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.
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:
Building a network of treatment and recovery services
Creating a supportive environment
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-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.
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.
Current Canadian Context
Decriminalization of Personal Use of Psychoactive Substances (Canadian Public Health Association Position Statement) : This 2017 position statement calls on the Federal Government to work with provinces and territories to decriminalize the possession of small amounts of psychoactive substances for personal use and provide alternatives to criminal summary convictions for offenses against the revised drug law, including the option to pursue treatment for a SUD. There are a number of other recommendations made as well, including providing amnesty for those previously convicted of drug-related offenses for possession of small amounts of psychoactive substances.
Decriminalization: Options and Evidence 2018 (Canadian Centre on Substance Use and Addiction): This policy brief reviews the various ways in which decriminalization of controlled substances is being interpreted and implemented internationally and in Canada.
Ministerial Mandate Letter to the Minister of Mental Health and Addictions: This letter from Premier Horgan expects a move towards decriminalization by working with police chiefs to push Ottawa to decriminalize simple possession of small amounts of illicit drugs for personal use; or, in the absence of prompt federal action, the development of a made-in-B.C. solution that will help save lives.
Decriminalization people who use drugs - a primer for municipal and provincial governments (HIV Legal Network): This primer outlines steps for municipal and provincial governments to decriminalize drug possession for personal use (i.e. “simple drug possession”) in their own jurisdictions.
After the War on Drugs: Blueprint for Regulation Executive Summary (Transform Drug Policy Foundation): A report that proposes specific models of regulation for each main type and preparation of prohibited drug, coupled with the principles and rationale for doing so.
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.
3. Harm Reduction and Safer Supply
Current Canadian/BC Guidelines
Current Canadian Context
Stimulus Connect - My Safe Supply: A webinar put on by the drug-use conference/coalition, featuring discussion from drug policy experts and Canadians who use drugs and what they want in a safe supply. People who use drugs share their experiences advocating for safe supply, trying to access safe supply, and living with safe supply. There is a focus on autonomy and access for people who use the safe supply. The website also has a list of 45 articles/sources relevant to safe supply.
A safer drug supply: a pragmatic and ethical response to the overdose crisis (CMAJ, 2020): Dr Mark Tyndall (former BC CDC Director) writes about what a pragmatic safe supply is and how it is an ethical response to the overdose epidemic.
Regarding Issues of the Safe Supply Options for Opioids in the “Risk Mitigation in the Context of Dual Public Health Emergencies” Guideline (Canadian Association for Safe Supply): A briefing note on issues regarding safer supply options currently available.
“It’s Helped Me a Lot, Just Like to Stay Alive”: a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada (Journal of Urban Health, 2020): A qualitative study on the effect of a novel hydromorphone tablet distribution program run in DTES, Vancouver, Canada. Patients report decreased use of illicit drugs, as well as improvement in well-being in terms of decreased injections, better pain management, and improved economic security.
Take Home Naloxone Program Report - Review of Data to December 2018 (Toward the Heart and BCCDC): A review of the Take Home Naloxone Program. Pg 24/25 summarize key findings + recommendations. These include the number of kits shipped and distributed (35.7% of kits distributed were used to reverse an overdose). Also reveals key findings related to 911 calling, rescue breathing, transport to hospital, the requirement of 2 naloxone doses and that most individuals don't experience adverse effects to naloxone.
Mobile supervised consumption services in Rural British Columbia: lessons learned (Harm Reduction Journal, 2019): Overall, the mobile supervised consumption services (SCS) were a viable alternative to a permanent site but presented many challenges that undermined the continuity and quality of the service. A mobile site may be best suited to temporarily provide services while bridging towards a permanent location. A needs assessment should guide the stop locations, hours of operation, and scope of services provided. Finally, the importance of community engagement for successful implementation should not be overlooked.
Impact of overdose prevention sites during a public health emergency in Victoria, Canada (PLOS ONE, 2020): Impact of overdose prevention sites in Victoria: zero deaths; earlier intervention to prevent overdoses and reduced trauma; more comprehensive implementation of harm reduction with the introduction of safer spaces for use, mitigation of stigma, and enhancement of the development of trust and relationships.
Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency (International Journal of Drug Policy, 2018): Discusses the need for harm reduction in shelters for the homeless population and challenges of implementing an overdose response when substance use is prohibited onsite. Shelters can be a site of risks and trauma for residents and staff due to experiencing, witnessing, and responding to overdoses.
An innovative acute care based intervention to address the opioid crisis in a Canadian setting (Drug and Alcohol Review, 2020): Describes an innovative, inter‐disciplinary model‐of‐care developed to address the needs of patients with a substance use disorder who present to the emergency department for medical care at St. Paul's Hospital in Vancouver, British Columbia. A range of addiction treatment modalities are offered, including withdrawal management, opioid agonist treatment (induction and stabilisation), alcohol and drug counselling and alcohol relapse prevention.
Safer opioid distribution in response to the COVID-19 pandemic (International Journal of Drug Policy, 2020): A commentary by Dr. Mark Tyndall (former BC CDC Director) on safer supply in the COVID-19 pandemic. Argues that COVID-19 makes safe supply all the more necessary.
Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study (Drug and Alcohol Dependence, 2020): Examines engagement with a hydromorphone distribution program in Vancouver, Canada. Barriers included operating hours, dosing schedule, and generic formulations. Facilitators included reliable source of opioids, agency, and program flexibility. Location in overdose prevention site a barrier and facilitator depending on needs. Such programs represent promising intervention to address the overdose crisis.
Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment (CMAJ, 2012): This epidemiological cost-effectiveness study using data from the North American Opiate Medication Initiative (in BC), found that while direct costs of diacetylmorphine (heroin) for treating refractory OUD are higher than direct costs of methadone, there is a net benefit in cost-effectiveness to diacetylmorphine considering indirect costs (particularly related to costs related to reduced criminal activity). Diacetylmorphine is also known to be more clinically effective (see: Phase 3 RCT in Canada). This study might support prescription heroin policy initiatives and heroin-based safe-supply policy initiatives.
Safe supply: The debate around prescribing opioids to people who use drugs (Healthy Debate): Opinion article discussing the debate around safe supply. Features Dr. Nanky Rai, a physician in Toronto, an advocate of safe supply, who discusses her experiences with safe supply for her patients.
Safe Supply Concept Document (Canadian Association of People Who Use Drugs): This report is a general outline of the “safe supply” concept, of what safe supply is, and the role of safe supply in drug policy. The purpose of this document is to provide clarity to what is meant by the term “safe supply” with a mind to keeping conversations on point when safe supply and drug policy are being discussed.
Opioid Overdose Prevention and Response in Canada (Canadian Drug Policy Coalition): Policy brief with recommendations divided into provincial and federal components. Examples of provincial: Add naloxone to provincial formularies, co-prescribe naloxone to patients at risk of opioid overdose, and transition plan & primary care support when an opioid is delisted. Examples of federal: Good Samaritan legislation for calling 9-1-1, naloxone availability in rural areas, naloxone available over the counter, and national data collection.
Securing Safe Supply During COVID-19 and Beyond: Scoping Review and Knowledge Mobilization: There is a low level of peer-reviewed evidence on safe supply models. Further, this evidence explores themes that are largely distinct from the priorities of people who use drugs (PWUD) who would benefit from safe supply and require services that are resilient to interruptions such as the COVID-19 pandemic. Given the clear need to address the epidemic-level risk of overdose mortality stemming from the unregulated (street) drug supply, the focus of public health systems in Canada should be to urgently scale up safe supply and retrospectively assessing the best model for delivery.
Intranasal Naloxone Availability in BC and Canada
Pharmacokinetic properties of intranasal and injectable formulations of naloxone for community use: a systematic review (Pain Management, 2018): Systematic review looking at pharmacokinetics of injectible vs nasal naloxone. Comparing intranasal spray with a concentrated naloxone dose of 2 or 4 mg in 0.1 ml and an auto-injector for intramuscular (im.) or subcutaneous (sc.) use with a naloxone dose of 0.4 or 2 mg. Both the approved intranasal spray and the im./sc. auto-injector demonstrated sufficient plasma exposure within the first 15–20 min after administration. Usability studies with laypersons in simulated overdose conditions have found that more than 90% of participants were able to successfully administer naloxone using the approved intranasal spray or im./sc. auto-injector without prior training; however, these studies have identified critical errors with the proper assembly and use of unapproved intranasal kits, even when training had been provided. Approved intranasal naloxone is appropriate for most patients, with the exception of those with known nasal pathology (e.g., polyps and chronic intranasal drug use).
Access to naloxone in Canada (including NARCAN™ Nasal Spray): Summary of Interim Order signed by Minister of Health that allowed importation of the NARCAN® Nasal Spray from the U.S. from July 6 2016 to July 5, 2017 (for 1 year only). To avoid any interruption in supply, the Health Canada-approved NARCAN™ Nasal Spray was made available for sale in Canada by the date of expiry of the Interim Order.
Why aren't physicians prescribing more buprenorphine? (Journal of Substance Abuse Treatment, 2017): Surveyed American physician attitudes towards buprenorphine prescription.
Perspectives on Drugs - Preventing Overdose Deaths in Europe (European Monitoring Centre for Drugs and Drug Addictions): Interventions with the most success in Europe have been (pg 2-4 summary of interventions): increased awareness of overdose risk (e.g. e-risk assessment), opioid substitution treatment, education and treatment for those released from prison, supervised drug consumption facilities, and improving bystander response (training families and peers of high-risk individuals).
Opioid overdose: preventing and reducing opioid overdose mortality (United Nations Office on Drug and Crime/WHO): Discussion paper recommending greater availability and access to naloxone, especially by healthcare providers and first responders. They also recommend over the counter naloxone, community distribution, and a focus on incarcerated populations post-release. Naloxone access should be analogous to that of epipens: anyone at risk of opioid overdose, and their close contacts, should have access to naloxone (pg 21-22: recommendations for naloxone distribution programs).
4. Resources for Engagement