Drug-Related Overdose Deaths in British Columbia and Ontario, 1992-2004
Fischer, Benedikt, Popova, Svetlana, Rehm, Jürgen, Ivsins, Andrew, Canadian Journal of Public Health
Objective: To compare rates of fatal drug-related overdose death (OD) cases - a major harm outcome of illicit substance use - in the two provinces of British Columbia (BC) and Ontario, and the two largest municipalities in those provincial jurisdictions, namely the cities of Vancouver and Toronto, between 1992 and 2004.
Methods: Provincial coroners' data of drug-related OD cases for the provincial jurisdictions of BC and Ontario, and the municipal jurisdictions of Vancouver and Toronto, are descriptively presented and compared.
Results: After drastic increases in the initial part of the observation period, OD rates in BC have been declining; moreover, due to major reductions of OD cases in Vancouver, the ratio of OD cases between Vancouver and the province of BC has fallen considerably. Conversely, OD rates in Ontario have remained stable at low levels, whereas Toronto has seen a slight decline in such rates during the observation period.
Interpretation: The recent establishment and expansion of treatment and harm reduction interventions may have influenced the decline of ODs in BC, yet similar interventions in Ontario did not have a similar effect, perhaps due to different patterns of illicit drug use. OD rates in jurisdictions across Canada need to be monitored and analyzed to inform evidence-based policy development.
MeSH terms: Street drugs; overdose; mortality; public policy; Canada
Mortality due to overdose death (OD) is a major harm associated with illicit substance use. Data from Western jurisdictions document that illicit drug user populations feature mortality rates six- to twentyfold that of average populations; each year, 1-2% of active illicit drug users die.1-4 Several Western jurisdictions experienced pronounced periods of increases in OD mortality in the previous decades.4-7 Socio-epidemiological analyses have demonstrated that drug userelated mortality is mostly concentrated in urban centres, where disproportionate numbers of drug users are located.5,8 Research suggests that fluctuations in OD mortality are probably associated with two major categories of determinants, namely a) systematic or environmental, and b) behavioural or user-specific determinants.9 For the former, the role of socio-urban characteristics, drug markets and OD response systems have been identified; for the latter, the importance of drug combinations, administration routes or tolerance (influenced by previous exposure to corrections or treatment) as well as factors of marginalization (housing) have been recognized.3,6,9-13 Specifically, the importance of certain drug combinations (e.g., opioidbenzodiazepine or -cocaine or -alcohol combinations) in OD incidents has frequently been confirmed.6,11,12
Targeted measures can reduce the occurrence of OD fatalities among drug user populations. Effective treatment interventions (e.g., opioid substitution programs) clearly reduce OD risk among drug users, while risk reduction measures (e.g., naloxone provision or Safer Injection Facilities) have been suggested to prevent the incidence or reduce the fatal consequences of overdose.6,14 Jurisdictions in which such interventions have been systematically expanded have witnessed demonstrable decreases in ODs in recent years.5,7
In Canada, there are an estimated 500-1,000 drug-related ODs annually;5,15 more precise figures are hindered by fragmented reporting systems. The province of British Columbia (BC) - and predominantly its main urban centre of Vancouver - made headlines in the mid-1990s with dramatic increases in ODs, peaking at more than one death per day.16,17 On the contrary, OD rates in Ontario have traditionally been low. The specified jurisdictions house some of the largest street drug use populations in the country. At the same time, illicit drug users in Vancouver and Toronto differ considerably in some major characteristics: while Vancouver houses a highly concentrated and visible street drug use population engaging predominantly in (combined) heroin and cocaine injection, Toronto's drug scene is rather dispersed and largely characterized by (in many cases non-injectable) use of a wide range of illicit prescription opioids as well as a high prevalence of oral crack use. …