National report: Apparent opioid-related deaths in Canada (released March 2018)

On this page

• Background
• 1.0 Apparent opioid-related deaths in Canada
• 2.0 Apparent opioid-related deaths by manner of death
  • 2.1 National and regional trends of accidental apparent opioid-related deaths
  • 2.2 Sex and age trends of accidental apparent opioid-related deaths
  • 2.3 Fentanyl, fentanyl analogues, and other substances involved in accidental apparent opioid-related deaths
  • 2.4 Apparent opioid-related deaths: suicide
• Considerations and Limitations

Background

Canada is experiencing a serious and growing opioid crisis. Across the country, it is having devastating effects on families and communities.

Accurate information about the crisis will help the efforts to reduce opioid-related harms and deaths.

The Government of Canada works closely with the provinces and territories to collect and share data on apparent opioid-related deaths.

The data in this report:

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

Changes from the last report include:

• the addition of available preliminary data from July to September 2017
• updates to previously reported data from January 2016 to June 2017
• sections reporting data separately for apparent opioid-related deaths classified as accidental or suicide, where available

1.0 Apparent opioid-related deaths in Canada

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 March 22, 2018:

• there were 2,946 apparent opioid-related deaths in Canada in 2016, corresponding to a death rate of 8.1 per 100,000 population (Table 1)^{Footnote a}
• there were at least 2,923 apparent opioid-related deaths from January to September 2017, corresponding to an estimated annual death rate of 10.6 per 100,000 population in 2017 (Table 1)^{Footnote b}
• an increase of 45%^{Footnote c} in the number of apparent opioid-related deaths was observed from January to September 2017 when compared to the same time period in 2016; however, this is subject to change as data become available or are updated

Table 1. Summary of apparent opioid-related deaths, 2016 and January to September 2017.^{Table 1 Footnote 1}

		2016	2017 (Jan to Sep)
Number		2946	2923
Rate per 100,000 population		8.1	10.6Table 1 Footnote 2
% male		68%	76%
Age group (years)	≤ 19	2%	2%
	20 to 29	18%	19%
	30 to 39	27%	28%
	40 to 49	21%	23%
	50 to 59	23%	19%
	60 to 69	7%	8%
	≥ 70	2%	1%
% involvingTable 1 Footnote 3 fentanyl or fentanyl analoguesTable 1 Footnote 4		51%	68%
% also involving non-opioid substancesTable 1 Footnote 5		71%	77%
Table 1 Footnote 1 Not all provinces and territories reported data for all manners of deaths, all stages of investigation, and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Return to table 1 footnote 1 referrer Table 1 Footnote 2 The estimated annual rate for 2017 is based on available data from January to September 2017. Return to table 1 footnote 2 referrer Table 1 Footnote 3 Given jurisdictional differences in death classification methods, the term "involving" includes deaths where the substance was either detected and/or directly contributed to the death. Return to table 1 footnote 3 referrer Table 1 Footnote 4 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 not involving fentanyl or fentanyl analogues in some provinces and territories. In addition, these data are preliminary and subject to change. Return to table 1 footnote 4 referrer Table 1 Footnote 5 These percentages do not include data from British Columbia, Saskatchewan, Ontario, Quebec, or Nunavut as these data were not available for both time periods. For Alberta, the data included in these percentages were for deaths with completed investigations only. Refer to Opioids and other substances for more details. Return to table 1 footnote 5 referrer

2.0 Apparent opioid-related deaths by manner of death

The following section presents apparent opioid-related death data according to the manner of death assigned by the coroner or medical examiner during, or following, an investigation (Table 2).

Accidental: Deaths where the completed investigation determined that the death was unintentional. This category also includes deaths with ongoing investigations where the manner of death was believed to be accidental or had not been assigned at the time of reporting.

Suicide: Deaths where the completed investigation determined that the opioids were consumed with the intent to die. This category also includes deaths with ongoing investigations where suicide was believed to be the manner of death at the time of reporting.

Undetermined: Deaths with completed investigations where the manner of death could not be assigned based on available or competing information.

Collecting data on how deaths occurred, including whether they were intentional or not, is critical in understanding how the opioid crisis is affecting Canadians. According to available data reported as of March 22, 2018, the majority of apparent opioid-related deaths were accidental (unintentional) in both 2016 (88%) and January to September 2017 (92%) (Table 2).

In other words, these data indicate that the vast majority of apparent opioid-related deaths were of individuals who did not intend to die. This distinction is important to inform an appropriate public health response. For example, the high percent of unintended deaths reinforces the concern that a variety of street drugs are being laced with toxic substances, such as fentanyl, without the knowledge of the people consuming them. Public health officials will be able to use this information in designing strategies to address these hidden risks in order to reduce harms and effectively prevent unintended apparent opioid-related deaths.

Table 2. Number and percent of apparent opioid-related deaths in Canada by manner of death, 2016 and January to September 2017.^{Table 2 Footnote 1}

Manner of death	2016		2017 (Jan to Sep)
	Number	Percent	Number	Percent
Accidental (unintentional)	2593	88.0%	2694	92.2%
Suicide	250	8.5%	126	4.3%
Undetermined	103	3.5%	103	3.5%
TotalTable 2 Footnote 2	2946		2923
Table 2 Footnote 1 Not all provinces and territories reported data for all manners of deaths, all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Return to table 2 footnote 1 referrer Table 2 Footnote 2 Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Return to table 2 footnote 2 referrer

2.1 National and regional trends of accidental apparent opioid-related deaths

The following section provides detailed information on accidental apparent opioid-related deaths, which also shows that some provinces and territories have been impacted more than others.

According to data reported as of March 22, 2018:

• there were 2,593 accidental apparent opioid-related deaths in Canada in 2016, corresponding to a death rate of 7.2 per 100,000 population (Table 2a)^{Footnote a}
• there were at least 2,694 accidental apparent opioid-related deaths from January to September 2017, corresponding to an estimated annual death rate of 9.8 per 100,000 population (Table 2a)^{Footnote b}

Table 2a. Number and rate (per 100,000 population) of accidental apparent opioid-related deaths by province or territory, 2016 and January to September 2017.^{Table 2a Footnote 1}

Province or territory	2016		2017
	Number	Rate	Number (Jan to Sep)	Estimated annual rateTable 2a Footnote 2
British ColumbiaTable 2a Footnote 3	966	20.3	1076	29.8
Alberta	551	13.0	522	16.2
Saskatchewan	69	6.0	25	2.9
Manitoba	57	4.3	55	5.5
Ontario	726	5.2	829	7.8
QuebecTable 2a Footnote 3	131	1.6	93	1.5
New Brunswick	26	3.4	25	4.4
Nova Scotia	40	4.2	45	6.3
Prince Edward Island	5	3.3	1	0.9
Newfoundland and Labrador	13	2.5	18	4.5
Yukon	5	13.1	4	13.9
Northwest Territories	4	9.0	1	3.0
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed
Total	2593	7.2	2694	9.8
Suppressed – Data may be suppressed in provinces or territories with low numbers of cases. Please see Considerations and Limitations for more information. Table 2a Footnote 1 Not all provinces and territories reported data for all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Return to table 2a footnote 1 referrer Table 2a Footnote 2 The estimated annual rates for 2017 are based on available data from January to September 2017. Return to table 2a footnote 2 referrer Table 2a Footnote 3 Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Return to table 2a footnote 3 referrer

Table 2b. Number of accidental apparent opioid-related deaths by quarter and province or territory, January 2016 to September 2017.^{Table 2b Footnote 1}

Province or territory	2016				2017 (Jan to Sep)
	Jan to Mar	Apr to Jun	Jul to Sep	Oct to Dec	Jan to Mar	Apr to Jun	Jul to Sep
British ColumbiaTable 2b Footnote 2	219	190	191	366	379	389	308
Alberta	117	138	143	153	156	176	190
SaskatchewanTable 2b Footnote 3	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Manitoba	11	10	13	23	31	20	4
Ontario	174	180	174	198	189	265	375
QuebecTable 2b Footnote 2	41	35	34	21	N/A	N/A	93
New Brunswick	11	3	6	6	8	8	9
Nova Scotia	14	8	15	3	17	15	13
Prince Edward IslandTable 2b Footnote 3	N/A	N/A	N/A	N/A	Suppressed	Suppressed	Suppressed
Newfoundland and Labrador	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Yukon	0	2	0	3	3	0	1
Northwest Territories	1	0	1	2	0	0	1
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
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 see Considerations and Limitations for more information. Table 2b Footnote 1 Not all provinces and territories reported data for all stages of death investigation, refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Return to table 2b footnote 1 referrer Table 2b Footnote 2 Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Return to table 2b footnote 2 referrer Table 2b Footnote 3 Only annual totals were available for Prince Edward Island (2016 data) and Saskatchewan (2016 and 2017 data); quarterly data were not available at the time of this publication. Return to table 2b footnote 3 referrer

2.2 Sex and age trends of accidental apparent opioid-related deaths

This crisis has affected Canadians from all walks of life. However, available data from January 2016 to September 2017, reported as of March 22, 2018, indicate there are differences by sex and age.

Although these trends vary by province or territory, at the national level:

• most (76%) accidental apparent opioid-related deaths occurred among males (Figure 2)
• the highest percent (28%) of accidental apparent opioid-related deaths occurred among individuals between the ages of 30 and 39 (Table 2c)

Table 2c. Percent of accidental apparent opioid-related deaths by age group and province or territory, January 2016 to September 2017.^{Table 2c 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 ColumbiaTable 2c Footnote 2	2%	18%	28%	24%	21%	6%	0%
Alberta	3%	21%	34%	19%	17%	5%	1%
Saskatchewan	3%	17%	38%	14%	18%	9%	1%
Manitoba	1%	27%	34%	15%	11%	10%	3%
Ontario	2%	21%	25%	22%	22%	7%	1%
QuebecTable 2c Footnote 3	0%	13%	21%	27%	23%	11%	1%
New Brunswick	2%	20%	20%	22%	22%	12%	4%
Nova Scotia	2%	18%	28%	19%	25%	8%	0%
Prince Edward Island	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Newfoundland and Labrador	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Yukon	0%	11%	56%	22%	11%	0%	0%
Northwest Territories	0%	40%	20%	0%	20%	20%	0%
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed	Suppressed
Total	2%	19%	28%	22%	21%	7%	1%
Suppressed – Data may be suppressed in provinces or territories with low numbers of cases. Please see Considerations and Limitations for more information. Table 2c Footnote 1 Not all provinces and territories reported data for all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Return to table 2c footnote 1 referrer Table 2c Footnote 2 British Columbia reports deaths related to all illicit drugs including, but not limited to, opioids. Return to table 2c footnote 2 referrer Table 2c Footnote 3 The percentages for Quebec do not add up to 100% as the '≤19' and '≥ 70' age groups were suppressed in the 2017 data reported due to low numbers of cases. For available 2017 data (July to September), Quebec reports deaths related to all illicit drugs including, but not limited to, opioids. Return to table 2c footnote 3 referrer

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

Apparent opioid-related deaths often involve^{Footnote d} 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.

Available data reported as of March 22, 2018, suggest that more accidental apparent opioid-related deaths have involved fentanyl or fentanyl analogues over time (Table 2d, Table 2e):

• the percent of accidental apparent opioid-related deaths involving fentanyl or fentanyl analogues was 55% in 2016 and increased to 72% in 2017 (January to September)^{Footnote e}
• the number of accidental apparent opioid-related deaths involving fentanyl or fentanyl analogues more than doubled in January to September of 2017 compared to the same time period in 2016

In addition, available data suggest that approximately 80% of accidental apparent opioid-related deaths from January 2016 to September 2017^{Footnote f} also involved one or more types of non-opioid substances.

Table 2d. Number and percent of accidental apparent opioid-related deaths involving fentanyl or fentanyl analogues by province or territory, 2016 and January to September 2017.^{Table 2d Footnote 1}

Province or territory	2016		2017 (Jan to Sep)
	Number	Percent	Number	Percent
British ColumbiaTable 2d Footnote 2	652	67%	901	84%
Alberta	355	64%	400	77%
Saskatchewan	8	12%	7	28%
Manitoba	30	53%	29	53%
Ontario	330	45%	541	68%
QuebecTable 2d Footnote 2	30	23%	15	16%
New Brunswick	3	12%	7	28%
Nova Scotia	10	25%	5	11%
Prince Edward Island	1	20%	0	0%
Newfoundland and Labrador	Suppressed	Suppressed	Suppressed	Suppressed
Yukon	4	80%	3	75%
Northwest Territories	1	25%	0	0%
Nunavut	Suppressed	Suppressed	Suppressed	Suppressed
Total	1424	55%	1908	72%
Suppressed – Data may be suppressed in provinces or territories with low numbers of cases. Please see Considerations and Limitations for more information. Table 2d Footnote 1 Not all provinces and territories reported data for all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Return to table 2d footnote 1 referrer Table 2d Footnote 2 Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Data on deaths related to illicit drugs where fentanyl or fentanyl analogues were detected is used here to estimate apparent opioid-related deaths involving fentanyl or fentanyl analogues. Return to table 2d footnote 2 referrer

Table 2e. Number of accidental apparent opioid-related deaths involving fentanyl or fentanyl analogues by quarter, January 2016 to September 2017.

	2016				2017 (Jan to Sep)
	Jan to Mar	Apr to Jun	Jul to Sep	Oct to Dec	Jan to Mar	Apr to Jun	Jul to Sep
TotalTable 2e Footnote 1	280	311	288	536	559	653	689
Table 2e Footnote 1 Not all provinces and territories reported data for all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Updates to previously reported data will be provided in future reports. Data from British Columbia and available 2017 data from Quebec (July to September) include deaths related to all illicit drugs including, but not limited to, opioids. Data on deaths related to illicit drugs where fentanyl was detected is used here to approximate apparent opioid-related deaths involving fentanyl. Only annual totals were available for Prince Edward Island (2016 data) and Saskatchewan (2016 and 2017 data); quarterly data were not available at the time of this publication. Return to table 2e footnote 1 referrer

2.4 Apparent opioid-related deaths: suicide

The following section provides information on apparent opioid-related deaths where the completed investigation determined that the opioids were consumed with the intent to die. This section also includes deaths with ongoing investigations where the manner of death was believed to be suicide.

Table 2f. Summary of apparent opioid-related deaths classified as, or believed to be suicide, in Canada, 2016 and January to September 2017.^{Table 2f Footnote 1}

		2016	2017 (Jan to Sep)
Number		250	126
Rate per 100,000 population		0.7	0.5Table 2f Footnote 2
% male		47%	54%
Age group (years)	≤ 19	2%	1%
	20 to 29	9%	10%
	30 to 39	11%	15%
	40 to 49	19%	17%
	50 to 59	29%	25%
	60 to 69	21%	17%
	≥ 70	11%	14%
% involvingTable 2f Footnote 3 fentanyl or fentanyl analoguesTable 2f Footnote 4		13%	18%
% also involving non-opioid substancesTable 2f Footnote 5		63%	77%
Table 2f Footnote 1 Not all provinces and territories reported data for all stages of investigation and all time periods (January 2016 to September 2017); refer to Table 4 for more details. Suicide data from Prince Edward Island (2016 and 2017) and Quebec (July to September 2017) were not available at the time of this publication. British Columbia reports deaths related to all illicit drugs including, but not limited to, opioids. Updates to previously reported data will be provided in future reports. Return to table 2f footnote 1 referrer Table 2f Footnote 2 The estimated annual rate for 2017 is based on available data from January to September 2017. Return to table 2f footnote 2 referrer Table 2f Footnote 3 Given jurisdictional differences in death classification methods, the term "involving" includes deaths where the substance was either detected and/or directly contributed to the death. Return to table 2f footnote 3 referrer Table 3 Footnote 4 These percentages do not include data from Quebec, Prince Edward Island, or Nunavut as these data were not available for both time periods. 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 not involving fentanyl or fentanyl analogues in some provinces and territories. In addition, these data are preliminary and subject to change. Return to table 2f footnote 4 referrer Table 2f Footnote 5 These percentages do not include data from British Columbia, Saskatchewan, Ontario, Quebec, Prince Edward Island, and Nunavut as these data were not available for both time periods. For Alberta, the data included in these percentages are for deaths with completed investigations only. Refer to Opioids and other substances for more details. Return to table 2f footnote 5 referrer

Considerations and Limitations

Definition of an apparent opioid-related death

An apparent opioid-related death is a death caused by an intoxication/toxicity (poisoning) resulting from substance use, where one or more of the substances is an opioid, regardless of how it was obtained (e.g. illegally or through personal prescription).

How apparent opioid-related deaths are counted

Counts are provided by the provinces and territories that collect data from their respective offices of Chief Coroners or Medical Examiners. Rates are calculated using the most current population data from Statistics Canada.

The data provided by the provinces and territories can include:

• deaths with completed or ongoing investigations
• deaths classified as accidental, suicide, or with an undetermined manner of death

These data do not include deaths due to:

• the medical consequences of long term substance use or overuse (for example, alcoholic cirrhosis)
• medical assistance in dying
• trauma where use of the substance(s) contributed to the circumstances of the injury that lead to the death, but was not directly involved in the death
• homicide

However, some provincial and territorial differences remain in the type of data reported and in the time periods for which data are available (refer to Table 4).

Table 4. Reporting periods and manners of death included in apparent opioid-related deaths data used for this report by province or territory.

		BCTable 4 Footnote 1	AB	SK	MB	ONTable 4 Footnote 2	QCTable 4 Footnote 3	NB	NS	PE	NL	YT	NT	NU
Reporting period (as of March 22, 2018)
2016	January to December
2017	January to March
	April to June
	July to September
Classification of deaths included in the reported data
Accidental	Completed investigations													N/A
	Ongoing investigations where manner of death was believed to be accidental				N/U	N/U								N/A
	Ongoing investigations where manner of death had not been assigned at the time of reporting		N/U						N/U		N/U	N/U	N/U	N/A
Suicide	Completed investigations													N/A
	Ongoing investigations where  the manner of death was believed to be suicide				N/U	N/U								N/A
Deaths with completed investigations and an undetermined manner of death														N/A
These data have been reported by the province or territory and are reflected in this report, unless otherwise specified N/U The classification is not used in the province or territory N/A Data were not available at the time of this publication Table 4 Footnote 1 British Columbia reports deaths related to all illicit drugs including, but not limited to, opioids. Return to table 4 footnote 1 referrer Table 4 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. Data from January 2016 to September 2017 include deaths with completed investigations; however, data from July to September 2017 include only deaths with ongoing investigations. Return to table 4 footnote 2 referrer Table 4 Footnote 3 Data from Quebec for 2016 were available for deaths with completed investigations only; 28% of deaths for 2016 were still under investigation. Following the launch of Québec's opioid surveillance system, data on apparent opioid-related deaths with ongoing investigations, where manner of death was believed to be accidental, were reported from July to September 2017; data from January to June 2017 were not available at the time of this publication. The available 2017 data included accidental deaths related to all illicit drugs including, but not limited to, opioids. Updates to historical data will be provided in future reports. Return to table 4 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 quarterly data, and for any data regarding sex and age distribution.
• Newfoundland and Labrador suppressed all counts less than five.
• Nunavut suppressed all counts less than five.
• Quebec suppressed counts less than five for deaths with ongoing investigations (July to September 2017)

In addition, suppression was applied in some instances where all data for a province or territory fell in a single category of a given table or figure.

Opioids and other 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 March 22, 2018. New or revised data submitted after this date will be reflected in future reports.
• 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), the use of 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. The time required to complete an investigation and related administrative processes is case-dependent and can range from approximately three to twenty-four months.
• This report is based on data that do not specify how the opioids were obtained (e.g. illegally or through personal prescription); the level of toxicity may differ depending on the source of the opioid.
• Jurisdictional differences in the death investigation process, death classification method, toxicology testing and the manners of death reported may impact the interpretation and comparability of the data presented in this report.
• 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 adjusted for existing differences in provincial and territorial age distributions.
• Rates for jurisdictions with relatively smaller populations may change substantially with even slight changes in the number of deaths. As a result, comparisons over time and between provinces and territories should be interpreted with caution.