Premature opioid-related deaths doubled in Canada after the onset of COVID-19 pandemic, and more than one in four deaths occurred in young adults, a new study suggested.

“The intersection of the COVID-19 pandemic with the drug toxicity crisis in Canada has created an urgent need to better understand the patterns of opioid-related deaths across the country to inform targeted public health responses,” the study authors wrote.

Some Canadian provinces were disproportionately affected by the crisis, they noted. For example, in Alberta, close to half of all deaths among people aged 20-39 years were opioid-related.

“Although the finding that the early loss of life was increasing over time was expected, the magnitude of this burden across Canada surprised me,” lead author Shaleesa Ledlie, MPH, a PhD candidate at the Leslie Dan Faculty of Pharmacy of the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News.

In addition to the increase in Alberta, she said, “in Manitoba, opioid-related death rates and the associated years of life lost increased almost fivefold between 2019 and 2021. This really reinforces the urgency of this issue across Canada and identifies regions where focused attention might be warranted.”

The study was published online on April 15 in Canadian Medical Association Journal.

Significant Increases

Researchers conducted a repeated cross-sectional analysis of accidental opioid-related deaths from 2019 through 2021 in nine Canadian provinces and territories. All provinces and territories for which age- and sex-stratified data were available at the time of the study were included: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, and the Northwest Territories. These areas represent 98% of Canada’s population.

Deaths were determined to be accidental or intentional by the coroner or medical examiner in each province or territory who investigated the death, according to Ledlie.

The primary outcome was the burden of premature opioid-related death, measured by potential years of life lost (YLL). The secondary outcome was the proportion of deaths attributable to opioids.

Overall, the annual YLL from opioid-related deaths doubled during the study period, from 3.5 YLL per 1000 population in 2019 to 7.0 YLL per 1000 in 2021.

In 2021, the highest burdens of death were observed among men (9.9 YLL per 1000) and young adults aged 20-29 years (12.8 YLL per 1000) and 30-39 years (16.5 YLL per 1000).

More than 70% of all opioid-related deaths occurred among men each year (73.9% in 2021), and about 25% of deaths occurred among people between the ages of 30 and 39 years (29.5% in 2021).

Geographic Variation

The annual increases by age and sex in each province and territory were generally consistent with the overall analysis. The observed changes in YLL over time varied geographically, however. They ranged from a 0.8-fold decrease in Nova Scotia (1581 YLL in 2019 to 1324 YLL in 2021) to a 4.7-fold increase in Manitoba (2434 YLL in 2019 to 11,543 YLL in 2021).

In 2021, the rate of YLL ranged from a low of 1.4 per 1000 in Nova Scotia to a high of 15.6 per 1000 in Alberta, whereas the absolute number of YLL ranged from 93 in the Northwest Territories to 111,633 in Ontario.

Between 2019 and 2021, the average percentage of all deaths attributed to opioids increased in all age groups. In 2019, 1.7% of deaths among people younger than 85 years were related to opioids. This proportion increased to 3.2% of deaths in 2021.

The largest relative increase between 2019 and 2021 (50.3%) was among young people. Opioid-attributable deaths increased from 19.3% to 29.0% among those aged 30-39 years. This change was followed by a 48.0% increase among those aged 20-29 years from 19.8% to 29.3%.

The authors noted that the study was limited by their inability to examine four provinces and territories for which the numbers of opioid-related deaths were suppressed because of small counts (ie, < 5). However, sensitivity analyses suggested that the demographic distribution of these deaths followed a pattern like that of the overall results.

More Information Needed

Commenting on the study for Medscape Medical News, S. Monty Ghosh, MD, MPH, an assistant professor at the University of Alberta, clinical assistant professor at the University of Calgary, and co-medical lead of Alberta Health Services’ Rapid Access Addiction Medicine program in Calgary, said, “The study was fairly robust in its evaluation. Their approach statistically is sound and makes sense, given the quality of data they received.” Ghosh did not participate in the analysis.

It would be important to know whether the premature deaths were polysubstance related, he noted. “More nuanced data in Alberta demonstrated that most of the deaths are related to polysubstance use on top of fentanyl. This includes alcohol, meth, as well as substance contaminants such as benzodiazepines, and more lately (outside of the research period), xylazine.”

Furthermore, Ghosh added, “It would be good to see more demographic information around the youth in Alberta. For instance, were they housed or unhoused? Are they Indigenous? Anecdotally, we know that blue-collar workers, especially those in Alberta who work in construction and oil rigs, have a disproportionate rate of substance use and at times substance death. This was seen in British Columbia and Ontario.”

What’s Being Done

The government of Alberta is responding to these data, said Ghosh. For example, in 2022, specialized funding was provided to enable young adults to access gold-standard opioid agonist treatment. The treatment was rolled out through Alberta’s Virtual Opioid Dependency Program (VODP) and other community-based addiction programs. “This [program] still needs to be more focused on homeless youth, however, who may not have access to technology or other resources.”

Furthermore, the government recently announced a $1.55-billion plan to continue building the Alberta Recovery model, he said. “This is the largest investment seen in our province. Safer supply or prescribed alternatives is very controversial in Alberta and thus is not an option available to this population.”

In addition, he said, the Ministry of Seniors and Community Social Services recently began “coordinated work with other ministries to support vulnerable and equity-deserving populations around this issue, including creating navigation centers for housing, income support, and access to treatment through the VODP.”

Ledlie noted that various policies and programs have been developed in response to the ongoing drug toxicity crisis. Some were included in a recent review that her team conducted to summarize the evidence from Canadian safer opioid supply programs. “We found that in general, these programs had positive impacts on clients, including reduced rates of opioid toxicities and improvements in quality of life.”

“Because most healthcare is coordinated at the provincial or territorial level, the investments into, and accessibility of, treatment and harm-reduction services tend to vary across Canada,” she said. “Even in regions where these programs exist, we know that they are not always accessible for various reasons, such as a lack of resources preventing widespread expansion and geographic barriers in more remote and rural regions.”

“One example of a simple yet life-saving harm reduction measure that has been effectively implemented by most provincial and territorial governments is the availability of publicly funded naloxone kits,” she added. “Given the widespread societal impacts of opioid toxicities described in our study, we believe it is pivotal for all levels of government to coordinate to ensure equitable access to evidence-based services across the country, while still providing the opportunity to tailor and adapt those responses to the unique needs of local communities.”

The study was supported by grants from the Ontario Ministry of Health and the Canadian Institutes of Health Research. Ledlie is supported by an Ontario Graduate Scholarship and the Network for Improving Health Systems Trainee Award. Ledlie and Ghosh declared no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.