Large number of Ontarians who died from opioid overdoses recently interacted with health-care system: study

Half of Ontarians who died of an opioid overdose in the early stages of the pandemic had interacted with the health-care system in the month before their deaths, a new report shows.

One in four had seen a doctor, gone to an emergency department or been discharged from hospital just a week prior, the research shows.

"That represents such an important missed opportunity for us to make sure that our health-care system is serving the needs of people who use drugs and helping connect them to the services that they need to help prevent these fatal overdoses," said Dr. Tara Gomes, an epidemiologist with Unity Health and investigator with the Ontario Drug Policy Research Network, who co-authored the study.

The report, titled "Patterns of Medication and Healthcare Use among People who Died of an Opioid-Related Toxicity during the COVID-19 Pandemic in Ontario," was released Tuesday by Unity Health and the Ontario Drug Policy Research Network. Public Health Ontario, the chief coroner's office and ICES, anon-profit health research organization, contributed to the report.

The authors are calling for a safer drug supply, expanded access to low-barrier treatment in health-care settings, affordable, supportive housing as well as more harm-reduction services and supervised consumption sites, especially outside cities.

"The loss of lives due to opioid toxicity in Ontario has only deepened during the COVID-19 pandemic," said Dr. Dirk Huyer, the Chief Coroner for Ontario, in a statement.

"Understanding how people interact with healthcare providers, support systems, and harm reduction services will help develop policies aimed at preventing further opioid-related deaths."

Deaths linked to opioids

The vast majority of deaths recorded between March and December 2020 89 per cent are linked to non-prescription opioids, almost exclusively fentanyl, the report found.

Gomes said two in three deaths occurred in those with evidence of an opioid use disorder. That means about one third of people had no evidence of a substance use disorder.

"It's likely that a large number of those people are people who are just occasionally using drugs," she said. "And they might actually be a population at higher risk of overdose from this really unpredictable drug supply because they haven't developed the same level of tolerance to these really potent drugs."

The research follows up on the group's work published in May, which showed fatal opioid overdoses were up more than 75 per cent in Ontario from March to December 2020 compared to the same timeframe the year before.

There were 2,050 people who died of an opioid-related overdose in about 10 months, compared to 1,162 from March to December 2019.

The researchers were able to link the vast majority of those deaths to other health-care data in an effort to better understand some of the circumstances. The increasingly volatile drug supply appears to be connected to the surge, Gomes said.

"Though the role of prescription opioids has historically been focused on as the major contributor to the overdose crisis, the report shows that the unregulated drug supply is primarily responsible for fatal overdoses, with deaths predominantly driven by fentanyl," the report said.

The researchers detected a five-fold increase in non-pharmaceutical benzodiazepines in fatal opioid overdoses during the pandemic.

"It's not that people are getting prescribed anti-anxiety medication, but that the unregulated drug supply is really being contaminated by benzodiazepines," Gomes said.

Non-regulated drugs harder to treat

The addition of benzodiazepines has further complicated the response to an overdose and subsequent treatment, she said.

"We're hearing people who are so highly sedated for the benzodiazepines in the drug supply that they can't be roused for hours and hours at a time even after administering Naloxone because that only reverses the opioid effect," Gomes said.

She said opioids mixed with benzodiazepines have been shown "to increase respiratory depression and sedation so it can make you more likely to have an overdose and a serious overdose because you're still heavily sedated and your breathing is you know, slowed even further."

The researchers also found that, when population is factored in, the opioid overdose death rate was nearly three times higher in northern Ontario compared to southern Ontario.

Meanwhile, the researchers dug into further understanding why the opioid crisis was hitting the homeless much harder than other populations, after their previous report found one in six people who died from an opioid overdose during the pandemic did not have a home.

The researchers found that population was interacting with the health-care system in similar rates as the rest of the population in the days and weeks before their deaths, but was much more likely to seek help from an emergency department than outpatient care, like a visit to a family doctor.

Gomes said they are seeing a high degree of mental health diagnoses among the homeless who died of an opioid overdose.

"Given the increasing rates of overdose among people experiencing homelessness during the pandemic, the scale-up of supervised consumption services in shelter settings and easily accessible treatment options is warranted," the researchers wrote.