Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample.

BACKGROUND: Clinical assessments are a primary method for ascertaining suicide risk, yet the language used across measures is inconsistent. The implications of these discrepancies for adolescent responding are unknown, which is troubling as multiple research areas (i.e. on culture, mental health language, and suicide communication) indicate individuals from varying sociodemographic backgrounds may communicate differently regarding mental health concerns. The aims of the current study are to investigate whether a geographically diverse sample of adolescents respond differently to directly and indirectly phrased suicide attempt questions (i.e. directly phrased includes the term 'suicide' and indirectly asks about suicidal behavior without using 'suicide'), and to examine whether sociodemographic factors and history of mental health service usage relate to endorsement differences. METHODS: Participants were N = 5909 adolescents drawn from the Emergency Department Screening for Teens at Risk for Suicide multi-site study. The lifetime suicide attempt was assessed with two items from an adapted version of the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008): (1) a directly phrased question asking about 'suicide attempts' and (2) an indirectly phrased question providing the definition of an attempt. RESULTS: An adolescent majority (83.7%) consistently reported no lifetime suicide attempt across items, 10.1% consistently reported one or more lifetime attempts across items, and 6.2% of adolescents responded discordantly to the items. CONCLUSIONS: Multivariable models indicated multiple demographic and mental health service variables significantly predicted discordant responding, with a notable finding being that father/stepfather education level at or below high school education predicted endorsing only the direct question.

Development of "CULTURE FORWARD: A strengths and culture-based tool to protect our native youth from suicide".

OBJECTIVE: Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities' health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled "CULTURE FORWARD" for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths. METHOD: The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development. RESULTS: Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources. CONCLUSIONS: CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities' strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Community Perspectives on Social Influences on Suicide Within a Native American Reservation.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation.

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

"Empowering Our People": Impact of a Culturally Adapted Evidence-Based Intervention on Sexually Transmitted Infection Risks Among Native Americans With Binge Substance Use.

BACKGROUND: The objective of this study was to evaluate a culturally adapted evidence-based intervention called EMPWR (Educate, Motivate, Protect, Wellness and Respect) for impacts on sexually transmitted infection (STI) screening and sexual health risk behaviors. METHODS: We enrolled Native American adults with recent binge substance use from a rural, reservation community in the Southwest into a 1:1 randomized controlled trial conducted on July 2015 to June 2019. All participants were offered non-clinic-based self-administered STI screening. Data were collected via self-report at baseline, 3 months, and 6 months after the intervention. Baseline and end line data are presented. RESULTS: Three hundred one participants were enrolled and had a mean age of 33.8 years; 46.5% of the sample were female, and 9.1% were employed at baseline. EMPWR participants were more likely to complete STI self-screening than control participants (38.2% vs. 23.8%, P = 0.0275). EMPWR participants reported fewer unprotected sex acts in the past 3 months (9.3 vs. 16.0, P = 0.001) and were more likely to refuse sex if their partner was not tested (23.6% vs. 12.4%, P = 0.049). The between-group difference in STI positivity 1 year after study completion was nearing statistical significance (intervention: 39.5% vs. control: 59.6%, P = 0.0575). CONCLUSIONS: The culturally adapted evidence-based intervention, EMPWR, increased uptake of STI screening and refusal of sex if partner was not STI tested and decreased the frequency of unprotected sex acts among Native American adults with recent binge substance use living on a rural reservation. Future research is needed to examine EMPWR impacts among other Native American subgroups and its potential for advancing sexual health equity in this high-priority population.

Wakȟáŋyeza (Little Holy One) - an intergenerational intervention for Native American parents and children: a protocol for a randomized controlled trial with embedded single-case experimental design.

BACKGROUND: Trauma within Native American communities compromises parents' parenting capacity; thus, increasing childrens' risk for substance use and suicide over the lifespan. The objective of this manuscript is to describe the Wakȟáŋyeza (Little Holy One) intervention and evaluation protocol, that is designed to break cycles of intergenerational trauma, suicide, and substance use among Fort Peck Assiniboine and Sioux parents and their children. METHODS: A randomized controlled trial with an embedded single-case experimental design will be used to determine effectiveness of the modular prevention intervention on parent-child outcomes and the added impact of unique cultural lesson-components. Participants include 1) Fort Peck Assiniboine and Sioux parents who have had adverse childhood experiences, and 2) their children (3-5 years). Parent-child dyads are randomized (1:1) to Little Holy One or a control group that consists of 12 lessons taught by Indigenous community health workers. Lessons were developed from elements of 1) the Common Elements Treatment Approach and Family Spirit, both evidence-based interventions, and 2) newly created cultural (intervention) and nutrition (control group only) lessons. Primary outcomes are parent (primary caregiver) trauma symptoms and stress. Secondary outcomes include: Parent depression symptoms, parenting practices, parental control, family routines, substance use, historical loss, communal mastery, tribal identity, historical trauma. Child outcomes include, externalizing and internalizing behavior and school attendance. Primary analysis will follow an intent-to-treat approach, and secondary analysis will include examination of change trajectories to determine impact of cultural lessons and exploration of overall effect moderation by age and gender of child and type of caregiver (e.g., parent, grandparent). DISCUSSION: Many Native American parents have endured adverse childhood experiences and traumas that can negatively impact capacity for positive parenting. Study results will provide insights about the potential of a culturally-based intervention to reduce parental distress - an upstream approach to reducing risk for childrens' later substance misuse and suicidality. Intervention design features, including use of community health workers, cultural grounding, and administration in Head Start settings lend potential for feasibility, acceptability, sustainability, and scalability. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04201184 . Registered 11 December 2019.

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Suicide in the pediatric population: screening, risk assessment and treatment.

The number of children and adolescents dying by suicide is increasing over time. Patterns for who is at risk are also changing, leading to a need to review clinical suicide prevention progress and identify limitations with existing practices and research that can help us further address this growing problem. This paper aims to synthesise the literature on paediatric suicide screening, risk assessment and treatment to inform clinical practice and suicide prevention efforts. Our review shows that universal screening is strongly recommended, feasible and acceptable, and that there are screening tools that have been validated with youth. However, screening may not accurately identify those at risk of dying due to the relative rarity of suicide death and the associated research and clinical challenges in studying such a rare event and predicting future behaviour. Similarly, while risk assessments have been developed and tested in some populations, there is limited research on their validity and challenges with their implementation. Several promising suicide-specific treatments have been developed for youth, but overall there is an insufficient number of randomised trials. Despite great need, the research evidence to support screening, risk assessment and treatment is still limited. As suicide rates increase for children and adolescents, continued research in all three domains is needed to reverse this trend.

Predicting 3-month risk for adolescent suicide attempts among pediatric emergency department patients.

BACKGROUND: The incidence of adolescent suicide is rising in the United States, yet we have limited information regarding short-term prediction of suicide attempts. Our aim was to identify predictors of suicide attempts within 3-months of an emergency department (ED) visit. METHODS: Adolescents, ages 12-17, seeking health care at 13 pediatric EDs (Pediatric Emergency Care Applied Research Network) and one Indian Health Service Hospital in the United States were consecutively recruited. Among 10,664 approached patients, 6,448 (60%) were enrolled and completed a suicide risk survey. A subset of participants (n = 2,897) was assigned to a 3-month telephone follow-up, and 2,104 participants completed this follow-up (73% retention). Our primary outcome was a suicide attempt between the ED visit and 3-month follow-up. RESULTS: One hundred four adolescents (4.9%) made a suicide attempt between enrollment and 3-month follow-up. A large number of baseline predictors of suicide attempt were identified in bivariate analyses. The final multivariable model for the full sample included the presence of suicidal ideation during the past week, lifetime severity of suicidal ideation, lifetime history of suicidal behavior, and school connectedness. For the subgroup of adolescents who did not report recent suicidal ideation at baseline, the final model included only lifetime severity of suicidal ideation and social connectedness. Among males, the final model included only lifetime severity of suicidal ideation and past week suicidal ideation. For females, the final model included past week suicidal ideation, lifetime severity of suicidal ideation, number of past-year nonsuicidal self-injury (NSSI) incidents, and social connectedness. CONCLUSIONS: Results indicate that the key risk factors for adolescent suicide attempts differ for subgroups of adolescents defined by sex and whether or not they report recent suicidal thoughts. Results also point to the importance of school and social connectedness as protective factors against suicide attempts.

Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide.

BACKGROUND: This study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research. METHODS: Our primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10-24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders' Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders' Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders' Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing. DISCUSSION: Due to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care. TRIAL REGISTRATION: Clinical Trials NCT03543865, June 1, 2018.

"Let our Apache Heritage and Culture Live on Forever and Teach the Young Ones": Development of The Elders' Resilience Curriculum, an Upstream Suicide Prevention Approach for American Indian Youth.

The White Mountain Apache Tribe have developed an innovative curriculum that connects youth through Elders to their heritage, traditions, and culture, which has been proven to be a protective factor for native Americans. The development process took 4½ years and included community stakeholder buy-in, Elders' Council group formation, extensive formative work to identify content, iterative feedback between curriculum writers and Elders, and Elder training prior to implementation. Members of the Elders' Council have been visiting the local schools to teach youth about the Apache culture, language, and way of life since February 2014 reaching over 1000 youth. This approach demonstrates a promising upstream suicide prevention strategy. We discuss the process of development, implementation, and lessons learned, as this curriculum has potential for adaptation by other Indigenous communities.

Exploration of Pathways to Binge Drinking Among American Indian Adolescents.

Binge drinking is a serious public health problem among American Indian adolescents, yet few theoretical models specific to this population and type of problematic drinking have been tested. The White Mountain Apache Tribe has begun surveillance of binge drinking and a related line of research to inform tailored prevention efforts. The goal of this paper is to use structural equation modeling to understand the relationships between different individual, family, peer, and cultural factors that predict or protect against binge drinking behavior among Apache adolescents ages 10-19 years old. A cross-sectional case-control study was completed with N = 68 Apache adolescents who required medical attention due to a recent binge event (past 90 days) and N = 55 controls with no lifetime history of binge drinking. The hypothesized model was estimated with Mplus using the WLSMV robust least squares estimator. In the final model, stressful life events were related to family functioning and peer relationships. In turn, family functioning affected peer relationships and adolescent impulsivity, which were both associated with greater risk of binge drinking. The path between peer relationships and having engaged in binge drinking was statistically significant for those expressing lower cultural identity, but not for those reporting higher cultural identity. Findings suggest preventive interventions should emphasize teaching coping skills to manage life stressors and handle impulsivity, strengthening families, and changing peer dynamics with social network-based approaches as well as social skill training. The model highlights the potentially important role of culture in strengthening positive peer relationships to reduce binge drinking risk.

Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department.

The pediatric emergency department (ED) is a critical location for the identification of children and adolescents at risk for suicide. Screening instruments that can be easily incorporated into clinical practice in EDs to identify and intervene with patients at increased suicide risk is a promising suicide prevention strategy and patient safety objective. This study is a retrospective review of the implementation of a brief suicide screen for pediatric psychiatric ED patients as standard of care. The Ask Suicide Screening Questions (ASQ) was implemented in an urban pediatric ED for patients with psychiatric presenting complaints. Nursing compliance rates, identification of at-risk patients, and sensitivity for repeated ED visits were evaluated using medical records from 970 patients. The ASQ was implemented with a compliance rate of 79 %. Fifty-three percent of the patients who screened positive (237/448) did not present to the ED with suicide-related complaints. These identified patients were more likely to be male, African American, and have externalizing behavior diagnoses. The ASQ demonstrated a sensitivity of 93 % and specificity of 43 % to predict return ED visits with suicide-related presenting complaints within 6 months of the index visit. Brief suicide screening instruments can be incorporated into standard of care in pediatric ED settings. Such screens can identify patients who do not directly report suicide-related presenting complaints at triage and who may be at particular risk for future suicidal behavior. Results have the potential to inform suicide prevention strategies in pediatric EDs.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012.

OBJECTIVES: We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. METHODS: Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. RESULTS: The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. CONCLUSIONS: Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.

Risk and protective factors for heavy binge alcohol use among American Indian adolescents utilizing emergency health services.

BACKGROUND: American Indian (AI) adolescents are disproportionately burdened by alcohol abuse and heavy binge use, often leading to problematic drinking in adulthood. However, many AI communities also have large proportions of adults who abstain from alcohol. OBJECTIVE: To understand these concurrent and divergent patterns, we explored the relationship between risk and protective factors for heavy binge alcohol use among a reservation-based sample of AI adolescents. METHODS: Factors at individual, peer, family, and cultural/community levels were examined using a cross-sectional case-control study design. Cases were adolescents with recent heavy binge alcohol use that resulted in necessary medical care. Controls had no lifetime history of heavy binge alcohol use. 68 cases and 55 controls were recruited from emergency health services visits. Participants were 50% male; average age 15.4 years old, range 10 to 19. Independent variables were explored using logistic regression; those statistically significant were combined into a larger multivariate model. RESULTS: Exploratory analyses showed adolescents who were aggressive, impulsive, had deviant peers, poor family functioning or more people living at home were at greater risk for heavy binge alcohol use. Protective factors included attending school, family closeness, residential stability, social problem-solving skills, having traditional AI values and practices, and strong ethnic identity. Confirmatory analysis concluded that school attendance and residential stability reduce the probability of heavy binge alcohol use, even among those already at low risk. CONCLUSIONS: Findings deepen the understanding of AI adolescent heavy binge alcohol use and inform adolescent intervention development fostering trajectories to low-risk drinking and abstinence.

Advancing suicide prevention research with rural American Indian and Alaska Native populations.

As part of the National Action Alliance for Suicide Prevention's American Indian and Alaska Native (AI/AN) Task Force, a multidisciplinary group of AI/AN suicide research experts convened to outline pressing issues related to this subfield of suicidology. Suicide disproportionately affects Indigenous peoples, and remote Indigenous communities can offer vital and unique insights with relevance to other rural and marginalized groups. Outcomes from this meeting include identifying the central challenges impeding progress in this subfield and a description of promising research directions to yield practical results. These proposed directions expand the alliance's prioritized research agenda and offer pathways to advance the field of suicide research in Indigenous communities and beyond.

Community-based surveillance and case management for suicide prevention: an American Indian tribally initiated system.

The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and self-injurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.

Risk pathways for suicide among Native American adolescents.

Native American (Native) adolescents have the highest suicide rates in the United States, yet no conceptual models describing risk factors specific to this population exist. We sought to further hone a Native-specific conceptual model developed from quantitative data with qualitative data collected from a longitudinal series of interviews with (N = 22) Native adolescents who had attempted suicide. Four levels of suicide risk emerged, detailing individual, family, community, and societal factors that affect youths' pathways to suicide, along with a variety of subthemes and constructs. Some themes parallel established models of suicide risk; however, others are unique to the experience of this sample, including the impact of overtaxed households and family composition, significant grief burden, contagion, and stigma surrounding treatment seeking. We suggest adaptations of existing themes and constructs in the model. We discuss practical implications for research and intervention development, along with strengths and limitations of the study.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities.

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Structural violence of racism and colonization are social determinants of suicide.Collaborative and power-sharing implementation strategies can disrupt oppression.Strengths-based collectivist strategies can buffer structural suicide risk.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study.

PURPOSE: Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation. METHODS: Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation. FINDINGS: Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described. CONCLUSIONS: The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.