Multi-drug involvement in apparent opioid and stimulant toxicity deaths in Canada from 2018 to 2023: Results

Insight on the substances involved in multi-drug toxicity deaths in Canada by analyzing death investigation data from Chief Coroners and Chief Medical Examiners from 2018 to 2023.

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Overall deaths

Between 2018 and 2023, 20,438 deaths were reported by up to 10 provinces and territories (P/Ts). The percentage of deaths involving both opioids and stimulants has grown in recent years, while the percentage of deaths involving opioids alone or stimulants alone has declined (Figure 1):

Figure 1. Distribution of substance-related opioid or stimulant toxicity deaths by substance class(es) involved in death, in Canada* (based on 6-10 P/Ts), 2018-2023

Figure 1: Text description

Figure 1.Percentage of deaths by substance class(es) involved, in Canada* (based on 6-10 P/Ts), 2018-2023

Figure 1: Notes
  • *Excludes data from BC, AB and MB for all years. Some P/Ts were unable to report deaths where both opioids and stimulants are involved. Deaths may involve other psychoactive substances. Refer to Technical notes for details on data availability and exclusions.
  • Each death was exclusively categorized into only 1 group based on the main substance(s) involved.

    • Deaths involving multiple substances

    Similarly, between 2018 and 2023, a rising trend was observed in the percentage of deaths involving multiple substances. This was in contrast to deaths involving a single substance or substance group (Table 1):

    Table 1. Percentage of opioid or stimulant toxicity deaths by number of substances or substance groups involved in a death, in Canada* (based on 6-10 P/Ts), 2018-2023

    Number of substances or groups Year of death
    2018 2019 2020 2021 2022 2023
    1 33% 32% 30% 27% 28% 23%
    2 46% 46% 47% 44% 41% 35%
    3+ 20% 22% 23% 30% 31% 42%
    Total* 100% 100% 100% 100% 100% 100%
    Table 1: Notes
  • *Excludes data from BC, AB and MB for all years. Refer to Technical notes for details on data availability and exclusions.
  • These categories are mutually exclusive as each death was categorized into 1 group based on the total number of substances and substance groups involved.
  • Up to 7 substances and substance groups may have been involved in a death (fentanyl + fentanyl analogues + non-fentanyl opioids + cocaine + methamphetamine + other stimulants + other psychoactive substances).

    • When examining deaths by substance group combination, there was a notable shift between 2018 and 2023 (Figure 2):

    Figure 2. Distribution of opioid or stimulant toxicity deaths by substance group combinations, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 2: Text description

    Figure 2. Percentage of all deaths by substance group combinations, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 2: Notes
  • *Excludes data from BC, AB and MB for all years. Some P/Ts were unable to report deaths where both opioids and stimulants were involved. See Technical notes for details on data availability and exclusions.
  • Percentages for each substance combination may not sum up to 100% due to differences in denominator used to calculate the proportion of deaths for each substance combination, as not all P/Ts submitted data for every combination.
  • Suppr. = Suppressed. n/a = not available

    • Common substances

    The most common single-substance and multi-substance combinations of opioids, stimulants, and other psychoactive substances have evolved over time (Figure 3a and Figure 3b):

    Multi-substance combinations

    Single substances

    Figure 3a. Distribution of opioid or stimulant toxicity deaths by most common substance and substance group combinations, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 3b. Distribution of opioid or stimulant toxicity deaths by most common single substance(s) or substance groups, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 3: Text description

    Figure 3. Frequency (n) and percentage (%) of all deaths by specific substance and substance group combinations, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 3: Notes
  • *Excludes data from BC, AB and MB for all years. See Technical notes for details on data availability and exclusions.
  • Percentages for each substance combination may not sum up to 100% due to differences in denominator used to calculate the proportion of deaths for each substance combination, as not all P/Ts submitted data for every combination.
  • "Most common" refers to substances and combinations were found in at least 5% of deaths in any year of the analyzed time period.
  • Suppr. = Suppressed. n/a = not available

    • By sex

    Between 2018 to 2023, similar patterns of substance combinations involved in toxicity deaths were observed in females and males (Figures 4a and 4b). There were some slight differences in percentages:

    In 2018, the most common combinations by sex were:

    In 2023, the most common combinations by sex were:

    Opioids only (1 substance group) dropped to 10% of deaths in 2023 for both males and females.

    Figure 4a. Distribution of opioid or stimulant toxicity deaths by substance group combinations among females, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 4b. Distribution of opioid or stimulant deaths by substance group combinations among males, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 4: Text description

    Figure 4. Percentage of all deaths by substance group combinations and sex, in Canada* (based on 6-10 P/Ts), 2018-2023

    Figure 4: Notes
  • *Excludes data from BC, AB and MB for all years. Refer to Technical notes for details on data availability and exclusions.
  • Percentages for each substance combination may not sum up to 100% due to differences in denominator used to calculate the proportion of deaths for each substance combination, as not all P/Ts submitted data for every combination.
  • Suppr. = Suppressed. n/a = not available

    • By age

    A similar distribution of substance group combinations by age group was observed across all years of the study. Data from 2023 is presented to highlight the most recent trends (Figure 5).

    In 2023, the most common substance group combinations for all age groups were:

    The percentage of deaths from opioids with other psychoactive substance was highest in the 0 to 19 year age group (28%) and declined with age. Opioids with stimulants was lowest in the 0 to 19 year age group (17%) and increased with age. Opioids with stimulants and other psychoactive substances was similar in age groups from 0 to 49 years old (30% to 31%) and then decreased in older age groups. The percentage of deaths involving opioids only (1 substance or group) or stimulants only (1 substance or group) was highest in the 60+ age group (16% and 17%, respectively).

    Figure 5. Distribution of opioid or stimulant toxicity deaths by substance group combinations by age group, in Canada* (based on 6-10 P/Ts), 2023

    Figure 5: Text description

    Figure 5. Percentage of all deaths by substance group combinations and age group, in Canada* (based on 6-10 P/Ts), 2023

    Figure 5: Notes
  • *Excludes data from BC, AB and MB for all years. Refer to Technical notes for details on data availability and exclusions.
  • Percentages for each substance combination may not sum up to 100% due to differences in denominator used to calculate the proportion of deaths for each substance combination, as not all P/Ts submitted data for every combination.
  • Suppr. = Suppressed. n/a = not available

    • By region

    Regional differences in the most common combinations of substances were consistent across all years of the study. Data from 2023 is presented to highlight the most recent trends (Figure 6).

    The percentages of deaths involving opioids with other psychoactive substances was highest in:

    The percentages of deaths involving opioids with stimulants was highest in:

    The percentage of deaths involving opioids with stimulants and other psychoactive substances was highest in:

    Figure 6. Distribution of opioid or stimulant toxicity deaths by substance group combination and jurisdiction in 2023

    Figure 6: Text description

    Figure 6. Frequency (n) and percentage (%) of all deaths by substance group combinations, by jurisdiction, 2023

    Figure 6: Notes
  • Not all P/Ts submitted data for every combination. Refer to Technical notes for data availability and exclusions.
  • Data may not sum up to 100% due to data suppression.
  • PEI, NU and NT were not presented as data were either suppressed or not available in 2023. QC was omitted from the regional analysis due to reporting limitations which underestimate the co-involvement of opioids and stimulants compared to other regions.
  • Suppr. = Suppressed. n/a = not available

    • Acknowledgements

    We recognize that the data used in this report may represent stories of pain, grief and trauma. This report cannot adequately reflect the burden borne by people in Canada. We acknowledge all those impacted by substance use and those who work to save lives and reduce substance-related harms on individuals and communities.

    We also express our gratitude to our partners and collaborators who provided the data on toxicity deaths and insights on the findings. This includes the provincial and territorial offices of chief coroners and chief medical examiners, provincial and territorial public health and health care partners, and persons with lived and living experience. Additionally, we extend our thanks to all reviewers for their valuable contributions to the report and constructive feedback.

    Suggested Citation

    Multi-Drug Involvement in Apparent Opioid and Stimulant Toxicity Deaths in Canada. Public Health Agency of Canada, Health Infobase.

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