There has been a surge in the abuse of opioid analgesics in the United States and Canada in the past 15 years. Although several risk management programs in the United States have been implemented to assess and characterize the abuse of new opioids - the first Canadian program was implemented at the request of Health Canada in late 2005 as a condition for the approval of Tramacet®. The primary element of this program was a network of drug treatment providers who distributed questionnaires to their patients that explored a number of misuse/abuse questions, including sources of drugs and psychiatric and other medical co-morbidities. To serve as a reference group, comparable studies were conducted in the U.S. in the same time period. Our results indicate that, as expected, tramadol has demonstrably low appeal to substance abusers both in Canada and the US. In a broader sense, our data show remarkably few differences between prescription opioid users in either country, with the exception of primary drug preference. Hydrocodone, the most commonly misused drug in the United States, ranked among the least preferred drugs in Canada, probably because the products were not prescribed in Canada in the time period we examined. Perhaps as a consequence, 20% of Canadian prescription opioid misusers expressed a preference for the more potent opioid, hydromorphone, a rate 10 times higher than in the U.S. Other than issues related to the drug of choice, our data reinforce the growing body of evidence indicating that prescription opioid users, no matter their nationality, have a large number of co-morbid physical and psychiatric issues.