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

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)
Executive Summary

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

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