PARTICIPANT CONSENT STATEMENT

The purpose of this survey is to gather vital information about drug-related issues in our community.  Your participation will help the Alliance for Better Communities and its partner agencies to plan efforts designed to reduce local substance use problems.

 Your participation in this survey is voluntary.  You may skip a question, if you choose to do so, or stop taking the survey at any time by exiting.  The survey will take approximately 10 minutes to complete. 

 Your participation in this survey is anonymous.  No information will be requested which can link your responses to you personally.  If you have questions about this survey, please contact the Alliance for Better Communities at 315-788-4660.

 By continuing below, you have freely agreed to participate in this survey and you are indicating that you are at least 18 years of age. 

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* 1. What is your gender?

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* 2. Do you identify as part of the LGBTQ2 + community?

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* 3. What is your age?

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* 4. What is your zip code?

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* 5. What is your employment status?

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* 6. What is your education level?

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* 7. Do you have any family history of opioid abuse?

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* 8. Have you ever used opioid-based pain medications that were prescribed to you? Such as hydrocodone (Vicodin, Norco, Lortab) oxycodone (OxyContin, Percocet, Percodan), or codeine.

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* 9. If you have used opioid-based pain medications prescribed to you, how old were you when you first used these medications?

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* 10. Did you use the opioid-based prescription medication/(s) as instructed by your medical professional?

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* 11. Have you ever used any of the below street-level opioids? Please check all that apply.

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* 12. How old were you when you first used street-level opioids?

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* 13. How did you obtain either the opioid-based prescription drugs or street-level opioids? Please check all that apply.

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* 14. How easy do you think it is to obtain opioid-based prescription medications not prescribed to you in your community?

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* 15. How easy do you think it is to obtain street-level opioids (heroin, fentanyl) in your community?

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* 16. How long did you misuse opioid-based prescription medications that were not prescribed to you? Such as hydrocodone (Vicodin, Norco, Lortab) oxycodone (OxyContin, Percocet, Percodan), or codeine.

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* 17. How long did you use street-level opioids (heroin, fentanyl)?

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* 18. How often did you use prescription medications not prescribed to you? Such as hydrocodone (Vicodin, Norco, Lortab) oxycodone (OxyContin, Percocet, Percodan), or codeine.

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* 19. How often do/did you use street-level opioids (such as heroin, fentanyl)?

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* 20. What route of administration do/did you prefer?

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* 21. On average, how much money do/did you spend per day on opioids?

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* 22. How many times have you ever overdosed on any opioids?

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* 23. If you have overdosed, was Narcan administered?

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* 24. Have you ever experienced any of the following withdrawal symptoms from opioid use? Please check all that apply.

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* 25. Have you ever gone to any of the following because of drug use? Please check all that apply.

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* 26. Have you ever been admitted to any of the below-listed facilities due to drug use? Please check all that apply.

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* 27. Have you ever participated in medication-assisted therapy/treatment?

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* 28. If you have participated in medication-assisted therapy/treatment, have you ever received or are currently on any of the following?

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* 29. If you have misused opioids, which other drug(s) do you currently use/misuse? Please check all that apply.

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* 30. Have you ever had a reoccurrence after a period of misusing opioids?

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* 31. If you have misused opioids, what is the longest time you have been free of opioids?

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* 32. Do you feel supported in your recovery by friends and family members?

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* 33. Have you ever worked with a peer advocate?

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* 34. If you have worked with a peer advocate, did you find it beneficial?

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