Research Proposal Editing

Survey about First Non-Medical Use of Opioid Drugs

You are being asked to participate in a research study; [PUT YOUR TITLE HERE]; a study conducted by Harjeet Kaur as part of the requirements for the MSW degree. This study will [BRIEFLY, LESS THAN A SENTENCE PUT THE PURPOSE OF THE PROJECT HERE]. Participation in this study is completely voluntary. This study will take approximately five minutes. This study is anonymous (we will not ask your name) and all data will be reported aggregate. You can choose not to take this survey or answer any specific questions without consequence.

The opioid drugs include Viocodin, Tramerol, Oxycontin, codeine, methadone, heroin, and various others available by prescription, or which may be illegal under state and/or federal law. A complete list is at the bottom of this survey. This survey is to help learn about how people, if they have used opioids for non-medical use, gain accessed to that drug the first time that they used. The survey is completely anonymous and asks only that respondents be over the age of 18.

1. YOUR AGE: ______ (If you are under the age of 18 right now, stop and do not continue this survey)

2. Have you ever used any opioid for non-medical purpose?

___ YES

___ NO (If no, stop and do not complete the survey)

3. Please indicate how you obtained that opioid for your first Non-Medical use only:

a. ___ My own prescription; I took a pill when I did not need it as prescribed.

b. ____ A family member’s prescription; I took one from a pill container with that family member’s knowledge

c. ____ A family member’s prescription; I took one from a pill container without that family member’s knowledge

d. ____ A friend’s prescription; my friend gave me one

e. ____Someone else’s prescription; I took one from their pills without their knowledge

f. ____ Sale by a friend or stranger of the pill or other opioid to me

g. ____ Some other method of acquisition. Please explain fully _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Was that opioid you first used a legal prescription drug, or an illegal substance?

a. _____ legal prescription drug b. _____ illegal substance

5. Have you ever used an illegal opioid substance?

a.______ Yes b. _____ No

6. Have you used opioids during the last twelve months for non-medical use?

a. _____ Yes b. _____ No

7. If you have used opioids during the last twelve months non-medical use, please check off on the following list the opioid which you have used the most:

Listing of Opioids and common street names

____ Codeine - Captain Cody, Cody, schoolboy

____ Fentayl - Apache, China girl, China white, dance fever

____Heroin - smack

____Hydrocodone (Norco,Vicodin,Lorcet,Lortab) -- hydro, narco, vike

____Hydromorphone (Dilaudid) - D, footballs, smack

____Meperidine (Demerol) -- demmies, pain killers

____Methadone - fizzies, water

____Morphine – dreamer, hows, Miss M.

____Oxycodone -- Hillbilly heroin, oxy

____Oxymorphone (Opama) –biscuits, blue Heaven, O bomb

____ Another opioid (please explain the type) ______________________________________________________

_____________________________________________________________________________________________________________