Categories:
· Demographics
· Perception of risk of prescription medication abuse
· Attitudes on availability of prescription medications
· Perception of prescription medication abuse
· Support for tighter enforcement of prescription medication abuse
· Support for prescription medication policies
· Support for school programs that address prescription medication abuse
Demographics
Are you:
r Male
r Female
How would you describe your racial or ethnic background?
r American Indian
r Asian
r Black or African American
r Caucasian
r Hispanic
r Other ______(Please specify.)
How old are you? ______
County of residence: ______
Zip Code: ______
How long have you lived in this county?
r Less than one year
r One to two years
r Two to five years
r Five to 10 years
r Ten years or longer
What is the highest level of education you received?
r Grade school
r Some high school
r High school diploma
r Some college
r Bachelor’s degree
r Graduate or professional degree
If you have children 21 years of age or younger, how old are they? (Check all that
apply.)
r I do not have children 21 years of age or younger.
r 0-4 years
r 5-9 years
r 10-14 years
r 15-17 years
r 18-21 years
r Over 21 years
Last year, what was your total household income from all sources, before taxes?
r $10,000 or less
r $10,001 to $20,000
r $20,001 to $30,000
r $30,001 to $40,000
r $40,001 to $50,000
r $50,001 or above
Regarding prescription medication, which of the following best describes you?
r I take prescription medication occasionally when prescribed by Doctor for temporary illnesses
r I take prescription medication prescribed by a doctor regularly because of a chronic condition..
Perception of risk of prescription medication abuse
Do you agree or disagree with the following statement? It is safer to get high on oxycontin and other prescription medication than street drugs.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? It is OK to take more than the recommended dosage of a prescription medication if you are feeling more pain than usual.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? Drugstores have a responsibility to help control the abuse of oxycontin and other prescription medication.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? Drugstores have a responsibility to help control the abuse of non-prescription medication such as cough medicines and nasal decongestants
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Perception of prescription medication abuse
“The next questions are about the abuse of prescription medications. By abuse, I mean taking prescription medications to get high, even if the person abusing the medication got it from a doctor. Another type of abuse is when a person goes to many different doctors for the same prescription medication or when someone gets prescription medication from someone who is not a doctor – that would include getting medication from a friend or family member or from someone without a license who sells prescription medications.
How concerned are you about prescription oxycontin and other prescription medication abuse in your community.
r Very concerned
r Concerned
r Not very concerned
r Strongly disagree
r Not sure
In your opinion which of the following age groups is the biggest abuser of oxycontin and other prescription medication in your community?
r Youth 12-17
r Young adults 18 -29
r Adults 30-45
r Adults 46 -64
r Senior Citizens 65 and over
Do you know someone who has taken oxycontin or other prescription medication to get high?
r Yes
r No
If you answered yes to the above question how old was the person?
r Youth 12-17
r Young adults 18 -29
r Adults 30-45
r Adults 46 -64
r Senior Citizens 65 and over
In your opinion which of the following prescription medications are most commonly abused in your community?
r Lortab
r Vicodin
r Oxycontin
r Percocet
r Don’t know
Perception of Prescription Medication Availability
In your opinion, how easy would it be for someone to obtain oxycontin or other prescription medication from a doctor in your community to get high?
r Very difficult
r Somewhat difficult
r Easy
r Very easy
r Not sure
In your opinion how easy would it be for someone to obtain oxycontin or other prescription medication from a friend or family member in your community to get high?
r Very difficult
r Somewhat difficult
r Easy
r Very easy
r Not sure
In your opinion how do people who abuse oxycontin and other prescription medication obtain it? (Check up to three that you feel are most common)
r Friends
r Family
r Internet
r Doctors who over prescribe
r Pharmacists/Pharmacist assistants who give or sell medications to people who don’t need them for medical purposes
r People who write false prescriptions
r Other ______
Do you agree or disagree with the following statement? Most doctors in my community follow the rules when it comes to writing prescriptions for their patients
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? Most pharmacists in my community follow the rules when it comes to processing prescriptions for their customers.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? Parents should do more to keep prescription medication out of the hands of kids.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Enforcement
Do you agree or disagree with the following statement. Using prescription medication to get high should not carry the same penalties as drugs such as crack, or heroin. (Note for survey implementers: penalties for the illegal use of prescription medications are the same as for crack, heroin, methamphetamine etc. The intent of the question is to measure whether the community perceives prescription medication abuse as serious as other illegal drug use).
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Do you agree or disagree with the following statement? Law enforcement officers should do more to control oxycontin and other prescription medication abuse.
Strongly agree
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not sure
Support for New Prescription Medication Policies
Would you be in favor of a state law that requires the presentation of a driver’s license or other suitable picture ID when paying for or picking up prescription medications?
r Yes
r No
Community support for youth prescription medication abuse prevention programs
Do you agree or disagree with the following statement? Prevention programs such as those taught in schools can be effective in reducing youth prescription medication abuse.
r Strongly agree
r Agree
r Disagree
r Strongly disagree
r Not Sure