Community Forum Summary

To View, Download, or Print Summary

In the spring of 2019, Montana State University Extension conducted five community forums in rural
areas of the state on the topic of Opioid Misuse Disorder. The events were publicly advertised in each
location as a community forum. Residents and stakeholders were invited to talk as a community and
discover together what is important in response to the opioid crisis. The events were facilitated
discussions to determine how individuals in communities view opioids and what some of the possible
solutions may be to address any issues identified by community members.

Aggregate of community members:

There were a total of 63 community members and moderators involved in all five forums. Represented in
this group were school administrators and nurses, state and tribal police, deputies and probation officers,
licensed addiction and mental health counselors, doctors, pharmacists, college professors, Tribal Health
employees, Indian Health Service (IHS) employees, public health officials, family planning professionals,
mental and behavior health center managers, senior center managers, attorneys, farmers, Justices of the
Peace, County Commissioners, reporters and community residents.

This document tis intended for public circulation. It is designed to supplement the current knowledge
about opioid misuse in Montana. The document offers raw commentary and unedited quotations that
were collected in a live and public setting. Each of the subsections are an aggregate of comments made
from participants throughout the forums.

When you hear the word “opioid”, what comes to mind?

Abuse
Brain chemistry
China
Constipation
Coping mechanism
Delusions/opium chewed in the Middle East
Diversion
Dopamine
Drugs
Escape
Fentanyl
Heroin
It’s hidden
Kids want to experiment
Kratom
Lack of understanding
Make some very sick and cause emotional
numbness too
Mental Health
“Non-medical prescribing”, sharing with family
and friends.
Old School
Opioid problem is affecting children and young
people.
Overdose
Over-prescription
Pain (2x)
Pain management: “For some people, opioids
help them get through the day”
Pain pills (2x)
Painkillers. When ranchers get hurt pretty bad,
they need painkillers.
Patient Pain Management
People think it is safe because it’s a legal,
prescribed drug
Pharmaceutical companies
Pills
Poppies
Poppy Plant
Prescribed after surgery
Ranching and Farming lifestyle, most people have
pain issues (2x)
Some people hate taking them even though they
need them.
Some people have an “addictive personality”
There is a balance between proper use and
misuse
There’s safe ways to use, but opioids are not
being safely used

What factors lead to opioid abuse?

ACCESS TO HEALTHCARE

One has his own insurance, he’s addicted but he can manage it. The other has no insurance,
goes to the clinic, most can’t afford insurance – now they aren’t giving meds for pain so they’re
going to the streets. And he gets questionable street drugs that who knows what’s in it?

BOREDOM

Someone had lived in Bozeman and is totally bored living back in their rural hometown. There
are no activities. The rat study was discussed, where rats were given 2 water bottles, one laced
with cocaine and one unlaced. Rats would use cocaine-based water to the point of overdosing
when they were in a bare cage. When they were given a cage with toys, games, activities –
none of the rats overdosed. It is because of CONNECTION.

CRITICAL POINT OF EDUCATION

A Pamphlet

At the time of prescription, patients don’t get a pamphlet. Who is in charge? Where is that
pamphlet that alleviates the provider from liability? The doctor has person back in 1-3 months
after prescribing a strong medicine! Who talks to them about legalities of sharing medications?
They don’t even know it is a controlled substance or that it is a felony to share medications.
When teaching a diabetic how to do a pen, why not share information about a controlled
substance. Naive prescribing – they don’t understand that opioids turn into street drugs.

FEAR OF BEING IN PAIN, EXPECTATION TO BE FREE OF PAIN

• How do we know when someone is really in pain?
• We think we are supposed to be immune from pain.

GENETICS

People that are bi-polar have genes that help them to crave opiates. There are also people
without the gene. Two people came to see him, one had the gene and the other didn’t. Person
with opiate gene would take 1 every 3 hours (vs. indicated 6 hours) and call for more.

• HOUSING

There was a study and the #1 cause of mental health issues was inadequate housing and crowded houses. No space of their own. Poor coping skills. Stigma that they’re not maintaining. 20 people living in a four person house cannot be maintained. The outside world does not understand the housing crisis on the reservations. Homesickness – people shouldn’t have to relocate, that is the whole point. Single and wedded new mothers dealing with post
partum - the housing effects their mental health.

INJURY

The point of addiction started when they got hurt. There is a way to do it properly, people just
aren’t educated.

KIDS USING

• Curiosity, desire to get high
  “With our kids we see that they’ll crush and snort just about anything just to see if they’re going to get high”
  Lack of education
  A lot of children live with their grandparents

LACK OF JOBS

LIFE OR LIMB PRIORITIZATION

IHS life or limb, treating people with pain. There are levels of care and the first priority is life,
and second priority is limb – 80% of budget went to alcohol/drug treatment. A patient with a
herniated disc, using best practices, was put on opioids. In Canada, there are long waiting lists
for surgeries – push pills at them. “Pain is the fifth vital sign.”

MARKETING

Prescriptions are advertised on radio and TV

MISINFORMATION

“Oxycontin is non-addictive – ha”.

OVERPRESCRIBING

It was stated that overprescribing the medication is a problem. Poor case management.
Prescriptions from bigger cities.

• Self-medication
• Addictive personalities
• “You’re going [to the doctor] to get help and someone you trust is prescribing something to help you feel better”
• “Is it easier to write a script and get somebody out of your office, or listen to them for an hour?”
• Patients want an instant result
• Prescribed opioids could lead to illegal use

PAIN ALTERNATIVES AREN’T AS MAINSTREAM

• A veteran in the group talked about his experience being rushed in, prescribed
  something, and rushed out of the VA without any discussion about pain alternatives.
• Some may be uneasy or not know about alternatives.

PEER PRESSURE

Especially among adolescents. This comment was seconded, saying people have nothing to
do. People that don’t work and have to budget – they are setting trash cans on fire out of
boredom. They need more family engagement. They need more employers.

PERFECT STORM

Paraphrasing from a law enforcement officer: We’ve always had a problem with self-medicating,
especially in ranching communities. You drink because you hurt, maybe there is a shift away from
alcohol to opioids. Opioids are seen as safe because they are prescribed by a doctor.

POLYPHARMACY & DOCTOR SHOPPING

• Those suffering from misuse know which doctor to go to.
• Strict policies may cause people to seek care elsewhere.

POVERTY

Prescriptions have value and poverty drives using and selling.

RACISM

We are a community of minorities and there is judgement. With other people continually
saying you have no self-worth, you’re going to use again. System is based on punitive. People are pre-judged – need to see the person separate from the addiction. The justice and medical systems fail to have empathy. Racism contributes to opioid addiction.

RURALITY

•  “Hoarding” due to lack of access, not wanting to drive to get a new prescription.
•  Not wanting to dispose of something “valuable” (especially older adults).
•  “In our small town we don’t have a pain management specialist, if they are chronic
  pain patients, it’s difficult for them to travel. We have to protect those people.”
•  In Montana, mental health is underserved, especially in the eastern part of the state.
• “Hoarding” due to lack of access, not wanting to drive all the way to Billings to get a new
  prescription.
• Not wanting to dispose of something “valuable” (especially older adults).
• “If people were able to get the medicine they needed, they wouldn’t feel the need to
  “hoard”.
•  You can get opioids nearby, you might have to drive to go to a physical therapist.
• Sharing with friends and family.
• Isolation, especially for elderly people.

TRAUMA

Trauma on a daily basis in households and historical trauma. The need for coping skills.

TRUST

The people trusted what was being given to them by the doctors. They did what they were
supposed to do. Next thing you know they are waiting outside of the clinic to purchase more.
People know you are on pain pills and they ask for your prescription. An elderly person was
knocked out during a theft – elder abuse. Their kids often are the ones who took them – patients
testing negative for their prescription opioids, not taking them. People trusted the doctors and now
are so addicted that they are hurting their animals to get medications. (A second person agreed).

UNDERREPORTING

The amount of opioid use, overdose death and injury is underreported.

UNDERREPORTED MENTAL ILLNESS

Bi-polar, schizophrenia, depression – they are in jail due to undiagnosed mental illness. Cooccurring chemical abuse and mental health issue. They lie about their opioids. 

What would prevent opioid misuse from occurring? What can we control?

ACTION - DO MORE THAN JUST TALK

We have to step up ourselves, frustrated that the state keeps bringing in Extension or state to
fix. It is our community that needs to fix it! What can I do to save my block for my grandkids?
One person got an entire street cleaned up. She reported them all to law enforcement and
also worked with the Housing Authority. Another asked what if the people own their own
homes? Then go to law enforcement, it is anonymous. It’s got to stop. Kids have no role
models. There are little kids who don’t know how to eat with utensils, wipe themselves, and
their teeth are rotting out. There is a breakdown of the family unit and a lot of foster care
activity. There are a couple of subcommittees that have been formed, but talk is as far as it
goes. Subcommittees plan but when it comes to action there are barriers. For example,
nobody reports opioid misuse because “it’s not our business”. 

BETTER HEALTH CARE

oThe nearest hospital is 3 hours away, and scheduling surgery takes time. In the mean time they are put on opioids.
o Mental health resources
o Better treatment for recovery.
o Addiction is misunderstood.

CAMPAIGNS & DATA COLLECTION

o Was DARE effective? The Meth campaign was effective. It is hard to identify a campaign for opioids. The people who are dying are 55 and older. They are talking a lot about kids, but no campaigns.
o There should be a survey on prevention.
o Advertising where people will see it
o Community information overwhelmingly comes from Facebook.

COMMUNITY ENGAGEMENT

o Make as many non-toxic places as possible for our children to go to
o Checking in with each other
o Checking in with someone after they are prescribed.
o Taking greater responsibility for the people that we know without judgement

o “What happens is, somebody will have a farm accident, a ranch accident. They will get Percocet, and the next thing you know, they're out driving an ATV. That someone is usually my husband. If it's not mine, it's somebody else's.”
o It is effective to hear people share their stories
o Talking about opioid misuse in church
o Drug Take Back Days seemed successful
o Have a spring cleaning day

COMMUNITY WATCH

o Preventing stealing of medications
o Some members brought up a story about someone going from garage sale to garage sale, using the bathroom at each house and stealing prescriptions.
o Assigning a family member to be the “watchdog” or point of contact when someone is prescribed opioids. 

• EDUCATION

o Where are people seeking information? Facebook (big yes!). Information should be at the clinics & on flyers hung on community buildings
o Have education about opioids on the peripheral, repeated small engagements and 1-on-1 will work. Getting a ranch loan? Oh here are these Deterra® bags. Impromptu works. People are more engaged with eye contact. People love to tease, “Eh, I’d rather visit with my friends.”, so meeting those people where they are will work
o Public Service Announcements/Radio Ads/Radio Shows. Script some PSAs. Do a radio show. Get those program heads, employees, community members. Have kids step forward and speak out. Include youth & elderly
o Education from providers & physicians (2x)
o As patients we need to advocate for ourselves and not be afraid to ask questions. (2x)
o Doctors may not be checking the controlled substance log
o Empowering people to assign someone to help them when prescribed. “You’re not totally all there when you’re on them.”
o Doctors may write a larger prescription because they know the patient lives in a rural area
o Giving out neutralization pouches with a prescription
o Education for Parents: Sports injuries, parents should be monitoring teens

o Maybe assigning a friend or family member to monitor the patient
o Home visits or follow up checks
o Education on holistic medicine; Yoga/mindfulness. One participant said: “When I hear ‘Yoga’, I’m scared”
o Alternative pain management
o Libraries could help distribute information regarding opioids & hold educational events
o Info Delivery: “There's a real problem with trying to turn it into something entertaining. It needs to be educational.”
o “I listen to the PSA's on TV. These are preaching to the choir, not preaching to the renegades. I know the businesses are paying for them, but I don't need to hear it again.”
o On idea - Pharmacist “brown bag” consultations. Bring in your medicine and the pharmacist will go through and describe what everything is for, potential side effects, and safe disposal methods.
o Education for Parents

EDUCATION FOR YOUTH

o Start with the youth. The youth need to know who they are. If you ask them, they don’t have any self-identity, they don’t know who they are. Need stress management courses and education about self-identity.
o Educate children
o We went into the schools and talked with kids – they don’t know what an opioid is. They need to be taught early.
o Reference to “grandma’s back pills”. “Coming to Auntie for her back pills.” Kids fake a back injury to earn pills. Now locked up in her purse. But they get into that too.
o The college doesn’t have educational programs as far as What does drug abuse look like? Where is that line? How can I see I may be an addict? Intro to freshman mandatory class could cover some of this. There is a lot of stigma, “Let me tell you about that student”…internal stigmas. No! Clean slate.
o DARE, MT Meth Project type education (2x)
o DARE is outdated
o Share success stories with youth
o Create YouTube videos similar to scared straight/drivers ed. Bringing in YouTubers to speak.

o “Backdoor method”, maybe using sports participation or game time to do some education.
o Parents may think: “If you talk to them about sex, they’re going to have sex, if you talk to them about drugs, they’re going to take drugs.”
o Regarding school curriculum: “It should be reading, writing, and let’s do some drug awareness.”
o Some might think it’s not a big deal to take a few pills from their grandparents
o Kids are addicted to their cellphones, maybe that has something to do with the tiredness, the depression.
o Utilizing social media

ELDERLY PROTECTION PROGRAM

There needs to be an Elder Protection Program and caregiver education. There should be a Protection
Plan – It should be national. They only have Partner Family Member Assault or it’s just illegal
possession. Even though it’s compromising that elder’s health by taking their meds. BINGO would be a
good place to talk about the dangers of transferring your medication. Elder charged with homicide
when youth went into cardiac arrest.
They should be educated about Pillseekers: How to Protect Themselves. Just went to doctors
and so and so just showed up. Offering to go get your meds for you. People know. Word
spreads, people show up at your doorstep. There needs to be an Elderly Abuse Law. Include
literature like Signs Someone is Seeking Prescription Opioids in conjunction with Signs of an
Overdose information. 

Personal Care Attendants & Community Health Representatives for the Elderly

• PCAs do not count pills, only family counts pills. Sometimes caregivers take meds!
• Caregivers should have the Deterra® bags, they will give the bags to them as well as to
  the primary caregiver.
• They will make a pamphlet to go with the bags and attach them to the bags.
• The bag looks like it’s going to explode.
• The bags are bio-degradable.
• If we remove the drugs from elderly’s homes, we remove them as a target for bullying
  and theft.
• Price out lock boxes, have community education and hold up a lock box, like a little gun
  safe.

ENCOURAGE GEDs 

His son’s IQ is 150 and they sent him to a big school, he became addicted to cocaine. 3 weeks
later, he had his GED.

ENFORCEMENT

Every child should live a childhood life. On her block there are 7 drug dealers. She has to holler at cars that go by. On one street lives a law enforcement officer, and on the next street they are selling drugs at every other house. Report to the authorities nothing is done. Is eviction the answer? They’re focusing on wanting the big dealer. People are on the warrant list but they just aren’t picked up.

Can Police become NARCAN certified?

The criminal justice system isn’t built to treat addiction.

Law enforcement officers discussed their experience with Fentanyl: “It can kill an officer that comes in
contact with it.”

EMPLOYEE ASSISTANCE PROGRAMS

There should be an assistance program at places of employment for people.

FUNDING

• Shortage of funds results in the life or limb level of care process (a long wait for non-life threatening surgeries where opioids are used to sustain the waiting period)
• Law enforcement is overstretched
• The criminal justice system isn’t built to treat addiction.
• “By the time it gets in our hands, it’s out of control, we can’t stop it. We’re always
  playing catch-up”.
• Mental health services are expensive and difficult to access.
•  “My daughter had a big problem requiring a psychiatrist. We had to wait six months to
  get into one, and we had to travel to Helena”.
• “At the hospital we have a lot of money.” There is a dental clinic doing everything from
  braces to dentures, etc. Using best practices, they are prescribing appropriately.

GAMBLING

Family members being at the casino is a problem.

GRANDPARENTS

It could happen to the perfect family. Her Uncle was sober for 40 years, his child died of
alcoholism. That demon is out there. They can’t watch the kids all the time. As a grandparent
she will influence her grandkids.

JOBS

Idle mind is the devil’s playground.

LEGISLATE

There has been discussion on declaring opioids as an illegal drug and therefore it could not be
prescribed.

MAT WAIVER TRAININGS

Cannot go cold turkey! Until we have quality treatment programs with Obamacare, etc. (now
they’re really not comprehensive.). 30-60 day treatment is not enough. Sober living etc. 1
year of treatment is needed at minimum. Medicare/Medicaid used to only cover 18 months of
treatment, now it is unlimited.

NORMALIZING

There is a normalization of drug use here. In her community, she couldn’t believe the
normalization, “so and so overdosed – that’s just the way it is.” Changes don’t happen
overnight, it’s generational. It takes 2 generations to stop a cycle. This person is 27 – active
parenting, families need to talk.

REGISTRIES: AMA Registry/NARCAN Registry

Who is on the AMA Registry? Do they have influence? There are judgmental doctors 90%. Are all
documents going from Point A to Point B - how much have they prescribed? The database only has 2016-2017 information. Can we create a NARCAN Registry through the State of Montana?

SELF ESTEEM (& JOBS)

STIGMA - THINK DIFFERENTLY

One person’s brother fell to opioids. She hit walls everywhere she went, went to courts. She
did not want to call social services so she picked up the kids herself. The wife is at treatment,
scared to go home because her husband is still using. The Dr. interrupted to go to the MAT
Clinic!! Think differently. The traditional treatment is to abstain, but MAT is different.
Opiates are different, cranking the liver up, increase receptors, tolerance changes each week.
Life is wrecked, in debt, sold everything, fractured bones. When you fall off the wagon with
opioids, you overdose. A MAT Clinic addresses this versus the old recovery methods of
abstention. OUD is a chronic disease. Suboxone is buprenorphine and naltrexone and can be
used to make an addict feel OK. Suboxone relieves cravings. A person on opiates = impaired.
Can’t drive. They can stabilize a heroin addict in one week at MAT using Suboxone. They can
put people back into society. It may not be perfect. Crime decreases when you don’t have the
cravings. Suboxone sits on the receptor and won’t let it in.

SAFE STORAGE

•  Nobody locks the doors to their house
• Gun safety, we lock up loaded guns but do not lock up our prescriptions.
• Somebody in the house needs to be the “watchdog”
• Marketing campaign so people are aware
• Utilizing social media about safe storage - Facebook is huge.
• Reminder could be put under cow prices at the cattle auction.
•  Prevents elder abuse, kids stealing from their grandparents.
• One community member said her husband kept a bottle of over the counter medicine
  for 16 years. Others in the forum agreed that this story is probably not unique.
• Older adults who grew up without a lot see the value in keeping unused meds around,
  they are valuable.
• Urging grandparents to hide/lock medication.

TAKE-BACK BOXES & DETERRA® DISPOSAL BAGS

One community has 4 or 5 take-back boxes and is trying to encourage using them. The
syringe collection program is working well. They are distributing Deterra® bags to their
elders.

• Don't assume that the county is taken care of because there's a take-back box in one
  town.
• There is a take back box at the pharmacy. The next town over is supposed to have one
  but doesn’t. There is one at the pharmacy and one at the police. Some of the stigma is
  “people take it from the box!”
•  “If people are coming in and drinking at the bar, [the take-back box is] literally across
  the street. It's really as close as it can be for people, like, if you have anything to do in
  town, the drop-off box isn't far away. Even if you're not disposing of it there, just that
  reminder. "Oh yeah, I probably shouldn't hang onto these." Maybe just trying to get
  that story out.”
• A lot of your ranchers are just, "I'm just going to throw it away in my dump. Why
  bother, you know?”
•  Deterra® Bags as Fillers: Some are using take back boxes. Deterra® bags are the fillers.
  Threatening or bullying behavior in the house can be remedied with the Deterra® bags
  as they won’t have to make a trip to the take back box, they can dispose of meds in the
  household trash. The bullying needs to be curtailed.
•  Some Deterra® bags will go to the college.
• Educate on safe disposal
•  Buy back medicines
• Getting the word out about safe-disposal boxes.
• A lot of people aren’t aware where (safe-disposal boxes) are
•  Not many knew this existed in their community
•  Giving out neutralization pouches with a prescription

TREAT OUD AS A CHRONIC DISEASE

Look at problem as a chronic disease (Suboxone/sometimes lifelong treatment)

WORK WITH THE JAIL SYSTEM

Work with the jail system – keep them out of jail through:

• Jobs
• Self esteem
• Native pride
•  Every native child should be able to ride a horse without a saddle

“There is a lot to do – sometimes you just have to pick
something and start!”

General Comments & Open Discussions

A Sense of Helplessness

“I think one of the problems though too is, it's nothing we can solve locally. Because big pharma
gives them kick-backs to write the prescriptions. So, when there's an incentive for them to write
the prescription with no oversight, there’s nothing we can do.”

Grandparents raising grandchildren

There seemed to be some concern about this happening in the community. One community
member said: “And some classes [of children in school] have more [non-nuclear families] than
others. I mean others you'll walk in and you're like "Oh yup, mom, dad, mom, dad, mom, dad,
that's good." None of the six that walked in had a mom and dad and 2.5 kids in their families. None
of them, not one of them that walked in.”

Economic stability of living in a small rural town

If there are no good jobs available, it just seems to go hand in hand. This is my perspective, but it
seems to me that in small communities, if you do not have an economic driver, and you do not
have good jobs available, the families are from lower socioeconomic levels, and there are more
issues.

Meth is still a problem

I don't know that we have a problem with the pills. It's the Meth, I feel that's our community's
problem. I'm a pharmacist and I know nothing about heroin, and all these crazy pharm parties
these kids are having.

Tactics that work other places may not work in rural Montana

I've been to places and they'll go "well, don't you go to McDonald's every day for lunch?".
McDonald's is 80 miles away.” (in a conversation about how other places do safe disposal and how
Montana is unique.)

Is it true or not true that, when they tell young women that are going to have babies, that if they
take alcohol, that there is a syndrome from sugar, that the child can become an alcoholic?

Methamphetamines? What does that have to do with opium?