Follow-up survey and qualitative research on opioid awareness, knowledge, and behaviours for public education (2021)
Final Report

Prepared for Health Canada

Supplier name: Earnscliffe Strategy Group
Contract number: HT372-213980/001/CY
Contract value: $189,163.06
Award date: November 9, 2021
Delivery date: February 11, 2022

Registration number: POR 037-21
For more information on this report, please contact Health Canada at:
cpab_por-rop_dgcap@hc-sc.gc.ca

Ce rapport est aussi disponible en français.

Follow-up survey and qualitative research on opioid awareness, knowledge, and behaviours for public education (2021)
Final Report

Prepared for Health Canada
Supplier name: Earnscliffe Strategy Group
February 2022

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 December 13, 2021 to January 12, 2022.

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 (2021).

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: cpab_por-rop_dgcap@hc-sc.gc.ca or at:

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

Catalogue Number: H21-313/2022E-PDF

International Standard Book Number (ISBN): 978-0-660-42138-4

Related publications (registration number): H21-313/2022F-PDF

Enquête de suivi et recherche qualitative sur la sensibilisation, les connaissances, et les comportements liés aux opioïdes aux fins de l'éducation du public (Final Report, French) ISBN Number 978-0-660-42139-1

^©Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2022

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 harms
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 and substance use
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 of the follow-up survey and qualitative research on opioid awareness, knowledge, and behaviours for public education.

The growing number of overdoses and deaths related to the use of opioids is a national public health crisis, and a crisis that is worsening under the COVID-19 pandemic. The opioid crisis is complex, and it affects all communities, all age groups and all socioeconomic groups. In 2018, Health Canada launched a multi-year public education campaign to address the growing opioid overdose crisis to raise awareness and to educate Canadians on the risks associated with problematic substance use, including the use of opioids (legal and illegal) as well as the role of stigma as a barrier to treatment.

In 2017, to help inform the ensuing public education campaign, Health Canada contracted Earnscliffe to conduct a baseline survey on opioid awareness, knowledge and behaviours. In 2019, we conducted follow-up research to determine whether results had changed since the baseline survey. More recently, further research was required to determine if awareness of and attitudes towards problematic opioid use have changed over the past few years, and if stigma has been reduced. This research provides evidence-based data and insights to guide Health Canada's marketing campaigns and policy development. The contract value for this project was $189,163.06 including HST.

To meet the current objectives, Earnscliffe conducted a two-phased research program involving both qualitative and quantitative research.

The initial phase involved qualitative research, which included a series of ten focus groups over three days (between December 13 and 16, 2021) with two segments of the Canadian population: men ages 20-59 and men (18+) in physically demanding jobs. For the first six groups, a maximum of eight (8) participants were recruited as participants. To increase participation on the third night, a maximum of ten (10) individuals were recruited for those four groups. In total, 76 people participated in the focus group discussions. Two sessions were conducted with participants in each of the following regions: Atlantic Canada, Quebec, Ontario, Prairies and British Columbia (BC). The groups in Quebec were conducted in French, while the groups in all other locations were conducted in English. The sessions were approximately 90 minutes in length.

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. As such, results are directional only.

The initial qualitative phase was followed by a quantitative phase involving an online survey, to update and compare results against baseline measures from the 2017 and 2019. We conducted a base survey of 1,000 Canadians aged 13 and older, plus oversamples of at least 300 additional interviews among each of the following six specific 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); and,
  • Males (aged 20-59).
• 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 2,827 respondents. 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 2,827 interviews were comprised of the following:

• A base national sample of n=1,017 Canadian residents aged 13 and older;
• An additional sample of n=300 youth aged 13-15;
• An additional sample of n=302 parents or caregivers of youth aged 13-15;
• An additional sample of n=300 young adults aged 16-24
• An additional sample of n=302 males aged 20-59
• An additional sample of n=304 people who used legal drugs in the form of prescribed opioids at some point in the past year; and
• An additional sample of n=302 people who used illegal drugs, either counterfeit prescriptions or other drugs, that could be laced with opioids, at some point in the past year.

Surveys were conducted between December 22, 2021 and January 12, 2022 in English and French. The online survey took an average of 19 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 20-59 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 user 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 provides the survey instrument used.

The key findings from the research are presented below. To ensure comparability, the survey largely remained consistent with questions asked in the 2019 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 Communicating about Substance Use in Compassionate, Safe and Non-Stigmatizing Ways.

For statistical information on prevalence, refer to the Canadian Alcohol and Drugs Survey (CADS) or the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS).

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 for the substances 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 refers to those who either used illicit drugs or used opioids without a prescription.
• One fifth of Canadians (21%) report having taken opioids in the past year, down 8% since 2019 and in line with results from the benchmark study conducted in 2017.
• Down from both previous waves of research (69% in 2019 and 66% in 2017), 56% of Canadians who have taken opioids in the past year say they always have a prescription when they take opioids. Parents (61%) are the most likely to say they always have a prescription in their names when they take opioids.
• Few (4%) have been refused a prescription for opioids when they needed it for pain.
• Illicit drug use has decreased slightly since 2019 (at 7%). Supported by the focus groups, illicit drug use may be higher among younger men than others.

Opioid awareness, impressions, and basic understanding

• The survey findings suggest that awareness of opioids is unchanged since 2019. Roughly two thirds (67%) are certain or pretty sure they know what an opioid is, compared to 69% in 2019.
• Despite stable awareness, familiarity and knowledge of opioids appears to have softened over the same period of time. Six in ten (61%) are somewhat or very familiar with at least one of the opioids referenced, however, a fifth (21%) say that they are not at all familiar with any, which is a significant increase since 2019.
• While focus group participants widely understood the term and spectrum of opioids, few mentioned illegally-produced opioids on their own.
• Returning to 2017 levels, after a 4% increase since 2019, over two in five respondents (43%) believe that all opioids referenced on the chart are dangerous. However, the combined proportion of those who think all or most are dangerous has barely shifted over time, with 81% in both 2021 and 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 (89%) 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 (61%) of respondents sense that the opioid crisis is serious in their community, down 9% since 2019.
• Familiarity with fentanyl has decreased some since 2019; but the predominant view that it is very dangerous has not.
• Two thirds (67%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl.
• Half (47%) know what naloxone is and what it is used for, though fewer know where to get it (26%) or how to administer it (18%).

Attitudes relating to behaviours, risk, and harms

• Since 2019, there has been a softening in awareness and concern about opioids in a few ways. Compared to 2019, fewer Canadians say they understand what makes opioids so dangerous, they could easily find help for dealing with an opioid use disorder if they needed to, would know what to do if they witnessed an overdose or could identify signs of an opioid use disorder.
• A slight majority (58%) believe that "opioid use disorder" and "addiction" mean basically or exactly the same thing.
• Few focus group participants were confident they would recognize the signs of an opioid overdose. Among those who were, they described the physical symptoms, including altered consciousness/lifelessness, changes to the eyes or breathing, or presence of vomit/vomiting.
• Consensus was not reached in the focus group discussion in regard to recognizing substance use disorders. Some participants felt that quantity was the determining factor, while others felt it was the impact caused by the substance.
• Most focus group participants said they would call 9-1-1 if they witnessed an opioid overdose, though some mentioned the use of naloxone, and a handful said they possess it.

Attitudes regarding stigma

• Respondents remain conflicted, simultaneously holding supportive views that indicate compassion and negative views that indicate stigma. Only 12% of respondents agree with the statement, "People who overdose on opioids get what they deserve." However, over three-quarters (79%) agree that, "People who have an opioid use disorder deserve the help that they need to lead a healthy lifestyle."
• Over half (57%) agree we should be using more of our health care resources to deal with opioid use disorder, a 7% decrease since 2019. In contrast, a third of respondents (32%) agree that, "People with any drug addiction are dangerous and untrustworthy."
• Respondents appear cognizant that stigma exists. Three quarters (74%) acknowledge that, "Society is not very friendly toward people with an opioid use disorder," which has increased 5% since 2019. Further, 61% agree that, "Society's attitudes about people with an opioid use disorder affect whether they seek help or treatment."
• Furthermore, a fifth (21%) agree with the statement "People who are dependent upon or addicted to opioids could stop taking them if they really wanted to," a quarter (25%) agree that "I don't have much sympathy for people who misuse opioids" and a third (31%) agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids."
• Focus group participants uniformly agreed that people with substance use disorders are stigmatized. However, for most, the degree to which and how stigma is applied depends on the substance used and the person using it.

Risk behaviour profiling

• Two fifths (42%) of respondents have at least one friend/family member that has been prescribed one of the referenced opioids (down 12% since 2019). One quarter (27%) of respondents know someone who became addicted (developed an opioid use disorder) to one of these drugs (down 6% since 2019). A quarter (23%) say a friend or family member used one of the drugs listed without a prescription. Nearly one in five have known someone who has died from an opioid overdose (16%) or had a non-fatal overdose of one of these drugs (14%).
• When asked the second time around if current/past opioid users have always, usually, sometimes, rarely, or never had a prescription, over half (57%) report illegal opioid use.
• Half (54%) report keeping their prescribed opioids in a location that is only accessible to them.
• A quarter of respondents (30%) return their unused pills/patches/liquids to their doctor/pharmacy/hospital, however a similar portion (26%) save them in case they need them again.
• Fifteen percent of respondents who have taken non-prescribed opioids do so daily, or many times.
• Over a third (34%) of those who have used non-prescribed opioids obtained them from a relative or friend who has a prescription. One in ten young adults (11%) relied on the Internet for their non-prescription opioids compared to 5% of the general population who have taken non-prescribed opioids.
• 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 (14%), for the feeling it causes (11%) or to get high (11%).
• Two thirds of illegal opioid users (65%) definitely would no longer take them if they discovered they contained fentanyl (an 8% decrease since 2019).
• Nearly one fifth (16%) take another drug/alcohol at the same time as an opioid at least sometimes, with the most common substances being alcohol and cannabis.
• Few (4%) who have used opioids have ever sought treatment for an opioid use disorder.
• Over half of parents (54%) whose teens have been prescribed opioids in the past year believe their teen is taking them as prescribed. Few parents (3%) say their teen has taken an opioid that was not prescribed to them; however, this proportion is significantly higher among parents who are illegal drug users (14%). Among parents who say their teen has not been prescribed an opioid in the past year, fewer (4%) say their teen has been prescribed an opioid at some earlier time in their life.
• Nearly two thirds (62%) of parents feel confident that they would know where to get help for their teen if they needed help for drug use.
• When asked where they think people their age obtain non-prescribed opioids a similar proportion believe the source is a drug dealer/stranger (47%), or a friend's (46%) or relative's (41%) prescription.

Opioid information

• Primary sources of trusted opioid information concerning the effects of opioid use include doctors (82% trust), and pharmacists (79%). However, for youth 13-15 their parents are also among the most trusted sources (79%).
• The least trusted sources of opioid use information include news outlets (32% trust), family members or friends who have never taken opioids before (21%) and people who are currently using opioids regularly (18%).
• Over two thirds (68%) of parents report discussing the topic of drugs in general with their children, whereas 59% of youth report having that discussion.
• In terms of seeking help for substance use, there was a general consensus that men seek help with substance use less often than other genders. Common sources of help or information included the media and online, Employee Assistance Programs, and doctors or other trained professionals.
• Most participants said they would be comfortable speaking to a close friend or family member about substance use or addiction, while fewer felt comfortable talking to a colleague or employer.

Views on chronic pain and chronic pain management

• Most current and past opioid users started taking opioids to control pain resulting from a medical procedure (44%), an injury (20%), or chronic disease (4%). One fifth (17%) started taking opioids to manage chronic pain.
• Current opioid users are more likely to take opioids today to manage chronic pain (42%), and less likely due to pain resulting from a medical procedure (31%) or injury (33%).
• One in ten (11%) opioid users who used opioids to manage pain say they felt they were treated differently by health care workers due to their opioid use. Half (48%) were negatively impacted by that treatment.
• Nearly all focus group participants had experiences or knew someone who has experienced chronic pain, especially among those who work in physically demanding jobs. Men in those jobs consider managing pain a key factor in substance use and addiction.
• Perceptions of treating chronic pain varied. Some spoke of alternative therapies, like physiotherapy, chiropractic care and acupuncture, whereas others mentioned the use of medications or cannabis to manage the pain.
• Access to alternative treatments for chronic pain was a barrier, either due to cost or wait times.

The role of stigma

As was undertaken in previous waves of research, 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. However, the data suggests that there may be an erosion of the Unsympathetic segment occurring over time.

• The evidence demonstrates that stigmatizing views about opioid use disorder continue to be held by a significant portion of the population.
• In keeping with the survey results, most focus group participants felt that stigma negatively impacts those with substance use addiction and makes them less likely to reach out for help.
• About one in four (24%) belong to the Unsympathetic segment and are defined by their belief that opioid use disorder is largely an issue of self-control, that they don't have much sympathy for people who develop the disorder and they feel the people who overdose get what they deserve. While not significantly different since 2019 (26%), there perhaps is an erosion of this segment occurring, as the membership of the Unsympathetic segment has statistically decreased by 4% since 2017.
• Another quarter (25%) demonstrate holding the opposite opinion on all three of these statements, making them Allies when it comes to addressing the opioid crisis. This is an identical proportion found when compared to 2019 (25%).
• Half of Canadians (51%) fall somewhere in between, holding conflicting or nuanced views on these three statements and making up the segment described as Ambivalent (compared to 49% in 2019).
• The segment to which one belongs appears to continue to relate to one's familiarity or exposure to opioids – either personally or among their friends or family.
• Moving people from being Ambivalent, or even Unsympathetic, to being Allies would appear to bring with it a greater appreciation for the need for increased public health resources being allocated to dealing with the crisis.
• Demonstrating that developing an opioid use disorder is not a matter of self-control and that treatment can be effective would appear to hold potential to assist with this aim.

View regarding alcohol consumption and substance use

• Over half support including health risks/warnings (66%) and ingredients (59%) on alcoholic beverage labels. Nearly half support the number of standard serving sizes per container (49%), and calories (46%) being listed.
• Three quarters (77%) agree that alcohol use increases a person's risk of developing serious health conditions.
• Mirroring the quantitative findings, focus group participants readily identified multiple negative health impacts alcohol has, including to the liver, heart and brain. Some of the specific illnesses linked to alcohol use included: sclerosis of the liver, cardiac issues, high blood pressure, pancreatic cancer, depression and dementia.
• Over half of respondents agree that alcohol use among youth is a serious problem in Canada (56%), and that the federal government should be doing more to address alcohol-related harms (53%).
• Many focus group participants spoke of the pervasiveness of alcohol today with concern. The COVID-19 pandemic is viewed as a factor in the increase in substance use.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-213980/001/CY
Contract award date: November 9, 2021

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 Policy on Communications and Federal Identity 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.

Date: February 11, 2022

Signed:

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.

The growing number of overdoses and deaths related to the use of opioids is a national public health crisis, and a crisis that is worsening under the COVID-19 pandemic. The opioid crisis is complex, and it affects all communities, all age groups, and all socioeconomic groups. In 2018, Health Canada launched a multi-year public education campaign to address the growing opioid overdose crisis to raise awareness and to educate Canadians on the risks associated with problematic substance use, including the use of opioids (legal and illegal) as well as the role of stigma as a barrier to treatment.

In 2017, to help inform the ensuing public education campaign, Health Canada contracted Earnscliffe to conduct a baseline survey on opioid awareness, knowledge and behaviours. In 2019, we conducted follow-up research to determine whether results had changed since the baseline survey. In 2021, further research was required to determine if awareness of and attitudes towards problematic opioid use have changed over the past few years, and if stigma has been reduced. This research provides evidence-based data and insights to guide Health Canada's marketing campaigns and policy development. The contract value for this project was $189,163.07 including HST.

The main objective of the research was to track changes since the Follow-up Survey and Qualitative Research on Opioid Awareness, Knowledge and Behaviours for Public Education conducted in 2019, regarding the current state of awareness, knowledge, attitudes, beliefs (including assessing opinions around varying harm reduction measures), and behaviours with respect to opioids and other controlled substances.

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

• Gain insight into awareness, perceptions, and attitudes among target audiences on issues related to opioid use in their communities, including:
  • Government actions; and,
  • Opinions on actions to respond to the crisis.

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 2019 survey;
• Understanding current views on this issue (including stigma);
• Identifying barriers, knowledge gaps and misperceptions related to opioids – including the misuse of opioids (both legal and illegal), problematic 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 involving both qualitative and quantitative research.

The sessions were approximately 90 minutes in length. Focus group participants were given an honorarium as a token of appreciation for their time ($100 for men ages 20-59 and $125 for men (18+) in physically demanding jobs). 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 group participants.

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. We took care to replicate the complicated structure and weighting processes employed in previous waves to ensure comparability of results. 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 among each of the following six specific 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); and,
  • Males (aged 20-59).
• People who use opioids, including
  • Those who only use opioids prescribed to them; and,
  • Those who use counterfeit prescriptions and/ or other illegal drugs that could be laced with opioids such as fentanyl.

Men aged 30-39 have been analyzed throughout the report, instead of the broader oversample of men aged 20-59 for consistency and tracking purposes.

The online survey was conducted using Leger's opt-in panel and upon completion, consisted of a final aggregate sample of 2,827 respondents. A total of 1,017 cases were collected as the sample of the general population. Oversamples (minimum of n=300) were also collected for the following groups:

• Youth (13-15)
• Parents or caregivers of youth (13-15)
• Young adults (16-24)
• Males (20-59)
• People who use legal drugs in the form of prescribed opioids at some point in the past year (incidence of 13%)
• 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%)

The profile of each oversample group is presented in the table 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 December 22, 2021, and January 12, 2022, in English and French. The online survey took an average of 19 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 20-59 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 user 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 provides the survey instrument used.

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 and 2019 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 instrument 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 understanding;
• Attitudes relating to behaviours, risk and harms;
• Attitudes regarding stigma;
• Risk behaviour profiling;
• Opioid information;
• Views on chronic pain;
• The role of stigma; and,
• Views regarding alcohol consumption and substance use.

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.

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 Alcohol and Drugs Survey (CADS) or the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS).

One in five (21%) report having taken opioids in the past year, down 8% since 2019, but represents a return to the 2017's benchmark study level (22%). A near identical proportion (19%) claim they have taken them, but not in the past year. Among opioid users, slightly over half (56%) say they always have a prescription for the opioids they take. This is a drop from both 2019 and 2017, which saw 69% and 66%, respectively. A larger proportion of Quebecers (64%) say they have never taken opioids, compared to other regions.

Adults 25 and older have the highest incidence of past year opioid use (41%) compared to young adults (23%) and youth (17%). Adults 25 and older are, however, significantly more likely to say they always have a prescription in their name compared to young adults (53% compared to 31%). Parents of 13-15 year olds are the most likely to say they always have a prescription in their name when they take an opioid (at 61%).

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

Overall, few (4%) have ever been refused a prescription for opioids when they needed it for pain. Among those who use drugs illegally, this number rises to 15%.

With regards to illicit drugs, the use of illicit drugs appears to have decreased slightly since 2019, with 7% of Canadians indicating they have taken at least one of these drugs in the past year (compared to 8% in 2019). Among those most used by respondents are ecstasy (15% have used) and cocaine (14% have used). Methamphetamine (6%) and heroin (3%) are less used among respondents. Illicit drugs appear to be slightly more popular among men 30-39 and legal opioid users, though incidence is low.

Q11. Have you taken any of the following?

Key takeaways: Opioids and illicit drug use

• One fifth of Canadians (21%) report having taken opioids in the past year, down 8% since 2019 and in line with results from the benchmark study conducted in 2017.
• Down from both previous waves of research, 56% of Canadians who have taken opioids in the past year say they always have a prescription when they take opioids. Parents (61%) are the most likely to say they always have a prescription in their names when they take opioids.
• Few (4%) have been refused a prescription for opioids when they needed it for pain.
• Illicit drug use has decreased slightly since 2019 (at 7%). Supported by the focus groups, illicit drug use may be higher among younger men than others.

Section B: Opioid awareness, impressions and basic understanding

Awareness of opioids is fairly broad and is unchanged since 2019. Roughly two thirds (67%) are certain or pretty sure they know what an opioid is, compared to 69% in 2019. Approximately one third of adults 25 and older (32%) and parents (35%) are certain they know what an opioid is, higher than among young adults (25%) and youth (8%). Identical to 2019, over a quarter of youth (28%) say they have never heard the term opioid or do not really know what it is. The group most certain of their knowledge is legal users – 81% are pretty sure or certain.

Upon being shown the reference chart, claimed familiarity drops, with 61% reporting they are familiar with at least one of the referenced opioids (compared to 65% in 2019). One quarter (24%) of Canadians say they are very familiar with at least one of the opioids referenced on the chart, while another 37% categorize their familiarity as "somewhat familiar." One fifth (21%), up 5% since 2019, say they are not at all familiar with any of the opioids listed.

Youth are less familiar with opioids than the other age groups. Nearly two in five (39%) say they are not at all familiar with any opioids, compared to 19% of young adults and 15% of adults 25 and older. The incidence of familiarity of opioids among youth has returned to 2017 levels, where an identical 39% said they were not at all familiar (an increase of 12% since 2019).

Legal and illegal users of drugs are more familiar with opioids – 53% and 35% respectively are very familiar. Parents' and men's (30-39) familiarity resemble that of the general population.

Qualitative insights: Awareness of and familiarity with opioids

Consistent with the survey findings, awareness of the term opioids was generally high, although, familiarity and knowledge varied widely. Nearly all were aware of the term "opioids" and there was general awareness of the spectrum of opioids, however, few mentioned illegally-produced opioids unaided. It did appear that participants in British Columbia were more familiar with opioids and talked about the crisis in that province, as well as mentioning specific neighbourhoods such as East Hastings, where opioid use was particularly evident and problematic.

Over four in ten respondents (43%) believe that all opioids referenced on the chart are dangerous, compared to 39% in 2019 and 45% in 2017. The combined proportion of those who think all or most are dangerous has barely shifted over time, with 81% in both 2021 and 2019, and 80% in 2017. Respondents from Ontario are less likely to believe all are dangerous (39%) than those from Atlantic Canada (53%), and Manitoba/Saskatchewan (54%).

Young adults are less wary of opioids than youth and adults 25+. Three in ten young adults (29%) believe all opioids are dangerous, compared to 44% of youth and 43% of adults 25+. Males 30-39 are the least likely to believe all the opioids references are dangerous (at 24%), which represents a 7% decrease since 2019. Illegal drug users are perhaps unsurprisingly less inclined to believe all are dangerous (25%), which is identical to the 2019 results (25%).

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 (87% very dangerous, 8% somewhat dangerous). Agreement is similarly high when it comes to the danger faced by people who use illegal drugs (82% very dangerous, 11% somewhat dangerous). Youth 13-15 are more concerned (82%) about the danger of opioids to them personally than young adults (70%) and those 25+ (68%). Legal drug users are less concerned about the danger opioids pose to them personally (59%), compared to all other groups.

The only notable change since 2019 is the proportion of Canadians who believe that opioids are dangerous for those who get them through a friend's/relative's prescription, which dropped 3% since 2019, but remains high at 91%.

Only half (50%) of Manitobans/Saskatchewanians believe that opioids are dangerous for themselves, personally, which is significantly lower than in all other regions in Canada.

The vast majority (89%) believe the term "illegal opioids" means opioids obtained on the street, a similar proportion to 2019 (87%) and 2017 (88%). Just under two thirds (61%) believe the term can include prescription opioids that are taken without a prescription, which is unchanged since 2019 but significantly lower than in 2017 (66%).

Youth (46%) and illegal drug users (54%) are less likely to equate illegal opioids with prescription opioids taken without a prescription. Whereas, Manitobans/Saskatchewanians are more likely to relate non-prescription use of opioids to illegal opioids (at 77%), compared to Canadians in Quebec (52%), Ontario (64%) and BC (57%).

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 those illegally made/manufactured, opioids purchased on the Internet, and opioids that contain other illegal drugs.

Perhaps not surprisingly given the timing of this research (during the fourth wave of the COVID-19 pandemic), overall awareness of Canada's opioid crisis is lower than in 2019 and 2017. One fifth (19%) considered themselves very aware of the opioid crisis, compared to 25% in 2019 and 28% in 2017. Half (48%) of Canadians say they are somewhat aware of the crisis, which is unchanged since 2019 (at 49%).

Youth (10%) and young adults (14%) are significantly less likely to categorize their awareness as "very aware" than most other groups and are also less likely to say they are somewhat aware (at 36% and 41%, respectively) than adults 25 and older (48%). A greater proportion of Quebecers (53%) are not aware of the opioid crisis, compared to all other regions.

Awareness is highest among legal opioid users. The vast majority (78%) are aware, a similar figure to 2019 (80%) and 2017 (79%). Awareness among parents has decreased – 68% are aware in the most recent data, compared to the 75% and 73% aware in 2019 and 2017, respectively. Less than two thirds (62%) of men 30-39 are aware of the opioid crisis in Canada.

Except for youth (45%), across the general population and oversamples, a majority or more sense that the opioid crisis is serious in their community. In fact, nearly two thirds of Canadians (61%) view the opioid crisis as very or somewhat serious in their community, which is down since 2019 (70%) but in line with the results in 2017 (65%).

Youth are less likely to view the crisis as serious (45%) compared to young adults (55%) and adults 25 and over (63%). Respondents in BC are particularly sensitive to the severity of the crisis – 44% categorize the crisis as very serious, more than in all regions across Canada.

Familiarity with fentanyl has dropped since 2019, with over four in ten respondents (44%) claiming they are very or somewhat familiar, compared to 49% in 2019. This year, there is an increase (4%) in the percentage of people who are not at all familiar with fentanyl (22% in 2021 and 18% in 2019), however, the results are consistent with 2017 (23%). There is some regional variation in familiarity – significantly more Quebecers are not familiar (70%) compared to all other regions.

The percentage of youth who are familiar with fentanyl remains lower than other cohorts (34% not at all familiar). Men's (30-39) familiarity with fentanyl is higher (56%) than the general population (44%). Parents' familiarity largely reflects the general population results (48%), however parents are more likely to say they are very familiar (17% compared to 11%). Familiarity among legal opioid users is the highest among all target groups (58%) and is unchanged since 2019 (59%).

Among those familiar with fentanyl, well over three quarters (80%) describe it as very dangerous, comparable to the 81% who felt the same way in 2019. While most across all oversamples agree it is dangerous, fewer young adults (66%), illegal drug users (67%) and men 30-39 (68%) believe fentanyl is very dangerous.

Two thirds of those familiar with fentanyl (67%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl. As in 2019, fewer youth (58%), young adults (55%), illegal drug users (54%) and men 30-39 (52%) perceive this as having a high risk. Very few (2%) believe there is not much or no risk. Respondents in BC perceive greater risk (77%) than those in Quebec (62%) or Ontario (67%). Women are more likely to categorize the risk as high (71%) compared to those that do not identify themselves as female (63%).

For the first time, survey respondents were asked about the awareness of naloxone, as well as where to get it and how to administer it. Nearly half (47%) of Canadians say they know what naloxone is and what it is used for, however, fewer know where to get it (26%) or how to administer it (18%).

Legal opioid users and illegal drug users have the strongest familiarity with naloxone than any other group. Despite that, the minority know where to get it (35% and 32%, respectively) or how to administer it (27% for both). Only a small proportion of youth know what naloxone is/what it is used for (21%), where to get it (13%) or how to administer it (12%).

Some regional differences exist as it pertains to familiarity with naloxone. Canadians in Quebec and Atlantic Canada are the least likely to know what naloxone is (28% and 37%, respectively) or where to get it (24% and 18%). Conversely, Albertans have the highest awareness of naloxone (59%), where to get it (36%) and how to administer it (23%).

Note that this question was not asked in 2017 or 2019.

Key takeaways: Opioid awareness, impressions, and basic understanding

• The survey findings suggest that awareness of opioids is unchanged since 2019. Roughly two thirds (67%) are certain or pretty sure they know what an opioid is, compared to 69% in 2019.
• Despite stable awareness, levels of familiarity and knowledge of opioids appears to have softened over the same period of time. Six in ten (61%) are somewhat or very familiar with at least one of the opioids referenced, however, a fifth (21%) say that they are not at all familiar with any, which is a significant increase since 2019.
• While focus group participants widely understood the term and spectrum of opioids, few mentioned illegally-produced opioids on their own.
• Returning to 2017 levels, after a 4% increase since 2019, over two in five respondents (43%) believe that all opioids referenced on the chart are dangerous. However, the combined proportion of those who think all or most are dangerous has barely shifted over time, with 81% in both 2021 and 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 (89%) 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 (61%) of respondents sense that the opioid crisis is serious in their community, down 9% since 2019.
• Familiarity with fentanyl has decreased some since 2019; but the predominant view that it is very dangerous has not.
• Two thirds (67%) think there is a high risk that illegal non-opioid drugs could be laced with fentanyl.
• Half (47%) know what naloxone is and what it is used for, though fewer know where to get it (26%) or how to administer it (18%).

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

Since 2019, there has been a softening in awareness and concern about opioids in a few ways. For instance, while the majority of Canadians say they understand what makes opioids so dangerous (60%), this represents a significant decrease since 2019 (67%) and is directionally lower than in 2017 (64%). Compared to 2019, fewer Canadians agree that they could easily find help for dealing with an opioid use disorder if they needed to (36% versus 45% in 2019), would know what to do if they witnessed an overdose (27% versus 33% in 2019) or could identify signs of an opioid use disorder (26% versus 39% in 2019). Unchanged since 2019, one quarter (27%) of Canadians agree that they would know what to do if they saw a person experiencing an overdose.

Legal opioid users have the highest incidence of agreement across all measures, followed by illegal drug users, while youth have the lowest. Fewer young adults say they know what makes opioids so dangerous in 2021 (59%) compared to in 2019 (66%), whereas the reverse is true of men 30-39 (67% in 2021 versus 60% in 2019).

Regionally, Albertans are the most confident that they could find help for an opioid use disorder if they needed to (49% agree). Along with British Columbians, Albertans are also the most likely to agree that they would know what to do if they saw someone experiencing an overdose (34% for both) and could identify the signs of an opioid overdose if faced with one (34% and 35%, respectively).

To inform public messaging and education, respondents were asked what they think of the terms "opioid use disorder" and "addiction." Just over half of Canadians (58%) believe that the terms are basically or exactly the same thing, while one quarter (25%) believe they are different. Roughly one third of illegal drug users (31%) and males 30-39 (36%) think they are different.

Qualitative insights: Substance use disorder and addiction

Focus group participants readily provided definitions of the term "addiction." While a variety of different interpretations were offered, the inability to easily stop doing something was common to all definitions. A lot of examples were offered, but it was clear that participants felt there were a wide range of substances (and even activities) to which people could be addicted.

On the individual level, substance use addiction was commonly deemed a combination issue, affecting health and social aspects of life, as well as community safety and law enforcement. However, at the societal level, it was commonly perceived that society does not regard those with a substance use addiction very well, and some noted that public awareness needs to improve.

In terms of the need to seek help related to substance use or addiction, there was consensus that men do so less often/readily than other genders. Some described seeking help as admitting failure, and that men are socialized to not accept/admit failure. The other factors preventing men from reaching out included a sense of denial among men and/or a lack of accountability among men.

Invariably in every group with men in physically demanding jobs, there was at least one participant who voluntarily identified themselves as "in recovery" from a substance use addiction.

Focus group participants were divided when it came to recognizing the signs of a substance use disorder. Some felt that there was a certain quantity that would determine if the use was problematic (e.g., daily use), others felt that substance use was only problematic when it had an impact on the user's personal/professional life, and some felt it was a combination of the two. Many recognized that it could be difficult to identify among men as substance use was so prevalent in today's society.

"If I told my buddies that I wasn't going to have a beer tonight, they would ask me what's the matter" – man in physically demanding job, Atlantic Canada

Recognizing problematic substance use was also dependent on the substance being considered. While most participants commonly referred to alcohol and cannabis when discussing substance use, some mentioned that substance use disorder is easier to identify when the substance is an illegal substance.

"You can't have moderate use of heroin" – man in physically demanding job, BC

Few participants indicated they would recognize the signs and symptoms of an opioid overdose if they saw it, and those who said they would recognize an overdose described the physical symptoms of altered consciousness/lifelessness, changes to the eyes or breathing, or presence of vomit/vomiting.

If encountering an opioid overdose, the most common response for participants was to call 9-1-1, though some mentioned the use of naloxone and clearing the individual's airway (if obstructed). A few participants specifically mentioned they were in possession of a "Narcan" kit or naloxone though most did not seem to carry it with them at all times.

"I trust emergency services to be better informed than I!" – man in physically demanding job, Prairies

Key takeaways: Attitudes relating to behaviours, risk, and harms

• Since 2019, there has been a softening in awareness and concern about opioids in a few ways. Compared to 2019, fewer Canadians say they understand what makes opioids so dangerous, they could easily find help for dealing with an opioid use disorder if they needed to, would know what to do if they witnessed an overdose or could identify signs of an opioid use disorder.
• A slight majority (58%) believe that "opioid use disorder" and "addiction" mean basically or exactly the same thing.
• Few focus group participants were confident they would recognize the signs of an opioid overdose. Among those who were, they described the physical symptoms, including altered consciousness/lifelessness, changes to the eyes or breathing, or presence of vomit/vomiting.
• Consensus was not reached in the focus group discussion in regard to recognizing substance use disorders. Some participants felt that quantity was the determining factor, while others felt it was the impact caused by the substance.
• Most focus group participants said they would call 9-1-1 if they witnessed an opioid overdose, though some mentioned the use of naloxone, and a handful said they possess it.

Section D: Attitudes regarding stigma

While people with an opioid use disorder still encounter stigma, the tracking data suggest, on balance, it has not worsened. There are some signs it may be improving over time. For example, in 2017 16% of Canadians felt that people who overdose on opioids get what they deserve. While that remained statistically unchanged in 2019 (14%), the proportion of respondents who agree with that statement has significantly dropped this year compared to the baseline metric (now at 12%). In 2019, respondents were asked if they agree or disagree with the statement that "people with an opioid use disorder are dangerous and/or untrustworthy" and 37% agreed. While the statement was changed to include "any drug addiction," fewer Canadians now agree that those with a drug addiction are dangerous/untrustworthy (32%).

Not all perceptions changed in the same manner. Fewer Canadians agree that more of our health care resources should be dedicated to dealing with drug addiction (57% compared to 64% in 2019; however, note the timing of this research (during the COVID-19 pandemic) and that this wording was also changed to be more inclusive of drug addiction). Increasing since 2017 (17%), one fifth of Canadians (21%) believe that those addicted to opioids could stop taking them if they "really want to." There is also a heightened level of agreement that society is not very friendly to people living with a drug addiction (74% versus 69% in 2019), and a decrease in perception that society's attitude has an impact on someone's likelihood to seek treatment (61% in 2021 versus 66% in 2019).

Despite any changes, stigma is still prevalent throughout Canada. Nearly a third of respondents (31%) agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids," and one quarter say, "I negatively judge people who are living with a drug addiction" (26%), and "I don't have much sympathy for people who misuse opioids" (25%). One fifth agree that "People living with a drug addiction should be cut off from services if they don't try to help themselves" (22%), and "It's mostly people who are homeless, down on their luck, or who already have other drug use problems who develop an opioid use disorder (addiction)" (19%).

There are also some additional conflicting perceptions. For example, a strong majority of Canadians agree that people living with an opioid use disorder deserve the help they need in order to live a healthy lifestyle (79%), that people living with a drug addiction can recover (77%) and that addiction to opioids is a disease (63%), however, nearly half (44%) agree that people living with a drug addiction cost the system too much money.

Most Canadians agree that the opioid crisis in Canada is a public health issue (75%), which has not changed over the tracking period (76% in 2019 and 74% in 2017). Furthermore, only one fifth (22%) agree that the opioid crisis is not as serious as COVID-19.

In terms of finding and seeking help, roughly half of Canadians feel they would be comfortable seeking help for an opioid use disorder if they ever developed one (57%) and would know how to get help (52%). A similar proportion of parents (55%) agree that they would know how to get help if they were ever to feel their teen were living with a drug addiction. That said, nearly one-third do not agree that they think their friends or family would be comfortable sharing with them that they had a drug addiction (30%). Only a fifth of Canadians (21%) would not want their friends or family to know if they were prescribed an opioid.

In keeping with 2019 (73%), three quarters of Canadians (75%) agree that "When following your doctor's instructions for taking an opioid painkiller, you can still become addicted."

Adults 25 and older appear to have a broader understanding of the causes of opioid use disorder, its consequences, and how to get help. Specifically, adults 25 and older are more likely to agree with the following statements than both youth and young adults:

• People who have an opioid use disorder (addiction) deserve the help they need to a lead healthy lifestyle (82%);
• I think people living with a drug addiction can recover (79%);
• Society is not very friendly toward people living with a drug addiction (77%);
• When following your doctor's instructions for taking an opioid painkiller, you can still become addicted (76%);
• The opioid crisis in Canada is a public health issue (75%);
• If I ever developed opioid use disorder (addiction), I would feel comfortable seeking help (61%); and,
• If I were ever to feel I may have developed an opioid or other substance use disorder (addiction), I would know how to get help (56%).

Altogether, legal opioid users have the highest levels of understanding of the causes and consequences of opioid use disorder, and lowest levels of agreement with stigma-related views. Most notably, over three quarters of legal opioid users agree with the statements, "People who have an opioid use disorder (addiction) deserve the help they need to a lead healthy lifestyle" (84%), "I think people living with a drug addiction can recover" (84%), "When following your doctor's instructions for taking an opioid painkiller, you can still become addicted" (80%), "The opioid crisis in Canada is a public health issue" (78%), and "Society is not very friendly toward people living with a drug addiction" (77%).

Illegal drug users are more likely to agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids" (35%), "Canada's opioid crisis is not as serious a public health crisis as COVID-19 is" (28%), "People who are dependent upon or addicted to opioids could stop taking them if they really wanted to" (25%), "It's mostly people who are homeless, down on their luck, or who already have other drug use problems who develop an opioid use disorder (addiction)" (25%), and "People who overdose on opioids get what they deserve" (18%). In keeping with an increase in these stigma-related views, illegal drug users are also more likely to say that they would not want their friends/family to know if they were prescribed an opioid (30%).

Perceptions held by parents and men 30-39 are largely in line with the general population. Of note, men 30-39 are more likely to agree that "Canada's opioid crisis is not as serious a public health crisis as COVID-19 is" (31%), compared to the general population (22%).

* Note that the response category was updated in 2021 with new language.
** Bear in mind the small sample sizes. Results should be regarded with caution.

* Note that the response category was updated in 2021 with new language

Qualitative insights: Views related to stigma

There was near consensus that those who have a substance use addiction are stigmatized, however, most recognized that the amount of stigma or the way it is applied depends on the person being stigmatized. Some participants mentioned that affluent individuals receive less stigma, whereas those in lower economic classes receive more stigma. Some noted that Indigenous people might receive more stigma than others.

"[The degree to which you are stigmatized] starts with your status in society" – man 20-59, Ontario

Further, participants felt that social acceptance and stigma differed based on substance use. For example, most seemed to suggest that there is not a lot of stigma associated with cannabis use and alcohol use (if not completely inebriated); whereas, illegal drug use was much more commonly seen as stigmatized. No participants offered their assessment of the degree to which those with opioid use disorder are stigmatized.

When it comes to how stigma associated with substance use and addiction impacts men, most agree that it is different. However, the perceptions of how it is different were mixed. Some think that men are stigmatized more than other genders, whereas others think it is more accepted among men and therefore, they are stigmatized less.

For some, it was perhaps not the stigma of having a substance use disorder, but instead the stigma of needing help for it. Many participants indicated that men are expected and taught not to show any signs of weakness and admitting that you cannot control your substance use could be seen as a sign of weakness.

"It's acceptable for women to go get treatment…Look at the Betty Ford Treatment Centre; there's no Buzz Aldrin Treatment Centre!" – man 20-59, Atlantic Canada

Perhaps in contrast to the survey findings, no participants shared an opinion that self-control had any impact on one's likelihood of developing a substance use disorder. In fact, many explicitly said the opposite. Common causes of substance use disorder mentioned by participants included trauma, mental health conditions, genetics and environmental factors.

Referring to how self-control does not have a role in addiction, one man in a physically demanding job from the Prairies said, "If you can stop, I don't think it's addiction."

When asked, many participants believed that someone could recover from a substance use disorder, though consensus was not reached. There was an additional divide on what recovery looked at, with some indicating abstinence is necessary while others thought that was not a requirement for all.

Focus group participants suggested possible ways to encourage a reduction in substance use, including: more public education on the short- and long-term side effects of substance use; increasing awareness of better coping mechanisms (e.g., meditation, exercise); fewer advertisements (for alcohol); and increasing the cost (as it relates to legal substances).

Key takeaways: Attitudes regarding stigma

• To some degree, there remains a level of agreement with both supportive views that indicate compassion and negative views that indicate stigma exists. Only 12% of respondents agree with the statement, "People who overdose on opioids get what they deserve." However, over three quarters (79%) agree that, "People who have an opioid use disorder deserve the help that they need to lead a healthy lifestyle."
• Over half (57%) agree we should be using more of our health care resources to deal with opioid use disorder, a 7% decrease since 2019. Perhaps contributing to that, a third of respondents (32%) agree that, "People with any drug addiction are dangerous and untrustworthy."
• Respondents appear cognizant that stigma exists. Three quarters (74%) acknowledge that, "Society is not very friendly toward people with an opioid use disorder," which has increased 5% since 2019. Further, 61% agree that, "Society's attitudes about people with an opioid use disorder affect whether they seek help or treatment."
• Furthermore, a fifth (21%) agree with the statement "People who are dependent upon or addicted to opioids could stop taking them if they really wanted to," a quarter (25%) agree that "I don't have much sympathy for people who misuse opioids" and a third (31%) agree that "A lack of self-control is usually what causes a dependence upon or an addiction to opioids."
• Focus group participants uniformly agreed that people with substance use disorders are stigmatized. However, for most, the degree to which and how stigma is applied depends on the substance used and the person using it.

Section E: Risk behaviour profiling

The frequency of respondents' acquaintances use of opioids has decreased since 2019. Two fifths (42%) of Canadians have at least one friend/family member that has been prescribed one of the referenced opioids, a 12% decrease since 2019. A quarter (27%) say that they have known someone who became addicted to one of these drugs, which is a notable 6% drop since 2019. A similar proportion (23%) report knowing someone who has used an opioid obtained without a prescription or on the street. Nearly one in five (16%) have known someone who has died from an opioid overdose, and 14% know someone who has had a non-fatal opioid overdose. One in ten (9%) of those with a teen child say their teen has been prescribed an opioid in the past year.

When compared to the general population, legal opioid users and illegal drug users are both more likely to report knowing someone who has been prescribed an opioid (72% and 50%, respectively), has become addicted to an opioid (43% and 41%, respectively), has used an unprescribed opioid (31% and 40%, respectively), has died from an opioid overdose (23% and 24%, respectively), and has suffered a non-fatal opioid overdose (23% and 27%, respectively).

Respondents living in Quebec are less likely to have a family member or friend who has been prescribed an opioid (24%) or have known someone who has become addicted to an opioid (18%) than other regions in Canada. Respondents in Alberta and BC are more likely to know someone who has died of an opioid overdose (both 22%), than residents in Quebec and Ontario (both 13%).

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

Over half (57%) of current and past opioid users indicate having taken opioids illegally (not always with a prescription) at some point in their life. In 2019, more responded that they had taken opioids illegally at some point (75%). Of the 466 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 41% now report having always had a prescription for all opioids they have ever taken. When compared to the general population, youth (25%), young adults (24%), illegal drugs users (22%) and males 30-39 (26%) are less likely to say they always had a prescription for the opioids they have ever taken.

As in 2019, a little over half of prescribed opioid users (54%) 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 young adults (46%), illegal drug users (53%) and those who do not use opioids (52%).

Prescribed opioid user behaviours with leftover opioids are largely unchanged since 2019. One third of Canadians (33%) report not having any leftovers when prescribed an opioid. For those with leftover prescribed opioids, a similar proportion are returning them to a pharmacy/hospital (30%) or saving them in the event of a future need (26%). One in ten (9%) are flushing/disposing of opioids in the garbage. Few (4%) gave them to others, though it is worth noting that more youth (14%), young adults (13%) and illegal drug users (12%) gave their leftovers to someone who needed them.

The proportion of respondents using opioids without a prescription almost daily or many times is slightly higher than in 2019 (15% vs 11%). At 28%, the proportion who have used them a few times has remained unchanged. As could be expected, more illegal drug users say they have used unprescribed opioids almost daily or many times (18%). What may be more surprising is that parents are just as likely to describe the same usage (19% daily or many times).

Fewer overall are relying on a friend or relative's prescribed opioid (34% vs 42% in 2019 and 45% in 2017), but when compared to 2017, more are getting them on the street (18% versus 12%) and the Internet (5% vs 2%). More males (15%), young adults (11%) and illegal drug users (9%) say they obtained their illegal opioids on the Internet than other cohorts. Compared to the general population, legal opioid users are more likely to say they got them from a friend's/relative's prescription (44%), whereas illegal drug users (12%) and adults 25+ (11%) are more likely to get them at a pharmacy.

Compared to the previous years, pain relief was a less predominant reason to take opioids not prescribed to them (54% in 2021, compared to 63% in 2019 and 61% in 2017). Fewer took them to see what it would feel like (14%), for the feeling it causes (11%) or to get high (11%). More young adults and illegal drug users took the opioids to see what it feels like (30% and 21%, respectively) or for the feeling it causes (25% and 16%, respectively). A greater proportion of men 30-39 (23%) took it for the feeling it causes compared to the general population. Fewer young adults (45%) took an opioid not prescribed to them to treat pain, when compared to legal opioid users (67%), adults 25+ (66%), parents 13-15 (64%) and illegal drug users (61%).

Two thirds (65%) of illegal opioid users say they definitely would no longer take illegal opioids if they discovered they contained fentanyl. This number has dropped since 2019, when 73% said they would definitely no longer take them. While the general population is more likely to definitely avoid illegal opioids containing fentanyl, the percentage of youth (47%), young adults (44%), illegal drug users (48%) and males (30-39) (43%) who definitely would not take them is markedly lower than other comparison groups.

Respondents in 2021 were asked how often, if at all, they took other drugs or alcohol at the same time as an opioid, and what that substance was that they took. The majority (69%) of current and past opioid users say they never took other drugs or alcohol at the same time as taking an opioid, though 22% report having done so sometimes or rarely. The proportion of "never" drops to approximately half among youth (57%), young adults (53%), illegal drug users (52%) and males 30-39 (52%).

Among those who have taken another substance alongside an opioid, the most common "pairing" is with alcohol (63%) or cannabis (50%). Fewer report taking cocaine (18%), methamphetamine (10%) or benzos (6%) with an opioid. It is worth noting that both young adults and parents are significantly more likely to have taken benzos in addition to an opioid (21% and 23%, respectively).

In keeping with results from 2019, few (4%) who have used opioids have ever sought treatment for an opioid use disorder. Just over one in ten (12%) of youth who have used opioids say they have sought treatment, compared to 5% of young adults and 3% of those 25+, which is in line with 2019 results.

The proportion of illegal drug users who have sought treatment is slightly higher than the general population (8%) and is slightly lower than the 2019 results (11%). Men 30-39 are also slightly more likely to report they have sought treatment (8%).

Over half of parents (54%) whose teens have been prescribed opioids in the past year believe their teen is taking them as prescribed. While caution must be taken when interpreting these results due to small sample size, this is slightly lower than the proportion in 2019 (61%) and significantly lower than in 2017 (81%). Few parents (3%) say their teen has taken an opioid that was not prescribed to them, which is also consistent with the previous research wave (6%). Among parents who say their teen has not been prescribed an opioid in the past year, fewer (4%) say their teen has been prescribed an opioid at some earlier time in their life when compared to 2019 (9%).

Asked for the first time in 2021, two thirds (66%) of parents of teens are very (27%) or somewhat (39%) confident that if they believed their teen needed help for drug use, they would know where to get it. That said, a fifth (18%) are not very confident that they would know where to find help and one in ten (9%) were not confident at all. Among the target segments, legal opioid users are the most likely to have this confidence (46% are very confident).

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

Half (51%) of youth believe that their peers are relying on a drug dealer or other stranger to get opioids without a prescription, a marked decrease since 2019 (66%). Fewer believe people their age are using a friend's prescribed opioids than in 2019 (32% versus 40%) or a fake prescription (12% versus 22%), while there is only a directional decrease in the percentage who believe their peers are using a relative's prescription opioids (35% versus 42%). There appears to be an increasing trend among youth who feel people their age get their opioids on the Internet (25% in 2021; 21% in 2019; 18% in 2017).

* Bear in mind the small sample sizes. Results should be regarded with caution.

Key takeaways: Risk behaviour profiling

• Two fifths (42%) of respondents have at least one friend/family member that has been prescribed one of the referenced opioids (down 12% since 2019). One quarter (27%) of respondents know someone who became addicted (developed an opioid use disorder) to one of these drugs (down 6% since 2019). A quarter (23%) say a friend or family member used one of the drugs listed without a prescription. Nearly one in five have known someone who has died from an opioid overdose (16%) or had a non-fatal overdose of one of these drugs (14%).
• When asked the second time around if current/past opioid users have always, usually, sometimes, rarely, or never had a prescription, over half (57%) report illegal opioid use.
• Half (54%) report keeping their prescribed opioids in a location that is only accessible to them.
• A quarter of respondents (30%) return their unused pills/patches/liquids to their doctor/pharmacy/hospital, however a similar portion (26%) save them in case they need them again.
• Fifteen percent of respondents who have taken non-prescribed opioids do so daily, or many times.
• Over a third (34%) of those who have used non-prescribed opioids obtained them from a relative or friend who has a prescription. One in ten young adults (11%) relied on the Internet for their non-prescription opioids compared to 5% of the general population who have taken non-prescribed opioids.
• 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 (14%), for the feeling it causes (11%) or to get high (11%).
• Three-quarters of illegal opioid users (65%) definitely would no longer take them if they discovered they contained fentanyl (an 8% decrease since 2019).
• Nearly one fifth (16%) take another drug/alcohol at the same time as an opioid at least sometimes, with the most common substances being alcohol and cannabis.
• Few (4%) who have used opioids have ever sought treatment for an opioid use disorder.
• Over half of parents (54%) whose teens have been prescribed opioids in the past year believe their teen is taking them as prescribed. Few parents (3%) say their teen has taken an opioid that was not prescribed to them; however, this proportion is significantly higher among parents who are illegal drug users (14%). Among parents who say their teen has not been prescribed an opioid in the past year, roughly one in ten (11%) say their teen has been prescribed an opioid at some earlier time in their life.
• Nearly two thirds (62%) of parents feel confident that they would know where to get help for their teen if they needed help for drug use.
• When asked where they think people their age obtain non-prescribed opioids a similar proportion believe the source is a drug dealer/stranger (47%), or a friend's (46%) or relative's (41%) prescription.

Section F: Opioid information

Primary sources of trusted opioid information concerning the effects of opioid use include doctors (82% trust) and pharmacists (79%). Both were also highly trusted in both previous waves. Youth also trust their parents (79%). In keeping with 2019 data, government follows next – 69% trust their regional/municipal health authority, 59% trust the Government of Canada and 57% trust their provincial/territorial government. Slightly fewer trust websites focused on health issues or content (50%) or school teachers (41%). The least trusted sources of opioid use information include news outlets (32% trust), family members or friends who have never taken opioids before (21%) and people who are currently using opioids regularly (18%).

There are a number of differences between age groups in level of trust. Youth and young adults place greater trust in school teachers (66% and 49%, respectively). Parents of teens are also particular trusting of school teachers (49%). Young adults are more trusting of websites (55%), and people who currently use opioids regularly (27%). Youth are more open to information from news outlets (42%) and friends/family who have never used opioids before (41%).

Quebecers and British Columbians are more trusting of their provincial governments (66% and 74%, respectively) than those who live in Ontario (50%), Manitoba/Saskatchewan (47%) and Alberta (42%).

Those making less than $40,000 per year are less likely to trust their doctor (71%) or a pharmacist (69%), compared to those making $40,000 or more.

As described above, the vast majority of Canadians have at least one trusted source of information on opioid use and its effects. However, not all sources of information consistently or reliably share quality information. Understanding this, five sources of information were identified as reliable sources, including the Government of Canada, provincial governments, regional or municipal public health agencies, doctors, and pharmacists. We then counted the number of respondents who trust (including both trust or strongly trust response options) at least one of those five sources. Using this measure, 86% of Canadians indicate trusting at least one of these reliable sources.

* Bear in mind the small sample sizes. Results should be regarded with caution.

* Bear in mind the small sample sizes. Results should be regarded with caution.

There is a sizeable divide between teens and their parents when it comes to discussing opioids and drugs. The majority of parents say they are having discussions with their teens about drugs (68%) and illegal drugs in general (56%), whereas 59% and 40% of teens, respectively, say those conversations have happened. Among teens, there has been a significant or directional decrease in conversations with their parents on each of these topics since 2019, whereas the proportion of parents who say the conversations have happened have either not changed, or in the case of the use of illegal drugs in general, have significantly increased since 2019 (56% versus 48%).

Qualitative insights: Sourcing of opioid help, advice, and treatment

There was a general consensus that men seek help with substance use less often than other genders. Some described seeking help as admitting failure, and that men are socialized to not accept/admit failure. Aside from gender norms, other factors preventing men from reaching out include ideas of denial among men and lack of accountability for men.