Survey on Opioid Awareness

For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.

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Table of Contents

Demographics (DEM)

Demographics (DEM) - Question identifier:DEM_Q05

What was your sex at birth?

  • 1: Male
  • 2: Female

Demographics (DEM) - Question identifier:DEM_Q10

What is your gender?

  • 1: Male
  • 2: Female
  • 3: Or please specify

Demographics (DEM) - Question identifier:DEM_Q15

What is your age group?

  • 01: 18 to 19 years
  • 02: 20 to 24 years
  • 03: 25 to 29 years
  • 04: 30 to 34 years
  • 05: 35 to 39 years
  • 06: 40 to 44 years
  • 07: 45 to 49 years
  • 08: 50 to 59 years
  • 09: 60 to 69 years
  • 10: 70 to 79 years
  • 11: 80 years and over

Demographics (DEM) - Question identifier:DEM_Q20

To determine which geographic region you live in, please provide your postal code.

Long Answer Length = 6

Opioid Content (OPI)

Opioid Content (OPI) - Question identifier:OPI_R05

This survey aims to better understand Canadians' awareness of opioids.

Opioids are pain medications, mostly available by prescription.

Some questions may be sensitive in nature, but all your answers will remain strictly confidential.

Opioid Content (OPI) - Question identifier:OPI_Q05

What is your level of awareness about the opioid issue in Canada?

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q10

Where have you learned about the opioid issue in Canada?

  • 1: Media
  • 2: Public awareness campaign
  • 3: Government website
  • 4: Other Internet sites
  • 5: Friends or family
  • 6: Other

Opioid Content (OPI) - Question identifier:OPI_Q15

In the past five years, have you used any products containing opioids, such as codeine, oxycodone, OxyContin, hydromorphone, morphine, fentanyl, methadone, Tylenol 3, naloxone, Percocet, Percodan, Tylox and heroin for either medical or recreational purposes?

  • 1: Yes
  • 2: No
  • 3: Prefer not to say
  • 9: DK

Opioid Content (OPI) - Question identifier:OPI_Q25

Where did you obtain these products?

  • 01: Directly from a health care professional, such as a doctor, pharmacist or dentist
  • 02: Family
  • 03: Friends
  • 04: Stranger
  • 05: Internet
  • 06: Other source
  • 07: Don't know
  • 08: Prefer not to say

Opioid Content (OPI) - Question identifier:OPI_Q30

Considering the last time you used opioids, what did you do with any left-over pills, liquids or patches?

  • 01: Had no left-over pills, liquids or patches (Include ongoing use.)
  • 02: Returned them to pharmacy or health care professional
  • 03: Gave them to someone else who needed them
  • 04: Flushed them or disposed them in garbage
  • 05: Stored in medicine cabinet
  • 06: Stored them somewhere else in the home
  • 07: Did something else with them
  • 08: Don't know
  • 09: Prefer not to say

Opioid Content (OPI) - Question identifier:OPI_Q35

Thinking about the left-over pain killers you stored at home, what was the reason that you did not dispose of them?

  • 1: For my own use at a later time
  • 2: For use by my family and friends, if needed
  • 3: I did not know how to dispose of them
  • 4: I forgot to dispose them
  • 5: Other
  • 6: Don't know
  • 7: Prefer not to say

Opioid Content (OPI) - Question identifier:OPI_R40

Indicate whether you agree or disagree with the following statements.

Opioid Content (OPI) - Question identifier:OPI_Q40A

If I had opioids, I would share my opioids to relieve the pain of a family member or friend

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40B

If I had opioids, I would share my opioids to help family members or friends coping with stress or other problems

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40C

If I had opioids, I would share my opioids for non-medicinal or recreational use

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40D

If I was prescribed opioids, I would not want my family members or friends to know

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40E

If I used opioids without a prescription, I would not want my family members or friends to know

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40F

If I used opioids, there could be a risk of developing an opioid dependency or an opioid use disorder

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q40G

I would feel comfortable seeking help or treatment for an opioid dependency or an opioid use disorder

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_R45

Indicate whether you agree or disagree with the following statements.

Opioid Content (OPI) - Question identifier:OPI_Q45A

I would recognize the signs of an opioid overdose

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q45B

I would call 9-1-1 if I was witnessing a suspected opioid overdose

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q45C

I would know what to do if I was witnessing a suspected opioid overdose

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q45D

I would know how to obtain Naloxone

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_Q45E

I would know how to administer Naloxone

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree

Opioid Content (OPI) - Question identifier:OPI_R50

Indicate whether you agree or disagree with the following statements.

Opioid Content (OPI) - Question identifier:OPI_Q50A

Harm reduction services are available in my community

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree
  • 9: DK

Opioid Content (OPI) - Question identifier:OPI_Q50B

Treatment options for an opioid dependency or problematic drug use are available in my community

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree
  • 9: DK

Opioid Content (OPI) - Question identifier:OPI_Q50C

Harm reduction services have public health benefits

  • 1: Agree
  • 2: Neither agree nor disagree
  • 3: Disagree
  • 9: DK

Opioid Content (OPI) - Question identifier:OPI_R55

Please indicate your level of awareness with the following statements.

Opioid Content (OPI) - Question identifier:OPI_Q55A

Using opioids, even for medicinal purposes, can impair driving a motor vehicle

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55B

Left-over opioids should be returned to a pharmacy for disposal

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55C

Problematic use of opioids can lead to an overdose or death

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55D

Mixing opioids with alcohol can magnify adverse effects, including a possible overdose

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55E

Mixing opioids with other medications can magnify adverse effects, including a possible overdose

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55F

Drugs obtained illegally or on the street have the potential to contain fentanyl

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_Q55G

There is new legal protection (under the Good Samaritan Drug Overdose Act) for people who seek emergency help for someone who has overdosed

  • 1: Very aware
  • 2: Somewhat aware
  • 3: Not at all aware

Opioid Content (OPI) - Question identifier:OPI_R60A

Please indicate, including yourself, the number of your household members that fall within each age group.

Opioid Content (OPI) - Question identifier:OPI_R60B

Age group

Opioid Content (OPI) - Question identifier:OPI_R60C

Number of members in your household

Opioid Content (OPI) - Question identifier:OPI_Q60A

Under 12 years

Min = 0; Max = 99

Opioid Content (OPI) - Question identifier:OPI_Q60B

12 to 14 years

Min = 0; Max = 99

Opioid Content (OPI) - Question identifier:OPI_Q60C

15 to 17 years

Min = 0; Max = 99

Opioid Content (OPI) - Question identifier:OPI_Q60D

18 to 24 years

Min = 0; Max = 99

Opioid Content (OPI) - Question identifier:OPI_Q60E

25 to 49 years

Min = 0; Max = 99

Opioid Content (OPI) - Question identifier:OPI_Q60F

50 years and older

Min = 0; Max = 99

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