Resources on the Overdose Crisis

Below is a collection of resources on the overdose crisis compiled by the policy development committee. Accompanying summaries for each resource may be taken directly from the source.

1. Statistics

BC Reports

  • BC Centre of Disease Control Overdose Response Reports: Includes data trends of illicit drug overdose events (weekly/monthly update graphs broken down by health region), knowledge updates + publications, infographics and maps.

  • Escalating BC's response to the overdose emergency: In September 2017, the provincial government announced a three-year, $322 million investment for comprehensive interventions focused on saving lives, connecting people to treatment and recovery, and addressing some of the root cause issues connected to problematic substance use, such as stigma. The response focuses on six key areas:

  1. Saving lives

  2. Ending stigma

  3. Building a network of treatment and recovery services

  4. Creating a supportive environment

  5. Advancing prevention

  6. Improving public safety

  • BC Ministry of Finance Budget and Fiscal Plan 2019/2020-2021/2022 (pg 13-14): $30 million over the fiscal plan has been provided to increase efforts in responding to the opioid overdose emergency in BC. Funding is directed to initiatives already being delivered by BC Emergency Health Services and BC CDC.

  • Response to the Opioid Overdose Crisis in Vancouver Coastal Health (VCH, 2019): The impact of the crisis has been uneven across VCH; Vancouver has had the highest overdose death rate of any area in the province, almost 10 times higher than the death rate in Richmond, which is the lowest in the province. Within Vancouver, the Downtown Eastside is the community most affected. Within the Coastal area, death rates are higher in some rural communities than in some urban centres. The most affected population in VCH faces greater social and economic inequalities than populations affected elsewhere. Those who died in VCH in 2017 were less likely to be employed and more likely to live in social or supportive housing than those who died outside VCH. Most of those who died used multiple substances including opioids, alcohol and stimulants such as cocaine and crystal meth. A significant percentage of those who died of opioid overdoses had primary alcohol use disorder and/or stimulant use disorder. Most of those who died had contact with VCH or PHC services in the year before death, with the Emergency Department the most common service accessed. In particular, St. Paul’s Hospital Emergency Department sees the highest number of patients with overdoses of all hospitals in BC. Most of those who died who used opioids daily had been on opioid agonist therapy (OAT) in the past, but were not retained on treatment.

  • Responding to BC's Public Health Emergency - Progress Update January to July 2020 (Ministry of Health): Progress report including mortality statistics, fentanyl detection rates, and the impact of COVID-19.

  • Joint Statement of Action to Address the Opioid Crisis: A Collective Response - Annual Report 2016-2017 (Canadian Centre on Substance Use and Addiction): A document created after the 2016 opioid conference and summit, that outlines the federal government and 30+ partnered organizations response to the crisis to date (pg 7-11 outlines actions taken to date).

  • Overdose Response Indicators (BCCDC): The indicators contained in this report measure progress on interventions across the province, and can be viewed at the provincial or regional health authority level, broken down by age and sex where possible. This report is updated monthly using the most up to date data available on each indicator. The interpretive text is updated quarterly.

  • Results of the Survey on Opioid Awareness, November 2017 (Statistics Canada): Opioid Awareness survey conducted by statistics Canada, highlighting the awareness of the general population in regards to the opioid crisis, how to recognize an overdose, willingness to assist in an overdose, stigma around the issue and more.

BC and International Landscape

  • Development and characteristics of the Provincial Overdose Cohort in British Columbia, Canada (PLOS ONE, 2019): Creation of an Overdose Cohort in BC that links public health surveillance, administrative health care data and records of opioid-related overdoses (fatal and non-fatal) to better enable understanding of how experience with the health system before and at the time of an overdose may interact with outcome. Compiled list of 14,292 overdose events between Jan 2015 and Nov 2016. Some statistics out of this cohort include: (1) 24% of fatal overdoses occurred in the most socially deprived category of individuals, despite only 14% of the reference cohort being in this category. (2) The vast majority of events (91%) were non-fatal. (3) Non-fatal events were more common in females, younger individuals. (4) In the majority of illegal drug deaths (78%) there was no ambulance response and only 12% were seen in emergency departments.

  • Known fentanyl use among clients of harm reduction sites in British Columbia, Canada (International Journal of Drug Policy, 2020): Previously assumed that exposure to illicit fentanyl among people who use drugs (PWUD) is primarily unknown and comes from a number of sources such as counterfeit prescription opioid tablets, heroin laced with the fentanyl, illicit fentanyl patches, and stimulants contaminated with fentanyl, however more recent evidence suggests otherwise. This article evaluated this by recruiting 486 clients. Findings: 64% had knowingly used fentanyl and high prevalence of known fentanyl use among PWUD in BC is in line with more recent studies in BC and USA suggesting an increasing number of PWUD use fentanyl knowingly

  • Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program (International Journal of Drug Policy, 2019): Overall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help.

  • Recent changes in trends of opioid overdose deaths in North America (Substance Abuse Treatment, Prevention, and Policy, 2020): Analyzed recent data from the United States, Ontario and British Columbia to examine trends in opioid overdose deaths to inform the public health response. The opioid crisis has evolved in North America, as a sizeable proportion of overdose deaths are now attributable to the several regulatory and environmental changes. These findings necessitate substance use policies to be conceptualized more broadly as well as the continued expansion of harm reduction services and types of pharmacotherapy interventions.

  • Evidence synthesis - The opioid crisis in Canada: a national perspective (Health Promotion and Chronic Disease Prevention in Canada, 2018): A review of the opioid crisis on a national scale, highlighting key statistics, trends, and current knowledge surrounding the opioid crisis. Highlights the disproportionate numbers of individuals impacted by the crisis, especially in BC. Provides a good understanding of the burden the opioid crisis has on the healthcare system in terms of hospitalizations, and also the degree of morbidity and mortality on our population.

  • Federal Response to the Opioid Crisis (Current HIV/AIDS Reports, 2018): US federal response to the opioid crisis. Key strategies include: 1)surveillance 2)advancing practice of pain management 3) improve access to addiction prevention and recovery support 4) target availibility of overdose reversing drugs 5) support research to advance understanding of pain and addiction

Prescription Practices

  • Prescription-related risk factors for opioid-related overdoses in the era of fentanyl contamination of illicit drug supply (Substance Abuse, 2020): A retrospective case-control study (Substance Use, 2020): Retrospective case-control study on the association between prescription medications as a risk factor for opioid overdose. Those with overdose were less less connected to health services compared with controls. For opioids related to pain, current therapy was associated with experiencing an overdose (OR ¼ 8.5, 95%CI: 7.3–10); history of long-term use had a stronger association than history of short-term use (OR ¼ 2.9, 95%CI: 2.6–3.3 vs OR ¼ 1.7, 95%CI: 1.5–1.8, respectively). While persons on methadone and buprenorphine (MOUD) were more likely to overdose compared to persons who were not on therapy (OR¼ 2.0, 95%CI 1.7–2.4), recent discontinuation of MOUD greatly increased the likelihood of overdose (OR ¼ 25.6, 95%CI 17.5–37.4). Active therapy of benzodiazepines and other sedating medications also significantly increased the likelihood of overdose.

  • Patterns, Changes, and Trends in Prescription Opioid Dispensing in Canada, 2005–2016 (Pain Physician, 2018): Compares rates of prescription opioid (PO) dispensing in Canada between provinces, from 2005-2016. Divided POs into 'strong' and 'weak' subtypes, and analyzed change in 'strong'/'weak' dispensing ratios. Noted that 'strong' PO formulations have changed in some regions of Canada, with substantial decreases for oxycodone occurring alongside substantial increases in hydromorphone, fentanyl, and to some extent – morphine formulations. States that this "substitution effect" where reductions in oxycodone dispensing occur alongside increases in the other 'strong' PO formulations have been observed elsewhere/US.

      • BC pattern:

          • Higher strong/weak PO ratio in 2016 vs 2005, However, in later in its observed timeline, the article notes that 'strong' PO dispensing has been reducing in BC due to extensive policy measures, however this has shown limited impact as public health harms continue

          • More hydromorphone dispensing in BC than before (73% more in 2016 vs 2015); hydrocodone, hydromorphone, oxycodone, fentanyl, meperidine, and morphine formulations were defined as ‘strong’ opioids

  • Impact of legislation and a prescription monitoring program on the prevalence of potentially inappropriate prescriptions for monitored drugs in Ontario: a time series analysis (CMAJ Open, 2014): A review of the Narcotics Monitoring System that was implemented in Ontario to track prescriber, patient, and pharmacy information for all opioid prescriptions. This review defines "inappropriate prescribing" as a single patient having a prescription to an opioid following a prescription for drug of the same class dispensed at a different pharmacy or from a different prescriber. This policy intervention looks at the benefits of tracing the three key elements that may lead to over-prescription/over-dispensing of opioids.

  • Real‐time monitoring of Schedule 8 medicines in Australia: evaluation is essential (Medical Journal of Australia, 2013): The use of a Real-Time Reporting system in Tasmania, Australia has been implemented to try and mitigate the prescription of opioids. The system may provide information that helps decision making regarding whether or not to prescribe opioids based on other medications/history, especially in an ER setting.

  • Prescription opioid dispensing in Canada: an update on recent developments to 2018 (Journal of Pharmaceutical Policy and Practice, 2020): British Columbia had the largest decline in strong prescription opioid (PO) dispensing in Canada from its peak rate (− 48.5%) in 2011. In 2018, BC featured the lowest strong PO and lowest weak PO dispensing rate.

  • Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015–2016 (Drug and Alcohol Dependence, 2019): The opioid epidemic is commonly thought to be strongly influenced by prescription of pharmaceutical opioids; this article offers some counterpoints to this and found the following for BC's drug overdose cases:

      • Most people did not have a prescription for an opioid for pain when they overdosed.

      • Half of cases had no opioid for pain prescriptions in past five years before overdose.

      • Prescriptions for psychoactive medications were common among people who overdosed.

      • Current or past use of medications to treat opioid use disorder was uncommon.

      • Regulation of prescribing may have limited short-term impact on the current opioid crisis.

Recent Media

2. Decriminalization

Current Canadian Context

International Landscape

  • The temporal relationship between drug supply indicators: an audit of international government surveillance systems (BMJ Open, 2013): This epidemiological multi-country study looked at government drug surveillance databases in several countries at price of drugs and purity or potency of drugs over time (minimum 10 year period), identifying what associations these factors had with the degree of drug prohibition policy. They found that potency/purity generally increased, while price decreased, over time while national spending on drug enforcement increased, and the authors argue that this finding suggests that efforts at controlling illegal drugs through prohibition/enforcement are failing.

  • The public health and social impacts of drug market enforcement: A review of the evidence (International Journal of Drug Policy, 2005): This narrative literature review looks at how police activities in drug markets affect the health and practices of people who use drugs, the delivery of healthcare, and the effects on surrounding communities. Some important findings include (1) enforcement has little effect on drug price, availability, or frequency of use, (2) drug markets are resilient to, and minimally affected by, enforcement activities, and (3) policing enforcement practices are associated with a breadth of harms, and there are a number of novel large and small-scale alternatives/modifications to drug market enforcement which may be more cost-effective and associated with less harm.

  • Is Decriminalisation Enough? Drug User Community Voices from Portugal (INPUD): A 2018 report by INPUD, the International Network of People who Use Drugs, discussing the impacts of Portugal's decriminalization of small amounts of drugs on drug users. Despite the improvements made, there are still harms being done against people who use drugs under this model: in particular, decriminalizing substances without fully legalizing them has meant that there are still problems with substance quality/purity, and people who use drugs are still highly policed and subjected to violence and discrimination. They stress that the partial decriminalization model is a first step, not a final step.

  • Public health and international drug policy (Lancet, 2016): This discusses the failed policies stemming from a view of drugs as "evil", and the damage done to people who use these drugs. Briefly reviews successful harm-reduction initiatives such as decriminalization in Portugal and the Czech Republic, as well as Vancouver's supervised injection sites and heroin-assisted treatment. Recommends a range of policy alternatives including decriminalization, harm reduction, access to controlled medicines and regulating the drug market. Urges policy makers to consider the evidence base in health and social sciences and public policy.

  • Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies (Cato Institute Whitepaper Series): This report examines the Portuguese decriminalization framework, which has shown: 1) postdecriminalization usage rates have remained roughly the same or even decreased slightly when compared with other EU states, 2) drug-related pathologies — such as sexually transmitted diseases and deaths due to drug usage — have decreased dramatically, 3) Drug policy experts attribute those positive trends to the enhanced ability of the Portuguese government to offer treatment programs to its citizens — enhancements made possible, for numerous reasons, by decriminalization.

  • What Can We Learn From The Portuguese Decriminalization of Illicit Drugs? (The British Journal of Criminology, 2010): This study examines Portugal's drug decriminalization in 2001, and analyses the criminal justice and health impacts against trends from neighbouring Spain and Italy. It concludes that contrary to predictions, the Portuguese decriminalization did not lead to major increases in drug use. Indeed, evidence indicates reductions in problematic use, drug-related harms and criminal justice overcrowding.

  • Drug Decriminalization in Portugal: Learning from a Health and Human-Centered Approach (Drug Policy Alliance): Press release from the Drug Policy Alliance highlighting the impact of drug decriminalization in Portugal. Among many outcomes, the paper indicated an 80% decrease in overdose-related deaths in Portugal following decriminalization.

  • Public Health Approach to Drug Use in Asia: Principle and Practices for Decriminalisation (IDPC): A recommendation for guiding drug policy developed by the International Drug Policy Consortium (IDPC). Focused on drug use in Asia, but provided beneficial evidence for decriminalization, diversion, and harm reduction services in managing the opioid crisis in Asia.

Recent Media

3. Harm Reduction and Safer Supply

Current Canadian/BC Guidelines

Current Canadian Context

Intranasal Naloxone Availability in BC and Canada

International Context

Recent Media