Case Highlights

The following video provides a brief introduction to the Opioid Crisis Case

• Canada’s drug/substance overdose crisis is resulting in an unprecedented number of overdoses and deaths. Between January 2016 and March 2021, nearly 23,000 Canadians died from apparent opioid toxicity (death caused by intoxication/toxicity [poisoning] resulting from substance use, where one or more substances are an opioid). (Government of Canada)
• The Canadian Substance Use Costs and Harms (CSUCH) working group estimated that opioid use cost Canadians over $5.9 billion in 2017. Lost productivity accounted for the majority of these costs (over $4.2 billion), followed by criminal justice costs (over $944 million), health costs (over $438 million), and other direct costs, including research and prevention, employee assistance programs and workplace drug testing, among others (over $320 million). The CSUCH also anticipates that the costs and harms associated with opioid use will continue to increase as deaths trend upwards.
• Opioid use disorder impacts people from all educational and socioeconomic backgrounds, and it often co-occurs with other mental health disorders.  Opioid use disorder is also associated with social issues such as poverty, homelessness, and incarceration (Government of Canada). A combination of one or more of these factors increases the difficulty associated with designing an appropriate solution.

• In response to the growing opioid crisis, provinces and their municipalities have implemented various actions as part of a comprehensive prevention strategy to save lives, prevent deaths and overcome the crisis.
• The case study on the opioid crisis explores various perspectives on the nature of the crisis and how these perspectives influence problem definition and strategy development. The case allows for a critical examination of statistics and various contextual factors, as well as a distinction between the roles of provincial governments and other stakeholders in harm reduction.

Case Description

The opioid crisis is a complex health and social issue with devastating consequences for individuals, families and communities. In 2018, the Canadian Institute for Health Information (CIHI) revealed a significant increase in fatal opioid-related poisonings across all provinces/territories, age groups, genders, and metropolitan areas in Canada. Specifically, an average of 17 Canadians were hospitalized daily due to opioid poisonings, with the national hospitalization rate for this type of poisoning increasing by approximately 53% over the last decade (CIHI 2018a). As well, there were around 12,000 apparent opioid-related deaths between January 2016 to December 2018, of which around 4500 occured in 2018, showing that rates have remained high and have increased by approximately 30% since 2016 (Public Health Agency of Canada 2019; CIHI 2018a). Further, increases in opioid use and abuse have contributed to an estimated tripling of blood-borne infections, such as hepatitis B and C (Gostin, Hodge, and Noe 2017). Approximately 22,828 people in Canada died due to apparent opioid toxicity (death caused by intoxication/poisoning resulting from substance use, where one or more substances are an opioid) between January 2016 and March 2021. In the first quarter of 2021 alone, 1772 Canadians died of apparent opioid toxicity.^[1]

Image by Mart Production Public Domain

The Government of Canada’s  response to the report of the standing committee on health on the opioid crisis states that “The current overdose emergency, driven primarily by a rapid increase in the use of fentanyl and other powerful illegal opioid drugs, has led to an unprecedented number of overdose deaths; but, this crisis reaches far beyond the illegal drug market. For many Canadians, this crisis has its roots in high levels of addiction to legal opioids, caused in part by inappropriate prescribing practices and poor education about the risks associated with opioids. For others, substance use disorders have much deeper roots in trauma, social and economic inequities and mental health issues”.^[2] Western Canada has been the region most impacted by opioid toxicity since 2016. In 2020, British Columbia, Alberta and Saskatchewan experienced the highest rates of apparent opioid toxicity deaths per 100,000 population, and 85% of all apparent opioid toxicity deaths took place in British Columbia, Alberta and Ontario.^[3] The proportion of apparent opioid toxicity deaths involving non‑pharmaceutical substances compared to pharmaceutical products increased in 2020. In 2018 and 2019, non‑pharmaceutical opioids accounted for 66% of deaths. In 2020, they accounted for 76% of apparent opioid toxicity deaths, and in the first half of 2021, 83% of deaths.^[4] The Canadian Substance Use Costs and Harms (CSUCH) Working Group estimated that opioid use cost Canadians over $5.9 billion in 2017. Lost productivity accounted for the majority of these costs (over $4.2 billion), followed by criminal justice costs (over $944 million), health costs (over $438 million), and other direct costs, including research and prevention, employee assistance programs and workplace drug testing, among others (over $320 million). The per-person costs as a result of substance use also increased largely due to the rapid increases in lost productivity costs attributable to opioid use, which are largely driven by opioid-related deaths. Given that the number of deaths related to opioid use remained high in 2019 and 2020, CSUCH anticipates that the costs and harms associated with opioid use will continue to increase.

Health is an area of shared jurisdiction in Canada. Sections 91 and 92 of the Constitution Act, 1867 assign exclusive legislative authority over certain matters to either the federal or provincial legislatures. These sections list some health‑related matters (e.g., hospitals, other than marine hospitals, are provincial matters). However, the constitution does not explicitly assign legislative power over health as a whole. As a result, health‑related measures can fall within the jurisdiction of either the federal or provincial legislatures, depending on each measure’s purpose and effect. Provincial legislatures have exercised their jurisdiction over health matters under sections 92(7) (hospitals), 92(13) (property and civil rights) and 92(16) (matters of a merely local or private nature) of the Constitution Act, 1867. Generally, these last two sections grant the provinces jurisdiction over health care services, the practice of medicine, the training of health professionals and the regulation of the medical profession, hospital and health insurance, and occupational health. Provincial and territorial governments are thus responsible for delivering most substance use prevention, treatment and harm reduction programs. The Parliament of Canada has exercised its jurisdiction over health matters under its criminal law power (section 91(27) of the Constitution Act, 1867), its spending power (inferred from federal jurisdiction over public debt and property (section 91(1A)), and its general taxing power (section 91(3)). Federal legislation respecting opioids includes, for example, the Controlled Drugs and Substances Act (CDSA) and the Food and Drugs Act. The spending power enables federal initiatives in health research, health promotion, health information, and disease prevention and control, as well as pilot projects related to provincial health initiatives. Additionally, the federal government directly funds or provides substance use prevention, treatment and harm reduction services to specific populations, such as First Nations and Inuit, members of the military and veterans, and people in federal prisons.(xxx reference for paragraph).

Image by the Province of British Columbia CC BY-NC-ND 2.0

The opioid crisis prompted response from the provincial and the federal government. For example, in Western Canada, the British Columbia and Saskatchewan governments established ministries of mental health and addictions. In February 2017, the Government of Canada announced a $65 million fund disbursed over five years for federal activities to support the implementation of the Canadian Drugs and Substances Strategy based on four major pillars ( Prevention, Treatment, Harm Reduction and Enforcement).  This funding can be used to increase national lab testing capacity, develop and implement a national public awareness campaign, increase research on problematic substance use, expand support for First Nations and Inuit communities, such as access to naloxone kits, strengthen national data surveillance and monitoring, fund grants and contributions to address various opioid-specific issues, and support new regulatory activities. The Government of Canada also implemented regulatory amendments which overturned the ban on the sale of diacetylmorphine (heroin) for emergency treatment and allows for the consideration of applications made to the Special Access Program. The government introduced Bill C-37 to simplify and streamline the application process for supervised consumption sites. Bill C-37  also provides law enforcement with tools to prevent illegal drugs from being imported and manufactured in Canada.^[5] However, these enabling actions alone are not enough as the opioid crisis intersects with several variables, including mental health, age, gender, location, socioeconomic status, race and ethnicity (Morin, Eibl, and Franklyn 2017). For example, over 50% of individuals with Opioid Use Disorder (OUD) – defined as a dependence on opioids and opioid medications – were also diagnosed with a mental health disorder in 2008, and it is suggested that this statistic has drastically increased in recent years (Astals, Domingo-Salvany, and Buenaventura 2008; Vashishtha, Mittal, and Werb 2017).

Provincial Governments, municipal governments, regulatory colleges, healthcare providers, front line workers and users of drugs all have a critical role in responding to the overdose emergency and turning the tide on the crisis.^[6]

Various approaches have been deployed to manage the crisis. Supervised injection sites are one such approach, which are health-focused locations where people can use drugs while being under the care of medical professionals who aid in reversing opioid overdoses, leading to a reduction in opioid-related deaths and preventing the spread of diseases associated with drug use by distributing clean needles and other supplies (City of Vancouver 2018). However, the funding available for this harm reduction approach is minimal, and the support given is inconsistent (Dooling and Rachlis 2010; Wood, Tyndall, Montaner, and Kerr 2006; Morin et al. 2017). As a result, it has not been widely implemented across Canada, despite having the potential to impact the opioid crisis positively (Gordon 2018). Morin et al. (2017) also note that the perception of appropriate solutions to address the crisis in the eyes of the government, law enforcement, the general public, medicine, pharmacology, community programs, media, public health, and health policy are often incompatible. For example, supervised injection sites, part of the previously discussed harm reduction approach, is hotly debated, with some government officials opposing them and halting their implementation (Gee 2018) and various law enforcement officials advocating for enforcement approaches instead (Graham 2008). Alternately certain health professionals are proponents of them and discuss their effectiveness, demand, and need (Bambang 2018). Discrepancies also exist between research and policy decisions concerning solutions (Morin et al. 2017), likely because there is a lack of consistent data collection and reporting at provincial/territorial and national levels (Canadian Public Health Association 2016).

Resources

• Canadian Substance Use Costs and Harms Scientific Working Group. (2020). Canadian substance use costs and harms 2015–2017. (Prepared by the Canadian Institute for Substance Use Research and the Canadian Centre on Substance Use and Addiction.) Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.
• HESA, Report and Recommendations on the Opioid Crisis in Canada, Sixth report, December 2016.
• The Honourable Jane Philpott, Minister of Health, Government Response to the Report of the House of Commons Standing Committee on Health Report Entitled Report and Recommendations on the Opioid Crisis in Canada. 
• Special Advisory Committee on the Epidemic of Opioid Overdoses. National report: apparent opioid-related deaths in Canada (January 2016 to June 2017)
• Government of Canada, “Graphs: Percentage of accidental apparent opioid toxicity deaths by origin of the opioid(s) directly contributing to death, among deaths with completed investigations only in Canada, 2018 to 2021 (Jan to June),” Opioid- and Stimulant‑related Harms in Canada (December 2021), Public Health Infobase, Database, accessed 6 January 2022.
• Government of Canada, “About opioids,” Opioids.