Opioid- and Stimulant-related Harms in Canada Published: (September 2021)

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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.
  • National rates of apparent opioid toxicity deaths for 2021 exclude Manitoba.
  • 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 seven 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

  1. Data reported by some provinces and territories do not include all manners of death (accident, suicide, undetermined) or stages of investigation (ongoing, completed); refer to Table A for more details.
  2. Data presented here will be updated quarterly, based on results of completed investigations.
  3. Rates for provinces and territories with relatively smaller populations may change substantially with even slight changes in the number of deaths.
  4. British Columbia data for 2016 and 2017 include deaths with completed investigations only. Overall numbers for British Columbia from 2018 to 2021 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.
  5. Quebec data from 2016 to 2019 include deaths with completed investigations only; death investigations were underway for 5% in 2019. Available 2020 and 2021 data from Quebec include unintentional deaths with ongoing investigations related to all illicit drugs including, but not limited to, opioids and stimulants. Preliminary data for drug-related poisonings, for which toxicology information was available, indicate that 49% of deaths between January 2020 and March 2021 involved an opioid.
  6. Data from Yukon include deaths with completed investigations only. In 2018, one apparent opioid toxicity death occurred in a different province following an overdose in Yukon. This death is included in the data from the jurisdiction where the death occurred and is not reported in the data from Yukon.
  7. 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.
  8. In Ontario, apparent opioid toxicity death data were captured using an enhanced data collection tool by the Office of the Chief Coroner as of May 1, 2017. Prior to this time period, retrospective case information was collected using a different tool.
  9. 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.
  10. Data from Nunavut were not included in national counts or percentages.
  11. Manitoba data from April 2020 to March 2021 were not available at the time of this update.

Manner of death

  1. Manner of death is assigned by the coroner or medical examiner during, or following an investigation. The data in this update include accidental, suicide and undetermined deaths.
  2. Suicide data were unavailable from Alberta (2018 to 2021), Prince Edward Island and Nunavut.

Sex and age group

  1. For most provinces and territories, data on the sex of the individual was based on biological characteristics or legal documentation.
  2. Data on deaths where sex was categorized as “Other” were excluded from analyses by sex, but were included in overall analyses.
  3. Due to rounding, percentages may not add to 100%.
  4. For Ontario, from January 2016 to April 2017, data on the sex of the individual reflected the sex assigned at birth or was based on biological characteristics at the time of death; as of May 2017, the perceived or projected identity of the individual was reported.
  5. Alberta uses data on the sex of the individual based on the medical examiner’s assessment, which is largely based on biological characteristics. In the 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.
  6. 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

  1. Refer to Table B below for details on opioids.
  2. Prior to 2018, the percentage of deaths involving fentanyl and/or fentanyl analogues represented a single category. For data reported for 2018 to 2021, 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.
  3. 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.
  4. 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.
  5. 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.
  6. Available 2020 and 2021 data from Quebec on deaths related to drugs 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.
  7. For Alberta and Ontario, only data on deaths with completed investigations, where relevant toxicology information was available, were included in percentages for fentanyl or fentanyl analogues.

Origin of opioid(s)

  1. The origin of opioid(s) refers to whether the opioids that directly contributed to the death were pharmaceutical, non-pharmaceutical, both or undetermined.
  2. Data on origin were only available for deaths with completed investigations from 2018 onward from between seven and eight provinces and territories depending on the year. Completed investigations represented 79% of apparent opioid toxicity death investigations from these provinces and territories over that period; refer to Table A for more details.
  3. Summary data and trends based on origin of opioid(s) should be interpreted with caution until additional data become available.
  4. 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.
  5. Pharmaceutical opioids also include those approved for use in humans in other countries, but not necessarily in Canada.
  6. 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.
  7. Origin categorization represents the best estimate based on the information available and should be interpreted with caution.
  8. 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.
  9. British Columbia only reports opioid toxicity deaths involving any illicit opioids, resulting in a high proportion of non-pharmaceutical opioids. For that reason, data on origin of opioid from British Columbia were not included in the national proportions.

Cocaine, methamphetamine and other stimulants

  1. Refer to Table B below for details on stimulants.
  2. 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’.
  3. Data on apparent stimulant toxicity deaths were available from between five and seven provinces and territories, depending on the year from 2018 to 2021 (Jan to Mar).
  4. 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.
  5. For Ontario, only data on deaths with completed investigations, where relevant toxicology information was available, were included in percentages for cocaine, methamphetamine and other stimulants.
  6. Data from Quebec on “other stimulants” also involve deaths involving methamphetamine.
  7. 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

  1. Refer to Table B below for details on other psychoactive substances.
  2. National-level percentages of accidental apparent opioid toxicity deaths involving other non-opioid substances do not include data from Nunavut as these data were not available.
  3. For Alberta, only data on deaths with completed investigations and specific substances causing death listed on the death certificate were included in percentages of accidental apparent opioid toxicity deaths involving other non-opioid substances.
  4. 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 (2020 to 2021).
  • 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 (as of ).
  BC AB SK MB ON QC NB NS PE NL YT NT NU
Available data on apparent toxicity deaths involving opioids
2016-2017 January to December
(C)

(C)

(C)

(C)

(C)

(C)
2018-2019 January to December
(C)

(C)

(C)

(C)

(C)
2020 January to December
(C)

(INC)

(C)

(C)

(C)
2021 January to March
(C)
n/a
(C)

(C)

(C)
Available data on apparent toxicity deaths involving stimulants
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)

(INC)
n/a n/a n/a
(C)
n/a n/a
2021 January to March
(C)
n/a
(C)
n/a n/a n/a n/a
(C)
n/a 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
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)
2018-20 January to December
(INC)
n/a n/a n/a n/a n/a
2021 January to March n/a n/a 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
  • (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-related 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

Acknowledgements

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

Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioid and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; September 2021. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants


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