Follow-up survey and qualitative research on opioid awareness, knowledge and behaviours for public education - Final Report

Prepared for Health Canada

Supplier name:  Earnscliffe Strategy Group
Contract number:  HT372-184591/001/CY
Contract value: $198,115.86
Award date:  March 19, 2019
Delivery date:  July 19, 2019

Registration number:  POR 137-18
For more information on this report, please contact Health Canada at:
hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Prepared for Health Canada
Supplier name:  Earnscliffe Strategy Group
July 2019

This public opinion research report presents the results of focus groups and an online survey conducted by Earnscliffe Strategy Group on behalf of Health Canada.  The research was conducted from June 2019 to July 2019.

Cette publication est aussi disponible en français sous le titre :  Enquête de suivi et recherche qualitative sur la sensibilisation, les connaissances et les comportements liés aux opioïdes aux fins de l'éducation du public

This publication may be reproduced for non-commercial purposes only.  Prior written permission must be obtained from Health Canada.  For more information on this report, please contact Health Canada at:  hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB
200 Eglantine Driveway, Tunney's Pasture
Jeanne Mance Building, AL 1915C
Ottawa, Ontario K1A 0K9

Catalogue Number: H21-313/2019E-PDF

International Standard Book Number (ISBN): 978-0-660-31568-3

Related publications (registration number:  POR 137-18):

H21-313/2019F-PDF (Final Report, French)
978-0-660-31569-0

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2019

Table of Contents

• Executive summary
• Introduction
• Detailed findings
  • Section A: Opioids and illicit drug use
  • Section B: Opioid awareness, impressions and basic understanding
  • Section C: Attitudes relating to behaviours, risk, and harm
  • Section D: Attitudes regarding stigma
  • Section E: Risk behaviour profiling
  • Section F: Opioid information
  • Section G: Views on chronic pain and chronic pain management
  • Section H: The role of stigma
  • Section I: Views regarding alcohol consumption
• Conclusions
• Recommendations
• Appendix A: Survey methodology report
• Appendix B: Focus group methodology report
• Appendix C: Discussion guide
• Appendix D: Recruitment screener
• Appendix E: Survey instrument

Executive summary

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results regarding the follow-up survey and qualitative research on opioid awareness, knowledge and behaviours for public education.

Canada is facing a national opioid crisis, evidenced by the growing number of overdoses and opioid related deaths.   In 2018, Health Canada launched a multi-year public education campaign to address the growing opioid crisis and to educate Canadians on the risks associated with opioids as well as the role of stigma as a barrier to treatment.  The current research project was undertaken to help Health Canada gain insights Canadians' attitudes and perceptions toward opioids.  Feedback from the research will provide Health Canada with evidence-based data and insights to guide their public education campaigns.

The objective of the research was to follow-up on the 2017 baseline survey regarding the current state of awareness, knowledge, attitudes, beliefs and behaviours regarding opioids. This phase also included research into impressions of alcohol use, knowledge of Canada's Low-Risk Alcohol Drinking Guidelines, and views on chronic pain and pain management.  This project included both quantitative and qualitative methodologies. The contract value for this project was $198,115.86 including HST.

The specific objectives of the quantitative phase included, but were not limited to:

• Re-assessing and comparing levels of awareness and knowledge on the issue of opioids, in comparison to pre-campaign levels cited in the 2017 baseline survey;
• Understanding current views on this issue (including stigma);
• Identifying barriers, knowledge gaps and misperceptions related to opioids - including the problematic use of opioids (both legal and illegal), substance use disorder, opioid overdose and related deaths to develop messaging that is meaningful and will resonate with target audiences; and,
• Understanding what types of information Canadians need and are looking for as it relates to opioids.

To meet these objectives, Earnscliffe conducted a two-phased research program.

We began with qualitative research, which included a series of ten focus groups with two segments of the Canadian population: men ages 30-39 and members of the general population 18 or older.  For each group, a maximum of ten (10) individuals were recruited as participants.  In total, 85 people participated in the focus group discussions.  Two sessions were conducted in each of the following five cities:  Toronto (June 10, 2019); Halifax (June 11, 2019); Montreal (June 11, 2019); Calgary (June 12, 2019); and Vancouver (June 13, 2019). The groups in Montreal were conducted in French, while the groups in all other locations were conducted in English. Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

In each city, the groups with men aged 30-39 began at 5:30 pm and were followed by the groups with members of the general population (18+) at 7:30 pm. The sessions were approximately 2 hours in length. Focus group participants were given an honorarium of $100 as a token of appreciation for their time.  Appendix B provides greater detail on how the groups were recruited, while Appendix C provides the discussion guide used for the focus groups and Appendix D provides the screener used for recruiting the focus groups.

It is important to note that qualitative research is a form of scientific, social, policy and public opinion research.  Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic.  Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.

The initial phase of qualitative research was followed by a quantitative phase involving an online survey, to provide current information and to compare results against baseline measures from the 2017 survey.  Health Canada required the conduct of a base survey of 1,000 Canadians aged 13 and older, plus oversamples of at least 300 additional interviews conducted among each of the following six specific target audiences identified by Health Canada:

• Subsets of the general public
  • Youth (aged 13-15);
  • Parents of youth aged 13-15;
  • Young adults (aged 16-24);
  • Males (aged 30-39);
• People who use opioids, including     
  • Those who use opioids and only use opioids prescribed to them; and
  • Those who use counterfeit prescriptions and/ or other legal or illegal drugs that could be laced with opioids such as fentanyl.

The online survey was conducted using Leger's opt-in panel and upon completion, consisted of a final aggregate sample of 2,833 respondents.  The 2,833 interviews were comprised of the following:

• A base national sample of n=1,003 Canadian residents aged 13 and older;
• An additional sample of n=308 youth aged 13-15;
• An additional sample of n=310 parents or caregivers of youth aged 13-15;
• An additional sample of n=310 young adults aged 16-24
• An additional sample of n=300 males aged 30-39
• An additional sample of n=302 people who used legal drugs in the form of prescribed opioids at some point in the past year; and
• An additional sample of n=300 people who used illegal drugs, either counterfeit prescriptions or other drugs, that could be laced with opioids, at some point in the past year.

The profile of each oversample group is presented in the tables below. Because respondents could qualify for more than one key target audience, the source of respondents was a combination of those found in the general population sample, those found specifically when sampling for that target audience, and those found when specifically targeting a different audience.

The tables below show the sample sources for each of the six target audiences.

Surveys were conducted between June 10 and July 3, 2019 in English and French. The online survey took an average of 16 minutes to complete.

Respondents for the online survey were selected from among those who have volunteered to participate in online surveys. The data for the general population sample was weighted to reflect the demographic composition of the Canadian population aged 13 and older. Because the online sample is based on those who initially self-selected for participation in the panel, no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population. The treatment here of the non-probability sample is aligned with the Standards for the Conduct of Government of Canada Public Opinion Research - Online Surveys.

The final data for the general population and the youth 13-15, young adults 16-24, and men 30-39 oversamples were weighted to replicate actual population distribution by region, age and gender according to the most recent Census (2016) data available. The data for the parent, legal and illegal user oversamples was weighted based on the profile found in the general population, by age, gender and region.  Appendix A provides full details on the survey methodology and Appendix E provide the survey instrument used.

The key findings from the research are presented below. Bolded results indicate that the result of the demographic group mentioned is significantly higher (at the 95% confidence interval) than the result found in other subgroups discussed in same analysis. To ensure comparability, the survey remained consistent with questions asked in the 2017 survey. This includes some terminology that Health Canada no longer uses as it is considered stigmatising. Readers are encouraged to use non-stigmatising language when talking about substance use. For more information on changing how we talk about substance use, please see: https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/stigma/stigmatips-talk-substance-use.html. Due to the use of non-probability online opt-in panels for data collection, statistical significance testing differences in results between years (2017 vs. 2019) is not appropriate and therefore, not provided.

For statistical information on prevalence, refer to the Canadian Tobacco and Alcohol Survey (CTADS), available at https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey.html or the Canadian Student Tobacco and Alcohol Survey (CSTADS), available at https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey.html.

Opioid and illicit drug use

• The study included investigation into a wide variety of opioids, referencing generic, trade and street names in order to ensure participants' responses on opioids related to the appropriate group of drugs.  Those who have used opioids were also categorized on the basis of whether they used opioids legally (always with a prescription) or illegally (not always with a prescription).  Participants were also asked to indicate use of a variety of illicit drugs including heroin, cocaine, ecstasy and methamphetamine, again including references to respective street names in each case.  Those who use any illicit drugs are categorized as illicit drug users.  For the purposes of this report, reference to illegal drug users mean any people who either used illicit drugs or used opioids without a prescription.
• Three in ten (29%) report having taken opioids at some point in the past year. This is a 7% increase since 2017 where two in ten (22%) reported the same. The percentage of people who have taken opioids but not in the past year is unchanged (21%, 2019; 20%, 2017).  Among teens aged 13-15, the percentage claiming opioid use is 19%, up from 10% measured in 2017.
• Among those who have taken opioids in the past year, over two-thirds (69%) report always having had a prescription - roughly the same as the proportion measured in 2017 (66%).
• The number of respondents who report having taken illicit drugs in the past year (8%) is higher than was found in 2017 (5%).

Opioid awareness, impressions and basic understanding

• The survey and focus group findings suggest that awareness of opioids has increased since 2017.    Over two-thirds (69%) of respondents report being knowledgeable about what an opioid is, a 6% increase since 2017 (63%).  Perhaps relatedly, some focus group participants volunteered having seen the Government of Canada public education ads about opioids.
• Despite the increased awareness stated above, familiarity and knowledge of opioids appears to have remained the same over time, with 26% of people reporting they are very familiar with at least one of the referenced opioids.
• Two in five respondents (39%) believe that all opioids are dangerous, compared to 45% in 2017. However, the number of respondents who think most are dangerous (42%) has increased since 2017 (35%), so the combined proportion of those who think all or most are dangerous has barely shifted (81% in 2019 and 80% in 2017).
• With respect to opioids obtained on the street, there is universal agreement across all segments that they are very/somewhat dangerous.
• The majority of respondents (87%) believe the term illegal opioids means opioids obtained on the street.  Fewer (61%) also believe the term can include prescription opioids that are taken without a prescription.
• A majority of respondents (70%) sense that the opioid crisis is serious in their community; consistent with focus group findings.
• Familiarity with fentanyl (49% very or somewhat familiar) has not changed since 2017 (48%); nor has the predominant view that it is very dangerous (81% in 2019 and 83% in 2017).
• Almost three-quarters (71%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl.

Attitudes relating to behaviours, risk and harms

• Since 2017, there has been a slight increase in concern about a number of opioid related impacts, scenarios and related attitudes.  More respondents understand what is so dangerous about opioids; are worried that opioids might harm people they care about; worry that if prescribed an opioid, they could become addicted (develop an opioid use disorder); think people in their families or friends could experience an overdose; and, seem slightly more comfortable identifying and reacting to opioid use disorder and overdoses although most do not feel they would be able to identify signs of an opioid use disorder or overdose.
• Concern about teens using opioids as prescribed has risen slightly since 2017, from 76% to 81%.
• Concern about teens using opioids without a prescription is roughly equal to 2017. Just over three-quarters (76%) are very concerned, compared to 75% in 2017.
• The focus group discussions explored a number of additional topics related to opioid overdoses and treatment options. Awareness and knowledge of naloxone was fairly limited although some participants had acquired a kit from a pharmacy in case of emergency.
• Irrespective of their views of supervised consumption sites, most agreed that the availability of onsite medical assistance, the ability to help people who wanted to deal with a substance use disorder, and the benefit of having people use while under supervision were benefits of this treatment approach.
• In the focus group discussions, reactions to the Good Samaritan Drug Overdose Act were also generally positive although some did question the exceptions, especially in the context of a dealer or someone with an outstanding warrant for a petty crime who could help save someone overdosing.

Attitudes regarding stigma

• Respondents remain conflicted with regards to their attitudes towards stigma; nearly two-thirds (64%) of respondents disagree with the statement, "People who overdose on opioids get what they deserve." However, over three quarters (82%) agree that, "People who have an opioid use disorder deserve the help that they need to lead a healthy lifestyle."
• Almost two-thirds (64%) agree we should be using more of our health care resources to deal with the opioid use disorder, a 9% increase since 2017. Despite the improvement, stigma is still prevalent throughout Canada. Over a third of respondents (37%) agree that, "People with an opioid use disorder are dangerous and untrustworthy."
• Respondents appear cognizant that stigma exists; two thirds (69%) acknowledge that, "Society is not very friendly towards people with an opioid use disorder." Further, 66% agree that, "Society's attitudes about people with an opioid use disorder affect whether they seek help or treatment."
• However, a fifth (19%) agree with the statement "People who are dependent upon or addicted (developed an opioid use disorder) to opioids could stop taking them if they really wanted to," a quarter (26%) agree that "I don't have much sympathy for people who misuse opioids," and a third (32%) agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids."

Risk behaviour profiling

• The claimed use of opioids among one's acquaintances has increased in all instances since 2017. More respondents report having one friend or family member that has been prescribed an opioid, knowing someone who became addicted (developed an opioid use disorder), having one friend or family member that has used an opioid obtained illegally or without a prescription, as well as knowing people who have had fatal or non-fatal overdoses.
• Over half (54%) of respondents have at least one friend/family member who has been prescribed one of the referenced opioids. A third (33%) of respondents know someone who became addicted (developed an opioid use disorder) to one of these drugs. A quarter say a friend or family member used one of the drugs listed without a prescription. Roughly one in five (17%) have known someone who has had a non-fatal overdose from one of these drugs, while the same proportion know someone who has had a fatal overdose.
• In terms of one's lifetime experience with opioids (rather than just the past year), only 23% of respondents who have ever taken an opioid say the opioids they have taken have always been prescribed for them.  Even among those who are current legal opioid users, this proportion is only as high as 33%.
• A variety of risk behaviours are fairly common.  A third (34%) of those who had opioids prescribed to them either saved leftover pills/patches/liquids (27%), gave them to someone who needed them (4%) or did something else with them that may involve the risk of use (3%); a third (35%) of those who have used non-prescribed opioids obtained them from a relative or friend who has a prescription; one in ten respondents (10%) who have taken non-prescribed opioids do so daily (3%), or many times (7%); and, 21% of those who took non-prescribed opioids indicate there is still some chance they would still take them if they knew they contained fentanyl.
• A majority (54%) took the opioids that were not prescribed to them for pain relief. Fewer took them to see what it would feel like (11%), for the feeling it causes (8%) or to get high (8%).
• Few (5%) who have used opioids have ever sought treatment for an opioid use disorder.
• Over half of parents (61%) whose teens have been prescribed opioids in the past year believe their teen is taking them as prescribed.
• When asked where they think people their age may obtain non-prescribed opioids, the majority (66%) of youth believe it would be from a drug dealer or stranger.

Opioid information

• The most trusted sources of opioid information concerning the effects of opioid use include doctors (82%, and pharmacists (81%). However, for youth 13-15, their parents are also among the most trusted sources (81%).
• The least trusted sources of opioid use information include news outlets (31%), family members or friends who have never taken opioids before (24%) and people who are currently using opioids regularly (20%).
• Almost two thirds (63%) of parents report discussing the topic of drugs in general with their children, and a near identical portion (64%) of youth report doing the same with their parents.
• Among a list of seven topics related to drugs in general or opioids specifically that may be discussed between parents and youth, the use of prescription opioids remains among the least discussed topics among parents and youth (19%).

The role of stigma

As was undertaken in the 2017 study, the sample was segmented into three groups based on their answers to three statements relating to either withholding sympathy or assigning blame to those who use opioids - Unsympathetic, Ambivalent, and Allies.  The evidence demonstrates that stigmatizing views about opioid use disorder continue to be held by a significant portion of the population and the incidence of each segment has remained fairly static.

• The Unsympathetic segment believe that opioid use disorder is largely an issue of self-control, they don't have much sympathy for people who develop the disorder and feel those people who overdose get what they deserve.  This segment is measured at 26% compared to 28% in 2017.
• Roughly equal in size is the Allies segment that holds views opposite to the Unsympathetic on all three points.  In this benchmark study, the Allies segment is slightly higher (25%) that was measured in 2017 (21%).
• The Ambivalent segment is the remaining half of the respondent population (49% vs 50% in 2017) and falls somewhere in between, holding conflicting or nuanced views on these three statements.
• The segment to which one belongs appears to continue to relate to one's familiarity with, or exposure to, opioids - either personally or among their friends or family.  Allies continue to have more experience with opioids in their immediate circle of family and friends.
• As focus groups suggest, people who hold stigmatizing views often have difficulty recognizing that the views they hold are, in fact, stigmatizing.  Believing that anyone can develop an opioid use disorder is used as proof their views are not prejudiced, even as they describe people with opioid use disorder in undesirable terms.

Views on chronic pain and chronic pain management (qualitative only)

• Most participants indicated knowing someone dealing with chronic pain.  Some clearly felt chronic pain affects many people today and expressed that it is still somewhat misunderstood and mysterious.  Some also pointed out that it comes with stigma because people living with pain are often questioned about whether their claims of constant pain are overstated or even real.  That said, when compared with conditions such as cancer, it was difficult for many to see chronic pain as serious, given the possible (fatal) outcomes of a condition like cancer.
• Nearly all participants were aware that one of the most common treatments for chronic pain is prescription drugs.  The widespread sense was that there seemed to be little or no trouble with access to pain medication (opioids).  A small number indicated having had some difficulty getting painkillers, but the general sense was certainly that if a participant needed medicine for chronic pain, they would have little trouble getting it - provided they could see their doctor.  Some offered there are alternative treatments such as physiotherapy, yoga, meditation or homeopathic medicines but that they are not always factored into treatment plans and they can be cost prohibitive.

Alcohol consumption

• A third of respondents (32%) report being familiar with Canada's Low-Risk Alcohol Drinking Guidelines. More than half (52%) are aware that a standard serving of a typical 5% beer is a 341ml bottle, though one in five (18%) believe it is a pint, and 12% say they do not know what a standard serving size is.
• In terms of number of servings, the plurality (29%) believe that 3-5 drinks per week would be 'low-risk' for men and women, and 0-2 would be more appropriate for youth (41%) and those aged 65+ (34%).
• In terms of labelling, two-thirds (65%) of respondents feel health risks/warnings should be included on the labels of alcoholic beverages. Roughly the same number (63%) feel that the number of standard serving sizes per container should also be included.
• The majority of respondents (75%) agree that alcohol use can increase the risk of developing serious health conditions.
• Over half of respondents agree that alcohol use among youth is a serious problem in Canada (60%), and that the federal government should be doing more to address alcohol-related harms (56%).

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number:  HT372-184591/001/CY
Contract award date:  March 19, 2019

I hereby certify as a Representative of Earnscliffe Strategy Group that the final deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research.  Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed:

Date:  July 19, 2019

Doug Anderson
Principal, Earnscliffe

Introduction

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results regarding the follow-up survey and qualitative research on opioid awareness, knowledge and behaviours for public education.

Canada is facing a national opioid crisis, evidenced by the growing number of overdoses and opioid related deaths.   In 2018, Health Canada launched a multi-year public education campaign to address the growing opioid crisis and to educate Canadians on the risks associated with opioids as well as the role of stigma as a barrier to treatment.  The current research project was undertaken to help Health Canada gain insights Canadians' attitudes and perceptions toward opioids.  Feedback from the research will provide Health Canada with evidence-based data and insights to guide their public education campaigns.

The objective of the research was to follow-up on the 2017 baseline survey regarding the current state of awareness, knowledge, attitudes, beliefs and behaviours regarding opioids. This phase also included research into impressions of alcohol use, knowledge of Canada's Low-Risk Alcohol Drinking Guidelines, and views on chronic pain and pain management.  This project included both quantitative and qualitative methodologies.

The specific objectives of the qualitative phase included, but were not limited to:

• Gather research on the current state of awareness, knowledge, attitudes, beliefs and behaviours regarding opioids.

The specific objectives of the quantitative phase included, but were not limited to:

• Re-assessing and comparing levels of awareness and knowledge on the issue of opioids, in comparison to pre-campaign levels cited in the 2017 baseline survey;
• Understanding current views on this issue (including stigma);
• Identifying barriers, knowledge gaps and misperceptions related to opioids - including problematic use of opioids (both legal and illegal), substance use disorder, opioid overdose and related deaths to develop messaging that is meaningful and will resonate with target audiences; and,
• Understanding what types of information Canadians need and are looking for as it relates to opioids.

To meet these objectives, Earnscliffe conducted a two-phased research program.

The first phase was qualitative and included a series of ten focus groups with two segments each of the Canadian population: men (30-39) and members of the general population (18+).  For each group, a maximum of ten (10) individuals were recruited as participants.  In total, 85 people participated in this phase of focus group discussions.  Two sessions were conducted in each of the following five cities:  Toronto (June 10, 2019); Halifax (June 11, 2019); Montreal (June 11, 2019); Calgary (June 12, 2019); and Vancouver (June 13, 2019). The groups in Montreal were conducted in French whereas all other locations were conducted in English. Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

In each city, the groups with men aged 30-39 began at 5:30 pm and the groups with members of the general population (18+) began at 7:30 pm. The sessions were approximately 2 hours in length. Focus group participants were given an honorarium of $100 as a token of appreciation for their time.  Appendix D provides greater detail on how the groups were recruited, while Appendix C provides the discussion guide used for the focus groups.

It is important to note that qualitative research is a form of scientific, social, policy and public opinion research.  Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic.  Because of the small numbers involved, the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn, and findings cannot reliably be generalized beyond their number.

The initial phase of qualitative research was followed by a quantitative phase involving an online survey, conducted in collaboration with the quantitative sub-contractor, Leger Marketing. The online survey was conducted using Leger's opt-in panel and consisted of a sample of 2,833 Canadian residents aged 13 and older.  A total of 1,003 cases were collected as the sample of the general population. In addition to the base sample of 1,003, oversamples were also collected, achieving the following sample sizes in each of the six audiences below:

• Youth (13-15) (n=308)
• Parents or caregivers of youth (13-15) (n=310)
• Young adults (16-24) (n=310)
• Males (30-39) (n=300)
• People who use legal drugs in the form of prescribed opioids at some point in the past year (incidence of 13%) (n=302)
• People who use illegal drugs, either counterfeit prescriptions or other drugs that could be laced with opioids at some point in the past year (incidence of 2%) (n=300)

The profile of each oversample group is presented in the tables below. Because respondents could qualify for more than one key target audience, the source of respondents was a combination of those found in the general population sample, those found specifically when sampling for that target audience, and those found when specifically targeting a different audience.

The tables below show the sample sources for each of the six target audiences.

Surveys were conducted between June 10 and July 3, 2019 in English and French. The online survey took an average of 16 minutes to complete.

Respondents for the online survey were selected from among those who have volunteered to participate in online surveys. The data for the general population sample was weighted to reflect the demographic composition of the Canadian population aged 13 and older. Because the online sample is based on those who initially self-selected for participation in the panel, no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population. The treatment here of the non-probability sample is aligned with the Standards for the Conduct of Government of Canada Public Opinion Research - Online Surveys.

The final data for the general population, youth, and young adult oversamples were weighted to replicate actual population distribution by region, age and gender according to the most recent Census (2016) data available. The data for the parents, men aged 30-39, legal and illegal user oversamples was weighted based on the profile found in the general population sample, by age, gender and region.

Bolded results presented in this report indicate that the difference between the demographic groups analysed are significantly higher than results found in other columns in the same demographic analysis.  Within the tables included in the body of the report, letters beside percentages indicate results that are significantly different than those found in the specific comparison columns indicated by the letter.  Unless otherwise noted, differences highlighted are statistically significant at the 95% confidence level. The statistical test used to determine the significance of the results was the Z-test.  Due to rounding, results may not add to 100%.  We have chosen not to include a total column to remain consistent with the 2017 reporting as well as the nature of the vast differences the oversample groups bring to the results.

The detailed findings from this research are presented in subsequent sections of this report. Appended to this report are the survey instruments and data tables (presented under a separate cover).

Detailed findings

The following report is divided into nine sections: opioids and illicit drug use; opioids awareness, impressions and basic knowledge; attitudes relating to behaviours, risk and harm; attitudes regarding stigma; risk behaviour profiling; opioid information; views on chronic pain; the role of stigma; and, alcohol. Each section presents the findings informed by the initial qualitative research and the follow-up quantitative survey. Except where specifically identified, the qualitative findings represent the combined results across the various audiences and for both English and French.  The quantitative findings focus primarily on the differences across the seven target segments:  the six oversamples and the general population as a whole.  Appended data tables provide results of findings across a much broader range of characteristics, behaviours and attitudes.

Details about the survey design, methodology, sampling approach, and weighting of the results may be found in the Survey Methodology Report in Appendix A. Percentages may not add up to 100% due to rounding. "Don't know" and "no response" are denoted by DK and NR respectively.

Section A: Opioids and illicit drug use

In order to determine whether respondents had taken any sort of opioid in the past year, they were shown the following table and asked if they had taken any of the drugs listed in the past year or at any point in their lives.

For statistical information on prevalence, refer to the Canadian Tobacco and Alcohol Survey (CTADS), available at https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey.html or the Canadian Student Tobacco and Alcohol Survey (CSTADS), available at https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey.html.

As respondents for the online survey were selected from among those who have volunteered/registered to participate in online surveys and thus constitute a non-probability sample, the results of this survey cannot be described as statistically projectable to the full population.  For statistical information on prevalence, refer to the Canadian Tobacco and Alcohol Survey (CTADS), available at https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey.html or the Canadian Student Tobacco and Alcohol Survey (CSTADS), available at https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey.html.

Over one-quarter (29%) report having taken opioids in the past year, up 7% from 2017's benchmark study. A near identical proportion (21%) compared to 2017 (20%) claim they have taken them, but not in the past year. Among opioid users, almost identical proportions in 2019 and 2017 (69% and 66%) say they always have a prescription for the opioids they take. A slightly larger proportion of Quebecers (58%) and residents of Manitoba and Saskatchewan (56%) say they have never taken opioids, compared to other regions. Respondents 55+ (80%) are most likely to have always had a prescription in their name.

The percentage of youth who have taken opioids in the past year has risen from 10% in 2017 to 19% in 2019. A greater proportion of youth also report having taken them, though not in the past year (8% vs 3%). Young adults have the highest incidence of opioid use (29%) compared to youth (19%) and adults 25+ (27%). Parents (33%) are more likely than youth and adults 25+ to have taken opioids in the past year.

A higher proportion of youth say they have always had a prescription in their name when they have taken opioids, compared to 2017 (54% vs 37%). While the proportion of young adults (52%) is similar, the incidence of adults who have always had a prescription is much higher (70%). Almost two-thirds of men 30-39 (63%) say they always have a prescription in their name.

*Bear in mind the small sample sizes for this question, results should be regarded with caution.

Overall, few (6%) have ever been refused a prescription for opioids when they needed it for pain. Among those who use drugs illegally, this number rises to 20%.

Respondents take cocaine (18%) and ecstasy (18%) more often than methamphetamine (11%) and heroin (4%). Illicit drug use has increased slightly since 2017, from 5% to 8% having taken at least one illicit drug in the past year. Each drug is slightly more popular among young adults 16-24. Men are more likely to have tried any of the drugs listed than women. For example, 22% of men have taken cocaine, compared to 13% of women.

*Bear in mind the small sample sizes for this question, results should be regarded with caution.

Overall, few (6%) have ever been refused a prescription for opioids when they needed it for pain. Among those who use drugs illegally, this number rises to 20%.

Respondents take cocaine (18%) and ecstasy (18%) more often than methamphetamine (11%) and heroin (4%). Illicit drug use has increased slightly since 2017, from 5% to 8% having taken at least one illicit drug in the past year. Each drug is slightly more popular among young adults 16-24. Men are more likely to have tried any of the drugs listed than women. For example, 22% of men have taken cocaine, compared to 13% of women.

Key takeaways: Opioids and illicit drug use

• Over one-quarter of Canadians (29%) report having taken opioids in the past year, up 7% from our benchmark study conducted in 2017.  The percentage of youth who have taken opioids in the past year has also risen 9% (from 10% to 19%) since 2017.
• Roughly two-thirds of opioid users in both 2019 and 2017 say they always have a prescription for the opioids they take. With respect to youth, just over half (52%) say they always have a prescription in their names when they take opioids.
• Consistent with the focus group findings, few (6%) have been refused a prescription for opioids when they needed it for pain.
• Illicit drug use has also increased slightly since 2017 (5% to 8%).

Section B: Opioid awareness, impressions and basic understanding

Awareness of opioids is fairly broad and has increased slightly since 2017. Roughly two-thirds (69%) are certain or pretty sure they know what an opioid is, up 6% since 2017. Over one-quarter of adults 25 and older are certain they know what an opioid is (28%), higher than among young adults (23%) and youth (14%). Over a quarter of youth (28%) say they have never heard the term opioid or do not really know what it is, less than in 2017 (36%). A greater percentage of Quebecers (17%) have never heard of/don't really know what an opioid is compared to respondents in Atlantic Canada (6%), Ontario (9%), Manitoba/Saskatchewan (7%) and Alberta (9%).

Over half of men 30-39 (60%) are pretty sure or certain they know what an opioid is. A very similar proportion of illegal drug users (62%) say the same. The group most certain of their knowledge is legal users - 75% are pretty sure or certain.

Familiarity with opioids has remained the same since 2017, with 26% of people reporting they are very familiar with at least one of the referenced opioids. Almost two-thirds (65%) are at least somewhat familiar with one, and just 16% are not familiar with any. More men are not at all or just a little familiar with at least one (36%) than women (30%).

Youth are less familiar with opioids than the other age groups. One quarter (27%) say they are not at all familiar with any opioids, compared to 15% of young adults and 16% of adults 25 and older. However, fewer youth now are not at all familiar with opioids than was the case in 2017 (39%).

Legal and illegal users of drugs are more familiar with opioids - 48% and 39% respectively are very familiar. These proportions are similar to the 2017 results (51% and 43%). Parents' and men's (30-39) familiarity resemble that of the general population.

Qualitative insights:  Awareness of and familiarity with opioids among focus groups participants?

Consistent with the survey findings, awareness of the term opioids was generally high, although, familiarity and knowledge varied widely across the country and the two focus group segments.  Members of the general population (across all regions) and those in Eastern Canada (including Toronto, Halifax and Montreal) were less knowledgeable than men 30-39 and participants in Western Canada (both Calgary and Vancouver).  Some, usually at least one or two participants in each group (other than those in Montreal), either had personal experience with opioid use or knew someone who had developed a substance use disorder.

When asked what drugs participants considered to be opioids, top-of-mind mentions, especially among members of the general population and those in Eastern Canada, were more often than not prescription medications.  Those volunteered most often included:  oxycodone, codeine, morphine, Percocet, and Dilaudid.  There seemed to be a little more confusion and uncertainty around drugs like cocaine, meth, and heroin.  Some participants, usually men 30-39, thought these drugs and others such as ecstasy, MDMA, and cannabis could be laced with fentanyl, but this was not commonly understood.  Those less knowledgeable often confused opioids with illicit drugs (i.e., cocaine, heroin, etc.), generally; ignorant of the fact that these drugs are not dangerous because they are opioids but rather because they could be laced with opioids such as fentanyl.

Two in five respondents (39%) believe that all opioids referenced on the chart are dangerous, compared to 45% in 2017. However, the number of respondents who think most are dangerous (42%) has increased since 2017 (35%), so the combined proportion of those who think all or most are dangerous has barely shifted (81% in 2019 and 80% in 2017). Respondents from Quebec are less likely to believe all are dangerous (30%) than those from Atlantic Canada (46%), Ontario (42%), Manitoba/Saskatchewan (47%) and Alberta (44%).

Young adults are less wary of opioids than youth and adults 25+. A quarter (25%) believe all opioids are dangerous, compared to 43% of youth and 42% of adults 25+. Illegal drug users are perhaps unsurprisingly less inclined to believe all are dangerous (25%), a decline since the 2017 survey (30%).

There is almost universal agreement across the general population and oversamples that opioids obtained on the street are very/somewhat dangerous to those who use them (88% very dangerous, 6% somewhat dangerous). Agreement is similarly high when it comes to the danger faced by people who use illegal drugs (82% very dangerous, 12% somewhat dangerous). Youth 13-15 are more concerned (82%) about the danger of opioids to them personally than young adults (69%) and those 25+ (70%). Legal drug users are less concerned about the danger opioids pose to them personally (60%), compared to the general population (69%).

The vast majority (87%) believe the term "illegal opioids" means opioids obtained on the street, a similar proportion to 2017 (88%).  Just under two-thirds (61%) also believe the term can include prescription opioids that are taken without a prescription, slightly lower than in 2017 (66%).

Men 30-39 (78%) and illegal drug users (76%) are the least likely of all the oversamples to equate illegal opioids with opioids obtained on the street, though large majorities still do. Non-users (59%), men 30-39 (58%) and youth (47%) are least likely to relate the term to prescription opioids taken without a prescription.

In terms of other demographic differences, women (90%) are more likely to say the term means opioids obtained on the street than men (84%). A greater percentage of Ontarians (63%), as well as those in Alberta (71%) and BC (66%) believe illegal opioids could include prescription opioids taken without a prescription. While virtually all respondents picked one of these two responses, a small number (2%) said that "illegal opioids" means something else to them.  Asked to explain these responses, the more common answers were that illegal opioids means both those purchased on the street and those used without a prescription, or means those that are homemade or purchased online.

Overall awareness of Canada's opioid crisis remains virtually unchanged since 2017 (73% vs. 74% in 2019 very or somewhat aware). The number of respondents who state they are 'very aware' has fallen slightly from 28% to 25%. More youth (58%) say they are aware of the opioid crisis than in 2017 (50%). However, they, along with young adults (69%), are less aware than adults 25 and older (77%). A greater proportion of Quebecers (42%) are not aware of the opioid crisis, compared to all other regions. Those with a household income of less than $40,000 are also less familiar (30% not aware) compared to those with incomes between $40,000-$80,000 (21%) and $80,000 or more (22%).

Awareness is highest among legal opioid users. The vast majority (80%) are aware, a similar figure to 2017 (79%). Three-quarters of illegal users are aware (75%), slightly higher than 2017 (70%). Awareness among parents has not changed - 75% are aware in the most recent data, similar to the 73% aware in 2017. Two-thirds (64%) of men 30-39 are aware of the opioid crisis in Canada.

Across the general population and oversamples, a majority or more, sense that the opioid crisis is serious in their community. In fact, over two-thirds (70%) view the opioid crisis as very or somewhat serious in their community, up slightly from 2017 (65%). Respondents in BC are particularly sensitive to the severity of the crisis - 43% agree it is very serious, significantly more than in Atlantic Canada (22%) and Quebec (19%). Respondents with a university degree are also more likely to view the crisis as serious in their community (74%) than those with only a high school diploma (67%).

Youth are less likely to view the crisis as serious (61%) compared to young adults (64%) and adults 25 and over (72%). Men 30-39 are less likely than the general population to rate the crisis as serious (61%). Parents are more concerned about the severity of the crisis than they were in 2017 (73% vs 68%). Those who use neither legal or illegal opioids feel the crisis is less serious (68%) than those who use legal (76%) or illegal (73%) opioids.

Qualitative insights:  scale and cause of the opioid crisis

Based on what they had heard, seen or read in the media, participants felt that there currently was an opioid crisis in Canada although the crisis in the United States was felt to be much more acute.  Most, including those in Eastern Canada, had the sense that the crisis was more serious in Western Canada, although the majority acknowledged that their communities were not immune, and some felt it was only a matter of time before it spread to their communities.

Despite the broad awareness of the term and the general tendency to describe the situation as a crisis, a lack of knowledge and/or inconsistency of knowledge was demonstrated as participants discussed the cause(s) of the opioid crisis. Most reasoned that it is the highly addictive nature of opioids that creates substance use disorder challenges that leads to black market activity.

When asked, the overwhelming majority of participants blamed the health care system for the crisis.  The following were cited as causes:

• Doctors are overworked and cannot spend enough time with each patient to properly diagnosis health concerns, and that it is much easier and more efficient for them to write a prescription than to explore alternatives.
• Doctors are not following or concerned with the rules around the prescription of opioids and they are not being held accountable for prescribing opioids.
• Doctors are receiving kick-backs from pharmaceutical companies for prescribing opioids.
• Pharmaceutical companies are making drugs available in volumes and ways they know are suspicious and problematic.
• Lack of education.

As mentioned previously, very few - outside the groups with men 30-39 in Calgary and Vancouver - instinctively linked the crisis to fentanyl (specifically recreational drugs being laced with fentanyl).  Worth noting, however, some men 30-39 in Calgary and Vancouver did attribute fentanyl to the opioid crisis describing it as highly addictive, easily accessible (some mentioned having heard of frequent large shipments of fentanyl from China), and inexpensive especially in the context of their feeling that a very small amount can produce a fairly significant feeling/impact.

Familiarity with fentanyl has not changed since 2017, with half (49%) of respondents claiming they are very or somewhat familiar. There was a slight (5%) decrease in the percentage of people who are not at all familiar with fentanyl. There is some regional variation in familiarity - significantly more Quebecers are not familiar (66%) compared to all other regions. Those with a household income of less than $40,000 are also less familiar (57% not familiar) compared to those with a household income of $80,000 or more (40%).

The percentage of youth who are not at all familiar has fallen by nine percentage points from 35% in 2017 to 26%, and they remain less familiar than older cohorts. Parents' familiarity with fentanyl is slightly higher (56%) than the general population (49%). Men's (30-39) familiarity largely reflects the general population results. Familiarity among legal (59%) and illegal (57%) drug users has increased slightly since 2017, when it was 52% and 56%, respectively.

Qualitative insights:  Awareness of and familiarity with fentanyl

As with the term opioids, participants seemed to be aware of the term fentanyl, but familiarity and knowledge varied significantly across region and segment.  In several groups, one or two participants described fentanyl as a particularly strong painkiller (i.e., specifically a horse tranquilizer) and/or that it could cause an overdose with even the most minute exposure.  A few participants referenced news stories about first responders having to wear special equipment to avoid the effects of coming into physical contact with fentanyl on the job.

Among those familiar with fentanyl, well over three-quarters (81%) describe it as very dangerous, comparable to the 83% who felt the same way in 2017. Respondents in Atlantic Canada (91%) and BC (90%) are more likely to believe fentanyl is very dangerous, particularly compared to Quebecers (76%), Ontarians (79%), and those in Manitoba/Saskatchewan (77%). While most across all oversamples agree it is dangerous, fewer youth (77%), young adults (74%), parents (72%), illegal drug users (65%) and men 30-39 (69%) believe fentanyl is very dangerous.

Almost three-quarters (71%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl.  Fewer youth (62%), young adults (63%), parents (61%), men 30-39 (51%) and illegal users (53%) agree.  Very few (3%) believe there is not much or no risk.  Respondents in BC perceive greater risk (79%) than those in Quebec or Ontario (68%).

Key takeaways: Opioid awareness, impressions and basic understanding

• The survey and focus group findings suggest that awareness of opioids has increased since 2017.  In fact, some focus groups participants volunteered having seen the Government of Canada public education ads about opioids.
• Roughly two-thirds (69%) are certain or pretty sure they know what an opioid is, up 6% since 2017.
• Despite the increased awareness, familiarity and knowledge of opioids appears to have remained the same over time, with 26% of people reporting they are very familiar with at least one of the referenced opioids.
• Two in five respondents (39%) believe that all opioids referenced on the chart are dangerous, compared to 45% in 2017. However, the number of respondents who think most are dangerous (42%) has increased since 2017 (35%), so the combined proportion of those who think all or most are dangerous has barely shifted (81% in 2019 and 80% in 2017).
• With respect to opioids obtained on the street, there is universal agreement across all segments that they are very/somewhat dangerous.
• The majority of respondents (87%) believe the term illegal opioids means opioids obtained on the street.  Fewer (61%) also believe the term can include prescription opioids that are taken without a prescription.
• A majority (70%) of respondents sense that the opioid crisis is serious in their community; consistent with focus group findings.
• Familiarity with fentanyl has not changed since 2017; nor has the predominant view that it is very dangerous.
• Almost three-quarters (71%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl.

Section C: Attitudes relating to behaviours, risk, and harms

Since 2017, there has been a slight increase in concern about opioids in a number of ways. For example, concern that opioids might harm someone respondents care about has risen by 6% to 56%. Though over half are concerned that opioids might harm the people close to them, fewer believe friends and family members could be at risk of developing opioid use disorder (37%) or overdosing (27%).

Respondents seem slightly more comfortable identifying and reacting to opioid use disorder and overdoses. More than in 2017, though still less than the majority, feel they would be able to identify signs of an opioid use disorder (39% vs 33%) or overdose (33% vs 29%), or would know what to do if they saw someone experiencing an overdose (30% vs 26%). As was the case in 2017, respondents are more confident in their ability to handle their own interactions with opioids. For example, 45% are confident they could easily find help for dealing with problematic opioid use, and almost all (80%) would ask their doctors for more information about side effects, risks or alternatives if they were prescribed an opioid.

In some respects, respondents' sense that opioids can be dangerous. Two-thirds (67%) agree they know what makes them so dangerous, and only one in five (22%) agree it is difficult to develop an opioid use disorder if following a prescription. However, just under half (47%) worry they could become addicted (develop an opioid use disorder) if prescribed an opioid. Few (10%) believe there are any circumstances under which it is acceptable to share a prescription for opioids.

Youth's attitudes towards opioids vary somewhat from those of young adults and adults 25+. Youth are less confident that they understand what makes opioids so dangerous (53% vs 66% of young adults and 66% of adults 25+) and more agree it is difficult to become addicted (develop an opioid use disorder) to opioids if using a prescription (31% vs 22% of adults 25+).

Legal opioid users claim to be more cognizant of the dangers of these drugs (75%) than illegal users (69%) and the general population (67%). Both legal and illegal drug users are more concerned about their ability to obtain a prescription - 30% of legal users and 34% of illegal users agree. They also claim to be better equipped than the general population when it comes to recognizing opioid use disorder (50% of legal and 50% of illegal users), an overdose (both 48%) and treating an overdose (42% and 43%, respectively). The percentage of both groups of users who are confident they could identify opioid use disorder (addiction) and overdose, as well as treat an overdose, has risen since 2017. For instance, notably fewer legal (29%) and illegal (31%) drug users in 2017 felt they would know what to do if they observed someone experiencing an overdose.

Parents are the most likely of all oversamples to think their family or friends could develop an opioid use disorder (addiction) (48%). Aside from illegal drug users, they are also most likely to agree their family/friends might experience an overdose (38%).

In contrast, men aged 30-39 are less concerned that opioids may harm people they care about (51%) and that family or friends might become develop an opioid use disorder (addiction) (32%). Similar to the findings among parents, men aged 30-39 are relatively more confident in their ability to identify signs of addiction (46%) or an overdose (39%) than the general population. They are also more likely to agree it is difficult to become addicted (develop an opioid use disorder) if you are following a prescription (34%).

Other notable demographic differences in attitudes about behaviour, risk and harms include that Quebecers (60%), Albertans (60%) and residents of BC (59%) are more concerned opioids might harm the people they care about. At the same time, Quebecers are least likely to think their friends/family might develop an opioid use disorder (28%, compared to 44% of those in BC and 40% of Albertans). Respondents in BC claim to be most capable to deal with an overdose - 40% say they would know what to do, compared to just 24% in Quebec and Manitoba/Saskatchewan. Indigenous respondents are more comfortable sharing opioid prescriptions - 32% say there are times when it is acceptable, compared to 9% of non-Indigenous respondents.

Respondents with higher levels of education claim to be more knowledgeable about opioids. For example, 77% of those with a post-grad degree and 71% of those with an undergrad degree say they know what it is about opioids that makes them so dangerous, compared to 61% of those with a high school education only.

Respondents with a household income between $40,000 and $80,000 appear more comfortable dealing with overdoses and opioid use disorder. A third (34%) would know what to do if they saw someone experiencing an overdose, compared to 24% of those with an income lower than $40,000 and 30% of those with an income greater than $80,000. Those with higher incomes are more confident they could get help with an opioid use disorder. Almost half (49%) of respondents with an income of $80,000 or more agree, compared to 40% of those with incomes lower than $40,000.

Concern about teens using opioids as prescribed has risen only slightly since 2017, from 76% to 81%. Parents are also slightly more concerned - 87% compared to 82%. However, the percentage of youth who say they are very concerned has risen substantially, from 19% in 2017 to 32%. Another 41% are somewhat concerned, for a total of 73%, compared to 61% in 2017.

Concern among the general population about teens using opioids without a prescription is roughly equal to 2017. Just over three-quarters (76%) are very concerned, compared to 75% in 2017. Less youth are very concerned about their peers using opioids without a prescription (62%) compared to young adults (70%), and adults (79%).

Qualitative insights:  Understanding of opioid overdoses and naloxone

When asked to describe signs related to an opioid overdose, symptoms were offered that seemed to be more related to overdoses of other drugs than specifically opioids (e.g., foaming at the mouth), but generally people assumed they would witness disorientation, blackouts or unconsciousness, slurred speech, and perhaps perspiring or "clamminess."

In terms of aiding in the event of a drug overdose, most participants described having an immediate instinctive reaction to call 911.  Many said they would do the "right thing" but beyond calling 911, few knew what more they could or should do and opinions varied widely.  Participants in Montreal felt that they would be inclined to more readily take an active role in helping with things like CPR, ensuring airways were not blocked, trying to keep people awake/conscious until help arrived, etc.  Elsewhere, participants were a little less inclined to do anything beyond calling 911.  They questioned whether they felt prepared or educated enough to know how to help someone experiencing an overdose, whether they might make things worse, or expose themselves to harmful substances.

Awareness and knowledge of naloxone was limited.  Some participants in each group had heard the term but knowledge varied considerably from group to group and by location.  In some groups, there were those who knew what naloxone was, including those who referred to it by the brand name "Narcan", and mentioned that naloxone kits could be easily acquired for free in any pharmacy.  In some groups, few were certain of what it was; often guessing it was an overdose kit.  Typically, about one or two participants per city had obtained a naloxone kit simply in the event they were out with friends and something went wrong.

Initial discussions suggested that most participants were in favour of supervised consumption sites, although there seemed to be some polarization of opinion.  Whether in support or opposed to them, most participants agreed that the main benefit to the community was the provision of clean equipment and keeping people safe from discarded syringes and the spread of disease.  Among those who were supportive, they praised the availability of medical assistance if necessary, the ability to help people who wanted to deal with a substance use disorder, and the benefit of having people do the drugs under supervision rather than alone. Conversely, those uncomfortable with or opposed to supervised consumption sites tended to feel that the existence of such sites may encourage drug use, that they tended to create a location that attracted undesirable people to a community, and some wrongly assumed that drugs were provided.  Correcting this misconception typically helped the person feel less opposed, but rarely made the individual supportive.

On an unaided basis, generally one or two participants in each group were familiar with laws that protected witnesses and bystanders, sometimes mentioning the "Good Samaritan Law" on an unprompted basis.  Those familiar tended to be able to recall the main points that someone who helps a person in overdose is not going to get in trouble themselves.  These individuals tended to feel positively about the law, based on what they had heard.

Participants were then read the following description:

"The Good Samaritan Drug Overdose Act became law in 2017 and provides some legal protection for individuals who seek emergency help (call 911 or your local emergency number) during an overdose.  More specifically, the Act protects individuals from being charged with simple possession of a controlled substance (drugs).  It covers by-standers who call for help or people experiencing overdose who call for help.  It will protect you if you choose to stay with the victim or leave the scene.  Instances where you are not protected: outstanding warrants, possessing with intent to distribute, production or trafficking of drugs, other crimes, etc."

On an aided basis, reactions continued to be quite positive.  The assumed context tended to fall into two categories: those who assumed this meant coming across someone on a street who had overdosed; and, those who imagined friends being together as one or more used recreational drugs.  Those who imagined the latter context tended to more immediately be able to describe the net effect as positive as friends would otherwise be scared to call if they themselves possessed or had taken drugs.  Those who assumed this was about coming across a stranger in crisis appeared less in need of the protection.

Regardless of the assumed context, there was no observed opposition to the concept although some participants still had concerns about whether they could really count on the Act being executed as written and, more importantly, whether the exceptions were problematic.  Some participants, particularly men 30-39, felt that the exceptions may be counter-productive and questioned whether they were ill-advised in some circumstances such as where a dealer or someone with an outstanding warrant for a petty crime or parking ticket could help save someone who is overdosing.  Inevitably, some reasoned that unshackling the dealers would be problematic as it may encourage use.

Key takeaways: Attitudes relating to behaviours, risk and harms

• Since 2017, there has been a slight increase in concern about opioids in a number of ways.  More respondents understand what is so dangerous about opioids that; are worried that opioids might harm people they care about; worry that if prescribed an opioid, they could become addicted (develop an opioid use disorder); think people in their families or friends could experience an overdose; and, seem slightly more comfortable identifying and reacting to opioid use disorder and overdoses although most do not feel they would be able to identify signs of an opioid use disorder or overdose.
• Concern about teens using opioids as prescribed has risen slightly since 2017, from 76% to 81%.
• Concern about teens using opioids without a prescription is roughly equal to 2017. Just over three-quarters (76%) are very concerned, compared to 75% in 2017.
• The focus groups discussions explored a number of additional topics related to opioid overdoses and treatment options. Awareness and knowledge of naloxone was fairly limited although some participants had acquired a kit from a pharmacy in case of emergency.
• Irrespective of their views of supervised consumption sites, most agreed that the availability of onsite medical assistance, the ability to help people who wanted to deal with a substance use disorder, and the benefit of having people use while under supervision were benefits of this treatment approach.
• Reactions to the Good Samaritan Drug Overdose Act were also generally positive although some did question the exceptions, especially in the context of a dealer or someone with an outstanding warrant for a petty crime who could help save someone overdosing.

Section D: Attitudes regarding stigma

While people with an opioid use disorder still encounter stigma, the tracking data shows it has not worsened since 2017. For example, 64% of respondents disagree with the statement, "People who overdose on opioids get what they deserve." which is a 9% increase since 2017. Furthermore, over three-quarters (82%) agree that, "People who have an opioid use disorder deserve the help they need to lead a healthy lifestyle." This is a 5% increase since 2017. Support for addressing the crisis has also risen, with almost two-thirds (64%) agreeing we should be using more of our health care resources to deal with opioid use disorder, compared to 55% in 2017.

Despite the improvement, stigma is still prevalent throughout Canada. Over a third of respondents (37%) agree that, "People with an opioid use disorder are dangerous and/or untrustworthy." Furthermore, there has not been much change in the proportion who say that, "People who are dependent upon or addicted to opioids could stop taking them if they really wanted to." (19% in 2019 vs 17% in 2017), "I don't have much sympathy for people who misuse opioids." (26% in 2019 and 27% in 2017) and, "A lack of self-control is usually what causes a dependence upon or an addiction to opioids." (33% in both 2019 and 2017).

Respondents appear cognizant that stigma exists and acknowledge that there are attitudes prevalent in society that might stop those who have an opioid use disorder, or even themselves, from discussing it with others. For example, two-thirds (69%) acknowledge that, "Society is not very friendly toward people with an opioid use disorder." Further, 66% agree that, "Society's attitudes about people with an opioid use disorder affect whether they seek help or treatment." Over two-thirds (69%) also agree that people who have an opioid use disorder may be embarrassed to seek help, and a quarter (74%) agree it may also be uncomfortable to share this information with family and friends. Fewer, though still a majority (60%), say that if they ever developed an opioid use disorder, they would find it difficult to tell friends and family.

As was noted in 2017, youth ages 13-15 are more likely to hold various stigmatizing views than those older than them. Very similar proportions in 2017 (45%) and 2019 (43%) agree that a lack of self-control is usually how people become addicted to opioids (develop an opioid use disorder). In contrast, 42% of young adults and 32% of those 25 and older agree. One in five (19%) youth agree that people who overdose on opioids get what they deserve, identical to the 2017 results (19%) and higher than the percentage of young adults 16-24 (18%) and adults 25+ who feel the same way (12%). Two in five (42%) youth also feel individuals with an opioid use disorder are untrustworthy and two-thirds (67%) would be disappointed if they found out a friend or family member had an opioid use disorder.

Adults 25+, in contrast, appear to have a broader understanding of the causes of opioid use disorder and its consequences. Almost three-quarters (73%) agree one can become addicted to opioids (develop and opioid use disorder), even if they are following a doctor's prescription, and slightly more agree the opioid crisis is a public health issue (77%). They are also more comfortable seeking help for an opioid use disorder (56%) compared to youth (45%) and young adults (41%). One topic all respondents agree on, regardless of age, is that addiction to opioids (opioid use disorder) is a disease - 64% of youth, 61% of young adults and 62% of adults 25+ agree.

Although legal and illegal drug users' attitudes about opioids and stigma are similar in some respects, there are notable distinctions. They have similar understandings of some of the causes and impacts of the crisis. A little over half of legal (56%) and illegal (59%) drug users agree people are overdosing because they did not realize the drugs they were consuming contained opioids and just under two-thirds (67% and 63% respectively) agree addiction to opioids is a disease. Over half of legal opioid users (54%), and illegal drug users (56%) believe opioids are over-prescribed. However, illegal drug users seem more likely to stigmatize. Among illegal users, 49%, compared to 40% of legal users, believe a lack of self-control is what causes addiction to opioids. A quarter of illegal users (26%) agree that people who overdose get what they deserve, compared to 18% of legal users, and a third of illegal users (34%) agree it is mostly people who are either homeless or already addicted (living with substance use disorder) to another drug who become addicted to opioids (develop an opioid use disorder), compared to 22% of legal users. A third (33%) of illegal users think people who are addicted to opioids (living with opioid use disorder) could stop if they really wanted to, compared to 25% of legal users. The results from 2017 reinforce the difference in stigmatizing attitudes when it comes to legal vs illegal users. For example, 41% of illegal drug users agreed that a lack of self-control causes addiction (opioid use disorder), compared to 32% of legal users.

Men 30-39 are notably more likely to hold stigmatizing views about opioids or those who use opioids than the general population. More believe people who are addicted (living with opioid use disorder) could stop taking opioids if they really wanted to (30% vs 19% in the general population), do not have sympathy for people who are addicted (33% vs 26%) and believe a lack of self-control is generally what causes one to become addicted (50% vs 33%).

Respondents in Alberta and BC (61% agree) are more likely to connect overdoses to people taking drugs they didn't realize had opioids or had higher doses than they expected, compared to respondents in Atlantic Canada (43%), Quebec (47%), Ontario (51%) and Manitoba/Saskatchewan (44%). Ontarians (24%) and respondents in BC (28%) are most likely to agree that it is people who are down on their luck, homeless or already addicted to drugs who develop an opioid use disorder. However, at least when it comes to BC respondents, they do not necessarily feel these people are dangerous - just 29% agree, significantly lower than the 50% in Manitoba/Saskatchewan who feel the same way. Fewer respondents in BC (66%) agree that even when following a prescription, one can become addicted to opioids (develop an opioid use disorder) than in any other region. In Ontario, 77% agree.

Those with a higher level of education claim to be more aware of stigma in society but are also more likely to hide their own opioid use. Three-quarters of those with an undergrad or postgrad degree (74%) agree society is not friendly toward people with an opioid use disorder, compared to 62% of those with a high school education and 57% of those who have not completed high school. At the same time, 65% of those with a postgrad and 63% of those with an undergrad degree say if they developed an opioid use disorder, they would find it difficult to tell friends and family, compared to 58% of those who have a high school diploma and 46% of those who have not completed high school.

Indigenous respondents hold some stigmatizing attitudes (38% agree people who overdose get what they deserve, compared to 12% of non-Indigenous respondents) and are also less likely to disclose prescribed opioid use (42% vs 19% among those who are not Indigenous).

Qualitative insights:  Views related to stigma

Virtually all participants agreed that people with a substance use disorder face stigma and that stigma is a problem.  The major contradiction that consistently showed up was that there was widespread sympathy for people with substance use disorder, agreement that the stigma has important negative effects (on mental health; on seeking help; on causing isolation and withdrawal from those who do not use drugs), and yet often a failure to recognize that their own descriptions of people with substance use disorder represent problematic stigma.  One impression common to all is that people with substance use disorder cannot be trusted because they are beholden to their disorder.  Several said people with substance use disorder will burn through their money and seem unhesitant to steal from loved ones, if necessary.  As one sympathetic participant put it, people with substance use disorder should not be feared, but they should not be trusted either.

Participants agreed that recovery from substance use disorder is possible but that it is typically a long, difficult, expensive process that is fraught with challenges.  Participants often offered that those with substance use disorder may have to restart treatment multiple times, having given into temptation - particularly, if they are still associating with those who enable use.  In most groups, two barriers consistently came up as significant and in need of removal: the limited accessibility of public programs and the cost of private options.  Public programs were typically seen as having waiting times that are months long, leading to a sense of futility.

Key takeaways: Attitudes regarding stigma

• Respondents remain conflicted, simultaneously holding supportive views that indicate compassion and negative views that indicate stigma. Nearly two-thirds (64%) of respondents disagree with the statement, "People who overdose on opioids get what they deserve." However, over three-quarters (82%) agree that, "People who have an opioid use disorder deserve the help that they need to lead a healthy lifestyle."
• Almost two-thirds (64%) agree we should be using more of our health care resources to deal with opioid use disorder, a 9% increase since 2017. Despite the improvement, stigma is still prevalent throughout Canada. Over a third of respondents (37%) agree that, "People with an opioid use disorder are dangerous and untrustworthy."
• Respondents appear cognizant that stigma exists.  Two-thirds (69%) acknowledge that, "Society is not very friendly toward people with an opioid use disorder." Further, 66% agree that, "Society's attitudes about people with an opioid use disorder affect whether they seek help or treatment."
• Though a fifth (19%) agree with the statement "People who are dependent upon or addicted to opioids could stop taking them if they really wanted to.", a quarter (26%) agree that "I don't have much sympathy for people who misuse opioids" and a third (33%) agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids."

Section E: Risk behaviour profiling

The frequency of respondents' acquaintances use of opioids has increased slightly since 2017. Over half (54%) have at least one friend/family member that has been prescribed one of the referenced opioids, a 4% rise from 2017. A quarter say a friend or family member used one of the drugs listed without a prescription, compared to 17% in 2017. A third (33%) of respondents know someone who became addicted (developed an opioid use disorder) to one of these drugs, whereas only a quarter (24%) reported the same in 2017. Roughly one in five (17%) have known someone who has had a non-fatal overdose of one of these drugs and an equal number (17%) have known someone who has had a fatal overdose. In 2017 one in ten (10%) knew someone who had experienced a non-fatal overdose and 12% knew someone who had a fatal overdose.

Legal opioid users, as one might expect, are more likely than those who use drugs illegally or who do not use drugs at all to report that one of their friends/family members has been prescribed an opioid (71%). Illegal users are most likely to report a friend or family member has used an opioid not prescribed to them (46%), known someone who has an addiction to opioids (53%), and had a fatal or non-fatal overdose (30% and 33%, respectively).

In terms of demographic differences, significantly more women (57%) have a friend or family member who has been prescribed an opioid compared to men (50%). Further, those living in Alberta were most likely to know someone who has been prescribed an opioid (69%), which is more than twice the amount of Quebecers who knew someone (33%). Interestingly, those living in Alberta were the least likely (8%) to have known someone who has had a non-fatal opioid overdose, while those living in Atlantic Canada were the most likely (29%).

Respondents living in British Columbia were most likely to know someone who has died of an overdose of one of these drugs (27%) and they were the most likely to know an illegal drug user (31%). Indigenous respondents were roughly three times more likely (63%) than non-Indigenous respondents (23%) to have a friend or family member who has used an opioid without a prescription or obtained on the street. With regards to education, post graduates were twice as likely to know someone who became addicted (developed an opioid use disorder) to opioids (45%), compared to respondents that did not complete high school (20%).

*Bear in mind the small sample sizes for question 26F. Results should be regarded with caution. This question was only asked of parents of teens 13-15.

Three-quarters (75%) of current and past opioid indicate having taken opioids illegally (not always with a prescription) at some point in their life. In 2017, fewer had ever taken them illegally (64%). Of the 726 identified as ‘legal opioid users’ (have used an opioid in the past year and always had a prescription when using an opioid in the past year), when expanding the timeframe to their entire lifetime, only 33% now report having always had a prescription for all opioids they have ever taken.

Slightly more prescribed opioid users (56% vs 52%) are reportedly storing their prescribed opioids in a location that can only be accessed by them. Legal opioid users are the most likely to claim they store their opioids in a location only they can access (61%) compared to illegal users (59%) and those who do not use opioids (51%)

More prescribed opioid users are flushing/disposing of opioids in the garbage (13%) than in 2017 (8%). Slightly fewer did not have leftover patches/pills/liquids (29% vs 37%). Roughly a quarter in both waves returned their opioids to a doctor or pharmacy or saved them in case they need them again. Few (4%) gave them to others, though it is worth noting that more men 30-39 (11%) and illegal drug users (9%) gave their leftovers to someone who needed them.

The proportion of respondents using opioids without a prescription almost daily or many times is roughly the same as found in 2017 (10% vs 9%). The proportion who have used them a few times has remained unchanged (23%). As could be expected, more illegal drug users say they have used unprescribed opioids almost daily or many times (20%). What may be more surprising is that parents are just as likely to describe the same usage (21% daily or many times).