National report: Apparent opioid-related deaths in Canada (December 2017)

The data in this report:

• are updated on a quarterly basis
• may change based on review and refinement
• have been collected by the provinces and territories from their respective offices of Chief Coroners/Medical Examiners
• have been shared through the Special Advisory Committee on the Epidemic of Opioid Overdoses (SAC)

Changes from last report include:

• the addition of available preliminary data from April to June 2017 (except for Manitoba, Quebec and Newfoundland and Labrador)
• updates to preliminary data from 2016 and January to March 2017

National and regional trends of apparent opioid-related deaths

The opioid crisis has affected every part of the country, but some provinces and territories have been impacted more than others. According to data reported as of December 11, 2017:

• there were 2,861^{Footnote a} apparent opioid-related deaths in Canada in 2016, corresponding to a death rate of 7.9^{Footnote a} per 100,000 population (Table 1)
• there were at least 1,460 apparent opioid-related deaths from January to June 2017 (Table 1)

Figure 1. Number and rate (per 100,000 population) of apparent opioid-related deaths by province or territory, 2016.

Province or territory	2016		2017 (January to June)
	Number	Death rate per 100,000 population	Number
British ColumbiaFootnote 1	985	20.7	798
Alberta	611	14.4	350
SaskatchewanFootnote 2	71	6.2	10
Manitoba	69	5.2	30Footnote 3
Ontario	867	6.2	214Footnote 4
QuebecFootnote 2	140	1.7	Suppressed
New Brunswick	32	4.2	17
Nova Scotia	53	5.6	37
Prince Edward IslandFootnote 2	5	3.3	Suppressed
Newfoundland and Labrador	16	3.0	Suppressed
Yukon	7	18.4	4
Northwest Territories	5	11.2	0
Nunavut	Suppressed	Suppressed	Suppressed
Total	2861	7.9	1460
Footnotes N/A - Data were not available at the time of this publication. Suppressed - Data may be suppressed in provinces or territories with low numbers of cases. Please refer to the Considerations and Limitations for more information. Footnote 1 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. Return to footnote 1 referrer Footnote 2 Saskatchewan, Quebec and Prince Edward Island report closed cases only. Updates to historical data will be provided in future reports. Return to footnote 2 referrer Footnote 3 Manitoba data from April to June 2017 were not available at the time of this publication. Return to footnote 3 referrer Footnote 4 Only data from May to June 2017 were available for Ontario; data from January to April 2017 were not available at the time of this publication. Updates to historical data will be provided in future reports. Return to footnote 4 referrer

Table 2. Number of apparent opioid-related deaths, quarterly, by province or territory, January 2016 to June 2017.

Province or territory	2016				2017 (January to June)
	Jan to Mar	Apr to Jun	Jul to Sep	Oct to Dec	Jan to Mar	Apr to Jun
British ColumbiaFootnote 1	221	191	195	378	389	409
Alberta	138	146	159	168	161	189
SaskatchewanFootnote 2	N/A	N/A	N/A	N/A	N/A	N/A
Manitoba	16	13	15	25	30	N/A
Ontario	214	218	195	240	N/A	214Footnote 4
QuebecFootnote 3	50	43	35	12	N/A	N/A
New Brunswick	12	4	9	7	9	8
Nova Scotia	17	14	17	5	19	18
Prince Edward IslandFootnote 3	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Newfoundland and Labrador	Suppressed	Suppressed	Suppressed	Suppressed	N/A	N/A
Yukon	0	2	2	3	4	0
Northwest Territories	2	0	1	2	0	0
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Footnotes N/A - Data were not available at the time of this publication. Suppressed - Data may be suppressed in provinces or territories with low numbers of cases. Please refer to the Considerations and Limitations for more information. Footnote 1 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. Return to footnote 1 referrer Footnote 2 Only annual totals were available for Saskatchewan; quarterly data were not available at the time of this publication. Return to footnote 2 referrer Footnote 3 Quebec and Prince Edward Island report closed cases only. Updates to historical data will be provided in future reports. Return to footnote 3 referrer Footnote 4 Only data from May to June 2017 were available for Ontario; data from January to April 2017 were not available at the time of this publication. Updates to historical data will be provided in future reports. Return to footnote 4 referrer

Sex and age trends of apparent opioid-related deaths

This crisis has affected Canadians from all walks of life. However, available data from January 2016 to June 2017, reported as of December 11, 2017, indicate there are differences by sex and age.

Although these trends vary by province or territory, overall:

• most (74%) apparent opioid-related deaths occurred among males (Figure 2)
• the highest percent (28%) of apparent opioid-related deaths occurred among individuals between the ages of 30 and 39 (Table 3)

Table 3. Percent of apparent opioid-related deaths by age group and province or territory, January 2016 to June 2017^{Footnote 1}.

Province or territory	Age group
	≤ 19	20 to 29	30 to 39	40 to 49	50 to 59	60 to 69	≥ 70
British ColumbiaFootnote 2	2.5%	18.4%	28.1%	23.2%	21.6%	5.8%	0.4%
Alberta	2.5%	20.2%	33.8%	17.6%	18.5%	6.5%	0.9%
Saskatchewan	0.0%	16.0%	35.8%	14.8%	22.2%	9.9%	1.2%
Manitoba	2.0%	23.2%	32.3%	14.1%	10.1%	13.1%	5.1%
Ontario	1.8%	18.9%	22.8%	21.4%	23.9%	8.6%	2.7%
Quebec	N/A	N/A	N/A	N/A	N/A	N/A	N/A
New Brunswick	2.0%	16.3%	18.4%	20.4%	24.5%	16.3%	2.0%
Nova Scotia	2.2%	15.6%	26.7%	16.7%	20.0%	14.4%	4.4%
Prince Edward Island	Suppressed
Newfoundland and Labrador	Suppressed
Yukon	0.0%	9.1%	36.4%	27.3%	9.1%	0.0%	18.2%
Northwest Territories	0.0%	60.0%	0.0%	0.0%	20.0%	20.0%	0.0%
Nunavut	Suppressed
Total	2.2%	19.0%	28.1%	20.8%	21.2%	7.3%	1.4%
Footnotes N/A - Data were not available at the time of this publication. Suppressed - Data may be suppressed in provinces or territories with low numbers of cases. Please refer to the Considerations and Limitations for more information. Footnote 1 Not all provinces and territories were able to report data for the full time period (January 2016 to June 2017). Table 3 includes only 2016 data for Quebec, 2016 data and 2017 data limited to May to June only for Ontario, and data from January 2016 to March 2017 only for Manitoba and Newfoundland and Labrador. Saskatchewan and Prince Edward Island report closed cases only. Updates to historical data will be provided in future reports. Refer to Table 6 for more details. Return to footnote 1 referrer Footnote 2 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. Return to footnote 2 referrer

Fentanyl, fentanyl analogues, and other substances involved in apparent opioid-related deaths

Apparent opioid-related deaths often involve^{Footnote b} multiple substances including one or more opioids as well as non-opioid substances. Knowing the type(s) of opioid and non-opioid substances involved in these deaths can help public health officials and other government agencies communicate risks and target harm reduction efforts.

Similar to previous updates, we are seeing more fentanyl or fentanyl analogues involved in apparent opioid-related deaths (Table 4, Table 5). According to available data reported as of December 11, 2017:

• the percent of deaths involving fentanyl or fentanyl analogues was 53% in 2016 and 74% from January to June 2017^{Footnote c}
• the number of apparent opioid-related deaths involving fentanyl or fentanyl analogues more than doubled in January to June of 2017 compared to the same time period in 2016

Non-opioid substances

We can also highlight the involvement of non-opioid substances in apparent opioid-related deaths.

According to available data, approximately 82% of apparent opioid-related deaths from January 2016 to June 2017^{Footnote d} also involved one or more types of non-opioid substances.

Table 4. Number and percent of apparent opioid-related deaths involving fentanyl or fentanyl analogues by province or territory, 2016 and January to June 2017.

Province or territory	2016		2017 (January to June)
	Number	Percent	Number	Percent
British ColumbiaFootnote 1	668	68%	662	83%
AlbertaFootnote 2	357	63%	257	76%
SaskatchewanFootnote 3	8	11%	2	20%
ManitobaFootnote 4	33	48%	14	47%
Ontario	353	41%	122Footnote 5	65%
QuebecFootnote 3	27	19%	N/A	N/A
New Brunswick	4	13%	4	24%
Nova Scotia	8	15%	4	11%
Prince Edward IslandFootnote 3	1	20%	Suppressed
Newfoundland and Labrador	Suppressed		Suppressed
Yukon	5	71%	2	50%
Northwest Territories	1	20%	0	Not applicable
Nunavut	Suppressed		Suppressed
Footnotes N/A - Data were not available at the time of this publication. Suppressed - Data may be suppressed in provinces or territories with low numbers of cases. Please refer to the Considerations and Limitations for more information. Please note: Higher percentages in 2017 compared to 2016 of apparent opioid-related deaths involving fentanyl or fentanyl analogues should be interpreted with caution. The observed differences between the two time periods may reflect relative increases in the numbers of deaths involving fentanyl or fentanyl analogues, or may reflect a delay in the reporting of deaths involving non-fentanyl-related opioids in some jurisdictions. Furthermore, these data are preliminary and are subject to change. Footnote 1 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. British Columbia data on deaths related to illicit drugs where fentanyl was detected is used here to approximate apparent opioid-related deaths involving fentanyl. Return to footnote 1 referrer Footnote 2 This table reflects data for unintentional/accidental deaths only from Alberta. Return to footnote 2 referrer Footnote 3 Saskatchewan, Quebec and Prince Edward Island report closed cases only. Updates to historical data will be provided in future reports. Return to footnote 3 referrer Footnote 4 Manitoba data from April to June 2017 were not available at the time of this publication. Return to footnote 4 referrer Footnote 5 This table reflects Ontario data from May to June 2017 for closed cases only; data from January to April 2017 were not available at the time of this publication. Updates to historical data will be provided in future reports. Return to footnote 5 referrer

Table 5. Number of apparent opioid-related deaths involving fentanyl or fentanyl analogues, quarterly, by province or territory, January 2016 to June 2017.

Province or territory	2016				2017 (January to June)
	Jan to Mar	Apr to Jun	Jul to Sep	Oct to Dec	Jan to Mar	Apr to Jun
British ColumbiaFootnote 1	123	127	120	298	327	335
AlbertaFootnote 2	69	81	87	120	126	131
SaskatchewanFootnote 3	N/A	N/A	N/A	N/A	N/A	N/A
Manitoba	8	2	8	15	14	N/A
Ontario	76	94	72	111	N/A	122Footnote 4
Quebec	10	9	6	2	N/A	N/A
New Brunswick	2	0	1	1	3	1
Nova Scotia	4	2	2	0	1	3
Prince Edward Island	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Newfoundland and Labrador	Suppressed	Suppressed	Suppressed	Suppressed	N/A	N/A
Yukon	0	1	1	3	2	0
Northwest Territories	0	0	0	1	0	0
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Footnotes N/A - Data were not available at the time of this publication. Suppressed - Data may be suppressed in provinces or territories with low numbers of cases. Please refer to the Considerations and Limitations for more information. Footnote 1 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. British Columbia data on deaths related to illicit drugs where fentanyl was detected is used here to approximate apparent opioid-related deaths involving fentanyl. Return to footnote 1 referrer Footnote 2 This table reflects data for unintentional/accidental deaths only from Alberta. Return to footnote 2 referrer Footnote 3 Only annual totals were available for Saskatchewan, quarterly data were not available at the time of this publication. Saskatchewan reports closed cases only. Updates to historical data will be provided in future reports. Return to footnote 3 referrer Footnote 4 This table reflects Ontario data from May to June 2017 for closed cases only; data from January to April 2017 were not available at the time of this publication. Updates to historical data will be provided in future reports. Return to footnote 4 referrer

Considerations and Limitations

Definition of apparent opioid-related death

An apparent opioid-related death is a death caused by intoxication/toxicity (poisoning) as a result of drug use, where one or more of the drugs is an opioid.

How apparent opioid-related deaths are counted

The data can include:

• open (preliminary) and closed (certified) cases
• non-natural manners of death (both intentional and unintentional)
• individuals with or without personal prescriptions

These data do not include deaths due to:

• chronic substance use (for example, the medical consequences of long term use or overuse of an exogenous [external] substance(s), such as alcoholic cirrhosis)
• medical assistance in dying
• trauma where an exogenous (external) substance contributed to the circumstances of the injury

However, some jurisdictional differences remain in the type of data reported and in the time periods for which data are available (refer to Table 6).

Table 6. Reporting periods and manners of death included in data used for this report by province or territory.

		BCFootnote 1	AB	SK	MB	ONFootnote 2	QCFootnote 3	NB	NS	PE	NL	YK	NT	NU
Reporting period (as of December 11, 2017)
January to December 2016		✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
January to March 2017		✓	✓	✓	✓			✓	✓	✓	✓	✓	✓	✓
April to June 2017		✓	✓	✓		✓		✓	✓	✓		✓	✓	✓
Deaths included in the reported data
Closed (certified) cases with completed death investigation	Unintentional/accidental	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
	Intentional/suicide		✓	✓	✓	✓	✓	✓	✓		✓	✓	✓	✓
	Undetermined manner of death	✓	✓	✓	✓	✓	✓	✓	✓		✓	✓	✓	✓
Open cases with ongoing death investigation		✓	✓		✓	✓		✓	✓		✓	✓	✓	✓
Footnotes ✓ - These data have been reported by the province or territory and are reflected in this report, unless otherwise specified. Footnote 1 British Columbia reports unintentional deaths related to all illicit drugs including, but not limited to, opioids. Return to footnote 1 referrer Footnote 2 As of May 1, 2017, apparent opioid-related death data in Ontario were captured using an enhanced data collection tool by the Office of the Chief Coroner. Only 2016 data and 2017 data limited to May to June were available; data from January to April 2017 were not available at the time of this publication. Updates to historical data will be provided in future reports. Return to footnote 2 referrer Footnote 3 Quebec data for individuals 19 years and younger were not available at the time of this publication. Quebec data were available for closed/certified cases only; 44% of the cases for 2016 were still under investigation. Updates to historical data will be provided in future reports. Return to footnote 3 referrer

Data suppression

The suppression of data in this report is based on the preferences of individual provinces or territories to address concerns around releasing small numbers for their jurisdiction.

• Prince Edward Island suppressed counts less than five for total and quarterly data, and for any data regarding sex and age distribution. However, if the total annual count of apparent opioid-related deaths is greater than four, annual counts less than five may be reported when presenting type of substance(s).
• Newfoundland and Labrador suppressed all counts less than five.
• Nunavut suppressed all counts less than five.
• While Yukon has typically suppressed counts of less than five, the decision was made between the Chief Medical Officer of Health and the Chief Coroner, to release smaller counts, due to the urgency of the current opioid crisis, the value of detailed ongoing surveillance, and the importance of being as transparent as possible while still maintaining confidentiality with respect to case details.

Opioids and other involved substances

Fentanyl and fentanyl analogues include, but are not limited to:

• 3-methylfentanyl
• acetylfentanyl
• butyrylfentanyl
• carfentanil
• despropionyl-fentanyl
• fentanyl
• furanyl-fentanyl
• norfentanyl

Non-fentanyl-related opioids include, but are not limited to:

• buprenorphine metabolites
• codeine
• dihydrocodeine
• heroin
• hydrocodone
• hydromorphone
• loperamide
• meperidine
• methadone
• monoacetylmorphine
• morphine
• normeperidine
• oxycodone
• tapentadol
• tramadol
• U-47700

Non-opioid substances include, but are not limited to:

• alcohol
• benzodiazepines
• cocaine
• W-18

Limitations of these apparent opioid-related deaths data

Data presented in this report should be interpreted with caution:

• This report is based on data submitted to the Public Health Agency of Canada on or before December 11, 2017. New or revised data submitted after this date will be reflected in future updates.
• Data released by provinces and territories may differ from the data provided in this report due to the availability of updated data, differences in the type of data reported (e.g. manners of death), alternate age groupings, differences in time periods presented, etc.
• As some data are based on ongoing investigations by coroners and medical examiners, they are considered preliminary and subject to change. Data are considered closed (certified) after completion of the death investigation by the coroner/medical examiner. The time required to complete an investigation and related administrative processes is case-dependent and can range from approximately 3 to 24 months.
• This report does not distinguish between pharmaceutical and non-pharmaceutical opioids, or prescription and non-prescription drugs, which may have differing levels of potency.
• Jurisdictional differences in the death investigation process, death classification method, toxicology testing and type of data reported (e.g. intentional/suicide deaths included or excluded) may impact the interpretation and comparability of the reported data.
• Information related to changes over time at the national level is based only on jurisdictions where data were available for all time periods of interest.
• Rates reported here have not been age-standardized and therefore have not been adjusted for existing differences in provincial and territorial age distributions.
• Rates for jurisdictions with smaller populations may change substantially with even slight changes in the number of deaths; comparisons over time and between jurisdictions should be interpreted with caution.