Community Forums to Address the Opioid Crisis: An Effective Grassroots Approach to Rural Community Engagement.

PURPOSE: With opioid overdose deaths on the rise in rural Minnesota and across the nation, the call for community-based grassroots efforts is stronger than ever. Recognizing that substance use prevention and recovery programming rely upon community resources, collaborative teams planned and implemented a series of nine community forums focused on opioid and heroin use across rural northeast Minnesota to educate and unite invested community members on the critical public health issue. This article examines the outcomes of the forums and the ingredients of a successful forum.
METHODS: Surveys were distributed at seven rural community forums to assess measures of growth in knowledge and awareness, as well as demographic characteristics of respondents.
FINDINGS: Forums planned by university faculty and community members were effective in increasing overall awareness and knowledge of the opioid crisis within each community. Forums that were rated more highly by attendees included speakers from varied professional backgrounds and integrated cultural strengths. Communities that planned forums together have reported increased collaboration to prevent and address substance use and increased community member engagement on local grassroots coalitions since the time of the forum.
CONCLUSIONS: Community forums have functioned as an effective grassroots approach to engaging rural community members in opioid use prevention and intervention efforts.

Opioid addiction is driving the substance use epidemic in the United States, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.[1] While death rates for the top leading causes of death such as heart disease and cancer have decreased substantially in the last decade, the death rate associated with opioid pain medication has increased markedly,[2] with drug overdose deaths nearly tripling in the United States between 1999 and 2014.[1] Minnesota has experienced an alarming increase in drug overdose deaths; in 2015, nearly half of all drug-related deaths in Minnesota were related to opiate pain relievers and heroin.[3] In 2016, Minnesota had 395 known opioid overdose cases, 194 involving prescription opioids and 150 involving heroin.[4] Rural communities in Minnesota and across the nation suffer a disproportionate burden from the opioid crisis,[4,5] experiencing higher rates of opioid misuse,[6] drug poisoning,[7] and deaths due to opioid overdose.[8] Substance abuse and misuse are issues at the forefront of many Minnesota communities, particularly those in northeast Minnesota, a rural region most devastated by the crisis.[9] Considering the disproportionate toll rural communities have suffered from the opioid crisis[5,6,10] and the lack of accessible treatment options,[11-13] it is not surprising that rural Minnesota communities suffer a heavier burden from the opioid crisis than their non-rural counterparts.[9]

The Surgeon General’s 2016 Report on Alcohol, Drugs and Health recognizes the value of “multi-sector, community-based coalitions to plan and implement effective prevention interventions with fidelity” and cites the importance of attention to community-level risk and protective factors for substance use.[14] The President’s Commission on Combating Drug Addiction and the Opioid Crisis also recognizes that on a community level, education and media campaigns work best when they “are well-targeted and supported by comprehensive community-based efforts that coordinate clinical, regulatory, economic, and social strategies,” further noting the key role of local prevention interventions.[15] The American Public Health Association echoes the powerful role the community can have in addressing the opioid epidemic, most notably in providing education and naloxone distribution,[16] educating community members on safe use, storage, and disposal of prescription medications,[17] and supporting education for health care providers focused on appropriate prescribing of opioids.[17] Although individual communities have a recognized role in addressing the opioid crisis and existing literature describes the impact of community partnerships on the opioid epidemic,[18-23] there is little published research regarding how to most effectively mobilize community resources toward sustainable community-specific action despite this recognized need. Minnesota has made great efforts to curb the rising tide of opioid panic, passing laws to expand access to naloxone, divesting liability from those who call 911 in the case of an overdose, and proposing a pharmaceutical tax that would reportedly funnel money to treatment.[24] These necessary changes notwithstanding, recovery is at its core a community process. Recovery is by no means a solo act; it requires a blanketing of protective factors while insulating oneself from the destabilizing effects of homelessness, unstable work, personal or cultural beliefs destructive to recovery, and learned social behavioral norms, all of which require community resources.[25]

Recognizing the need for stronger communities, and in response to distressing opioid-related trends, collaborative teams composed of community members, public health professionals, university faculty, law enforcement, and medical professionals, among others, have begun approaching the opioid crisis in rural Minnesota from the bottom-up through community coalitions.[18] Coalitions have proven effective in raising awareness and galvanizing community efforts around a variety of topics surrounding substance misuse, including syringe exchanges[19] and naloxone distribution,[20,21] as well as youth substance use.[22,23] Over the past four years, community teams throughout northeast Minnesota organized nine community forums on heroin and opioid abuse, reaching over 800 people in eight different communities, most of them rural. At these forums, held at neutral and accessible community spaces and lasting approximately 2 h in length, information was presented on the nature of opioid and heroin use at both national and local levels, and speakers from various backgrounds shared their personal stories of recovery, advocacy, or impact. Each forum included a community meal and opportunity to socialize prior to the event, and in most cases, free childcare was offered. Forum attendees were provided were provided an opportunity to gather information from resource booths, ask questions of the speakers, express concerns, and network with one another over a unifying issue. Most significantly, these forums served as a springboard for residents to come together to address opioid abuse: each forum resulted in momentum to build or strengthen a local community coalition that could use the assets of their community to find local solutions to the opioid abuse crisis.

This article will describe the value of a series of community forums in northeast Minnesota that addressed opioid and heroin abuse, exploring their deep and sustained impact on community knowledge and engagement on the crisis, and detailing the steps taken within communities that resulted from the forums. Recognizing that solutions to the opioid crisis require multi-disciplinary and multi-pronged approaches, and that opioid misuse is heavily influenced by social determinants of health,[25] especially in rural communities,[5] this article highlights the critical need for communities to unite to address the opioid crisis and outlines how forums support this objective. It also examines participant feedback through survey data to determine what the core components of a community forum focused on heroin and opiates are, how these components might be adapted in a culturally responsive manner for different rural communities, and how different communities identified distinct priorities in addressing the opioid crisis locally.

Methods

Community forums were held at nine locations throughout rural northeast Minnesota from October 2015 through March 2018. Each forum was planned by a university researcher (one of the authors) and a planning team composed of community leaders and local public health officials. Each forum included a variety of professional speakers from health care, public health, law enforcement, and treatment and recovery, as well as individuals from the community who shared their own personal stories of addiction and recovery. Each forum also included a resource fair with booths providing attendees with information on prevention, treatment and recovery, harm reduction, health care access, and guidance on joining a local grassroots coalition to address the opioid crisis.

To gather community feedback on the value of community forums and community members’ preferred next steps in addressing the opioid crisis in their community, paper surveys were distributed to attendees at seven of the nine community forums, yielding a total of 684 responses. The survey tool (Supplemental Appendix A) was created in the fall of 2015 based on feedback from the one rural drug abuse task force County Drug Abuse Task Force and guidance from the University of Minnesota Clinical and Translational Science Institute (CTSI). The survey was designed with participant privacy in mind, clustering demographic questions on the last page so that participants could tear this page off if they did not wish to answer questions about age, gender identity, race, educational status, or community represented. University researchers and community partners analyzed the data from each forum, creating reports that were later disseminated to the appropriate communities, tribal leaders, and stakeholders so that the data could guide future community initiatives. The study was determined to be exempt from Institutional Review Board (IRB) by the University of Minnesota IRB.

Results

A description of the community populations, dates, and attendance at the nine community forums held in northeast Minnesota can be found in Table 1. One community (Community A) held two forums, whereas the rest of the communities held one forum at the time of this writing.

Table 1.

Community forum location, date, and attendance.

	Community population (per Census 2016 estimate)	Date of forum(s)	Event attendees	Surveys collected
Community A	12 111	October 2015	275	158
Community A	12 111	September 2016	102	51
Community B	3453	October 2016	121	39
Community C	7401	November 2016	132	82
Community D	1830	May 2017	292	190
Community E	3390	October 2017	42	0
Community F	492	January 2018	203	84
Community G	1720	February 2018	44	0
Community H	294	March 2018	108	80

The overall response rate across forums was 51.86%, with 684 of 1319 recorded attendees filling out a survey. The 684 survey respondents represented a diverse subsection of the rural workforce, with the highest representation in health care (93, 13.6%), while 46.93% designated themselves as simply representing the community rather than a particular organization or group. The majority of respondents were age 45 or older (59%), identified as female (72%), and declared their race/ethnicity as White (70%). Of the total forum population, 22% identified as Native American/American Indian. For the two forums held on reservations (Communities D and F), data were analyzed for the subset of Native American and, if applicable, enrollees of a particular tribe. Native American community members in Community D found their forum more useful in every category measured. At both forums, the Native American subgroup skewed older and more heavily female than the general pool of respondents.

As illustrated in Table 2, forum attendees ranked the forums highly in measures of satisfaction and usefulness. When each attendee was asked how likely they were to attend a similar forum in the future, attendees gave an aggregate rating of 7.88 on a 10-point scale, with the score steadily increasing from the first forum in the fall of 2015 (6.61) to the last in early 2018 (8.55). Attendees reported that they found the forums to be informative and useful (average 4.32 on a 5-point Likert-type scale) and would attend a similarly themed forum in the future (4.31).

Table 2.

Mean satisfaction ratings of the forums at which surveys were distributed.

	The forum was informative and useful[a] (standard deviation)	The forum met my expectations[a] (standard deviation)	I learned new information about how to help my community address drug abuse[a] (standard deviation)	How likely is it that you would attend a similar forum in the future?[b] (standard deviation)
Community A (2015)	3.94 (.83)	3.61 (.95)	3.32 (1.06)	6.61 (2.52)
Community A (2016)	4.35 (.66)	4.19 (.82)	4.02 (.87)	7.29 (2.43)
Community B (2016)	4.62 (.74)	4.3 (.8)	4.37 (.53)	7.95 (1.15)
Community C (2016)	4.49 (.55)	4.31 (.62)	4.04 (.75)	7.76 (1.24)
Community D (2017)	4.21 (.62)	4.07 (.71)	3.87 (.81)	8.49 (1.66)
Community F (2017)	4.25 (.7)	4.01 (.78)	3.97 (.72)	8.51 (1.75)
Community H (2018)	4.37 (.58)	4.31 (.64)	4.1 (.67)	9.58 (1.68)

On a 5-point Likert-type scale, with 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

On a 10-point scale, with 0 =“not at all likely” and 10 =“extremely likely.”

Despite the fact that each forum was promoted via a variety of methods, including flyers, newspaper, Facebook, radio, and workplace newsletter, word of mouth via co-worker, friend, or family reportedly drew nearly half (47.95%) of attendees. Flyers and newspaper advertisements were also reportedly useful in drawing 45.61% of individuals who took the survey. Radio and television advertising and notices in community education booklets also drew notable numbers in communities where they were used. Community members who attended a forum and filled out a survey reported that they saw a need for additional substance use prevention programming for youth (38% of total responses), as well as a need for future community forums (21% of total responses), increased enforcement on drug distribution (9% of total responses), and increased grassroots efforts as a part of a coalition (9% of total responses). Distinct priorities for each community emerged in forum survey data and are summarized in Table 3.

Table 3.

Priorities resulting from community forums.

Community forum	Resulting priorities
Community A (2015)	Increased emphasis on community and family education focused on substance use and recovery and the use of creative approaches to reach community membersPromotion of collaborative efforts between diverse communities (eg, native and non-native communities, diverse socioeconomic classes, agencies)Strengthening local coalition for resource-sharing and information-sharing
Community A (2016)	Identified need to increase local referrals and substance use resources due to a lack of treatment and recovery related facilities in the areaCommitment to building a stronger coalition; consideration of an additional coalition in a different area of the countyIdentified need to address the lack of housing to support addiction prevention and intervention effortsIdentified need to address stigma around substance use and mental healthContinued commitment to community education focused on substance use
Community B	Increased attention to public education on substance useContinued commitment to the workplan of the local coalitionIdentified need for mental health awareness and efforts to reduce stigmaIdentified need for area health care systems to provide access to medication-assisted treatment
Community C	Identified need to more purposefully include schools and faith communities in substance use prevention and intervention effortsIdentified need to educate community members and leaders on the role that stigma plays in the opioid crisis and how to self-examine and address stigmaIncreased attention to education focused on prescription drug disposal
Community D	Identified need for further community conversations about mental health and reducing stigma around mental health and substance useIncreased communication and collaboration among organizationsEducation and assistance for family members of those struggling with addiction
Community E	Identified need for further community collaborations and engagement around substance useCreation of a local coalition to focus on the prevention of substance use and addressing substance useIdentified need for inter-agency (eg, law enforcement, public health, health care) collaboration and communication
Community F	Identified community desire to examine and implement approaches used successfully in other tribal communitiesIdentified need to provide youth and adult community members with chemical-free programmingInterest in finding ways to include youth in cultural activities and bring together youth and elders
Community G	Identified community desire to examine and implement approaches used successfully in tribal communitiesIdentified need for further community education on substance use related topicsIncreased engagement in local opioid-focused coalitions to build relationships with outside agencies in treatment, recovery, and public health
Community H	Identified community desire to increase efforts focused on the prevention of youth substance use in the local schoolCreation of a community coalition, in collaboration with a local multi-denominational church group, to focus on chemical-free programming for youth and area adultsFocus on naloxone access for community members and local emergency medical services

Long-term outcomes of the community forums, although difficult to quantify, are undeniable in their impact. In every community that held a forum, the forum event reportedly led to stronger relationships between key community stakeholders, public health, and concerned community members through both informal interactions and through organized coalition activities. Forums also resulted in a clearer portrait of community needs and steps to address the opioid crisis in their backyards. Several coalitions learned that community members reported needing more information about substance use prevention, and as a result, they began working more closely with their Regional Alcohol Tobacco and Other Drug (ATOD) Coordinator and local public health to plan community education sessions and trainings. Other coalitions focused their efforts on supporting individuals and families seeking recovery, organizing community events, such as substance-free social events, to accomplish this goal. At least one coalition learned from forum data that mental health was an even greater concern for their community than substance use—and was actually a root cause of their substance use epidemic. As a result, the coalition planned a second forum with a specific mental health focus, with mental health speakers and resources. Other communities have focused on expanding harm reduction programming and providing community members with naloxone trainings and kits or in providing education on appropriate opioid prescribing to their health care community.

Furthermore, attendees were also given the opportunity to attend a resource fair in which regional substance use, mental health, harm reduction, and medical treatment professionals provided additional information on their programming, providing individual education where desired and opening the door for future referrals to treatment.

Discussion

The most impactful of forum results were less measurable and occurred months and years after each forum was held in a community. The communities that hosted a local grassroots community coalition focused on addressing substance use prior to the forum observed an increase in community member coalition membership and engagement as a result of the forum. Communities that did not previously have a coalition used the forum to identify and unite key stakeholders and interested community members to form a new coalition. Coalition-building was one of the goals of each community forum, and attendees were invited to either join an existing coalition or start a new coalition at each forum. New and existing grassroots community coalitions were given access to forum survey data that outlined their peers’ and neighbors’ desires for future work, which they used to map community needs, direction, and appropriate next steps in their community. For example, at one forum, qualitative responses yielded youth prevention as the most commonly suggested next step for community action; as a result, the coalition that formed from the forum has focused its efforts on prevention education in schools.

Expanding community coalition work led to increases in collaboration among community members, key stakeholders, and public health professionals. While some of the results of these strengthened relationships and collaborations—such as resource-sharing, more effective referrals, and increased collaboration around other critical community needs—are not quantifiable, others can be tracked more easily. Five of the nine communities that held a forum have united together to apply for grant funding to support their continued work in the communities, including prevention programming through the Drug Free Communities grant, increased naloxone access through the Statewide Targeted Response to the Opioid Crisis Grant, and grants to support research collaborations that strive to make rural Minnesota communities more recovery-friendly. Rural counties neighboring those that held forums have observed the positive impact and ripple effects that community forums have had in Communities A-G, and several have begun planning their own forums for the near future.

Taking into account both qualitative analysis of surveys and informal verbal feedback, this study allowed for the “voice” of the community to be heard regarding their priorities on building prevention and treatment resources. Forum attendees reported a strong desire for information regarding the opioid crisis that has impacted their communities, as well as a need for guidance about how to fight back. Although no causal implications can be made, qualitative data shed light on the most and least effective aspects of the forums.

Attendees at every forum reported that they most appreciated the personal stories of hope and recovery shared by other community members, this being the most frequently cited strength of the forums per qualitative responses (roughly 51% of total responses). There was strong desire for panels with a variety of speakers, approaching the substance misuse landscape from many angles. Representation from the treatment and recovery community was particularly sought-after: although data collected cannot indicate a direct correlation, the forum that had the strongest recovery presence, in which a local treatment center helped organize the forum, was rated by attendees as being the most informative and useful and best in providing useful tools to address drug abuse, providing new information about how to help in one’s own community, and increasing awareness of both prescription drug and heroin abuse within the community. Other sectors of representation in forum panels that were reportedly appreciated by attendees included professionals from law enforcement, education, tribal and public health, health care providers, and local government officials.

For ethnically diverse communities, mindfulness toward their history and cultural backgrounds, and in some cases historical trauma, must inform all aspects of the forum. Representation of these groups on panels and in the planning stages is imperative to ensure that forum programming is culturally appropriate and builds upon the strengths of the community.

Attendee reports and informal feedback have allowed forum planning teams to learn more about the necessary components of a successful community forum and what pitfalls to avoid. Attendees have indicated that a community meal, free childcare, a facility accommodating of crowd size and welcoming to all groups, and an adequate public address (PA) system are all characteristics of a well-run forum. Forums that did not advertise free childcare (Forums E and G) or a community meal (Forum G) had considerably less attendance than other forums. An understanding of cultural norms and practices is critically important to ensure that forum attendees feel as though their event is culturally relevant and impactful. Cultural practices must be communicated to forum speakers who are not from the community in advance to avoid dissonance or discomfort. At one forum, cultural practices including the need for elders to eat first and the need to not interrupt an elder who is speaking were not communicated to forum guests or speakers; as a result, these cultural practices were not respected properly and several forum attendees voiced their concern that the event was not culturally relevant and lacked proper planning. Likewise, community forums that include expert panels of community members, rather than outside experts, were viewed as more successful than forums that did not carefully consider the lineup of speakers. It is essential that forums are planned in close collaboration with members of the community who are familiar with cultural norms and know who the local experts are and how to engage them. Of the two forums held in reservation communities, one carried a stronger cultural emphasis, incorporating an opening prayer, drumming group, and a speaker from a regional Native-focused prevention task force. In all measures, this forum was rated more highly by attendees than the other, which more closely aligned with non-reservation forums and lacked the distinctly cultural component.

While five of the nine community forums described in this manuscript were supported by university or state grants that allowed for the inclusion of the community meal, other forums were able to secure funding for a meal through community donations or from local farmers who donated meat to feed forum attendees and community members who volunteered to cook the meat. In other cases, local community restaurants and caterers have deeply discounted food prices to ensure that a community meal is available, and local businesses have also partnered to assist with food costs. Without the assistance of engaged community members on the planning team who are aware of the resources available in each community and how to secure those resources, the provision of a community meal and the resulting increased forum attendance that meals secure are likely impossible.

Partnerships with local public health have been essential in planning successful forums in each referenced community. Public health professionals are aware of community needs and resources, as well as how to ensure that forum momentum and later initiatives are sustainable. In some communities, public health nurses have provided childcare for forum attendees to both meet the requirement for background-checked childcare providers and to engage with local families that might benefit from home visiting services. Local public health and the Regional ATOD Prevention Coordinators have been instrumental in building and sustaining coalitions in each referenced community.

Coalition-based action, as well as steps taken by other organizations, has contributed to important and lasting change in these communities. As illustrated in Table 3, forums assisted community members in identifying priorities in their region; coalitions were then able to strategically build off of these priorities. Communities B and D, which left their forums with mental health as a priority area, have since collaborated on a series of mental health-focused community events. Forums in this region also enhanced collaboration among various agencies, who have joined local coalitions in their work. Coalitions have been built in each community by increasing the visible presence of the coalition at community events, reporting on the work of the coalition to organizations in the community, and in planning community events that call attention to the work of the coalition. Successful coalitions are adaptable to the needs of their members, adjusting meeting times and locations to ensure accessibility of attendance, and frequently evaluate their goals and successes by engaging members. Successful coalitions engage frequently with their Regional Alcohol, Tobacco and Other Drug Prevention Coordinator to provide coalition members and coalition leaders with training on substance use prevention topics and to facilitate coalition-wide strategic planning.

Each referenced community has taken a unique approach to meeting the community needs identified at a community forum. As an example, community H identified an urgent need for naloxone education and distribution to address alarming increases in opioid overdose rates. Due to bolstered coalition and law enforcement collaborations, this community is now partnered in a grant that will increase naloxone access in their rural community and surrounding areas. Community C has made efforts to engage medical professionals with an upcoming summit focused on opioids and increased prescriber education on opioid and naloxone prescribing.

In a community that perceived a lack of collaboration between native and non-Native community members, coalition activity in Community A has increased its emphasis on culturally relevant work, which has led to stronger partnerships, more equitable coalition membership, and enhanced sharing of resources. In addition, Community A has sustained efforts to educate the public on substance misuse, promote positive norms for youth, compile a directory of local treatment and support resources, and focus efforts on reducing stigma. Communities A, G, E, and F also partnered on a Statewide Targeted Response to the Opioid Crisis grant that increased naloxone access, educated community members, prescribers, and pharmacists, expanded opioid treatment facilities, and supported harm reduction programming. Thanks in part to coalition efforts in Community E, this remote community received a substantial federal planning grant to expand local treatment resources. Because Communities D and F had a strong track record of collaboration around the opioid crisis and strong coalitions, they were selected as work sites in a separate federal grant that provides opioid-related technical assistance and education to community members and health care providers. Coalitions remain active and growing in each of the forum communities, a testament to the initiative of community members, the validity of their views on what is needed in the community, and the power of their action.

Limitations

Although the impact of the community forum can be observed and described in each of the communities that hosted a forum, this impact is difficult to assess quantitatively. As with other prevention efforts, it is difficult to assess whether the forums may have prevented new substance use in the community or how many individuals or their families sought treatment resources as a result of the forum.

Future research

Future research may involve standardized community health assessments focused on substance use, complementing those already conducted by statewide offices, to better capture the impact of the forum on opioid-related metrics. Qualitative data collected from focus groups with community stakeholders, including individuals in short- and long-term recovery from a substance use disorder, are also extremely valuable in identifying community priorities for substance use prevention and intervention (Palombi unpublished data). Focus group data have been used as a component of a community health assessment in neighboring counties and have been valuable in informing coalition priorities, illuminating the need for a focus on chemical-free community programming, chemical-free spaces for socializing, youth afterschool activities and programming, and a need for more accessible substance use treatment facilities in rural and remote communities. Community member input in focus groups, at community forums, and at other community events consistently point to the role of stigma in perpetuating the opioid crisis; yet there were no questions in the survey that asked about this specifically; future forum surveys will ask community members to provide specific guidance on addressing stigma in their communities.

Conclusions

Forums have long united disparate, diverse communities around unifying issues.[26] The conversations, collaborations, and community education that occurred as a result of the northeast Minnesota forums unquestionably resulted in improvements in community health with ripples that can be felt years later and with a constantly growing group of individuals invested in change. Although Minnesota has made great legislative efforts to stem the heavy flow of overdose deaths and hospitalizations, recovery and prevention inherently require the leveraging of grassroots resources. Untangling the complicated web of economic and social factors involved requires nothing less than a seismic effort on the part of the whole community. By pooling community expertise and resources, the community forums enlisted the help of every individual present in doing their part to create substance-free communities and address social determinants of health.

Click here for additional data file.

Supplemental material, Appendix_A_Community_Forum_xyz1263041ea5ca3-converted for Community Forums to Address the Opioid Crisis: An Effective Grassroots Approach to Rural Community Engagement by Laura Palombi, Michelle Olivarez, Laura Bennett and Amanda N Hawthorne in Substance Abuse: Research and Treatment