Opioid addiction occurs in every state, county, socioeconomic group, and ethnic group in the United States and is currently one of the fastest growing public health epidemics in the United States.1 It is estimated that 46 Americans die each day from prescription opioid overdoses, equating to 17,000 deaths annually.1 Many communities and states have utilized task forces to address the opioid and heroin abuse problem that plagues so many areas of the United States; in 2014, 34 states reported having an existing prescription drug abuse task force, up from 29 states in 2012.2
In Minnesota, opioid abuse is not a new problem, but it is becoming increasingly widespread each year. Rural Carlton County is in northern Minnesota and encompasses communities including Cloquet, Barnum, Moose Lake, Esko, Cromwell, Carlton, Wrenshall, and the Fond du Lac Reservation, a community composed of the Fond du Lac Band of Lake Superior Chippewa. Except for the town of Cloquet, all of Carlton County is rural, based on the definition of a (1) Census Place, (2) Census Urban Area, and (3) rural-urban commuting area (RUCA) codes.
The Carlton County community has carried a heavy burden as it witnesses and experiences the morbidity and mortality that accompany prescription and recreational drug abuse. Additionally, it has been reported that Carlton County has one of the highest per-capita rates of property crimes related to drug abuse and the highest distribution of illegal drugs in the state of Minnesota.3,4
Due in part to stricter regulation on synthetic opioid prescriptions and a shift toward tamper-proof formulations, making opioids more difficult to abuse, the United States has seen a drastic increase in heroin abuse in recent years.5 Multiple studies have found that nearly 80% of heroin users started with prescription opioids,6–8 and it has been estimated that over half a million people are abusing heroin in the United States.9 From 2002 to 2013, rates of death from heroin overdose nearly quadrupled in the United States, from 0.7 deaths to 2.7 deaths per 100,000 people, with rates almost doubling from 2011 to 2013.10 Individuals who transition from abusing prescription drugs to using heroin do so for a variety of reasons which include increased availability, differences in price, and difficulties with tamper-proof formulations of prescription drugs.6 In Northern Minnesota, Carlton County has experienced a drastic increase in heroin use in the past 5 years and has seen the number of individuals admitted for treatment of heroin abuse increase from 19 to 127 cases between the years of 2011 and 2013.5 It is known that community forums have an impact on reducing the burden of drug abuse, as this has been the case in neighboring St. Louis County, which hosted several community forums in the spring of 2015.11
In an effort to address this public health epidemic, individuals from Carlton County, the Fond du Lac Reservation community and neighboring St. Louis County formed the Carlton County Drug Abuse Task Force. In this group, community members, medical professionals, law enforcement professionals, and treatment professionals—affected by substance abuse and interested in public health, addiction and recovery—joined forces to find solutions for this community. Through intense discussion at quarterly Task Force meetings, the group decided that a Community Forum on Heroin and Opioid Abuse was a necessary step in addressing the drug abuse epidemic. Following the decision to organize a Community Forum, it was necessary to pursue additional funding to provide a meal for community members, childcare and rental of a space large enough to hold several hundred people; several Task Force members applied for and received funding for the event. In the months prior to the event, considerable thought and effort went into determining what the best location for the event would be, as it was important that the event be held in a “neutral” place that members of the Fond du Lac Band and members of the Cloquet community both felt comfortable. It was necessary to choose a date for the panel far in advance to accommodate the busy schedules of the panelists and event organizers.
The Community Forum was held at an area forestry center, a facility owned by the University of Minnesota but utilized by many community agencies for their meeting facilities. Childcare providers and event organizers arrived to the event location 1 hour prior to set up signage, arrange seating for attendees and panelists in the auditorium, and to enssure that all audio/visual equipment was working properly. Resource tables with information on substance abuse prevention, treatment and recovery were set up and attended by local agency representatives, and a table with a Task Force sign-up sheet for community members was also located in the foyer area. Forum attendees were provided with a free meal and opportunity to socialize prior to the event.
Attendees were welcomed to the event by one of the event organizers, and then they were introduced to the event moderator, a local law enforcement professional. Each panelist was given 5–10 minutes to share their perspective pertaining to the opioid abuse epidemic in Carlton County. One panelist from the community, who lost one of his children to overdose, shared a very powerful story and was one of the main strengths of the Forum, according to attendees.
The Community Forum on Heroin and Opioid Abuse was attended by an extremely diverse group of community members. The most common characteristics of individuals who completed an event survey included age greater than 45 years old (61%), female gender (68%), and declaring their race/ethnicity as white (55%) or American Indian (30.3%). Of those representing a community, 31% resided in Cloquet, 24% on the Fond du Lac Reservation, and the rest in smaller communities in the county. Approximately 4 out of 5 (82.3%) attendees reported that they found this forum to be useful and informative. Forty-one percent of attendees reported that they planned to contact others they met at the forum to followup on ideas that were discussed. Almost 9 out of 10 respondents (85.4%) reported that they were hopeful that there would be a similarly themed forum next year. Nearly half of respondents (46.2%) reported learning new information about how to help their community address drug abuse. At the end of the Community Forum, 65 community members signed up to take a more active role in finding solutions to drug abuse in Carlton County and became new members of the Carlton County Drug Abuse Task Force.
The Community Forum highlighted the need to determine effective ways to reach out to those affected by drug abuse as well as their families. Specific action points that the forum highlighted included reducing inappropriate prescribing and dispensing, identifying individuals who are at increased risk of abuse, educating the public, improving access to substance abuse treatment, and expanding access to naloxone to treat prescription opioid and heroin overdoses, which is consistent with some published literature.6 The survey utilized in this event was useful in helping to identify areas where future community forum development is needed and which elements should be continued.
Overall, the Community Forum was very well received by the Carlton County community. Many attendees reported a strong appreciation for the personal story shared by a community member and indicated that this was one of the most memorable pieces of the forum. The most common negative feedback received from attendees included the need for a larger meeting space, and that despite a microphone, it was difficult for some audience members to hear panelists and other audience members speak.
Not all forum attendees were aware of the relatively new Carlton County Drug Court, a problem-solving court specifically designed to intervene with people who are diagnosed with a substance use disorder and are involved in the criminal justice system. Drug courts are a collaborative effort by judicial, law enforcement, corrections, substance use disorder treatment, mental health, social work, tribal, and other community partners. The Carlton County Drug Court helps clients receive the correct level of care for their substance use disorder, mental health, and any other need that may be related to why they are committing crimes. Combining this with intensive supervision ensures a more cost-effective method to treat the individual and also maintain public safety.
Community members with expertise in treatment and recovery, along with mental health professionals, have voiced concerns about the importance of systems change to improving recovery outcomes. Recovery from addiction to heroin and opioids is filled with challenges, but the longer a person is involved in treatment programs, the more likely he or she is to improve his/her life and maintain abstinence.12 Recovery is much more than the act of discontinuing a substance; it requires a combination of reframing old subconscious habits, crippling belief systems, and social learning, all of which require long-term support in implementing and practicing new coping skills,13 and all of which require community resources. The Community Forum reaffirmed that a large component of the drug abuse epidemic in Carlton County is directly related to a lack of resources in the areas of housing, transportation, education, gainful employment, and treatment options. A majority of opioid-dependent individuals in Carlton County simply do not have the recovery tools that are necessary to support long-term sobriety. The Community Forum provided Carlton County with the momentum it needed to move forward united toward the goal of a substance-free community. The Task Force now includes new members of the community, meets monthly rather than quarterly, and has begun sponsoring monthly educational talks on topics related to addiction, recovery, and the prevention of substance abuse. Additionally, Task Force members from various disciplines take turns writing a monthly addiction-related article for the local newspaper in an effort to keep community members abreast of ways that they can be a part of the solution to substance abuse and to educate them on addiction and recovery. Funding for the next Carlton County Community Forum, as well as several prescriber-education sessions, has already been obtained.
Acknowledgments
Funding: The authors acknowledge the University of Minnesota Clinical and Translational Science Institute for grant funding, which made the Carlton County Community Forum on Heroin and Opioid Abuse possible. The authors declare no conflicts of interest.
The authors gratefully acknowledge the dedication and support of the Carlton County community in uniting to address the drug abuse epidemic. May the work from this community partnership bring some peace to those who have lost a loved one to overdose or addiction and save other families from the pain of loss. The authors also acknowledge the contributions of Dr. Timothy Stratton, Leslie Beiers, Phil Norrgard, Rik, Colsen and Timothy Walters for their expertise and editing guidance.
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