drug addiction in canada essay

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• v.38(6); 2018 Jun

Evidence synthesis - The opioid crisis in Canada: a national perspective

Introduction:.

This review provides a national summary of what is currently known about the Canadian opioid crisis with respect to opioid-related deaths and harms and potential risk factors as of December 2017.

We reviewed all public-facing opioid-related surveillance or epidemiological reports published by provincial and territorial ministries of health and chief coroners’ or medical examiners’ offices. In addition, we reviewed publications from federal partners and reports and articles published prior to December 2017. We synthesized the evidence by comparing provincial and territorial opioid-related mortality and morbidity rates with the national rates to look for regional trends.

The opioid crisis has affected every region of the country, although some jurisdictions have been impacted more than others. As of 2016, apparent opioid-related deaths and hospitalization rates were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. Current evidence suggests regional age and sex differences with respect to health outcomes, especially when synthetic opioids are involved. However, differences between data collection methods and reporting requirements may impact the interpretation and comparability of reported data.

Conclusion:

This report identifies gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis. The Public Health Agency of Canada will continue to work closely with the provinces, territories and national partners to further refine and standardize national data collection, conduct special studies and expand information-sharing to improve the evidence needed to inform public health action and prevent opioid-related deaths and harms.

• The opioid crisis is growing in Canada, driven by both illegal and prescription opioid use. Fentanyl and analogues appear to be fuelling the rise in opioid-related deaths.
• This crisis is having a devastating impact on the health and lives of Canadians, their families and communities across the country. In 2016 alone, there were 2861 opioidrelated deaths and 16 opioid-related hospitalizations each day.
• While the opioid crisis has affected every region of the country, western Canada (British Columbia and Alberta) and the northern territories (Yukon and Northwest Territories) have experienced the highest burden.
• Nationally, most apparent opioidrelated deaths occurred among males (74%); individuals between 30 and 39 years of age accounted for the greatest proportion (28%).
• Evidence reveals that this crisis is not restricted to opioids; 82% of apparent opioid-related deaths from January 2016 to June 2017 also involved one or more non-opioid substances.

Introduction

The opioid crisis is growing in Canada, driven by both illegal and prescription opioids. In 2016, there were 2861 apparent opioid-related deaths * in Canada, which is equivalent to eight people dying each day, 1 and is greater than the average number of Canadians killed daily in motor vehicle collisions in 2015. 2 However, this statistic represents just the tip of the iceberg; on average, 16 Canadians were hospitalized each day due to opioid-related poisonings in Canada in 2016. 3 This is not a problem restricted to persons who use illegal or street drugs; rather, this is a national public health crisis that affects people in communities across Canada, across all ages and across all socioeconomic groups.

* An apparent opioid-related death (AORD) is “a death caused by intoxication/toxicity (poisoning) as a result of drug use, where one or more of the drugs involved is an opioid.” 1

The purpose of this review was to provide a summary of the existing body of evidence on the Canadian opioid crisis, based on available data, to assist with identifying trends and gaps in knowledge and to provide policy makers with a national perspective. In order to better understand the crisis and its impact on Canadians across the country, we reviewed all public-facing, opioid-related surveillance and epidemiological reports published by provincial and territorial ministries of health and chief coroners’ and medical examiners’ offices. In addition, we reviewed available reports and published articles from federal partners and external organizations mentioning opioid-related harms, opioids, opiates, fentanyl, fentanyl analogues or synthetic opioids published or shared prior to December 2017. We synthesized the data by comparing provincial and territorial historical opioid-related mortality and morbidity trends (where available), and by comparing current provincial and territorial rates with the national rates to identify regional trends and differences. Information collected through bilateral discussions with the provinces and territories on opioid-related health outcomes and data from Health Canada on prescribing practices and analysis of seized drug shipments were included to provide the context for the national synthesis.

At the time of this review, all provinces and territories were reporting opioidrelated mortality data to the Public Health Agency of Canada (PHAC) through the Opioid Overdose Surveillance Task Group (OOSTG). The OOSTG includes federal, provincial and territorial (FPT) partners, as well as other national partners. The OOSTG is responsible for coordinating national surveillance of opioid-related harms, including the development of national case definitions (such as “apparent opioid-related deaths”).

Individually, six provinces had reported historical data on opioid-related mortality. Eight provinces had published reports on the opioid crisis, with all reporting on mortality; four reported data from emergency medical services (EMS) or first responders; and four reported data on communitybased naloxone distribution programs. Three of the provinces included analysis of potential risk factors in their published reports. The information from these reports forms the basis of this synthesis.

Prescription opioids: use, supply and access

The current opioid epidemic follows on the enormous growth in use of prescription opioids in Canada in recent decades. Since the early 1980s, the volume of opioids sold to hospitals and pharmacies for prescriptions in Canada has increased by more than 3000%. 4 In 2016, over 20 million prescriptions for opioids were dispensed, 5 which is equivalent to nearly one prescription for every adult over the age of 18 years, making Canada the second-largest consumer of prescription opioids in the world, after the USA. 6

In Canada, prescription opioid–related harms and rates of nonmedical prescription opioid use (“misuse”) have been increasing since 1999. 6 According to estimates, by 2008 nonmedical prescription opioid use was the fourth most prevalent form of substance use (after alcohol, tobacco and cannabis), making it more common to misuse a prescription opioid than to use heroin or cocaine. 7

The prevalence of prescription opioid use in Canada (“within the previous 12 months”) is estimated to be one in six (from the 2015 Canadian Tobacco, Alcohol and Drugs Survey [CTADS]). 8 While the CTADS found just 2% of those who used a prescription opioid reported misusing them, a more recent online survey from Health Canada (2017) found that nearly one-third of those who had used an opioid in the past year did not always have a prescription. This proportion increased to almost half in teens younger than 18 years and 88% among persons using illegal drugs. 9

There are many routes that allow for prescription opioids to be diverted for nonmedical use, including sharing with family members, “double doctoring,” prescription fraud and forgery, street drug markets, thefts and robberies and Internet purchases, making it difficult to estimate the proportion diverted. 7 Through its surveys, Health Canada found that the most common source of opioids used without a prescription was a family member. 9

No national measures of prevalence of illegal opioid use were found. Nationally, in 2015 the prevalence of illicit drug use (“within the previous 12 months”) was 2% (1% females; 3% males). This included use of crack, cocaine, ecstasy, speed or methamphetamines, hallucinogens or heroin and therefore was not specific to opioids. 8

The rising presence of fentanyl and other synthetic opioids: evidence from illegal drug seizures and death investigations

In 2016, opioids were among the top 10 controlled substances most frequently detected by Health Canada’s Drug Analysis Service (DAS), ranking just below marijuana, cocaine and methamphetamines among all samples tested from substances confiscated by police and border security from across the country. Heroin, fentanyl and its analogues, hydromorphone, oxycodone and morphine were the most frequently detected opioids in samples analyzed by DAS. 10

Synthetic opioids such as fentanyl, W-18 and U-47700, to name but a few, are extremely potent. Fentanyl and its analogues (e.g. carfentanil, furanylfentanyl, acetylfentanyl) are becoming more prevalent on the illegal drug market and are increasingly combined with other controlled substances, which increases their potential toxicity and the risk of an overdose. In 2017, Health Canada found fentanyl or an analogue in more than 50% of heroin samples tested by DAS (tested between January 2012 and September 2017), and has also started to detect it in samples of methamphetamines and cocaine (2% each). 11 A review of available literature found that fentanyl was first reported in British Columbia and Alberta in 2011. 12 , 13 Since then, the proportion of deaths involving fentanyl in these provinces has risen dramatically. 12 , 13

The pattern of apparent opioid-related deaths is changing along with the increasing presence of synthetic opioids in the illegal market. Fentanyl has now been detected in the illegal drug supply in all Canadian jurisdictions. 10 , 14 Nationally, the proportion of reported apparent opioidrelated deaths involving fentanyl or an analogue was 53% in 2016 1 and appears to be on the rise, according to preliminary reports for 2017.

In British Columbia, fentanyl was involved in 68% 1 of the 985 illicit drug deaths † in 2016, up from 4% in 2012. 12 , 15 During the first half of 2017, the proportion of deaths involving fentanyl or an analogue in the province rose to 83%. 1 In contrast, the number of illicit drug overdose deaths not involving fentanyl has remained relatively stable, at 300 per year 15 ( Figure 1 ).

In Alberta, there were 611 apparent opioid- related deaths in 2016. 1 , 16 From 2014 to 2016, the proportion of deaths involving fentanyl or an analogue increased from 26% to 63%, 16 while deaths due to other opioids remained constant and non-opioidrelated overdose deaths declined by almost 200%. 16 This trend continued during the first six months of 2017 in Alberta, with the proportion of opioid-related overdose deaths involving fentanyl or an analogue rising to almost 80%. 1 , 16

Ontario has also reported a rising proportion of fentanyl-related deaths. 1 , 17 In 2016, there were 867 apparent opioid-related deaths. From 2012 to 2016, the proportion of deaths involving fentanyl increased from 26% to 41% 17 ( Figure 2 ).

Carfentanil, which is 100 times more powerful than fentanyl, presents another growing concern and has been detected in British Columbia, 15 , 18 Alberta, 16 Manitoba 19 and Ontario. 17 In 2016/17, DAS tested 91 seized samples of carfentanil: 56% from British Columbia, 17% from Alberta, 19% from Manitoba and 7% from Ontario. 20 In Alberta, there were 29 deaths in 2016 involving carfentanil, and in the first six months of 2017 there were at least 89 deaths. 16

Health outcomes: apparent opioid-related deaths

By 2016, apparent opioid-related death rates revealed a national public health crisis. The opioid epidemic had affected communities across the country ( Figure 3 ). Nationally, the rate of apparent opioidrelated deaths was 7.9 per 100 000 population in 2016. 1 However, there were pronounced regional differences, with western provinces reporting some of the highest death rates: British Columbia reported a rate of 20.7 per 100 000 population (985 illicit drug overdose deaths) and Alberta reported a rate of 14.4 per 100 000 population (611 opioid-related overdose deaths). Based on available data, these two provinces alone accounted for the majority (56%) of opioid-related deaths in 2016. 1 Yukon and the Northwest Territories also reported high rates of 18.4 and 11.2 per 100 000 population, respectively. 1 Rates for apparent opioid-related deaths were relatively lower in the other jurisdictions, but suggest a possible rise in some provinces, including Ontario. 1 , 17 , 19 , 21 , 22

Age and sex

In 2016, the highest percentage (28%) of apparent opioid-related deaths in Canada occurred among individuals between the ages of 30 and 39. 1 Though age at death does not appear to vary greatly across jurisdictions, age may be a factor when the type of opioid is considered. In Alberta, when fentanyl and its analogues were involved, younger men represented more deaths (mean age: 38 years) as compared to deaths involving other opioids (mean age: 42 years). 16

From January 2016 to June 2017, most apparent opioid-related deaths in the nation occurred among males (74%). However, information collected from the provinces and territories indicates that the sex of individuals dying from an apparent opioid-related overdose may vary by region. In the western jurisdictions of British Columbia, Alberta, Yukon and the Northwest Territories, more men are dying than women (approximately 4:1); in Ontario, men are also more likely to die than women (2:1). However, in some Prairie and eastern provinces (Saskatchewan, Manitoba, New Brunswick, Nova Scotia and Newfoundland and Labrador), women represent nearly as many opioid-related deaths as do men (1:1 to 3:2) 1 ( Figure 4 ).

In some jurisdictions there appear to be other important variations by age and sex. In Alberta and Ontario, where data segregated by age and sex were presented, older women (aged 44 years and older) represented more deaths from an opioidrelated overdose than their younger male counterparts. 16 , 17 This pattern was also reflected in recent studies of registered First Nations in British Columbia and Alberta, where First Nations women dying of an opioid-related overdose were on average 15 to 20 years older than their male counterparts. 23 , 24

These differences in death rates may reflect some jurisdictional differences in the death investigation process, death classification method, toxicology testing or type of data reported (e.g. the inclusion or exclusion of suicide deaths) and thus caution should be used when interpreting these numbers.

Risk factors for apparent opioid-related deaths

Several reports published by the provinces also looked at risk factors. The reports we reviewed from British Columbia, Alberta and Manitoba showed that the majority of opioid-related overdose deaths occurred indoors, in private residences, in larger urban centres, though many deaths also occurred on the periphery of these urban centres and in a large number of smaller communities as well. 15 , 16 , 18 , 19 In Alberta and Ontario, those who died tended to reside in lowerto middle-income neighbourhoods; however, deaths occurred in neighbourhoods across all socioeconomic groups. 16 , 25

Combined use of opioids with non-opioid substances, such as alcohol, benzodiazepines, cocaine and W‑18, to name a few, may also be a risk factor. According to available data, approximately 82% of apparent opioid-related deaths from January 2016 to June 2017 also involved one or more non-opioid substances. 1

Previous access to certain prescribed medications was also analyzed by three provinces. In Manitoba, a chart review performed by the Office of the Chief Medical Examiner found the most frequently prescribed medications, six months prior to an apparent opioid-related death, were an opioid (60%), an antidepressant (52%) and a benzodiazepine (47%). 19

The Alberta report also found differences in the proportions of deaths from an opioid- related overdose involving an opioid other than fentanyl, and deaths in which fentanyl was involved. Specifically, individuals who died of an opioid-related overdose involving an opioid other than fentanyl were nearly twice as likely to have accessed a (listed) health care service (77% vs. 41%), 16 or to have been dispensed an opioid (66% vs. 23%) or antidepressant (38% vs. 14%) from a community pharmacy in the 30 days prior to their death ( Figure 5 ). This suggests that there may be differences in the risk factors for opioid-related deaths when fentanyl is involved and those involving other opioids.

Special populations

First Nations ‡ populations across the country are heavily impacted by high rates of problematic substance use. 26 As early as 2014, First Nations communities were raising the alarm about the number of opioidrelated overdose deaths on reserves in southern Alberta. 27 The provinces of British Columbia and Alberta published reports highlighting the impact of the opioid crisis on First Nations communities from January 2016 to March 2017. Both reported similar findings: First Nations people were five times more likely than their non–First Nations counterparts to experience an opioid- related overdose event and three times more likely to die from an opioid-related overdose. 23 , 24 In Alberta, fentanyl was involved in 18% more opioid-related deaths among First Nations people than non–First Nations. 23 No distinction for type of opioid involved was available from the British Columbia report.

In both provinces, First Nations men and women were almost equally likely to experience an opioid-related overdose event. 23 , 24 In Alberta, First Nations men and women were also equally likely to die from an opioid-related overdose, while in British Columbia, First Nations males were more likely to die than females (5:3) from an opioid-related overdose. In both provinces, First Nations women were more likely to die than non–First Nations women, who represented less than 30% of non–First Nations deaths. 1 In both British Columbia and Alberta, older First Nations women (aged 50 to 54 years) represented a higher proportion of all opioidrelated deaths in both provinces, whereas First Nations men were younger (30 to 34 years), 23 , 24 which is in keeping with apparent opioid-related death rates for men in the general Canadian population. 1

Alberta’s report also examined hospitalizations and emergency department (ED) visits. In Alberta, First Nations individuals were five times more likely than non–First Nations people to be hospitalized and six times more likely to present at an ED for an opioid poisoning. First Nations people were also twice as likely to be dispensed an opioid as non–First Nations individuals, and tended to be at least five years younger at the time the drug was dispensed than non–First Nations individuals. 23 Because information from First Nations and other ethnic populations are not readily available in other jurisdictions, regional comparisons were not possible at this time.

Homeless populations are also at risk of opioid-related harms. In British Columbia, data collected in EDs found that unstable housing (i.e. no fixed address or unknown address) was reported by approximately 30% of those presenting for a known or suspected overdose, and by almost 50% of young people aged 13 to 18 years. 12

Another at-risk population resides in provincial and territorial prisons and federal penitentiaries. These institutions house populations with a high prevalence of problematic substance use. From 2011/12 to 2013/14, Correctional Service Canada reported 92 unintentional overdose events, 12% of which were fatal. In 2014/15, there were 6 fatal overdoses (13.5 per 100 000 population). Male inmates with a reported prior substance use problem were most likely to overdose. Illegally obtained (as opposed to prescription) drugs were most commonly linked with fatal overdoses. 28

Health outcomes: hospitalizations

Hospitals use the term opioid poisoning to describe an opioid-related overdose, according to International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10-CAii) version 2015 coding. § The Canadian Institute for Health Information (CIHI) extracts data from the Hospital Morbidity Database (HMDB) for hospitalizations (100% national reporting). From March 2016 to March 2017, opioid poisonings were responsible for an average of 16 hospitalizations per day in Canada. This represents an increase of over 50% nationally in the past 10 years, with the largest increases occurring in the past three years. 3 Adults aged 45 years and older had the highest rates of hospitalization for opioid poisonings, although the fastest growing rates were seen in the younger age groups (15 to 44 years). Rates varied across the country. The highest rates for opioid-related hospitalizations (in 2016/17) as well as the fastest growing rates (occurring between 2014 and 2017) were in the western provinces of British Columbia (25.0 per 100 000 population) and Alberta (23.1 per 100 000 population) and in the territories (34.5 per 100 000 population) excluding Nunavut 3 ( Figure 6 ). In 2016/17, more than half of the hospitalizations for opioid poisonings were considered unintentional, 31% were considered intentional and 17% were of unknown intent. 3 The majority (63%) of the unintentional poisonings occurred in people aged 65 years and older while intentional poisonings were more prevalent in the younger age group of 15 to 24 years. 3 Nationally, hospitalization rates have increased by 24% over the past three years for men and 10% for women. In 2016/17, the rate of hospitalization of males surpassed that of females for the first time. 3 There did not appear to be notable regional differences with respect to age or sex for opioid-related hospitalizations. 25

Health outcomes: emergency department (ED) visits

Data are collected by EDs and reported to CIHI to the National Ambulatory Care Reporting System (NACRS) (64% national coverage; 100% coverage in ON, AB, YK) 3 using ICD10-CAii version 2015 coding. As these data are not nationally representative, where possible they have been supplemented by surveillance reports from provinces where available. In light of these different data sources, regional comparisons are not possible for ED visits.

In Alberta, over the past five years, opioid- related ED visits have more than doubled, reaching 88.6 per 100 000 population in 2016/17. Contributing to this increase, heroin and synthetic opioid (including fentanyl) poisonings rose nearly tenfold each to approximately 20 per 100 000 population (for both) in 2016/17. During this same time period, opioid-related ED visits tripled for males and almost doubled for females. The greatest increases were observed in the younger age groups (15 to 44 years), for which rates have tripled, reaching more than 150 per 100 000. Most of these increases have occurred over the past three years. 3

In Ontario, over the past five years, opioid- related ED visits increased by almost 50%. More specifically, ED visits for heroin rose fourfold to 5.7 per 100 000 population and more than doubled for synthetic opioid poisonings (including fentanyl), reaching 5.5 per 100 000 population in 2016/17. Rates have increased by 65% among males and 30% among females. The increases were greatest in the younger age groups (25 to 44 years), where rates almost doubled, reaching 57 per 100 000 population in 2016/17. Again, these increases mostly occurred over the past three years. 3

In British Columbia, males made up 66% of ED visits for suspected opioid overdoses. Nearly two-thirds of the patients were aged 20 to 39 years, and most ED visits occurred in larger urban centres. (This information was reported from 47 EDs in three regional health authorities between June 2016 and March 2017). 12

In Manitoba, over the past five years, agestandardized ED admission rates for the Winnipeg Regional Health Authority have remained stable. In 2016, females represented 65% of all ED visits for suspected opioid overdoses; over half of them were younger than 24 years. 19

Health outcomes: emergency medical services (EMS), first responders and 911 calls

Information from EMS and first responders is collected in most provinces and territories at either the provincial/territorial level or, as in Ontario and Quebec, within municipalities. 29 This is a rich data source that may provide a glimpse into overdoses in communities. British Columbia, Alberta and Manitoba have analyzed and reported on these data, while other jurisdictions and municipalities are collecting and sharing EMS data with their respective health departments.

In British Columbia, during 2016, the estimated rate of illicit drug overdoses attended by paramedics was 190 per 100 000, which means that for every illicit drug overdose death in the province, paramedics responded to almost 10 overdose events. With the emergence of fentanyl into the illegal drug supply, the severity of overdose events where naloxone is administered has been increasing along with the number of repeat overdoses in both sexes. 12

In Alberta, during 2016, EMS responded to over 1600 opioid-related events, which means that for every apparent opioidrelated death in the province, EMS responded to almost three opioid-related overdose events. Eighty percent of these events occurred in the non-central urban cores of Edmonton and Calgary. 16

In Manitoba, between 2015 and 2016, EMS calls for opioid-related events increased by 70%. The majority of cases were males aged 20 to 29 years; females were on average substantially older (≥ 50 years). Of the suspected overdose events attended by EMS, 18% were never transported to an ED or a hospital. 19

Health outcomes: Community-based naloxone distribution and use

Additional information on opioid-related harms and overdoses occurring in communities may come from monitoring the distribution and use of naloxone takehome kits (“kits”) in communities and from data collected at supervised injection sites and overdose prevention sites (BC). Kit distribution and use are currently being monitored in approximately half of the provinces and territories by collecting information on opioid-related overdose events reported when used kits are replaced. 29 Currently, British Columbia, Alberta and Manitoba report on the numbers of kits distributed and used in communities and provide some information on overdose events. In British Columbia, from August 2012 to June 26, 2017, 459 303 kits were distributed and 10 000 were reported used to reverse an overdose on self or other. 30 Between January 1, 2016, and June 30, 2017, 18 852 kits were dispensed in Alberta and 1707 overdoseevent reversals were reported. 16 Between December 29, 2016, and March 31, 2017, 258 kits were distributed across Manitoba and 30 kits were reported used during overdose events. 19 Because information collected on kit use is not consistently reported across the country, regional comparisons were not possible at this time.

† British Columbia reports on all illicit drug overdoses and deaths, including but not limited to opioids, and includes “street drugs” (both controlled and illegal drugs); “medications not prescribed to the decedent but obtained/purchased on the street, from unknown means or where the origin of the drug [was] not known”; and combinations of the previous two with prescribed medications. 15,p.1

‡ The reports cited in this section for First Nations populations concerned individuals self-identifying as First Nations and did not include data on Métis or Inuit.

§ ICD-10-CAii version 2015 codes used to identify opioid poisonings that resulted in hospitalizations and ED visits (T40.0–T40.4, and T40.6) (excluding “suspected” diagnosis). Hospitalizations and ED visits were categorized as: accidental (X42), intentional (X62) and unknown (Y12 and “missing data”). This analysis was limited to “significant opioid poisonings,” using the diagnosis types M, 1, 2, 6, W, X and Y. 3

The objective of this review was to synthesize the published evidence to describe the epidemic of opioid-related harms occurring in Canada. The current body of evidence points to a national opioid crisis— no region is unaffected by opioids; however, there are notable regional differences. In 2016, rates of apparent opioidrelated deaths and hospitalization were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories; preliminary data from 2017 suggest that rates are continuing to climb in parts of the country. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. While there did not appear to be regional differences with respect to age and sex for opioidrelated hospitalizations and ED visits, increasing rates in the younger age groups are a source of concern.

Prescription opioid use appears to be an early driver of the current crisis. However, the increasing toxicity of substances on the illegal market is likely driving the recent rise in deaths in many Canadian jurisdictions. As of September 2016, fentanyl was detected in the illegal drug supply in all Canadian jurisdictions and is increasingly being detected in other illegal drugs as well. The impact of this trend in the illegal market can be observed in available data on health outcomes. In 2016, the proportion of reported apparent opioid-related deaths involving fentanyl or an analogue was 53% nationally, and this trend appears to be continuing in 2017. In both British Columbia and Alberta, the provinces hardest hit by this crisis to date, it has become more and more evident that illegally manufactured fentanyl and its analogues are responsible for the observed increases in drug overdose deaths. Dr. Perry Kendall, the former Provincial Health Officer for British Columbia who was at the forefront of the crisis, summed up the evolving situation concisely: “If we’ve got fentanyl and carfentanil now replacing heroin and other safer opioids on the streets, then this might be the new normal in terms of danger and a toxic drug supply.” 31

Initial analysis of potential risk factors found the majority of opioid-related deaths occurred when the individual was alone, indoors in a private residence located in a larger urban centre; those who died tended to reside in lower- to middle-income neighbourhoods; and more than 80% of deaths involved one or more non-opioid substances. The first reports focusing on First Nations communities in western Canada confirmed that First Nations people are more likely than their non–First Nations counterparts to experience and die from an opioid-related overdose event, especially First Nations women. Other at-risk communities appear to be individuals with unstable or unknown housing status and incarcerated populations. Additional research is necessary to understand underlying risk factors and the effect of health issues such as mental health on health outcomes.

Available data from first responders, EMS, supervised injections sites and harm reduction agencies were not sufficient to make regional comparisons on opioid-related overdoses occurring in communities at this time. However, preliminary information from EMS and community-based kit distribution and use monitoring programs are beginning to reveal the extent of opioidrelated overdose events not captured through the health care system, and suggest that we are only seeing the tip of the iceberg of impact on health outcomes from opioids. At the time of this report, the three provinces collecting data on kit use combined reported a total of almost 12 000 kits used to reverse opioid overdoses in communities.

Obtaining reliable information on overdose events in the community is a challenge. It is complicated by the stigma attached to opioid use and the lack of knowledge in the general population of problematic substance use and overdoses. A recent survey by Statistics Canada found that less than one-third of Canadians would recognize the signs of an overdose and only 7% would know how to obtain and administer naloxone to treat an overdose. 32 Another national study, by the Canadian Centre on Substance Use and Addiction (CCSA), that looked at the use of kits in the community found that 911 was not called in 30% to 65% of the instances when naloxone was administered by a member of the community. The reason most commonly cited (33%) for not calling was concern about police involvement and possible arrest. 33

This report also identified gaps in evidence and areas for further investigation to improve our understanding of the opioid- related harms. These gaps include risk factors; accurate estimates of prevalence of opioid use; nonfatal opioid-related events occurring outside the health care system; national estimates of opioid-related ED visits; and data on special populations including but not limited to Indigenous and other ethnic groups more broadly, as well as marginalized groups such as homeless individuals.

Strengths and limitations

For this report, we reviewed all publicfacing, opioid-related surveillance and epidemiological reports published by provincial and territorial ministries of health and chief coroners’ and medical examiners’ offices on opioid-related deaths, harms and potential risk factors.

There are, however, limitations to the evidence we reviewed. Data sources were constantly being updated throughout the writing of this article, and new, more comprehensive evidence published after January 2018 is not included in this review. This synthesis does not present new information, and extensive reviews of health outcomes, the nonmedical use of prescription opioids, and risk factors for problematic substance use were beyond its scope. It is also important to underscore the significant role of stigma around problematic substance use and marginalized communities, which may contribute to underreporting and subsequent underestimates of the prevalence of use of opioids in the Canadian population. In addition, technology for toxicology screening is constantly improving to keep pace with new drugs. This may impact capacity to detect synthetic opioids such as fentanyl and its analogues and should be considered when evaluating trends. Furthermore, jurisdictional differences in case investigation methods, case definitions, classification methods and toxicology testing may also limit the extent to which comparisons can be made. Therefore, caution should be used when drawing conclusions at this time.

In this review we endeavoured to synthesize available evidence in order to provide a national summary that might be used to support public health action. We also identified gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis.

A more comprehensive evidence base is essential to inform a concerted, national response to prevent and reduce further opioid-related harms. To provide the evidence necessary to inform and tailor an effective public health response, PHAC will continue to work with federal, provincial and territorial partners to further refine and standardize national data collection as well as to explore the expansion of information sharing to include nontraditional data sources. PHAC will also continue to support our federal partners through the Federal Action on Opioids, 34 and collaborate with provincial and territorial officials through the Special Advisory Committee on the Epidemic of Opioid Overdoses and its Surveillance Task Group (OOSTG) to improve the quality and accessibility of evidence. Better quality evidence will lead to an improved understanding of which populations are at greater risk of death and harms related to the problematic use of opioids, and will allow for more informed and targeted programs and policies to effectively reduce the impact of this crisis on Canadians.

Acknowledgements

The data presented in this synthesis represent the published work of health and justice officials, first responders and community leaders across the country who are working tirelessly and collaborating extensively to contribute to the knowledge base in order to combat this crisis.

Conflicts of interest

The authors declare no conflicts of interest.

Authors’ contributions and statement

JH conceived the review and provided guidance and input throughout the process. LB designed the methodology, researched and synthesized the information and wrote the paper.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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Substance abuse in canada: stats, impact and resources for adults and teens, millions of canadians will develop substance use disorder at some point in their lives, many of them young adults and teens..

by Angelica Bottaro

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According to the Canadian Mental Health Association (CMHA) , 21 per cent, or roughly six million people, will experience substance abuse disorder in their lifetime.

What is substance abuse?

• An overpowering desire to use illicit substances
• Increased tolerance to the substances they choose to use
• Withdrawal symptoms when the substance is no longer available

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• Hallucinogens
• Hypnotics, sedatives, and anti-anxiety drugs (sleeping pills, benzodiazepines, barbiturates)
• Inhalants, such as aerosol sprays, gasses, and paint thinners
• Prescription and non-prescription opioid painkillers (codeine, oxycodone, heroin)
• Prescription and non-prescription stimulants (Adderall, cocaine, methamphetamine)
• The way the substance is taken, whether orally, injected, or through inhalation
• How quickly the drug crosses over the blood-brain barrier, triggering the reward centre in the brain
• How long it takes to feel the effects of the drug
• The chances of a drug inducing a level of tolerance or withdrawal symptoms
• Loss of appetite or refusal to eat
• Withdrawing from family or social relationships
• Sudden changes in behaviour and mood
• Engaging in risky behaviours such as sharing needles, unprotected sex, and driving while under the influence
• Feeling hostile or being in denial when the topic of substance abuse is brought up
• Not taking care of oneself physically
• Engaging in secretive behaviour to hide drug use
• Using substances while alone
• Taking more of the drug or substance and for longer periods of time than before
• Having an uncontrollable desire to use the substance even during periods of downtime
• Trying to control drug use and not being able to
• Spending more and more time trying to obtain illicit substances or spending more time using and recovering from use
• Being unable to perform optimally at work, school, or home because of substance use
• Failing to stop using the drug, even if it negatively affects relationships
• Continuing to use the substance even when it’s causing or worsening physical and psychological health issues
• Developing a tolerance to the drug that requires the user to need more to have the same effect
• Experiencing withdrawal symptoms, such as sleep issues, changing moods, aches and pain, fatigue
• Genetics or family history of substance use disorder
• How the substance alters brain chemistry
• Mental health disorders
• Access and exposure to illicit drugs
• Adverse childhood experiences, such as abuse or other traumatic events

Current substance abuse statistics in Canada

People of all ages and backgrounds can develop substance use disorder. That said, the most likely are those between the ages of 15 and 24 and those identifying as male . Between 2016 and 2017, 1 in 205 Canadians were treated for substance use disorder, with 62 per cent being male.

Alcohol is the most common substance tied to substance use disorder in the country. Roughly 19.1 per cent of Canadians over the age of 12 are considered heavy drinkers, with 23.5 per cent of males and 14.8 per cent of females accounting for those numbers. The age group most affected by alcohol overuse are those between 18 and 34.

Canadians under the age of 18 also misuse alcohol, with roughly 3.7 per cent of youth aged 12 to 17 classified as heavy drinkers in the country. These numbers were documented in 2015 and have remained relatively unchanged since.

Alcohol addiction also comes with some dire consequences. Roughly 249 per 100,000 hospitalizations are caused by alcohol, which is 13x higher than those caused by opioid use, and 22 per cent of substance-use-related deaths in 2014 were attributed to alcohol.

A report released by Stats Canada found that alcohol-related deaths have continued to grow since 2014, especially during the pandemic. It was reported that 3,875 deaths driven by alcohol occurred in 2021. The majority of those deaths occurred in people under the age of 65. Men are more likely than women to experience an alcohol-related death, but it still occurs in both sexes.

Opioids are often given to people to relieve pain after injuries. They are typically prescribed for a set period of time, but they are highly addictive. Because of that, people who take opioids for pain are at a higher risk of developing substance use disorder. Research shows that approximately two per cent of people who receive an opioid prescription misuse them.

That said, opioids can also be obtained through illegal means, and roughly one-third of people who misuse opioids do so without ever having a prescription. Statistics have also found that approximately 12 per cent of Canadians over the age of 15 use opioids, with 9.7 per cent engaging in problematic use of the drug.

The number of people using opioids problematically varies significantly by age group. According to reports highlighting the problematic use of opioids in 2018, roughly 17,900 people between the ages of 15 and 19 engage in opioid abuse.

Between 2016 and 2023 , there were 40,642 deaths directly related to opioid misuse in the country. Those numbers continue to climb. When assessing opioid abuse based on deaths, it’s found that the age group most affected is those between 30 and 39, with roughly 74 per cent of those deaths occurring in males.

The deaths that occurred due to opioids were primarily driven by the addition of fentanyl, a highly fatal substance. Roughly 84 per cent of opioid deaths involve fentanyl.

Prescription drugs

Stimulants are abused more than opioids, with 19 per cent of Canadians who use them reporting problematic use. Sedatives are the lowest on the list of prescription-based drugs, with only one per cent of people abusing them.

Prescription drug misuse is also high in terms of substance abuse in Canada, and roughly five per cent of Canadians who use prescription-based drugs with psychoactive ingredients were found to display behaviours of addiction when taking the medications.

Roughly 23 per cent of Canadians 15 and older have been prescribed medications that have psychoactive properties. Females are more likely to be prescribed psychoactive pharmaceuticals than males, at rates of 27 per cent and 19 per cent, respectively. The two most common, besides opioids, are sedatives and stimulants.

• Benzodiazepines
• Hypnotics (nonbenzodiazepine sleep medications)

Stimulant-related deaths are not as prevalent as opioid-related deaths but still affect Canadians of all ages who have substance use disorder. According to data, roughly 41 per 100,000 people lost their lives due to a stimulant overdose in 2020.

There is no data to show how many overdose deaths are caused by sedatives in the country. However, central nervous system depressants, not including alcohol and opioids, were estimated to be indirectly involved in roughly 509.1 deaths in 2017.

Illicit drugs

Canada has one of the highest levels of illicit drug use in the world. Illegal drugs account for three per cent of substance abuse reports in the country. The drugs reported include cocaine, crack, ecstasy, speed, hallucinogens, and heroin. Cocaine is the most-used illegal substance in the country, which changed when cannabis was legalized. Before then, cannabis was in the top spot.

Data has found that of all users who engage in illicit drug use, five per cent were found to experience harmful effects of the drug, driven by misuse. Young adults between 20 to 24 were the most likely to experience harm because of drug use, at a rate of 14 per cent, with those aged 15-19 reporting harm because of drug use at a rate of six per cent. Adults over the age of 25 were the lowest to experience harmful effects from illicit substance use at a rate of three per cent.

Of all the stimulant-related deaths, illicit stimulants, such as cocaine, are thought to be the highest driver of premature death caused by substance use at a rate of 65 per cent , and methamphetamines follow closely behind at a rate of 55 per cent .

• Panic attacks
• Feeling faint or dizzy
• Losing consciousness
• Heart and blood pressure problems
• Nausea and vomiting

The number of people seeking help for these issues has heightened since the legalization of cannabis in the country at a rate of five per cent.

Impact of substance abuse on Canadian society from a cost perspective

The overall cost of substance abuse in Canada was a staggering $49 billion in 2020 alone. Between 2007 and 2020, the overall cost per person with substance use disorder was $1,291 per year, with alcohol addiction being the most considerable cost burden. Most illicit substances saw an overall increase in total cost per person in 2020 from 2007:

• Stimulants: 71.8 per cent increase
• Opioids: 66.4 per cent increase
• Alcohol: 21.3 per cent increase
• Cannabis: 5.2 per cent increase

Social impact of substance abuse on mental health

The existence of a pre-existing mental health disorder increases the risk of developing substance use disorder two-fold, and 20 per cent of people with a mood disorder also have substance use disorder. People with schizophrenia are the most likely to develop a substance use disorder in those with pre-existing mood disorders at 50 per cent.

On the opposite side, people with substance use disorder are also more likely to develop a mood disorder at a rate of three times compared to the general population. Roughly 15 per cent of people with substance use disorder also have a mood disorder. Those aged 15-24 are the most likely to experience substance use disorder, a mental health disorder, or both.

Men are more likely to develop substance use disorder, whereas females account for more cases of mood disorders in the country. That said, both disorders can affect males and females. Those who fall into the lowest income group are as much as four times more likely to report poor mental health, putting them at a heightened risk of developing substance use disorder as well.

Resources available for substance abuse in Canada

• Kids Help Phone
• Drug Rehab Services
• CAPSA Peer Support
• Alcoholics Anonymous
• Narcotics Anonymous
• SMART Recovery
• Moms Stop the Harm – Holding Hope Support Groups
• Families for Addiction Recovery
• Wellness Together Canada

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Angelica Bottaro is the lead editor at Healthing.ca, and has been content writing for over a decade, specializing in all things health. Her goal as a health journalist is to bring awareness and information to people that they can use as an additional tool toward their own optimal health.

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Research publications

About this publication

Executive Summary

1 introduction, 2.1 deaths, 2.2 hospitalizations, 2.3 emergency medical services responses, 2.4 effect on national life expectancy, 2.5 use of prescription opioids, 2.6 prevalence of fentanyl and fentanyl analogues, 2.7 naloxone distribution and use, 2.8 economic impacts.

• 3 Covid‑19 and the Opioid Crisis

4.1 Age

4.2 sex and gender, 4.3 indigenous identity, 5.1 federal jurisdiction over health matters, 5.2 response from the federal government.

• 5.3 Response from the Parliament of Canada

Opioid‑related harms have reached crisis proportions in many countries, including Canada. Almost 23,000 Canadians died due to apparent opioid toxicity between January 2016 and March 2021. Many other people faced life‑threatening medical emergencies or other harms. These harms have been linked to many causes, including opioid‑prescribing practices and the presence of very potent opioids such as fentanyl and fentanyl analogues in the drug supply. The COVID‑19 pandemic has further worsened outcomes. The opioid crisis has touched Canadians from all walks of life, although it has not done so equally: people with certain identities, including men and Indigenous people, have been disproportionately harmed. In response to the crisis, the federal government has made investments and launched a variety of initiatives. Parliament has also addressed the issue by enacting legislation and proposing a range of other measures.

Opioids are substances with pain‑relieving properties. They include compounds extracted from opium poppy seeds and synthetic and semisynthetic compounds with similar properties and the ability to interact with opioid receptors in the brain. 1

Opioids can refer to both approved prescription medicines and to illicit “street” (or non‑pharmaceutical) drugs. In Canada, pharmaceutical opioids are primarily prescribed to treat pain. 2 Commonly prescribed opioids include codeine, oxycodone, hydromorphone, fentanyl, morphine and tramadol. 3

However, opioid use can cause harm. Individuals who use opioids can experience long‑term adverse health outcomes, such as liver damage, increased tolerance (meaning that a larger dose is required to achieve the same effects), worsening pain or withdrawal symptoms, among others. 4 Individuals can also use opioids in ways that are considered problematic, such as by using an opioid that was not prescribed to them or by using a prescribed opioid medicine in a manner other than as directed by a health professional, which can increase the risk of harm. 5 Some people who use opioids develop opioid use disorder. Like other substance use disorders, opioid use disorder is a treatable medical condition, although many people face challenges in accessing treatment. 6 If an individual takes too much of an opioid, they may experience breathing difficulties, unconsciousness or death. 7 In Canada and other countries, opioid‑related harms have reached crisis proportions. 8

This HillStudy offers an introduction to selected health aspects of the opioid crisis in Canada. It includes some key statistics, considerations related to the impact of the crisis on different groups of people, and information about recent federal initiatives and activities in the Parliament of Canada intended to address the crisis.

2 Measuring the Opioid Crisis

There has been a considerable increase in the use of prescription opioids since the 1980s. Increased prescription use has been followed by more reports of harms associated with prescription opioid use and an increased rate in the use of non‑prescription opioids. By 2016, eight Canadians were dying from opioid‑related toxicity each day. 9 The opioid crisis can be measured in many ways. The sections below highlight a few national statistics, which, while not exhaustive, constitute a starting point for understanding the scope and nature of the opioid crisis in Canada.

The federal–provincial/territorial Special Advisory Committee on the Epidemic of Opioid Overdoses publishes data on some opioid‑related harms, including deaths. Approximately 22,828 people in Canada died due to apparent opioid toxicity between January 2016 and March 2021. In the first quarter of 2021 alone, 1,772 Canadians died of apparent opioid toxicity. 10

The annual total of apparent opioid toxicity deaths in Canada has increased over time, as shown in Figure 1. In 2020, 6,306 people died of apparent opioid toxicity, which is an average of about 17 deaths per day. Between 2018 and the first quarter of 2021, over half of opioid deaths also involved a stimulant. 11 However, the trends have been different for accidental apparent opioid toxicity deaths and intentional (suicide) apparent opioid toxicity deaths. While deaths from accidental apparent opioid toxicity deaths have increased, the annual number of deaths from intentional apparent opioid toxicity has decreased each year between 2017 and 2020. 12

Figure 1 – Annual Total of Apparent Opioid Toxicity Deaths in Canada, 2016–2020

Source: Government of Canada, “Graphs: Number of total apparent opioid toxicity deaths in Canada, 2016 to 2021 (Jan to Mar),” Opioid‑ and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021.

Apparent opioid toxicity deaths have not been equally distributed across the country. Western Canada has been the most affected region since 2016, although rates of opioid toxicity deaths have climbed in other parts of the country, including in Ontario. In 2020, as illustrated by Figure 2, British Columbia, Alberta and Saskatchewan experienced the highest rates of apparent opioid toxicity deaths per 100,000 population, and 85% of all apparent opioid toxicity deaths took place in British Columbia, Alberta and Ontario. 13

Finally, the proportion of apparent opioid toxicity deaths involving non‑pharmaceutical substances compared to pharmaceutical products increased in 2020 over the previous two years. In 2018 and 2019, non‑pharmaceutical opioids accounted for 66% of deaths. In 2020, they accounted for 76% of apparent opioid toxicity deaths, and in the first half of 2021, 83% of deaths. 14

Figure 2 – Number and Rate of Total Apparent Opioid Toxicity Deaths, by Province or Territory, 2020

Source: Government of Canada, “Maps: Number and rates (per 100,000 population) of total apparent opioid toxicity deaths by province and territory in 2020,” Opioid‑ and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 1 December 2021 (select “2020” from the drop‑down menu).

There were 27,604 opioid‑related poisoning hospitalizations across Canada (excluding Quebec) between January 2016 and the first half of 2021, 15 including 5,240 cases in 2020, the highest reported number since 2016. 16 While opioid‑related poisoning hospitalizations outnumbered apparent opioid toxicity deaths between 2016 and 2019, in 2020, there were about 1,000 more apparent opioid‑related toxicity deaths than hospitalizations. 17

Other opioid‑related hospitalizations (excluding Quebec) include 6,185 hospitalizations for adverse drug reactions from prescribed opioids and 10,082 hospitalizations for opioid use disorders between April 2018 and March 2019. 18

During the first year of the COVID‑19 pandemic (April 2020 to March 2021), there were almost 32,000 Emergency Medical Services (EMS) responses to suspected opioid overdoses, based on available data from eight provinces and territories, according to the Special Advisory Committee on the Epidemic of Opioid Overdoses. 19 Many regions of Canada recorded more EMS  responses to suspected opioid overdoses during each quarter since the start of the pandemic than in any other quarter since the beginning of national surveillance in 2017. 20

From 2016 to 2017, for the first time in decades, life expectancy at birth in Canada did not increase for either males or females. Statistics Canada determined that this stagnation was largely a result of accidental drug poisoning deaths among young adult men (particularly in British Columbia and Alberta, which saw decreases in life expectancy), which offset life expectancy gains in other areas. Opioid‑related accidental drug poisoning deaths led to a 0.11‑year (40 days) loss of life expectancy for men. 21

From 2017 to 2018, female life expectancy at birth increased from 84.0 to 84.1 years, while male life expectancy at birth remained unchanged. Again, Statistics Canada reported that the stagnation in male life expectancy was a result of an increase in mortality between ages 25 and 45 years, which was “likely related” to the opioid crisis. 22

The 2018 Canadian Community Health Survey estimated that 12.7% of Canadians aged 15 years and older reported prescription or non‑prescription use of pain medications containing opioids in the last year. 23 Other surveys have also found that a considerable percentage of Canadians have recently used prescription opioids, although precise figures vary. 24

Opioid prescribing in Canada has declined in recent years. According to the Canadian Institute for Health Information (CIHI), the proportion of people in the study population who were prescribed opioids decreased from 14.3% to 12.3% from 2013 to 2018. In addition, during this period, fewer people started opioid therapy; fewer people were prescribed opioids on a long‑term basis; people on long‑term opioid therapy were prescribed lower doses; and more people stopped long‑term opioid therapy. The dosage and duration of therapy among people starting opioids remained relatively stable. 25 These trends coincide with numerous initiatives intended to reduce the harms associated with prescription opioid use, some of which are mentioned in this HillStudy, although it is difficult to attribute these trends to any particular initiative. A revised guideline on prescribing opioids for chronic non‑cancer pain was released in 2017, but the  CIHI  data likely do not reflect the full impact of the new guideline because of lag time in prescriber education. 26

Still, Canadians are among the world’s largest consumers of prescription opioids. The International Narcotics Control Board reported that, between 2017 and 2019, the countries reporting the highest average consumption of the main six opioid analgesics for pain management (codeine, fentanyl, hydrocodone, hydromorphone, morphine and oxycodone), were the United States, Germany, Austria, Belgium and Canada. 27

Fentanyl is a very potent opioid. It can be dispensed by prescription, although other opioids are prescribed more often. 28 It is also present on the illegal market, where it is frequently added to other substances such as heroin. 29 Fentanyl was the most common opioid detected among drug samples seized by law enforcement and analyzed by Health Canada’s Drug Analysis Service in 2020. 30

In 2016, there were more non‑fentanyl opioid deaths than fentanyl‑related opioid deaths. Since then, opioid‑related deaths involving fentanyl have become more prevalent than non‑fentanyl deaths. By 2020, there were 3.5 times more deaths involving fentanyl than those involving non‑fentanyl opioids. 31

Naloxone is a drug used to temporarily reverse the effects of an opioid overdose. It can be administered by anyone who encounters an individual suspected of overdosing on an opioid. Take‑home naloxone kits are available without a prescription at most pharmacies and local health authorities in Canada. 32

An environmental scan developed by the Canadian Research Initiative in Substance Misuse, released in June 2019, found that more than 590,000 publicly funded naloxone kits had been distributed across more than 8,700 distribution sites in Canada, and more than 61,000 kits had reportedly been used to reverse an overdose. 33

The Canadian Substance Use Costs and Harms Working Group estimated that opioid use cost Canadians over $5.9 billion in 2017. Lost productivity accounted for the majority of these costs (over $4.2 billion), followed by criminal justice costs (over $944 million), health costs (over $438 million), and other direct costs, including research and prevention, employee assistance programs and workplace drug testing, among others (over $320 million). 34

3 Covid-19 and the Opioid Crisis

Fentanyl consumption appeared to increase in the early months of the COVID‑19 pandemic, based on a Statistics Canada analysis of data from wastewater samples from treatment plants in five cities (Halifax, Montréal, Toronto, Edmonton and Vancouver). Wastewater fentanyl loads per capita were similar to pre‑pandemic levels in April 2020, but nearly twice as high in May 2020 and close to three times higher in June and July 2020. 35

Opioid‑related harms also increased during the pandemic. As stated above, there were approximately 6,306 apparent opioid toxicity deaths in Canada in 2020, representing a 71% increase over 2019 and a 43% increase over 2018 data. 36 There were also 5,240 opioid‑related poisoning hospitalizations in Canada in 2020 (a 16% increase compared to 2019 and a 4% increase over 2018). In British Columbia, there were 17,011  EMS responses in 2020 (a 26% and a 27% increase over 2019 and 2018, respectively). 37

In a June 2021 statement, the co‑chairs of the Special Advisory Committee on the Epidemic of Opioid Overdoses concluded that

[a] number of factors have likely contributed to a worsening of the opioid overdose crisis during the COVID‑19 pandemic in Canada, including the increasingly toxic and unpredictable drug supply; increased feelings of isolation, stress, anxiety and depression; and the limited availability or accessibility of health and social services for people who use drugs, including life‑saving harm reduction and treatment. 38

A Public Health Agency of Canada simulation model released in June 2021 indicates that the number of opioid‑related deaths may remain high or even increase throughout the remainder of 2021. 39

4 Recognizing Diverse Experiences

Each individual’s experience with opioids is influenced by multiple factors, including social determinants of health such as income, housing and access to health care. Some groups of people who use opioids are more likely than others to experience adverse health and social outcomes. To illustrate that the opioid crisis affects different groups of people in different ways, some statistics on opioid‑related harms disaggregated by selected identity factors are presented below.

Rates of opioid‑related harms appear to differ across age groups, as shown in Figure 3. The highest proportion of accidental apparent opioid toxicity deaths since 2016 has consistently been among those individuals aged 30 to 39 years. The highest proportion of hospitalizations since 2016 has been among those people aged over 60 years each year. 40

Figure 3 – Percentage of Accidental Apparent Opioid Toxicity Deaths by Age in Canada, 2016–2021 (January to June)

Note: Data for Manitoba from October 2019 to December 2020 are not included. Data for British Columbia from 2018 to 2020, and for Quebec from 2019 to 2020, include deaths related to all “illicit drugs,” which are not limited to opioids. Age data are suppressed in some provinces or territories with low numbers of cases. Source: Government of Canada, “Graphs: Percentage of accidental apparent opioid toxicity deaths by age group in Canada, 2016 to 2021 (Jan to Jun),” Opioid‑ and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 1 December 2021.

Disaggregated data reveal additional age‑based differences. For instance, in 2020, individuals aged between 30 and 39 years made up a larger proportion of accidental apparent opioid toxicity deaths involving fentanyl compared to deaths involving non‑fentanyl opioids. 41

Opioid‑related data may also be disaggregated by age in combination with other identity factors, such as sex, to reveal intersectional trends. 42

In 2020, 76% of people who died due to accidental apparent opioid toxicity in Canada were male, remaining almost unchanged in the first half of 2021. 43 While 63% of total hospitalizations for accidental opioid‑related poisonings were among males, 44 females made up 55% of hospitalizations for  intentional opioid‑related poisonings in 2020. 45

Sex and gender differences in accidental apparent opioid‑related deaths are not the same among all population groups in all regions. Among First Nations people in Alberta, for example, males and females were almost equally represented among accidental apparent opioid toxicity deaths from 2016 to 2018. 46 However, the proportion of deaths occurring among males increased to 66% in the first six months of 2020. 47

Opioid‑related behaviors and outcomes differ by gender and sex in other complex ways. For instance, people of different sexes and genders who are hospitalized for reasons related to their opioid use may also face different mental health challenges. 48

Many national statistics on opioids are not disaggregated by Indigenous identity. However, available data indicate that in many parts of Canada, Indigenous communities have been disproportionately harmed by opioids. For instance:

• A Statistics Canada analysis of hospital discharge data from 2011 to 2016, linked to data from the 2011 National Household Survey, revealed elevated rates of opioid‑related hospitalizations among people who identified as Indigenous. The age‑standardized rate of opioid poisoning hospitalizations among First Nations individuals living on reserve was 5.6 times higher than the rate among the non‑Indigenous population. The rates among Métis and Inuit were each 3.2 times higher than the rate among the non‑Indigenous population. 49
• In Alberta, a report of the Alberta First Nations Information Governance Centre and Alberta Health found that First Nations people experienced 22% of all opioid poisoning deaths in the first six months of 2020, despite comprising only about 6% of the province’s population. The rate of accidental apparent opioid poisoning deaths per 100,000 population was seven times higher among First Nations people compared to non–First Nations people during this period. 50
• In British Columbia, a First Nations Health Authority report revealed that First Nations people experienced 14.7% of all drug toxicity deaths in 2020, despite comprising only 3.3% of the province’s population. First Nations women died of drug toxicity at 9.9 times the rate of other women in the province, while First Nations men died at 4.3 times the rate of other men. 51

These figures should be interpreted in the appropriate social and historical context. Many systemic factors are relevant to opioid use in First Nations, Métis and Inuit communities, including intergenerational trauma and economic inequities created by the residential school system and other forms of colonization. 52 First Nations, Métis and Inuit communities also have diverse strengths and cultural resources that help to support good health. Indigenous governments and organizations have developed initiatives that take advantage of their community’s strengths to address the opioid crisis and other substance use and mental health issues. 53

5 Federal Response to the Opioid Crisis

Health is an area of shared jurisdiction in Canada. Sections 91 and 92 of the  Constitution Act, 1867 assign exclusive legislative authority over certain matters to either the federal or provincial legislatures. 54 These sections list some health‑related matters (e.g., hospitals, other than marine hospitals, are a provincial matter). However, the constitution does not explicitly assign legislative power over health as a whole. As a result, health‑related measures can fall within the jurisdiction of either the federal or provincial legislatures, depending on each measure’s purpose and effect. 55

Provincial legislatures have exercised their jurisdiction over health matters under sections 92(7) (hospitals), 92(13) (property and civil rights) and 92(16) (matters of a merely local or private nature) of the  Constitution Act, 1867 . Generally, these last two sections grant the provinces jurisdiction over health care services, the practice of medicine, the training of health professionals and the regulation of the medical profession, hospital and health insurance, and occupational health. 56 Provincial and territorial governments are thus responsible for delivering most substance use prevention, treatment and harm reduction programs.

The Parliament of Canada has exercised its jurisdiction over health matters under its criminal law power (section 91(27) of the  Constitution Act, 1867 ), its spending power (inferred from federal jurisdiction over public debt and property (section 91(1A)), and its general taxing power (section 91(3)). Federal legislation respecting opioids includes, for example, the  Controlled Drugs and Substances Act (CDSA) and the  Food and Drugs Act . The spending power enables federal initiatives in health research, health promotion, health information, and disease prevention and control, as well as pilot projects related to provincial health initiatives. 57

Additionally, the federal government directly funds or provides substance use prevention, treatment and harm reduction services to specific populations, such as First Nations and Inuit, members of the military and veterans, and people in federal prisons. 58

The federal government has made investments and launched initiatives aimed at preventing and responding to opioid‑related harms. 59 Some federal initiatives, for example, include efforts to restrict opioid marketing and advertising, 60 a consultation on a proposal to develop new regulations for supervised consumption sites, 61 and the development, in collaboration with the United States, of a Joint Action Plan on Opioids. 62 The federal government has also had a series of national drug strategies since 1987; the most recent strategy was announced in 2016. 63 More recently, the Government of Canada has taken some actions to support individuals who use opioids and other substances during the COVID‑19 pandemic, such as allowing provinces and territories to establish new temporary supervised consumption sites. 64

5.3 Response from the Parliament of Canada

Parliament has also taken steps to address the opioid crisis in recent years. In 2016, the House of Commons Standing Committee on Health studied the opioid crisis in Canada and made 38 recommendations, calling for action in the areas of national leadership, harm reduction, prescribing, treatment, mental health supports, data collection, law enforcement, border security and supports for First Nations communities. 65 The federal government subsequently tabled its response to the report, in which it listed several commitments to action by federal and provincial governments, as well as stakeholder groups. 66 In its response, the federal government highlighted that the Governor in Council had issued an order to amend Schedule IV of the  CDSA to control certain chemicals used to produce fentanyl, which will help to interrupt the illegal supply of the substance. The response also pointed to some bills before parliament, which have subsequently come into force.

Bill C‑37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts, was introduced in December 2016 and received Royal Assent in May 2017. The bill amended the  CDSA in part to simplify the application procedure for supervised consumption sites. 67 As well, the federal government supported Bill C‑224, An Act to amend the Controlled Drugs and Substances Act (assistance – drug overdose), also known as the Good Samaritan Drug Overdose Act, which received Royal Assent in May 2017. 68 Bill C‑224 established an exemption from charges of simple possession of a controlled substance, as well as some other charges related to simple possession, for individuals who call 911 for themselves or another person experiencing an overdose, and for other people at the scene.

Several other bills related to opioid use died on the  Order Paper at the dissolution of the 43 rd  Parliament:

• Bill C‑22, An Act to amend the Criminal Code and the Controlled Drugs and Substances Act; 69
• Bill C‑235, An Act to amend the Controlled Drugs and Substances Act and to make consequential amendments to other Acts; 70
• Bill C‑236, An Act to amend the Controlled Drugs and Substances Act (evidence‑based diversion measures); 71  and
• Bill C‑286, An Act to amend the Controlled Drugs and Substances Act and to enact the Expungement of Certain Drug‑related Convictions Act and the National Strategy on Substance Use Act. 72

Parliamentarians have also responded to the opioid crisis using other elements of the parliamentary toolkit, for example, by proposing motions, tabling petitions and asking questions in Parliament. Some of these initiatives have called on the Government of Canada to declare the opioid crisis a national public health emergency under the  Emergencies Act , to develop a pan‑Canadian overdose action plan, to decriminalize simple possession and to pursue legal action against opioid manufacturers, among other measures. 73

• World Health Organization, Opioid overdose , 4 August 2020. [ Return to text ]
• Government of Canada, “ About opioids ,” Opioids . [ Return to text ]
• Government of Canada, “ Long‑term health effects ,” Opioids . [ Return to text ]
• Government of Canada, Problematic Opioid Use (fact sheet) . [ Return to text ]
• Government of Canada, Opioid overdose . [ Return to text ]
• Ibid. [ Return to text ]
• Government of Canada, “Key Findings,” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Government of Canada, “Graphs: Percentage of total apparent opioid toxicity deaths involving stimulants in Canada, 2018 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 September 2021. [ Return to text ]
• Government of Canada, “Graphs: Number of suicide apparent opioid toxicity deaths in Canada, 2016 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Government of Canada, “Maps: Number and rates (per 100,000 population) of total apparent opioid toxicity deaths by province and territory in 2020,” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 1 December 2021 (select “2020” from the drop‑down menu). [ Return to text ]
• Government of Canada, “Graphs: Percentage of accidental apparent opioid toxicity deaths by origin of the opioid(s) directly contributing to death, among deaths with completed investigations only in Canada, 2018 to 2021 (Jan to June),” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 6 January 2022. [ Return to text ]
• Government of Canada, “Key Findings,” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 6 January 2022. [ Return to text ]
• Government of Canada, “Graphs: Number of total opioid‑related poisoning hospitalizations in Canada, 2016 to 2021 (Jan to June),” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 6 January 2022. [ Return to text ]
• “Opioid‑related poisoning hospitalizations” refers to the number of discharged inpatient hospitalization visits, rather than the number of individual patients. This national count of opioid‑related poisoning hospitalizations does not include data from Quebec. [ Return to text ]
• Government of Canada, Opioid‑related harms and mental disorders in Canada: A descriptive analysis of hospitalization data . These figures refer to the number of acute inpatient hospitalizations, not the number of patients, and it is possible that some individuals may have been hospitalized more than once during this period. Additionally, an individual may be hospitalized for an opioid‑related poisoning and an opioid use disorder at the same time, as illustrated by the fact that the number of total hospitalizations for opioid‑related harms is lower than the sum of hospitalizations for individual harms. Furthermore, opioid use disorder hospitalizations are likely undercounted. For more analysis, see Government of Canada, Understanding a broader range of opioid-related hospitalizations in Canada . [ Return to text ]
• Government of Canada, “Graphs: Number of  EMS  responses to suspected opioid‑related overdoses by quarter in British Columbia, 2017 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. There is no national case definition for Emergency Medical Services (EMS) responses to suspected opioid‑related overdoses. This national count of  EMS  responses to suspected opioid overdoses does not include data from Quebec, Prince Edward Island or Nunavut. Data from British Columbia include EMS  responses to suspected overdoses related to all “illicit drugs,” which are not limited to opioids. [ Return to text ]
• Statistics Canada, “ Changes in life expectancy by selected causes of death, 2017 ,” The Daily , 30 May 2019. [ Return to text ]
• Statistics Canada, “ Life tables, 2016/2018 ,” The Daily , 28 January 2020. [ Return to text ]
• Statistics Canada, Pain relief medication containing opioids, 2018 , Health fact sheets, 25 June 2019. This estimate excludes the territories. The Canadian Community Health Survey does not survey on reserves. [ Return to text ]
• For information about other surveys of past‑year prescription opioid use, see Canadian Centre on Substance Use and Addiction, Prescription Opioids (Canadian Drug Summary) , 2020. [ Return to text ]
• Ibid., p. 7. [ Return to text ]
• Government of Canada, Fentanyl . [ Return to text ]
• Government of Canada, Drug analysis Service: Summary report of samples analyzed in 2020 . The Drug Analysis Service analyzes some, not all, drugs seized by law enforcement. [ Return to text ]
• Government of Canada, “Graphs: Percentage of total apparent opioid toxicity deaths by type of opioids in Canada, 2016 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Government of Canada, Naloxone . [ Return to text ]
• Canadian Research Initiative in Substance Misuse, Naloxone Distribution Environmental Scan . The time period assessed by this environmental scan differs across provinces and territories, due to variations in the dates when naloxone programs were first launched and the dates when data were reported. [ Return to text ]
• Statistics Canada, “ Wastewater analysis suggests that consumption of fentanyl, cannabis and methamphetamine increased in the early pandemic period ,” The Daily , 26 July 2021. [ Return to text ]
• It should be noted that the number of opioid‑related deaths in 2019 was lower than the previous three years. [ Return to text ]
• Government of Canada, “Graphs: Number of  EMS  responses to suspected opioid‑related overdoses in British Columbia, 2017 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Dr. Theresa Tam and Dr. Jennifer Russell, Joint Statement from the Co‑Chairs of the Special Advisory Committee on the Epidemic of Opioid Overdoses – Latest Modelling Projections on Opioid Related Deaths and National Data on the Overdose Crisis , PHAC , 23 June 2021. [ Return to text ]
• Government of Canada, Modelling opioid‑related deaths during the COVID‑19 outbreak . [ Return to text ]
• Government of Canada, “Graphs: Percentage of total opioid‑related poisoning hospitalizations by age group, in Canada, 2016 to 2021 (Jan to June),” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 6 January 2022. [ Return to text ]
• Government of Canada, “Graphs: Percentage of accidental apparent opioid toxicity deaths by type of opioids and age group in Canada, 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Government of Canada, “Graphs: Percentage of accidental apparent opioid toxicity deaths by sex in Canada, 2016 to 2021 (Jan to June),” Opioid- and Stimulant‑related Harms in Canada (December 2021) , Public Health Infobase, Database, accessed 6 January 2022. [ Return to text ]
• Government of Canada, “Graphs: Percentage of accidental opioid-related poisoning hospitalizations by sex, in Canada, 2016 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Database, Public Health Infobase, Database, accessed 19 October 2021. [ Return to text ]
• Government of Canada, “Graphs: Percentage of intentional opioid‑related poisoning hospitalizations by sex, in Canada, 2016 to 2021 (Jan to Mar),” Opioid- and Stimulant‑related Harms in Canada (September 2021) , Database, Public Health Infobase, Database, accessed 19 October 2021. For most provinces and territories, data on the sex of the individual was based on biological characteristics or legal documentation. In Ontario, as of May 2017, the perceived or projected identity of the individual was reported. In Alberta, sex data is based on the medical examiner’s assessment, although the medical examiner may indicate the individual’s gender when it is known. [ Return to text ]
• The Alberta First Nations Information Governance Centre and Alberta Health, Alberta Opioid Response Surveillance Report: First Nations People in Alberta , December 2019, p. 5. [ Return to text ]
• The Alberta First Nations Information Governance Centre and Alberta Health, Alberta Opioid Response Surveillance Report: First Nations People in Alberta , June 2021, p. 11. [ Return to text ]
• Government of Canada, Opioid‑related harms and mental disorders in Canada: A descriptive analysis of hospitalization data . [ Return to text ]
• Gisèle Carrière, Rochelle Garner and Claudia Sanmartin, “ Social and economic characteristics of those experiencing hospitalizations due to opioid poisonings ,” Health Reports , Statistics Canada, Vol. 29, No. 10, 17 October 2018, pp. 25–26. “Age‑standardized rates” are used to compare rates between populations while accounting for differences in the age structure of the populations. See Statistics Canada, Age‑standardized Rates . [ Return to text ]
• Alberta First Nations Information Governance Centre and Alberta Health, Alberta Opioid Response Surveillance Report: First Nations People in Alberta , June 2021,  pp. 3–4. [ Return to text ]
• First Nations Health Authority, First Nations Toxic Drug Deaths Doubled During the Pandemic in 2020 , News release, 27 May 2021. [ Return to text ]
• See, for example, Thunderbird Partnership Foundation et al., Honouring Our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada . [ Return to text ]
• Constitution Act, 1867 , 30 & 31 Victoria, c. 3 ( U.K. ). [ Return to text ]
• Marlisa Tiedemann, The Canada Health Act: An Overview , Publication no. 2019‑54‑E, Library of Parliament, 17 December 2019. For more detail, see Martha Butler and Marlisa Tiedemann, The Federal Role in Health and Health Care , Publication no. 2011‑91‑E, Library of Parliament, 20 September 2013. [ Return to text ]
• See, for example, Government of Canada, Substance use treatment centres for First Nations and Inuit . [ Return to text ]
• Government of Canada, Federal actions on opioids to date , June 2021. [ Return to text ]
• Government of Canada, Restricting the Marketing and Advertising of Opioids . [ Return to text ]
• Health Canada, Consultation to inform proposed new regulations for supervised consumption sites and services: Closed Consultation . [ Return to text ]
• Government of Canada, Canada–United States Statement on Joint Action Plan on Opioids . [ Return to text ]
• Government of Canada, The New Canadian Drugs and Substances Strategy , Backgrounder. [ Return to text ]
• Government of Canada, Helping people who use substances during the COVID‑19 pandemic . [ Return to text ]
• HESA , Report and Recommendations on the Opioid Crisis in Canada , Sixth report, December 2016. [ Return to text ]
• The Honourable Jane Philpott, Minister of Health, Government Response to the Report of the House of Commons Standing Committee on Health Report Entitled Report and Recommendations on the Opioid Crisis in Canada . [ Return to text ]
• Bill C‑37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts , 42 nd  Parliament, 1 st  Session. See also Robin MacKay and Marlisa Tiedemann, Legislative Summary of Bill C‑37: An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts , Publication no. 42‑1‑C37‑E, Library of Parliament, 17 March 2017. [ Return to text ]
• Bill C‑224, An Act to amend the Controlled Drugs and Substances Act (assistance – drug overdose) , 42 nd  Parliament, 1 st  Session. [ Return to text ]
• Bill C‑22, An Act to amend the Criminal Code and the Controlled Drugs and Substances Act , 43 rd  Parliament, 2 nd  Session. [ Return to text ]
• Bill C‑235, An Act to amend the Controlled Drugs and Substances Act and to make consequential amendments to other Acts , 43 rd  Parliament, 1 st  Session. [ Return to text ]
• Bill C‑236, An Act to amend the Controlled Drugs and Substances Act (evidence‑based diversion measures) , 43 rd  Parliament, 2 nd  Session. [ Return to text ]
• Bill C‑286, An Act to amend the Controlled Drugs and Substances Act and to enact the Expungement of Certain Drug‑related Convictions Act and the National Strategy on Substance Use Act , 43 rd  Parliament, 2 nd  Session. [ Return to text ]
• See, for example, Petition 432-01076 (Health) , presented to the House of Commons on 8 June 2021; and House of Commons, “Opposition Motions,” Notice Paper , 4 November 2020. [ Return to text ]

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Progressive politics, ideas & culture

PHOTO ESSAY: The faces behind Vancouver’s overdose crisis

Photojournalist aaron goodman provides an inside look at one woman's struggle with addiction on the west coast.

Aaron Goodman @aaronjourno

More information on the Outcasts Project can be found at outcastsproject.com .

Cheryl prepares to use drugs in her apartment in Vancouver’s Downtown Eastside.

We need for you people to see that we’re not stereotyped monsters. We’re people just like you, just with an addiction. Something that we do a little bit more than others… When you look at this, take it with a grain of salt, because it could be your own daughter, it could be your own son out there doing exactly what I’m doing, but they had the door closed.

A drug addict’s world is not just the drugs, it’s how they get them, what you gotta’ do to get them. Sex trade, you know. Stealing, killing, whatever it might take just to get that extra dollar to get that extra fix so you can feel numb for the rest of the day. Not necessarily it’s always that, but in my life, I just want you to know that I’m struggling and I need that extra help.

Cheryl cries in the yard of a church where her father’s funeral was held.

I hope the people see through this [essay] all the points, all the emotions and desires, needs, and wants that we need, that you can help us down the road be able to successfully show our governments that people need the extra bit of help because we can’t do it on our own.

Cheryl self-injects her medication at Providence Health Care’s Crosstown Clinic in Vancouver.

I want to show the people that this place is where we get our injections for our heroin opiate program, just show them that we need these places so heroin addicts can get off the streets. Heroin can be contaminated with many different poisons out there that can severely give us infections, because they put hog dewormer in the heroin on the streets. The clinical heroin here, there’s no bad chemicals or poisons in the drug. It helps us through the day, takes our aches and pains away, everything that heroin used to do.

In other places of the world, they had this study and it’s helped them, that’s why they brought it to Canada, here to [British Columbia]. And for us, the people who are in it, we’re so lucky and should be so grateful to have such a great program.

Cheryl paints her nails prior to a court appearance for a sexual assault she experienced.

I’m sure there’s hundreds of photos that could show my life different. But my life today is a recovering heroin addict. I’m 124 pounds. I used to weigh 97 pounds. There’s so many good things, and positive ways of looking at my life. If a picture could show all that emotion in one? That would be great, but it won’t and that’s all that my voice could tell you.

Cheryl self-injects drugs in her apartment in Vancouver’s Downtown Eastside.

I think that people see a girl looking in the mirror, looking in fear, like what is she doing with the needle in her neck, sticking in her neck, that’s a pretty dangerous site to be injecting. But that’s the reality of that picture. It’s me being all strung out on dope, trying to get that shot into me, and it’s filled with blood and I’m trying to plug it into my vein cause I need that drug that’s in there so I can get off and get high, numb whatever pain I’m going through in that moment.

I was all fucked up on drugs that day, yeah. It shows my emotion, my fear, my determination. [I wish the photo had] maybe a little bit more light… Just to show it’s hard to inject into your neck like that. Just to show the picture more. To see what kind of struggle it is to inject in your neck. And to show maybe just a little bit more emotion to the people just to show what and why I’m doing that to myself.

Cheryl returns to an alley in Vancouver’s Downtown Eastside where she lived for several years.

People viewing this photo might see some young girl, downtown, in a back alley. Looks like it’s a rough alley. A young girl, maybe she’s strung out, or maybe she’s determined to find drugs or who knows what they see in this photo. They just see a young girl smiling and looking down the alley.

Yeah, it shows all of me. I just hope the people see me in this photo—that I’m a striving, struggling drug addict. That I’m trying to better my life.

Aaron Goodman is a journalist, researcher, and instructor. His work focuses on amplifying the voices and experiences of people affected by social injustices, human rights abuses, conflict, and genocide. You can follow him on Twitter: @aaronjourno.

Why is Canada's illicit drug supply so deadly and what's being done about it?

'on any given day, nobody knows what they're using,' says one addiction medicine physician.

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Canada's overdose crisis has worsened during the pandemic, with the number of people dying from illicit drugs soaring to new heights in many provinces. 

The Public Health Agency of Canada (PHAC) says 2020 was the deadliest year for overdose deaths since it started recording the numbers in 2016. From January 2020 to June 2021, more than 9,800 Canadians died from an opioid overdose . 

According to those who research and work with drug users, the country's increasingly toxic drug supply is to blame. 

Why is Canada's illicit drug supply increasingly deadly?

Data suggests that the pandemic has a part to play in how toxic the supply has become. Supply volatility increased dramatically once pandemic lockdowns were declared in March 2020, according to the Canadian Centre on Substance Use and Addiction (CCSA). 

"The entire drug supply has gotten a lot more messy since COVID started.… The borders closed, and the drug supply routes aren't the same and people are just using what they can," said Doris Payer, a co-ordinator and researcher with the CCSA. 

Prescription opioid OxyContin was introduced in 1996 and is widely seen as a catalyst to the opioid crisis that has claimed hundreds of thousands of lives across North America. Drug manufacturers marketed opioids aggressively, particularly OxyContin, which lawsuits claim they falsely suggested was safer and less prone to misuse than other opioids. 

However, as more people began using the drug, more people started misusing it. Dealers turned huge profits as the painkiller became a popular street drug, and OxyContin eventually made its way from cities into remote communities .

In 2012, the manufacturers of OxyContin, Purdue Pharmaceuticals, reformulated the drug to make it harder to crush or melt down , with the intent of discouraging abuse. But making pharmaceutical opioids less available didn't change the fact that thousands of people were addicted to them, so many people turned to the streets and to other opioids, including heroin.

As the demand for illicit opioids increased, drug dealers began adding the powerful synthetic opioid fentanyl  to the illicit supply of heroin to maximize profits.

In 2016, a study by Public Health Canada found that fentanyl was fuelling a rise in  opioid-related deaths . The study said fentanyl, which was becoming more prevalent on the illegal drug market, was being increasingly mixed in with other illicit drugs, increasing the risk of an overdose. 

Much more potent than oxycontin, the relatively cheap-to-make opioid has been increasingly mixed into other street drugs, killing hundreds of people across Canada, but particularly in B.C. and Alberta . In 2016, PHAC recorded more than 2,800 opioid-related deaths. 

Data from drug-checking services Toronto and B.C. that test the substances used by people and inform them on what they contain shows fentanyl now dominates the market. 

In 2020, 69 per cent of opioids seized by law enforcement agencies across Canada consisted of fentanyl or fentanyl analogues , according to Health Canada's Drug Analysis Service (DAS).

But Paxton Bach, an addiction medicine physician and co-medical director of the B.C. Centre on Substance Use, said fentanyl itself isn't the only reason people are overdosing and dying. 

Rather, it's because "on any given day, nobody knows what they're using" or how much they're using, Bach said.

Fentanyl is still detected in an overwhelming majority of illicit drug deaths  in Canada, according to PHAC, but the unpredictability and potency of other substances mixed in with the fentanyl are making the supply more dangerous. 

• These 5 myths about B.C.'s toxic drug crisis are hurting efforts to stop the deaths, say experts
• Over 2,300 people died in B.C. in 2021 due to illicit-drug overdoses, coroner reports

The latest drug health authorities are sounding the alarm about is benzodiazepines. 

According to a recent report by the B.C. Coroner Service, the number of drug samples in which benzodiazepines were detected in B.C. went from 15 per cent to 53 per cent in a little more than a year.

Benzodiazepine, which is typically prescribed as a sedative, is dangerous when paired with fentanyl because the sedation increases the risk of an overdose, according to Health Canada. 

Calls for supply regulation as benzodiazepines appear in street narcotics across Canada

Pat Fifield, an overdose prevention support worker at a supervised consumption site in Toronto, said the illicit drug market has been flooded with new substances for years.

Over the past two years, Fifield said almost all fentanyl tested at supervised consumption sites in Toronto also contains synthetic cannabinoids, benzodiazepines or psychoactive substances. Toronto's drug-checking program shows a similar plethora of substances .

Synthetic cannabinoids are manufactured chemicals that affect the brain in a similar way to cannabis plants. Psychoactive substances are chemical substances that change a person's mental state by affecting the way the brain and nervous system work.

• 'Extreme' levels of fentanyl and benzodiazepines found in drug samples in B.C. Interior

Often, people are using these new substances unintentionally — and that's what makes the current situation so deadly, said Bach. 

"The speed at which the unregulated drug supply is evolving and getting more unpredictable and dangerous is outstripping our response." 

How did we get here?

Canada's unpredictable drug supply has roots that extend far beyond the country, said Martin Raithelhuber, an illicit synthetic drugs expert working with the United Nations Office on Drugs and Crime (UNODC) in Vienna, Austria.

"The development you're seeing in Canada has a global dimension," said Raithelhuber. 

Since 2008, more than  1,000 new psychoactive substances have been reported to the UNODC. 

B.C. determined to battle opioid crisis after record overdose deaths in 2021

Raithelhuber said this is largely because information on how to synthesize drugs is widely available online.

"A lot of these substances first appeared in pharmaceutical research — they're so-called failed medicines. But the literature is there and it becomes accessible through the internet."

He also said the rise of cryptocurrencies and the dark web have made it easier to sell drugs anonymously.

Raithelhuber said that it is easier and cheaper to produce synthetic drugs than to produce organically derived drugs such as heroin, which involves growing and harvesting the poppy. 

• Yukon has joined B.C. in declaring a substance use emergency. What does that mean?

How are people being affected?

Fifield said the changes in the illicit drug supply have made harm-reduction work more difficult and the lives of drug users more precarious.

Naloxone, a fast-acting antidote that reverses the effects of an opioid overdose, doesn't act on benzodiazepines or on most other synthetic substances found mixed in with opioids. 

Similarly, the increasingly toxic drug supply is complicating medical care for drug users.

"On the medicine side of things, we're seeing a lot more unpredictable withdrawal and unpredictable response to our traditional medications," said Bach.

For people who use drugs, it can mean life or death. 

Frank Coburn, 70, has been using opioids and cocaine for more than 20 years and works as a harm-reduction worker in Toronto.

"You pray to God or whatever force is there that rules the world that this is not going to kill you," he said. 

"The tainted drug supplies are killing people all over the place."

What's being done?

Harm-reduction services have become more widely available in recent years. 

Supervised consumption sites have started popping up in most urban centres  in Canada. They provide a safe, clean space for people to bring their own drugs to use in the presence of trained staff. 

There are  38 federally authorized supervised consumption sites offering services in Canada, according to Maja Staka, press secretary for the office of the federal minister of mental health and addictions.

Naloxone distribution programs, public awareness campaigns and addiction treatments to help wean people off of certain drugs have also ramped up in the past few years.

Coburn said a safe supply is the only thing that will curb the number of illicit-drug-related deaths in Canada. 

People who use drugs have been calling for safe and regulated drugs for decades. The goal is to enable people who use drugs to access regulated substances, such as medical-grade heroin, from a legal source, rather than toxic versions from illicit markets

So far, safe supply programs have limited scope. The programs exist in a handful of cities in B.C., Ontario, Quebec and New Brunswick and users need a doctor's prescription.

• Vancouver votes to support application that would create safe drug 'compassion clubs'

B.C. chief coroner calls for access to safer drug supply after record overdose death

For Bach, the only way to curb overdose deaths is by expanding the availability of safe-supply programs and reducing barriers to accessing them.

"The No. 1 thing that we can do to curb overdose deaths is provide a predictable, safer alternative to a poisoned, volatile, unpredictable drug supply that's continuing to evolve much faster than we can keep up." 

David Golesworthy uses opioids and lives in London, Ont., one of the first cities in Canada to put in place a prescription-led safe supply programs.

But he hasn't been able to sign up to the program run through the London Intercommunity Health Centre because demand far outstrips availability and there's a waiting list.

Carolyn Bennett, the federal minister of mental health and addictions, told CBC she agrees that safe supply "is going to be the way that we will save the most lives," but remained vague on a possible timelines for the expansion of safe supply programs across Canada.

"I'm interested in learning more about and putting in place the research to firstly do no harm and to make sure that the [safe supply] proposals are effective, because only then can they be sort of scaled up and used in other parts of the country." 

Decriminalizing illicit drugs could help tackle the opioid crisis, experts say

Meagan Jasper, a recovering methamphetamine addict and harm reduction worker based in Moose Jaw, Sask., said more funding for harm reduction services is desperately needed.

Saskatchewan saw its deadliest year in terms of overdose deaths in 2021  with 464 people confirmed or suspected to have died from drug toxicity. 

"We are so far behind other provinces," said Jasper. 'Until the long-term solutions are there, like the treatment beds, housing, things like that, we need to keep people alive long enough through harm reduction until we're ready to help them."

Coburn and Fifield believe decriminalizing illegal drugs would lead to a safer supply because all substances would be federally regulated. 

They both noted that after Portugal decriminalized the personal possession of all drugs in 2001,  overdose deaths and rates of drug use fell . They have since remained consistently  below the EU average .

• NDP to introduce new bill to decriminalize drug use as overdose deaths soar
• As overdose numbers climb, B.C. drug advocates question role of addictions ministries

The federal NDP party, the Toronto Board of Health and health practitioners in B.C. are pushing the federal government to decriminalize illicit drugs.

Bennett said the government is "looking very carefully" at decriminalization proposals, but said "we need to make sure there's a good implementation plan." 

ABOUT THE AUTHOR

Maya Lach-Aidelbaum is a reporter with CBC Yukon. She has previously worked with CBC News in Toronto and Montreal. You can reach her at [email protected]

• Follow Maya Lach-Aidelbaum on Twitter

With files from Nicole Ireland and Adam Miller

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Understanding Addictions among Indigenous People through Social Determinants of Health Frameworks and Strength-Based Approaches: a Review of the Research Literature from 2013 to 2016

• Health Disparities in Addiction (D Barry, Section Editor)
• Published: 28 September 2016
• Volume 3 , pages 378–386, ( 2016 )

Cite this article

• Holly A. McKenzie 1 ,
• Colleen A. Dell 2 , 3 &
• Barbara Fornssler 3 , 4  

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Purpose of Review

This paper reviews recent research (2013 to 2016) about addictions among Indigenous people. The review concentrates on Indigenous people living within Canada while drawing on literature from countries with similar settler-colonial histories (namely: USA, Australia, and New Zealand).

Recent Findings

Research indicates that Indigenous people, particularly youth, carry a disproportionate burden of harms from problematic substance use in relation to the general population in Canada. While much research continues to focus on the relationship between individualized risk factors (i.e., behaviors) and problematic substance use, increasingly researchers are engaging a social determinants of health framework, including Indigenous-specific determinants. This includes strength-based approaches focusing on protective factors, including the role of traditional culture in Indigenous peoples’ wellness.

Since focusing on individualized risk factors and deficit-based frames are inadequate for addressing Indigenous peoples’ health, recent research engaging a social determinants of health framework and strength-based approaches is promising.

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Preventing Substance Use Among Indigenous Adolescents in the USA, Canada, Australia and New Zealand: a Systematic Review of the Literature

The cedar project: using indigenous-specific determinants of health to predict substance use among young pregnant-involved indigenous women in canada.

Mental Health and Substance Use Co-Occurrence Among Indigenous Peoples: a Scoping Review

In this paper, Indigenous people refers to those who are the original inhabitants of the land we are discussing. Within Canada, Indigenous people include First Nations, Métis, and Inuit people.

The National Survey on Drug Use and Health and the Behavioral Risk Factor Surveillance System uses “White” as a racial/cultural group and a racial/ethnic group.

According to the 2012 Canadian Alcohol and Drug Use Monitoring Survey, this is not due to substantial decreases in illicit drug use.

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Acknowledgment

The authors are grateful to Indigenous community-based researchers who reviewed and provided expert comments on an earlier draft of this paper: Sharon Acoose, Laura Hall, and Erin Settee.

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Holly A. McKenzie

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In the above article, the authors refer to a research project led by the second author. All procedures performed in this study involving human participants were in accordance with the Canadian Interagency Advisory Panel on Research Ethics’ standards according to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (2nd Edition) (TCPS 2), particularly, Chapter 9: Research involving the First Nations, Métis and Inuit Peoples of Canada and with the Indigenous principles of Ownership, Control, Access and Possession (OCAP).

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McKenzie, H.A., Dell, C.A. & Fornssler, B. Understanding Addictions among Indigenous People through Social Determinants of Health Frameworks and Strength-Based Approaches: a Review of the Research Literature from 2013 to 2016. Curr Addict Rep 3 , 378–386 (2016). https://doi.org/10.1007/s40429-016-0116-9

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DOI : https://doi.org/10.1007/s40429-016-0116-9

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Addiction Among Youth: What Is Happening In Canadian Classrooms

By the time they graduate from high school, an alarming number of students will have been offered, tried, and/or used drugs. The younger an individual is when drug abuse begins, the greater the likelihood of a lifetime addiction to that drug developing.

According to Health Canada’s most recent Cigarette, Alcohol and Drug Use Survey, Canadians aged 15-19 are continuing to report drug use. In 2017:

• 57% reported alcohol use· 8% reported smoking cigarettes
• 19% reported using cannabis
• 20% reported use of at least one of cannabis, cocaine or crack, ecstasy , speed or methamphetamine, hallucinogens, and heroin
• 18% reported using prescription stimulants like Ritalin, Concerta, Adderall, or Dexedrine

Drug use before age 15 is a reality for Canadian teens, and is a strong predicator of substance abuse later on. Attitude toward drug use is another predictor, as students who display a positive attitude to substance abuse are more likely to engage in this behaviour.

In Alberta, 24.5% of students from grade 7 to 12 reported illicit drug use in the past year. The most commonly used drugs were hallucinogens like magic mushrooms, Ecstasy, cocaine, solvents, stimulants, glue, and crystal meth.

The Yukon, Northwest Territories, and Nunavut each have large numbers of Aboriginal communities that have teenage drug use rates well above the national average.

In the United States, 9 out of 10 people addicted to a substance took it for the first time before their 18th birthday. Use before age 15 multiplies the risk of addiction by seven, compared with use that begins after age 21. Alcohol, marijuana, cigarettes and prescription medications are among the drugs most commonly used by young people in American high schools. By graduation:

• 66% report having tried alcohol, 40% report having been drunk in the past 30 days
• 40% report having smoked a cigarette
• 50% report having tried cannabis, 7.5% report having done so for the first time before age 13
• 20% report illegal use of prescription drugs
• 44% reported knowing a student who sold marijuana, Ecstasy, cocaine or crack, and/or prescription medications on school property

In both Canada, and the US, drug abuse among young people is a serious issue, and many begin before high school. This greatly increases the risk of developing a substance use disorder. Focusing intervention efforts on children in middle school, and during their teenage years, is crucial, and well supported by addiction research.

Drug Addiction Among Youth

A single use of any drug creates a physical dependence. Cravings then develop that can only be satisfied by having more of that drug. As this use continues, a tolerance to the drug develops. This perpetuates the cycle of craving and consumption as the dependency worsens. Eventually, this will result in a psychological dependence in addition the physical one, as the user begins to feel as if the drug is “needed” emotionally as well as physically.

Addiction to one substance can increase the likelihood of developing an addiction to another. Tolerance to softer drugs like nicotine and alcohol can lead to experimentation with harder drugs like marijuana, opioids, Ecstasy, cocaine, and heroin. One use of a drug creates a physical dependence, and the cycle continues, leading to a second, or even a third addiction.

Adolescents are extremely vulnerable to peer pressure. If a friend is using drugs, that offers the opportunity for exposure to those drugs, and displays a positive attitude on behalf of the friend, both factors in the likelihood of drug abuse. Add to this an adolescent’s propensity for risk tasking behaviour and impulsive decision making, and the probably of a substance use disorder developing goes up exponentially.

Because the adolescent brain is still maturing, it is more susceptible to both physical and psychological dependence. It is also developing at such a rate that the physical and social-emotional changes during this time period can manifest as mild anxiety, depression and behavioural challenges in many youth.

While mild anxiety during adolescence is extremely common, more serious mental illnesses often emerge during these years. Addressing these immediately offers the best chance of managing them effectively. These conditions are often found to be the underlying cause for addiction. Accessing services like counselling, and having the support of family members, can prevent a lifetime of drug abuse.

The Effects of Drug Addiction Among Youth:Learning and Life Choices

A brain is not fully developed until age 25. Drug abuse during adolescence can cause irreparable damage, leading to permanent cognitive impairment. Any illicit drug use will interfere with, and chemically alter, the normal pattern in the brain. This will result in a permanent rewiring of the how the brain processes information, affecting the ability to learn, remember, focus and concentrate.

This damage will affect academic performance, resulting in lower grades, more frequent absences from school, and an increased risk of not graduating from secondary school. More and more Canadian students are not completing education at the secondary school level as a result of substance abuse. This also perpetuates the cycle of addiction, as youth who are not in school are at an increased risk of abusing drugs.

Not graduating from high school limits life choices dramatically. It eliminates the possibility of accessing a degree program at a university, or a diploma program at a college. Career options are extremely limited and, obtaining and maintaining employment will be an ongoing struggle.

If a young person shows signs of depression, anxiety, withdrawal, changes in mood or attitudes, unusual irritability and outbursts, changes in sleeping patterns, changes in friends and interests, it is cause for concern. Changes in academic performance, and attitudes toward school are also potential indicators of illicit drug use and addiction, particularly if these changes are sudden and dramatic.

If substance abuse is suspected, immediate intervention is essential to address the issues at school, as well as other possible harm related to the drug use. Health care providers like a family doctor and a psychologist can begin the process of diagnosing the addiction and any underlying mental illnesses, or suicidal behaviour.

Adolescents haven’t developed the same decision making capabilities as adults, and do not appreciate the consequences of their actions. It is also very possible that a mental health condition has gone undiagnosed at this young age, and that drugs are being used to treat the symptoms of those conditions.

Suicide attempts among youth due to an untreated illness or poor decision making, are a terrible reality, as are accidental overdoses. Both are potentially fatal. It is crucial to seek advice from educators, guidance counsellors and school officials as soon as there is an awareness of any problem. Students at this age are so concerned about image among their peers, teachers and parents, that speaking up and asking for help themselves is unlikely to happen without the support of a caring adult.

The Effects of Drug Addiction Among Youth:Violence and Crime

Substance abuse among youth is also linked to violence, crime, and gang membership. Canadian law enforcement agencies report this beginning as young as middle school.

Violence related to substance abuse among youth can occur during the commission of a crime, but it is more likely to occur within the home, with a family member, or at school. Parents who are addicts are often involved in negligence, maltreatment, physical and sexual abuse of their children. Drug related violence of children is a strong predictor for later substance abuse by the victims.

Early substance abuse among youth is among the risk factors for delinquency. Criminal activity becomes a means to support the addiction. Shoplifting, breaking and entering, and prostitution are the most common methods to obtain the drug itself, or the money to purchase it, usually from a dealer.

Schools are where at least some of these drug purchases are occurring, along with the associated violence. This criminal activity increases the likelihood of more crime, as well as continued use of drugs. Persistent delinquency during youth, combined with substance abuse, is a predictor for participation in criminal activity as an adult.

Involvement with the criminal justice system, particularly incarceration, perpetuates the cycle of violence, crime and substance abuse disorders, and exacerbates mental health conditions. What is most alarming is that the cycle is beginning in middle school.

What the Education System is Doing:Is it Enough?

Drug prevention training.

School based drug prevention programs have become commonplace in recent years. These programs start as early as elementary school, and continue through high school. They have made their way into classrooms, but how effective are they?

A great deal of research on drug prevention education has been done to determine best practice in creating curricula and implementing the strategies. A large number of programs have been thoroughly evaluated, so educators can make an informed decision.

The approaches that proved to be largely ineffective in reducing substance abuse, were those that focused primarily on facts about drugs and the dangers of drug abuse, fear arousal programs emphasizing risks associated with drug use, programs that focus on the evils of drug use, and programs that foster self-esteem building and personal growth.

Adolescent choices regarding alcohol and drug use are affected by social context, physical and emotional needs, and pressure by peers or others. Strategies that didn’t rely on that understanding, and that focused solely on the teaching of facts or the development of healthy attitudes, were ineffective.

Alternatively, helping students develop resistance skills does appear to reduce substance abuse. This training includes an awareness of the power of social influence to engage in drug use, and specific strategies for resisting that influence.

Drug prevention training for students and teachers is one strategy being used by the education system to address addiction among youth in Canadian schools. But is it enough?

Credit Recovery

Dropout rates in high schools are higher among youth who use drugs. The only way to graduate from high school, if a student does leave early, is to make up any missed credits.

Many school districts offer Credit Recovery courses. If a student completed the course, but not at a passing level, they can take a Credit Recovery course. If the course was not completed, or if it was not taken at all, either because the student left school or was asked to leave, Credit Recovery may not be an option.

The Credit Recovery course would provide basic learning skills, as well as any missed curricula. However, it would not address substance abuse, behavioural challenges, involvement with law enforcement, or underlying mental health conditions. It also does not alter the school environment itself, which contributed to the challenges that led to the student leaving school.

Recovery Schools

Recovery schools are an alternative to the current model of education and drug prevention training. They are high schools that are designed for students who are suffering from a substance abuse disorder, or from mental health conditions like anxiety, depression, or ADHD, and are in recovery.

The schools provide coursework in the provincial or state curriculum, as they help students work toward completion of secondary school and attainment of a high school diploma. What they offer, that public schools do not, is support with their recovery program, as well as flexibility in how the curriculum is delivered.

In addition to administrative staff and teachers, there are addiction counsellors and mental health providers on site. They provide support to the families as they learn about addiction, and how to best help support their child. This multidisciplinary approach is well supported in the research as best practice.

With all of these supports in place, drug use is not the norm in these schools. Recovery schools are common in the U.S., and can be found in many parts of the country, with the first opening in the 80’s. Some are fully or partially funded by the state, but many are not. The lack of public funding means that parents may have to pay tuition, and many students who need the services of the school will not be able to afford them. As a private school, it can also close at any time.

Canada’s one Recovery school, based on the model in the U.S., officially opened in Ontario in 2015. The director, Eileen Shewen, began her mission to open the school after a frustrating search for an appropriate program for her daughter, and having seen the success of the American schools.

Equally frustrating was her attempt to secure funding from the Ontario government, and they were forced to close less than four years later. The dismay of parents who had fought in vain to find schools within the public education system for their own children, was heard nationwide.

Traditional schools only address curriculum, and not any of the other needs of a student suffering from a substance abuse disorder or a mental health condition. Recovery schools teach the whole child, and operate from a truly collaborative approach. This supportive environment reduces the stigma associated with drug use, and makes learning possible for the first time.

A radically new approach to publicly funded education is needed.

Picture Credit:  verywellfamily   By Lisa Linnel-Olsen.  Updated August 13, 2019

Sources used for the article

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• Preventing Problematic Substance Use in Youth Copyright:  October, 201
• https://www.healthlinkbc.ca/health-topics/alcohol-and-drug-use-young-people Alcohol and Drug Use in Young People BC Health Links:  Health Wise Staff, Adaption date:  2/20/2019
• Teen Substance Use and Risk CDC – Centers for Disease Control and Prevention Page last reviewed:  April 1, 2019
• https://www.ccsa.ca/ Neuroscience in Youth Drug Prevention Programs Report prepared for the Canadian Center on Substance Abuse, 2015
• https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/sclbsd-drgbs/index-en.aspx School Based Drug Prevention:  Promising Programs Report Prepared for Public Safety Canada, Date modified:  2018-01-31
• High School For Teens with Mental Health, Addiction Issues Opens Doors Global News, April 8, 2015

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Drug addiction in Canada is a growing concern. Since 2016, an estimated 27,000 people have died from drug use.

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The Drugs Canadians are Using

Since the COVID-19 pandemic, there has been an increase in the unregulated drug supply in the country. Urinalysis reports have shown that cocaine, crack cocaine, methamphetamine, and amphetamine accounted for most of the stimulant use in the country.

Fentanyl was detected most often in British Columbia and Thunder Bay and was last detected in Manitoba and Nova Scotia. In addition, there was an increase in unregulated benzodiazepine use across the country.

Recognizing Substance Use

After a Treatment Program

Drug Addiction in Canada

• Alcohol is the most common drug used by Canadians, and its use has significantly increased. The risky use of alcohol is still most prevalent among young adults in the country, aged 18 to 24.
• The use of prescription stimulants in the country has increased since 2015. The prescription stimulant use prevalence is highest among youth aged 15 to 19. In addition, roughly 60% of postsecondary students aged 17 to 25 who reported using prescription stimulants reported problematic use.
• Opioid pain medication is estimated to be used by 11.8% of Canadians, and roughly 3% report using it for non-medical purposes. Between January 2016 and December 2019, there were 15,393 opioid-related deaths in Canada. The rates of emergency department visits for opioid poisoning have doubled for younger adults aged 24 to 44.

Safeguarding Sobriety

Series on Intervention

Canada's opioid crisis.

Illegal drugs are a significant problem in Canada, especially opioids. Since 2016, there have been more than 9,000 apparent opioid-related deaths. In 2017, roughly 11 lives were lost each day because of opioid overdose.

• Approximately 94% of opioid overdose deaths happen by accident.
• Young adults aged 15 to 24 are the fastest-growing age group needing hospital care from an opioid overdose.
• Street drugs across the country have been tainted with opioids, such as fentanyl.
• There are higher rates of opioid prescribing in the country.

Detox, drug rehab, and aftercare support are the best approaches to treating opioid addiction and dependency. 

Youth and Young Adults are at the Highest Risk

The rates of illicit drug use in Canada remain the highest among youth aged 15 to 24. Canadian youth remain the top users of cannabis in the country.

• Canada is only one of six countries with youth cannabis use rates over 20%.
• Youth in Canada are initiating cannabis use at a younger age.
• The prevalence rates of cannabis are highest among Indigenous street-involved youth.
• The rates of illicit drug use were five times higher among youth aged 15 to 19 and young adults aged 20 to 24.
• The rates of prescription drug abuse were highest among youth aged 15 to 19 and young adults aged 20 to 24.

Youth and young adults need drug rehabilitation to overcome these problems. Without adequate treatment and community aftercare support, these drug problems continue into adult life and become difficult to treat.

Five Key Reasons for Relapse

Treatment Series

Series on treatment, early prevention and rehabilitation  necessary steps.

Prevention and education remain the best options to prevent drug addiction in Canada. In addition, it remains the most cost-effective approach.

Prevention programs and campaigns reduce the demand on an already strained system while reducing the cost of substance use within society.

However, it does not trump the need for treatment and rehabilitation. In Canada, the provinces and territories are responsible for providing public drug rehabilitation. Yet, access to public drug rehab is limited, and there are often long wait times.

Stigma and Societal Costs

Significant stigma is still attached to drug and alcohol addiction, especially injection drug use. Stigma mainly affects people affected by poverty and homelessness. In addition, discrimination is associated with illicit substance use, which restricts individuals’ access to certain types of healthcare.

The social costs are also significant. Substance use has costly health, community, and economic impacts, placing an economic burden on the public. The combination of crime and addiction in Canada costs taxpayers billions each year.

The perceptions of drug use in the country are changing. Reports have shown there are variations in societal perceptions surrounding drug use. Over the last ten years, there have been increases in perceptions of the seriousness of medical and illicit drug use. 

However, knowing the risks does not stop people from using drugs. These are the problems that must be addressed through prevention, education, rehabilitation, and community aftercare support.

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Canadian Drugs and Substances Strategy: Prevention and education

How the strategy supports prevention and education initiatives across Canada.

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About prevention and education, how prevention and education fits into the strategy.

Prevention and education initiatives support communities and raise awareness to influence the health and well-being of people living in Canada. They aim to:

• reducing risk factors
• increasing protective factors
• reduce healthcare and social costs by preventing substance use related harms
• give people the facts they need to make informed choices around substance use and where to get help

Addressing risk factors and increasing protective factors, especially early in life, is key in reversing the current trends of substance use related harms.

Risk factors increase the likelihood of substance use related harms and negative health outcomes. Some examples include:

• mental illness
• drug availability
• negative school atmosphere
• exposure to peer substance use
• unstable housing or homelessness
• trauma and childhood adversity, like child abuse and neglect

Protective factors are positive physical, social and mental health influences that can help reduce substance use related harms. Some examples include:

• physical safety
• social inclusion
• safe neighbourhoods
• a positive school environment
• caregiver involvement and monitoring
• stable, permanent and appropriate housing
• healthy behavioural development, like coping skills and emotional regulation

Youth is a crucial life stage when life-long behaviours develop. Substance use at this age can:

• harm brain development and function
• increase the risk of developing substance use disorders

Other factors may interact with each other to:

• put people at greater risk for mental health and substance use related harms
• limit people's access to important supports

These factors are often called the social determinants of health.

Experiences of discrimination, racism and historical trauma are important social determinants of health for certain groups in Canada, such as:

• Black people
• Indigenous Peoples
• 2SLGBTQIA+ people

Chronic pain can also have major impacts on a person's mental and emotional health. Unmanaged pain has also been identified as a key driver of higher-risk substance use.

Learn more:

• Chronic pain and opioids
• Social determinants of health and health inequalities

It's important to pay attention to risk and protective factors when planning actions that help to:

• address the overdose crisis in Canada
• reduce substance use and its related harms

To meet the needs of people at risk, including youth and marginalized populations, we're:

• investing in community-led programs to prevent or reduce harms related to substance use
• raising awareness through public education and outreach activities
• addressing underlying inequities related to substance use related harms

Investing in community-led programs to prevent or reduce harms related to substance use

We invest in community-led programs that help prevent and reduce substance use related harms.

This program provides funding to other levels of government and organizations that are:

• not-for-profit
• community-led

Funds go towards innovative treatment, harm reduction and recovery projects that aim to:

• minimize substance use related harms
• at-risk populations
• other marginalized populations

Substance Use and Addictions Program

A community-based funding program designed to support communities to help prevent and delay substance use among youth in Canada, and lower experiences of substance use and associated harms into adulthood.

Youth Substance Use Prevention Program

This program provides funding to time-limited projects across Canada that help reduce HIV and hepatitis C among people who share injection and inhalation drug-use equipment. Harm Reduction Fund

The strategy also contributes to supporting programs that provide First Nations and Inuit communities with access to mental wellness services, which:

• reduce risk factors
• promote protective factors
• improve associated health outcomes
• Mental health and wellness in First Nations and Inuit communities

We're also supporting the Youth Gang Prevention Fund through the National Crime Prevention Strategy. This program funds projects that:

• provide exit strategies for youth who belong to gangs
• aim to prevent at-risk youth from joining or re-joining gangs

Youth Gang Prevention Fund National Crime Prevention Strategy

We're also supporting the Crime Prevention Action Fund through the National Crime Prevention Strategy. This program provides funding to evidence-based community crime prevention initiatives that address known risk and protective factors among vulnerable groups, especially:

• chronic offenders
• children and youth aged 6 to 24

Crime Prevention Action Fund National Crime Prevention Strategy

We're also supporting the Northern and Indigenous Crime Prevention Fund through the National Crime Prevention Strategy. This fund supports culturally sensitive crime prevention practices which address known risk and protective factors to:

• reduce vulnerability to crime
• promote community safety approaches

The fund supports programs in Indigenous communities both on and off-reserve and in the North. Northern and Indigenous Crime Prevention Fund National Crime Prevention Strategy

We also developed resources for schools and community organizations that support youth, outlining practical approaches to preventing substance use related harms:

• Preventing substance-related harms among Canadian youth through action within school communities: A policy paper
• Blueprint for Action: Preventing substance-related harms among youth through a Comprehensive School Health approach

Raising awareness through public education and outreach activities

We raise awareness of substance use related harms, ways to reduce those harms, and the importance of reducing stigma through:

• public education
• outreach activities
• awareness campaigns

These activities provide factual information to support people in making informed choices around substance use and helping those around them. Activities include:

A youth awareness program that educates teens and youth on the risks of opioids and substance use and ways to reduce harms. Know More Opioids

This awareness campaign gives educators information and resources to help teens understand the potential effects of cannabis use on their brain and mental health. Pursue Your Passion

This self-led module educates teens on the harms and risks associated with youth vaping, and helps prevent the uptake of vaping products. Consider the Consequences of Vaping

This campaign promotes seeking help, and provides links to resources and supports. It's especially aimed at men working in physically demanding jobs who are at higher risk of substance use related harms, including overdose. Ease the Burden Campaign

This multi-year campaign raises awareness of:

• how to respond to an overdose
• the Good Samaritan Drug Overdose Act
• the impacts of stigma on people who use drugs

Stigma leads people to hide their substance use, and prevents them from getting help for fear of reprisals and being labelled or judged. Our resources promote information about stigma and includes an interactive gallery of real stigma stories. Stigma around drug use Gallery (Health Canada Experiences)

A training program for law enforcement to help reduce stigma and support frontline officers who interact with people who use substances. Drug Stigma Awareness Training

Resources and information for people who need help with substance use, including overdose prevention resources and where to get naloxone in your community. Get help with substance use

We also provide opioids awareness resources, which include:

• fact sheets
• wallet cards
• an audio series

Awareness resources for opioids

Addressing underlying inequities related to substance use related harms

We work at a federal level to support programs that address inequities in Canada which can be underlying causes of substance use related harms. Health is influenced by many factors, including:

• access to care
• employment status

We aim to address inequities related to these factors through federal programs, such as:

• Mental health and wellness initiatives
• Reaching Home: Canada's Homelessness Strategy
• Opportunity for All – Canada's First Poverty Reduction Strategy
• Funding opportunities for programs that address gender-based violence

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The Impact of Drugs on the Teenage Brain

Here is an overview of the research on drug abuse from a teenager's perspective..

Updated September 4, 2024 | Reviewed by Davia Sills

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• Teenage years are a time of rapid brain development, making teenagers more vulnerable to the effects of drugs.
• The teenage brain is not fully developed; this can lead to poor decision-making and risky behaviors.
• Different drugs may affect the teenage brain in different ways.

This post was coauthored by Gabriella P. Oettinger and Juan M. Dominguez, Ph.D.

As we begin the new school year, the importance of understanding the challenges and risks that students face becomes particularly pressing. Amid these challenges, illegal substance use remains a serious issue, especially given its impact on the developing teenage brain.

This summer, my laboratory at the University of Texas at Austin welcomed a bright high school student as a volunteer. Members of my lab are interested in how hormones act in the brain to influence response to drugs of abuse. This student was engaged in primarily archival research on this topic.

During her time with us, I assigned her a recently published review article on the potential effects of various drugs on the developing teenage brain [1]. Given her aptitude and enthusiasm, I expected her to find the article accessible. However, while she understood and processed most of the material, she struggled with some of the more complex aspects of the paper. It then dawned on me that even highly capable teenagers might find it challenging to capture such crucial information about drugs and the teenage brain.

The teenage years are a time of significant brain development, and understanding how drug abuse might impact this process is important for young people, not just brain scientists. This recognition led to the collaborative project presented below, where we coauthored this entry, hoping to make some of the science behind drug effects on the teenage brain more accessible from the standpoint of a teenage student. In this piece, we discuss key points from the review article and explore how different substances can affect the brain during this critical stage of development. It is our hope that this entry will reach the most relevant audience for this topic: teenagers.

In 2022, over 70 million teenagers reported using some form of illegal drug. By 2023, more than 30 percent of high school seniors admitted to using drugs in the past year. The immediate dangers of substance use are well-known, but for teenagers, the risks extend beyond the immediate. The teenage brain is in a crucial stage of development, making it particularly susceptible to the potential long-term impacts of drugs.

As many teenagers may have heard from their parents, drug use is especially dangerous during these years because the brain is still developing. Unfortunately, as much as teenagers don’t want to hear it, this isn’t just parental advice; it’s the reality. This has real implications for the long-term health and well-being of young people. The brain is constantly changing during adolescence , making teenagers more susceptible to the effects of drugs.

Substance use disorder is characterized by three main features: a compulsion to take the drug, an inability to control intake, and the emergence of negative emotions when not using the drug. Drug addiction includes both impulsive and compulsive behaviors ; impulsive disorders are marked by tension and excitement before acting, while compulsive disorders involve anxiety and relief after the act. The transition from impulsive to compulsive drug-taking characterizes a shift from a positive to a negative drive for substance use, a pattern that has both a significant social and economic cost. Drug addiction literally changes the brain’s pathways, and these changes don’t just disappear when someone stops using drugs.

Teenagers are particularly vulnerable to drugs for several reasons.

One key area of the brain that isn’t fully developed during the teenage years is the frontal lobe, which is responsible for rational decision-making and self-regulation . This lack of development makes it harder for teenagers to control their drug use, increasing the risk of addictive disorders.

The frontal lobe also helps regulate emotions, so when it is underdeveloped, teenagers may struggle while coping with stress and are more likely to turn to unhealthy coping mechanisms like drug use. In addition, while most teenagers understand the short-term dangers of drug use, such as alcohol poisoning, lung damage from smoking, or the risk of overdosing, many of them are less aware of the long-term effects. Drugs can effectively alter the developing brain, affecting not only the likelihood of drug abuse but also other aspects of mental and physical health into adulthood.

While the ways that drugs affect the teenage brain is still a topic of great interest to many behavioral neuroscientists who study it to this day, we already have significant insight into the changes that can be impacted by drugs in this stage of development. The teenage brain is still developing, and this rapid process continues until the mid-20s, when it experiences a significant slowdown.

During adolescence, the brain’s neural pathways are not fully developed. This can make the integration of reward stimuli stronger, meaning that, on average, emotions and drug effects are felt more strongly by teenagers than by adults. This increased intensity can make teenagers more susceptible to addiction.

The brain’s reward pathways, which encourage the repetition of activities that provide pleasure (reinforcement), are also very sensitive during adolescence. When drugs disrupt the balance of neurotransmitters, the brain starts to reroute these pathways to reward drug use, leading to a cycle of dependence and abuse.

While most drugs act in the same brain reward systems, the specific changes and effects may be different. The following includes a general description of the effects of some of the more widely used drugs in teenagers.

Nicotine: Research shows that teenagers find nicotine more pleasurable than adults. Nicotine binds to receptors in the brain, triggering the release of dopamine , which creates a sensation of feeling good. Over time, the brain creates more of these receptors, leading to cravings and dependence. The developing reward system in teenagers makes them particularly vulnerable to nicotine addiction .

Cannabis: Teens’ brains react differently to cannabis compared to adults. While adults may experience heightened anxiety and reduced movement after using cannabis, teenagers are less affected by these aversive effects, leading to increased use. This increased use can have effects on memory , cognition , and IQ . Additionally, early cannabis use has been linked to greater sensitivity to other drugs, like cocaine, later in life.

Alcohol: Adolescents metabolize alcohol faster than adults, meaning it leaves their system quicker. However, drinking alcohol during adolescence can negatively impact the development of the hippocampus, the brain region responsible for memory formation. Teens are also more sensitive to the rewarding effects of alcohol, which increases the risk of binge drinking and addiction.

Cocaine: Cocaine creates a surge of neurotransmitters like dopamine, leading to a short-lived high followed by a crash. Teenagers are less sensitive to cocaine’s effects than adults, but their sensitive reward system makes them more prone to addiction. The impulsive decision-making, which is common in teenagers, is worsened by cocaine use and can lead to immediate dangers and long-term damage to the brain.

Opioids: Opioids are particularly dangerous due to their high risk of addiction and overdose. Teenagers exhibit greater levels of sensitization to opioids, leading to a quicker development of dependence. The combination of a developing reward system and greater sensitization to opioids makes teenagers more likely to engage in drug-seeking behaviors, increasing the risk of addiction and overdose.

In summary, being a teenager comes with a multitude of new experiences, challenges, and responsibilities. The brain is in a crucial stage of development, adapting to new physical, social, and academic situations. However, this growth also makes teenagers more vulnerable to the effects of substances. The part of the brain responsible for impulse control and decision-making isn’t fully mature, which can lead to risky behaviors and poor decision-making. Understanding the potential effects of drug use on the developing brain is essential to help educate those who are most susceptible and for preventing substance use disorder, thereby promoting long-term health.

[1] Ahmadi-Soleimani, S. M., Salmanzadeh, H., & Azizi, H. (2023). Experimental Evidence on Age-related Differential Outcomes Associated With Substance Abuse. Basic and Clinical Neuroscience, 15(1), 27-36. http://dx.doi . org/10.32598/bcn.2023.587.1

Juan Dominguez, Ph.D. , is a professor at the University of Texas.

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Home — Essay Samples — Nursing & Health — Substance Abuse — Impact of Drug Addiction on Society

Impact of Drug Addiction on Society

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Levels of Drugs in the Wastewater of Canadian Cities

Experimental information.

The data are considered preliminary and are therefore subject to change in the future.

Note: This visual will timeout after 15 minutes of inactivity. Refreshing the page will reload the visual; however, any changes made will be lost.

The data used to create this interactive web application is from the following data table:

The data used to create this interactive web application is from the following listed data tables:

• Drug metabolites in wastewater in select Canadian cities, by month, 2022 to 2023

Additional information

The purpose of the Canadian Wastewater Survey (CWS) drug component is to measure the levels of drug residues from controlled and illegal drugs in the wastewater of several municipalities across Canada. The CWS collects wastewater in 7 municipalities: Halifax, Montréal, Toronto, Prince Albert, Saskatoon, Edmonton, and Metro Vancouver. Combined, these cities cover a population approaching 9 million people. The number of wastewater treatment plants from which samples were collected in each municipality is as follows: Halifax (3), Montreal (2), Toronto (4), Prince Albert (1), Saskatoon (1), Edmonton (1), Vancouver (5). Data from the CWS provide information that complements and enhances other Statistics Canada programs related to economic and social statistics that include health and lifestyle conditions. Although the CWS started collection in 2019, this dashboard displays data from 2022 to 2023.

Wastewater-based epidemiology

Measuring drug levels in wastewater can complement other sources of data on drug use (e.g. deaths, drug seizure data) by providing information on geographical and temporal trends. After a drug is used, the body breaks it down, producing drug metabolites that are excreted in feces and urine and enter the wastewater system. Some amount of the consumed drug (parent drug) can be excreted intact alongside its metabolites. The measurement of specific metabolites in the wastewater can reflect the use of their parent drugs by the population serviced by the wastewater plant. By considering the number of people served by the wastewater treatment plant, a value of daily excreted amount of drug per capita can be calculated (daily load per capita).

Importantly, the values presented are estimates of the excreted amount of drug metabolites in the wastewater and do not correspond directly to consumption levels of the parent drugs . Another source of the parent drug in wastewater could be unconsumed drug dumped into the sewer system.

Wastewater samples are collected for seven consecutive days starting the second Monday of every month (2022) or the second Wednesday (2023). Each sample is a composite of 24 hours of influent arriving at the wastewater treatment plant. The samples are shipped to a laboratory of the Health Canada’s Regulatory Operations and Enforcement Branch in Toronto (Ontario) and analyzed by mass spectrometry to measure drug metabolites concentrations. The daily loads per capita are calculated by considering the total volume of influent arriving to the treatment plant in the day of sampling and the estimated population in the sewershed. The population estimates based on 2021 StatCan Census of Population and projected forward using growth estimates for the census subdivisions including each treatment plant catchment. Missing samples were multiply imputed to create valid monthly estimates and variances. The imputation model accounts for the location, month, day of week of the missing samples and substances’ levels in the wastewater for other days of the week. From the daily results, the CWS produces monthly estimates of levels (mass loads per capita) of drug metabolites in the wastewater of each municipality.

Measured substances

The CWS currently includes estimates for ten substances. Among them are excreted products of controlled and illegal drugs .

Some drug metabolites are exclusive to their parent drug, such as benzoylecgonine to cocaine, i.e. they are not excretory products of any other drug's metabolism. Because they clearly point to a particular drug, these metabolites are ideal targets for wastewater-based drug epidemiology. Unfortunately, not every drug of interest has such suitable specific metabolites.

• Amphetamine : a widely used stimulant.
• Cannabis (THC-COOH): a derivative of tetrahydrocannabinol which is the primary psychoactive compound in cannabis.
• Cocaine (Benzoylecgonine) : the primary and an exclusive metabolite of cocaine, a stimulant drug.
• Codeine : a prescription painkiller medication and also available in some places as an over-the-counter medication. Codeine is metabolized to morphine and excreted as unchanged codeine.
• Fentanyl (Norfentanyl) : the primary metabolite of fentanyl, a potent prescription painkiller medication that is often obtained from illicit sources and misused.
• Ecstasy (MDMA): 3,4-methylenedioxymethamphetamine (MDMA) is ecstasy also known as "molly", a psychoactive drug used for recreational purposes.
• Methadone : a synthetic drug used to treat opioid dependence and chronic pain.
• Methamphetamine : a potent stimulant drug.
• Morphine : a potent painkiller medication. Many opiates produce morphine when metabolized. For example, morphine is the most abundant metabolite of heroin and of its main metabolite, 6-monoacetylmophine. Morphine is also an excretory product of morphine itself and its derivatives, and of codeine. Thus, consumption of codeine and of other drugs that contain codeine derivatives will also contribute to morphine levels in the wastewater.
• Oxycodone : a prescription painkiller medication that is often obtained illegally and misused.

Limitations and other considerations

Wastewater-based epidemiology is an inexpensive and powerful tool for estimating city-level drug consumption. However, there are some limitations in the analysis and interpretation of estimates from wastewater samples:

• The CWS is not designed to produce data that is representative of the entire Canadian population.
• The population coverage by the area served by the wastewater treatment plant varies for each municipality.
• The results from the analysis do not provide insights about those who use drugs, such as their demographics, drug co-consumption, or specific location. They can only provide information about the overall drug consumption trends in the region.
• Moderate and small differences between cities must be interpreted carefully since each city's wastewater sewershed is different and that can be in part the source of the differences in results between cities. Some cities can have larger floating populations.
• Drug residues degrade in the wastewater and may be converted into other compounds. It is important to note that the absence of detection of a drug residue in the wastewater does not necessarily mean the parent drug was not consumed. For example, this could be due to high chemical instability of the drug metabolite in wastewater. This loss of residue can occur at different stages: in wastewater, in transport after collection, and in storage (at decreased intensity due to the frozen storage of the samples, which may affect comparability of the results between two different time frames).

Subedi, B. & Burgard, D. (2019). Wastewater-Based Epidemiology as a Complementary Approach to the Conventional Survey-Based Approach for the Estimation of Community Consumption of Drugs. Wastewater-Based Epidemiology: Estimation of Community Consumption of Drugs and Diets . Ed(s) Subedi, B., Burgard, D., & Loganathan, B. ACS Symposium Series; American Chemical Society. Washington, DC. https://pubs.acs.org/doi/pdf/10.1021/bk-2019-1319.ch001

• Wastewater analysis and drugs, a program of the European Union Drugs Agency
• National Wastewater Drug Monitoring Program reports of the Australian Criminal Intelligence Commission

How to use this interactive visual

The dropdown menu Select a substance allows the user to select one of the substances currently measured by the drug component of the Canadian Wastewater Survey (CWS).

The dropdown menu Select one or multiple cities allows the user to select one or multiple cities where the CWS currently collects. Selecting a previously selected city will unselect it. A plot will be produced showing the estimates of average daily amounts of the substance in wastewater per capita (also referred to as daily loads) across time for the selected substance for each of the selected cities. The error bars correspond to standard errors. It is also possible to select " All cities combined ". That consists of a combined population-weighted estimate of all the cities available for each month. To exit this menu, click on the text box or anywhere else or hit the Tab key.

The content will be updated dynamically, according to the selections.

It should be noted that, by default, the scale of each plot is different: when the check box Show free scales is selected each displayed plot will have its own independent scale along the daily load per capita axis (y-axis). This can be useful for some drugs whose loads ranges vary greatly from city to city, making it easier to see patterns within each panel. Unchecking Show free scales will show all the cities with the same scale.

Optionally, the period of collection can be selected with Start of the collection period and End of the collection period . The CWS collected monthly in 2022 and every other month in 2023. By default, the timeline corresponding to the selected period range is displayed. Select the Show year to year comparisons check box to compare the corresponding months of 2022 and 2023.

More information

Note of appreciation.

Canada owes the success of its statistical system to a long-standing partnership between Statistics Canada, the citizens of Canada, its businesses, governments and other institutions. Accurate and timely statistical information could not be produced without their continued co-operation and goodwill.

Standards of service to the public

Statistics Canada is committed to serving its clients in a prompt, reliable and courteous manner. To this end, the Agency has developed standards of service which its employees observe in serving its clients.

Published by authority of the Minister responsible for Statistics Canada.

Use of this publication is governed by the Statistics Canada Open Licence Agreement .

Catalogue no. 71-607-X