Addressing Canada's Opioid Crisis: A Qualitative Study of the Perspectives of Youth Receiving Substance Use Services : Canadian Journal of Addiction

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ORIGINAL STUDY

Addressing Canada's Opioid Crisis: A Qualitative Study of the Perspectives of Youth Receiving Substance Use Services

Hawke, Lisa D. PhD1,2; Zhu, Na PhD1; Relihan, Jacqueline1; Darnay, Karleigh MSW1; Henderson, Joanna PhD1,2

Author Information
The Canadian Journal of Addiction: June 2022 - Volume 13 - Issue 2S - p S39-S47
doi: 10.1097/CXA.0000000000000148
  • Free

Abstract

BACKGROUND

Opioid-related deaths have been steadily increasing over the past decades,1 leading to the current state of opioid crisis in Canada. In the past 5 years, the opioid crisis has taken the lives of over 21,000 Canadians,2 affecting all segments of society.1 There are regional variations in the demographic profiles of those dying from opioid overdose; in many regions, younger adults are highly affected.1 In Ontario, some 8% of opioid-related deaths are among youth under the age of 25.3

In the Ontario Student Drug Use and Health Survey, 11% of youth in grades 7 to 12 have reported nonmedical use of a prescription opioid pain reliever in the past year.4 They most often acquired the opioids from a parent. Some 6% have reported using prescription drugs, including opioids, to get high, and many have reported polysubstance use.5 Importantly, the nonmedical use of prescription opioids can be a precursor to the use of drugs that are criminalized: a Canadian study found that among youth who use criminalized drugs, 31% began with nonmedical prescription opioids use.6

A number of factors are associated with problematic opioid use among youth. Health-related factors include experiencing chronic pain,7 being prescribed opioids,7 and having mental health challenges.8–10 Other factors include experiencing trauma8; being unemployed and out of school; being homeless;11 and experiencing the challenges associated with a lower socio-economic status.12 Polysubstance use,9 early tobacco and cannabis use onset,9,10 and easy access to opioids play important roles in opioid use and the development of opioid use concerns.3 Substance contamination poses additional risks.1 Compared to adults, youth who are seeking treatment for opioid use may have more severe presentations in terms of polysubstance use, concurrent mental health challenges, and substance use severity,13 suggesting the need for youth-specific services and responses to the opioid crisis.13

Currently, a new factor is influencing the opioid crisis: the COVID-19 pandemic. While youth substance use as a whole does not appear to have been seriously affected by the pandemic,14,15 the opioid crisis has changed.16 Canadian data suggests a marked increase in opioid-related emergency responses, hospitalizations, and deaths in 2020 compared to previous years.2 The pandemic and associated public health responses have imposed psychosocial stressors that may be driving an increase in opioid-related harms. For example, social isolation and job losses have occurred concurrently with disruptions in substance supply chains and mental health and substance use services; youth mental health challenges have increased, and some may be using substances to cope with pandemic-related challenges.2,17,18

The opioid crisis was already at critical levels before the pandemic and it has since worsened. Broad-based strategies to address the opioid crisis are therefore urgently required. The strategies must be guided by evidence, and this evidence must integrate the perspectives of youth who use substance use services.19,20 By building services through a process that integrates youth perspectives in service design and delivery, the resulting services arguably become more appropriate and responsive, increasing willingness to access services and reducing the risks of pursuing unethical and even harmful service approaches.21,22,23

Objective

This study examines the perspectives of treatment-seeking youth regarding strategies to address the opioid crisis among youth, to provide critical guidance for developing and implementing opioid use services and interventions.

METHOD

This project emerged from the Ontario node of a Canadian national project examining youth perspectives on opioid use across Canada and contexts, as part of the Canadian Research Initiative in Substance Misuse. The Ontario node focused on at-risk youth who were seeking substance use services in a tertiary care hospital, where high levels of polysubstance use and concurrent mental health challenges are typically observed. As a key component of this overarching pan-Canadian project, this subproject was the only one to recruit a sample of youth seeking treatment for substance use disorders, providing a critical lens on opioid use treatments.

Participants

Participants were 20 youth recruited from a substance use and concurrent disorders program at the Centre for Addiction and Mental Health (CAMH), a tertiary care hospital in Toronto, Canada. Demographic characteristics and opioid experiences are presented in Table 1. Ages ranged from 15 to 23. Half of participants had been prescribed opioids in their lifetimes; the vast majority had at least experimented with opioids. All were seeking services for substance use disorders. The clinical and sociodemographic characteristics of youth seeking substance use services through this CAMH program have been described in multiple previous works.9,24,25 The services typically treat youth who have considerable overlapping needs in terms of polysubstance use with concurrent mental health challenges9,24,25 and other related psychosocial challenges.26,27

Table 1 - Participants’ Demographic Characteristics and Experience With Opioids.
Demographic Characteristic n (%)
Age (yrs)
 15–17 5 (25.0%)
 18–20 9 (45.0%)
 21–23 6 (30.0%)
Gender
 Boy/man 9 (45.0%)
 Girl/woman 10 (50.0%)
 Gender expansive 1 (5.0%)
Living area
 Urban 16 (80.0%)
 Suburban 4 (20.0%)
Has been prescribed opioids 10 (50.0%)
Has at minimum experimented with opioids 17 (85.0%)

Procedure

After providing informed consent, participants attended either a focus group (seven in total) or an individual interview (two conducted), facilitated by 1 to 2 staff members; one post-doctoral research fellow led all focus groups and interviews; the lead facilitator was accompanied by one bachelor's level research analyst for several focus groups with multiple youth. Focus groups had 2 to 4 youth. A semi-structured interview guide was used. Questions examined participants’ perspectives on opioid use, and on services that they were aware of for youth who use opioids or who have opioid use problems, with a focus on their perspectives on services that they considered helpful and services that did not consider helpful. Participants completed a demographic questionnaire at the end of the discussion. All focus groups and interviews were audio-recorded and transcribed. The study was approved by the CAMH Research Ethics Board.

Analyses

Transcripts were analyzed using thematic analysis in NVivo 12 software. First, a research staff familiarized themselves with the study objective, interview guide, and transcripts. Together with an investigator, they extracted codes based on the content that was prominent in the transcripts. After initial coding, they came together with the project team of partners making up the broader national project, where the teams shared their respective tentative coding schemes. Together, the teams refined their coding schemes across sites based on similarities in order to create a master codebook that all partners agreed upon; differences in opinions were resolved via consensus. Supported by weekly meetings, a research staff member then coded all transcripts using the master codebook, creating new site-specific codes for any content that did not fit the master codebook. After all transcripts were coded, codes were reviewed and checked against the transcripts and any discrepancies were resolved by improving upon or revising the coding scheme. Themes were then developed from the codes: a post-doctoral research fellow, research staff member, and investigator brought the codes together to address the research questions. Any discrepancies were resolved through discussion.

RESULTS

Youth perspectives on strategies to address the opioid crisis among youth were clustered into seven themes: (1) increasing awareness and balanced early education about substance use and opioid use; (2) increasing awareness and education about services; (3) increasing access to a continuum of youth-oriented service options; (4) providing services that emphasize ease of access and youth autonomy; (5) implementing a harm reduction approach; (6) providing respectful, responsive service providers; and (7) making changes at the systems and policy-levels.

Increasing awareness and balanced early education about substance use and opioid use

Youth reported on the importance of increasing awareness and balanced education about opioid use and about substance use in general in order to normalize discussions. Youth advocated for earlier education, such as before secondary school.

I also think that people should start learning about substance use at a younger age, because I remember I didn’t start learning about it until high school, and by that time I had already started using. It was too late, so people should start learning in, like, grade seven. (Participant A)

Participants expressed wanting information about physiological effects, long-term effects, and pathways to addiction; however, they wanted balanced information, including positive effects, not just information about negative consequences. For example, one youth explained:

[Provide] more information so that it gives the person an actual choice, instead of just bombarding them with negative imagery and being, like, ‘it’ll ruin your life.’ (Participant B)

Participants wanted to access information about opioids and substance use online through a centralized website. They also wanted public health campaigns in the community, for example with easily accessible pamphlets and signs across the city, particularly in high-risk areas such as government housing. They further wanted information to be available in schools, via posters and presentations that are developed and led by youth. The value of youth-led education was captured by the following:

Most of the time, in schools, if there are presentations on that kind of stuff, it's really not yielded towards students. It's not presented in a way where the students would want to pay attention to it… I feel like most of those kind of presentations you see at school made by your teachers or principals or whatever, they would be so much better and better tethered to students if it was made by students. (Participant C)

Increasing awareness and education about services

Youth reported that it is important to increase awareness and education about services for youth who use opioids and other substances.

I feel like there are a lot of services, but the main problem is people not knowing that they exist. So, I feel like in schools and around the community, they should really advertise that they exist more, because a lot of people just don’t know where to get help. (Participant A)

Participants suggested raising awareness about service availability through a wide variety of venues. For example, they suggested using the media and online sources. They also recommended raising awareness about services in schools, as well as in the community, with posters in walk-in clinics, subway stations, and other public spaces.

[I] remember in grade 8, they would do assemblies, and everyone would come. Assemblies about stuff like that – and hand out maybe packages of places you can get help. (Participant D)

Increasing access to a continuum of youth-oriented service options

Youth indicated that more opioid use and substance use programs and services are needed. They wanted a full continuum of service options to be available in a variety of service settings. Among the types of services recommended were counseling, family physician care, psychiatric care, case management, follow-up support, and helplines. Both drop-in and ongoing service models were valued. Support and education for the family members of service-seeking youth were also recommended.

Many youth discussed the importance of connecting with other youth with similar experiences, in the form of attending support groups or activity groups, connecting with friends with similar experiences, or being connected with a peer support worker.

I feel like peer mentors are like the number one key to helping anybody. (Participant E)

Participants wanted high-intensity services, such as residential or in-patient services, with help transitioning back into the community and into community-based services. Recommended intensive services included inpatient services, detoxification, and opioid replacement services. One participant described the benefits of intensive services:

When you’re in an environment like this, it's kind of hard to lie because you’re here every day (…). I would just go into therapy and be like ‘Yup, yup, I’m fine, mhm, mhm,’ and then I’d just go home and go back to using and stuff. When I was [inpatient], it's like, 1) I can’t use when we’re here, but 2) it's hard to keep a straight face all day and be like ‘Yeah, I’m fine.’ You make these relationships with the people who are your supporters (…). You become so comfortable that you can actually just talk to them. (Participant F)

The settings recommended for these types of services were also varied, including community centers, schools, hospitals, and rehabilitation centers. Participants also wanted service settings to be youth specific, and to offer safe and friendly environments. One participant noted: “I’d say more of like a homey, cozy feeling.” (Participant G) Another described their preference for youth-specific services:

I have been to NA and AA, and I’ve been going on and off since I was like sixteen. So, going into those groups, there are older men, and there have been situations where they make me uncomfortable. (…) I think they sometimes have youth groups in the mental hospitals, kind of like AA, NA but just for youth. (Participant H)

Building on the idea that a continuum of services should be offered, participants suggested providing integrated, coordinated services that incorporate addiction, mental health, physical health, social, financial, and quality-of-life service options in one location:

[A]lso having access to just social help in general. If you need financial help, you can have people there for that, like financial advisors. I don’t know. Usually people with addictions aren’t just facing addiction. There are a lot of other things going on in their lives that they don’t have help for, which is maybe why they’re coping in such an unhealthy way. (Participant C)

It is important to note that, for many of the types of services identified as being positive strategies, some aspects of that service were considered negative. For example, both positive and negative aspects of in-patient services were described:

I think it was beneficial in a lot of ways, such as routine and focus on other things in your life besides substances, but I think it was also not the best for … I don’t know how to explain it really. I think it's… just like being trapped somewhere. (Participant I)

Similarly, while many youth appreciated services such as peer connections, group treatments, hospital-based services, and helplines, a few youth identified each of these services options as unhelpful. For example:

I also think that those help phones, helplines, or hotlines – I don’t really see the helpfulness in it, because they’re gonna be like, ‘Yeah everything's gonna be okay. I’m gonna refer you to a doctor.’ You know, it's just the same thing again and again. (Participant J)

Providing services that emphasize ease of access and youth autonomy

Youth recommended that services be characterized by ease of access. For example, they wanted services to be free and locally available 24/7, either without any waitlist or with regular follow up about their waitlist status. Multiple youth explained why rapid access is so important. For example, one youth explained the importance of rapid, same-day drop-in access:

Personally, I like drop-in services, because I can book an appointment for 3 weeks from now and not necessarily be in the mood to share, not necessarily be in the mood to talk addictions. It's something when I’m not necessarily in a crisis—but at a peak of possibly a near crisis—I’m able to go somewhere and see someone that day, that hour, based on necessity. So I’m a big fan of drop-in programs, especially for youth. I think that's most important for the youth category out of all of them. (Participant K)

Youth also wanted to be able to access services autonomously and discreetly, particularly maintaining confidentiality from parents.

I think a lot of youth are very worried about being discreet. As I mentioned before, they’re willing to take their own recovery steps, but don’t want someone else choosing their recovery steps for them. A lot of people would want to be able to recover without their parents or parental figures knowing, definitely because of the stigma. It is an illness, and realistically you’d be better off with the most help possible. But I feel like a lot of youth would be more willing to seek more services if they knew it could be discreet – if they knew they could do it without fearing the trouble they might get into. (Participant K)

Similarly, one youth explained why autonomy and control are so important:

They don’t want to listen to what the youth want or what they need. You know what I mean? We’re often pushed to the sidelines and choices are made for us. And that kind of makes us not want to listen to people with authority. (Participant C)

Implementing a harm reduction approach

Participants explained that, from their perspective, some youth will inevitably experiment with substances, regardless of the prevention initiatives that may be put into place. They therefore felt that a harm reduction approach was paramount:

No matter what, a portion of the population is going to be doing stuff like that. So, taking precautions is more important than trying to get people not to use and arresting people over it. (Participant B)

In terms of specific harm reduction strategies, participants suggested that naloxone kits, needle exchange services, and opioid agonist treatments be free and easily accessible. A number of youth also mentioned the importance of drug testing kits:

I would love to see testing kits available like naloxone kits, so that if you were using a different drug other than opioids, you could tell if there were opioids in the substance you’re using. (Participant K)

Participants further suggested improvements to safe injection sites to promote access and reduce stigma, for example by placing them in nice buildings without police patrols and ensuring they are open 24/7.

I also feel like an ideal service wouldn’t be in a tent. I feel like that is something that is definitely causing stigma. (Participant C)

Participants suggested mobile vans for safe use supplies, as well as a buddy system to provide protection in case of overdose. They further recommended that education be provided on safe use. However, concerns about certain harm reduction approaches were also raised. For example, one youth expressed that testing kits might not be helpful for all.

I personally use test kits, but I know there were one or two times where I didn’t because, you sometimes reach a point with drugs where you don’t care. But, yeah I think test kits might work for some people, but for maybe the majority they might not work. (Participant D)

Providing respectful, responsive service providers

Youth noted the value of service providers who are respectful and responsive. They wanted service providers to show that they care:

So there's a ‘human touch’ part, a humanity piece for you, [service providers] that do more than just a paycheck and a job – and that you see me as a person and that I am a person. (Participant G)

Participants also expressed that service providers should be well-trained, nonjudgmental, and discreet, striving to provide a safe space and meet the youth where they are at, rather than pushing them toward a specific solution.

You don’t jump right to being like, ‘Oh they’re an addict.’ You don’t really throw it in their face. You let them come forward to you with it – make them feel very safe and comfortable. (…) I also think that there should be places with strict [rules] with who they hire. If someone's miserable, why the ∗∗∗∗ are they in this field. (Participant D)

Making changes at the system/policy levels

Youth had a number of suggestions for changes at the systems and policy levels. Youth discussed decriminalizing and legalizing substance use, in part to reduce stigma and shame about accessing treatment. They explained that if substance use were decriminalized, it would be “less cool” (Participant J), “less interesting” (Participant J), and “a lot less dangerous.” (Participant L) One participant explained how decriminalization would impact service utilization:

These people probably know damn well that the police can do whatever they want with you and you shouldn’t trust them. So you know, if I was like that, I’d probably also not go to injection sites. So, I think they need to be, you know – decriminalization, for example, would make people feel completely safe. (Participant K)

Participants suggested some programs requiring policy-level decisions, notably a drug buy-back program. They further suggested that greater regulations be put into place for prescribing opioids.

It really is an issue right to the top of pharmaceutical companies – getting doctors to overprescribe. And I think now the way to combat that would be really holding doctors more accountable for the prescriptions they are giving out – and especially with youth. (Participant K)

Youth also recommended that youth be engaged at the systems level in designing strategies, programs, and services, in order to tailor the opioid response to young people:

I’m a huge believer in that youth really do have the biggest impact. You know what I mean? And with all these new governmental laws that are happening, I feel like it's the most crucial time to encourage them to make these changes, give them the opportunity to shape the society that they’re in. (Participant C)

DISCUSSION

This study examined the perspectives of substance use service-seeking youth on strategies to address the opioid crisis in Canada. Youth proposed increasing awareness and balanced early education about opioids and about services; increasing the availability of a continuum of youth-oriented services that emphasize ease of access, youth autonomy, and harm reduction; ensuring that service providers are responsive and caring; and spearheading change at the systems and policy levels.

The importance of increasing youth awareness of the risks of opioid use has been demonstrated—particularly the risks of prescribed opioids.28,29 However, youth emphasize that the information provided in awareness-raising initiatives must be balanced, without overemphasizing fear,30 and that youth-led interventions are preferred. Various youth-oriented education, awareness and prevention initiatives have been developed and tested, including school-based interventions and gamification programs.22,23,31 This line of work must continue, to provide evidence-based strategies that span from population-based primary prevention to targeted prevention among at-risk youth.32,33 Youth seek information about opioids from a variety of sources.34 In this study, youth wanted information to be available broadly in the community, in schools, online, and through high-visibility public health campaigns. This points to the importance of developing coordinated youth-engaged public health campaigns that include prevention and promotion activities in schools, alongside awareness campaigns in community settings, and health education in healthcare settings, all combined with web-based campaigns offering readily available, balanced, high quality information.

Even with strong awareness initiatives in place, participants believed that, inevitably, some youth will use opioids. This highlights the importance of developing a strong evidence base of effective treatments and services for youth who use opioids.35 The types of treatments and services available must be varied. There is no single approach that all youth consider to be the primary strategy for all; in fact, services that are considered helpful by some may considered unhelpful by others. Service variety, flexibility, and choice, then, are keys to reaching the greatest number of youth in need. This aligns with previous literature demonstrating that autonomy, choice, and individualized treatment plans are keys to patient-centered care in substance abuse treatment.36

Our team's scoping review found that evidence on youth-oriented opioid use services is lacking.35 While there are positive early findings for some psychosocial, pharmacological, and harm reduction interventions for youth, more trials, particularly rigorous trials, are needed. As Canada grapples with the opioid crisis and its possible exacerbation due to the COVID-19 pandemic,2 there is a pressing need for substantial research projects that collaboratively develop, rigorously test, and continuously refine youth-focused opioid use interventions, potentially with a focus on integrating various forms of services.37 Given the urgency of the opioid crisis, the trials must be pragmatic: they must include implementation in real-world settings and use the tools of implementation science to enable real-time intervention refinement and rapid scale-up. High-quality evidence is needed, and it is needed now. A slow-paced scientific process, with its considerable knowledge-to-practice gap,38 will not do.

The Integrated Youth Services (IYS) model offers diverse, coordinated care for mental health and substance use, as well as supports in other spheres of life,39,40 reflecting the preferences of participants in the current study. It provides low-barrier, rapid access to a continuum of care, with youth engagement, harm reduction, a non-stigmatizing approach, and peer support as core considerations. Both the IYS model and the youth recommendations in the current study align with “youth-friendliness” in services, that is, an overarching concept that brings together youth values and preferences for services and service structures.41 While IYS does not typically offer high-intensity services for opioid use challenges, such as residential care and safe injection sites, this may be an area for enhanced collaborations to ensure that youth who use opioids have access to the services they need. IYS might also be an appropriate setting for implementing, testing, and scaling targeted prevention and early intervention services in the context of a coordinated continuum of care.

Notably, it is essential that youth be engaged as partners in policymaking and in the design and delivery of youth-focused services.42,43 Youth have valuable insights into what works for youth and therefore can make important recommendations for service development and policy change. By co-developing strategies to address the opioid crisis with youth, for youth, systems leaders can ensure that their strategies resonate with and meet the needs of young people today.

The project was developed as part of a pan-Canadian collaborative initiative to understand the experiences of Canadian youth regarding opioids. Certain limitations should be kept in mind. Notably, participants were recruited from one urban hospital-based tertiary care treatment center, which may have limited the breadth of findings; however, it should be noted that this was one study within a broader pan-Canadian project that, together, provides well-rounded pan-Canadian perspectives. Focus groups were small, which may have limited the range of topics explored as participants built upon the responses of other participants. Only limited demographic information was collected and the diversity of the sample cannot be thoroughly reported. A diverse sample of youth from a variety of geographic areas, in both urban and rural areas, would enhance the findings.

CONCLUSIONS

An effective, youth-oriented response to Canada's opioid crisis requires listening to young people's perspectives and implementing strategies to address the situation in ways that meet their needs. Youth emphasize the importance of increasing balanced, youth-led opioid education, awareness, and access to a continuum of services, with a balanced harm-reduction lens. They want autonomy and ease of access to services; they further want services to be youth-specific and coordinated, supporting them in various aspects of their lives. Engaging youth at the service design and policy levels will ensure that Canada's opioid response is in step with the needs of young people.

ACKNOWLEDGMENT

We thank Ayah Ellithy for her coding support.

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Keywords:

opioids; substance use; youth; consommation de substances psychoactives; jeunes; opioïdes

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