isthereanythingyou’dliketoadd?

Narcanmayenableuserstocontinueusing.OnceNarcansavesyou,there'snodetoxortreatment,sothe"veryviciouscycle"continues.

KeyInformant-HeroinRecoveryCommunity

1.Tellmeabouthowyoustartedusingheroin?Thinkingaboutotherpeopleyouknow,howdidtheystart?

Onewasalreadyusingopioids.Onestartedsmokingheroin,thenIV,thenwithotherdrugs(cocaine).

2.Howdo(did)you,orpeopleyouknowobtainheroin? Fromotherpeople,includingdrugdealers.

3.Whatconsequenceshaveyouseenfromheroinuse?Didyouknowabouttheseconsequencesbeforeyoustartedusing?

Afteraddiction,becomehomeless,jobless,losefamily,andmayincludejail,sexualexploitation,ordeath.Didnotknowconsequencesbeforehand.

4.Howlikelydoyouthinkitisthatpeoplewhouseheroinwillfacetheseconsequences?Andwhichonesmighthavepersuadedyoutonotstartusing?

It'sjustamatteroftime.Knowingtheconsequencesmaynotdeteruse,"itwon'tbeme"orwilluseotherdrugs.

5.Whatotherthingsthatcouldhavepreventedorintervened?

Doctorsnotprescribeopioids.Peoplehavetomakeadecisiontoquit;havetotreattheirillness(maybelifechallenges)inahealthywayinsteadofdrugs.

6.Whatwouldyouhavedoneifheroinwasn'treadilyavailable? Useanotherdrug.

7.Whatresourcesarethereforpeoplewhowanthelpwithheroinuse?

NarcoticsAnonymousorAlcoholicsAnonymous(12stepprogram)

8.Whatresourcesdoyouwishwereavailable?

Comprehensivedetox,hospital,treatment(drug-free)centerthatteacheslifeskills.

9.TellmewhatyouknowaboutNaloxone,sometimesknowasNarcan?Howdoyouthinkitcouldbedistributedtomakeitmorereadilyavailable?

Naloxonesavelivesbutmakesuremedicalcareissought.Distributefromneedleexchangeandhomelessshelters.

10.Doyouknowofcommunityprogramsthatofferdetoxortreatmentprograms? Few,mustbesobertoenter.

11.Wheredoyougetinformationaboutheroinuseorrecovery? AlcoholicsAnonymousorVolunteersofAmerica.

12.Isthereanythingyou’dliketoadd? (noresponse)

KeyInformant-Parents

1.Atwhatpointdoyouthinkthemisuseofprescriptionopioidsisdangerous?

Prescriptionmedicinethatisnotprescribedtothem,orifitisthey'renotfollowingdoctor'sorders.

2.Whataresomeoftherisksorconsequencesofassociatedwithmisusingopioidsthatyouhaveseen?Howlikelyisitthatsomeonemisusingopioidswillsuffertheseconsequences?

Family,health,andfutureallimpactedfromaddiction.Consequencesarehighlylikelytooccur.

3.HoworwhatcausespeopleinAnchoragetobegintakingprescriptionopioids?Whathappensthatendsupleadingtoaddiction?

Foryouth,sportsinjuries,peerpressure,andgetdrugsfromfamilies.Kidswithmentalhealthissuesmayuseopioidstoself-medicate(anxiety),thenbuildtolerance,andmaybecomeaddicted.Parentsmaybenaiveandnotlockupdrugs.Kidsoftendonotknowthelong-termconsequencesoftakingprescriptionopioids.

4.Hadyourdoctororpharmacistdiscussedtherisksofaddictionwithyou?

Doctorsdidnotsharetherisksofprescriptionopioidaddiction,andwhentheyouthwasincrisisoveritthedoctor'sofficedidnothelp.Doctorsneedtoknowwheretosendpeoplefortreatment.

5.Forpeoplewhoaremisusingopioids,howdoyouthinktheyobtainthem?Whatdoyouthinkcouldbedonetolimitthisaccess?

Demographicsmayleadtomoreopioidprescriptions.Thisperson'sexperienceiswithwhitemiddle-classfamilieswheredoctorsmaymorefreelyprescribeopioidstoprivateinsurance.

6.Whataresafewaystostoreopioids?

Countpillsandlockthemoutofreachofchildren.Educateparentsandchildrenonalternativewaystomanagepainandproperuseofprescriptiondrugs.

7.Whatwouldyoubewillingtodotolimitaccesstoprescriptionopioids?(storage,dropoff,pillpod) Lockopioidsup,havemoredrugtake-backevents.

8.Didyouknowwheretofindsupportandservicesforyourchild?Whatsupportsdoyouwishwereavailabletoyou,andtoyourchild?

No,wedidnotknow.Commercialstoadvertiselocalhelp.Eliminatethestigmaofdruguse,don'tbeafraidtotalktoyourkidsaboutdrugs.Parentsshouldlearnwarningsigns.

9.TellmewhatyouknowaboutNaloxone,sometimesknowasNarcan?Howdoyouthinkitcouldbedistributedtomakeitmorereadilyavailable? (noresponses)

10.Whatthoughtsormessageswouldyouliketosharewithotherparents?

Shareyourstorytobecomepartofthesolution.Worktogethertoeducateourcommunityandourkidstolearntoacceptdifferentwaystodealwithpainmanagementorwaystofeelbetter.

KeyInformantTreatmentProviders

1.Whatdoesitmean,tothemedicalprofession,tomisuseprescriptionopioids?

Togethigh,leadstoaddictionandoverdose,repeatedERvisits.Somedoctorsgetitandofferalternativetreatment,othersjustkeepprescribing.

2.HowconcernedareyouaboutopioidmisuseinAnchorage?Whataboutheroin?Whatisitaboutopioidmisuseandheroinusethatconcernsyou?

Allareveryconcerned.Opioidusemayleadtoheroinuse,whichischeaper,oranotherdrug.Needmoreenforcementtopolicestreetdealers.

3.Tellmeaboutstoriesyouhearabouthowpeoplestartedusingopioidsmisusingopioids,andstartedusingheroin.(sportsinjuries,starttogethigh…)

Sportsinjuries.Workinjurythatleadstoprescription,thenheroinischeaper.Paindoctor.ClosingPalmerCorrectionalFacilitymeantpeoplecouldnotreceivetreatment,thendealerstargetedthemagain.

4.Whatrisksdoyourclientsperceivewithmisusingopioids?Whataboutheroin?(addiction,death,losingkids,jobs,homelessness…)

Youthclientsdon'tcareaboutrisks,justaboutgettingahigh.Clientsdon'tseetherisksuntilit'stoolate.ItcanbelosingkidstoOCSorhomelessness.Hospitalsreceivehigherfundingbasedon"satisfactionscores"ifprescribingopioidsoverprolongedperiods.

5.Withyourpatients,whatdoyouthinkcouldhavebeendonetopreventtheirinitialuseandeventualaddiction?Whatinformationmighthavecausedthemtohesitatebeforestarting?

Preventioneducationhelps,includinghighschools.Peerinterventionwouldbekey.Hospitaldatabasethatflagsrepeatvisits,sotheycanbeeducated.

6.Whatwouldhelpaftertreatmenttokeepthemfromusingagain?

ContinuingCaregroups,structuredsobersupportgroups.Buildupresiliency.Learningbasiclifeskills(job),healthierhabitsandhobbies.

7.Whoarethepeoplemostaffectedbyopioidmisuse?Heroin?

Teens,youngadultsandmiddleageadults.Especially18-25or20-30yearolds.

8.WhattrendsareyouseeingwithprescriptionopioidandheroinuseinAnchorage?

Bothopioidandheroinuserising.Doctorshoppingforpills.Heroinischeaper.Peoplemaskingtheiraddictions.

9.WhatcanyourecommendtoaddresstheopioidmisuseprobleminAnchorage?Heroin?

Trainteenstointervenewithpeers.Getridof"patientsatisfactionscore"paincontracts.Bettereducation,affordableandaccessibledetoxandrehab.

10.Isthereanythingelseyou’dliketoadd?

Educationandsupportsysteminplace.ER'streataddictionandhavefacilitytotransportpatienttoimmediately.

KeyInformant-PharmacistsandPrescribers

1.Whatdoesitmean,tothemedicalprofession,tomisuseprescriptionopioids?

Prescriberhastotrusttheirpatientandprescribeaccordingtothepain.Usebeyondmedicalrecommendations.Orprovidingopioidstosomeonewhomtheywerenotprescribed.

2.HowconcernedareyouaboutopioidmisuseinAnchorage?Whataboutheroin?Whatisitaboutopioidmisuseandheroinusethatconcernsyou?

Yes,concerned.Prescribersmaynotknowhowmuchapatientistaking.Ifprescriberhastohelppatientusingheroin,theyhavetogotothemofteninadangerousenvironment.Publicsafety.Negativeeffectsonfamily.

3.HowdoyouthinkmostpeopleinAnchorageobtainprescriptionopioidsthataremisusingthem?

Fromsomeoneelse.Falseprescriptions,overprescribing,pharmacyrobberies,orpurchasingfromsomeonewhoobtainedtheminthatway.

4.Fromwhatyou’veseen,whatdoyouthinkcausespeopletostartmisusingprescriptionopioids?HowaboutusingHeroin?

Teenslackknowledgeandthinkofitaspartydrug.Misuseofopioidsmayleadtoheroinuse.Recreationaluse.self-medication,overusewithpooroversightofpractitioner,unrealisticexpectationofpaincontrol,poorawarenessofalternatives,notfollowingaftercareplan(physicaltherapy).

5.Whatrisksdoyourclientsperceivewithmisusingopioids?Whataboutheroin?

Heroinusersmaymarkwhichveinformedicalprofessionalstouse.Patientsdon'tsharesenseofrisk.Eitherunconcerned,unaware,orbenefitoutweighsrisks.Patientsunderappreciaterisk.

6.Whatwasthelikelihoodyouthinkpeoplethinktheyareatriskofbecomingaddictedtoopioids?Heroin? Notsure.Lowforopiates,highforheroin.

7.Whoarethepeoplemostaffectedbyopioidmisuse?Heroin?

Communitysuffersmostthrougheconomicsandperceptionofsafety.Userismostaffected,thenimmediatefamilyandfriends,thencommunity.

8.WhattrendsareyouseeingwithprescriptionopioidandheroinuseinAnchorage?

Shootingupmorphine,takingDilaudid.Hospitalsadvertisewhenthey'reoutofDilaudidtominimizeseekers.Heroinandopioiduseontheriseinoverdose/deaths.Increasedproviderawareness,butnochangeinprescribingorprescriptionvolume.Possiblegreatersenseofpatientdemandforopioids.

9.WhatcanyourecommendtoaddresstheopioidmisuseprobleminAnchorage?Heroin?

Trackingsystemforprescribers.UseNSAID'sbeforeopioids.(non-steroidalanti-inflammatorydrugs)

10.Isthereanythingelseyou’dliketoadd? Educationforkids.

KeyInformantLawEnforcement

1.Inyourexperience,howarepeopleobtainingprescriptionopioids?Whataboutheroin?

Peoplegetopioidsfromlegitimateprescriptions,maybebuyingorstealingfromfriends/family.Thenaddictionandheroinusemightfollow.YouthtendtousemoremarijuanaandsmokewithXanax,thanopioidsorheroin.Forheroin,fromadrugdealer,afriend,familymember,orusing/sharingheroin.

2.WhataresomeoftheconsequencesyouareseeingfromopioidmisuseinAnchorage?Whataboutheroin?

Higherpropertycrime,overdosedeaths,dysfunctionalfamilies,jailtime,lossofjob,divorce/separation,lossoftrust,financialburden,lossofchildcustody,poorjudgment,violentcrimes,stealing,domesticviolence.Forboth.Heroinandfentanylleadtomoreoverdoses.Youthdon'tknowlong-termconsequences.

3.Whatareyouhearingabouthowpeoplestartmisusingprescriptionopioids?Heroin?

Doctorsover-prescribedbydosageorduration.Keepexcessmedicationforfutureusetoselfmedicate,thinkingit's"safe."Opioidaddictsmayturntoheroinsinceit'scheaperandeasiertofind.Kidsinsingleparent,low-incomefamilies,withmentalhealthortraumaissuestendtomorelikelyleadtofullhabitoraddiction.Startbymanagingpain,thenbuildatolerance,andnotrealizethey'readdicteduntilit'stoolate.

4.WhattrendsareyouseeingwithprescriptionopioidmisuseinAnchorage?Heroinuse?

Prescriptionpadtheftandthediversionofpharmaceuticalopioids.Useofthemailservicetoorderopioidsandheroin.Youtharegettinglessprescriptionswrittenforthemselvesnow,sotendtotakefromothers.Parentsnaivethatchildwouldusepills.Higherpotencyheroinisavailablesopeopleareoverdosingmoreeasily.Fentanylmixedwithheroin.

5.Whatarepeopleinyourprofessiondoingtocombattheheroin/opioidprobleminAnchorage?Whatwouldyouliketoseechange?

DEA’s360strategy:1.     LawEnforcementactionagainstherointraffickers.2.     DiversionControla)     EnforcementactionsagainstDEAregistrantswhichincludedoctors,pharmacists,veterinariansandnursesoperatingoutsidethelaw.b)     Long-termengagementwithpharmaceuticaldrugmanufacturers,wholesalers,pharmaciesandpractitionerstocomeupwithreasonablesafeguardsagainstthedangersofopioidtreatmentandaddiction.3.      CommunityOutreachSupportyouthon"front-end"inprobation(notinstitutionalized)todo"SevenChallenges"substanceabuseprogram,andPrimeforLife.Joburinalysis,awareness,prevention&treatment,education.

6.WhatotherrecommendsdoyouhaveonhowtoaddresstheopioidmisuseprobleminAnchorage?Heroin?

Treatopioiduseasanepidemic.Stateputintopracticereasonablemeasurestocurtailtheusebyproviders. Educatethepublic,includinginschools. Retaineffectivepenaltiesforthosethatpossessanddistributeheroin. 

7.Whatchallengesdoyouseetomakingthosethingshappen?

ChallengesincludeStaterulessurroundingSB91inrelationtoheroinoropioiddistributionandpenalties.Statedatabaseinthelimitingofopioidprescriptionsinquantityandduration.Youthwithcognitivedelayshavetroubleunderstandingthelong-termconsequencesofopioiduseandcannotmakethebestdecisionsforthemselves.Parentsusingdrugsmodelsthatbehavior,andifOCSgetsinvolvedthecyclecontinues.Fundingfortreatment,lawenforcement,prevention,coalitions,socialworkers,therapists,publichealth,etc.Communitybuy-intosupportpeopleinrecovery.

KeyInformant-KeyCommunityMembers

1.HowdomostpeopleinAnchorageviewusingprescriptionsopioidstogethigh?Whataboutheroin?

Pillformorinjecting.Thereisaperceptionthatthosewhoabuseopioidprescriptionsarelosers,ill-educated,unhygienic,cannotholdajob,overallbadpersonratherthan"regularpersonjustlikeyouandI."Increasescrimeandsafetyconcerns.Althoughbotharebad,opioidabuseismore"forgivable/overlooked"thanheroin.Prescriptiondrugsareaddictiveespeciallywhenusedinamannernotconsistentwiththelabelingorusedsomeoneotherthanthepatient.Basedonthenews,heroinuseseemstobeontherise.

2.Howdoyouthinkmostpeopleobtainprescriptionopioids?Whataboutheroin?

Multiplevisitstomedicalfacilitieslikethedoctorsoffice&ERtoobtainopioidprescription.Giveitawayorsellto/fromfamily/friendsBuyingfromdrugdealers."Blackmarket"foropioidsandheroin.Canbebroughtinfromotherstates.Youthgetfrompeersinschool,parent'smedicinecabinets,stealingotherpeople'sprescriptions.

HigherCrimeratesandsafetyconcerns.OverdosesTakingresourcesawayfromAPDandAFD.Addiction&dependency.Quick-payingjobs,likeservingtoprostitution,tobuymoredrugs.Increaseofdeceptivebehaviorlikelyingandstealing.Unhealthyweightlossinheroinusers.Openedsyringesinpublicparksandparkinglots.

4.Whatcausespeopletostartmisusingprescriptionopioids?Heroin?

Painmanagement.Lackofknowledgeofaddictionwhenbeginningopioiduse.Depression.OtherDruguse.Economic/Financialimpactssuchaslosingajoborhouse.Curiosity-learningfromusers/dealersinhigh-riskareas,ratherthansafereducation.Compulsivedrugseekingforheroin.Heroincanbecut/mixedwithotherdrugs/poisonsorwhitesubstancessuchassugar,starchorpoweredmilk,causingmoredanger.

5.WhattrendsareyouseeingwithprescriptionopioidmisuseandheroinuseinAnchorage?

Epidemicisregularlyinthenews.It's"notinthedark"anymore.Usedsyringesleftinpublicareas.Ifeelthatuseisincreasing.Opioidmisuseiscommonamongstteensandyoungadults.AccordingtonewsstoriesmanyHeroinaddictsstartedwithOpioidmisuse.

Comingtogethertobrainstormsolutions&strategies.Makingthecommunityawareofthelevelofseriousness,andthateveryonehasthepotentialtobecomeanaddict.Myprofessiondoesnotcombatthisproblem.Wetieinfactsaboutdrugstonicotinewhilepromotingdrug-freesociety.Iwouldliketoseemoreeducationfromschools&parentstokidsontheimportanceoffollowingdoctorsorderswithprescriptionmeds.Offeringpreventativemeasures/services,treatmentservicesandtransitiontoindependenceservicesamongotherservicestoadolescentsandadults.

7.WhatdoyourecommendtoaddresstheopioidmisuseprobleminAnchorage?Heroin?

Communityawarenessandeducation,inthegeneralcommunityandtheschooldistrict.Moreandbetterresourcesforthoseinneedofhelp.Education/awareness,talkingaboutitopenly,addressthatthereisaproblem,nottostereotypeitaslowSESpeopleonly.Reducestigma.Sharingknowledgewiththoseclosesttous.Helpingothersdealwiththepressuresoflifewithalternativepositive,healthyways,likeexercisingandvolunteering.Medicalhelpforthosesufferingwithmentalillnessandsubstanceabusesuchasanxiety,depression&post-traumaticstressdisorder.Peopleusewhenlifeisnotworkingout.Helpintervenebyhelpingsethealthypriorities,includingbalanceddiets.

8.Whatarechallengestowhatyou’dliketoseehappening?

Peoplewillseekahigh,andaddictshavetowanttoquit.Educationmaynotbeenough.Loworlackofcity/statebudget.Notenoughprofessionalsinthefield.Druglordsaredangerouspeopleandmaykillwhenpeopleinterferewiththeirbusiness.(Somethingcanbedoneaboutthisifwealljoinefforts)Parentusingwhiletheirchildrenareinrecoveryandareusingaroundthem.(Childrenwithpoorsupportsystem.)

KeyInformant-Media

Generallypeopleviewusingopioidsinanegativewayorasdangerous.Maystartwithopioidprescriptionorrecreationallyleadingtoaddiction;thenmaybeintoheroinuse.Needtoseeabuseasanillnessratherthanjudging.Mostpeopleknowopioidsaredangerous.Parentsknowmorenow,butwedon'tknowwhoisnewlygettingaddicted.InJuneau,thewholeclassof2007hadrampantaddiction.Kenaihashighheroinuse.Communityhasmoresympathyforheroinusersthanotherdrugsbecauseweallknowsomeone.Heroinispublichealthcrisisnow,whichhasracialundertones.

DoctorsTheStreet,orblackmarket,andeasilyinTownSquarePark.Drugsareeasytogetinhalfwayhousesorcorrectionssystem.Pillmills-howmanyinAnc?Peoplegetheroinfromanetworkoflow-leveldealersconnectedtoCAandWAStates.Evenmomswithkidsinwithdrawalwillsometimesgobuyherointohelplessentheirkids'withdrawalsymptoms.

LosecustodyofkidstoOCS.Ifparentstryingtogetclean,dealingwithOCSmakesthatharder.Babiesbornaddicted,thenOCS.DeathLossofJob.It'snotaproblemofawareness.Peopleknowtherisks.

Heroinischeaper,andthereisacommunitybuiltarounddruguse.Peopleareself-medicatingaroundtraumasintheirlives.Peopleareself-treatingothertrauma,aimlessness,depression,etc.,thatleadstoheroinandopioiduse.Givepeoplemoreoptions,likejobcorps.

JayButlersaidtherearethreewaves:1.Prescriptionpainkillers,2.Heroin,3.Syntheticdrugs(likeFentanyl)."Weneedmoredetox"istoosimplistic.Replacementtherapyismoreeffective(vivitrol,methadone,soboxone).Methadonehasworkedforsomepeople,butthereisastigma.

Inthemediawe'renotdoingenoughsolutionsreporting.Reportingpersonalstoriescanreducestigma.TheAnchoragePresshasdonesomegoodin-depthreporting.Nowit'srecognizedasanationalproblembecauseofraceandeconomics.Thisisatopicofinteresttoeditors.Thingsthatwork,notwhatisbrokenistheangleweprefer.But,ourreaderstendtolikethetragediesthatpeoplecanrelateto,morethanthesolutionsstories.

Moreneedleexchanges,likeFourA's.Treatingthisproblemlikeapublichealthcrisis.CriminalJusticeReformforthelong-termimpact.Moreresourcesfortreatment.Likeanimmediatehelp/actioncenteroranemergencymentalhealthcenterorcrisisnumber.Changeinpublicperceptionofthoseusingasbadpeople;it'snotamoralissue.Preventionmeasures,suchasgiving17-25yearoldsalternativestomaketheirlivesbetter,tocareforthemandbuildtheirself-worth’s.Haverealpeoplesharetheirstory.

Notenoughtreatmentoptionsthatwork,likePartnersReentrySystem.Supportforaddictsthatareinjails,moretrainingforguardsandmoreresourcestowithdrawals.Treatwithdrawalslikeemergency,opportunitytointervene.RestrictavailabilityofdrugstothoseinHalfwayHousesbyincreasingthequalityofguards.Naloxone.Goodbutdoesn'tgetattheroot.Awareness.Peopleknowdrugsarebad.Ads,radios,etc.don'twork.Youngpeopleconsumemediabetterandaresavvierthanthoseads.

KeyInformant-AdditionalKeyCommunityMembers

Peoplethinkdoctor'sprescriptionsaresafe.Mayleadtochronicaddiction,andpossiblygoingtothestreetforheroin.Peoplethinkheroinusersarejunkiesorrockstarsandnotsomeonetheyknow,butnowthey'relearningneighborsorhousewifedownthestreetare"pillpopping"togethigh.Theyviewopioidsaseasytogetsincethey'renotillegalandareprescribedbyadoctor.Heroinisillegalbecausethegovernmentsaysso.

“Doctorhop”togetopioidprescriptions.(Thereneedstobesomemechanismtostopprescriptionabuse.)Peoplestartwithprescriptionsforlegitimatepain.Buyorstealfrompeopletheyknowhaveprescriptions.HurtthemselvespurposelyinordertogototheERandgetacoupleday'ssupply.Peoplearebuyingheroinonthestreetsfromdrugdealers.

DomesticviolenceChildreninneedofaidduetoabuseorneglect.Pettycrimestosupporttheirhabit.Overcrowdedjails. OveruseofandfullERs/Hospitals.Lackofenoughtreatmentfacilities.Poorhealthofthoseaddicted.Death.Heartbreak.Averagemiddleclasspeoplewithopioidaddictions.It'scheapertogetheroin,somoreuseit.

Painfromworkers’compensationinjuries,caraccidentinjuries,etc. Prescriptionopioidsmightleadpeopletoturntothestreetforillegalheroin.Itfeelsgood/likethefeeling.Itbecomesawaytocopewiththingslikedepression,frustration,anger,trauma,etc.Over-prescribedopioidmedication.Heroin-becauseitischeaperandeasiertoobtainthanaprescriptionmed.

Thepeopleusingsenttojail,somorepeopleinprisons.Over-useofERandPolice.Increaseofoverdoses.Increaseofchildabuse&neglect.Youngerpeopleusingandgettinghooked;likeathletes,goodstudents,&middleschool-ers.Ruralcommunitiesexposedatanearlierage.Usingisconsideredcoolbyperformers&entertainers,theycallit"lean"or"sizzurp"whichiscodeineIthinkmixedwithjuiceorpop.Influencesyoungerpeople.Heroinnotaspopularwithmainstreamentertainers.IncreasedintransferofSTDHIV/AIDSthroughunprotectedsexandneedlesharing.

Mostpreferaddictstobeputbackoutonthe street(fromjail)becausetheyperceivenothingwrongisbeingdone. Promotelongerjailsentenceswithmandatorydrugrehabilitationprogramswhileinjail.Peoplearemoreawareofwarningsignsofdrugabuse.Prescribersaren'tsoquicktogiveopioidprescriptions.Discussedopeningatreatmentcenterbutlogisticallyitisnotpossibleduetolackoffunding.Considernaturalmethodsoftreatment;physicaltherapy,iceorheattreatment,dietandexercisetherapy,andeducationforpeople.Focusontheyoungergenerationtogrowandbuildahealthiergeneration.Limitthenumberofpillsprescribedatatime.Medsshouldbedistributedbydosethroughathirdparty.Peoplebeingprescribedshouldbeheldaccountableandtoldofconsequences.Theyshouldalsobetestedtohavepillsintheirsystemtoensuretheyare

Morepoliceonthestreet.Stifferpenaltiesforrepeatoffenders;2ndoffenseforselling/usinganyopioidorheroin,senttojailfortherestofyourlife.Gettotherootofwhypeopleusethroughtherapy&treatmentthatisaffordableandeasytoaccess.Moredetoxbedsandtreatment.Considerotherpaintreatmentsbeforeopioiduse.Limitamountprescribed.Educationontreatingthebodybetteratanearlyagetoavoidpainlaterinlife."Takecareoftheoldpersonyouaregoingtobecome."

Shutdownthecourtsystem's“revolvingdoor”problemwiththesamepeopleinandoutofthejailsystemforthesamecrimes.Money/ResourcesAnchoragemunicipalityleadershiptobeactiveinfindingsolution.Gettinglocalagenciestocampaignforfunds;suchasAlaskaNativeCorporationsinvillages.Doctorstostopover-prescribingHoldpatientsaccountabletousingmedicationresponsibly,andusingsafestorage,likelockingthemupandnotsellingthem.Parentsandfamiliesmodelbetter,healthier,andsubstance-freelifestylestoyouth,especiallyAlaskaNativeyouth.

APPENDIXB–SummaryofCommunityReadinessAssessment

HealthyVoicesHealthyChoicesCommunityReadinessAssessmentPartnershipsforSuccess:OpioidandHeroinPrevention

Non-medicalprescriptionopioidandheroinusefor18-25year-olds

Purpose(forinterviewertoread)

ThankyouforjoiningtheHealthyVoicesHealthyChoicescoalitiontodayforourcommunityreadinessassessmentinterviews.WeareconductinganeedsassessmentforAnchoragetopreventandreducethenon-medicaluseofprescriptionopioidsandheroinfor18-25year-olds,aswellasthenon-medicaluseofprescriptionopioidsfor12-17year-olds.Thepurposefortoday'ssurveyistobetterunderstandthelevelofcommunityreadinessinpreventingnon-medicaluseofprescriptionopioidsandheroininAnchorage.Thismodelofassessmentuseskeyinformantinterviewswithstakeholderswhoareknowledgeableandrepresentvarioussectorsinthecommunity.Youhavebeeninvitedtoparticipatebecauseyourepresentanimportantcommunitysectorandarealsoknowledgeableabouttheissue,community,andresources.Iwillaskaseriesofquestionsonfiveareas:1)communityknowledge,2)leadership,3)communityclimate,4)knowledgeabouttheissue,and5)resourcesforefforts.Today,whenIreferto"theissue,"Iamreferringto:

Today's"Issue:"thenon-medicaluseofprescriptionopioidsandheroinfor18-25year-oldsinAnchorage.

Let'sgetstarted!Introductions

Inclusionactivity:talktoapartnerandshareyourstoryofhowyou’vegottentowhereyouarenow(2minutes)whileyourpartnerlistens.Thenyourpartnerwillgiveyoufeedbackonwhatyoulearnedaboutthem.Repeatandswitchsotheotherpartnerforsharingandlistening.

CommunityReadinessInterviewQuestionsCommunityKnowledge

1. Everyonescorethecommunitylevelofcommunityconcernfortheirsector.2. ArethereeffortsinAnchoragethataddressissue?3. Canyoubrieflydescribeeachofthese?4. Abouthowmanycommunitymembersareawareofeachofthefollowingaspectsofthe

efforts?(None,afew,some,many,ormost)a. Haveheardofefforts?

b. Cannameefforts?c. Knowthepurposeofefforts?d. Knowwhotheeffortsarefor?e. Knowhowtheeffortswork(e.g.activitiesorhowthey'reimplemented)?f. Knowtheeffectivenessoftheefforts?

5. Basedonthat,whydoyouthinkyourcommunitymembershavethisamountofknowledge?

6. Aretheremisconceptionsorincorrectinformationamongcommunitymembersaboutthecurrentefforts.

7. Isanyoneinthecommunitytryingtogetsomethingstartedtoaddresstheissues?Canyoutellmeaboutthat?

Leadership1. Everyonescorethecommunitylevelofcommunityconcernfortheirsector.Explain.2. Howmuchofapriorityisaddressingthisissuetoleadership?Canyouexplainwhyyou

saythis?3. I’mgoingtoreadalistofwaysthatleadershipmightshowitssupportorlackofsupport

foreffortstoaddressissue.Canyoupleasetellmewhethernone,afew,some,manyormostleaderswouldordoshowsupportinthisway?Also,feelfreetoexplainyourresponsesaswemovethroughthelist.Howmanyleaders…

a. Atleastpassivelysupporteffortswithoutnecessarilybeingactiveinthatsupport?

b. Participateindeveloping,improvingorimplementingefforts,forexamplebybeingamemberofagroupthatisworkingtowardtheseefforts?

c. Supportallocatingresourcestofundcommunityefforts?d. Playakeyroleasaleaderordrivingforceinplanning,developingor

implementingefforts?(prompt:Howdotheydothat?)e. Playakeyroleinensuringthelong-termviabilityofcommunityefforts,for

examplebyallocatinglong-termfunding?4. Doestheleadershipsupportexpandedeffortsinthecommunitytoaddressissue?5. Howmuchofapriorityisaddressingthisissuetoleadership?Canyouexplainwhyyou

saythis?

CommunityClimate1. Everyonescorethecommunitylevelofcommunityconcernfortheirsector.Explain.2. Howmuchofapriorityisaddressingthisissuetocommunitymembers?Canyouexplain

youranswer?3. I’mgoingtoreadalistofwaysthatcommunitymembersmightshowtheirsupportor

theirlackofsupportforcommunityeffortstoaddressissue.Canyoupleasetellmewhethernone,afew,some,manyormostcommunitymemberswouldordoshowtheirsupportinthisway?Also,feelfreetoexplainyourresponsesaswemovethroughthelist.Howmanycommunitymembers…

a. Atleastpassivelysupportcommunityeffortswithoutbeingactiveinthatsupport?

b. Participateindeveloping,improvingorimplementingefforts,forexamplebyattendinggroupmeetingsthatareworkingtowardtheseefforts?

c. Playakeyroleasaleaderordrivingforceinplanning,developingorimplementingefforts?(prompt:Howdotheydothat?)

d. Arewillingtopaymore(forexample,intaxes)tohelpfundcommunityefforts?4. Abouthowmanycommunitymemberswouldsupportexpandingeffortsinthe

communitytoaddressissue?Wouldyousaynone,afew,some,manyormost?Ifmorehowmighttheyshowthissupport?

KnowledgeAbouttheIssue

1. Everyonescorethecommunitylevelofknowledgefortheirsector.Explain.2. Wouldyousaythatcommunitymembersknownothing,alittle,someoralotabout

eachofthefollowingastheypertaintotheissue?(Nothing,alittle,someoralot)a. issue,ingeneralb. thesignsandsymptomsc. thecausesd. theconsequencese. howmuchissueoccurslocallyf. whatcanbedonetopreventortreatissueg. theeffectsofissueonfamilyandfriends?

3. Whatarethemisconceptionsamongcommunitymembersabouttheissue?

ResourcesforEfforts1. Everyonescorethecommunitylevelofknowledgefortheirsector.Explain.2. Howarecurrenteffortsfunded?Isthisfundinglikelytocontinueintothefuture?3. I’mnowgoingtoreadyoualistofresourcesthatcouldbeusedtoaddressissueinyour

community.Foreachofthese,pleaseindicatewhetherthereisnone,alittle,someoralotofthatresourceavailableinyourcommunitythatcouldbeusedtoaddressissue?

a. Volunteers?b. Financialdonationsfromorganizationsand/orbusinesses?c. Grantfunding?d. Experts?e. Space?

4. Wouldcommunitymembersandleadershipsupportusingtheseresourcestoaddressissue?Pleaseexplain.

5. Onascaleof1to5,where1isnoeffortand5isagreateffort,howmucheffortarecommunitymembersand/orleadershipputtingintodoingeachofthefollowingthingstoincreasetheresourcesgoingtowardaddressingissueinyourcommunity?

a. Seekingvolunteersforcurrentorfutureeffortstoaddressissueinthecommunity.

b. Solicitingdonationsfrombusinessesorotherorganizationstofundcurrentorexpandedcommunityefforts.

c. Writinggrantproposalstoobtainfundingtoaddressissueinthecommunity.d. Trainingcommunitymemberstobecomeexperts.e. Recruitingexpertstothecommunity.

6. Areyouawareofanyproposalsoractionplansthathavebeensubmittedforfundingtoaddressissueincommunity?

AdditionalPolicy-RelatedQuestions:

Foryoursector…1. Howreadyisyourcommunitywithpromotingalternativestoopioiduse?2. HowreadydoyouthinkAnchorageistostartstoringproperlyinasafeanddiscarding

oncethey’reexpiredornolongerneeded?3. Whatdoyouthinkthelevelofreadinessarepeoplereadytostarttalkingaboutstigma

foropioids?4. Whatdoyouthinkthelevelofreadinessarepeoplereadytostarttalkingaboutstigma

forheroin?5. Howwillingdoyouthinkyoursectoristothinkingtheneedleexchangeisagoodidea?

HealthyVoicesHealthyChoicesCommunityReadinessAssessmentPartnershipsforSuccess:OpioidandHeroinPrevention

Non-medicalprescriptionopioidusefor12-17year-olds

Purpose(forinterviewertoread)

ThankyouforjoiningtheHealthyVoicesHealthyChoicescoalitiontodayforourcommunityreadinessassessmentinterviews.WeareconductinganeedsassessmentforAnchoragetopreventandreducethenon-medicaluseofprescriptionopioidsfor12-17year-olds,aswellasthenon-medicaluseofprescriptionopioidsandheroinfor18-25year-olds.Thepurposefortoday'ssurveyistobetterunderstandthelevelofcommunityreadinessinpreventingnon-medicaluseofprescriptionopioidsandheroininAnchorage.Thismodelofassessmentuseskeyinformantinterviewswithstakeholderswhoareknowledgeableandrepresentvarioussectorsinthecommunity.Youhavebeeninvitedtoparticipatebecauseyourepresentanimportantcommunitysectorandarealsoknowledgeableabouttheissue,community,andresources.Iwillaskaseriesofquestionsonfiveareas:1)communityknowledge,2)leadership,3)communityclimate,4)knowledgeabouttheissue,and5)resourcesforefforts.Today,whenIreferto"theissue,"Iamreferringto:

Today's"Issue:"thenon-medicaluseofprescriptionopioidsfor12-17year-oldsinAnchorage.

Let'sgetstarted!Introductions

Inclusionactivity:talktoapartnerandshareyourstoryofhowyou’vegottentowhereyouarenow(2minutes)whileyourpartnerlistens.Thenyourpartnerwillgiveyoufeedbackonwhatyoulearnedaboutthem.Switchsotheother

CommunityReadinessInterviewQuestionsCommunityKnowledge

1. Everyonescorethecommunitylevelofcommunityconcernfortheirsector.2. ArethereeffortsinAnchoragethataddressissue?3. Canyoubrieflydescribeeachofthese?4. Abouthowmanycommunitymembersareawareofeachofthefollowingaspectsofthe

efforts?(None,afew,some,many,ormost)a. Haveheardofefforts?b. Cannameefforts?

c. Knowthepurposeofefforts?d. Knowwhotheeffortsarefor?e. Knowhowtheeffortswork(e.g.activitiesorhowthey'reimplemented)?f. Knowtheeffectivenessoftheefforts?