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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2021 Jan 11;112(3):449–455. doi: 10.17269/s41997-020-00460-w

Low school belongingness and non-prescription opioid use among students in Ontario, Canada

Shaezeen Syed 1, Hugues Sampasa-Kanyinga 1, Hayley A Hamilton 2,3, Mila Kingsbury 1, Ian Colman 1,4,✉
PMCID: PMC8076367  PMID: 33428115

Abstract

Objectives

School belonging impacts a range of factors, including academic performance, school attendance, relationships with peers and teachers, mental and physical health, and drug and alcohol use. Previous studies have shown that a lack of belonging to one’s school is associated with substance use. The objective of the study was to examine the association between low school belongingness and the use of opioids in students in grades 9 through 12 in Ontario, Canada.

Methods

Data were gathered from 6418 participants in grades 9–12 who responded to the 2015 Ontario Student Drug Use and Health Survey (OSDUHS). Logistic regression analyses were used to model associations between low school belongingness and opioid use, adjusted for gender, grade, ethnicity, socio-economic status, and living situation.

Results

Overall, low school belongingness was associated with non-prescribed opioid use (OR = 1.11, 95% CI 1.05–1.17). Feeling unsafe at school (OR = 1.43, 95% CI 1.23–1.66) was associated with elevated odds of using non-medically prescribed opioids. Girls who felt that they were not a part of their school community were at elevated odds of using opioids (OR = 1.35, 95% CI 1.16–1.56); this association was not observed among boys.

Conclusion

The findings suggest that low school belongingness may be associated with the use of non-prescribed opioids in students. These findings suggest that school-based interventions aimed at improving social cohesion and feelings of belongingness and safety may be beneficial in reducing the use of non-prescription opioids among adolescents.

Keywords: School, Belongingness, Non-prescription opioid use, Adolescents

Introduction

School belongingness, school connectedness, or school membership refer to the extent to which a student feels like they belong to their school (Shochet et al. 2006). Feelings of belonging to the school community have been associated with better academic outcomes and lower rates of risky behaviours among adolescents (Boston and Warren 2017; Resnick et al. 1993; Resnick et al. 1997). School belonging impacts a variety of factors, including academic performance, school attendance, involvement in classroom activities and extracurricular activities, relationships with peers and teachers, mental and physical health, drug and alcohol use, and gang-related activities (Finn 1989; Goodenow and Grady 1993; Korpershoek et al. 2019). Students who have poor relationships with their peers and teachers and disengage from school-related activities are more likely to report negative outcomes, such as drug use, depressive symptoms, and failure to complete school (Henry et al. 2012; Li and Lerner 2011; Morinaj and Hascher 2019; Stoddard and Veliz 2019).

Previous studies have shown that feelings of alienation or lack of belonging are associated with substance use (Bond et al. 2007; Yusek and Solakoglu 2016). As Fletcher and colleagues proposed, drugs may be used among students who feel disconnected from their school as a way to connect to one another (Fletcher et al. 2009). In addition, a challenging academic environment may provoke feelings of frustration, anger, and other negative emotions (Fletcher et al. 2009). Students may use drugs as a maladaptive coping mechanism to alleviate symptoms of distress related to pressures to perform well in school (Johnson et al. 2011).

Most research has focused on the association between school belongingness and the use of cigarettes, cannabis, and alcohol. In 2007, a school-based longitudinal study by Bond and colleagues examined the relationship between school connectedness in early secondary school and mental health, substance abuse, and educational achievement in a sample of 2678 Australian students (Bond et al. 2007). The findings demonstrated that students with low school connectedness were at elevated risk of regular smoking, drinking alcohol, and using cannabis (Bond et al. 2007). In another school-based study, Gaete and colleagues explored the association between school membership and cigarette, alcohol, and cannabis use in 2508 secondary school students in Santiago, Chile (Gaete et al. 2018). The study found that a strong sense of school membership was related to a low risk of smoking, drinking, and cannabis use (Gaete et al. 2018).

While associations between cannabis, cigarettes, and alcohol and school belonging have been established, less is known about the relationship between school belongingness and the use of non-prescribed opioid pain relievers. Of all controlled substances, opioid analgesics are the most likely to be misused or abused by adolescents (Fortuna et al. 2010). In Canada, recreational use of opioids among secondary school students remains a pressing problem (Probst et al. 2020). In 2017, approximately 11% of students in Ontario were using non-medically prescribed opioid pain relievers, such as codeine, Percocet, or Demerol (Boak et al. 2017). More than 2% of deaths in Canadian adolescents (i.e., under 19 years of age) between 2016 and 2017 were attributed to opioid overdose, and the mortality rate associated with opioid misuse is expected to rise (Public Health Agency of Canada [PHAC] 2018). The growing number of overdoses and deaths caused by opioids has been called a national public health crisis (PHAC 2018). Therefore, it is crucial to identify risk factors for non-prescribed opioid use in adolescents in order to develop and implement appropriate strategies to reduce opioid use and the negative consequences associated with its use. One recent Canadian study suggested a supportive school environment may reduce the risk of opioid misuse among students with mental health difficulties (Probst et al. 2020). However, less is known about how specific aspects of the school environment, including a sense of belongingness, may impact students’ risk of opioid misuse.

The present study aimed to examine the relationship between school belongingness and non-medically prescribed opioid use in secondary school students in Ontario. We hypothesized that a low sense of belonging to the school community would be associated with higher use of opioid pain relievers. As a secondary objective, we also examined gender differences in the association between low school belongingness and opioid use. Some sources suggest that adolescent opioid use is higher among girls than boys (AlBashtawy et al. 2015; Boyd et al. 2006). However, other recent estimates have shown higher use among adolescent boys than girls (Canadian Centre on Substance Use and Addiction 2020; Osborne et al. 2017), highlighting the need for further examination of gender differences. Risk factors for substance misuse may differ for boys and girls—for example, one study of adolescent problem drinking found that peer relationships were a stronger predictor of alcohol use among girls than among boys (Yeh et al. 2006). Girls tend to report higher levels of school belongingness and school engagement than boys (Goodenow and Grady 1993; Huyge et al. 2015; Ma 2003); therefore, we might expect mechanisms linking school belongingness and non-prescription opioid use to differ for boys and girls.

Materials and methods

Study population

Data were obtained from the 2015 Ontario Student Drug Use and Health Survey (OSDUHS) (Boak et al. 2015), a biennial province-wide survey of students in grades 7 through 12 in the public and Catholic school boards in Ontario, Canada. Administered in class as a self-reported, anonymous survey, the OSDUHS reports on the prevalence of health-risk behaviours in school-aged youth. The survey uses a stratified cluster sample design. Of the 349 schools that were invited to participate, 220 schools from 43 school boards participated in the survey; the student participation rate was 59%. Student non-response was due to absenteeism (11%), unreturned consent forms (29%), and other reasons (1%). Additional details on the study design are provided elsewhere (PHAC 2018). Written informed consent was obtained from parents/guardians and consent/assent was obtained from students prior to participating in the survey. Ethics approval was obtained from the Research Ethics Boards of the Centre for Addiction and Mental Health (University of Toronto), York University, and the participating school boards.

In the current study, the analysis was restricted to 6418 students in grades 9 through 12 who had completed the OSDUHS questionnaire.

School belongingness

Items measuring school belongingness were derived and adapted from the National Longitudinal Study of Adolescent Health School Connectedness scale (McNeely et al. 2002). School belongingness was measured using the three following questions: “I feel safe in my school”, “I feel close to people at this school”, and “I feel like I am part of this school”. Possible responses to these questions included strongly agree, somewhat agree, somewhat disagree, and strongly disagree. Each item was treated as a scale variable. A new variable combining all 3 items was constructed such that higher scores indicate lower levels of school belonging. This measure has been indicated to be a good measure of school belonging among middle and high school students (Sampasa-Kanyinga and Hamilton 2016). The score ranged from 3 to 12 and showed a good internal reliability with a Cronbach alpha of 0.71.

Non-medically prescribed opioids

Use of opioids without a prescription in the last 12 months was measured with the following question: “In the last 12 months, how often did you use pain relief pills (such as Percocet, Percodan, Tylenol #3, Demerol, OxyNeo, Oxycontin, codeine) without a prescription or without a doctor telling you to take them? (We do not mean regular Tylenol, Advil, or Aspirin that anyone can buy in a drugstore)” (1 or 2 times; 3 to 5 times; 6 to 9 times; 10 to 19 times; 20 to 39 times; 40 or more times; used without a prescription, but not in the last 12 months; never used without a prescription in lifetime; and do not know what pain relief pills are). A dichotomous variable was created to reflect “no use of non-medically prescribed opioids” as those students who did not use opioids within the year, used with a prescription, or had no knowledge of opioids, and “use of non-medically prescribed opioids” as those students who used opioids 1 to 40 or more times.

Covariates

Covariates of interest included gender (male and female), grade (9 through 12), ethno-racial background, subjective socio-economic status (SES), and living situation. A total of 12 ethno-racial background categories (White, Chinese, Japanese, Korean, South Asian, Black, Indigenous, Filipino, Latin/Central/South American, Southeast Asian, and West Asian, or Arab) existed in the original survey. For analysis purposes, this variable was treated as a dummy variable for Black, East/SE Asian, South Asian, and other, with the reference category being White. Subjective SES used a Likert scale ranging from 1 (worst off) to 10 (best off) and was treated as a continuous variable. Living situation was measured using the following item: “Not everyone lives with both parents in one home. Some people spend part of their time in one home, and the other part of their time in another home. Please choose one of the following statements that best describes your living situation.” Response options included “I live in one home only” and “I split my time between 2 or more homes”.

Statistical analyses

Descriptive statistics were used to derive weighted estimates for socio-demographic variables, as well as school belongingness items, and use of non-medically prescribed opioids in the last 12 months. Unadjusted and adjusted odds ratios and 95% confidence intervals assessed the relationship between each of the three school belongingness items (low feelings of safety at school, low feelings of closeness to people at school, low feelings of belonging to the school), the combined low school belongingness score, and the use of non-medically prescribed opioids using logistic regression models. Adjusted models accounted for gender, grade, ethno-racial background, subjective SES, and living situation.

Two-way interaction terms were used to assess potential moderation by gender, race, and SES. We additionally investigated whether associations between low school belongingness and opioid use could be moderated by experience of being a bullying victim. School bullying victimization was measured using the following question: “Since September, how often have you been bullied at school?” Responses included “Was not bullied at school since September”, “Less than once a month”, “About once a month”, “About once a week”, and “Daily or almost daily”. A dichotomous measure was constructed to represent “have not been bullied at school” and “been bullied at school at least once” since September. Domain analyses were used to stratify by gender to examine the association between low safety, low closeness, low belonging, and combined low school belongingness score, and opioid use.

Listwise deletion restricted the sample to only those who had complete data across all study variables, resulting in a 4% reduction in the sample size (N = 6418). Excluded participants were younger than those who were included in our analyses. All analyses were weighted and accounted for school clustering in STATA 16.0 (StataCorp. College Station, TX, USA).

Results

Approximately 4% of students reported feeling unsafe in their school, 13% reported that they did not feel close to people in their school, and 16% of students reported that they did not feel like they belonged to their school. Ten percent of students reported using an opioid without a prescription in the last 12 months (Table 1). Female students were more likely to report low closeness to people at school (p < 0.001).

Table 1.

Characteristics of participants in the 2015 Ontario Student Drug Use and Health Survey (OSDUHS)

Variable Weighted proportion, %a
Male (n = 2904) Female (n = 3514) Full sample (N = 6418)
Age 16.0 15.9 16.0
Grade
  Grade 9 21.2 21.9 21.5
  Grade 10 22.1 22.8 22.4
  Grade 11 23.4 23.8 23.6
  Grade 12 33.3 31.6 32.5
Ethno-racial background
  White 60.8 57.2 59.1
  Black 6.4 7.3 6.8
  East/SE Asian 12.1 13.7 12.9
  South Asian 8.3 9.4 8.9
  Other 12.4 12.4 12.4
Subjective SES
  Mean (SD) 7.0 (1.6) 6.9 (1.7) 6.9 (1.6)
Bullying victimization
  No 81.3 75.2 78.3
  Yes 18.7 24.8 21.7
Living situation
  Live in one home only 87.6 87.8 87.7
  Split time between 2 or more homes 12.4 12.2 12.3
I feel safe in my school
  Strongly agree 57.7 48.8 53.4
  Somewhat agree 38.0 46.6 42.2
  Somewhat disagree 3.4 4.1 3.7
  Strongly disagree 0.9 0.5 0.7
I feel close to people at this school
  Strongly agree 43.5 36.7 40.2
  Somewhat agree 46.2 48.2 47.1
  Somewhat disagree 7.8 11.1 9.4
  Strongly disagree 2.5 4.0 3.2
I feel like I am a part of this school
  Strongly agree 40.8 36.1 38.5
  Somewhat agree 44.2 47.9 46.0
  Somewhat disagree 10.6 11.9 11.2
  Strongly disagree 4.4 4.2 4.3
Combined school belongingness score, mean (SD) 5.0 (1.6) 5.2 (1.8) 5.1 (1.7)
Opioid use without prescription (last 12 months)
  Yes 9.6 11.2 10.4
  No 90.4 88.8 89.6
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SES, socio-economic status; SD, standard deviation

aData are shown as weighted proportion unless otherwise indicated

After adjusting for covariates, the combined low school belongingness score was associated with non-prescription opioid use (OR = 1.11, 95% CI 1.04–1.17). Feeling unsafe at school and feeling low belonging to the school were significantly associated with non-prescription opioid use (OR = 1.43, 95% CI 1.22–1.67 and OR = 1.22, 95% CI 1.08–1.38, respectively; Table 2). Feeling low closeness to people at school was not associated with non-prescription opioid use (OR = 1.06, 95% CI 0.89–1.25).

Table 2.

Unadjusted and adjusted logistic regression model of the associations between feeling unsafe, feeling low closeness, and feeling low belonging and use of non-medically prescribed opioids in the last 12 months using odds ratios and 95% CI (N = 6418)

Variable Unadjusted Adjusted a
OR (95% CI) OR (95% CI)
Feeling unsafe at school 1.48 (1.27–1.72) 1.43 (1.23–1.66)
Feeling low closeness to people at this school 1.16 (0.97–1.38) 1.06 (0.90–1.24)
Feeling like I am not a part of this school 1.33 (1.18–1.50) 1.22 (1.09–1.38)
Combined school belongingness 1.15 (1.08–1.22) 1.11 (1.05–1.17)
Total score
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OR, odds ratio; CI, confidence interval

Note: Italicized entries denote statistically significant differences at p < 0.001

aResults are adjusted for gender, grade, ethno-racial background, subjective socio-economic status, and living situation

Gender-specific analyses showed that the combined low school belongingness score was associated with non-prescription opioid use among females (OR = 1.15, 95% CI 1.07–1.23) but not among males. Feeling unsafe at school was associated with opioid use among both male and female students (OR = 1.44, 95% CI 1.16–1.79 and OR = 1.42, 95% CI 1.17–1.73, respectively; Table 3). In addition, females who reported that they felt that they did not belong to their school had greater odds of using non-prescribed opioids (OR = 1.35, 95% CI 1.15–1.57); this association was not observed among males. Feeling low closeness to people at school was not significantly associated with non-prescribed opioid use for either males or females.

Table 3.

Adjusted logistic regression model of the associations between feeling unsafe, feeling low closeness, and feeling low belonging and use of non-medically prescribed opioids in the last 12 months using odds ratios and 95% CI, stratified by gender (N = 6418)

Variable Male Female
OR (95% CI) OR (95% CI)
Feeling unsafe at school 1.44 [1.16–1.79] 1.42 [1.17–1.73]
Feeling low closeness to people at this school 0.91 [0.69–1.21] 1.19 [0.98–1.43]
Feeling like I am not a part of this school 1.11 [0.92–1.36] 1.35 [1.16–1.56]
Combined school belongingness 1.06 [0.96–1.17] 1.15 [1.07–1.23]
Total score
Open in a new tab

OR, odds ratio; CI, confidence interval

Results are adjusted for grade, ethno-racial background, subjective socio-economic status, and living situation

Italicized entries denote statistically significant differences at p < 0.001

There were no significant interactions by race, SES, and bullying victimization.

Discussion

The findings of this large, population-based study suggest that a low sense of belonging to one’s school may increase the risk for non-prescription opioid use. Our findings support and extend previous research linking low school belonging and substance misuse and suggest that there may be gender-specific associations between school belongingness and opioid use.

Low school belonging showed a moderate association with non-medically prescribed opioid use. Though we did not find any gender differences in opioid use, we did observe gender differences related to school belongingness—low school belongingness was associated with opioid use among female students but not among males. It has been hypothesized that girls may be at particular risk of using leftover opioid medication in the home (McCabe et al. 2013)—for example, to self-treat problems like depression, which is more common among adolescent girls than among adolescent boys (Petersen et al. 1991; McHugh et al. 2013). Our study extends these findings, suggesting that females may be more likely to use non-prescription opioids to cope with stress manifesting from a low sense of belonging to their school community. Contrary to research suggesting that female students typically have a higher sense of belonging to their school (Huyge et al. 2015), we did not find evidence for higher feelings of school belongingness among female students—in fact, girls were more likely to report low connection to people at their school. Girls who develop a sense of detachment from their school may be at particular risk of engaging in negative coping behaviours, including substance misuse. For example, Perra and colleagues reported that female students were more likely than male students to use drugs in order to manage anxieties and unhappiness related to their sense of disconnection with their school (Perra et al. 2012). Our findings suggest that gender-specific school-based interventions aimed at reducing opioid misuse may be appropriate.

Our results highlight a strong association between feelings of personal security at school and the likelihood of using opioids; students who felt unsafe at school were more than two times more likely to use opioids. A study found that the presence of unsafe places in and around the school influenced adolescent substance use directly and indirectly through the effects of violence and victimization (Reid et al. 2006). To further elaborate on unsafe school environments, the presence of threatening and injuring behaviours, weapon-carrying, and physical fighting might indicate greater availability and accessibility of substances on school property. Lowry and colleagues suggested that students who were given or sold illegal drugs at school were likely to use substances more often and were more likely than other students to become involved in violent acts and crimes in school (Lowry et al. 1999). Security officials and school personnel may play a key role in preventing violent crimes and drug-related activities on school property.

Strengths and limitations

The study has a number of limitations. Because the study uses a cross-sectional design, it becomes difficult to interpret causation and a temporal sequence. It is possible that using opioids leads to rejection by student peers. Additionally, the study relied on self-reported data, including sensitive items regarding illicit substance use. Students may have been unwilling to report such behaviour in a classroom setting; however, students were instructed that all responses would be anonymous. Additionally, we would expect that any misclassification due to willful misreporting would bias results towards the null. The students also self-reported subjective SES, which could lead to misclassification. Finally, although this is a large and representative sample of secondary students in Ontario, the results may not be generalizable to students from subsidized and private schools. The present study also features several strengths, such as the inclusion of a large population-based sample of secondary school students. This study also uses measures adapted from valid and reliable questionnaires.

Conclusion

This is the first study exploring the association between low school belongingness and non-medically prescribed opioid use among secondary school students. This study has shown that adolescents were more likely to use non-medically prescribed opioids if they reported low school belonging. These results are relevant to educational leaders in the midst of an opioid epidemic and suggest school-based interventions aimed at improving social cohesion and feelings of belongingness and safety may be beneficial in reducing the use of non-prescription opioids among adolescents.

Acknowledgements

This work was partly supported by the Research Council of Norway through its Centres of Excellence funding scheme, project number 262700, and by the Canada Research Chairs program (IC).

Author contributions

SS, IC, HS, and HH contributed to the study conception and design. Data analysis was performed by SS. All authors interpreted results. The first draft of the manuscript was written by SS. All authors provided critical feedback and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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