A new report finds that nearly two-thirds of people who died from substance-related toxicities between 2018 and 2022 had previous encounters with the health-care system for substance-use disorders — but were not able to access treatment in time to save their lives.
A fifth had been treated in hospital for a non-fatal overdose in the year prior. While the majority of these overdoses were due to opioids, of those diagnosed with opioid-use disorders, less than a third received treatment in the month before their death.
Overall, more than 10,000 people in Ontario died over the span of the report’s study period, with a 72 per cent increase in the last year as compared to the first.
Dr. Tara Gomes is a scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and ICES, a principal investigator at the Ontario Drug Policy Research Network, and one of the report’s authors. TVO Today speaks with Gomes about the rise in deaths during the pandemic, the current state of the overdose crisis, and what needs to change to connect people with the right treatments in hospital and in the community.
TVO Today: Your report notes that there were over 10, 000 accidental substance toxicity deaths in Ontario between 2018 and 2022, with a 72 per cent increase in the last year as compared to the first. What accounts for this increase?
Dr. Tara Gomes: We really saw this acceleration in substance-related deaths, namely from opioids, cocaine, and methamphetamines, early on in the pandemic. And those elevated rates have continued to at least mid-2022, which is the timeframe that this report covers.
I think there are probably a number of reasons for this.
We do know that there were a lot of public-health measures introduced that affected people’s ability to access community-based programs and different health services. That could have created fewer safe spaces for people who use drugs and reduced access to some of the networks of support that people use to keep themselves safe.
The other piece has to do with the unregulated drug supply, which has really changed over the last few years. Just before the pandemic, we saw substances like benzodiazepines come into the fentanyl supply, and that increased throughout the pandemic. That really changed the way people were using these drugs. Benzodiazepines are a sedative, so they’re highly sedating, especially when mixed with fentanyl. We also know some people will then use cocaine or methamphetamine, which are stimulants, to counteract those effects.
When you start to see an unpredictable supply, people change their habits of use to try to manage those effects. It can lead to worsening harms because people are using multiple substances, and they don’t know exactly what might be in the supply they are purchasing — and that can create this perfect storm of harm.
TVO Today: What should our response to this look like?
Gomes: We really need to understand the ways people are engaged in the health-care system and how we can use that understanding to inform not only what responses are needed, but also where they need to be placed. So we do know that a lot of people engaged with the health-care system in the year before death, either because of a previous overdose or some other emergency-department or hospital visit where it was noted they had an opioid- or substance-use disorder. These are opportunities to identify people at risk of harm and connect them to treatment, not just within the hospital setting, but back in their community.
Those connections don’t always happen, because our emergency departments aren’t always set up with people that have the expertise and training to be able to best know how to support people who use drugs. So I think one core element is improving our ability to connect people to treatment and harm-reduction services, along with coordinating their transition back into the community so that we can really support them in an ongoing way.
The other thing is a large number of people who are dying from these overdoses either don’t have a substance-abuse disorder, are using drugs only recreationally, or are ineligible for treatment. That’s where we need to start talking more about harm reduction, safe spaces to use drugs, and safer alternatives to the unregulated supply to help keep people safe and prevent these toxicities.
TVO Today: What are some barriers that people who use drugs face in accessing treatment?
Gomes: There are many. One is that we don’t have physicians and doctors who are trained to prescribe treatment and to help get people into treatment across the province consistently. Not every doctor or nurse practitioner who is trained learns how to treat substance-use disorders. This is especially pronounced in northern and rural parts of the province.
These treatment programs can also be quite intensive for people. For example, if you’re starting methadone, you have to go into the pharmacy every single day for an observed dose. You can’t miss a day. That can be really difficult if you have a job or a family that you’re taking care of. The expectation to engage with the health-care system daily can be really hard for people to sustain over months and years. So there has been a move toward thinking about flexibility, giving people take-home doses so that can support keeping them in treatment. That’s critical.
Pharmacies can also decide if they’re going to dispense that medication. And not all of them decide to do so. If you live in a community with only one pharmacy, and they’ve decided they don’t want to provide that medication, then you might have to travel to a different community in order to access treatment.
We also have to make sure that the treatments match the supply. Our unregulated supply right now is very potent; that means people need higher doses of treatment to not go into withdrawal. Clinically, people are catching up and identifying ways to prescribe higher doses, different combinations of drugs to help prevent that withdrawal. But it takes time for clinicians to really learn what’s needed and to implement that in practice. So we need to accelerate how we adapt and tailor treatment to the actual supply that people are exposed to, to make sure it’s meeting people’s needs.
TVO Today: What else could the provincial government be doing to address this crisis?
Gomes: There have been investments provincially and federally in different responses, but I don’t necessarily think the level of investment matches the urgency of the tragedy that we’re facing right now. We are losing about seven people every single day in Ontario from a substance-related death. We need to make sure that we are mobilizing resources and general supports as much as possible across our health-care system.
The provincial government plays a role in that. For example, with safe-consumption sites, we need to make sure those are accessible, adequately funded, and tailored to the needs of people. Right now, they are mainly tailored to people injecting drugs, but most people are inhaling drugs right now. How do we adapt these services to these changing patterns of drug use? How do we invest in safer supply and treatment within our health-care system? We need to make sure that we have the tools that people need when they need them: whether it be treatment, a hospital stay, or a safer alternative to the unregulated supply. There isn’t just one response that is going to work here — we need to make sure we have investment in a broad array of supports for people.
TVO Today: What surprised you most in your research?
Gomes: I’d say at this point it’s hard to surprise me. A lot of the indicators of harm that we’ve seen in the past just continue to come to the forefront. This highly unpredictable supply, the fact that people are using so many substances and experiencing harm from them, it really shouldn’t be surprising to us anymore.
We know why this is happening. We can see the signs; we can see these trends. We know what we can do to try to at least better support people. At this point, it’s about taking this information and turning it into action, finding ways for people to come together across various sectors to find the gaps in the system and fill them. Because we do need to fill them. We’re losing people every single day.
This interview has been condensed and edited for length and clarity.