The ‘fentanyl epidemic’ in Canada – Some cautionary observations focusing on opioid-related mortality

doi:10.1016/j.ypmed.2017.11.001

Preventive Medicine

Volume 107, February 2018, Pages 109-113

https://doi.org/10.1016/j.ypmed.2017.11.001 Get rights and content

Abstract

In Canada, opioid-related overdose mortality has steeply increased in recent years; as a substantial number of opioid-related deaths are related to fentanyl products, this phenomenon has widely been described as the ‘fentanyl epidemic’, also implying that these deaths are largely caused by clandestinely produced illicit fentanyl products. We examined numbers and rates of opioid- and fentanyl-related deaths in six pan-Canadian provinces with respective (coroner-based) data available from 2010 to 2016. While fentanyl-related deaths are clearly increasing from relatively low levels in all provinces, those increases are strongest in the two Western provinces (e.g., British Columbia, where fentanyl accounts for the majority of opioid deaths in 2016 and Alberta), and, to some extent, Ontario. However, fentanyl-related deaths remain a minority of deaths in Ontario (40%) and the remaining provinces (< 25%). Furthermore, it is uncertain what proportion of fentanyl-related deaths is actually related to illicit fentanyl products. We conclude that fentanyl-related overdose deaths have risen – most strongly in the West – due to both a high availability of medical fentanyl products, as well as an influx of illegal fentanyl products. In most provinces, the majority of opioid deaths remain associated with other (non-fentanyl) products. Appropriate (prevention, treatment and policy) interventions need to be targeted at the full range of opioid deaths from different sources. Overall, a realistic framing of the social (e.g., media) discourse about the nature of the ‘opioid overdose death crisis’ is required, which is not exclusively an ‘illicit fentanyl death crisis’ even though this may be a socio-politically appealing image.

Introduction

For more than a decade, North America has been home to a growing public health crisis related to opioid drugs, with high levels of opioid misuse, and associated health burdens including but not limited to morbidity (e.g., hospitalizations) and mortality (overdose deaths) (Fischer and Rehm, 2017, Kolodny et al., 2015). In particular, opioid-related mortality has been rising persistently in both Canada and the United States; in Canada, there were an estimated total of 2458 opioid-related deaths in 2016, a death toll higher than that for many other major causes of premature deaths (e.g., similar to the national fatality total from motor-vehicle accidents and homicides combined) (Government of Canada, 2016, Rudd et al., 2016).

Previous examinations of opioid-related overdose mortality in Canadian provinces had shown that the vast majority of such deaths was associated with (a variety of) prescription opioids originating, directly or indirectly, from the medical system (Gomes et al., 2017a, Murphy et al., 2015). In recent years, select data indicated an increasing contribution of fentanyl-type opioid products to opioid-related overdose mortality in Canada (Gomes et al., 2017a, Jafari et al., 2015, Fischer et al., 2015). These increasingly included clandestinely produced, commonly potent, illicit fentanyl products, a substantial portion of which are assumed to originate overseas (e.g., China) in the recent years (with similar developments observed in the United States) (Frank and Pollack, 2017, Lucyk and Nelson, 2017, Suzuki and El-Haddad, 2017). Notably, these developments have been framed and communicated (e.g., by mass media as well as in policy discussions) that the ‘opioid crisis’ in Canada has evolved into a ‘fentanyl epidemic’ (CBC News, 2017, Howlett et al., 2017, Ireland, 2016). In these contexts, it has been commonly suggested or implied that the ‘opioid crisis’ in Canada had actually become an ‘illicit fentanyl epidemic’, i.e. a health and mortality crisis mainly caused by illicit (and largely foreign) opioid products (The Star, 2017). These characterizations, evidently, imply rather distinct causes and drivers of the ‘opioid crisis’, as well as different priorities and directions for interventions.

On this basis, we seized the opportunity to examine actual patterns and trends of opioid-related mortality, and the specific contribution of fentanyl products to these deaths, based on available data in select Canadian jurisdictions (provinces) in recent years.

Section snippets

Methods

Prior to 2016, there were no national estimates of opioid-related mortality for Canada (and even the 2016 national data are not broken down by opioid type); in addition, a barrier to national mortality estimates assembled from provincial datasets had been that provincial monitoring systems relied on inconsistent analysis methods and standards for opioid-related overdose deaths (or no specific data existed at all) (Murphy et al., 2015). Within these limitations, we identified select provincial

Results

All data reported are shown in Table 1.

While numbers of total opioid-related deaths were highest in ON for all years (except 2016), corresponding opioid-related death rates were initially similar in all provinces (except for QC) but rose to singularly highest levels in BC in 2016. Respective rates were consistently lowest in QC throughout the examination period.

Fentanyl-related overdose death rates were similar (i.e., ~ 2/100,000 or lower) in the six provinces until 2013, subsequent to which

Discussion

Our examination identified a rather differentiated picture in regards to opioid- and fentanyl-related overdose death patterns and trends in the pan-Canadian provincial jurisdictions under study for the period 2010–2016. Opioid-related deaths have risen most substantially in BC and (presumably, while given the lack of complete data) in AB; opioid-related death rates were lower, with less substantial increases in other provincial jurisdictions. Similarly, fentanyl-related deaths have starkly

Acknowledgments

The authors thank Ms. Cayley Russell for valuable assistance in data collection support towards the preparation of the present manuscript.

Funding

This work was supported by Canadian Institutes of Health Research (CIHR) (grants #SMN-139150 and #SAF-94814), as well as by the endowed 'Chair in Addiction Psychiatry' (Dr. B. Fischer), Department of Psychiatry, University of Toronto.

Declaration of conflicting interests

The authors have no conflicts of interest to declare.

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Short CommunicationThe ‘fentanyl epidemic’ in Canada – Some cautionary observations focusing on opioid-related mortality

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

Funding

Declaration of conflicting interests

Ann. Emerg. Med.

Drug Alcohol Depend.

Drug Alcohol Depend.

Guideline for opioid therapy and chronic noncancer pain

CMAJ

Fentanyl Crisis: Drug Overdoses Claim Unprecedented 922 Lives in B.C. in 2016

Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone

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Notes on the sociology of deviance

Soc. Probl.

Revisiting the ‘paradigm shift’ in opioid use: developments and implications 10 years later

Drug Alcohol Rev.

The Crucial Opioid Interventions Canada Needs Now

High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009

Pharmacoepidemiol. Drug Saf.

Trends and changes in prescription opioid analgesic dispensing in Canada 2005–2012: an update with a focus on recent interventions

BMC Health Serv. Res.

Prescription opioids, abuse and public health in Canada: is fentanyl the new centre of the opioid crisis?

Pharmacoepidemiol. Drug Saf.

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CMAJ

‘Delisting’ OxyContin® to reduce prescription opioid-related harms in Ontario (Canada)—gauging effects 5 years later

Pharmacoepidemiol. Drug Saf.

Statistical Methods for Rates and Proportions

Addressing the fentanyl threat to public health

N. Engl. J. Med.

Professional Powers: A Study of the Institutionalization of Formal Knowledge

Panic and Indifference: The Politics of Canada's Drug Laws : A Study in the Sociology of Law

Short Communication
The ‘fentanyl epidemic’ in Canada – Some cautionary observations focusing on opioid-related mortality