Substance use among street-involved youth in Canada: Pan-Canadian findings from the People with Lived and Living Experience Survey

Resources

Due to the sensitive nature of substance use and the drug toxicity crisis, certain parts of this report may cause emotional distress. Mental health supports are available:

• Mental health support: get help - Canada.ca

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• Get help with substance use - Canada.ca
• Interactive map: Canada's response to the opioid crisis

Introduction

Studies have shown that in Canada, homelessness among youth is associated with poor nutrition, victimization, higher-risk substance use, and limited access to health and social services^{Footnote 1Footnote 2Footnote 3Footnote 4Footnote 5}. This often leads to harmful effects on health, isolation among youth, and higher rates of substance use and mental health problems^{Footnote 6}.

Although street-involved youth are at higher risk of substance-related harms, they are under-represented in survey data on substance use. In response, Health Canada developed a targeted survey called the People with Lived and Living Experience Survey (PWLLES) to examine substance use and related harms among street-involved youth, with input from a peer researcher and other stakeholders. This report focuses on quantitative findings from the PWLLES, which collected responses from September 2021 to February 2023 from youth aged 14-24 years who were 1) experiencing homelessness, unstable housing, spent most of their time in the streets, and/or accessed services for street involved youth, and 2) who had used alcohol, tobacco, cannabis, or other drugs in the past year.

Key findings

Demographics and social determinants of health

There were 442 participants from 16 sentinel sites across 9 Canadian cities that completed the survey. Ontario (37.8%) and the Prairies (25.1%) accounted for the greatest proportion of participants. The Atlantic region had low participation (less than 5.0%), and no sentinel sites were engaged in the Territories. At the city level, Windsor (22.9%), Montreal (17.2%), and Vancouver (15.8%) had the greatest proportion of participants (Figure 1).

Figure 1 - Text description

City	Number of participants (Number of sites)	Percentage of participants (%)	Total
Windsor	101 (2)	22.9	442
Montreal	76 (2)	17.2
Vancouver	70 (3)	15.8
Toronto	66 (3)	14.9
Edmonton	38 (1)	8.6
Winnipeg	38 (1)	8.6
Calgary	29 (2)	6.6
Halifax	18 (1)	4.1
Saskatoon	6 (1)	1.4
Note: The size of the circle on each city is scaled proportionally to the number of PWLLES participants in that city.

The average age of all participants was 20.7 years (standard deviation [SD] = 2.7 years). Most participants (80.1%) were above the legal age for alcohol consumption in their province. The majority identified as cisgender (86.9%), with slightly more cisgender males (46.4%) than cisgender females (40.5%) [Table 1]. Just over half reported their sexual orientation as heterosexual or straight (55.4%), followed by bisexual or pansexual (17.9%). Approximately 1 quarter of participants (26.0%) identified as Indigenous, and of these, 74.8% identified as First Nations. One (1) third of respondents (33.9%) identified as visible minorities, and of these, the most commonly reported racialized identities were Black (38.0%); Other race, including multiracial identity (18.7%); and Latino (13.3%).

Most participants reported currently living in a shelter or refuge (29.1%), or a rented house or apartment (alone or shared) [28.9%]. Approximately 3 quarters of participants (73.3%) stated that they were not currently attending a school, college, CEGEP or university. Most participants (70.4%) were unemployed, while 24.2% reported currently having full-time, part-time, or seasonal employment.

Table 1: Demographic and social determinants of health of participants in the PWLLES, September 2021 to February 2023 (n = 442)

Demographic characteristics	Number of participants	Percentage of participants (%)	Total
Gender identity
Cisgender male	205	46.4	442
Cisgender female	179	40.5
Non-binary	29	6.6
Transgender female	12	2.7
Transgender male	11	2.5
Prefer not to answer	6	1.4
Sexual orientation
Heterosexual/straight	245	55.4	442
Bisexual or pansexual	79	17.9
Gay or lesbian	35	7.9
Sexual orientation, n.e.c.	24	5.4
Prefer not to answer	59	13.3
Indigenous identity
Not Indigenous	293	66.3	442
IndigenousFootnote *	115	26.0
Prefer not to answer or do not know	34	7.7
Population Group
Visible minority	150	33.9	442
Not a visible minority	258	58.4
Prefer not to answer or do not know	34	7.7
Current living situationFootnote ‡
Shelter/refuge	120	29.1	412
Rented house/apartment (alone/shared)	119	28.9
Parents'/carers' family home	61	14.8
No fixed address/couch surfing/staying with friends	50	12.1
Boarding house/hostel/single room occupancy hotel (SRO)	30	7.3
Other	32	7.8
Footnote ‡ 'Prefer not to answer' was excluded from the denominator. Return to footnote ‡ referrer Footnote * 74.8% of Indigenous participants identified as First Nations. Métis, Inuit, and Prefer not to answer are not reported due to small cells and risk of re-identification. n.e.c. not elsewhere classified Return to footnote * referrer

Substance use trends

Among participants who had ever used each respective substance, the most used substances in the past 30 days were cannabis (85.0%), cigarettes (81.2%), alcohol (80.3%), illegal drugs (57.0%), and vaping nicotine (55.7%) [Table 2].

Table 2: Past 30-day substance use among PWLLES participants, September 2021 to February 2023 (n = 442)

Prevalence of substance use	Number of participants	Percentage of participants (%)	Total
CannabisFootnote ‡	328	85.0	386
Smoking cigarettesFootnote ‡	290	81.2	357
Alcohol (more than a sip)Footnote ‡	331	80.3	412
Illegal drugsFootnote †	150	57.0	263
Vaping nicotineFootnote ‡	244	55.7	438
StimulantsFootnote ‡	83	46.1	180
Sedatives or tranquilizersFootnote ‡	61	39.1	156
Opioid or opioid-containing pain-relieversFootnote §	75	38.9	193
Footnote ‡ 'Prefer not to answer' was excluded from the denominator. Return to footnote ‡ referrer Footnote † 'Prefer not to answer' was less than 5%. Return to footnote † referrer Footnote § Participants were asked to name a pain-reliever used in the past 30 days instead of whether they used a pain-reliever in the past 30 days. Estimates shown are for opioid pain-relievers or pain-relievers containing opioid(s); over-the-counter medications and other classes (e.g., benzodiazepines) were not included. 18.7% reported 'Prefer not to answer', 17.1% reported 'Do not know' and 3.1% were missing. Return to footnote § referrer Note: 'Do not know' was not an option for all questions except those on opioid or opioid-containing pain relievers. Only participants who had ever-used each respective substance were eligible for corresponding questions on past 30-day use.

The average age at first use of each substance type ranged from 13.8 to 17.2 years (Figure 2). On average, participants reported first using cannabis (13.8 years), stimulants (13.8 years), and alcohol (14.0 years) at a younger age compared to other substance types. Stimulants are sometimes prescribed to help with attention or concentration problems, such as Attention Deficit Hyperactivity Disorder (ADHD). Of those who had ever used stimulants, 62.2% had received a formal diagnosis of ADHD. The younger age of initiation for stimulants may be related to use of prescribed stimulant medications for ADHD. Sedatives or tranquilizers are sometimes prescribed to help people sleep, calm them down, or to relax their muscles. Illegal drugs or 'street drugs' (e.g., cocaine, heroin, etc.) cannot be obtained by prescription. The average age of first use was higher for sedatives or hypnotics (16.4 years), illegal drugs (17.0 years), and injected drugs (17.2 years).

Figure 2 - Text description

Substance	Average age (years)	Standard deviation for age (years)	Number of participants
Cannabis	13.8	2.8	317
Stimulants	13.8	4.2	180
Alcohol	14.0	3.2	330
Pain relievers	15.6	3.5	158
Sedatives or tranquilizers	16.4	2.8	156
Illegal drugsFootnote §	17.0	2.9	127
Injected drugs	17.2	2.9	35
Footnote § For the first illegal drug mentioned. Return to footnote § referrer Note: Stimulants, pain relievers, and sedatives or tranquilizers included either prescribed or non-prescribed substances. 'Prefer not to answer' and 'Do not know' were excluded from the denominators since missing values could not be used in the calculation of the mean and standard deviation. Ages greater than 1 were included in the denominator. Only participants who had ever used pain-relievers were eligible for answering 'Age at first use of pain-relievers'. Only participants who had ever used sedatives were eligible for answering 'Age at first use of sedatives'. Only participants who had ever used stimulants were eligible for answering 'Age at first use of stimulants'. For all other substances listed, only participants who had used each respective substance in the past 30 days were eligible for answering 'Age at first use'.

Past 30-day binge drinking, defined as 5 drinks or more per occasion for males and 4 drinks or more per occasion for females, was reported by 65.0% of participants who consumed alcohol in the past 30 days. Among those who reported using cannabis in the past 30 days, 35.4% reported using cannabis more than once a day. Furthermore, among those who reported smoking cigarettes in the past 30 days, 70.3% reported smoking cigarettes daily. Of participants who consumed alcohol in the past 30 days, 65.0% reported combining or mixing alcohol with another substance. 51.2% of participants who used cannabis in the past 30 days reported combining or mixing cannabis with another substance. 51.6% of all participants reported combining or mixing tobacco with cannabis.

Substance use behaviours and related harms

Of participants who had used an illegal drug in the past 30 days, the majority (69.6%) reported that it was very easy to obtain an illegal drug (i.e., within 90 minutes). Most (57.0%) stated that they obtained an illegal drug by buying or trading something for it, and nearly 1 quarter (23.7%) said it was given to them by someone.

In the past 30 days, 13.6% stated they had used a drug or substance that was not what they thought it was, 57.0% obtained drug use or preparation equipment, and 45.5% stated they shared drug use or preparation equipment. Approximately 1 in 10 participants (10.2%) reported that they injected a drug in the past 30 days.

Participants most frequently reported that their cannabis or drug use had harmful effects on their:

• Mental health (37.1%)
• Finances or ability to meet basic needs (34.2%)
• Home life, family, or relationships (33.5%)

Impacts in other areas of life (i.e., work, studies, employment, physical health, or relationships) were reported by at least 28.1% of participants (Figure 3).

The most common reported consequences of cannabis or drug use in the past 30 days were:

• Severe withdrawal symptoms (31.0%)
• Housing problems (29.0%)
• Difficulty learning things (28.1%)

Figure 3 - Text description

Harmful effects due to cannabis or drug use in the past 30 days	Number of participants	Percentage of participants (%)	Total
Experienced harmful effects due to drug use in the past 30 days
Mental health	164	37.1	442
Finances/ability to meet basic needs	151	34.2	442
Home life, family, or relationships	148	33.5	442
Work, studies, or employment opportunities/security	139	31.4	442
Physical health	138	31.2	442
Friendships or social life	124	28.1	442
Note: Categories were not mutually exclusive.

Driving under the influence was defined as one or more drinks of alcohol within the past hour, using cannabis within the past 2 hours, and using any drug other than alcohol or cannabis within the past hour. Within the past year, driving under the influence of cannabis (15.8%) was more frequently reported than driving under the influence of alcohol (12.9%) or under the influence of other drugs (7.2%). Similarly, being a passenger of a driver under the influence of cannabis (39.8%) was more frequently reported than being a passenger of a driver under the influence of alcohol (32.1%) or under the influence of other drugs (30.8%).

One (1) third of participants (33.0%) reported having overdosed in their lifetime, and of these, the majority (56.2%) had overdosed within the past year. During the most recent overdose, most participants were aware of the drug used (70.5%); however nearly half of all participants (45.9%) were not aware of the potency of the drug used (Figure 4). More than 1 in 5 participants (21.9%) were alone during their most recent overdose. Nearly half of participants (47.9%) reported taking multiple drugs at the same time during their most recent overdose. Participants were asked to name the main drug believed to be responsible for their most recent overdose, where fentanyl was the most commonly reported substance.

Figure 4 - Text description

Characteristics of recent overdose	Number of participants	Percentage of participants (%)	Total
Aware of drug used for most recent overdose	103	70.5	146
Taking other drugs at the same time during most recent overdose	70	47.9	146
Aware of potency of drug used during most recent overdose	61	41.8	146
Alone during most recent overdose	32	21.9	146
Note: 'Prefer not to answer' was 5.5% for 'Aware of drug used for most recent overdose', 6.2% for 'Taking other drugs at the same time during most recent overdose', 6.2% for 'Aware of potency of drug used during most recent overdose', and 8.2% for 'Alone during most recent overdose'. 'Do not know' was less than 5.0% for 'Aware of drug used for most recent overdose' and 'Taking other drugs at the same time during most recent overdose'. 'Do not know' was 6.2% for 'Aware of potency of drug used during most recent overdose'. 'Do not know' was not an option for 'Alone during most recent overdose'.

Treatment and support

Close to half (42.8%) of the participants reported having ever obtained a naloxone kit. Obtaining a kit in case someone on the streets or at a venue needs it was the main reason reported (37.0% of participants who had ever obtained a naloxone kit). Other reasons for obtaining a kit included (Figure 5):

• In case it was needed for a friend (24.3%)
• In case the participant needed it for themselves (24.3%)

Figure 5 - Text description

Main reason for obtaining naloxone kitFootnote †	Number of participants	Percentage of participants (%)	Total
In case someone on the streets or at a venue needs it	70	37.0	189
In case a friend needs it	46	24.3	189
In case you need it for yourself	46	24.3	189
In case someone in your family needs it	17	9.0	189
Other	6	3.2	189
Footnote † Prefer not to answer was less than 5%. Return to footnote † referrer Note: 'Do not know' was not an option for Main reason for obtaining naloxone kit. Categories are mutually exclusive.

A similar proportion of participants reported ever feeling that they needed professional help for alcohol, cannabis, and/or drug use (31.9%), as those who have ever sought professional help (32.6%). Among those who reported having ever sought treatment, 38.9% reported seeking professional help in the past 30-days, while 28.5% stated that they were currently trying to get into treatment (including methadone).

Approximately 1 third (30.3%) of participants ever received professional help for alcohol, cannabis, or drug use, where 21.3% voluntarily received professional help and the remaining 9.0% stated that they involuntarily received help (e.g., checked-in by a parent or guardian). Among those who had ever received treatment, 45.5% reported having received professional help in the 30-days prior to survey completion. The most frequently reported types of treatment and supports for those currently receiving treatment were:

• Counsellor (60.7%)
• Detox/youth detox e.g., withdrawal management (18.0%)
• Treatment centre (11.5%)
• Other out-patient treatment program (11.5%)

With respect to accessing treatment other than alcohol and/or drug treatment, youth have reported seeking a variety of services. The most frequently reported services were (Figure 6):

• Housing services, such as shelters (31.4%)
• Foodbanks (28.3%)
• Income-support services (26.9%)
• Employment services (14.7%)

Figure 6 - Text description

Services accessed other than alcohol and/or drug treatment	Number of participants	Percentage of participants (%)	Total
Housing services, including shelters	139	31.4	442
Foodbanks or other services offering food security	125	28.3	442
Welfare, disability or other income-support benefits/services	119	26.9	442
Employment services	65	14.7	442
Emergency room treatment	46	10.4	442
Legal services	44	10.0	442
Education or training	38	8.6	442
Childcare	12	2.7	442
Note: Categories were not mutually exclusive.

Limitations

1. The survey results are not generalizable to the general Canadian population.
2. Recruitment difficulties due to reduced staffing during the COVID-19 pandemic, Hurricane Fiona in Atlantic Canada, and the general logistics of engaging with the hard-to-reach population of street-involved youth may have contributed to low response rates. As a result, sampling may not capture differences between sentinel sites in a region, and prevalence estimates may not be representative of the street-involved youth population.
3. The data collection process may have led to engagement issues for some respondents (e.g., questionnaire was too long or repetitive, respondents did not want their responses audio recorded). This, in turn, affected low completion rates.
4. Recall errors when self-reporting on past drug use (i.e., recall bias) or answering in a way to minimize drug use behaviors due to stigma (i.e., social desirability bias) may have contributed to underreporting of substance use prevalence.
5. Impacts of the COVID-19 pandemic (e.g., economic stress, social isolation, reduced access to drug treatment services) may have influenced substance use among street-involved youth.
6. The sample size of this survey was not large enough to perform statistical tests on the results.
7. The estimate of participants currently attending a school, college, CEGEP or university may have been influenced by the significant number of participants that completed the survey during the summer months when school was not in session.

Technical Notes

• The option 'Not a visible minority' includes Indigenous people, in accordance with the Employment Equity Act and Statistics Canada's definition of 'Visible minority of a person'. Visible minority includes identifying as Black, East/Southeast Asian, Latino, Middle Eastern, South Asian, or other race^{Footnote 7}.

Acknowledgements

We would like to acknowledge and thank the contributions of the street-involved youth who shared their experiences as part of the PWLLES. The PWLLES was possible due to the collaboration between 16 centres across Canada that serve street-involved youth and the Office of Drug Research and Surveillance at Health Canada.

References