Opioid- and Stimulant-related Harms in Canada Published: (June 2023): Health Infobase

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Technical Notes

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Definitions

Apparent opioid toxicity death (AOTD): A death caused by intoxication/toxicity (poisoning) resulting from substance use, where one or more of the substances is an opioid, regardless of how it was obtained (e.g., illegally or through personal prescription). Other substances may also be involved.
Apparent stimulant toxicity death (ASTD): A death caused by intoxication/toxicity (poisoning) resulting from substance use, where one or more of the substances is a stimulant, regardless of how it was obtained (e.g., illegally or through personal prescription). Other substances may also be involved.
Ongoing investigation: Coroners and medical examiners continue to collect information on how and why the death occurred. Data for ongoing investigations are considered preliminary and subject to change.
Completed investigation: Coroners and medical examiners have collected all available information on how and why a death occurred. The time required to complete an investigation and related administrative processes is case-dependent and can range from approximately three to twenty-four months.
Manner of death - Accident: Deaths with completed investigations where the coroner or medical examiner determined that the death was unintentional. This category also includes deaths with ongoing investigations where the manner of death was believed to be unintentional or had not been assigned at the time of reporting.
Manner of death - Suicide: Deaths with completed investigations where the coroner or medical examiner determined that the opioids were consumed with the intent to die. This category also includes deaths with ongoing investigations where suicide was believed to be the manner of death at the time of reporting.
Manner of death - Undetermined: Deaths with completed investigations where a specific manner of death (e.g., accident, suicide) could not be assigned based on available or competing information. For this manner of death category, provinces and territories report only completed investigations with the exception of British Columbia which also includes data from ongoing investigations.
Opioid origin – Pharmaceutical: Deaths with completed investigations where all opioids that directly contributed to death were manufactured by a pharmaceutical company and approved for medical purposes in humans. Pharmaceutical origin does not indicate how the opioids were obtained (e.g., through personal prescription or by other means).
Opioid origin – Non-pharmaceutical: Deaths with completed investigations where all opioids that directly contributed to the death were not manufactured by a pharmaceutical company or not approved for medical purposes in humans.
Opioid origin – Both pharmaceutical and non-pharmaceutical: Deaths with completed investigations where the opioids that directly contributed to the death were a combination of pharmaceutical and non-pharmaceutical opioids, without any opioids of undetermined origin.
Opioid origin – Undetermined: Deaths with completed investigations where, for one or more opioids that directly contributed to the death, it was not possible to determine whether the opioid was pharmaceutical or non-pharmaceutical.

How apparent opioid and stimulant toxicity deaths are counted

Counts or record-level information are provided by the provinces and territories that collect data from their respective offices of Chief Coroners or Chief Medical Examiners. Crude and age-adjusted rates are calculated using the most current population data from Statistics Canada. Age-adjusted rates used the 2016 Canadian population as a reference and direct standardization was applied.

Crude rates: summarize the situation within a region at a certain time period and have not been adjusted for existing differences by provincial and territorial age distributions (e.g., (number of deaths / population) x 100,000).
Age-adjusted rates: have been adjusted for existing differences by provincial and territorial age distributions using the 2016 Canadian population as a reference. These rates assume that all regions have the same age distributions and are useful when comparing between regions and over time.

The data provided by the provinces and territories can include deaths:

with completed or ongoing investigations
where manner of death is classified as accident, suicide, or undetermined

These data do not include deaths due to:

the medical consequences of long-term substance use or overuse (for example, alcoholic cirrhosis)
medical assistance in dying
trauma where use of the substance(s) contributed to the circumstances of the injury that lead to the death, but was not directly involved in the death
homicide

However, some provincial and territorial differences remain in the type of data reported and in the time periods for which data are available (refer to Table A).

Limitations of the data on apparent opioid and/or stimulant toxicity deaths

Data presented in this update should be interpreted with caution.

This update is based on data submitted to the Public Health Agency of Canada on or before . New or revised data reported after this date will be reflected in future updates.
Data released by provinces and territories may differ due to the availability of updated data, differences in the type of data reported (e.g., manners of death), the use of alternate age groupings, differences in time periods presented and/or population estimates used for calculations, etc.
As some data are based on ongoing investigations by coroners and medical examiners, they are considered preliminary and subject to change. The time required to complete an investigation and related administrative processes is case-dependent and can range from approximately three to twenty-four months.
This update is based on data that do not specify how the opioids or stimulant were obtained (e.g., illegally or through personal prescription); the level of toxicity may differ depending on the opioid or stimulant (substance(s) involved, concentration, and dosage).
Provincial and territorial differences in the death investigation process, death classification method, toxicology testing, and the manners of death reported may impact the interpretation and comparability of the data presented in this update over time and between provinces and territories.
Data on apparent opioid toxicity deaths and stimulant toxicity deaths are not mutually exclusive. A high proportion of deaths involving a stimulant also involved an opioid. Adding up those numbers would result in an overestimation of the burden of opioids and stimulants.
Provinces and territories are included in calculations of national crude and age-adjusted rates if they have submitted data for at least one quarter of a given year.
Quarterly totals for Canada may not equal the annual totals due to suppressed data for some provinces and territories with low number of deaths.
Data on apparent stimulant toxicity deaths were only available from five to eight provinces and territories depending on the year. Therefore, national numbers and rates are not provided in this update. Refer to Table A for more details.

Notes on provincial and territorial data

Due to differences in identifying and reporting cases, comparisons over time and between provinces and territories should be interpreted with caution.

General notes

Data reported by some provinces and territories do not include all manners of death (accident, suicide, or undetermined) or stages of investigation (ongoing or completed); refer to Table A for more details.
Rates for provinces and territories with relatively smaller populations may change substantially with even slight changes in the number of deaths.
British Columbia data from 2016 to 2018 include deaths with completed investigations only. Overall numbers for British Columbia from 2019 to 2022 include deaths with ongoing investigations related to all illicit drugs, including but not limited to opioids and stimulants, used alone or in combination with prescribed/diverted medication. However, stratified data (e.g., by sex, age group, etc.) are based only on opioid toxicity deaths for which investigations are completed.
Quebec data from 2016 to 2020 include deaths with completed investigations only; death investigations were underway for 3% in 2020. These data encompass deaths that are attributable to opioids for apparent opioid toxicity deaths and deaths that are attributable to stimulants for apparent stimulant toxicity deaths. Available 2021 and 2022 data from Quebec include unintentional deaths with ongoing investigations. These data encompass deaths related to drug or opioid-related intoxication, including, but not limited to, opioids and stimulants. Preliminary data for drug-related poisonings, for which toxicology information was available, indicate that 51% of deaths between January 2021 and December 2022 involved an opioid.
Data from Yukon include deaths with completed investigations only. Between 2016 and 2022, two apparent opioid toxicity deaths occurred in a different province following an overdose in Yukon. These deaths are included in the data from the jurisdiction where the deaths occurred and are not reported in the data from Yukon.
Data from Prince Edward Island include accidental deaths with completed investigations only. Only annual totals were available for 2016 data from Prince Edward Island; quarterly data for 2016 were not available at the time of this update.
In Ontario, apparent opioid toxicity death data were captured using an enhanced data collection tool by the Office of the Chief Coroner (OCC) as of May 1, 2017. Prior to this, retrospective case information was collected using a different tool. Effective September 1, 2021, apparent opioid toxicity death data are captured in the OCC’s new case management system for death investigations.
For Newfoundland and Labrador, data on apparent opioid toxicity deaths between January 2016 and December 2019 were based on the detection of opioids as indicated on the toxicological report. As of 2020, data include deaths where opioids directly contributed to the death.
Data from Nunavut were not included in national counts or percentages.
Manitoba data from April to December 2022 were not available at the time of this update.

Manner of death

Manner of death is assigned by the coroner or medical examiner during or following an investigation. The data in this update include deaths with a manner of accident, suicide, or undetermined.
Suicide data were unavailable from Alberta (2018 to 2022), Prince Edward Island and Nunavut.

Sex and age group

For most provinces and territories, data on the sex of the individual was based on biological characteristics or legal documentation.
Data on deaths where sex was categorized as “Other” were excluded from analyses by sex, but were included in overall analyses.
Due to rounding, percentages may not add to 100%.
For Ontario, from January 2016 to April 2017, sex reflected the sex assigned at birth or biological characteristics at the time of death. From May 2017 to December 2017, sex reflected the perceived or projected identity of the individual. As of January 2018, sex reflects the sex assigned at birth or biological characteristics at the time of death.
Alberta uses data on the sex of the individual based on the medical examiner’s assessment, which is largely based on biological characteristics. In a small subset of cases where the individual was known to identify with a gender different than their biological sex, the medical examiner may indicate their identified gender.
Data on deaths where age group was categorized as “Unknown” were excluded from analyses by age group, but were included in overall analyses.

Fentanyl, fentanyl analogues, and non-fentanyl opioids

Refer to Table B below for details on opioids.
Prior to 2018, the percentage of deaths involving fentanyl and/or fentanyl analogues represented a single category. For data reported for 2018 to 2022, some provinces and territories did not report fentanyl analogue information or required additional information to differentiate fentanyl from fentanyl analogues until investigations are completed. Therefore, deaths involving fentanyl analogues may be included in the fentanyl percentages for some jurisdictions.
The sum of percentages by type of opioids may not add up to 100% because a death may involve more than one type of opioid.
Observed trends of accidental apparent opioid toxicity deaths involving fentanyl or fentanyl analogues should be interpreted with caution until additional data become available. In addition, changes to testing practices during the reporting period may affect observed trends.
Given provincial and territorial differences in death classification methods, the term “involving” includes deaths where the substance was either detected and/or directly contributed to the death. Substances can be detected through toxicology testing and may or may not have directly contributed to the death. Direct contribution to the death is based on investigation by coroner or medical examiner.
Available 2021 and 2022 data from Quebec on deaths related to drugs or opioid toxicity where toxicology information was available and fentanyl (or fentanyl analogues) was detected were used to approximate apparent opioid toxicity deaths involving fentanyl (or fentanyl analogues), among deaths where opioids were detected.
For Alberta, only data on deaths with completed investigations, where relevant toxicology information was available, were included in percentages for fentanyl, fentanyl analogues, or non-fentanyl opioids.
For Ontario, only data on deaths where a cause of death was available were included in percentages for fentanyl, fentanyl analogues, or non-fentanyl opioids.

Origin of opioid(s)

The origin of opioid(s) refers to whether the opioids that directly contributed to the death were pharmaceutical, non-pharmaceutical, both or undetermined.
Data on origin were only available for deaths with completed investigations from 2018 onward from between seven and ten provinces and territories, depending on the year. Completed investigations represented 77% of accidental apparent opioid toxicity death investigations from these provinces and territories over that period; refer to Table A for more details.
Summary data and trends based on origin of opioid(s) should be interpreted with caution until additional data become available.
Origin categorization is based on toxicology results and scene evidence and does not indicate how the substances were prepared, their appearance, or how they were ‘advertised’; nor should it be used to infer the timing or mode of consumption.
Pharmaceutical opioids also include those approved for use in humans in other countries, but not necessarily in Canada.
For the purposes of origin categorization, deaths involving fentanyl are categorized as “suspected non-pharmaceutical” when there is: 1) no evidence of a patch, vial, or other pharmaceutical formulation at the scene, or 2) no/unknown evidence of a prescription. These deaths are grouped with deaths involving non-pharmaceutical opioids.
Origin categorization represents the best estimate based on the information available and should be interpreted with caution.
Origin refers only to the opioid(s) involved in death and should not be used as an indication of prior use of opioids of the same or other origin.
British Columbia only reports apparent opioid toxicity deaths involving any illicit opioid(s), resulting in a high proportion of non-pharmaceutical opioids. For that reason, data on origin of opioids from British Columbia were not included in the national proportions.

Cocaine, methamphetamine and other stimulants

Refer to Table B below for details on stimulants.
Amphetamine is a known metabolite of methamphetamine but can also be consumed separately and directly contribute to a toxicity death. Deaths where amphetamine (without methamphetamine) directly contributed to the death are reported under ‘other stimulants’. In situations where both methamphetamine and amphetamine were consumed separately, and both directly contributed to death, the death is reported under both methamphetamine and ‘other stimulants’.
Data on apparent stimulant toxicity deaths were available from between five and eight provinces and territories, depending on the year from 2018 to 2022.
The sum of percentages by type of stimulant may not add up to 100% because a death may involve more than one type of stimulant.
For Ontario, only data on deaths where a cause of death was available were included in percentages for cocaine, methamphetamine, and other stimulants.
Data from Quebec on “other stimulants” include deaths involving methamphetamine.
For Alberta, only apparent opioid toxicity deaths with completed investigations are used in the numerator for percentage of deaths involving stimulants. As a result, these values may change when more investigations are completed.

Other psychoactive substances

Refer to Table B below for details on other psychoactive substances.
For Alberta, only data on deaths with completed investigations, where specific substances causing death were listed on the death certificate, were included in percentages of accidental apparent opioid toxicity deaths involving other non-opioid substances.
For Ontario, only data on deaths with completed investigations, where relevant toxicology information was available, were included in percentages of accidental apparent opioid toxicity deaths involving other non-opioid substances. Data for non-opioid substances from Ontario between January 2016 and April 2017 were based on their detection and do not include alcohol; as of May 1, 2017, data on non-opioid substances are based on their direct effects and include alcohol.

Data suppression

The suppression of data in this update is based on the preferences of individual provinces or territories to address concerns around releasing small numbers for their jurisdiction.

Quebec suppressed counts less than five for deaths with ongoing investigations (2021 and 2022).
Nova Scotia suppressed all counts for age group 0 to 19 years when stratified by sex.
Prince Edward Island suppressed counts between one and four for quarterly data, and for any data related to sex or age distribution.
Newfoundland and Labrador suppressed counts between one and four for quarterly data, and data related to substances involved and sex or age distribution.
Yukon suppressed counts between one and four for data related to sex or age distribution.
Nunavut suppressed all counts less than five.

In addition, suppression was applied in some instances where all data for a province or territory fell in a single category of a given table or figure.

Table A. Reporting periods, manners of death, and availability of opioid and stimulant data included in this update by province or territory
Available data on apparent toxicity deaths involving opioids as of
		BC	AB	SK	MB	ON	QC	NB	NS	PE	NL	YT	NT	NU
2016-2018	January to December	^(C)		^(C)			^(C)			^(C)	^(C)	^(C)
2019	January to December			^(C)			^(C)			^(C)	^(C)	^(C)
2020	January to December			^(C)			^(C)			^(C)	^(C)	^(C)
2021	January to December			^(C)						^(C)	^(C)	^(C)
2022	January to December			^(C)	^(INC)					^(C)	^(C)	^(C)
Available data on apparent toxicity deaths involving stimulants as of
2018	January to December	^(C)	n/a	^(C)	n/a		^(C)	n/a		n/a	n/a	n/a	n/a	n/a
2019	January to December	^(C)	n/a	^(C)			^(C)	n/a		n/a	n/a	n/a	n/a	n/a
2020	January to December	^(C)	n/a	^(C)			^(C)	n/a		n/a	^(C)	n/a		n/a
2021	January to December	^(C)	n/a	^(C)			n/a	n/a		n/a	^(C)	^(C)		n/a
2022	January to December	^(C)	n/a	^(C)	^(INC)		n/a	n/a		n/a	^(C)	^(C)		n/a
Classification of deaths included in the reported data
Accident	Completed investigations
	Ongoing investigations where manner of death was believed to be unintentional		-	n/a		-				n/a	n/a	n/a		n/a
	Ongoing investigations where manner of death had not been assigned at the time of reporting	-		n/a			n/a			n/a	-	-		n/a
Suicide	Completed investigations		^(INC)							n/a
Suicide	Ongoing investigations where the manner of death was believed to be suicide		n/a	n/a		-	n/a			n/a	n/a	n/a		n/a
Deaths with completed investigations and an undetermined manner of death										n/a
Available data on origin of opioid(s)
2018	January to December				n/a		n/a			n/a	n/a	n/a	n/a	n/a
2019	January to December						n/a			n/a	n/a	n/a	n/a	n/a
2020	January to December						n/a			n/a		n/a	n/a	n/a
2021	January to December						n/a					n/a		n/a
2022	January to December				^(INC)		n/a					n/a		n/a
These data have been reported by the province or territory and are reflected in this update, unless otherwise specified (C)Data includes deaths with completed investigations only (INC)Data was not available for the entire period -The classification is not used in the province or territory n/aData were not available at the time of this publication

Table B. Types of opioids and stimulants
Category	Includes (but are not limited to):
Fentanyl and fentanyl analogues	3-methylfentanyl acetylfentanyl acrylfentanyl butyrylfentanyl carfentanil crotonyl fentanyl cyclopropyl fentanyl despropionyl-fentanyl fentanyl fluoroisobutyrlfentanyl (FIBF) furanylfentanyl methoxyacetylfentanyl norfentanyl
Non-fentanyl opioids	2-methyl AP-237 AH-7921 AP-237 brorphine buprenorphine metabolites codeine desomorphine dihydrocodeine etodesnitazene heroin hydrocodone hydromorphone isopropyl-U-47700 isotonitazene loperamide meperidine methadone metonitazene mitragynine monoacetylmorphine morphine MT-45 normeperidine oxycodone tapentadol tramadol U-47700 U-49900 U-50488
Stimulants	amphetamine atomoxetine catha cocaine dexamfetamine ethylphenidate lisdexamfetamine MDA MDMA mephedrone methamphetamine methylphenidate modafinil pemoline phentermine pseudoephedrine TFMPP
Other psychoactive substances	alcohol benzodiazepines gabapentinoids ketamine LSD PCP psilocin W-18 Z-drugs

Data suppression
Table A. List of diagnosis codes included for opioid-related poisonings
Table B. List of diagnosis codes included for stimulant-related poisonings
Table C. List of diagnosis codes included for non-opioid poisonings co-occurring with opioid poisonings
Table D. List of diagnosis codes included for non-stimulant poisonings co-occurring with stimulant poisonings
Table E. List of diagnosis codes included for non-stimulant/non-opioid poisonings co-occurring with opioid or stimulant poisonings
Disclosure
Data source
Acknowledgements
Suggested citation

Definitions

Opioid-related poisoning hospitalization: Acute care hospitalizations that recorded a significant diagnosis for opioid-related poisoning. Please see Table A for a list of diagnosis codes for opioid-related poisonings.
Accidental opioid-related poisoning hospitalization: An opioid-related poisoning hospitalization that is considered to be non-intentional in nature and is defined by a diagnostic “X42” ICD-10-CA code associated with any significant opioid-related poisoning codes (T40.0-T40.4 and T40.6, see Table A for more information).
Intentional opioid-related poisoning hospitalization: An opioid-related poisoning hospitalization that occurred as a result of purposely self-inflicted harm and is defined by a diagnostic ”X62” ICD-10-CA code associated with any significant opioid-related poisoning codes (T40.0-T40.4 and T40.6, see Table A for more information).
Undetermined opioid-related poisoning hospitalization: An opioid-related poisoning hospitalization that is categorized by physician documentation of undetermined/unknown intent and is defined by a diagnostic “Y12” ICD-10-CA code associated with any significant opioid-related poisoning codes (T40.0-T40.4 and T40.6, see Table A for more information).
Stimulant-related poisoning hospitalization: Acute care hospitalizations that recorded a significant diagnosis for stimulant-related poisoning. Please see Table B for a list of diagnosis codes for stimulant-related poisonings.
Accidental stimulant-related poisoning hospitalization: A stimulant-related poisoning hospitalization that is considered to be non-intentional in nature and is defined by a diagnostic “X41” or “X42” ICD-10-CA code associated with any significant stimulant-related poisoning codes (T40.5 and T43.6, see Table B for more information).
Intentional stimulant-related poisoning hospitalization: A stimulant-related poisoning hospitalization that occurred as a result of purposely self-inflicted harm and is defined by a diagnostic “X61” or “X62” ICD-10-CA code associated with any significant stimulant-related poisoning codes (T40.5 and T43.6, see Table B for more information).
Undetermined stimulant-related poisoning hospitalization: A stimulant-related poisoning hospitalization that is categorized by physician documentation of undetermined/unknown intent and is defined by a diagnostic “Y11” or “Y12” ICD-10-CA code associated with any significant stimulant-related poisoning codes (T40.5 and T43.6, see Table B for more information).

How poisoning hospitalizations are counted

Data on opioid- and stimulant-related poisoning hospitalizations are extracted from the Discharge Abstract Database (DAD), a national administrative database from the Canadian Institute for Health Information (CIHI) that compiles information on hospital discharges (including deaths, sign-outs, and transfers) from acute care institutions in all provinces and territories, except Quebec. CIHI receives the data directly from acute care facilities or from their health/regional authority or ministry/department of health. Data were accessed from the SAS grid managed by the Data Coordination and Access Program at the Public Health Agency of Canada (PHAC). Only inpatient hospitalizations from acute care facilities were included in the analyses.

Opioid and stimulant- related poisoning hospitalizations were identified as follows:

Poisoning diagnoses were based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA), which is used to code up to 25 diagnoses per hospital record, as it is the national standard for reporting morbidity. Refer to Table A for details on the ICD-10-CA codes used to identify opioid-related poisonings (T40.0-T40.4 and T40.6) and Table B for details on the ICD-10-CA codes used to identify stimulant-related poisonings (T40.5 and T43.6). Additional ICD-10-CA codes were used to classify the hospitalizations by intent.
Hospitalizations were included if the opioid or stimulant-related poisoning diagnosis was considered influential to the time spent and/or treatment received while in hospital, identified by diagnosis types “M” (most responsible diagnosis (MRD)), “1” (pre-admission comorbidity), “2” (post-admission comorbidity), and “W”, “X”, “Y” (service transfer diagnosis).
Hospitalizations where the diagnosis was considered questionable, as indicated by prefix code of “Q”, were excluded.

Crude and age-adjusted rates are calculated using the most current population data from Statistics Canada. Age-adjusted rates used the 2016 Canadian population as a reference and direct standardization was applied.

Crude rates: summarize the situation within a region at a certain time period and have not been adjusted for existing differences by provincial and territorial age distributions (e.g., (number of hospitalizations / population) x 100,000).
Age-adjusted rates: have been adjusted for existing differences by provincial and territorial age distributions using the 2016 Canadian population as a reference. These rates assume that all regions have the same age distributions and are useful when comparing between regions and over time.

In April 2023, PHAC began leading the data analysis and preparation of this report. Prior to this, Health Canada was conducting the analysis and preparing the reports. PHAC and Health Canada access the data through two different applications, for which the data are updated at different frequencies. Values reported in June 2023 onward may be slightly different from historically reported values.

Limitations of the data on poisoning hospitalizations

General notes

The unit of observation for this analysis was a discharged inpatient hospitalization visit, rather than an individual patient. The time period reported is the calendar year in which a patient was discharged from the nursing unit of the reporting facility. The province or territory reflects the location of the reporting facility where the hospitalization occurred.
To facilitate comparisons over time as well as across jurisdictions, age-adjusted rates per 100,000 population per year were calculated using the latest population estimates from Statistics Canada.
Data on hospitalizations from Quebec are not included in the Discharge Abstract Database; subsequently, Quebec is excluded from these analyses.
Data from Yukon, Northwest Territories and Nunavut were combined due to small numbers.
Data collected through DAD or the ICD-10-CA codes do not specify how the opioids were obtained (e.g. illegally or through personal prescription); the level of toxicity may differ depending on the opioid (substance(s) involved, concentration, and dosage).
Data after March 31, 2022 are provisional and may be less complete and/or subject to change.

Intention

Poisonings were further examined by the documented reason for the poisoning, based on ICD-10-CA diagnostic type “9” (external cause of injury), and classified into three categories: accidental, intentional, and undetermined/unknown.
Poisonings are classified as accidental unless there is clear documentation of intentional self-harm or undetermined intent.
When there was no documentation of intent, hospitalizations were excluded from analysis by intention, but were included in the total number of cases.

Sex and age group

For most provinces or territories, data on the sex of the individual was based on biological characteristics or legal documentation. Data on hospitalizations where sex was categorized as “Other” were excluded from analyses by sex, but were included in the overall analyses. Data on hospitalizations where age group was categorized as “Unknown” were excluded from analyses by age group, but were included in overall analyses. Due to rounding, percentages may not add to 100%.

Fentanyl and fentanyl analogues

Data on accidental opioid-related poisoning hospitalizations involving fentanyl or fentanyl analogues should be interpreted with caution as data on fentanyl-related poisoning hospitalizations became available starting April 1, 2018. As a result, fentanyl-related data presented for 2018 are limited to April to December. The ICD-10-CA classification codes to describe outcomes related to fentanyl and fentanyl analogues (“T40.40 – Poisoning by fentanyl and derivatives”) were used in data collection starting 2018-19 fiscal year, as they did not exist prior to that.

Co-occurring non-opioid poisonings

Opioid-related poisoning hospitalizations were further examined for diagnoses of poisoning from one or more co-occurring non-opioid substance in the same hospital stay. Diagnoses for non-opioid substance-related poisoning were identified using ICD-10-CA codes and included poisonings from psychoactive substances. These codes were limited to diagnoses considered influential to the time spent/treatment received in hospital and cases where the diagnosis was considered questionable, as indicated by prefix code “Q”, were excluded. Co-occurring poisonings due to non-psychoactive substances (such as non-opioid analgesics, etc.) and anti-depressants were not included. Refer to Table C for details on ICD-10-CA codes used to identify non-opioid-related poisonings.

Co-occurring non-stimulant poisonings

Stimulant-related poisoning hospitalizations were further examined for diagnoses of poisoning from one or more co-occurring non-stimulant substance in the same hospital stay. Diagnoses for non-stimulant substance-related poisoning were identified using ICD-10-CA codes and included poisonings from other substances. These codes were limited to diagnoses considered influential to the time spent/treatment received in hospital and cases where the diagnosis was considered questionable, as indicated by prefix code “Q”, were excluded. Refer to Table D for details on ICD-10-CA codes used to identify non-stimulant-related poisonings.

Co-occurring non-stimulant/non-opioid poisonings

Stimulant and opioid -related poisoning hospitalizations were further examined for diagnoses of poisoning from one or more co-occurring non-stimulant/non-opioid substance in the same hospital stay. Diagnoses for non-stimulant/non-opioid substance-related poisoning were identified using ICD-10-CA codes and included poisonings from other substances. These codes were limited to diagnoses considered influential to the time spent/treatment received in hospital and cases where the diagnosis was considered questionable, as indicated by prefix code “Q”, were excluded. Refer to Table E for details on ICD-10- CA codes used to identify non-stimulant/non-opioid-related poisonings.

Data suppression

Counts greater than 0 and less than five have been suppressed as per CIHI privacy guidelines.

Table A. List of diagnosis codes included for opioid-related poisonings
Code	Details
T40.0	Poisoning by opium
T40.1	Poisoning by heroin
T40.2	Poisoning by other opioids
T40.20*	Poisoning by codeine and derivatives
T40.21*	Poisoning by morphine
T40.22*	Poisoning by hydromorphone
T40.23*	Poisoning by oxycodone
T40.28*	Poisoning by other opioids not elsewhere classified
T40.3	Poisoning by methadone
T40.4	Poisoning by other synthetic narcotics
T40.40*	Poisoning by fentanyl and derivatives
T40.41*	Poisoning by tramadol
T40.48*	Poisoning by other synthetic narcotics not elsewhere classified
T40.6	Poisoning by other and unspecified narcotics
* Introduced as of April 1, 2018

Table B. List of diagnosis codes included for stimulant-related poisonings
Code	Details
T40.5	Poisoning by cocaine
T43.6	Poisoning by psychostimulants with abuse potential (excl. cocaine)
T43.60**	Poisoning by methamphetamine with abuse potential
T43.68**	Poisoning by other specified psychostimulants with abuse potential
T43.69**	Poisoning by unspecified psychostimulants with abuse potential
** Introduced as of April 1, 2022

Table C. List of diagnosis codes included for non-opioid poisonings co-occurring with opioid poisonings
Code	Details
T40.5	Poisoning by cocaine
T40.7	Poisoning by cannabis (derivatives)
T40.70**	Poisoning by cannabis (derivatives), edibles and ingestibles
T40.71**	Poisoning by synthetic cannabinoids
T40.79**	Poisoning by cannabis (derivatives), unspecified
T40.8	Poisoning by lysergide (LSD)
T40.9	Poisoning by other and unspecified psychodysleptics (hallucinogens)
T42.3	Poisoning by barbiturates
T42.4	Poisoning by benzodiazepines
T42.6	Poisoning by other antiepileptic and sedative-hypnotic drugs
T42.7	Poisoning by antiepileptic and sedative-hypnotic drugs, unspecified
T43.6	Poisoning by psychostimulants with abuse potential (excl. cocaine)
T43.60**	Poisoning by methamphetamine with abuse potential
T43.68**	Poisoning by other specified psychostimulants with abuse potential
T43.69**	Poisoning by unspecified psychostimulants with abuse potential
T43.8	Poisoning by other psychotropic drugs, not elsewhere classified
T43.9	Poisoning by psychotropic drug, unspecified
T44.9	Poisoning by other and unspecified drugs primarily affecting the autonomic nervous system
T51	Toxic effect of alcohol
T51.0	Toxic effect of ethanol
T51.1	Toxic effect of methanol
T51.2	Toxic effect of 2-propanol
T51.3	Toxic effect of fusel oil
T51.8	Toxic effect of other alcohols
T51.9	Toxic effect of alcohol, unspecified
** Introduced as of April 1, 2022

Table D. List of diagnosis codes included for non-stimulant poisonings co-occurring with stimulant poisonings
Code	Details
T40.0	Poisoning by opium
T40.1	Poisoning by heroin
T40.2	Poisoning by other opioids
T40.20	Poisoning by codeine and derivatives
T40.21	Poisoning by morphine
T40.22	Poisoning by hydromorphone
T40.23	Poisoning by oxycodone
T40.28	Poisoning by other opioids not elsewhere classified
T40.3	Poisoning by methadone
T40.4	Poisoning by other synthetic narcotics
T40.40*	Poisoning by fentanyl and derivatives
T40.41*	Poisoning by tramadol
T40.48*	Poisoning by other synthetic narcotics not elsewhere classified
T40.6	Poisoning by other and unspecified narcotics
T40.7	Poisoning by cannabis (derivatives)
T40.70**	Poisoning by cannabis (derivatives), edibles and ingestibles
T40.71**	Poisoning by synthetic cannabinoids
T40.79**	Poisoning by cannabis (derivatives), unspecified
T40.8	Poisoning by lysergide (LSD)
T40.9	Poisoning by other and unspecified psychodysleptics (hallucinogens)
T42.3	Poisoning by barbiturates
T42.4	Poisoning by benzodiazepines
T42.6	Poisoning by other antiepileptic and sedative-hypnotic drugs
T42.7	Poisoning by antiepileptic and sedative-hypnotic drugs, unspecified
T43.8	Poisoning by other psychotropic drugs, not elsewhere classified
T43.9	Poisoning by psychotropic drug, unspecified
T44.9	Poisoning by other and unspecified drugs primarily affecting the autonomic nervous system
T51	Toxic effect of alcohol
T51.0	Toxic effect of ethanol
T51.1	Toxic effect of methanol
T51.2	Toxic effect of 2-propanol
T51.3	Toxic effect of fusel oil
T51.8	Toxic effect of other alcohols
T51.9	Toxic effect of alcohol, unspecified
* Introduced as of April 1, 2018
** Introduced as of April 1, 2022

Table E. List of diagnosis codes included for non-stimulant/non-opioid poisonings co-occurring with opioid or stimulant poisonings
Code	Details
T40.7	Poisoning by cannabis (derivatives)
T40.70**	Poisoning by cannabis (derivatives), edibles and ingestibles
T40.71**	Poisoning by synthetic cannabinoids
T40.79**	Poisoning by cannabis (derivatives), unspecified
T40.8	Poisoning by lysergide (LSD)
T40.9	Poisoning by other and unspecified psychodysleptics (hallucinogens)
T42.3	Poisoning by barbiturates
T42.4	Poisoning by benzodiazepines
T42.6	Poisoning by other antiepileptic and sedative-hypnotic drugs
T42.7	Poisoning by antiepileptic and sedative-hypnotic drugs, unspecified
T43.8	Poisoning by other psychotropic drugs, not elsewhere classified
T43.9	Poisoning by psychotropic drug, unspecified
T44.9	Poisoning by other and unspecified drugs primarily affecting the autonomic nervous system
T51	Toxic effect of alcohol
T51.0	Toxic effect of ethanol
T51.1	Toxic effect of methanol
T51.2	Toxic effect of 2-propanol
T51.3	Toxic effect of fusel oil
T51.8	Toxic effect of other alcohols
T51.9	Toxic effect of alcohol, unspecified
** Introduced as of April 1, 2022

Disclosure

Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors, and not necessarily those of CIHI.

Data source

Discharge Abstract Database (DAD), Canadian Institute for Health Information, 2016 to 2022

Data suppression
Table A. Case definitions for suspected opioid-related overdose EMS responses for provinces and territories
Table B. Reporting periods and available variables included in suspected opioid overdose EMS data used for this update by province or territory
Table C. Specific reporting periods included in suspected opioid overdose EMS data used for this update, by region
Acknowledgements
Suggested citation

Case definitions

There is currently no national case definition for Emergency Medical Services (EMS) responses to suspected opioid-related overdoses. Therefore, each region reports data based on their respective provincial or territorial case definition (refer to Table A). Due to differences in these case definitions, comparisons over time and between provinces and territories should be interpreted with caution.

How suspected opioid-related overdoses are counted

Counts are provided by the provinces and territories that collect data from their respective Emergency Medical Services.

The data provided by the provinces and territories include EMS responses to suspected overdoses where:

Naloxone was administered by a member of the Emergency Medical Services or a bystander on site, or
Naloxone was not necessarily administered but an opioid-related overdose was suspected.

These data do not include suspected overdoses where:

Emergency Medical Services were not contacted or the client was gone on arrival

However, some provincial and territorial differences remain in the type of data reported and in the time periods for which data are available (refer to Table B and Table C).

Limitations of the EMS data on suspected opioid-related overdoses

Data presented in this update should be interpreted with caution.

This update is based on data submitted to the Public Health Agency of Canada on or before . New or revised data reported after this date will be reflected in future updates.
Data released by provinces and territories may differ due to the availability of updated data, the use of alternate age groupings, differences in time periods presented and/or population estimates used for calculations, etc.
This update is based on data that do not specify how the opioids were obtained (e.g., illegally or through personal prescription); the level of toxicity may differ depending on the opioid (substance(s) involved, concentration, and dosage).
No drug or laboratory testing is undertaken by any province or territory to confirm whether ingestion of an opioid has actually occurred. As a result, the number of patients receiving naloxone might be an overestimation of the actual number of opioid-related overdoses as naloxone will not have an effect if opioids were not taken.

Notes on provincial and territorial data

Due to differences in case definitions, comparisons over time and between provinces and territories should be interpreted with caution.

General notes

Data reported by some provinces and territories may not include age group and sex information; refer to Table B for more details.
Data presented here are updated on a quarterly basis and are subject to change as new or updated information becomes available.
Data were not available for Quebec, Prince Edward Island and Nunavut.
Data from British Columbia include EMS responses to suspected overdoses related to all illicit drugs including, but not limited to, opioids. While data are updated quarterly, there may be a lag in reporting. As a result, discrepancies may be noted between the national quarterly reporting of suspected overdoses in BC and the quarterly reporting of suspected overdoses by BCEHS, please refer to section 1 of the latest report.
Starting in 2018, Alberta provincial EMS data covers nearly 100% of ground ambulance services in Alberta. Data from air ambulance and interfacility transfers are not included. In 2017, EMS data were only available for the cities of Calgary and Edmonton.
Saskatchewan reports data from licensed ambulance services only. These data do not include events where naloxone was administered by bystanders or other first responders (e.g., police or firefighters).
The case definition changed for Saskatchewan in May 2022 to also include situations where there was a suspected overdose, but someone other than a paramedic (e.g., police, fire, or friend) administered naloxone. This change only affects prospective data collected in the province from 2021 onwards.
Manitoba reports their data for two distinct regions: 1) Winnipeg, and 2) Northern and rural Manitoba.
Northern and rural Manitoba data include land and air transports, but excludes interfacility transports. Naloxone administration counts are based on information either collected from the on scene caller or provided by the dispatched EMS personnel to the MTCC during call back.
The reporting format of data from the Winnipeg Fire Paramedic Service changed in November 2021, from the number of incidents requiring administration of naloxone to number of persons requiring administration of naloxone. This change affects both retrospective and prospective data collected in the city, and results in an increase in the number of EMS responses for all reporting years.
Ontario data relies on documentation by paramedics and extraction from Ministry of Health designated Base Hospitals. Data submitted for the province for April to June 2018 and for January to March 2019 were only available for the geographical area containing ~95.5% and ~99.6% of the Ontario population (based on 2016 Statistics Canada Census), respectively.
The number of patients receiving naloxone may overestimate the actual number of opioid-related overdoses as naloxone will not have an effect if opioids were not consumed. Therefore, New Brunswick reports the number of patients responding to naloxone. These data do not include overdoses where patients were dead on arrival or were not given naloxone by Ambulance New Brunswick.
Newfoundland and Labrador EMS data may underestimate the burden of suspected opioid-related overdose instances in the province. The number of suspected opioid-related EMS responses is subject to change due to a lag in reporting of retrospective naloxone administration.
Yukon EMS data were only available for the city of Whitehorse.
Northwest Territories EMS data were only available for the city of Yellowknife.

Sex and age group

EMS data on suspected opioid-related overdoses where sex was categorized as “Unknown” were excluded from analyses by sex, but were included in overall analyses.
EMS data on suspected opioid-related overdoses where age group was categorized as “Unknown” were excluded from analyses by age group, but were included in overall analyses.
Due to rounding, percentages may not add to 100%.
Overall sex- and age-specific trends reflected in this document are based on data from the regions reporting data for the most recent year. Individual findings may fluctuate within individual provinces and territories.
British Columbia data by age group were not reported.
Saskatchewan data by sex and age group were only reported from 2018 to 2022.
Winnipeg, Manitoba data do not include individuals nine years or younger.
Newfoundland and Labrador data by sex and age group were not reported.
Yukon data by sex and age group were only reported from 2019 to 2022.

Data suppression

Counts of five or less were suppressed to address concerns around releasing small numbers.

Table A. Case definitions for suspected opioid-related overdose EMS responses for provinces and territories with available data as of
Region	Data Source	Primary Case Definition
British Columbia	BC Emergency Health Services (BCEHS)	The current British Columbia Centre for Disease Control (BCCDC) Overdose Surveillance definition for paramedic attended overdose events is based on a cluster analysis algorithm, which codes ambulance-attended events as overdose cases when naloxone was administered by paramedics OR where the paramedic impression codes are related to recreational drug overdose and the Medical Priority Dispatch System (MPDS) code was consistent with possible drug overdose.
Alberta	Alberta Health Services	Documentation of opioid medical control protocol or administration of naloxone.
Saskatchewan	Provincial Ambulance Information System	Emergency response calls with an assessment of "Overdose/poisoning with bystander medication administration” OR where Narcan (naloxone) is administered by ambulance crews and the patient has an assessment code for Possible Narcotic Overdose.
Winnipeg, Manitoba	Winnipeg Fire Paramedic Service	The number of suspected overdose cases receiving naloxone from Winnipeg Fire Paramedic Service (WFPS).
Northern and rural Manitoba	Medical Transportation Coordination Centre	The number of suspected overdose cases in northern and rural Manitoba receiving naloxone from EMS dispatched through the Medical Transportation Coordination Centre (MTCC) or a bystander on scene.
Ontario	Ontario Ambulance Call Reports	Suspected opioid overdose requiring administration of naloxone by paramedics (as indicated by Medication Code “Naloxone (610)”)
New Brunswick	Ambulance New Brunswick	A patient who responded to naloxone that was administered by an Ambulance New Brunswick first responder for a suspected opioid overdose.
Nova Scotia	Emergency Health Services Nova Scotia	The number of emergency responses where naloxone was administered by an intensive care Paramedic, an advanced care Paramedic or a critical care Paramedic when respiration or airway were compromised despite basic life support airway management AND an opioid intoxication was suspected.
Newfoundland and Labrador	Provincial Medical Oversight Office	Emergency response to an opioid-related overdose where naloxone is administered by paramedics.
Whitehorse, Yukon	Yukon Emergency Medical Services	Paper-based patient care reports: Suspected opioid overuse is identified during the 9-1-1 call taking process; and/or Opioid overuse or overdose are identified in the Patient Care Report’s narrative, history of event, or chief complaint; and/or Naloxone administered by a designated emergency responder, allied health care provider, or layperson at the scene. Electronic-based patient care reports: Primary problem or final primary problem classified as “suspected opioid overdose”; and/or Procedure code: Naloxone administered by designated emergency responder, allied health care provider, or layperson at the scene.
Yellowknife, Northwest Territories	Yellowknife Fire and Ambulance Services	Suspected overdose identified as chief complaint and an opioid identified as the overdose product OR suspected overdose identified as the chief complaint and naloxone administered by paramedics.

Table B. Reporting periods and available variables included in EMS data on suspected opioid-related overdoses used for this update by province or territory
Reporting period (as of )
		BC	AB	SK	MB	ON	QC	NB	NS	PE	NL	YT	NT	NU
2017	January to December			n/a	^(INC)	n/a	n/a		n/a	n/a	^(INC)			n/a
2018	January to December			^(INC)		^(INC)	n/a		^(INC)	n/a	^(INC)			n/a
2019	January to December						n/a			n/a	n/a			n/a
2020	January to December						n/a			n/a	n/a			n/a
2021	January to December						n/a			n/a	n/a			n/a
2022	January to December						n/a			n/a	n/a			n/a
Data availability by variables collected
Sex data				^(INC)			n/a			n/a	n/a			n/a
Age group data		n/a		^(INC)			n/a			n/a	n/a			n/a
These data have been reported by the province or territory and are reflected in this update, unless otherwise specified (INC)Data were not reported for the full time period. Please refer to Table C for more details. n/aData were not available at the time of this publication

Table C. Specific reporting periods included in EMS data on suspected opioid-related overdoses used for this update, by region
Region	Reporting period
British Columbia	January 2017 to December 2022
Alberta	January 2017 to December 2022
Saskatchewan	April 2018 to December 2022
Winnipeg, Manitoba	January 2017 to December 2022
Northern and rural Manitoba	May 2017 to December 2022
Ontario	April 2018 to December 2022
New Brunswick	January 2017 to December 2022
Nova Scotia	June 2018 to December 2022
Newfoundland and Labrador	April 2017 to March 2018
Whitehorse, Yukon	January 2017 to December 2022
Yellowknife, Northwest Territories	January 2017 to December 2022

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Acknowledgments

This update would not be possible without the collaboration and dedication of provincial and territorial (PT) offices of Chief Coroners and Chief Medical Examiners as well as PT public health and health partners and Emergency Medical Services data providers. We would also like to acknowledge the Canadian Institute for Health Information (CIHI) for collecting and providing the data used for reporting opioid- and stimulant-related poisoning hospitalizations.

Suggested Citation

Federal, provincial, and territorial Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioid- and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; June 2023. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/

Opioid- and Stimulant-related Harms in Canada Published: (June 2023): Health Infobase

On this page

Definitions

How apparent opioid and stimulant toxicity deaths are counted

Limitations of the data on apparent opioid and/or stimulant toxicity deaths

Notes on provincial and territorial data

General notes

Manner of death

Sex and age group

Fentanyl, fentanyl analogues, and non-fentanyl opioids

Origin of opioid(s)

Cocaine, methamphetamine and other stimulants

Other psychoactive substances

Data suppression

On this page

Definitions

How poisoning hospitalizations are counted

Limitations of the data on poisoning hospitalizations

General notes

Intention

Sex and age group

Fentanyl and fentanyl analogues

Co-occurring non-opioid poisonings

Co-occurring non-stimulant poisonings

Co-occurring non-stimulant/non-opioid poisonings

Data suppression

Disclosure

Data source

On this page

Case definitions

How suspected opioid-related overdoses are counted

Limitations of the EMS data on suspected opioid-related overdoses

Notes on provincial and territorial data

General notes

Sex and age group

Data suppression

Learn more about opioids and stimulants in Canada