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

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 résumé analytique est aussi disponible en français.

This executive summary 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 executive summary, 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

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.

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.
• 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