Androscoggin County
Substance Abuse Prevention Collaborative
Five- Year Strategic Prevention Plan
2007-2012

Report prepared by:
Healthy Androscoggin
300 Main Street
Lewiston, ME 04240
Phone: (207) 795-5990
Fax: (207) 795-5992
Email: info@healthyandroscoggin.org

Funding and guidance provided by:
Maine Office of Substance Abuse
Strategic Prevention Framework State Incentive Grant

September 2007

Table of Contents

Section I: Introduction …………………………………………………………	      3-9	

Section II: Defining the Problem ……………………………………………..      9-19

Section III: Recommendations for Action……………………………………	  19-35

Section IV: How You Can Help……………………………………………….	  35-37

Section V: Summary & Contact Information ….……………………………          37

Sources …………………………………………………………………………..	   8-39

Appendix A- Acknowledgements & ASAP Collaborative Team Members…    40

Appendix B- Planning Model and Program Specific Logic Models ………	41-46

Appendix C- Five Year Goals and Objectives & Funding Plan…………….   47-56

Appendix D- Memoranda of Understanding Sample………………………..  57-59

Appendix E- Data sheets on consumption/ consequences of 
substance use ……………………………………………………………   60-67

Appendix F-  Androscoggin County Readiness Survey…………………….    68-69

Appendix G- Summary Report of Focus Groups, Key Informant 
Interviews, and Community Surveys ………………………………..    70-115

Appendix H: Healthy Androscoggin Substance Abuse Prevention
Strategic Planning Questionnaire …………………………………….0  116-119

Please note: ASAP Planning Team minutes and meeting handouts are available upon request. 

Androscoggin Substance Abuse Prevention - “A.S.A.P.” - Collaborative
Five-Year Strategic Prevention Plan 2007-2012

Section I. Introduction

In the May 2007 “Androscoggin County Profile: A Portrait of Our Communities,” substance abuse was identified as one of the two top health concerns facing our county. Substance abuse, especially alcohol, emerged as the second most pressing health concern in Androscoggin County by a margin of only two percentage points behind heart disease and stroke. A planning team of sixteen community partners led by Healthy Androscoggin was formed to probe the county’s substance abuse problems more deeply, identify the key problem areas, and develop strategies to address them. 

In a community survey conducted as part of our local needs assessment, respondents rated the substance abuse problem in Androscoggin County as moderately severe or severe.

Part of a statewide effort involving every Maine county, the Androscoggin Substance Abuse Prevention Planning Team was charged by the Maine Office of Substance Abuse with developing a “strategic” plan, or roadmap for substance abuse prevention, as soon as possible to recommend effective action to prevent the serious health, social and economic consequences of substance abuse at the local level.  “A.S.A.P” — the Androscoggin Substance Abuse Prevention Collaborative Planning Team began its work more than eleven months ago. 

With a grant and technical assistance from the Maine Office of Substance Abuse, the ASAP Planning Team studied extensive data, and prioritized substance abuse problem areas. We identified which factors contribute to the county’s most serious substance abuse problems, what resources are or could be available, and how they could be applied for maximum impact for positive change. In this strategic substance abuse prevention plan we recommend prevention strategies which have been proven effective by research and experience to reduce substance abuse. We will show how you can help, and where you can go for more information. 

As we looked at facts detailing the extent of the substance abuse problems in Androscoggin County, it became clear that substance abuse, though of most serious concern in our youth population, reaches across all ages and all sectors of our population. Though a critical place to start, focusing solely on school-based, youth-focused substance abuse prevention programs will not address this widespread public health crisis. We must work for changes across the entire population if we are to stop the devastating consequences of substance abuse in our county.

The vision of our A.S.A.P. Collaborative, therefore, is: To work together to prevent the harmful effects of substance abuse─ among all ages and across the entire community.
This plan reflects the current needs of the people of Androscoggin County and is intended to guide prevention policy, suggest allocation of prevention resources, and coordinate the substance abuse prevention work across the community. This strategic plan will be updated regularly, and ongoing strategies will be based on community needs and ongoing evaluation of progress toward our goals. We hope the information presented here will spur the community to action to address the harmful effects of substance abuse among our people. This is a plan for action, a foundation on which to build and sustain substance abuse prevention in Androscoggin County over the next five years. 

The ASAP Planning Team:
The Androscoggin Substance Abuse Prevention Collaborative includes 16 community partners led by Healthy Androscoggin, a non-profit community coalition dedicated to improving the health and well-being of Androscoggin County citizens. Partners in our Androscoggin Substance Abuse Prevention Collaborative include: Lewiston, Auburn and Lisbon police departments and the Androscoggin County Sheriff’s Department, educators and students from local schools and colleges, health and mental health professionals, local business and community leaders, and Androscoggin County United Way. Each ASAP team member was invited to participate in this planning process because of their professional expertise and knowledge of the community, and this diverse group represents a broad spectrum from across Androscoggin County.  

Our work is only beginning! We welcome all interested community members or organizations to join the ASAP Collaborative. Information on how to do so is included at the end of this report. 

Geographic Area Served:
The ASAP Collaborative serves Auburn, Durham, Greene, Leeds, Lewiston, Lisbon, Mechanic Falls, Minot, Poland, Sabattus, Turner, and Wales — all of the towns in Androscoggin County with the exception of Livermore and Livermore Falls. After much discussion with our regional partners, it was agreed that the Healthy Community Coalition in Farmington would cover these two towns as the individuals living in those communities are more likely to go to Farmington/ Wilton to seek information and services.

Maine Office of Substance Abuse – a public health approach to prevention:
The “Strategic Prevention Framework” is a repeating five-step process designed to assist local communities to develop and implement strategies to decrease substance use and abuse. Developed at the national level by the Substance Abuse and Mental Health Services Agency, the state of Maine has been implementing this Strategic Prevention Framework for the past three years, and has provided grants and technical assistance for Maine counties engaged in this work. 

The five ongoing steps of the “Strategic Prevention Framework” are to:

1. Conduct a community needs assessment. This information was released to the community in a report entitled, “Androscoggin County Profile: A Portrait of Our Communities” in May 2007.
2. Mobilize or build capacity. For several years an effective substance abuse prevention coalition has been working in Androscoggin County. This strategic prevention framework planning process focused on the current substance abuse problems in our county, what work has been effective and should continue or be expanded, and who else should be involved. 
3. Develop a comprehensive strategic plan. This five-year plan includes a year-one action plan of strategies to address the most pressing substance abuse needs in Androscoggin County. As you will note, significant funds have already been obtained for many of these strategies identified as critical next steps. There are key areas that are not yet funded, and this plan includes steps to obtain the necessary resources and sustain the work detailed in this plan over the next five years. 
4. Implement evidence-based prevention programs and infrastructure development activities. “Feel good” activities that have not been proven by research and practice to reduce substance use will no longer be funded by government or charitable foundations. “Outcome-based strategies” which employ prevention resources in the most effective way are the focus of this strategic plan.
5. Monitor progress and evaluate effectiveness. Accountability for results is the key to effective substance abuse prevention. A strategic plan requires methods of proof to document that goals and objectives have been met, or to make mid-course corrections so that they are met. 

All of these steps are meant to be a circular process that continues to build momentum and provide direction for action to reduce the harmful effects of substance abuse on our people and our community. 

Addressing the economic, social, and health consequences of substance abuse is the purpose of this prevention plan. Using a public health approach – population level change and outcomes-based prevention – we can level our efforts at positively impacting the specific factors that extensive research has shown cause the consumption patterns and resulting consequences. These causative factors are called in social science terms “intervening variables.” These are also referred to in the prevention field as “risk and protective factors.” Research shows that when these key areas are positively changed, substance abuse is reduced. They include:

•	Enforcement - How laws relating to illegal substance use are enforced in the community
•	How effective school substance abuse policies are and how well they are enforced
•	Retail Access - How available substances are through licensed retail outlets in the community				
•	Social Access - How available substances are through social networks in the community
•	Price and promotion of substances that impact consumption patterns, such as targeted advertising to increase consumption among specific age and social groups in the community
•	The social norms or acceptability of substance use by individuals, families and the community 
•	
“I think people think prescription drugs are safe because they are from a doctor.” - College student focus group participant

How individuals in the community perceive the risk or harm from substance abuse 
•	How well parents in the community monitor the behavior of their children and provide positive role models for them 
•	How available screening and early intervention services are for youth and young adults in the community

“Alcohol is readily available to underage drinkers in the downtown area.” 
-	Parent focus group participant

			 
“The issue is embedded is U.S. culture. This is the time to get wasted every night.”
—College student focus group participant

Data Sources Consulted:
The ASAP Planning Team reviewed numerous sources of local, state and national data when compiling this report  to identify the priority substance abuse problems to be addressed in Androscoggin County. Some of the data sources we consulted included:
•	Maine Youth Drug & Alcohol Use Survey, (MYDAUS) an in-depth survey of Maine middle and high school youth sponsored by the Maine Office of Substance Abuse and conducted in Maine schools every other year. (A “Summary of MYDAUS/Youth Tobacco Survey 2006 Results for Androscoggin County” was prepared for The Maine Center for Disease Control and Prevention and Maine Office of Substance Abuse, Bureau of Health and Human Services by Market Decisions of Portland, Maine, August 2006.)
•	The Youth Tobacco Survey
•	Treatment Data System information gathered by Maine Office of Substance Abuse for Androscoggin County, 2000-2006 
•	Qualitative and quantitative data gathered for this planning process from focus groups, community health surveys, and key informant interviews, in partnership with Bates College, spring and summer 2007 
•	“Sub-cultural Needs Assessment of Young Adults: An Exploration of 18-25 Year Old, Non-collegiate, Emerging Adults,” Healthy Androscoggin and Bates College, July 2006. 
•	“Androscoggin County Profile: A Portrait of Our Communities,” Healthy Androscoggin, May 2007, community health, education, housing, employment, environment and economic indicators. Included data from MYDAUS; Monitoring the Future; National Household Survey on Drug Abuse; Youth Risk Behavior Surveillance System; and Behavioral Risk Factor Surveillance Survey. 

In addition, Maine Office of Substance Abuse contracted with the firm Hornby-Zeller to provide a Substance Use and Consequences Profile for each Maine County. Sources included: Maine General Population Survey, 2004; Prescription Monitoring Program for Fiscal Year 2004; Office of Substance Abuse Indicator Data (Department of Public Safety Uniform Crime Reporting, 1991-2004); National Center for Health Statistics Multiple Cause of Death Public-Use Files, 1999-2001; Treatment Data System, 2000-2003, U.S. Census Bureau; Fatality Analysis Reporting System 1991-2003; the Lobster Book, Safe and Drug-Free Schools 2001-2002 and 2003-2004; and Maine Drug Enforcement Agency data 1997-2003.    

Efforts to date:
Healthy Androscoggin expanded its focus to include substance abuse prevention in early 2002 and has successfully leveraged support from school administrators, local police departments, County Sheriffs, State police, treatment providers and many other community groups. With the creation of the Project Unite Committee, Healthy Androscoggin has an active group of 45 individuals who meet bi-monthly to discuss and plan a number of prevention initiatives to decrease alcohol, marijuana, and other drug use by youth and young adults.

To date, Healthy Androscoggin has spearheaded a number of initiatives in Androscoggin County designed to impact the use and abuse of substances in our County. With grant funding from the Maine Office of Substance Abuse as well as the federal Substance Abuse and Mental Health Services Administration, Healthy Androscoggin has implemented several evidence-based strategies for reducing youth substance use, focusing on youth ages 12- 17. These strategies include:

•	Increased law enforcement to enforce underage drinking laws and decrease youth 
access to alcohol and drugs.
•	Provided training to area police officers on alcohol and other drug laws.
•	Conducted Responsible Retailing Trainings for local stores.
•	Provided free server- seller training for local bar and restaurant staff and store clerks. 
•	Implement social marketing campaigns to increase the awareness of parents on providing alcohol or place for minors to consume alcohol.
•	Organized representatives from area schools to review and analyze Maine Youth Drug and Alcohol Use Survey (MYDAUS) data and plan effective strategies for their schools.

In addition, we have conducted a county readiness assessment to determine how well positioned our collective would be to create and implement a countywide substance abuse prevention plan. (Survey included in Appendix F). We asked coalition members and community partners, identified as collaborators on the Prevention Planning Team, to complete the County Readiness Assessment. Our method for soliciting survey participants including asking all members of our Board of Directors, the members of the Project Unite Substance Abuse Prevention Committee (part of Healthy Androscoggin) and the partners we identified as being key members of the Strategic Prevention Planning Team. 

A total of 17 surveys were returned. The organizations or community sectors that participated in completing the survey identified themselves in the following ways:
2 Business owners
3 Youth Services Organizations
3 Community-based health, social service, and/or prevention providers
1 Medical Care & hospital representative
6 Law Enforcement/Court officials (Lewiston, Auburn, Lisbon Police departments included)
4 School representatives (Auburn, Lewiston, Poland, and Lisbon schools represented)
5 Local Government officials
7 Parents/Citizens
1 Community Coalition (including an HMP and DFC grantee)

Note: Respondents could choose more than one category to identify themselves. 

Eighty-four percent of the respondents in the Community Readiness survey indicated that both our coalition and the county are ready to undertake a needs assessment and strategic planning process to address substance abuse prevention. And with the recent release of our Androscoggin County Profile, the needs and resources of our communities have been clearly identified. 

More than 70 percent of respondents to this survey believe Healthy Androscoggin has already begun coordinating the efforts of local partners into a strategic countywide effort to build prevention capacity across the county. Healthy Androscoggin has extremely strong core leadership, data collection expertise, and a demonstrated ability to work collaboratively with community groups and agencies. Over the past year, we have brought together a diverse planning group and have effectively facilitated an in-depth planning process. The resulting five year strategic plan has been the product of many hours of research, reviewing and analyzing data and discussing the most pressing needs and top priorities of our communities.

Section II: Defining the Problem

When analyzing all available data the ASAP Team asked four key questions: 
•	Does the consumption of one substance appear to be more of a problem than others?
•	Does one consequence appear to be more of a problem than others?
•	Is there a pattern of consumption among certain age groups that is of particular concern?
•	How does Androscoggin County compare with the State of Maine?
When necessary we sought additional data and guidance from community experts to address “knowledge gaps” which emerged in our analysis of available data. Bates College Professor of Psychology Kathy Low, who is also a clinician at St. Mary’s Hospital, conducted additional research specifically for our substance abuse needs assessment. This research involved analysis of 38 surveys on substance abuse in Androscoggin County submitted by selected constituents ranging from law enforcement to educators to youth. Professor Low also conducted five focus groups, consisting of parents from a downtown neighborhood, college students, local immigrants, law enforcement personnel, and clergy from several denominations. Finally, the ASAP Team identified a variety of key informants who might enrich the data, and a total of 11 one-on-one interviews were conducted. (Detailed summaries of the qualitative data results are included in Appendix G).
Key informants were a local psychiatrist, a child caseworker, two college health center employees, a home health care professional, a pharmacist, a bar owner, the manager of a local sports venue, an older adult service provider, an alcohol marketer, and a liquor store manager. The purpose of the survey, focus groups and key informant interviews was to solicit a variety of perspectives on substance abuse in the county, to identify key substances and populations for intervention and to invite suggestions about strategies for prevention and treatment. Perhaps not surprisingly, the information gathered in these three studies confirmed what the ASAP Team saw when analyzing the consumption and consequences data — across the board, alcohol, marijuana and misuse of prescription drugs were cited as the substance abuse issues of greatest concern in Androscoggin County. 
A summary table of the key themes that emerged from our primary data collection efforts has been created.
Summary Table of Key Themes from Healthy Androscoggin’s Focus Group and Key Informant Interviews

		Focus Group Participants		
	Survey Respondents	Parents of Youth	College Students	Immigrants	Law Enforcement	Clergy	Key Informant Interviewees	
* Most Problematic Substances	-Alcohol
-Marijuana
-Rx drugs
-Illicit drugs	-Alcohol
-Rx drugs
-Illicit drugs
-Marijuana	-Alcohol
-Rx drugs/
Stimulants
-Marijuana	-Tobacco among men	-Alcohol
-Marijuana
-Rx drugs
-Illicit drugs	-Alcohol
-Tobacco	-Alcohol
-Rx drugs
-Illicit drugs
-Marijuana	
Consequences/Related Issues of Substance Abuse		-Unemployment
-Poverty
-Homelessness
-Stress
-Domestic Violence	-Stress
-Competitiveness	-Fitting into U.S. culture 	-Poverty (low-income youth)
-Crime/Violence
-Mental disorders
-Decrease in family functioning	-Stress (low income families)
-Death of spouse (older adults)	-Stress
-Mental disorders/Depression	
Barriers to Prevention	-Media/ Advertising
-Social norms
-Few consequences of substance abuse	-Availability of substances
-Absence of religion
-Adults providing substances to minors
-Discrimination against “downtown kids” in schools	-Substances are readily available
-Social norms
-Mentality of invincibility
	-Immigrant youth are exposed to substance users in schools	-Availability of substances
-Few cons. of illegal drinking among Bates students
-Light penalties for marijuana possession	-Social norms among college drinkers	-Media/Advertising
-Lack of family involvement
-Absence of religion
-Availability of substances	
Prevention Strategies	-More family involvement w/ youth
-More prevention programs in schools
-Increased enforcement	-Beat cops
-Reducing cost of 12 hr club
-Chem-free space for youth
-Summer programs for youth (field trips, camps)	-Awareness campaign
-Education	-Parenting and educational classes for parents about substance abuse prevention in kids	-Mentoring
-Rewards for youth who don’t use	-Family groups
-Parish nurses
-Businesses’ HR depts. Providing educational materials
	-More family involvement/Mentoring
-More religion and morality/Values training
-More prevention programs in schools
-Increased monitoring by and of substance providers
-Summer programs for youth	
Barriers to Treatment		-No detox programs for youth in downtown		-Low awareness of treatment options		-No compliance and follow-up after treatment	-Affordability of treatment
-Transportation to treatment center	
Treatment Strategies		-Provide detox programs for youth in downtown						
*Most Problematic Substances are roughly ranked by the severity of the problem as perceived by participants.

Bolded items indicate overlap between items mentioned in more than data collection method or items mentioned consistently within a data collection method.

In addition, there were several promising suggestions from community members which came out of the surveys and interviews and these will be discussed in more depth by the ASAP Team. Ideas community members shared included:
•	More family involvement with youth
•	More prevention programs in schools
•	Summer programs for youth, field trips and camps
•	Awareness campaigns for parents
•	Parent eduction programs on substance abuse tailored to the needs of immigrant families
•	Education programs for college students and other young adults not in college
•	Mentoring programs for youth
•	Family support groups
•	More religion/morality/values training for youth and young adults
•	Provide substance abuse treatment programs for youth downtown
There were two areas of concern to ASAP Team members, but there is insufficient data at this time to substantiate them as priority problems. Marijuana use by young adults; and substance abuse by those over the age of 65, especially alcohol and prescription drugs, both warrant further investigation. Included in this strategic plan are strategies to obtain further data to establish the extent of these problems. 
Once the data had been examined and the priority problems to be addressed were identified, the ASAP Team determined which “intervening variables” or causative factors contributed to the problem in Androscoggin County. Of the many factors which were identified for each problem, a rating system recommended by Maine Office of Substance Abuse was used to determine which were both of “high importance” in impacting the problem at the local level, and “changeable” given the resources and readiness of the community. If an item was considered of “high importance” but of “low changeability” at this time, we discussed ways to build community capacity to change that causative factor or “intervening variable.”

In the example below (Team Minutes, April 2, 2007), the discussion about high-risk drinking among 18-25 year old young adults resulted in the following “grid,” from which it was easier to identify the causative factors most important to change in order to reduce this consumption pattern and its consequences in our county – those which appear in the “High/High” box. A further discussion resulted in the refining of these priorities as they are now reflected in our strategic prevention plan. If the factor was listed as of high importance, but “low changeability,” meaning that the community does not have the resources or readiness to change them at this time, we determined if there were “capacity building” strategies we could undertake that could make them “changeable” in the future. 

Example of Priority Grid Exercise: High-Risk Drinking/18-25 year olds

Changeability

Importance		High						Low_____________
								
High		Enforcement/Perceived Enforcement			Social Norms
		Retail Access						Social Access
Screening and Early Intervention	
		Parental Monitoring (Young Adults 
living at home)
_______________________________________________________________________
Low		Knowledge of Health Risks				Price Promotion		_________________________________________________________________

From the ASAP Team data analysis and discussions, six problem areas emerged as the top concerns to address in Androscoggin County’s substance abuse prevention plan over the next five years, and the team identified the key “variables” or factors which both should and could be changed in order to address the problems, given current community resources and readiness for change: 

•	Problem: Underage drinking among youth ages 12 to 17
o	Causative Factors: Enforcement; Parental Monitoring	
•	Problem: High-risk drinking (sometimes called ‘binge drinking’)among young adults ages 18 to 25
o	Causative Factors: Enforcement, Retail Access, Screening and Early Intervention 
•	Problem: Misuse of prescription drugs among youth ages 12 to 17
o	Causative Factors: Social access (home and peers), Parental Monitoring, Knowledge of health risks
•	Problem: Misuse of prescription drugs among young adults ages 18 to 25
o	Causative Factors: Retail access, knowledge of health risks, and social access
•	Problem: Inhalant use among youth ages 12 to 15
o	Causative Factors: Knowledge of health risks, school policies, parental monitoring
•	Problem: Marijuana use among youth ages 12 to 17
o	Causative Factors: Enforcement, parental monitoring, school policies

As a result of identifying key priorities and available resources, the Goals of our Five-Year Strategic Prevention Plan are focused on the following substances and age groups:
•	Alcohol - Goals: Reduce underage drinking among 12-17 year old youths and reduce high-risk drinking among young adults ages 18 to 25
•	Marijuana  - Goal: Reduce marijuana use among youth ages 12 to 17
•	Prescription Drugs - Goals: Reduce the misuse of prescription drugs among youths ages 12 to 17 and among young adults ages 18 to 25
•	Inhalants - Goal: Reduce inhalant use among youths ages 12 to 15

Alcohol
By far the substance of highest concern among all age groups is the legal drug, alcohol– legal for adults over age 21 that is. Underage drinking persists as the most serious substance abuse issue for youth and young adults in Maine and in Androscoggin County. In the Androscoggin County MYDAUS data, 26 percent of middle and high school students had used alcohol in the thirty days prior to the survey. Among grade twelve students, the thirty-day use figure was 48.5 percent. Lifetime alcohol use was 42.9 percent among sixth to twelfth grade students; and for twelfth graders the lifetime use rate was 69.3 percent. 

High-Risk Drinking

Nearly sixty-four percent of the respondents in the survey of non-collegiate 18-25 year olds reported drinking in the previous thirty days, and on average they consumed 6.6 drinks in one sitting.
Source: Healthy Androscoggin Survey

An alarming trend among youth and young adults is frequent alcohol consumption, as well as consumption of large quantities of alcohol at one sitting. For example 28.8 percent of twelfth grade students reported they had participated in “binge drinking” (five or more drinks in one sitting) in the two weeks prior to the MYDAUS survey. Among 12-17 year olds, the largest group identifying themselves as drinkers also consumed frequently – 16.1 percent reported they had drunk alcohol more than ten times in the previous thirty days. 

For young adults ages 18 to 25, often referred to as “emerging adults,” in a key study in Androscoggin County of those not attending college full time, 63.8 percent reported drinking within the previous thirty days, and on average these young adults consumed 6.6 drinks in one sitting. This group reported an average of 10.8 “binges” (five or more drinks in a sitting) in the thirty days prior to the survey. 

In the Behavioral Risk Factor Surveillance System data from 2004-05, adults who binge drank in the previous thirty days was 17.2 percent in Androscoggin County compared to 14.4 percent for Maine. Adult binge drinking is also higher in Androscoggin County than in the U.S. as a whole, and while Maine’s percentage of adult binge drinkers has decreased since 2003, Androscoggin County’s percentage remains high.

The consequences of underage drinking and high-risk drinking among youth and young adults are clear and include: increased traffic accidents and fatalities; increased crime; disruptions to education; decreased workplace safety and productivity; and increased medical and mental health costs, and costs for substance abuse treatment, enforcement, and adjudication. The terrible toll on families and “affected others” has far-reaching consequences, but is difficult to quantify. It is also difficult to determine how many unintended pregnancies, sexually transmitted diseases, and sexual and domestic assaults are the result of underage and high-risk drinking (or for that matter other substance abuse). The financial cost of substance abuse in Maine is estimated at $619 million for treatment, incarceration and indirect costs such as services to victims of violent crime.

In fatal accidents involving drivers under the age of 21, the percentage of drivers who were alcohol-involved increased from 6.3 percent in the period between 1994 and 1998, to 22.9 percent in the period between 1999 and 2003. (This increase was also a statewide trend.) The percentage of young adult drivers between the ages of 21 and 29 who were involved in fatal crashes and were alcohol involved actually declined overall in the state (61 percent to 54.3 percent) but increased in Androscoggin County from 20.8 percent to 31.4 percent. 

Among adults of all ages in Androscoggin County in 2004, nearly 75 percent of total substance abuse treatment admissions for those persons over 18 years of age involved alcohol. And death by underlying cause – liver cirrhosis – increased five-fold from 1999 to 2001, from 2.9 per one-hundred-thousand persons to 11.5. It is also estimated nationally that 20 percent of suicides and 30 percent of homicides are alcohol or drug related. 

Marijuana
Overall marijuana use among Androscoggin County youth is lower than the state average, and the trend in the MYDAUS data over the past six years has been downward, perhaps reflecting the success of the prevention education efforts over the past several years. 

In 2000-2006 MYDAUS data, prior 30-day use of marijuana in Androscoggin County was 13.4 percent compared to 14.1 percent for Maine. The overall trend since 2000 is downward; in 2000 the past 30 day marijuana use was 18.1 percent compared with 13.4 percent in 2006.

"Marijuana use has become so common place that many teens don't even consider it a drug.  When you witness the toll marijuana takes on the motivation and productivity of these young folks, their feelings about themselves and their abilities, it is truly heartbreaking.  We absolutely must do more to prevent marijuana use... the future of our teen population depends on it."
- Vicky Wiegman, Substance Abuse Counselor, 
Lewiston Public Schools

Such positive trends notwithstanding, nearly a third of twelfth graders had used marijuana within the previous thirty days, a figure which has held steady over three MYDAUS surveys. Nearly half of our county’s youth have used marijuana by the time they reach grade 12. Of all school suspensions or removals from school for drug and alcohol violations, marijuana was cited in 22.5 percent of cases compared to alcohol at 11.3 percent.

When looking at individual school district data, there are pockets of concern which warrant further examination. (In the table below we have de-identified school districts to avoid unproductive school-by-school comparisons.) In district two marijuana use spikes in grades nine through twelve. The jump in marijuana use from grade eight to grade nine is also dramatic in district two. In districts three and four there is a sharp increase in marijuana use from grade six to grade seven. This data must be monitored over time to see if there are particular areas in which we should target specific interventions to bring these consumption numbers down. 

Table 1. Marijuana, Prior 30-Day Use Androscoggin County
MYDAUS 2006 by “De-identified” School & Grade:
School	Grade 6	Grade 7	Gr.8	Gr.9	Gr.10	Gr.11	Gr. 12	
One	n/a	.6%	2.1	12.5	14.1	19.6	29.5	
Two	1.2%	4.3	6.0	25.5*	20.8	25.6	34.5*	
Three	1.6	6.1*	10.1	14.8	20.1	30.3	32.4	
Four	2.0	4.8*	4.2	11.6	17.8	23.1	24.9	
* Asterisks indicate significantly higher rates than the state rate for the same grade.

Consequences
The concern among educators on the ASAP Team is compelling. Students who are smoking marijuana are not attentive in the classroom, are not engaged in learning, and are draining educational and law enforcement resources, they say. These youth are endangering their health through the effects of smoke on their young lungs and harmful chemical effects on still-developing brains and bodies. Marijuana is not a drug that can be ignored or treated with complacency. 

Messages to youth about the health hazards of marijuana are mixed and reflect mixed community attitudes. In a community questionnaire conducted for the ASAP Team in Androscoggin County, 75 percent of respondents identified youth marijuana use as a serious problem. However, the summary report detailing the focus groups conducted as part of the ASAP Team data collection efforts, reflects community ambivalence about marijuana use:
 
“The parent group and college students tended to believe that marijuana was a less critical problem than alcohol abuse, and reported that marijuana use was widely accepted in their communities. In contrast, law enforcement personnel reported concerns about marijuana use, but were frustrated by obstacles to enforcing the law. For example, they noted that possession of small amounts of marijuana is less serious than underage tobacco smoking in the State of Maine. They also observed that marijuana is readily available, sometimes homegrown, and therefore hard to monitor in terms of access.”   

Young Adults ages 18-25 marijuana use
Local survey evidence suggests that marijuana use is a serious problem for the 18-25 year old population. In the Androscoggin Sub-Cultural Population survey, 27.5 percent reported they had smoked marijuana in the thirty days prior to the survey, and these smokers averaged 3.2 days of smoking per month. In addition, 10.6 percent of the respondents were heavy marijuana users, reporting more than twenty days use in the previous month. But there is no age-specific consumption data for this segment of the population to corroborate this as a priority problem area for Androscoggin County, as available data is aggregated for all adults ages 18 and older. 

More data needs to be collected before we can determine if marijuana use among 18-25 year olds is also a priority problem, but the first problem regarding this age group is filling this information gap.

Misuse of Prescription Drugs
There is much concern in Maine and nationwide about the growing problem of misuse of prescription medications across the age span. Youth and young adult misuse of prescription drugs is of particular concern. 

Youth
Androscoggin County is similar to the state rate for youth reporting they had ever misused prescription drugs in the MYDAUS, just about 12 percent. The overall trend is downward since 2002, (2002: 16.3 percent; 2004: 14.8 percent; 2006: 11.7 percent) 

There are areas of concern when looking at middle school through ninth grade data at individual school districts. At one school system the percentage of ninth grade students reporting they had misused prescription drugs was a staggering 23.2 percent (compared to the state rate of 11.9). Overall the MYDAUS data shows that nearly double the number of ninth graders had misused prescription drugs than the number of eighth graders, 7.9 percent to 13.8 percent. Though the overall rate of misuse of prescription drugs was similar to the state rate, Androscoggin County students in grades seven, eight and nine used at rates higher than the state figures for the same grades.

According to the ASAP Team data analysis the prescription drugs of particular concern for youth are opiates and stimulants. The youth perception of the risk or harm from misuse of prescription drugs is quite low in both the MYDAUS and in other survey data, including key informant interviews. Educators at the high school and college levels report hearing comments from their students such as: ‘a doctor prescribes it so it must be safe,’ and ‘if people take this stuff for years with no problems, me taking it a few times can’t be harmful.’

Educators, and health and mental health professionals comment that there is simply too much medication floating around in people’s home medicine cabinets, indicating that people are unsure how to safely dispose of excess medications after being told they should not flush it down toilets or throw into regular trash collections. Educators report that frequently, when a student has an injury or surgical procedure, peers ask for their ‘leftover’ painkillers for recreational use. 

In the focus groups we conducted, parents, students and law enforcement personnel all reported that prescription drug abuse is on the rise and is a critical concern. Participants described diversion of prescription drugs for recreational reasons; frequent mixing of such drugs; and relatively easy access to even the most addictive substances (Oxycodone, Hydrocodone). Drugs that were identified most frequently were psychostimulants and narcotics. 

Even experts at the Maine Office of Substance Abuse say it is hard to track patients who “doctor shop,” going from one health care practitioner to another who may not be aware of other drugs prescribed by other practitioners. The Prescription Monitoring System was established to document when an individual ‘crosses the threshold’ for number of prescriptions in their name. However, in a recent statewide forum on prescription drug abuse, it was reported that only about 25 percent of the pharmacies in Maine participate in the voluntary Prescription Monitoring System, and many doctors are not even aware that this information could be available to them. Not all pharmacies are consistent in requiring identification when customers pick up prescriptions, adding to the problem of over-access.

The consequences of misusing prescription drugs for youths can be addiction or even sudden overdose, or more long-term health impacts. For youth there are the same potential consequences as use of other substances, along with the increased risk of accidental overdose from taking too much or mixing with other drugs or alcohol. Young people misusing prescription drugs risk the educational and employment foundation for their futures.  

Prescription Drug Misuse by Young Adults Ages 18 to 25
As seen in Treatment Data System reporting, a significant and growing number of patients are seeking treatment for addiction to prescription drugs, either as the primary drug for treatment or in combination with alcohol and/or other drugs. Eleven percent of total treatment admissions included prescription drug addiction in the 2002-06 Treatment Data System figures. This is nearly double the state rate of 6.5 percent. 

College students who participated in our focus groups report regular use of stimulants such as Ritalin and Adderall, especially during heavy stress periods, to ‘help them focus’ and ‘improve their academic performance.’ The results are too often accidental overdose and addiction. In the key informant interviews, two college health center providers reported that prescription drug abuse is a “profound concern, and a relatively new phenomenon. Increasingly, these providers are seeing students who mix prescription drugs with alcohol and/or marijuana with deleterious effects.” 

The Elder Population and Prescription Drug Abuse 
An area that needs further investigation is the issue of misuse of prescription drugs in the 65 and over age group. Evidence gathered at the state level and pilot studies in two other counties in Maine suggests strongly the collection of data on the consumption patterns and consequences of misuse of prescription drugs and alcohol abuse among the older population in Androscoggin County. In one key informant interview we conducted, a home health care worker reported that the key drugs of concern in the elderly patients he sees are benzodiazepines (medications used to treat insomnia and anxiety), narcotics and pain medication, and alcohol, in descending order. 

State and national data indicate that prescription drug abuse is on the rise for all adults, but the ASAP Team is recommending the elder population in this county be studied in more depth. Substance Abuse among the elderly is of particular concern since the population of the county and the state as a whole is aging and there may be insufficient resources to address the substance abuse problems in this age group as the current ‘baby boom’ generation reaches retirement age.

Youth Inhalant Use
Inhalants are not illegal substances and are available to youth literally everywhere in their homes, schools and communities. Inhalants are cheap or free and many adults are not even aware that there are serious health consequences – brain damage and even death – from inhaled exposure to common and apparently ‘harmless’ substances. ‘What can be harmful about a can of whipped cream?’ as one team member put it. Youth do not always perceive inhalants as a drug, nor do they realize the serious consequences of ‘huffing’ such items as aerosol propellants or common office products to ‘get high.’ 

Student inhalant use in Androscoggin County is higher than state averages. Lifetime inhalant use for Androscoggin County students increases steadily among 6th through 9th graders where it peaks and then decreases. Student inhalant use with Androscoggin County is higher than use among Maine students when averaged over grades 6 through 12. The graph illustrates that lifetime inhalant use increases steadily among 6th graders through 9th graders where it peaks for both Maine and Androscoggin County students. Lifetime inhalant use then decreases through the 12th grade. Inhalant use trend data from MYDAUS shows an increase in lifetime inhalant use in our county between 2004 (11.9 percent) and 2006 (13.4 percent), and thus inhalant use represents an area of youth substance use that requires immediate action and close monitoring. Because inhalant use can have serious, even fatal, results very quickly, the ASAP Team considers this problem to be a priority area to be addressed.

Section III: Recommendations for Action

Addressing the priority problems that emerged from a close review of the data for Androscoggin County, we have begun to focus our prevention resources on the causative factors that we can and must change to reduce substance abuse in our county. Applying strategies which research and experience have proven to produce the outcomes we seek will ensure the goals of this prevention plan are met. We will continually assess our progress and revise our strategies wherever indicated in order to achieve our vision – to prevent the harmful effects of substance abuse among all ages and across our entire community. 

Year One Strategies
In the Year One Action Plan we outline the strategies we will implement in the first year of this prevention plan. Much of the work to be done has been approved and will be funded by the Maine Office of Substance Abuse, and the federal Drug-Free Community grants administered by Healthy Androscoggin on behalf of the ASAP Team and other collaborative partners. Tobacco prevention and cessation efforts funded by the Healthy Maine Partnerships, Maine Center for Disease Control and Prevention are not listed specifically in this substance abuse prevention plan but these efforts will continue to be implemented and evaluated by Health Androscoggin. A funding plan is incorporated  to secure resources to implement year-one strategies not yet funded.
Through the Maine Office of Substance Abuse (OSA) grants, strategies to reduce underage drinking and high-risk drinking among 18 to 25 year olds will be implemented beginning in the fall of 2007.  Prescription drug misuse has also been identified as a statewide priority and work is underway through the auspices of Maine OSA to develop state and local strategies to deal with this issue focusing on youth and young adult populations. 

Work under the federal Drug-Free Community Support Program (DFCSP), through the Substance Abuse and Mental Health Services Administration, will be focused on the priorities of that grant program, which are to reduce underage drinking, illicit drug use, and marijuana use by youth and young adults. Several strategies have overlapping benefits to reduce use of multiple substances across age groups.

Plans are underway to secure local resources for capacity building and collaboration strategies for the second half of year one, either through agreements for in-kind services or contributions from local agencies, organizations and businesses. Unfunded strategies are mostly in the areas of marijuana and inhalant use, which were identified by the ASAP Team as Androscoggin County priorities but not identified as statewide priorities by the Maine Office of Substance Abuse. Education efforts in collaboration with local higher education institutions also require resources to be implemented in the first year of the strategic plan.

Each of the objectives of this plan follow the causative factors or “intervening variables” we have identified as the most effective way to reduce the problem for each of the priority target populations and substances. The ASAP Team has prioritized the following key strategies to address in our five-year strategic prevention plan. Prevention initiatives will often impact more than one substance and will benefit more than one target population. 

There is strong agreement among our planning team members that a key strategy to reduce substance abuse is by reaching families in the home. Parental monitoring of children and youth is the number one way to positively impact consumption of drugs and alcohol, but parents do not always know how to effectively monitor their children and teens and need guidance and support to raise drug-free children. The “Find Out More, Do More” parent education program has been proven effective in countless communities across the country and has been used with success here in our own county. We must expand the opportunities for parents to learn about substance abuse and how to prevent and/or detect it in their children by bringing the course to more parents. 

In the area of “Retail Access,” implementing the “Responsible Retailer” training program for area businesses licensed to sell alcohol will reduce retail access to alcohol by minors, reducing underage drinking and high-risk drinking by minors. Increased store surveillance will also impact these priority objectives. Reducing misuse of prescription drugs by both youth and young adults will occur when retail access is addressed at the statewide levels through cooperation with doctors and pharmacists, and retailers led by the Maine Office of Substance Abuse. 

Reducing “Social Access” to alcohol by minors, and illegal access to prescription drugs for all ages will reduce underage drinking, high-risk drinking and misuse of prescription drugs by youths and young adults. Strategies to stop adults from providing alcohol to minors include police patrols to decrease such “shoulder tap” parking lot buying of alcohol for minors by strangers. And the “Parents Who Host Lose the Most” program will reduce underage drinking by teaching adults the serious consequences for furnishing alcohol to minors and/or places for them to consume alcohol. Social marketing campaigns to encourage parents to secure home supplies of alcohol will also reduce social access to alcohol by minors. Participating in statewide efforts to provide proper disposal of prescription drugs will reduce social access to illegal prescription drugs by youths and young adults. 

Increasing the effectiveness of law enforcement in the areas of underage drinking will also positively impact high-risk drinking by minors. Training for those who serve alcohol to reduce over-service to those young adults of drinking age who are visibly intoxicated will reduce high-risk drinking in that population. Continuing successful programs which offer alternatives to youths who commit drug or alcohol violations will allow more young people to get the redirection and services they need and stay in school. 

Underage Access to Alcohol Investigator
During our substance abuse strategic prevention planning process, our team of key stakeholders decided that hiring a law enforcement officer to work with law enforcement agencies and our substance abuse prevention task force (Project Unite), would be one of the most important things we could do to decrease underage drinking, high-risk drinking and youth access to alcohol. We convened a sub-group of our strategic prevention planning team to determine how this could best be set up in our service area.  The sub-group consisted of the Auburn Police Chief and representatives from the Lisbon Police department, Lewiston Police department, the Androscoggin County Sheriff’s Department and Healthy Androscoggin.  

The sub-group created the job description and decided to follow the Maine Drug Enforcement Agency model whereby an existing employee of a law enforcement agency fills the position and the rate of pay is equivalent to that of a State Police detective. The sub-group decided to call the position the Underage Access to Alcohol Investigator and as part of their job responsibilities, this officer will seek to sustain the position by working with municipalities to increase liquor licensing fees or in other ways. 

The Chiefs and the Sheriff decided the ‘hosting’ agency will provide office space, computer, Internet access, telephone and other services needed for the position. They will also provide gasoline and maintenance on the vehicle. A local auto dealer, Rent It! of Maine, Inc., agreed to donate a rental vehicle to the project for the first year at a value of $7,000.  

All of the substance abuse prevention work at the county level is part of a comprehensive statewide effort. One strategy included in this prevention plan did not emerge as a high priority in our ASAP Team deliberations: Increasing knowledge of the health risks of high-risk drinking by young adults. (Item 2 C) However, local strategies to carry out this state priority were required in the work plans for the OSA grant, and are incorporated in this plan. Inhalant use is a local priority, and funds will be secured to educate parents to monitor their children around these seemingly ‘harmless’ substances which are so widely available and potentially dangerous.

Successful prevention efforts in the schools must be continued. Two areas which will be focused on in this plan are to increase the effectiveness of school substance abuse policies and to continue the work of a subcommittee of the ASAP Team to track and analyze MYDAUS data. The “MYDAUS Workgroup” is comprised of local school substance abuse counselors and Healthy Androscoggin substance abuse prevention staff. Detailed information is available in the MYDAUS survey but it takes time and expertise to analyze and interpret the data so it is used for maximum benefit. Continuing the analysis of this and other consumption data will help us as we monitor our progress and measure the success of our prevention efforts countywide. 

A member of the ASAP Team has been involved with the statewide task force led by Maine Office of Substance Abuse to review and update school substance abuse policies to ensure they are up to date with the latest research and best practices. This representative will make a report to the ASAP Team this fall and the Team will lead local efforts to implement the recommendations of the statewide task force. 

The following pages detail our Year One Action Plan. A summary of the five-year goals and objectives, along with the plans to fund the strategies in year one, is included in Appendix C.

Androscoggin Substance Abuse Prevention (“ASAP”) Collaborative
Strategic Substance Abuse Prevention Plan
Year One Action Plan

Goal 1:  Reduce Underage Drinking by youth ages 12-17 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures/
Benchmarks	Funding Source	
1.A. Increase effectiveness of retailers policies and practices that restrict access to alcohol by underage youth.	Conduct Healthy Androscoggin’s “Responsible Retailing” training	Oct. 2007
&
Ongoing	Substance Abuse Prevention Manager (SAPM)	By June 2008, youth advocates and local law enforcement will conduct at least 20 trainings with stores for the Responsible Retailing program.
Follow up interviews with trained managers/owners will take place at 1 month and 6 month intervals.	Maine Office of Substance Abuse (OSA)	
	Conduct certified server/seller training for employees of on and off premise licensees.	Oct 2007 – May 2008	Community Mobilizing and Training Coordinator (CMTC)	By June 2008, a minimum of 75 employees and owners will be trained.	OSA	
	Conduct compliance checks following the Department of Public Safety protocol.	Oct 2007 – June 2008	Under Age Access to Alcohol Investigator (UAAI)	By June 2008, all off premise licensees will have completed at least one compliance check.  HA will work with Muskie to develop a tool to measure impact. Crime data; violations data will also be analyzed to measure impact.	OSA	
	Conduct in-store surveillance, with cooperation of management.	Oct. 2007
&
Ongoing	 UAAI	By June 2008, minimum of 2 interviews with store owners will be conducted to determine the effectiveness of the program. By June 2008, a store owner survey will also be conducted to determine if in-store surveillance has improved their compliance rates.	OSA	
1.B. Decrease alcohol advertising/promotions that appeal to youth.	Conduct Healthy Androscoggin’s “Responsible Retailing” training	Oct. 2007
&
Ongoing	Substance Abuse Prevention Manager (SAPM)	By June 2008, youth advocates and local law enforcement will conduct at least 20 trainings with stores for the Responsible Retailing program.
Follow up interviews (to determine extent of policy change comparing before and after) with trained managers/owners will take place at 1 month and 6 month intervals.  	Maine Office of Substance Abuse (OSA)	
	Work with the Maineiacs staff to develop a plan to reduce the advertising and promotions in the Colisee that appeal to youth.	October 2007	SAPM	A youth 2 Youth group will conduct an advertising each month at the Colisee to determine the level of advertising for alcoholic products.	OSA	
	Conduct certified server/seller training for employees of on and off premise licensees.	Oct 2007 – May 2008	Community Mobilizing and Training Coordinator (CMTC)	By June 2008, a minimum of 75 employees and owners will be trained.  A better understanding of the effects of advertising on youth alcohol consumption will be assessed through pre and post surveys.	OSA	
1.C. Increase effectiveness of policies/practices affecting social access to alcohol by youth for underage drinking.	Implement store surveillance to target 21 plus buying for minors	Sept. 2007 & Ongoing	UAAI
Alcohol Enforcement Teams (AET)	Within one year, 21+ year olds and merchant violation of juvenile alcohol use and access law will decrease by 15%. Crime and violations data will be analyzed to measure impact.	Federal Drug-Free Communities Support Program grant (DFC)	
	Investigate possession charges by juveniles and minors to determine the furnisher of the alcohol.	Sep 2007 – Jun 2008	UAAI	The number of furnishing violations will increase by 10%.  Local crime data and alcohol enforcement team reports will be used.	OSA	
	Social Mktg. Campaign to focus on alcohol in the home	Sept. 2007	CMTC	By December 2007, HA will implement the social marketing campaign.  By June 2008, HA will evaluate the campaign by administering a parent survey to assess 1. Parents’ willingness to host/provide alcohol to minors and; 2. Perceptions regarding the consequences of furnishing. 	OSA	
	Implement “Parents Who Host Lose the Most” program	2008
Prom and Graduation Season	CMTC 	HA will implement a survey by June 2008 to at least 50 parents to determine to what extent parents are less likely to host/ provide alcohol to minors as a result of the campaign.	OSA/DFC	
	Conduct Awareness Campaign focus on consequences of furnishing alcohol to minors	Sept. 2007
& ongoing	CMTC	HA will implement a survey by June 2008 to at least 50 parents to determine to what extent parents are less likely to provide alcohol to minors as a result of the campaign.	OSA/DFC	

Objective	Activity	Timeline	Who is Responsible	Measures/
Benchmarks	Funding Source	
1.D. Increase effectiveness of local underage drinking law enforcement policies, programs and practices	Investigate possession charges by juveniles and minors to determine the furnisher of the alcohol.	Sep 2007-Jun 2008	UAAI 	By June 2008, the number of furnishing violations will increase by 10%.  Local crime data and alcohol enforcement team reports will be reviewed annually.	OSA	
	Review local policies for consistency with Maine Chiefs of Police model policy for underage drinking law enforcement	Sept. 2007	UAAI	By December 2007, HA will review local policies and create a measurement tool (with the assistance from the Muskie school) to determine how well policies are followed by department staff. By June 2008, at least two local police department will have a written improvement plan to present to the Dept. Chief/ Sheriff for approval.	OSA	
	Provide tech. asst. to law enforcement agencies for policy updates	2007-08	UAAI	By June 2008, HA will provide TA to two local police departments  through a series of meetings.  By June 2008, at least two local police departments will have a written improvement plan	OSA	
	Continue alternative to suspension programs for youth who violate  laws and/or school policies regarding alcohol or other drugs	2007-ongoing	CMTC	Healthy Androscoggin will continue to offer the monthly Diversion program reaching at least 100 students annually. Annually, 75% of participants will indicate (via pre and post test) that their knowledge of the detrimental effects of substance use has increased.  Annually, 25% will express (via pre and post test results) an increase in their readiness to change their use.	DFC	
	Local law enforcement to patrol for underage drinking violations.	Sep 2007 – Jun 2008	UAAI
Alcohol Enforcement Teams	Alcohol enforcement teams will conduct a minimum of 24 patrols per year.  Also, By Sep 2008, juvenile summonses for alcohol use and access violations will increase by 10%.  Using local crime and school statistics.	DFC	
	Train police officers in proper handling of liquor-licensing violations and include awareness section on what has been accomplished in the community to date.	Oct 2007 – Mar 2008	UAAI	By September 2008, 100 officers in Androscoggin will be trained on juvenile alcohol use and access laws.
Also, Mean score on post training survey will be higher than on the pre training survey.		
	Capacity Building – Explore opportunities for law enforcement agencies and schools to legally share student violations information 	2007-ongoing	UAAI	By June 2008, Healthy Androscoggin, Law Enforcement partners and school contacts will conduct at least one meeting to discuss school and department policies related to information sharing.	In-Kind agency employee release time for meeting attendance	
1.E. Increase use of recommended parental monitoring practices for underage drinking	Implement “Find Out More/Do More” program in local schools and workplaces
	Oct. 2007 & ongoing	SAPM & Worksite Wellness Coordinator	Annually, HA will implement the Find Out More, Do More Program in 5 schools and 3 worksites.  
By June 2008, HA will administer parent surveys to help evaluate the initiative.
Annual survey results will indicate that at least 50% who received Find Out More, Do More materials have recalled at least one message on parental monitoring.  	OSA	
	Implement a social marketing campaign (aimed at parents and other adults) on the health effects of underage drinking.	Dec 2007 – Sept 2008	CMTC	Maintain summary sheet on the number of materials disseminated and media hits throughout the County.
A minimum of 10 employers will take part in the campaign.	DFC/OSA 	
1.F. Increase effectiveness of school substance abuse policies	Take active role in statewide efforts to inventory and review all school substance abuse policies to ensure best practices	Summer 2007 and school year 
2007-08	SAPM	By December 2007, HA will inventory and review school substance abuse policies. 
By July 2008, HA will identify two best practices for increasing the effectiveness of school substance abuse policies.	In-kind agency employee release time to attend meetings
OSA	

Goal 2:  Reduce High-Risk Drinking by young adults ages 18-25 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
2.A. Increase effectiveness of retailers policies and practices that restrict availability of alcohol that encourages high risk drinking.	Conduct Healthy Androscoggin’s “Responsible Retailer” training	Oct.
2007
&
Ongoing	CMTC	By June 2008, youth advocates and local law enforcement will conduct at least 20 trainings with stores for the Responsible Retailer program.	OSA	
	Conduct in-store surveillance, with cooperation of management.	Oct. 2007
&
Ongoing	 UAAI	By June 2008, minimum of 2 interviews with store owners will be conducted to determine the effectiveness of the program. By June 2008, a store owner survey will also be conducted to determine if in-store surveillance has improved their compliance rates.	OSA	
	Conduct certified server/seller training for employees of on and off premise licensees.	Oct 2007 – May 2008	CMTC	By June 2008, a minimum of 75 employees and owners will be trained.	OSA	
	Promote retail policies and practices such as reducing sales/services to visibly intoxicated adults	2007-08	UAII	By June 2008, Healthy Androscoggin will survey store owners/managers to determine what policies/ policies have been changed as a result of the training.	OSA	
2.B. Increase effectiveness of local underage law enforcement policies, programs and practices impacting minors ages 18-21	Increase investigative capacity of local law enforcement to uncover the sources of alcohol for minors who are arrested for underage drinking violations.	2007-08	UAAI	By December 2007, HA will create a measurement tool with the assistance from the Muskie school, to determine how well policies are followed by department staff. By June 2008, at least two local police departments will have a written improvement plan to present to the Dept. Chief/ Sheriff for approval. 	OSA	
2.C. Reduce appeal of high-risk drinking by increasing knowledge of the health risks among young adults	Work with local colleges and students to develop programs/
activities to raise awareness of the health risks of high-risk drinking	2007-08	HA/College partners	At least two young- adult created programs/activities will be conducted on college campuses by June 2008. By  April 2008, HA will administer student surveys to measure an increase in awareness of health risks associated with high risk drinking.	OSA	
	Develop and disseminate materials to employees (via worksites) on the health effects of underage drinking/high risk drinking.	2007-ongoing	Worksite Wellness Coordinator	By June 2008, a minimum of 10 worksites will partner with HA to promote awareness of the health effects of high risk drinking in the 18-25 year old population. 	OSA	

Goal 3:  Reduce marijuana use among youth ages 12-17 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
3.A Increase effectiveness of school substance abuse policies	Take an active role in statewide efforts to inventory and review all school policies; where needed implement changes to ensure best practices	Summer
2007
through school year 2007-08	SAPM
	By December 2007, HA will inventory and review school substance abuse policies. 
By July 2008, HA will identify two best practices for increasing the effectiveness of school substance abuse policies.	Maine Office of Substance Abuse (OSA); In-Kind agency staff release time to attend meetings	
3.B. Increase use of recommended parental monitoring practices for marijuana use among youth	Implement “Find Out More/Do More” program in local schools and workplaces	Oct. 2007 & ongoing	Worksite Wellness Coord. & SAPM	Annually, HA will implement the Find Out More, Do More Program in 5 schools and 3 worksites.  
By June 2008, HA will administer parent surveys to help evaluate the initiative.
Annual survey results will indicate that at least 50% who received Find Out More, Do More materials have recalled at least one message on parental monitoring.  	OSA	
3.C. Increase effectiveness of law enforcement for youth marijuana use	Continue offering alternative to suspension programs for youth who violate  laws and/or school policies regarding alcohol or other drugs	Ongoing	CMTC	Healthy Androscoggin will continue to offer the monthly Diversion program reaching at least 100 students annually. Annually, 75% of participants will indicate (via pre and post test) that their knowledge of the detrimental effects of substance use has increased.  Annually, 25% will express (via pre and post test results) an increase in their readiness to change their use.	Drug-Free Communities Support Program grant
(DFCSP)	
	Capacity building- Explore opportunities for police and schools to legally share individual students’ alcohol and other drug violations to ensure early intervention for at-risk students	2007-2008	UAAI	By June 2008, Healthy Androscoggin, Law Enforcement partners and school contacts will conduct at least one meeting to discuss school and department policies related to information sharing.	In-kind agency employee release for attending meetings	

Goal 4:  Reduce Misuse of Prescription Drugs among youth ages 12-17 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
4.A. Reduce youth social access to prescription drugs	Promote the UMaine Center on Aging Pilot medication disposal program when it becomes state-wide.	2008	CMTC	Healthy Androscoggin will count and report on the number of sites in Androscoggin County that participate in pilot program by June 2008.	DFCSP/ OSA	
	Help promote medication disposal program through quarterly HA newsletter to local physicians	Ongoing	CMTC	By June 2008 at least 1000 newsletters will be distributed to local physicians. 	HMP	
4. B. Provide information about the Prescription Monitoring System (PMS) to the local medical community	Educate medical providers about the PMS through our physician newsletter	Fall 2007 & Ongoing	Physical Activity, Nutrition & Tobacco Manager (PANT)	By June 2008 at least 1000 newsletters will be distributed to local physicians. By June 2008, there will be a 10% increase in the number of physicians/clinicians registered in PMS.
	HMP	
4.C. Increase effectiveness of school substance abuse policies	Take an active role in statewide efforts to inventory and review all school policies and where necessary change to ensure best practices	2007-2008	SAPM	By December 2007, HA will inventory and review school substance abuse policies. 
By July 2008, HA will identify two best practices for increasing the effectiveness of school substance abuse policies.	OSA	

Goal 5:  Reduce Misuse of Prescription Drugs by young adults ages 18-25 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
5.A. Decrease social access to prescription drugs by young adults	Promote the UMaine Center on Aging Pilot medication disposal program when it becomes state-wide.	2008	CMTC	Healthy Androscoggin will count and report on the number of sites in Androscoggin County that participate in pilot program by June 2008.	DFCSP/OSA	
	Help promote medication disposal program through quarterly HA newsletter to local physicians	Ongoing	CMTC	By June 2008, at least 1000 newsletters will be distributed to local physicians.	HMP	
	Develop and disseminate materials on the legal consequences of misuse of prescription drugs.	2008	Worksite Wellness Coordinator	By June 2008, at least 10 worksites will receive materials on the legal consequences of misusing prescription drugs.	OSA	
5.B. Increase knowledge of health risks for misuse of prescription drugs among young adults
	Work with a local college to conduct a one-hour seminar on the health and legal risks of misusing prescription drugs	November 2007	SAPM	By December 2007, at least 15 CMCC students will attend a seminar on the health risks and legal consequences of prescription drug misuse. 
50% of participants will indicate (via pre and post test) an increase in their knowledge of the health and legal risks of misusing prescription drugs.	In-kind by Central Maine Community College for photocopying of hand outs.
OSA	

Goal 6:  Reduce Inhalant Use among youth ages 12-17 in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
6.A. Increase parental knowledge of the health risks of youth inhalant use	Work with the MYDAUS workgroup to educate parents on the consequences of youth inhalant use.	2007-2008
	SAPM	By June 2008, at least one parent forum on inhalant abuse will be conducted in Androscoggin County. A Parent forum survey will be administered by HA to help assess the effectiveness of the program.	Partnership with local school systems to be explored.	
6.B. Increase effectiveness of school substance abuse policies	Take an active role in statewide efforts to inventory and review all school policies and where required implement changes to ensure best practices.	2007-2008	SAPM	By December 2007, HA will inventory and review school substance abuse policies. 
By July 2008, HA will identify two best practices for increasing the effectiveness of school substance abuse policies.	OSA	
6.C. Increase use of recommended parental monitoring practices to prevent youth inhalant use	Promote parental monitoring using “Find Out More, Do More” through schools and worksites.	2008	SAPM & Worksite Wellness Coord.	Annually, HA will implement the Find Out More, Do More Program in 5 schools and 3 worksites.  
By June 2008, HA will administer parent surveys to help evaluate the initiative.
Annual survey results will indicate that at least 50% who received Find Out More, Do More materials have recalled at least one message on parental monitoring.  	DFCSP	

Goal 7:  Build capacity to address, and community collaboration for, substance abuse prevention in Androscoggin County.

Objective	Activity	Timeline	Who is Responsible	Measures-
Benchmarks	Funding Source	
7.A. The MYDAUS workgroup will assist with implementation of strategic prevention plan.	Assist schools to map out priorities for their substance abuse prevention work plans, ensure cohesion with county strategic prevention plan and assist with implementation.	2007-08	SAPM	Annually, HA will convene quarterly mtgs with the Maine Youth Drug and Alcohol Use Survey (MYDAUS) workgroup.
Annually, the local MYDAUS workgroup will review MYDAUS data, identify priorities and determine action steps.  	In-kind agency employee release time to attend meetings
OSA	
7.B. Increase and diversify the members of Project Unite committee.	Recruit at least two new members from under-represented community sectors.	2008	SAPM	By June 2008, at least two new members will attend and participate in the Project Unite committee.	DFC	

“A quick fix-it program is not going to work. It needs to be broad reaching and deep. We can do better.” 
—Local pharmacy director, Key Informant Interviewee

Building Community Resources and Readiness for Change

To be fully successful in implementing this plan, we must continue to engage more sectors of the community in substance abuse prevention. Through focus groups, key informant interviews and organizational networking, we have brought a diversity of viewpoints and experience to the strategic planning process. We have identified groups and organizations we believe need to be involved on an ongoing basis. We will continue to reach out to include more students, parents, educators, faith-based organizations, community organizations, (especially those which serve youth), business and community leaders, and policy makers at all levels of government. In order to sustain this work, we will need partnerships with local businesses, community organizations and faith-based organizations. Substance abuse negatively impacts every area and population of our community. Only when we all recognize the needs and urgency for action will we achieve the ambitious goals of this prevention plan. 

Specifically we will:
•	Reach out to faith-based organizations 
•	Support increased access to affordable substance abuse treatment, screening and early intervention for young adults, those in college and in the workforce.
•	Increase the community’s capacity to provide substance abuse prevention services to those young adults who are neither in school nor working. 

There are also knowledge gaps, which emerged from our examination of data during the community needs assessment process. We have made it part of our prevention plan to obtain the resources to further study the following:

•	Consumption patterns and consequences of substance use and abuse in the over 65 population in Androscoggin County, especially in regards to alcohol and prescription drugs
•	Consumption and consequences of marijuana use in the 18-25 year old emerging adult population in Androscoggin County
 
Areas that are not included in this plan but which we believe are critical in order to develop resiliency and provide the protective factors for our children and youth:
•	Increase youth opportunities for involvement in the community. A first step is to inventory what is currently available in the county and what barriers to participation exist
•	Increase youth access to recreational and outdoor opportunities
•	Increase adult supervision of children and youth

Cultural Sensitivity
Because Androscoggin County is home to an increasingly diverse population, it is vital to ensure that our substance abuse prevention work is linguistically and culturally appropriate. When conducting our focus groups with immigrant populations, we learned that we must take a different approach to substance abuse prevention when working with New Americans such as our immigrants from Somalia. Somali parents are worried about the influences and effects of peer pressures on their children to engage in substance use. In our focus groups these parents asked for information on how to talk to their children and teens about substance use, and how to effectively monitor their children and youth for signs of substance use.

As part of our commitment to ensuring our outreach efforts and communication plans are culturally and linguistically appropriate, Healthy Androscoggin is in the process of writing a Cultural Competency Plan, which will be reviewed and adopted by our Board of Directors by June 2009.  

We serve many diverse populations - low-income, low literacy, speakers of multiple languages, individuals who are Gay-Lesbian-Bi-sexual-Transgender or Questioning (GLBTQ) and other groups, each with unique needs. Strategies that are effective for the mainstream public may not be with subpopulations. From examining our organizational strengths and weaknesses relative to cultural sensitivity, to ensuring that we have translated and adapted materials appropriately for the populations we serve, to engaging in outreach to all the diverse groups in our community, we are committed to ongoing attention to and reflection of cultural sensitivity. We will serve all of the people in our community, regardless of race, language, ethnicity, income, gender, national or sexual orientation or religion. 

“It is time to focus on people instead of material aspects of the community…
We need to start striving to volunteer.”
 
—Local liquor store manager, 
Key Informant Interviewee

Section IV: How You Can Help

 First and foremost, be informed! 
•	Increase your knowledge about substance abuse issues in your community, and suggest that any organizations you belong to share information about substance use and abuse. 
•	Keep this issue in the forefront of public discussion.
•	Sign up for our list-serve or mailing list to keep abreast of the issue.
•	Participate in surveys about substance abuse if you are asked – it only takes a little of your time and the information is vital to ensure that resources are used in the most effective way. We need your help, support and feedback on a regular basis.

 Be an advocate for substance abuse prevention!
•	As a citizen, voter and/or taxpayer, support programs, policies and services to prevent substance abuse across the entire community. Vote for representatives to office who support such programs, policies and services. 
•	Support substance abuse education programs in schools and in the community.
•	Support a drug and alcohol detoxification center in the local downtowns, accessible to people who lack transportation.
•	Work to increase higher education and training, employment and housing opportunities for young adults.

 Be a mentor for children and youth!
•	Increase adult supervision of children and youth throughout the community.
•	Be involved in or support community organizations that provide services and opportunities for involvement for children and youth, especially free or affordable summer recreational opportunities.
•	Even if you don’t know it, you are a role model – either positive or negative – for children and youth, even if you are not a parent or grandparent. Be careful what you do and how you behave – children are watching!

 If you are a parent or grandparent – 
•	Monitor your children or grandchildren and be informed about the signs of substance use and abuse.
•	Be a good role model and talk to your children about the dangers of substance use.
•	Properly dispose of excess medications in your home.
•	Secure alcohol and inhalants in the home so they are not accessible to children and youth.
•	Never provide alcohol to minors or places for minors to drink or do drugs.
•	Address the mental health and medical needs of your children or grandchildren before they become chronic problems. 

 If you are a business owner or employer – 
•	Provide substance abuse education for your employees, especially those who are parents.
•	Commit to a drug and alcohol free workplace.
•	Support financially and through in-kind services the substance abuse prevention efforts in your local community.

 If you are licensed to sell alcoholic beverages in the community – 
•	Participate in the Responsible Retailer programs. 
•	Cooperate with efforts to increase surveillance to reduce underage access to alcohol.
•	Support increases in liquor licenses and fees to support increased law enforcement of underage drinking.

 If you are a social service provider, educator or healthcare professional-
•	Be informed on substance abuse issues in your community and seek to provide top quality services to your clients and consumers. 
•	Talk with your clients/ patients about their substance use as early identification of problems is critical in getting the appropriate treatment.
•	Provide information and link clients/ patients with community resources including substance abuse prevention information and treatment services when needed.
•	Keep this issue in the forefront of public discussion.

 If you are in a position of leadership or a policy maker - 
•	Be informed on substance abuse issues in your constituency and seek to inform others. 
•	Ensure that all policy decisions you make are viewed through a “public health lens.”

Section V: Summary

In conclusion, Healthy Androscoggin has successfully led a planning team of 16 community partners to examine the extent of substance use in the community across the lifespan (youth, young adults, adults and the elderly), to identify the key problem areas, and develop strategies to address them. The resulting countywide strategic prevention plan was written over the course of the past year and will be implemented with support from various community groups and organizations. Every person has a role to play in preventing the toll of substance abuse. Whether you are a parent, business owner, law enforcement provider, educator, policy maker, or concerned citizen you can contribute to the success of this prevention plan. 

The section above provides quick and simple strategies for community members to review and adopt to help in the coordinated effort to reduce and prevent substance abuse. We welcome your participation in the ongoing efforts and invite you to join Healthy Androscoggin. Contact information is provided below. 

For more information, contact:
Healthy Androscoggin
300 Main Street, Lewiston, ME 04240
Phone: 207-795-5990
Fax: 207-795-5992
Email: info@healthyandroscoggin.org

Visit us on the web at:
 www.healthyandroscoggin.org

Sources

1.	“Androscoggin County Profile: A Portrait of Our Communities,” a community needs and resources assessment compiled by Healthy Androscoggin and community partners, released May 2007. 

2.	Behavioral Risk Factor Surveillance System, (BRFSS) Maine Center for Disease Control and Prevention. http://www.maine.gov/dhhs/bohodr/brfss.htm

3.	Maine Office of Substance Abuse, State Prevention Plan, October 2004.

4.	“Maine’s Strategic Prevention Framework State Incentive Grant, Substance Consumption and Consequences County Profiles,” prepared by Hornby Zeller Associates, Inc., for the Maine Office of Substance Abuse, Revised September 2006. 

5.	Maine Youth Drug and Alcohol Use Survey (MYDAUS), 2000, 2002, 2004 and 2006. Summary of MYDAUS and the Youth Tobacco Survey 2006 Results for Androscoggin County prepared by Market Decisions of Portland, Maine, for Maine Centers for Disease Control and Prevention and the Office of Substance Abuse, Bureau of Health and Human Services, August, 2006. (MYDAUS is administered biennially to all schools with sixth through twelfth grade students who choose to participate. In 2004, more than 75,600 students from 140 Maine school districts participated. For full report, go to www.maine.gov/maineosa/survey/report.php

6.	“Hancock County and Statewide Needs, Resources, and Readiness Assessment on Older Adults Alcohol Abuse,” Maine Office of Substance Abuse and University of Maine Center on Aging, August 2006. 

7.	“Sub-Cultural Needs Assessment of Young Adults:  An Exploration of 18-25 Year Old, Non-Collegiate, Emerging Adults,” Healthy Androscoggin and Bates College, July 2006.

8.	Treatment Data System, Androscoggin County, 2000-2006, Maine Office of Substance Abuse, Primary Drug Leading to Admission by Age Group and Gender.

9.	Primary Research Conducted by Bates College Professor Kathy Low with Healthy Androscoggin consultant Erin Guay and Bates student intern Katherine Forester: 
a.	Quantitative: Surveys, analysis of 38 surveys on substance abuse in Androscoggin County submitted by selected constituents ranging from law enforcement to educators to youth. 
b.	Qualitative: Focus Groups: Conducted with parents of a downtown neighborhood; college students; local immigrants; law enforcement personnel; and clergy from several denominations.
c.	Qualitative: Key Informant Interviews:  One-on-one interviews with key informants:  a local psychiatrist, a child caseworker, two college health center employees, a home health care professional, a pharmacist, a bar owner, the manager of a local sports venue, an adult service provider, an alcohol marketer, and a liquor store manager.

10.	Format and guidance for this strategic substance abuse prevention plan came from “Maine’s Strategic Prevention Framework Guide to Assessment and Planning,” August 2006, prepared for Maine Office of Substance Abuse by Hornby Zeller Associates, Inc.

Appendix A: Acknowledgements & ASAP Collaborative Team Members

Healthy Androscoggin would like to thank the members of the Androscoggin County Substance Abuse Prevention (ASAP) Collaborative for all of their hard work and dedication over the past year. Without your continued support, we would not have been able to conduct such an extensive review of the data and prioritize the key areas of concern. Your commitment to substance abuse prevention for the citizens of this County is to be commended.  Thank you.

A special thank you to Kathy Low, Katherine Forester, and Erin Guay for all your time and dedication to carefully analyzing survey data, conducting focus groups and key informant interviews to help fill in the missing pieces and paint a picture of the community’s perception of substance use and abuse. We appreciate all of your efforts. 

We would like especially thank Rent It! of Maine, Inc., whose contribution of a one-year vehicle rental for the new Underage Access to Alcohol Investigator exemplifies the way all of us have something important to contribute to the work of reducing substance abuse in our communities. 

We would also like to acknowledge all the skills of our consultant, Gay Grant of The Write Way, for her technical assistance, group facilitation and writing expertise. You helped us to achieve our vision and never once doubted we could get there!

The ASAP Planning Team Members include:
Robert Ulrich, Lewiston Police Department
Phil Crowell, Auburn Police Department
Bernie McAllister, Lisbon Police Department
Stephen Gross, student, Poland High School
Brenda Joly, Evaluator, Muskie
Vicky Wiegman, Substance Abuse Counselor, Lewiston Schools
Kathy Low, Professor, Bates College
Kathleen Harrison, Central Maine Community College
Kelly Affleck, St. Mary’s Hospital
Paula Jursa, Tri-County Mental Health Services
Larry Marcoux, Androscoggin County United Way
Angela Westhoff, Healthy Androscoggin
Wendy Tardif, Healthy Androscoggin
Katherine Forester, Bates student Intern
Erin Guay, Healthy Androscoggin Consultant
Gay Grant, Healthy Androscoggin Consultant

A final thanks to the Maine Office of Substance Abuse and our project officer, Anne Rogers, for the funding, guidance and support to make this project possible. 

Appendix B:  Five Year Planning Model and Program Specific Logic Models for:
1.	Diversion Program
2.	Parents Who Host, Lose the Most Social Marketing Campaign
3.	Community Collaboration
4.	Alcohol Enforcement Teams

HEALTHY ANDROSCOGGIN: DIVERSION PROGRAM LOGIG MODEL

Program Components	

Strategy

Initial Outcomes

Intermediate Outcomes

Long Term Outcomes

Increase knowledge of the detrimental effects of substance use among program participants

Healthy Androscoggin

Schools

Local Law Enforcement

Clients

Participants report a decreased change in current substance use pattern

Reduce subsequent youth substance use violation in school settings

	

Diversion Program

Participants will express an increase in readiness to change their current substance use pattern

School referred participants will increase their use of community resources

Reduce subsequent youth substance use violations in the community

Increase knowledge of resource people

HEALTHY ANDROSCOGGIN: PARENTS’ WHO HOST, LOSE THE MOST 
SOCIAL MARKETING CAMPAIGN LOGIC MODEL

Social Marketing (Parents Who Host, Lose the Most..Don’t Be a Party to Teen Drinking)

Initial Outcomes

Program Components

Media

Business and Civic Groups

Youth

Parents

Project Unite

Healthy Androscoggin

Long-Term Outcomes

Intermediate Outcomes

Strategy

Parents report an increase in knowledge of the legal and financial consequences of “hosting” 

Decrease underage alcohol consumption

Parents decrease their sponsorship of/involvement in/knowledge of opportunities for underage drinking

HEALTHY ANDROSCOGGIN: COMMUNITY COLLABORATION LOGIC MODEL

PROGRAM 	              STRATEGY		  INITIAL		INTERMEDIATE		LONG-TERM

Project
Unite

Reduce youth substance use

COMPONENTS				         OUTCOMES		    OUTCOMES	            OUTCOMES

Healthy
Androscoggin

Legislators 

Law Enforcement

Local Government

State Government

Parents

Youth

Probation Officers

Judges/DA’s

Substance Abuse Healthcare Professionals (Schools, Community)

Community 

School Administrators

A more diverse Project Unite will improve county capacity to address youth substance use through increased knowledge and Evidenced Based Practices (EBPs)

Project Unite members believe that they can impact youth substance use

Each Project Unite sector creates a work plan focusing on countywide substance use prevention plan

Each Project Unite member will carry out action steps of the countywide substance abuse work plan

HEALTHY ANDROSCOGGIN: ALCOHOL ENFORCEMENT TEAM LOGIC MODEL

PROGRAM 	              STRATEGY		  INITIAL		INTERMEDIATE			LONG-TERM

Alcohol Enforcement Team

Healthy
Androscoggin

Project Unite

Law Enforcement

Local Government

State Government

Parents

Youth

Merchants

Media

COMPONENTS				         OUTCOMES		    OUTCOMES	           		 OUTCOMES

AET members will be more knowledgeable about juvenile alcohol use/access laws and proper enforcement protocols

Local LEA norms around enforcement improve

Decrease in 21+ yr. olds and merchant violations of juvenile alcohol use and access  laws

Increase in juvenile alcohol use and access law violations

Reduce youth substance use

LEA who received training comply with best practices as identified in chiefs’ model policy

Increase perception of enforcement of juvenile alcohol use and access  laws

Appendix C: Five Year Goals, Objectives and Funding Plan

Androscoggin County Substance Abuse (Prevention) Collaborative
Five-Year Goals and Objectives and Funding Plan
2007-2012

The five-year goals and objectives below are followed by year-one strategies. Funding has been obtained from grants and local resources for the majority of these strategies. Maine Office of Substance Abuse (OSA) will fund strategies to reduce underage drinking and high-risk drinking among 18 to 25 year olds, and the approved work plans will be begin in this fall.  Prescription drug misuse has also been identified as a statewide priority and work is underway through the auspices of Maine OSA to develop state and local strategies to deal with this issue, focusing first on youth and young adult populations. 

Work under the federal Drug-Free Community Support Program (DFCSP), through the Substance Abuse and Mental Health Services Administration, are focused on reducing underage drinking, illicit drug use, and marijuana use by youth and young adults. Several strategies have overlapping benefits to reduce use of multiple substances across age groups, but are repeated under each goal and objective to which they apply.

Several capacity building and collaboration strategies have yet to be funded. Plans are underway to secure local resources to implement these strategies in the second half of year one, either through agreements for in-kind services or contributions from local agencies, organizations and businesses. These items are highlighted in the text below for easy reference. Unfunded strategies are mostly in the areas of marijuana and inhalant use, which were identified by the ASAP Team as Androscoggin County priorities but not identified as statewide priorities by the Maine Office of Substance Abuse. Expanding collaboration with local higher education institutions to expand substance abuse education for college students also require resources to be implemented in the first year of the strategic plan.

Goal 1. Reduce underage drinking by youth ages 12-17 in Androscoggin County.

Objective 1.A: Reduce youth retail access to alcohol.
	Strategies:
•	Provide “Responsible Retailer” training to ensure alcohol is not sold without proper identification. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Provide increased store surveillance to decrease access to alcohol by minors through retail establishments. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 1.B.: Reduce youth social access to alcohol.
Strategies:
•	Law enforcement partners will conduct “Shoulder Tap” store parking lot surveillance to decrease the incidence of adults purchasing alcohol for minors (persons under the age of 21). (Funded by Maine Office of Substance Abuse, 2007 and ongoing.) 
•	Develop a social marketing campaign that focuses on the most likely place for a minor to get alcohol- their own home. (Partially funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Implement the “Parents Who Host Lose the Most” program to educate parents about the consequences of furnishing a place for minors to consume alcohol. (Funded by Maine Office of Substance Abuse; continued from 2006 to 2008.)
•	Implement a media campaign on the consequences of furnishing alcohol to minors. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 1.C.: Increase effectiveness of local underage drinking law enforcement policies, programs and practices.
	Strategies:		
•	Investigate underage drinking violations to determine the source. Underage Access to Alcohol Investigator, (UAAI). (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Review local law enforcement policies pertaining to underage drinking to ensure all policies are consistent with the Maine Chiefs of Police model policy for underage drinking law enforcement. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)  
•	Provide technical assistance to law enforcement agencies who adopt the Maine Chiefs of Police model policy for underage drinking law enforcement. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Continue offering alternative to suspension programs for youth who violate state law and/or school policies regarding alcohol and other drugs. (Funded by federal Drug Free Communities Support Program grant.)
•	Explore opportunities for police and schools to legally share individual students’ alcohol and other drug violations. Prevention Collaborative volunteers, law enforcement agencies are key partners on this initiative. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 1.D:  Increase use of recommended parental monitoring practices for underage drinking. 
	Strategies:
•	Distribute the “Find Out More, Do More” parent education materials through local worksites (i.e. payroll stuffers) and schools. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Create bulletin board displays for worksites on healthy lifestyles and including parental monitoring as one of the monthly topics. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Conduct workshops for middle school parents using the presentation created by OSA on parental monitoring and work with school nurses, substance abuse counselors and school-based health center staff to provide resources to parents. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Develop culturally and linguistically appropriate educational materials for immigrant parents on the topic of how to talk with their children about alcohol. (Funded by Maine Office of Substance Abuse; research and focus group testing to begin in 2008.)

Objective 1.E.: Increase effectiveness of school substance abuse policies. (See 3.A; 4.E; 6.B)
	Strategies:
•	Take an active role in statewide efforts to inventory and review all school policies; where needed implement changes to ensure best practices. (Sponsored by Maine Office of Substance Abuse; 2007-08, Prevention Collaborative volunteers.)
•	Continue the efforts of the Maine Youth Drug and Alcohol Use Survey (MYDAUS) workgroup, including local school substance abuse counselors and Healthy Androscoggin staff, to examine the MYDAUS data in order to track trends and better focus resources. (Prevention Collaborative volunteers, Healthy Androscoggin and school staff are key partners. Partially funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Monitor school district level data and develop trend comparisons in MYDAUS data from 2000- 2008. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Goal  2. Reduce high-risk drinking among young adults ages 18-25 in Androscoggin County.

Objective 2.A.: Decrease promotions and pricing that encourage high risk drinking. (See 1.A)
Strategies:
•	Provide “Responsible Retailer” training and server-seller training for establishments which are licensed to sell alcohol and provide support for store surveillance and interviews with owners. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Promote responsible retail policies and practices that discourage high-risk drinking, such as reducing sales/service to visibly intoxicated adults and work with bar owners to decrease the number of special promotions and pricing that encourages excessive drinking. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 2.B.: Increase effectiveness of local underage law enforcement policies, programs and practices impacting young adults ages 18-20. (See 1.C)
Strategies:
•	Investigate underage drinking violations to determine the source. Underage Access to Alcohol Investigator, (UAAI). (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Provide increased store surveillance to decrease access by minors to alcohol through retail establishments. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 2.C: Reduce appeal of high-risk drinking by increasing knowledge of the health risks of such drinking among young adults. 
	Strategies:
•	Work with local colleges and college students to develop programs and activities to raise awareness of the health risks associated with high-risk drinking. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Explore the possibility of collaborating with an employer that has a large population of young adults to develop strategies to raise awareness of the health risks of high-risk drinking among non-college-attending young adults. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Corporate sponsor, civic group, local grants/ donations.)
•	Provide screenings and early intervention programs for young adults through worksites and local colleges. 

Goal  3. Reduce marijuana use among youth ages 12-17 in Androscoggin County.

Objective 3.A.:  Increase effectiveness of school substance abuse policies. (See 1.E; 4.E; 6.B)
	Strategies:	
•	Take an active role in statewide efforts to inventory and review all school policies; where needed implement changes to ensure best practices. (Sponsored by Maine Office of Substance Abuse; 2007-08, Prevention Collaborative volunteers.)
•	Continue the work of the subcommittee of the Prevention Collaborative (led by local school substance abuse counselors and Healthy Androscoggin staff) to examine the Maine Youth Drug and Alcohol Use Survey data in order to track trends and recommend the direction of prevention resources. (Prevention Collaborative volunteers, Healthy Androscoggin and school staff are key partners. Partially funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 3.B.:  Increase use of recommended parental monitoring practices for marijuana use among youth. (See 1.C)
	Strategies:
•	Build capacity to develop strategies and programs to educate parents about the health risks of youth marijuana use. (Currently not funded, capacity building to begin in 2008 and implementation in 2009. Potential funding sources might include: Partnering with Safe and Drug Free Schools Initiatives, Corporate foundations, and local grants/ donations.)
•	Tie into national parent education campaigns to increase awareness of the risks of marijuana use and target messages on parental monitoring. (Currently not funded, capacity building to begin in 2008 and implementation in 2009. Potential funding sources might include: Partnering with Safe and Drug Free Schools Initiatives, Corporate foundations, and local grants/ donations.)
•	Distribute the “Find Out More, Do More” parent education materials through local worksites (i.e. payroll stuffers) and schools. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Create bulletin board displays for worksites on healthy lifestyles and including parental monitoring as one of the monthly topics. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Conduct workshops for middle school parents using the presentation created by OSA on parental monitoring and work with school nurses, substance abuse counselors and school-based health center staff to provide resources to parents. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Track changes by pre- and post-testing participant knowledge at workshops and through parental pre and post surveys at worksites. (Funded by Maine Office of Substance Abuse; to begin 2007-08.) 

Objective 3.C.: Increase effectiveness of law enforcement for youth marijuana use.(See 1.C)
	Strategies:
•	Continue offering alternative to suspension programs for youth who violate state law and/or school policies regarding alcohol and other drugs.  (Funded by federal Drug Free Communities Support Program grant; ongoing.)
•	Increase police patrols with follow-up and investigation by the Underage Access to Alcohol Investigator. (Funded by Maine Office of Substance Abuse; to begin 2007-08.)
•	Explore opportunities for police and schools to legally share individual students’ alcohol and other drug violations to ensure early intervention for at-risk students. Prevention Collaborative volunteers, law enforcement agencies are key partners on this initiative. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Local/state law enforcement agencies, civic groups, local grants/ donations.) 

Goal 4. Reduce mis-use of prescription drugs among youth ages 12-17 in Androscoggin County. (See Goal 5)

Objective 4.A.: Reduce youth social access to prescription drugs. (See 5.B)
	Strategies:
•	Promote the UMaine Center on Aging Pilot medication disposal program when it becomes state-wide in order to decrease illegal access to prescription drugs through home medicine cabinets. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Partnering with UMaine Center for Aging in their pilot project.)
•	Help promote the Prescription Monitoring System through the quarterly newsletter for physicians distributed by Health Androscoggin. (Funded by Healthy Maine Partnerships; to begin 2007-2008.)
•	Research and develop other strategies to decrease youth social access that might include holding parent educational forums on youth selling their prescriptions to peers and the dangers of using other people’s drugs. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Partnering with local school districts and making this a priority in Safe and Drug Free Schools funds or applying for a Safe Schools, Healthy Learners Grant).

Objective 4.B. Increase youth knowledge of health risks of misusing prescription drugs. 
	Strategies:
•	Collaborate with Maine Youth Drug and Alcohol Use Survey work group to develop strategies for use in schools to educate students on the health risks of misusing prescription drugs. (Funded by federal Drug-Free Community Support Program grant; to begin 2007-08.)

Objective 4.C.: Increase parental monitoring by educating parents of the health and legal risks of misuse of prescription drugs.
	Strategies:
•	Implement parent education programs at area worksites about the dangers of prescription drug abuse and tie these to medication disposal programs. (See 4.A.) (Currently not funded, capacity building to begin in 2009. Potential funding sources might include: Corporate Foundations, Maine Community Foundation, local businesses and charitable organizations.
•	Research and develop other strategies to increase parental monitoring and educate parents on the health risks of misuse of prescription drugs. These strategies might include holding parent educational forums on youth selling their prescriptions to peers and the dangers of using other people’s drugs. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Partnering with local school districts and making this a priority in Safe and Drug Free Schools funds or applying for a Safe Schools, Healthy Learners Grant).

Objective 4.D.: Provide information about the prescription monitoring system to the local medical community.
	Strategies:
•	Conduct a focus group with local health practitioners and pharmacists. (Currently not funded, exploring partnership with local colleges and researchers to conduct focus group at no charge; to be done in 2008.)
•	Educate the local medical community about the use and information available through the statewide Prescription Monitoring System through the coalition’s HMP physician newsletter. (Funded by Healthy Maine Partnerships; to begin 2007-08.)

Objective 4.E.: Increase effectiveness of school substance abuse policies. (See 1.E; 3.A; 6.B)
	Strategies:	
•	Take an active role in statewide efforts to inventory and review all school policies; where needed implement changes to ensure best practices. (Sponsored by Maine Office of Substance Abuse; 2007-08, Prevention Collaborative volunteers and educators.)
•	Continue the work of the subcommittee of the Prevention Collaborative led by local school substance abuse counselors and Healthy Androscoggin staff to examine the Maine Youth Drug and Alcohol Use Survey data in order to track trends and recommend prevention resource direction. (Prevention Collaborative volunteers, Healthy Androscoggin and school staff are key partners. Partially funded by Maine Office of Substance Abuse; to begin 2007-08.)

Goal 5. Reduce mis-use of prescription drugs among young adults ages 18-25 in Androscoggin County.  (See Goal 4)
	
Objective 5.A.: Build capacity to work with local pharmacies to reduce access to illegally obtained prescription drugs among young adults. 
	Strategies:  
•	Prevention Collaborative members who attended the July 2007 statewide Prescription Drug Symposium will report to the Prevention Collaborative at the fall meeting. (Sponsored by the Maine Office of Substance Abuse.)
•	Develop a local action plan to address illegal access to prescription drugs through retail outlets. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.)
•	Increase the number of pharmacies that require proper identification for prescription drug pick up. (Currently not funded, capacity building to begin in 2008-2009. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.)

Objective 5.B.: Decrease social access to prescription drugs among young adults. (See 4.A)
Strategies:
•	Assist area colleges to develop student-led educational programs for peers on the legal and financial risks of illegally selling or giving prescription drugs (such as loss of financial aid and legal costs). (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.
•	Collaborate with area social service and health agencies and local employers to educate non-college-attending young adults on the legal and financial risks of illegally using, giving or selling prescription drugs. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.
•	Promote the UMaine Center on Aging Pilot medication disposal program when it becomes state-wide in order to decrease illegal access to prescription drugs through home medicine cabinets. (Currently not funded, capacity building to begin in 2008. Potential funding sources might include: Partnering with UMaine Center for Aging in their pilot project.)
•	Help promote the Prescription Monitoring System through the coalition’s HMP quarterly newsletter for physicians. (Funded by Healthy Maine Partnerships; to begin 2007-2008.)

Objective 5.C.: Increase knowledge of health risks for misuse of prescription drugs among young adults. 
	Strategies:
•	Assist area colleges to develop student-led educational programs on the health risks of misusing prescription drugs. (Currently not funded, capacity building to begin in 2008-2009. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.
•	Collaborate with area social service and health agencies and local employers to educate non-college-attending young adults on the health risks of illegally using, giving or selling prescription drugs. (Currently not funded, capacity building to begin in 2008-2009. Potential funding sources might include: Corporate foundations, partnerships with pharmaceutical companies, local businesses and charitable organizations.

Goal 6. Reduce inhalant use among youth ages 12-17 in Androscoggin County.

Objective 6.A.: Increase parental knowledge of the health risks of youth inhalant use. 
	Strategies:
•	Create and distribute media messages and educational materials on the severe and potentially fatal consequences of inhalant use to raise parental awareness; use in combination with the parent education program “Find Out More, Do More;” offer in locations convenient to parents. (Currently not funded, capacity building to begin in 2008-2009. Potential funding sources might include: Corporate foundations, civic groups, local businesses and charitable organizations.)
•	During parent substance abuse prevention forums provide special breakout sessions on inhalants. (Currently not funded, explore partnerships with local school administration and the MYDAUS workgroup members to plan and implement in 2008-2009).

Objective 6.B.:  Increase effectiveness of school substance abuse policies (See 1.E; 3.A; 4.E)). 
	Strategies:
•	Take an active role in statewide efforts to inventory and review all school policies; where needed implement changes to ensure best practices. (Sponsored by Maine Office of Substance Abuse; 2007-08, Prevention Collaborative volunteers and educators.)
•	Continue the work of the subcommittee of the Prevention Collaborative to examine the Maine Youth Drug and Alcohol Use Survey data in order to track trends and recommend prevention resource direction. (Prevention Collaborative volunteers, Healthy Androscoggin and school staff are key partners. Partially funded by Maine Office of Substance Abuse; to begin 2007-08.)

Objective 6.C:  Increase use of recommended parental monitoring practices to prevent youth inhalant use. 
•	Offer the parent education program “Find Out More, Do More,” to help parents monitor their children for inhalant use. (Funded by federal Drug-Free Community Support Program grant; to begin 2008.)

Goal 7. Healthy Androscoggin will continue to build capacity to address, and community collaboration for, substance abuse prevention in Androscoggin County.

Objective 7.A.: Increase and diversify the members of Project Unite (Healthy Androscoggin’s Substance Abuse Prevention Committee). 
Strategies:
•	Recruit at least two new committee members annually. (Funded by the federal Drug Free Community Support Program grant; to begin 2008).
•	Recruit members from under-represented community sectors such as faith-based organizations and culturally diverse groups. (Funded by the federal Drug Free Community Support Program grant; to begin 2008).
•	Develop a Cultural Competency Plan to ensure culturally competent outreach and communication plans have been implemented. The plan will adopted by the Healthy Androscoggin Board of Directors. (Funded by the Maine Centers for Disease Control and Prevention; to begin 2008). 
•	At least two youth advocacy members will attend and regularly participate in more than half of Project Unite meetings. (Funded by the Maine Office of Substance Abuse; to begin 2008).

Objective 7.B.: Project Unite Members and MYDAUS Workgroup Members will assist with implementation of the Countywide Strategic Prevention Plan. 
	Strategies:
•	Each Project Unite sector will create a work plan focusing on the Countywide Substance Use Prevention Plan. (Funded by the federal Drug Free Community Support Program grant; to begin 2008).
•	Project Unite members will carry out action steps of the Prevention Plan. (Funded by the federal Drug Free Community Support Program grant; to begin 2008).
•	Members of the MYDAUS workgroup will assist with implementing the countywide strategic prevention plan as it pertains to their local school districts. (Funded by the Maine Office of Substance Abuse; to begin 2008).

Objective 7.C.: Develop action plan for obtaining additional data on marijuana use by young adults ages 18-25 as well as alcohol and prescription drug misuse in the 65+ population.
	Strategies:
•	Develop a plan to research marijuana use/ abuse in young adult population as well as alcohol and prescription drug misuse in the over 65 population as the ASAP Collaborative felt additional data is needed on these two topic areas. (Currently not funded; potential funding sources include the United Way, civic groups and social service organizations).
•	Research funding opportunities and/or partnerships with research institutions to obtain this needed data. (Currently not funded; potential partnership to be explored with local colleges, State University system, and social service organizations). 

Appendix D: Memoranda of Understanding

Signed MOUs with Auburn, Lewiston and Lisbon Police Departments and the Androscoggin County Sheriff’s Office are on file at Healthy Androscoggin. Below is a sample MOU between Healthy Androscoggin and the Lewiston Police Department.

Other MOUs are available upon request.

Memorandum of Understanding
Between
Healthy Androscoggin and Lewiston Police Department

Healthy Androscoggin is a community coalition located at 364 Main Street, in Lewiston, Maine.  The mailing address is 300 main Street, Lewiston, Maine, 04240, the telephone number is (207) 795-5990 and the website is www.healthyandroscoggin.com.  Central Maine Community Health (CMCH) acts as the fiscal agent for Healthy Androscoggin.  CMCH is a non-profit, 501 (c) (3).  Healthy Androscoggin’s (HA) mission is to empower the citizens of Androscoggin County to make healthy choices in relation to nutrition, physical activity and substance use (tobacco, alcohol, etc.)

The Lewiston Police Department (LPD), located at 171 Park Street in Lewiston, Maine, is committed to preventing youth substance abuse.   

Purpose
The purpose of this agreement is to establish working procedures between the Lewiston Police Department and Healthy Androscoggin in the delivery of increased enforcement of underage drinking and access to alcohol laws and the implementation of the Countywide strategic prevention plan, as it relates to law enforcement, between September 1, 2007 and August 31, 2008.  The funding for this project is provided through RFP#G107192 issued by the Maine Department of Health and Human Services Centers for Disease Control and Office of Substance Abuse and distributed by Healthy Androscoggin, and the Drug Free Communities Support Program as administered by the Substance Abuse and Mental Health Services Administration.

The Lewiston Police Department agrees to:     
1.	Provide a contact person to coordinate with the Substance Abuse Prevention Manager and Underage Access to Alcohol Investigator as part of the Alcohol Enforcement Team Leaders Task Force.
2.	Attend meetings of the coalition/Project Unite and actively participate in the planning and implementation process for the substance abuse prevention plan.
3.	Attend training sessions regarding prevention planning, assessment and implementation when necessary.
4.	Participate in generating community support.
5.	Coordinate compliance checks and enforcement of underage drinking and access to alcohol laws.  This will include:
•	Working in partnership with the Auburn and Lisbon Police Departments, and the Androscoggin County Sheriff’s Office through mutual aid agreements;
•	Participating on the Alcohol Enforcement Team Leaders Task Force;
•	Filing a report after each detail with the Underage Access to Alcohol Investigator.
6.	Provide minimum of 1 officer to be trained to conduct the Responsible Retailing Program to liquor licensees in Lewiston;
7.	Provide a monthly report to the Underage Access to Alcohol Investigator by the 15th of the month following.

The Lewiston Police Department also agrees that if an LPD officer is hired as the Underage Access to Alcohol Investigator, the LPD will provide office space, office furniture, computer, Internet access, phone, fax and other general office supplies as well as gasoline and vehicle insurance and maintenance on the vehicle donated by Jim’s Auto Sales.

Healthy Androscoggin agrees to:
1.	Provide technical assistance for the enforcement objectives that are part of the work plan that is included in the strategic prevention plan. 
2.	Provide reimbursement for compliance checks, Responsible Retailing Training, officer training, party patrols and participation on the Alcohol Enforcement Team Leaders Task Force.

Healthy Androscoggin also agrees that if an LPD officer is hired as the Underage Access to Alcohol Investigator, HA will provide $700 for general office supplies.

______________________________		____________________________
Healthy Androscoggin Representative		LPD Representative

_____________					___________
Date							Date

Appendix E: Data Sheets on Substance Use Consumption and Consequences (See 
following pages).
Indicator	Overall Rate of use, 2006	Group with highest rate, 2006	Compared to state?	Other notes	
Lifetime use: alcohol	42.9%	10+ occasions	Lower		
Lifetime use: marijuana	23.7%	10+ occasions	Lower		
Lifetime misuse: prescription drugs	11.7%	1-2 occasions	About the same		
Previous 30-day use: alcohol	26%	1-2 occasions	Lower		
Previous 30-day use: marijuana	13.4%	10+ occasions	Lower		
Previous 30-day misuse: prescription drugs	6.2%	1-2 occasions	About the same		
Previous 2-week participation in binge drinking by grade	4.3%	12th grade	About the same	Follows same trends as state—increases with age	
Previous 2-week participation in binge drinking by gender	13% female
12.7% male	Female	Lower		
Age first tried alcohol	49.5% 14 or older; 20.5% less than 14; 30.1% never used	14 or older	N/A	Changes over time?
Relatively constant	
Age first tried marijuana	54.9% never used; 30.7% 14 or older; 14.4% less than 14	Never used	N/A	Changes over time?
“Never used” increased steadily from 48.4% to 54.9%	
Appendix E.1 : Indicator Data for Androscoggin County Substance Use Among Middle & High School Students 
          (from County Profile Supplement)
Substances of greatest concern in our county:
	Alcohol and marijuana in the data presented here.  Does this correlate with other sources (i.e. MYDAUS data) for other substances?  By school?

Subpopulations/age groups of particular concern in our county:
	Where is the data on subpopulations?  Age groups of concern: 14+ teens; 12th graders use of alcohol is 69.3%.  Students drinking heavily (10+ times) is a larger number than students consuming 1-2 times; lifetime use of alcohol and marijuana.

Substances consumed in our county at a higher rate than the state:
	None shown in these tables.  Urban v. rural?

Areas where we need more information (such as who, what, where, why and when):
	Subpopulations: LGBT
 	Substances other than the three listed in these tables, especially inhalants 
	ADHD in kids?

Appendix E2: Indicator Data for Substance Use Among Adults in Androscoggin County (from County Profile Supplement)

Indicator	Overall Rate of use, 2006	Group with highest rate, 2006	Compared to state?	Other notes	
Lifetime use: alcohol	93.5%	91.8%	Higher	Not a substantial difference	
Lifetime use: marijuana	37.9%	40.5%	Lower		
Lifetime misuse: prescription drugs		4.9%			
Previous 30-day use: alcohol	55.2%	56.6%	Lower		
Previous 30-day use: marijuana	4.2%	4.0%	Higher		
Previous 12-month participation in binge drinking	54.9%	50.8%	Higher		
Previous 30-day participation in binge drinking	32.6%	27.8%	Higher		
Previous 30-day participation in binge drinking by gender	66.1% male
42.5% female	57% male
44.4% female	Higher male
Lower female		
Individuals crossing the threshold for prescription drugs	43.1% male 
56.9% female
	37.3% male 
62.7% female
		Same trend as state—female percentage overall higher than male percentage	
Median age of individuals crossing the threshold	40	42	Lower	About the same age	

Substances of greatest concern in our county:
	Alcohol; to a lesser extant marijuana 

Substances consumed in our county at a higher rate than the state:
	Alcohol use is higher and binge drinking, especially in males, is higher than the state

Areas where we need more information (such as who, where, when, why and what):
	Drugs other than those here; breakdowns of “underage” (18-20 year olds) and other adult age groups, e.g. 21-30, would be helpful

Consequences of concern in my county among particular subpopulations/age groups:
1.	There was an increase in fatal crashes involving alcohol over the 5 year period from 26.6% in 1994-1998 to 34.1% in 199-2003.
2.	While Maine’s overall rate decreased from the 2 (5-year) periods, the county’s percentage of young drivers (ages 21-29) in fatal crashes who were alcohol involved increased from 20.8% in 1994-1998, to 31.4% in 1999-2003.  There was a slightly upward trend in this category for all adult drivers, from 13.8 to 16.8.

Indicator	Rate of consequence in most recent year	Compared to state?	Trends over time?	Other notes	
Juvenile arrests for alcohol violations	801 per 100,000	Higher	Increase	Spikes in 1998, again in 2000-2001, drops in 2002	
Juvenile arrests for drug violations	632 per 100,000	Higher	Increase	Steady increase with spikes in 2000-2001, drops in 2002	
Percent of all youth drivers (under age 21) in fatal crashes where alcohol was involved	22.9%	About the same	Increase	Huge increase from 6.3% in 1994-1998	
Suspensions/removals due to alcohol or drugs	N/A	Lower	N/A	Per 100,000: alcohol 11.3; marijuana 22.5; other 3.8	
Appendix E3: Indicator Data: Substance Use Consequences Among Youth in Androscoggin County (from County Profile Supplement)

Consequences of concern in my county:
	There was a substantial increase in fatal crashes for drivers under 21 from 6.3% to 22.9%

Consequences in which my county exceeds the state:
	Juvenile arrests for alcohol and other drugs, but this might be a positive trend reflecting increased law enforcement 

Consequences where we need more information:
	Why were there spikes in arrest rates for both alcohol and drug violations 2000-2001 followed by a drop?

Indicator	Rate of consequence in most recent year	Compared to state?	Trends over time?	Other notes	
Rates of reported crimes per 1,000 people by type	26.4 property
7.4 violent	N/A	No change		
Arrests for alcohol violations, age 18 and older	1134	Higher		Similar pattern as state, but an increase over 1996-1997 period	
Adult OUI arrests, age 18 and older	656	About the same	Increase	Increase over previous years but decrease over the 10 years	
Arrests for drug violations, age 18 and older	783	Higher	Increase	Steady increase; nearly double the state in the same year	
Percent of total fatal crashes over 5 years that were alcohol-related	34.1%	Higher	Increase	Compared to other counties?
Androscoggin is the 6th highest	
Percent of all young adult drivers (21-29) in fatal crashes involving alcohol	31.4%	Lower	Increase	Increased from 20.4% in 1994-1998	
Percent of all adult drivers (30 and older) in fatal crashes involving alcohol	16.8%	Lower	Increase		
Deaths by underlying cause	26	N/A	Increase	Cirrhosis deaths rose from 2.9 to 11.5	
Appendix E4: Indicator Data: Substance Use Consequences Among Adults in Androscoggin County (from County Profile Supplement)

Indicator	Rate of consequence in most recent year	Compared to state?	Trends over time?	Other notes	
Overdose deaths	8.5	Lower	Increase	Increase from 1997-2003 of 2 deaths per 100,000	
Treatment admissions (all ages)	1,223 per 100,000	Higher	Increase	Is this due to availability of treatment in county?	
Percent of total treatment admissions (18 and older) involving alcohol	74.8%	Higher	Decrease
	Up and down but down from 2000 (82.8 %)	
Percent of total treatment admissions (18 and older) involving marijuana	32.6%	About the same	No change	Stayed within the same 10 point range	
Percent of total treatment admissions (18 and older) involving prescription drugs	11%	Lower	Increase	Nearly double the 2000 rate of 6.5%	

Consequences of concern in my county:
Alcohol-related fatal crashes are higher than state rates, 6th highest in the state.  Arrests for drug violations were nearly double the state; trend is increasing.
	
Consequences of concern in my county among particular subpopulations/age groups:
	Though the percent of young drivers (21-29) in fatal crashes was lower than the state, it stands at 31.4% which is an increase over the time period.  It was 20.8%.

Consequences in which my county exceeds the state:
	Alcohol violation arrests; drug violation arrests; percent of total crashes that were alcohol related increased, and is 6th highest in the state; total treatment admissions and treatment involving alcohol are high.
Consequences where we need more information:
Why are treatment admissions higher?  Availability issue?  Are arrests for violations (alcohol & drug) due to increased law enforcement?

Appendix F: Androscoggin County Readiness Survey

County Readiness Assessment

Healthy Androscoggin is applying for an Office of Substance Abuse Grant and we hope you will help us determine our readiness to address substance abuse issues as a coalition and across the county.  We would like you to fill out this questionnaire individually and then we will average the answers to get a group score.

Not 
 True
1	Some-
what
2	Mostly True
3	
True
4	Leadership Group Readiness 	
				1.	We have recruited local partners from all geographic areas of the county.
	
				2.	We have identified all entities in the county that are currently active in providing substance abuse prevention programs and services.	
				3.	We have recruited local partners from all entities currently active in providing substance abuse prevention programs and services.	
				4.	We have begun to coordinate the efforts of local partners into a strategic countywide effort to build prevention capacity across the county.	
				5.	We are committed to integrating local and countywide plans with the state SPF-SIG strategic plan and the state health plan.	
				6.	We have begun or are ready to begin the process of compiling existing needs and resource assessments that have been completed in our county.	
				7.	We are ready to examine our local data, use data supplied by the SPF-SIG epidemiologist, and identify information gaps.	
				8.	We are ready to identify needs, resources, and priority strategies in our county related to substance abuse prevention including inter-relationships between substance abuse prevention and other prevention and health promotion efforts.	
				9.	We have a strong leadership core of people within our group.
	
				10.	Within our core group, we have the knowledge base, experience and talent to launch a broad-based community effort.	
				11.	Within our core group, we have members with group development skills, e.g., listening skills, facilitation, consensus-building and problem-solving skills.	
				12.	Our coalition/group members understand their roles clearly and know how they can contribute to group goals and objectives.	
				13.	Our coalition/group has clear and specific working agreements that help the group do its work effectively.	
				14.	Our coalition/group reflects the diversity of our county (e.g., ethnicity, race, gender, socioeconomic status, leadership style, geography,  etc.)	
				15.	Our coalition/group members are networked to the communities in our county and to our prevention and health promotion focused organizations; and they have a good understanding of the history and politics of our communities and prevention efforts.	
				16.	Our coalition/group members are willing to put community agendas before their own.
	
				Total number of group attributes checked in each column

Organizational/Partner/County Readiness:
Use the following checklist to help you assess the readiness of your county’s organizations and institutions to participate. (See scoring instructions for first checklist.)
Turn over  

Not 
 True
1	Some-
what
2	Mostly True
3	
True
4	Organizational/Partner/County Readiness 	
				1.	We have engaged the organizations, businesses and individuals in our county who have a history of active involvement in substance abuse prevention in the county as well as other prevention and health promotion efforts.	
				2.	Organizations that partner with us have missions similar to our group’s and have made community health improvement and quality of life a priority.	
				3.	We have a countywide coalition, a coalition of coalitions, or a collaborative that provides a defined organizational structure to support our countywide work.  	
				4.	A fiscal agent that can meet all the requirements of a state contract has been identified for our strategic planning effort.	
				5.	Partnering organizations participate in collaborative planning and action.
	
				6.	Organizations and partners feel that they will benefit from engaging in a county-wide collaborative effort.	
				7.	Organizations and partners will provide the necessary financial, physical, or human resources, or will assist in recruitment of those resources.	
				8.	We have a core of committed organizations and people who want to focus their attention on improving the quality of life in our county and are ready to spend the political energy necessary to make a go of it.	
				9.	We have enough acceptance from the communities in our county to move our effort ahead.
	
				10.	We have buy-in from the town and city governments in our county.
	
				11.	We have identified individuals and groups that may feel threatened by our efforts and have relationships built with them or know people who do.	
				12.	We have people in our community who are strongly committed to the idea of bringing diverse voices together and have a strategy in place to ensure that all community voices are being engaged.	
				
Total number of organizational/sponsorship readiness attributes checked in each column	
 
Please indicate what community sector(s) you represent: (you may check more than one)

___ Business                         ___ Local Government                                    ___ Local Media

___ Civic Group                  ___ Religious Leader/Organization                ___ Parent/ Citizens

___ Youth Services Organization       ___ Youth

___ Community-based Health, Social Services & Prevention Providers (public & nonprofit organizations 
       & Councils)

___ State Sponsored Local Prevention & Health Promotion Coalitions (HMP, OneME, C4CY, HC, etc.)

___ Medical Care & Hospital Sector

___ Law Enforcement & Court System

___ Schools (Pre-K to 12, after school programs, higher Ed, etc.)	

Appendix G: Summary Report of Focus Groups, Key Informant Interviews, and Community Surveys

Preventing Substance Abuse in Androscoggin County: 
A Multi-Modal Study of Causes, Trends 
and Potential Solutions 

July 2007

Prepared for Healthy Androscoggin
by Dr. Kathryn Low and Katherine Forester of Bates College, and Erin Guay
With funding from the Maine Office of Substance Abuse and Healthy Androscoggin

Executive Summary
	In the winter and spring of 2007, Healthy Androscoggin collected survey data, conducted focus groups, and carried out key informant interviews to identify substance abuse problems and related issues in Androscoggin County.  The purpose of this multi-modal data collection strategy was to solicit a variety of perspectives on substance abuse in the County, to identify key substances and populations for intervention, and to invite suggestions about strategies for prevention and treatment.

	Data were both quantitative and qualitative.  Quantitative data involved analyses of 38 surveys on substance abuse in Androscoggin County submitted by selected constituents ranging from law enforcement to educators to youth.  To compliment the quantitative data, five focus groups were conducted, consisting of parents from a downtown neighborhood, college students, local immigrants, law enforcement personnel, and clergy from several denominations.  Finally, the SPEP Committee identified a variety of key informants who might enrich the data, and one-on-one interviews were conducted.  Key informants were a local psychiatrist, a child caseworker, two college health center employees, a home health care professional, a pharmacist, a bar owner, a sports manager, an older adult service provider, an alcohol marketer, and a liquor store manager.

Survey Data

Survey data suggest that there is a moderate to severe problem with substance abuse in the County.  In particular, alcohol (65% of respondents), marijuana (75% of respondents), and prescription drugs (67.5% of respondents) were identified as key substances.   Adults perceived more problems with underage drinking, tobacco, adult drinking and prescription drug use than youth (all p<.05).  Based on survey responses, better education about the risks of substance abuse and closer adult supervision of youth were the highest priorities.

Focus Groups

Focus group results varied considerably depending on participants.  Without exception, all the groups agreed that alcohol was a key concern.  Downtown parents noted that domestic violence and economic problems were tied to alcoholism.  College students acknowledged problem drinking and its correlates, including poor performance and damage to college property.  Immigrant participants did not themselves report problems with alcohol, but had observed problems in their neighborhoods, and were concerned about their children being exposed to drinking in school or neighborhood settings.  Law enforcement noted the high cost of alcohol abuse for the County in terms of accidents, diversion of resources, and violence.  Similarly, the clergy participating noted that alcohol was probably the most widespread problem they encountered, and the most resistant to intervention.

Attitudes toward marijuana were more mixed.  The parent group and college students tended to believe that marijuana was a less critical problem than alcohol abuse, and reported that marijuana use was widely accepted in their communities.  In contrast, law enforcement reported concerns about marijuana use, but were frustrated by obstacles to enforcing the law.  For example, they noted that possession of small amounts of marijuana is less serious than underage tobacco smoking in the State of Maine.  They also observed that marijuana is readily available, sometimes homegrown, and therefore hard to monitor in terms of access.  While there was ambivalence about marijuana as a problem, all agreed that other illegal drugs were more worrisome. Only the downtown parents and law enforcement reported serious concerns with cocaine, crack, methamphetamine or other illegal drugs.

Parents, students and law enforcement all reported that prescription drug abuse is on the rise, and is a critical concern.  The immigrant and clergy interviewees had less information about this problem.  Participants described diversion of prescription drugs for recreational reasons, frequent mixing of such drugs, and relatively easy access to even the most addictive substances (Oxycodone, Hydrocodone).  Drugs that were identified most frequently were psychostimulants and narcotics.

In terms of prevention and treatment, all the groups believed that additional education, particularly about the hazards of non-medical use of prescription drugs and mixing such drugs with alcohol would be beneficial.  Law enforcement and the parent group also noted that closer monitoring of children might prevent problems, along with recreational or outdoor programs for underserved youth.  Several groups speculated about risk factors for substance abuse, including depression, stress, poverty, and unemployment.  Addressing these issues early and aggressively might prevent some secondary problems.  In addition, law enforcement and the parent group suggested that limiting access might be beneficial.  For example, both cited examples of local businesses that sell alcohol to minors.  In terms of treatment, accessible, affordable treatment is needed, particularly for those who have few resources.  Several focus group interviewees noted that long-term abuse in adults was unlikely to change, and that treatment efforts should be focused on younger abusers. Participants praised the benefits of Alcoholics Anonymous (AA), but also noted that the AA meetings downtown have become less helpful in recent years, and that AA doesn’t always appeal to youth. Medically supervised treatment is expensive and not always easy to access. Even college students in the community reported having difficulty in finding psychotherapists for treatment.  Both law enforcement and clergy indicated a willingness to partner with public health agencies to work on these issues.  The faith-based group noted that in some areas, parish nursing or parish-based interventions have been helpful.

Key Informants

Key informant interviews were conducted with ten community members.  Across interviewees, alcohol, marijuana, cocaine and prescription drugs were identified as particular problems.  Factors impacting substance abuse that informants identified were:  media, parent involvement, religious and family influences, accessibility, mental health problems, and education.  Several participants cited media influences as important, and described alcohol advertising at sporting events, and celebrity substance abuse problems as examples.  Such advertising and media attention makes substance abuse more acceptable, some argued.  Many interviewees also mentioned parent involvement and family life as important protective factors.  Parent monitoring of children, an intact family, and promotion of family values were seen as potentially protective.  In addition, three interviewees mentioned religion and spirituality as important resources for the community.  The erosion of religious traditions and communities has, according to these interviewees, been a problem.  Several suggested church groups, values training and similar strategies for reducing risk.  Three informants discussed accessibility to alcohol, in particular, as a problem.  One informant suggested better enforcement of the drinking age, and a more thorough licensing procedure for vendors.   More than half of the informants agreed that mental health issues, including stress, depression and other disorders, were important risk factors for abuse.  Along these same lines, the psychiatrist noted that some substance abuse problems are related to self-medicating for untreated disorders.  Several respondents identified drug and alcohol education as a potential strategy for reducing risk.  In addition, general education which provides opportunities in terms of employment and economic advantages may be beneficial, as several informants observed that poverty was an important risk factor for stress, and in turn, for substance abuse.

Key informants had a variety of suggestions for treatment.  Several noted that parents and families are part of the problem, and should be included in the solution.  Family treatment, values training or psychoeducational interventions might help.  One informant noted the need for benzodiazepine treatment in the County.  Another described the difficulty of accessing treatment even where it exists—learning about the options, transportation and affordability are all potential obstacles.  Several informants suggested that interventions with youth such as summer recreational activities, values training, and other outdoor opportunities might be effective.  One vendor recommended more education for those who receive liquor licenses. Another suggested partnering businesses with agencies to work on health issues or sponsor programming. Virtually all agreed that the problem is a complex one, and will require more than a brief program or community intervention.  At least one informant noted that the change will have to be profound and “cultural” and not just a “quick fix”.  Several of these informants expressed an interest in partnering with public health agencies on these issues.

Conclusion

Results of this multi-method data collection project suggest that alcohol, illicit drugs, prescription drugs abuse and marijuana are the major substance abuse concerns in Androscoggin County.  Respondents identified media, accessibility, poverty, mental health problems, and family dysfunction as potential contributors to substance abuse. Increasing parent involvement with and monitoring of youth, reducing access, empowering law enforcement, values and/or religious strategies, and adequate education about drugs and alcohol were identified as potential interventions.  In terms of treatment, respondents suggested religious and/or spiritual strategies, better access and affordability, and addressing a variety of substances, including benzodiazepines.

Summary of Key Themes Across Data Collection Methods

		Focus Group Participants		
	Survey Respondents	Parents of Youth	College Students	Immigrants	Law Enforcement	Clergy	Key Informant Interviewees	
Most Problematic Substances*	-Alcohol
-Marijuana
-Rx drugs
-Illicit drugs	-Alcohol
-Rx drugs
-Illicit drugs
-Marijuana	-Alcohol
-Rx drugs/
Stimulants
-Marijuana	-Tobacco among men	-Alcohol
-Marijuana
-Rx drugs
-Illicit drugs	-Alcohol
-Tobacco	-Alcohol
-Rx drugs
-Illicit drugs
-Marijuana	
Consequences/Related Issues of Substance Abuse		-Unemployment
-Poverty
-Homelessness
-Stress
-Domestic Violence	-Stress
-Competitiveness	-Fitting into U.S. culture 	-Poverty (low-income youth)
-Crime/Violence
-Mental disorders
-Decrease in family functioning	-Stress (low income families)
-Death of spouse (older adults)	-Stress
-Mental disorders/Depression	
Barriers to Prevention	-Media/ Advertising
-Social norms
-Few consequences of substance abuse	-Availability of substances
-Absence of religion
-Adults providing substances to minors
-Discrimination against “downtown kids” in schools	-Substances are readily available
-Social norms
-Mentality of invincibility
	-Immigrant youth are exposed to substance users in schools	-Availability of substances
-Few cons. of illegal drinking among Bates students
-Light penalties for marijuana possession	-Social norms among college drinkers	-Media/Advertising
-Lack of family involvement
-Absence of religion
-Availability of substances	
Prevention Strategies	-More family involvement w/ youth
-More prevention programs in schools
-Increased enforcement	-Beat cops
-Reducing cost of 12 hr club
-Chem-free space for youth
-Summer programs for youth (field trips, camps)	-Awareness campaign
-Education	-Parenting and educational classes for parents about substance abuse prevention in kids	-Mentoring
-Rewards for youth who don’t use	-Family groups
-Parish nurses
-Businesses’ HR depts. Providing educational materials
	-More family involvement/Mentoring
-More religion and morality/Values training
-More prevention programs in schools
-Increased monitoring by and of substance providers
-Summer programs for youth	
Barriers to Treatment		-No detox programs for youth in downtown		-Low awareness of treatment options		-No compliance and follow-up after treatment	-Affordability of treatment
-Transportation to treatment center	
Treatment Strategies		-Provide detox programs for youth in downtown						
*Most Problematic Substances are roughly ranked by the severity of the problem as perceived by participants.
Bolded items indicate overlap between items mentioned in more than data collection method or items mentioned consistently within a data collection method.

Survey Data 
Questionnaires were handed out to community members with an interest in substance abuse prevention in the Lewiston/Auburn area. Forty participants responded. The questionnaire included a demographic question regarding their role in the community (i.e. teacher, law enforcement officer, etc.) and thirty questions regarding perceptions of substance abuse in the community (fifteen quantitative questions and fifteen qualitative questions). Questions were separated into three age groups: youth (>18), adults (18-65) and older adults (65+). The data were coded quantitatively on a Likert-type scale:
 1 = Not a problem at all
 2 = Somewhat of a problem 
 3 = Big problem 
 4 = Very serious problem 

Qualitative questions such as “What are the causes of youth substance abuse in your community?” and “What are the barriers adults face in getting treatment?” were analyzed for dominant emerging themes. Results
Participants self-identified as school employees (n = 12), youth (n =11), healthcare providers (n = 6), parents (n = 3), law enforcement officials (n = 2), substance abuse counselors (n = 3), a SPEP Committee member (n=1), and a concerned citizen (n=1). One participant did not respond to the demographic question. Percentages reported are for the number of responses per question relative to total responses. For the “Youth” section of the questionnaire, the majority of participants rated every substance a “Big problem” or a “Very serious problem”: alcohol (65%), tobacco (59.1%), marijuana (75%), prescription drugs (67.5%) and illicit drugs (67.5%). For the “Adult” section of the questionnaire, alcohol (74%), tobacco (60%), and marijuana (60%) were rated as a “Big problem” or a “Very serious problem”. For older adults, roughly 25 % of participants did not respond. The participants that responded rated older adult alcohol use “Somewhat of a problem” or a “Big problem” (52.5%). The rest of the substance categories (tobacco use, illicit drug use and prescription misuse) were rated “Somewhat of a problem”. 
An independent t-test was used to test for differences between youth and adults in perceptions of substance use and abuse in Androscoggin County. Youth perceived the following substance issues as less problematic than did the adults surveyed: underaged drinking (M = 2.09, t (36) = -4.80, p  < .01), underage tobacco (M = 2.09, t (36) = -3.19, p = .003), adult drinking (M = 2.45, t (36) = -2.41, p = .02), adult tobacco (M = 2.09, t (36) = - 3.25, p = .003), older adult drinking (M = 1.67, t (28) = -3.25, p = .003), and older adult prescription drug use (M = 1.80, t (29) = -2.40, p = .02). 
For the qualitative questions, the significant themes that emerged were the need for increased family involvement with youth, increased adult supervision for youth and increased prevention programming in the schools.  Barriers to prevention are the mixed messages that teens receive from the community and the media, general adolescent attitudes, and individual issues.  Themes for adult use in the community focused on the continuation of habits established in youth.  This reiterates the need for prevention during adolescence.  Respondents indicated that messages to adults are more family focused than individual focused.  A common theme for youth and adult barriers to prevention are the general social acceptance of substance use and a belief that even if a user gets caught, the consequences are few, if any.  The major theme for the older adult section of the survey is a lack of awareness that there is a problem in that cohort. 
Discussion
Questionnaire results showed that respondents perceived a moderately severe to severe substance use problem in Androscoggin County.  The majority of participants perceived youth substance use as a “Big problem” or a “Very serious problem”.  The results from the youth section expose a risk group in Androscoggin County that may differ from Maine OSA’s priorities, specifically with youth marijuana use.  The perception among the majority (75%) of participants in this sample is that marijuana is a serious problem, yet marijuana is not one of Maine’s three substance use targets.  Based on the data, it is critical for Healthy Androscoggin, as a community coalition, to address marijuana in prevention efforts. 
Qualitatively, a number of themes emerged regarding substance abuse in the community.  Overall, the community believed that the best prevention strategies are increasing substance abuse education and adult supervision of youth.  Specifically, prevention should begin in the home through good role modeling, adult supervision and involvement in the community and continue in the schools through classes and programs.  Participants noted that messages from the community appear to be mixed.  Advertising and television shows depict adolescent and young adult substance use as positive, while specific messages from schools and some parents are negative.  Unfortunately, there are some mixed messages from parents, with some approving of alcohol use or allowing it in the home. 
Healthy Androscoggin has the resources to target youth and adult substance abuse.  Underage drinking, for example, can be targeted through increasing enforcement.  Underage drinkers obtain alcohol through friends and family over 21.  If the police can enforce legal consequences for providing alcohol to youth, the rates of youth alcohol use may decrease. 
A major finding of the questionnaire was the gap between youth and adult perceptions of use.  Youth perceived fewer problems than adults in the categories of Youth Alcohol Use, Youth Tobacco Use, Youth Illicit Drug Use (marginally), Youth Prescription Use (marginally), Adult Alcohol Use, Adult Tobacco Use, Adult Illicit Drug Use, Elderly Alcohol Use and Elderly Prescription Use.  These data indicate that adults perceive substance use in the county as more problematic than youth in the community.  These included two categories that Maine OSA prioritized for the Strategic Plan: youth alcohol use and youth prescription drug use.  The significant differences between adults and youth on these measures show that perceived substance abuse norms vary by age.  Young people, during a time of risk taking and experimentation, adhere to norms of accepting substance use.  Alternatively, it may be that youth perceive substance use to be less widespread than adults.  A limitation of the questionnaire is that it did not ask about perceived prevalence of substances, but only about perceived magnitude of the problem.  A future study could clarify Androscoggin youth’s perceptions of substance use. 
Substance abuse was rated as less of a problem for older adults than for the youth and adult populations.  This suggests either that the community does not perceive a problem with older adult use, or is unaware of any problem.  However, about 25 % of the participants did not respond to questions regarding older adults.  This suggests that many participants do not have the knowledge to make an assessment of older adult substance abuse.  The results demonstrate a general lack of awareness of older adult substance problems, as described by Benshoff and Harrawood (2003).  Generally, future, in-depth studies of older adult substance abuse need to obtain better data on this population. 
In the final question regarding the participants’ personal roles in addressing substance abuse in Androscoggin County, most participants focused on the “Under 18” cohort.  Mentoring, educating, and advocating were perceived to be as the best ways to contribute.  This focus on “Under 18” can be explained because the sample consisted of primarily school-based educators, substance abuse counselors and youth. 
Overall, respondents felt that prevention is most effective during adolescence.  However, prevention was not limited to in-schools programs.  Perceptions of effective strategies include parents, families and adults.  Participants believe that a general increase in adult supervision of youth would decrease substance use problems.  These survey data suggest that the elderly population is being neglected in the area of substance prevention.  Increased contact with the community might be helpful in reconnecting older adults and preventing late onset substance abuse. 

Focus Groups
Four focus groups consisting of parents of local youth (defined as having at least one child under 18), college students, members of a local immigrant population, and members of local faith based organizations were carried out to collect further data on substance abuse.  Focus groups were chosen as the method of data collection for two main reasons.  First, to develop an evidence-based prevention program for Androscoggin County, the data need to be specific to the region.  Second, focus groups allow for many opinions to be expressed and for participants to interact.  The specific types of focus groups were chosen based upon previous data collection, survey results, and advice from the SPEP Committee. 
The questions asked during the focus groups did not pertain to a participant’s personal use of substances, but to perceptions of use within the community and to ideas about effective prevention measures.  This was emphasized both in the consent forms and reinforced during the focus groups.  Questions were specific to each focus group.
The confidentiality of all participants was guaranteed.  No names were attached to the responses given; pseudonyms were explicitly explained and encouraged at the beginning of each focus group.  The sessions were recorded.  The consent forms explained that a participant could consent to participate in the group and request that the session not be recorded.  During transcription and analysis, no real names were recorded.  During data analysis, the tapes were kept in a locked filing cabinet.  At the conclusion of data analysis, the tapes were destroyed. 
Parent Focus Group
	The parent focus group occurred at the Empower Lewiston office in Lewiston, Maine in June 2007, and was facilitated by Kathy Low.  Eight parents or grandparents attended, along with one additional participant who had no children of her own, but lived with extended family members who were youth.  All the participants were women from low-income families, broadly defined.  Parents’ primary concerns were economic, and employment was the most frequently cited antidote to substance abuse.
	First, parents were concerned about the social climate downtown.  They reported that drugs and alcohol are readily available, and that both are sold in their neighborhoods.  They also noted that prostitution is a problem in the downtown area, and that children are exposed to inappropriate sexual activity.  Parents observed that the prostitutes are often also substance abusers, and that the problems seem to be related.
	When asked to identify risk factors or concerns related to substance abuse, some parents reported that stress and unemployment were important contributors to problems.  One parent observed, “There is no work in walking distance, we don’t have cars…there are few opportunities.  I wish they would bring back the shoe shops, because it kept you busy and out of trouble.  Kids are just hanging out with nothing to do.”  In addition, they asserted that the church, primarily Catholicism, was playing a less central role in the lives of people in the city, and that this erosion of religion was a contributor.  “Priests used to scare us, and we behaved”, one mother recalled.  
	Specific substance abuse concerns were primarily related to alcohol abuse and to illicit drug use.  Many parents had had alcohol problems in their families, and linked alcohol abuse to unemployment, poverty, and stress.  Alcohol is readily available to underage drinkers in the downtown area.  Several mothers reported seeing youth purchase alcohol, or were aware that there are adults in the community who buy for and/or serve minors.  Some youth also reportedly steal alcohol from local stores.  Some mothers had reported such activity to police, with allegedly little effect.  Parents also noted that prescription drugs are being diverted and sold on the street, and that kids get involved in dealing in order to make money.  Again, parents speculated that more employment opportunities might prevent this.  
There was also concern about subsidies for city housing, “city slips”, which have changed in recent years, and have reduced the availability of affordable housing in the downtown area.  The parents report that their teenage children have no place to live and can’t afford apartments because of cuts in benefits.  As a result, teens begin dealing or live on the streets or with friends in situations that promote alcohol and drug abuse.  Without decent housing or responsibility, the parents feel kids have little motivation to stay sober.  In addition to alcohol, parents had concerns about painkillers and other prescription and illegal drugs, like narcotics, that are addictive.  Mothers also noted a need for detoxification programs for youth, along with treatment that might be more youth oriented and would occur in the downtown area.
Parents were less concerned about marijuana, which one mother thought, “should be legalized…it’s ridiculous, it’s no worse than alcohol.”  Another mother reported that, the “cops confiscate marijuana and don’t do anything about the problem”.  In general, parents did not believe that law enforcement is helpful.  Several described serious problems or conflicts with police, including their children being involved in fights with or being targeted by local officers.  One parent wondered about the return of “beat cops” who knew neighborhoods and residents better.  Parents perceive the police as biased against downtown residents and youth, and as perhaps targeting certain residents and/or neighborhoods.
Parents talked briefly about tobacco, noting that many of the adults in the community are addicted to cigarettes and would like to quit.  They also reported that many young children, including those as young as eight, are reportedly using tobacco in the downtown area.  Parents reported that children buy or steal cigarettes with little difficulty, and that some parents provide cigarettes to children.  They are not sure that cigarettes should be prioritized by Healthy Androscoggin at this point; they have more concern about drugs that are intoxicants.
Parents were disappointed with the schools, noting that their children were generally unsuccessful at the middle and high school in Lewiston, and that the school administrators and teachers tended to treat children from downtown differently.  “The high school is all about going to college…., and if you’re one of our kids, they don’t really care”, stated one parent.  Parents did not have confidence that the school could help with substance abuse programs, and weren’t sure that any effective substance abuse education was occurring.
Treatment programs for downtown youth are essential, parents asserted, and there are few available in the downtown area, within walking distance, that are youth-oriented.  The women noted that several previous programs had been located in the downtown that had disappeared.  Alcoholics Anonymous (AA) meetings are a possibility, but parents felt that youth were not interested in the AA approach, and had trouble with the religious aspects of AA.  
“Kids don’t want to go to AA—they don’t want to change, and there are people 
showing up drunk at AA, and it’s really not working.  They don’t like the religion,
and when drunks show up, it doesn’t help.”

Some had used Al Anon and other resources in the past.  The 12-hour club, a substance free gathering place, was also a resource that was mentioned, but there is a charge for attending the club that is prohibitive.  Parents believed that a chem-free space for youth, a gym or some other facility, might be helpful.  In addition, the parents mentioned summer programming for children as a possible resource.  Field trips, camps, pool activities and other downtown activities (for example, there used to be camps in Kennedy Park) that were available and low cost would help children stay out of trouble in the summer.  “Yes, get them out of the city”, one mother concurred.
In sum, parents in downtown Lewiston are most concerned about employment and opportunities for their children.  Alcohol and prescription drug abuse are their primary concerns.  Although many parents report that their children use or are exposed to marijuana use and tobacco, they are less concerned about these substances.  Employment and housing opportunities were identified as critical; in addition, treatment programs that are youth oriented would be helpful.  Finally, recreational programming for younger children might be beneficial, particularly if it involves activities outside of their neighborhoods.
College Focus Group
	The college student emerging adult focus group was run at Bates College and involved eight students.  Students were recruited through a convenience sample.  Participants were Bates College undergraduates, between nineteen and twenty-two years old. 
Heavy Drinking
	The substances perceived to be the most prevalent among college students were alcohol, stimulants, marijuana, and cigarettes.  Alcohol was perceived to be the most frequently used.  All of the participants agreed that alcohol defined the college experience for student drinkers.  Respondents indicated that alcohol facilitates both social life and stress relief, despite its negative impact on academic life.  The group also expressed that although other options for social activities exist, most college students choose to drink. 
	 Alcohol was perceived to be easy to obtain regardless of age, and to be socially acceptable for college students.  These students reported that general use was not preventable.  As an example, the group believed that strict college drinking policies and the federal drinking age are causes of binge drinking during college.  The group was in agreement that the stricter the drinking policy, the more college students will binge drink in their rooms (“pre-gaming”).  The group suggested that lenient drinking policies at colleges encourage students to act responsibly in their drinking behaviors.  Liberalizing college drinking policies could lead to fewer binge drinking episodes for college students.  However, the group felt that nothing else could change the culture of drinking on college campuses due to the alcohol-related culture of the United States. 
“The issue is embedded in the United States culture. This is the time in our life to get wasted every night. So do it, we are not accountable for it anyway.” 

Heavy drinking in college was attributed to characteristics of emerging adulthood as well. The group described a general perception of being invincible at this stage of life: 
“I guess we feel we are invincible. I trust my friends will take care of me or anyone else if I get out of control.”

“It’s the college mentality: I can get ‘belligerent’ 3, 4 times a week, everyone else is and when else can I do this the rest of my life?”
	
This “mentality of invincibility” contrasts with the group consensus that a significant number of problem drinkers attend college.  College students may perceive themselves to be immune to risks of binge drinking (i.e., sexual assault or alcohol overdose).  But, college students recognize problem drinking behaviors in their peers.  The group, however, could not come to a consensus on a definition of problem drinking:
“Isn’t it more about dependence than anything else? I mean, my aunt has alcohol problems and she needs to drink every morning. No one here is like that yet.”
		
“I think it is more than that, I mean, you have a problem if you drink a lot, and then are embarrassed or regret how you acted. It’s when you have a problem with it.”
	
	When prompted with examples of problem drinking behaviors like blacking out or repeated hospitalizations for alcohol overdose, the participants felt that none of those examples defined a problem drinker.  The group cited that those problems may make a college student a “one night problem drinker”, not a “true problem drinker”.  This highlights a misperception of college students.  This group seemed to have no knowledge of qualities that define healthy drinking, problem drinking and dangerous drinking.  There was no mention or Blood Alcohol Level, negative physiological consequences of heavy drinking over time, alcohol dependence or any behavioral consequences of problem drinking.  The “mentality of invincibility” can begin to be broken down by targeting these specific perceptions.  The participants suggested that an awareness campaign may work with college students.  However, they acknowledged that information about alcohol is readily available to students on campus currently and is not well used.  No suggestions were made regarding how to design a campaign that would appeal to college students.
Prescription Drug Misuse
	The group perceived that prescription drug misuse is increasing among college students, especially stimulant misuse.  Stimulant misuse was described as increasing in social acceptability and in prevalence.  Although marijuana was perceived to be more commonly used, stimulants were perceived as the most rapidly increasing type of substance use among college students. 
Researcher: “What other drugs define or are a large part of the college experience?”
Participant: “I would say stimulants, but not for recreation like alcohol, but for academic reasons. I mean, you ask 5-10 people during finals and half will sell to you and the other will tell you they used some Adderall.”

	Participants agreed that the motivations to use stimulants were for academic reasons and some recreational use.  Drugs such as methylphenidate (Ritalin) and amphetamine/dextroamphetamine (Adderall) were mentioned as strategies for competitive students to maintain focus and intensity during stressful academic times.  Prescription stimulants were likened to “drinking many cups of coffee to get through a tough night of work, but in one dose”.  Participants explained that perception of safety and the over diagnosis of ADHD contribute to students’ willingness to misuse stimulants:
“I mean, there are no real side effects are there? So many people are diagnosed with ADHD that don’t have it, and they are fine for tens of years on stimulants. If someone took it one or two nights a semester to get through some work, how bad can it be?”
	
“I think people think prescription drugs are safe because they are from a doctor, they are one pill and that is that.”

	Participants also acknowledged that there is a subgroup of students who misuse stimulants for recreational purposes.  Students may snort stimulants to get high or to supplement their alcohol use.  Again, the focus group attributed these patterns to the perception that prescription drugs are safe. 			Other prescription drugs like painkillers and drugs used for relaxation, such as sleeping pills and muscle relaxants, were reported as commonly used and attractive drugs for college students.  The respondents indicated that because prescription drugs are more socially acceptable than drugs like cocaine, they are more attractive to college students.  Again, they are perceived as relatively safe and lacking side effects characteristic of substances like alcohol.  Members of the group thought that prescription misuse most likely does not have as many risks as other substances.  Participants perceived that: culturally, the U.S. is overmedicated; and, college is a stressful and competitive time.  As it is unlikely that these will change, it may be a waste of resources to target prescription drug misuse:
“What it comes down to is, it is just not worth stopping. There is no real large negative health impact of stimulants if you use them one or two times a week. Considering the strain on money in communities like Lewiston, prescription drugs are kind of the least of the their worries.”
	
“I mean until they (the school) stop giving six hours of work a night and projects and papers and expect students to be active in the community, those students are going to need to use something some time.”

Marijuana Abuse
	The use of marijuana among college students was perceived to be completely acceptable, and was reportedly the norm among a subgroup of students.  Marijuana was only discussed briefly and no major negative consequences were discussed.  Most participants mentioned that because marijuana is not addictive, there are no negative health consequences.  Interestingly, not even lung damage from smoking was mentioned, despite the high level of anti-smoking education this cohort has received.  Participants compared smoking marijuana to alcohol use, and concluded that drinking is a significantly more destructive and widespread issue among college students. 
	The facilitator of this focus group would like to note that the lack of discussion of marijuana during this focus group and its widespread use expose a failure in substance abuse prevention programs.  Students need to be educated about the negative consequences of marijuana use.  However, it is also important to research the habits of college bound marijuana users compared to those of non-college bound emerging adult marijuana users.  Differences in habits of marijuana use during adolescence between these groups may have significant consequences in determining college attendance or employment status of emerging adults.  Future research comparing these two groups in terms of marijuana use or other substances could show important targets for substance abuse prevention programs.
	The use of harm reduction (HR) methods may be one way to reduce the use of marijuana by emerging adults.  HR methods focus on reducing the harm related to substance use, not reducing use per se (Swift, Copeland, & Lenton, 2000, 102).  HR methods for marijuana would include educating users about the health and legal risks of use.  Health risks of acute use include: negative psychological effects, disruption of cognitive functioning, and increased risk of psychotic symptoms among at-risk users.  HR techniques have been shown to reduce college student substance use (i.e., BASICS for alcohol use). An HR intervention focused on marijuana could be developed to combat the high prevalence of marijuana use. 
Cigarette Use
	Finally, cigarette use was discussed.  The participants agreed that the prevention efforts of schools, the media and health care providers have been extremely successful in combating cigarette use.  This group estimates that no more than 20% of college students smoke on a regular basis.  The group perceived that low rates of cigarette use are linked to its low social acceptability.  Of all the substances discussed, the participants perceived that social acceptability of smoking is lowest.  For example, non-smokers who hang out with smokers are more likely to start to smoke than nondrinkers who hang out with drinkers.  Also, many college students who travel or study abroad begin to smoke.  The group cited many examples of this:
	“Look at all the kids that come back from abroad. So many of them smoke, or smoked while they were abroad. Some continue when they comeback. It’s like if you are around smoking, you will do it. Not because it tastes so great the first time or there is an immediate satisfaction, but because it just what other people are doing.”

Smoking in Europe is widespread and socially acceptable.  Even American students who have participated in smoking prevention programs are highly susceptible to smoking abroad.  This phenomenon demonstrates the strength of social norms of smoking.  
	Smoking was perceived as less debilitating than drinking in the 18-25 years olds.  For example, college student problem drinkers may experience hangovers and academic problems because of their alcohol use.  In contrast, a college student cigarette smoker will perform as well as a non-smoker.  Participants perceived the possibility of becoming addicted to smoking at a young age as a major deterrent to smoking. 
	To explain why some emerging adults choose to smoke, the group once again blamed the “mentality of invincibility”.  For the small proportion of emerging adults who smoke on a regular basis, it is perceived that they do not believe they will experience the negative consequences of smoking. 
“It’s the ‘that won’t happen to me’ mentality of college, just like why many people drink a lot. Some people feel that way about smoking. Or that they deserve it, they are stressed out students.”

	The group’s perceptions about smoking provide some evidence that prevention efforts over the past fifteen years have been effective in educating young people about the dangers of smoking.  However, these focus groups suggest to substance abuse prevention planners that more needs to be done to change the behaviors of “social smokers”, those college students who only smoke when they use alcohol or are under stress.  Social smoking still carries health risks of which many college students may not be aware.  A future study could follow college attending emerging adult “social smokers” and their smoking habits to record quit attempts, stress management skills, and health outcomes post-college.  This information could be used in prevention programs for emerging adults who self-identify as a “social smoker”.
Immigrant Focus Group 

	The immigrant community focus group was completed at the Lewiston Adult Learning Center in Lewiston, Maine in April 2007.  Kathy Low from Bates College facilitated.  Katherine Forester, also of Bates College, assisted with note taking.  The group was comprised of eight participants: six Somali (four male, two female), one Chinese female, and one Congolese female.  Their teacher also participated and assisted with communication.  The class was an upper level English-only language class.  All participants consented to their participation and the tape recording of the group.  However, the tape recording was not used during analysis due to poor quality. 
	Although the group was diverse in nationality, all of the participants reported low rates of drug and alcohol use.  The Somali participants attributed the low prevalence of alcohol and drug use to their Islamic religion.  Muslims are permitted to smoke cigarettes, so cigarette use was reportedly widespread.  One participant shared his experience with smoking and recent smoking cessation.  He described quitting cold turkey as “very hard”, but that he was motivated to quit because of its effect on his health.  The participants were aware the cigarettes cause cancer.  Cigarette smoking seemed to be the biggest substance abuse issue among this population. 
Healthy Androscoggin’s smoking cessation efforts should reach out to this group, especially in places like Fairview and the other predominantly immigrant housing communities in Lewiston.  The participants also noted that female Somalis do not smoke cigarettes.  The female Somali participants agreed with this statement, although they were virtually silent throughout the focus group.  It would be informative to hold a female-only immigrant focus group, as it was clear that the female Somali participants were deferring to the men during the discussion. 
	At the teacher’s prompting, the difference between legal and illegal drugs was discussed.  The example of marijuana was provided as an illegal drug, and alcohol was used as an example of a legal drug.  Participants reported little illegal drug use among Somalis because of religious reasons.  Participants reported they witnessed less illegal drug use in downtown Lewiston compared to other cities like Atlanta and New York City.  The participants described Lewiston as a “quiet place” and perceived the area as safe.  The teacher explained that many of the students at the Adult Learning Center live in housing projects such as Fairview, not in downtown Lewiston.  In these almost exclusively immigrant housing projects, there is a low prevalence of alcohol and drug use.  In addition, the importance of compliance with legal prescription drugs, explained as drugs from a doctor, was discussed.  Participants reported receiving health care from Central Maine Medical Center residency program international clinic and with Maine Care. 
	Participants had a clear understanding of the necessity of obtaining help for substance abuse problems.  They cited that the doctor was the best place to get help for such issues.  No other options were mentioned.  Although a small group, they did not perceive many other available options for substance abuse treatment.  More outreach could be provided to the immigrant community about other places to obtain substance abuse treatment, especially for smoking cessation. 
	The biggest concern of the group was the exposure of the participants’ children to drugs and alcohol through school.  The participants were between the ages of twenty and fifty, with children in the local elementary and middle schools.  The participants acknowledged that their children are exposed to a range of cultures and values, and they want their children to fit in here in the United States.  But, the participants were concerned about the level of drug and alcohol use their children may witness among non-Muslim students.  They did not want their children to learn risk behaviors from other children.  They also reported feeling unable to discuss substance use or those types of behaviors with their children.  The participants reported a general feeling of not knowing how to approach substance abuse issues with their children.  The Somali men (as the women remained extremely quiet) requested parenting and educational classes on substance abuse prevention for their children.  Healthy Androscoggin could work collaboratively with the Adult Learning Center to implement immigrant focused parental education classes about substance abuse and prevention.  Culturally inclusive parent education in the schools will also be critical.  Any program focused on parents will have to include information tailored to immigrant parents. 
The participants asked about other commonly used substances and their effects on health, such as sugar and coffee.  Diabetes from too much sugar was reported as a problem for the immigrant community, especially because of a lack of safe places to exercise in the area.  The participants asked about the negative health effects of coffee.  The facilitator, Kathy Low, explained that coffee in small amounts is not thought to be harmful. 
Further research is needed to learn more about the prevalence of “cat” or “kah”.  The participants mentioned this drug as one used by Muslims.  However, little information is known about its use, and the language barrier interfered with the facilitators learning more about how and where it’s used.  Little was learned through this focus group, despite participants mentioning its use. 
More outreach is needed for this population.  Over the next ten years, it may be reasonable to predict increasing substance use among the adolescents of the immigrant community due to assimilation.  Increasing education and parenting classes in this community could help reduce increases in abuse. Furthermore, smoking cessation outreach will be vital for the health of this community.
Law Enforcement Focus Group
The law enforcement focus group was held in May 2007.  Six participants attended, including school resources officers, juvenile detectives, corrections officers, assistant DA –juvenile cases, and a district court judge.  Kathy Low facilitated with the assistance of Wendy Tardif, and Katherine Forester took notes and analyzed the data. 
	Alcohol, marijuana and prescription drugs were reported to be substances of most concern in the community.  Alcohol was perceived to be the most prevalent problem because of its widespread accessibility.  Substance abuse was perceived to be a problem for adolescents and emerging adults that were no longer in school, either drop outs or in the criminal justice system.  However, most participants agreed that substance abuse, especially of the previously mentioned substances, was a widespread problem among high and low-income families.  The underlying causes of substance abuse vary by socio-economic class.  The law enforcement officials in this focus group perceived that low-income substance abusers may turn to substance abuse because of a lack of resources.  Maine also may have higher rates of substance abuse problems because it is a rural state.  There is less support for substance abusers further away from the urban centers of Lewiston and Portland. 
	The biggest problems related to substance abuse were perceived to be the increases in crime (both crimes as a result of substance abuse, for example, stealing alcohol, and as a result of being under the influence, for example, driving drunk), mental health consequences and decrease in family functioning.  Child abuse was discussed in particular.  The participants also perceived that more than 50% of crime is attributable to substance abuse.  These officers reported that eliminating substances from society would bring a 50% decrease in crime.	
In the discussion of substances in particular, alcohol was perceived as accessible from a variety of sources.  Issues in accessibility include vendors not carding consistently, adults furnishing to the underage, and parents providing to minor children.  The police are aware of adults in the community who are willing to provide to minors.  Tobacco is a problem for law enforcement officials dealing with adolescents because parents often provide cigarettes to children.  Tobacco is legal for minors in the home, and parents often perceive it as a lesser of two evils compared to marijuana and alcohol.  Many parents have reported to law enforcement officials that they need to “pick their battles” with their children and provide cigarettes.  Tobacco is also a common way to relieve stress for many people.  Similarly, marijuana was perceived to be easy to obtain.  The law enforcement officers reported that marijuana is easy to grow across Maine and that there is little that they can do to investigate and prosecute growers.  The state debate over medicinal marijuana in the media is sending mixed messages to marijuana users, especially youth.  The biggest issues with other illicit drugs are dealing with laced marijuana and prescription drug misuse and abuse.  Law enforcement officials are seeing an increasing prescription drug misuse problem among adolescents.  Also, the perception among law enforcement officials is that adult drug seekers are not as monitored as they should be mainly because providers are not as aware of problems as they need to be.  However, the majority of juvenile offenders use alcohol and tobacco products.  Androscoggin County has not yet seen the increase in “harder” drugs like the coastal areas of Maine. 
In regards to college problem drinking, the participants perceive that students at a residential college like Bates face fewer legal consequences of illegal drinking, so there is increased use among that population.  They noted a relatively low incidence of such problems at CMCC, primarily a commuter school.  One issue related to the high level of binge drinking at Bates is the number of city resources that are used by high-risk drinkers that could be used in other ways.  For example, police units and ambulances may be needed to transport a student with alcohol poisoning to the hospital, instead of dealing with other medical emergencies in the city of Lewiston.  If that underage student had not been drinking, or drinking at that high level, those resources could be better used.  Central Maine Community College does not have the same high risk drinking issues as Bates College because its on campus community is only 80-100 students.  Also, CMCC is a dry campus and their no-alcohol policy is strictly enforced by a residence hall supervisor in the evenings and on weekends.  Overall, there is a different culture at CMCC with regard to alcohol consumption on campus. 
The law enforcement officials also brought up a few other key issues not addressed in the protocol.  A major policy issue that they perceive as having a negative impact on the community is the consequences for youth being caught with cigarettes versus marijuana.  Youth (under 18) arrested with cigarettes are charged as an adult, so they are more heavily penalized.  Youth caught with marijuana are charged as children, so they are less heavily fined, and are rarely accountable for that fine.  The participants felt that this discrepancy sends the message to youth that marijuana is less serious than cigarettes.  It is a confusing policy issue, especially for the juvenile corrections officers who deal directly with youth offenders. 
An alarming trend that the police officers in particular noticed was that more and more adolescents and emerging adults are choosing to drink hard liquor rather than beer.  They attributed this change to the ease of stealing liquor bottles in comparison to beer, the better taste of the flavored vodkas and the marketing to youth and females of hard liquor rather than beer.  This might have an impact on the number of alcohol poisonings and deaths because strength of hard liquor compared to beer.
The final question for the participants was to make a “wish list” of ways to reduce substance abuse if money was not an issue.  The group wanted to increase contact between youth and positive role models in society, especially for the youth in the criminal justice system who have little contact with positive adults.  Also, a reward system for youth who don’t use was thought to be a potentially effective strategy.  A program like “Student Citizen of the Year” could be created that would offer a scholarship to students who remained substance free throughout high school.  If their habits could be studied more in depth, kids who make the “right choices” could be acknowledged in ways similar to the academic and athlete stars. 
Faith Based Organizations Focus Group
The faith based organization leader focus group was held in May 2007.  Kathy Low and Wendy Tardif facilitated, and Katherine Forester took notes.  The participants consented to a tape recording of the session.  There were three participants, all local, Lewiston/Auburn area faith-based organization leaders.  Two of the participants worked primarily with Bates College students, whereas the third, a local Catholic priest, also worked with multiple congregations, including rural parishes, in Androscoggin County. 
	The participants all expressed interest in increasing the use of faith-based organizations in the fight against substance abuse.  They wanted to learn more about what they could provide to substance abusers or to their faith communities in terms of substance abuse prevention and/or treatment. Specifically, they asked for a substance abuse help resource guide that they could provide to their faith community.  Such a document or brochure would include information about local resources and treatment options for those with substance abuse problems.  Listings of treatment facilities, points of contact, or phone numbers might be useful.  These clergymen also agreed that alcohol was the drug of most concern in Androscoggin County.
	The participants all had at least some contact with youth in their faith communities.  All three participants were employed at Bates in the chaplain’s office, and in their roles at the College, they have considerable contact with students.  They perceived that among college students, consumption of alcohol is well accepted and a part of campus culture, rather than a weekend activity.  However, they noted that the students who adhere to religious or spiritual practices tend not to participate in that drinking culture.  The college chaplain noted that often freshman get “sucked in” and “try or experiment” when they arrive at college.  Eventually, the more religious students tend to transition out of the drinking culture and find a different on-campus identity.  The participants noted that the “work hard, party hard” mentality of college contributes to widespread and heavy use of alcohol.
Those students who do drink heavily and also have contact with the faith community on campus often express that they drink more than they intend to.  However, the atmosphere at college does not facilitate reduction in heavy drinking.  Although faith based leaders consider themselves a resource for substance abusing students, they perceive that they are underused by youth.  The youth who do express a willingness to reduce their drinking and substance abuse on campus tend not to have severe substance abuse problems. 
The participants also noted that a lot can be learned from the international community on campus and in the community.  International students tend to participate in more alternative activities rather than activities oriented around alcohol in college.  The community of non-drinkers on campus is small, but it has developed its own support system.  Although the most devoutly religious students tend not to drink as much, the participants were not sure if being religious is truly a protective factor among students, or whether other differences, for example, their international status, resulted in different behavior.  The participants reported not hearing much about other substances being used on campus. 
	The Catholic priest had the most contact with faith communities off-campus, therefore many of the perceptions of substance abuse in the context of ministering to a parish are related to his experiences. 
He perceived that tobacco use in Androscoggin County to be higher than ideal, especially with the support and information available.  Most of the contact he has with patients about smoking cessations occurs with terminally ill patients dying from tobacco-related illnesses.  Smokers or those with tobacco addictions do not seek help from faith-based leaders until an illness occurs.  He also observed that lower income community members tend to smoke.  He attributed this to the added stress in their lives due to economic hardship.  They also lack the resources to quit smoking.  The other participants had no direct contact with adult smokers, as their faith communities are limited to college students. 
	In terms of alcohol use among adults in Androscoggin County, AA has a strong presence in the faith community.  The catholic priest suggested that it is often used as a resource for his parishioners because it is free and widely available.  These clergy members also agreed that there are many substance abuse treatment resources available to community members.  Specifically, they noted that there seem to be lots of treatment programs, but compliance and follow through were problems.  They requested a condensed list of these resources to provide to their faith community after the focus group.  He suggested that Healthy Androscoggin could use public service announcements as a way to inform people about alcohol abuse and alcohol resources in the community.  They should be aired at times when community members may be most likely to abuse alcohol or other substances (e.g., Christmas and holidays). 
	All the participants expressed an interest in knowing more about elderly substance abuse in the community.  However, they expressed concern that the ritualized cocktail hours of the elderly generation certainly place them at risk for developing substance abuse problems.  Also, the stress of a death or decline (physical or mental) of a spouse may also place the elderly at increased risk.  One way to increase intergenerational contact, which may help youth and the elderly prevent substance abuse problems is a program called “family groups”.  This model is used in two of the Catholic churches (St. Phillip’s and St. Katharine’s) in the area.  It is used in parishes where the community is made of up people who moved to the area and have immediate family all over the United States.  It brings people together in groups resembling a “typical” family:  there is a generation of elderly, middle aged, young people and youth.  This group facilitates activities such as game nights, camping trips, and dinners to simulate the social support provided by family.  In the two parishes that use these groups, the intergenerational groups are highly successful.  The clergy also described, “parish nurses”, health care workers who are associated with specific parishes and can assist with medical screenings and basic health information after services or in the context of parish gatherings.  This is one strategy for providing medical screenings and information to elderly parishioners who are housebound or rarely get out.
	In addition, the group suggested using the human resources departments of businesses that have many retirement age workers to start providing information to people before they retire.  This could be used at Bates, where older employees may have a substance abuse problem and be too fearful of social stigma to reach out for help.  The human resources department could reach out to workers instead.  This non-job-threatening strategy could help those older workers in need before retirement cuts them off from the available resources.  
	The group discussed at length the importance of increased connections between faith-based organizations and public coalitions like Healthy Androscoggin.  Direct contact and trust in faith based leaders have could be used to disseminate health information or information about local initiatives.  At this time, the group believed that this type of relationship is being under-utilized by Healthy Androscoggin and other public health groups. 

Key Informant Interviews
	Interviews with key informants were completed during May, June and July to supplement the data already collected.  Key informants were community members who were determined to have unique insight or knowledge of substance abuse within Androscoggin County.  Ten interviews were completed.  Examples of key informants include substance abuse counselors from local colleges, law enforcement officials, home health workers, alcohol marketers and a pharmacy manager.  The interviews were comprised of twelve questions taken from the SPEP Questionnaire and modified for an interview format.  
Psychiatrist
A child and family psychiatrist was interviewed in May 2007.  She generally serves a low-income population of children with special needs and psychiatric diagnoses.  Many are disabled and/or Mainecare patients. 
The most problematic substance based on this informant’s experience is alcohol, followed by prescription drugs.  She is particularly concerned about diversion of narcotics.  Although some of her patients and families have difficulty with marijuana, she asserted that alcohol is a more serious threat to families.  She has also seen more crystal methamphetamine addiction recently, and is aware of some inhalant, crack and IV drug use in her patient population. 
Alcohol has been particularly troubling for this informant because of its negative impact on families and children, and because of its widespread availability.  She often sees families with alcohol dependency in three generations.  Father-son relationships in alcoholic families have been particularly problematic in her experience, and she believes paternal alcoholism has a powerful effect on sons.  Domestic violence arising from alcohol abuse is a secondary and very serious problem, in her estimation.
In terms of prevention of both alcohol and drug diversion/abuse, she believes that it is difficult to monitor the availability of substances adequately.  Because many of her patients and their families have criminal histories, they are exposed to illegal drugs frequently.  She also notes the tendency for those patients or parents with malintent to get multiple prescriptions and divert prescription drugs for non- medical use.  For some patients, she has begun to use patches or other delivery systems, rather than pills.  These can’t be put on someone else, and are slow release, so they reduce illicit use. She is also careful about prescribing in situations in which she believes the parents may use or sell the children’s drugs, but it is not always easy to detect this kind of abuse.  While physicians can help with this, she believes pharmacies and perhaps agencies will also have to monitor the situation.  In addition, she noted poverty, unemployment, and lack of education as risk factors for substance abuse.
Recommendations for prevention and treatment include more services for children or teens, specifically.  She finds that most families know where to get services, and many have been through multiple treatment programs for substance abuse.  She has both patients who overuse the system, and those who never seek help.  For example, there are families for whom there is considerable stigma around dependency or abuse who don’t get treatment.  She believes that education and reduction of stigma may help.  She also notes the existence of malingerers, individuals who overuse services and exaggerate their difficulties.  She also noted that she rarely sees the “index cases”, the users, but sees the fall out in children and spouses of alcoholics who are her patients.
This informant noted the association between mental health problems and substance abuse, and advocated prevention of mental health problems like depression and anxiety, or very early intervention at school age.  She also commented on the connection between physical disability and substance dependence. Reducing mental and physical impairments will, in her estimation, also reduce substance abuse.
For prevention and treatment, she believes AA is helpful to some, but would like more education around treatment.  AA is often rejected by the fathers in her families, for example.  Stress reduction and management would also help.  Many don’t seem motivated to seek treatment, and she relates this to a hopelessness in the impoverished segments of the community.  She also speculated about possible careful screening peri-natally to protect young children from substance abuse—home visits by nurses, physician screens to identify substance abuse in parents, etc.  She also wondered if Fetal Alcohol Syndrome rates and reports could be a screening strategy for addressing the problem.
This informant wonders about spirituality and the role of religiousness in this community and in the well being of people in the county. She noted that many individuals with whom she works have difficulty finding meaning in life, and seem directionless.  These profound problems are difficult for a single provider to address, so will likely need systemic approaches.
In sum, this informant identified alcohol as the most problematic substance in the county, followed by prescription drug diversion and abuse.  According to this informant, education, access to services, early screening and intervention, and strategies that might confer “meaning” in life might be useful.  
Child and Family Case Worker
	A child and family social work professional was interviewed in May 2007.  When asked to identify problematic substances, she listed alcohol, marijuana and tobacco.  She believes that marijuana abuse is a growing concern.  She also notes that many of her clients who have substance abuse problems have children with behavioral and emotional difficulties.
	In terms of causes of substance abuse, she mentioned parental monitoring, stress in families and children, depression, self-medication, and people being unable to cope.  Many of her clients are addicted, and find they can’t cut back and still function.  Some have access to treatment, but have difficulty with cessation.  Most are aware that they need to cut back or quit smoking, but are unable to be successful.  Poverty plays a role in the stress and hopelessness these patients feel.
	Media is also a contributing factor, according to this informant.  Kids respond to local advertising and things they see in movies or videogames.  Enforcement seems to be working, although sometimes police, “let people off too easy”.  She reported, for example, that one of her clients violated a substance-related probation, and got very little response.  Stronger penalties and better enforcement might help. This informant also advocated higher taxes on alcohol and cigarettes to make them less affordable.
	Barriers to treatment include limited resources, literacy, and mental health issues.  Many people can’t access treatment because of other disabilities, or because they can’t afford it.  She also has clients who are very limited cognitively who can’t negotiate the paper work or the system in order to get treatment.  She perceives the poor as most at risk in a variety of ways.
	In terms of prevention, this informant believes that schools could do more prevention education, and that local public health agencies should continue with media messages and programs designed to reduce use and abuse.  Parent monitoring should be encouraged, and programs like “Those Who Host Lose the Most” seem effective.  She also believes that many think marijuana is safe, and would like to see more education and enforcement around marijuana use.  Because her parents often use, even around their children, she is uncertain about how to address this issue from the public health standpoint.
College Health Educator/Health Center Staff
	Two college health center providers were interviewed in June 2007. Substances of primary concern in the college setting are alcohol, marijuana, and prescription drug abuse, in that order.   According to the college informants, binge drinking accompanied by alcohol poisoning has increased in the last several years.  Alcohol is readily available, either through older students, or through retail purchase.  Informants were concerned that increased enforcement may also inadvertently increase risk for students.  When intoxicated, students who are under age may hesitate to come forward or to seek help because of fear of legal or institutional reprisals.  Further, students drink in isolation, often secretly, or drink hard liquor because it’s easier to conceal and transport.  Students are also combining alcohol with other drugs, or with energy drinks, with untoward effects.  Health center informants perceive these factors as increasing risk of alcohol toxicity.  The informants noted that college women may have more difficulty with alcohol than men, and were interested in exploring gender differences related to abuse.
	Informants were also concerned about marijuana use, which they perceive as widespread.  Marijuana is readily available, either from other students, or in the local community.  Students tend to view the drug as benign, although there are clearly some users who become dependent.
	Prescription drug abuse is a profound concern of the health center informants, and a relatively new development.  Increasingly, these providers are seeing students who mix prescription drugs with alcohol and/or marijuana, with deleterious effects.  Students tend to perceive prescription drugs as safer than illegal drugs.  Psychostimulants are readily available and are often used in combination with alcohol, sometimes intra-nasally.  The informants also believe that students are abusing narcotics, although this is less common.
	Causes of substance abuse are primarily stress and peer pressure.  The informants believe that norms have changed, and that drinking to get drunk has become normative in residential college settings.  They also speculate that some students are self-medicating for stress or depression, as these problems have increased in this population over the last decade or two.
	Media messages are a problem, as are retail practices.  The informants were concerned about “specials” at bars, like “two-for-one” nights, and that alcohol is promoted in the media in association with sporting events and television programs.  Parents should also be more involved, these informants believe.  Many students have not had adequate education or discussions with parents about drugs and alcohol, particularly prescription drugs.  Perhaps parent workshops and discussions about how parents of young adults can handle these conversations would be useful.
	Barriers to treatment include a lack of programming for youth, access to services, expense of therapy, and difficulties getting psychiatric treatment when needed.  Some agencies that used to accommodate Bates students are no longer in the community.  The informants find that one-on-one counseling with a registered substance abuse counselor is effective, but expensive.  Enforcement of rules and policies, and reduced access help, but also increase risks in some cases (see above).
	In sum, alcohol, marijuana and prescription drug abuse are key issues in this population.  Better access to treatment, more parent involvement and education, and addressing access/media issues are potential prevention strategies.
Home Health Care Worker
A social worker employed in home health care from Androscoggin Home Health was interviewed in June 2007.   For elderly clients served by the agency, the key drugs of concern are benzodiazepines, narcotics and pain medication, and alcohol, in descending order.  This informant reported that in the elderly, addiction to benzodiazepines is a critical problem.  Those with problems are often older people who have never had previous dependencies, but who’ve been prescribed anxiolytic medication by their physicians.  Other drugs that reduce anxiety, like Selective Serotonin Reuptake Inhibitors (SSRIs), are less problematic, and he rarely sees problems with these prescriptions.  He believes that drug advertisements, including those for anxiety and sleep medications, may contribute to the perception that these drugs are safe.  He also noted that the availability of funds for prescriptions may contribute to the problem.
Alcohol is also an issue in the elderly, homebound population.  This informant noted that some individuals have more difficulty with pain or sleep as they age, and sometimes use alcohol to assist with both. 
“The older French people, for example, they’ll use coffee brandy to get to sleep.  That’s a French tradition.  And then they have a bit more, a bit earlier, and before you know it, they have a problem.” 

 He also noted that some stop drinking, but substitute benzodiazepines for the alcohol as they age.  He occasionally sees marijuana use in elderly clients, but does not believe this is widespread. The informant also noted that tobacco is an issue, with approximately 15-20% of his patients smoking, but also added that he doesn’t believe his patients would be receptive to cessation.  Many have long-standing habits, and are unlikely to quit.  He does have patients who get addicted to pain medications, but these are less of a concern than those with dependency on benzodiazepines.  He is not concerned about drug use in the terminally ill patients that the agency serves.
Other drugs of concern in the County are illegal drugs and cocaine.  He sees relatively little of these types of drug abuse in his population.  He noted that treatment is difficult to access, particularly for the elderly.  Many inpatient programs are reluctant to accept elderly patients for fear that they will have difficulty with discharge placements. He also observed that there are no treatment options for benzodiazepine addiction locally.
This informant recommended intervening with patients, physicians and pharmacists to try to identify those patients at risk for prescription drug dependence, and particularly benzodiazepines.  In terms of prevention, he believes educational programming for all parties would be helpful. Because these drugs also produce sedation, they can contribute to falls and other health problems in the elderly.
Local Pharmacy Director
	A pharmacy director was interviewed in June 2007.  The pharmacy serves all those needing prescription medication.  He named Vicodin, marijuana, cocaine and alcohol as the most available substances within the community and identified Vicodin as a substance whose prevalence has increased in the past five years. 
	When asked about the main causes of substance abuse, he focused on the breakdown of family and spirituality.  According to this interviewee, the disintegration of these entities has led to a lack of self-discipline, increased materialism and a desire for immediate gratification, ultimately leading to substance abuse.  
“People aren’t taught values like they used to be and the reasons why it is important to have values.”

He spoke to the mixed messages being sent to our community about substance use and abuse, and how celebrities often indirectly promote substance abuse.  He lamented that celebrity status is not used for good, but rather is an end all be all.  Furthermore, messages are being sent that substances are a way out from one’s problems and that is acceptable to be irresponsible with drugs and alcohol.  He also noted that there are also anti-substance use messages being delivered to the community.
	He believes that teenagers are the most at-risk for substance abuse because they haven’t experienced the consequences of their behavior.  People in their 20s and 30s, as well as baby boomers, were mentioned as possible populations at-risk for substance abuse, although teenagers were perceived as the most at-risk group within the community.
	According to this interviewee, the consequences of substance abuse are crime and violence on a community level, and are lowered inhibitions leading to infidelity and irresponsibility on an interpersonal level.  He also noted that substance use robs people of their ambitions, which then further damages the community. 
In order to deter individuals from using harmful substances, he advocates for instilling values into our youth and adults through spiritual life, family, and interactions with good citizens in the workplace.  He noted that Big Brothers, Big Sisters is an effective substance use prevention strategy as it uses mentoring to instill values while giving youth someone to look up to. Linking community members to area church groups will also provide positive role models for youth. 
The interviewee stressed that the main barrier to prevention is not funding. 
“Too often we throw money at a problem and it eases consciences but doesn’t get the job done.”

Rather than funding, he stressed the need to encourage basic values, principles and self-discipline among community members.  He also emphasized that, as a community, we should not be afraid of being judgmental of others, as being judgmental can be valuable as a way to keeping people healthy.  In his words it is “a healthy peer pressure.” 
	In terms of treatment, he stated, “The biggest barrier is people not wanting to help themselves.”  He noted that the community offers help in the form of meetings and counseling, but that the motivation to seek these resources is lacking.  After another moment of thought, he stated that advertising available resources and erecting a referral center would be helpful.  This referral center would be a central place that could direct community members to the resources they need.  However, again, he emphasized that people have to want to improve their situation.  He also spoke directly about specific drug treatments.  He feels as though heroin treatment can work well when followed properly, however methadone treatment programs often maintain individuals’ abusive behavior rather than treating it.  In terms of treatment for alcohol, he believes that Alcoholics Anonymous is a positive program, but overall, an investment in one’s substance use treatment program is the key to success. 
	Although the pharmacy director often stressed that he is not a fan of giving away help, he also spoke to creating a balance between enabling individuals to get the treatment they need without providing financial support outright.  For instance, he stressed that if we take away driving privileges from a drunk driver then we must provide public transportation to get that individual to work.  He also mentioned that people need to work themselves out of their problems without being reliant on Medicaid.
	Just before the conclusion of the interview, he summed up his views on substance abuse prevention and treatment by saying, 
“A quick fix-it program is not going to work. It needs to be broad reaching and deep.  We can do better.”

Bar/Nightclub Owner
	A local bar and nightclub owner was interviewed in June 2007 for his unique perspective as a purveyor of alcohol and substance abuse prevention promoter.  The population that he serves includes anyone over 21 who reside in the area between Boston, MA and Bar Harbor, ME.  The average age that he serves is 35 years old.  The top three most available substances are tobacco, alcohol, marijuana, prescription drugs and cocaine (ordered from most available to least).  Both prescription drugs and cocaine have increased in prevalence over the previous five years, while tobacco use is on the decline due to effective programs that make purchasing tobacco difficult. 
	In his opinion, the 23-27 year olds are those most at risk for substance abuse because they don’t know their substance use boundaries.  Interestingly, he thinks that the 21 and 22 year olds have learned from educational interventions presented in the schools that they should use designated drivers when spending a night at the bar.  However, in his estimation, the 21 and 22 year olds feel protected from harm because of their designated driver and thus feel they can do more substances without getting in trouble, such as prescription drugs, cocaine and pot. If this is true, then the designated driver message is effectively reaching this population, but it may be having the negative side effect of teaching youth that a driver protects them from all harm.
	When asked about the main causes of substance abuse in the community, he mentioned a lack of parenting in our community and that friends are now acting as parental figures for our youth.  He also mentioned that due to the breakdown of religion, youth aren’t afraid of going to hell if they take substances. 
“If kids are afraid they’ll go to hell, then it keeps kids away [from substances].  Police use intimidation and fear, but police are just men, not God.”

Society sends the message that it is ok to act out and find an easy way out of your problems with a “magic pill”.  This combined with confusion about the dangers of prescription drugs gives people permission to seek out drugs.  However, the bar owner cited peers as the ones sending the most messages about substance use.
In terms of substance abuse prevention, he stated that kids need to know that they have someone to talk to who they can trust if they have concerns about substance use.  He feels that you can’t keep youth from experimenting, but you can provide educational interventions that make youth more comfortable talking openly with police officers and other adults.  As part of this effort, there should also be greater communication between schools and parents, although he noted that schools are weary of policing youth for substances.
The interviewee spoke at length that our policies surrounding substance use and related enforcement need to be more stringent and should be uniform for both convenience stores and bars.  For instance, he feels as though those who serve alcohol or sell tobacco should be of legal age themselves and not just 18 years old as the law currently mandates.  He also feels that substance servers or sellers should take a class in order to be licensed for their jobs.  Law enforcement should have an occasional presence at bars and convenience stores to ensure that servers and sellers are indeed licensed and do not have any OUIs on their own records.  He asked how we can expect a bartender to get a cab for someone who has had too many drinks when the bartender has an OUI themselves.
In addition, the bar owner spoke about changes he’d like to see in the liquor licensing process.  For instance, he wants to see individuals interviewed about their business before receiving a liquor license, in order to ensure that the individual intended to follow liquor laws.  Furthermore, he wants the number of liquor licenses limited within each county in order to raise the value of these licenses and to limit the number of establishments that law enforcement needs to patrol.  In order to fund responsible substance use education, he would like to see half of the cost of the license earmarked for education.  He also feels that bar owners should be required to attend classes themselves regarding substance use and abuse and they should be forced to donate their time to local substance abuse prevention causes. 
The bar owner promotes the idea of using new technologies to protect individuals from making bad decisions.  For instance, he mentioned a device that can be installed into automobiles which prevents drivers from starting their engines if the device’s breathalizer indicates that the driver is intoxicated.  He also presented an idea to mark individuals’ driver’s licenses if they get a violation related to substance use. This would allow bar owners to check licenses at the door and immediately know who has a previous violation so that person’s alcohol consumption and behavior can be watched closely.  Finally, he suggested a whistle blowers program to allow citizens to anonymously report drug users in their neighborhoods which could be funded by fines to drug users.
Substance use treatment, in this bar owner’s view, is lost on adults.  He feels that adults cannot get effective treatment for substance use and that instead community prevention and treatment efforts should concentrate on the youth.  He also added that adults in the community feel that local organizations are giving disproportionate aid to the Somali population, and that these organizations are not interested in helping the rest of the community.  Finally he mentioned that within our society, people are afraid to talk about substance abuse, so we need to open up a dialogue about this issue and send a message that we will no longer tolerate substance abuse.  In order to take pride in our community we need to take care of it and build pride within our schools and sports teams. 
Sports Manager
	A sports manager was interviewed in July 2007.  The manager works with a wide range of the Androscoggin county population including all ages, genders and races. He believes that the most available substances in the county are alcohol and marijuana. Due to the fact that he moved to Androscoggin County recently, he is unaware of what substances, if any, have increased over the past five years.
	The main causes of substance abuse in any community, according to this interviewee, are family issues, depression and stress.  The availability of substances aggravates the substance use problem, as it is very easy to purchase alcohol everywhere in the community from convenience stores to local supermarkets, which sends the message that alcohol is acceptable.  However, the You Booze You Lose Program is one initiative that he mentioned, which reportedly sends positive messages to youth not to drink and drive and to abstain from underage drinking.
	When asked about substance abuse prevention, this manager advocates for more family events and providing a safe space for kids and youth to hang out in order to keep them off the streets.  He also suggests a designated driver promotion program be presented in the schools.  He views the people living in the downtown neighborhoods to be at the greatest risk for substance abuse.  The poor/lower class was also identified as an at-risk population. 
	He listed several consequences of substance abuse in Androscoggin County including death, unhealthy lifestyle, job loss, unhappiness/depression, while the effective deterrents to substance abuse are gyms and community events.  A lack of information about substance abuse treatment was cited as a common local barrier, as was funding for treatment programs.  In order to improve access to substance abuse treatment, this manager thinks that school-based awareness programs, and advertising on public access television are both effective ways to disburse information regarding substance abuse treatment.  He also suggests having the balloon festival or other prominent event sponsored by Healthy Androscoggin or other local groups in order to promote substance abuse treatment. 
	It was clear during the course of the interview that the sports manager was unsure how to answer some of the interview questions because of his recent arrival to the area, but he showed some interest in the topic and seemed open to partnering with Healthy Androscoggin and other local organizations on future health-related projects. 
Older Adult Service Provider
	A service provider to older adults, who is employed by Seniors Plus, was interviewed in July 2007.  In addition to the elder population, she also works with disabled adults within the community.  When asked to list the top three most available substances within the area, she listed alcohol, prescription drugs and tobacco.  She believes that the prevalence of prescription drugs has increased in the past five years among the general population and that there is an increase in tobacco use in college-aged youth.  She drew the latter information from an article she had recently read in the newspaper. 
	According to her experience, substance abuse among young to middle aged adults is caused by our culture and peer pressure.  However in the older adult community, substance abuse is mainly caused by depression and isolation.  She has heard both pro-substance use messages from marketers as well as prevention messages locally.  Interestingly, after being asked about the populations that are most at-risk for substance abuse, she listed teenagers before older adults 55 or 60 years old and older, despite of her work with older adults.  She believes the consequences of substance abuse to be death, suicide, ill health, broken families, overcrowding of jails, and increased violence. 
	When questioned about the barriers to substance abuse prevention, this Seniors Plus employee stated, “human development.” 
“Teens will do something that goes against establishment; they will rebel in one way or another.  We bring up our kids to know that drugs and alcohol are bad and kids go against this.”

One’s acceptance of popular culture, which dictates that substance use is ok, was also mentioned as a significant barrier to substance abuse prevention.  In addition, she thought that people have difficultly using substances in moderation, like alcohol and prescription drugs, because they are not labeled by society as completely positive or negative.  She also expressed that prevention is difficult in a world where people are using substances as a salve for their wounds.  
“Unless we have a perfect world, we will have substance use.”  
In order to effectively deter people from substance abuse, she advocates for education and a decrease in advertising by substance producers. 
	She feels that effective substance abuse prevention includes: education, limiting youth access to tobacco, more frequently requesting ID for substance purchases, instituting smoke-free public buildings, increasing the legal driving age, and stiffer sentences for possessing illegal substances.  However, after stating the latter two prevention strategies she expressed uncertainty about how effective they truly are.  She feels that it is important to reach teens by working with parents and other people who surround teens, while also educating parents and health care providers about the health effects of substance use.  Parents should also be educated about the consequences of providing alcohol to minors.  In order to reach teens directly, she proposed shocking teens into changing their behavior by taking them to a jail or morgue or presenting them with a drunk driver who has killed someone.  Alternatively, a campaign could demonstrate to teens how professional marketers use manipulative techniques for advertising dangerous substances. 
	She also briefly discussed enforcement of drunk driving and drug use, and feels that our society should use stricter sentencing and find the source of drug distribution to attack our community drug problems.  She hypothesized that if we made marijuana legal, drug abuse of this substance might actually become a non-issue because it would lose its “charm” as in illegal substance.  
	Among the barriers to substance abuse treatment, this service provider listed inadequate funding for recovery programs (she noted that this is particularly true in New Hampshire where she previously worked) and a lack of awareness about substance abuse issues among the 55 and older community.  She is particularly concerned that physicians are not aware of substance abuse as an issue within the older adult community, and thus they don’t think to ask their patients about it.  For instance, she thinks that physicians aren’t careful to ensure that their patients are taking their medications as instructed and aren’t screening patients for depression, which could lead to substance abuse.  In order to improve this situation, she believes that increased funding for recovery programs and increased education for medical professionals regarding substance abuse in the older adult community are necessary.  Research should be conducted to explore the effects of medication and “cocktails of pills” on the elderly. Then this information should be presented to the general public and medical professionals.  One important piece of information that medical professionals should pass along to their patients is that a half glass of wine for a 70 year old has the same effect as a whole glass of wine on a 30 year old.  Finally, she feels that consumers and families could also use education that substance abuse is a problem in the elderly community and that it is never too late to treat it. 
	Although the interviewee did not discuss the prevalence of prescription drug abuse among older adults, she gave a sense that it is an issue of concern, but certainly not a crisis.  However, it should be noted that this key informant is still relatively new to this community, and thus a more thorough understanding of local substance abuse issues and trends should draw from input from other community members familiar with older adults and the disabled.
Distillery Marketing Manager
	An alcohol marketer for a local distillery was interviewed in July 2007 about her opinions regarding substance abuse in the area.  She is responsible for marketing alcohol to all of Maine and resides in the greater Portland area. Hence the discussion was not specific to Androscoggin County. Also of note, her opinions drew upon second-hand knowledge from her boyfriend who is a Portland police officer.  The population within Androscoggin County that she works with includes 21 to 40 year old males and females. 
	She feels that the top three most available substances in the area are alcohol, marijuana and cocaine, and these substances are the most prevalent for the population with whom she works.  Cocaine has increased in the past five years in her opinion.  When asked about the populations most at-risk for substance abuse, she listed 8th graders through 30 year olds and primarily males, but she senses that the at-risk population also includes some females.  She then specified that recurrent substance use and abuse occurs in the 21 to 30 year old age bracket.  
	The recurring theme of the interview was that substance abuse is caused by the messages that teens and young people receive from their families, peers and the media.  All of these entities influence one’s view of acceptable behavior and also demonstrate specific substance use techniques.  She feels that family background and peers are particularly strong predictors of one’s likelihood of substance use.  As mentioned in an earlier key informant interview, this marketer also believes that the illegality of substances increases their allure to teens in particular.
“If adults are doing substances, then the kid will.  Kids then spread the word to their friends. It’s a domino effect.”

The consequences of substance abuse she listed include addiction leading to crime, and particularly theft.  An increase in crime then leads to the need for a larger police force and increased court use.  To deter community members from substance abuse, she believes in education and harsher penalties for substance related crimes, including zero tolerance policies.  
	Combating substance use in light of these influences would be difficult, she thought, but should start with reaching kids with education and anti-drug messages when they are young while also sending the message that youth need to pick their friends wisely.  On a community level, she suggests shows and trade booths at the mall that advertise anti-drug messages and designating a weekend as “substance abuse awareness weekend.”  Again, these prevention efforts would target teens and young adults.	
	Substance abuse treatment is currently hindered by a lack of awareness that help is available and is confidential, according to this marketer.  She listed the following possible remedies to make the availability of treatment well known: general marketing and publicity to the community and advertising at schools. 
Liquor Store Manager
	The manager of a local liquor store was interviewed in July 2007.  He primarily works with 16 to 50 year olds, most of who are Androscoggin County residents.  In his estimation, the top three most available substances in the county, and among the population he works with, are marijuana, prescription drugs and alcohol.  Alcohol use has increased over the past five years, which he estimated from an increase in alcohol sales at his store over this time period.  However, he was unsure about changes in the prevalence of other substances in the area. 
	He feels that 10 to 35 year olds are the most at-risk population for substance abuse because advertising and packaging is geared toward the young, while substance abuse “isn’t even a topic” for older adults.  He discussed how substance abuse is caused by low self-esteem, peer pressure and financial stress. Those uncomfortable with themselves tend to follow other people’s actions and thus use substances as a way to make friends.  People with a low self-image are also more susceptible to peer pressure from others with whom they want to identify.  Although peer pressure is predominately an issue among youth, it is also an issue among adults as well.
	The accessibility of substances in the community was also mentioned as a barrier to substance abuse prevention efforts.  In his store employees closely watch customers accompanied by underage youth to assess if the adult might be purchasing alcohol for the youth.  The store’s employees then flag customers who have previously bought alcohol for youth and they refuse to sell to these individuals in the future.  However, not all liquor stores are as vigilant about monitoring their customers as his store has been.
	The messages being sent to community members regarding substance abuse are mainly positive, in his view.  There has been a large increase in the number of campaigns that advise people of the consequences of substance use and there are more disclaimers on substance packaging.  The Boys and Girls Club and similar community organizations are also sending anti-substance messages.  He advised that new anti-substance campaigns should reach teens through newer technologies like the computer, Internet and cell phones.	
	Among the consequences to local substance abuse, he mentioned the burden on taxpayers and individuals.  Substance abuse can lead to increased expenses related to medical treatment and counseling which are largely born on the taxpayer.  Drug activity weighs on the individual’s body and causes premature aging and disease.
	Androscoggin County community members may not seek treatment for substance abuse because of a lack of desire to make a life change and or a lack of opportunity to get the information necessary to seek treatment.  He cited specific instances in which someone might lack the ability to seek treatment including not having a computer or a driver’s license.  His solution to the treatment access problem is to install small information centers throughout the city where people can casually stop in to ask questions regarding substance use treatment and other health issues.  Perhaps people might open up to new possibilities during the course of their visit to the information center, including seeking help.  He suggested that local businesses could provide one room of office space for these information centers, and based on his own experience, most businesses would be happy to get involved in this way.
	When speaking about substance abuse prevention strategies, the liquor store manager again turned to the idea of getting local business more involved in health issues.  He believes that current partnerships between business, government and community organizations have led to successful ventures like the Auburn Skate Park.  In this spirit, he felt that companies could donate money toward field events and community organization outings seeking to improve health and decrease substance abuse.  He suggested the churches could partner with Healthy Androscoggin to make a website to coordinate all of the smaller efforts occurring within the community.  Again, he emphasized that soliciting a little bit of money from each local business would make businesses feel more involved with their community and could go a long way in prevention and treatment efforts.  For instance, businesses could donate enough money to send one downtown Lewiston kid to a Maine camp in the summer time as way to show them a different way of life than they may typically see. If fifty businesses would commit, then fifty kids could have this experience together. 
“Some kids may never have seen a fishing pole.  [At camp] they may think, we don’t have to be on the street.”

The liquor manager also spoke at length about the need for individuals to make a greater commitment to their community. 
“It is time to focus on people instead of the material aspects of the community…We need to start striving to volunteer.” 

	Finally, the subject of Lewiston-Auburn as a melting pot arose and he spoke about the need to bring youth together to teach them that “we are people, no matter who we are,” and to get kids to see the similarities in their ideas about community and health.  In some way, which was left undefined, community organizations need to bring youth together. 

	  

Appendix H: Healthy Androscoggin Substance Abuse Prevention Strategic Planning Questionnaire

Healthy Androscoggin
Substance Abuse Prevention Strategic Planning Questionnaire

We are collecting information from people who live or work in Androscoggin County. Below are several questions asking your opinion about the problems associated with substance abuse and ideas about how to prevent substance abuse.  We have separated the survey by age group.  Feel free to skip the questions for a particular age group that you do not feel comfortable answering.  We hope to use this information to better identify and respond to community needs by creating a county-wide substance abuse prevention plan. Your feedback is VERY important! If you need additional space, feel free to use the back of the survey.

Your participation is voluntary and please do NOT write your name on this questionnaire.

Section I. Participant Information	

1. I am a ______________: (check one)
	 Parent	 Coalition member
	 School employee	 Concerned citizen
	 Business owner	 Law Enforcement/ Criminal Justice System
	 Local government rep	 Youth
	 Healthcare provider	 Substance Abuse Counselor/ Treatment provider
	 Other: Please describe______________________

Section II. Substance Use for Youth (Under 18 years of age)	

							Not a problem	Somewhat of          Big             Very Serious
							At all	                   A problem          Problem             Problem
2. To what extent is underage drinking a 	 	       1		      2	           3	    4
     problem in Androscoggin County?

3. To what extent is tobacco use by those	       	        1		      2	           3	    4
      under 18 a problem?

4. To what extent is marijuana use a problem                    1		      2	           3	    4
     by those under 18?

5. To what extent is illicit drug abuse a problem                1		      2	           3	    4
     by those under 18?
     
6. To what extent is prescription drug abuse a                    1		      2	           3	    4
     problem by those under 18?

7.	Are there are other substances you feel are a problem with those under 18?  
If so, what substances?_______________________________________________________

8. What do you think causes youth substance use? ___________________________________
____________________________________________________________________________
9. What messages are youth getting from the community about drinking/ drug use and where are the messages coming from?
____________________________________________________________________________

10. What are the barriers to solving the problem of alcohol/drug use by youth?
____________________________________________________________________________
____________________________________________________________________________
11. ****Important:  What are your suggestions for preventing youth drug/alcohol use?
____________________________________________________________________________
____________________________________________________________________________

Section III. Substance Use for Adults (ages 18 -65)	

Not a problem	Somewhat of          Big             Very Serious
							At all	                   A problem          Problem             Problem

12. To what extent is alcohol abuse a 	 	       1		      2	           3	    4
     problem for adults ages 18- 65?

13. To what extent is tobacco use a use by those	        1		      2	           3	    4
      ages 18-65?

14. To what extent is marijuana use a problem                 1		      2	           3	    4
     by those ages 18-65?

15. To what extent is illicit drug abuse a problem              1		      2	           3	    4
       by those ages 18-65?

16. To what extent is prescription drug abuse a                   1		      2	           3	    4
       problem by those ages 18-65?

17. What do you think causes substance use in adult populations? Are the causes different depending upon the age of the adult, for example those ages 18-30 vs. adults ages 50-65? Please explain.
____________________________________________________________________________
____________________________________________________________________________

18. What messages are adults getting from the community about drinking/ drug use and where are the messages coming from?
____________________________________________________________________________
____________________________________________________________________________

19. What are the barriers to solving the problem of alcohol/drug use for adults?
____________________________________________________________________________
____________________________________________________________________________

20. What are your suggestions for preventing adults from abusing drugs & alcohol?
____________________________________________________________________________
____________________________________________________________________________
Section IV. Substance Use for Elders (those over 65 years)                                                     	             
Not a problem	Somewhat of          Big             Very Serious
							      At all	                   A problem          Problem             Problem
21. To what extent is alcohol abuse a 	 	      1		      2	           3	    4
     problem for adults over 65?

22. To what extent is tobacco use a use by those	        1		      2	           3	    4
      over 65?

23. To what extent is marijuana use a problem                  1		      2	           3	    4
     by those over 65?

24. To what extent is illicit drug abuse a problem              1		      2	           3	    4
       by those over 65?

25. To what extent is prescription drug abuse a                   1		      2	           3	    4
       problem by those over 65?

26. What do you think causes substance use in the elderly populations?
____________________________________________________________________________
____________________________________________________________________________

27. What messages are older adults getting from the community about drinking/ drug use and where are the messages coming from?
____________________________________________________________________________
____________________________________________________________________________
28. What are the barriers to solving the problem of elder alcohol/drug abuse?
____________________________________________________________________________
____________________________________________________________________________
29. What are your suggestions for preventing elders from abusing drugs & alcohol?
____________________________________________________________________________
____________________________________________________________________________

Section IV. Prevention Planning 	
30. What do you think your role might be in helping to address the problem of drinking and drug use in Androscoggin County? What age group (circle all that apply):   
under18   		18-30    			30-65   		65 & over
____________________________________________________________________________
31. What other feedback would you like to share? ____________________________________________________________________________
____________________________________________________________________________
Thank you for your participation! Please return to Healthy Androscoggin at 300 Main St. Lewiston, ME 04240