Community Norms Tool Box

Questions Prescription Medication 

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:
 Male
 Female

How would you describe your racial or ethnic background?

 American Indian
 Asian
 Black or African American
 Caucasian
 Hispanic
 Other ____________ (Please specify.)

How old are you? ____________

County of residence: ____________

Zip Code: ____________

How long have you lived in this county?

 Less than one year
 One to two years
 Two to five years
 Five to 10 years
 Ten years or longer

What is the highest level of education you received?

 Grade school
 Some high school
 High school diploma
  Some college
 Bachelor’s degree
 Graduate or professional degree

If you have children 21 years of age or younger, how old are they? (Check all that
apply.)
 I do not have children 21 years of age or younger.
 0-4 years
 5-9 years
 10-14 years
 15-17 years
 18-21 years
 Over 21 years

Last year, what was your total household income from all sources, before taxes?
 $10,000 or less
 $10,001 to $20,000
 $20,001 to $30,000
 $30,001 to $40,000
 $40,001 to $50,000
 $50,001 or above

Regarding prescription medication, which of the following best describes you?

 I take prescription medication occasionally when prescribed by Doctor for
temporary illnesses
 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.
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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.
 Strongly agree
 Agree
 Disagree
  Strongly disagree
 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.
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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.
 Very concerned
 Concerned
 Not very concerned
 Strongly disagree
 Not sure

In your opinion which of the following age groups is the biggest abuser of oxycontin and
other prescription medication in your community?

 Youth 12-17
 Young adults 18 -29
 Adults 30-45
 Adults 46 -64
  Senior Citizens 65 and over

Do you know someone who has taken oxycontin or other prescription medication to get
high?
 Yes
 No
If you answered yes to the above question how old was the person?
 Youth 12-17
 Young adults 18 -29
 Adults 30-45
 Adults 46 -64
 Senior Citizens 65 and over

In your opinion which of the following prescription medications are most commonly
abused in your community?
 Lortab
 Vicodin
 Oxycontin
 Percocet
 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?
 Very difficult
 Somewhat difficult
 Easy
 Very easy
 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?
 Very difficult
 Somewhat difficult
 Easy
 Very easy
 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)
 Friends
 Family
 Internet
  Doctors who over prescribe
 Pharmacists/Pharmacist assistants who give or sell medications to people who
don’t need them for medical purposes
 People who write false prescriptions
 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

 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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.
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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.
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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).
 Strongly agree
 Agree
 Disagree
 Strongly disagree
  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
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 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?

 Yes
 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.
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 Not Sure