Drug overdose deaths from multiple substances on rise in Ontario since start of pandemic: report

Just the other day, Dr. Marko Erak treated a patient in Toronto'sHumber River Hospital emergency room who had overdosed on carfentanil, anextremely toxic opioid.

Stronger drugs are a common theme that's worrying doctors like Erak.

"The amount of resources taken to resuscitate certainly are higher," he told CBC News outside of the ER earlier this week.

While the COVID-19 pandemic has subsided for now, Erak said,it left poor mental health and financial hardshipin its wake. This, he suspects, is fuelling a "tsunami of overdoses."

And the overdoses are becoming more complicated, as Eraksaid he finds that people end up having more than one drug in their system.

A new report published Thursday shows that's the case across Ontario, with people increasingly dying from multiple toxic substances since the start of the pandemic.

It's a trend that's also apparent throughoutCanadaand inthe United States, where recent research shows that the number of overdose deaths from fentanyl and a stimulant (cocaine or methamphetamine) increased more than 50-fold from 2010 to 2021.

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A new report finds that after the COVID-19 pandemic began, overdose deaths in Ontario from multiple substances surpassed deaths from a single substance.

The report, released by the Ontario Drug Policy Research Network(ODPRN) and Public Health Ontario, also offers more details on the victims and the drugs that killed them. It points to an increasingly toxic and unregulated drug supply, which is creating more complicated addictions that require nuanced treatments.

"What surprised me the most was just the complexity of it," said Tara Gomes, the report's lead author, a research scientist based out ofUnity Health Toronto and a principal investigator with the ODPRN.

"Understanding the full complement of all these different substances that are contributing to harm and how often they're being used together in different ways really just shed a light on how difficult it is to address this issue."

Between 2018 and 2021, there were 8,767 accidental deaths from toxic drug and alcohol use across Ontario.

Data from 2021 shows that 2,886 Ontarians died from consuming a toxic substance whichequates to the deaths of eight people every day. It's also five times higher than the number of people who died in traffic accidents in the province that same year, according to the report.

At the same time, the number of deaths from 2021 wasalso nearly double the amount in 2018.

Multi-substance deaths on the rise

The study focused on the following four substances, which were found to be involved in the majority of the deaths: opioids, alcohol, benzodiazepines and stimulants.

Benzodiazepines are a class of sedative drugs that are often prescribed for anxiety or sleep disorders, while stimulants are used to increase alertness and, in this study, include cocaine, methamphetamine and amphetamine.

Before the pandemic, the number of people dying from one or two substances was relatively similar. But after the COVID-19 emergency was declared in March 2020, more deaths occurred as a result of at least two substances.

The report also notedthat most of these people were found to have a mixture of opioids and stimulants in their system.

"A lot of the time, we think people are likely knowingly using the drugs together," Gomes said in an interview with CBC News.

"Sometimes people might use a stimulant like cocaine or methamphetamine to try and counteract the sedating effects of the opioid supply, for example."

But, she said,there could also be cross-contamination of the drugs, where the substances unknowingly get mixed together.

The report points out that 96 per cent of benzodiazepine deaths in 2021 also included opioids. Gomes saidthis combination is likely because benzodiazepines extend the effects of the opiates.

When combined, the report states, there is double the risk that a person will die or have increased withdrawal symptoms.

"The changing drug supply is leading to people sometimes being exposed to many different substances that they don't know they're being exposed to and that can increase the harm for them," Gomessaid.

Why it's harder to treat multi-substance use

When stimulants and benzodiazepines are mixed with opioids, it complicates the overdose response, as naloxonealone which is used to reverse or reduce the effects of opioids won't reverse the effects of the other drugs.

Harm reduction worker Kyle Arnold saidthe overdose response training he offers has changed over the years because of the complex drug supply.

Arnold, who lives in Thunder Bay, Ont., and is a program co-ordinator for People Advocating for Change Through Empowerment (PACE), saidwhile they used to inject people two or three times with naloxone, it can now takeup to nine times.

"Every time you use those naloxones and you're doing those [chest] compressions, you have to check and see if they're breathing again, because just because they're not popping up and their eyes aren't open doesn't mean they're not breathing, [since]that benzo is still sedating them so much," he said.

When an overdose patient arrives in the ER, Dr. Erak, of HumberRiver Hospital, saidtheir behaviour and symptoms are quickly assessed. Often, he said, people are "violent" and "agitated."

"They are just out of sorts, they're not themselves," he said. "These individuals are in quite a lot of distress."

Other times, peopleneed to be resuscitated. But depending on the drug or the concoction consumed, Erak said,more intensive resources could be required.

In particular, he said,people can be admitted to the intensive care unit for constant naloxone infusions. If naloxone doesn't work, Erak said,the person can possibly require a breathing machine or a medically induced coma.

"For the most part, the individuals that are lucky enough to make it to the emergency room survive," he said.

But he equates it to a game of roulette and next time, the person might not be so lucky.

Deaths 3 times higher in northern vs. southern Ontario

Of those who died in 2021, the study foundthat:

• 52.7 per cent were between the ages of 25 and 44.
• 75 per cent were men.
• 40.2 per cent lived in lower-income neighbourhoods.

Toxic substance deaths were also about three times higher in northern Ontario compared withsouthern parts of the province in 2021. The rate of death was similar across urban and rural regions, with most people dying in a private residence.

Earlier this week, First Nations chiefs in northern Ontario called for a public emergency and social crisis to be declared given the disproportionate mental health and addictionissues the region is facing.

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Dr. David Marsh, vice-dean of research, innovation and international relations at the Northern Ontario School of MedicineUniversity in Sudbury, Ont., saidit's more difficult to access addictiontreatment in the province's north.

"When we look at how far people with opiate use disorder travel to get treatment in northern Ontario, the average is 124 kilometres, compared to 16 kilometres in southern Ontario, so distance makes a big difference," he said.

People tend to be more spread out and can live further from a hospital, Marsh said, so when a crisis occurs, it can take longer for emergency services to arrive and provide care.

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Gomes noted that northern communities also have more Indigenous people.

Intergenerational trauma from colonization and the residential school system, along with improper housing or access to clean water, are factors that can impact people's substance use, she said.

She saidculturally appropriate treatment options need to be a priority for these communities.

No 'one size fits all' solution

One way to target the complexity highlighted in the report, Gomes said, is to ensure that treatment programs address multi-substance addictions.

Marsh said there needs to be better co-ordination between different parts of the system that are working to help people, such ashousing, social assistance support, primary care and addictionprograms. He said he'd also like to see patient outcomes better tracked across the province.

"Unfortunately, 2022 looks to be even worse than 2021, and things just continue to deteriorate so it's really a crisis," he said.

Erak, who's on the front lines of theworsening crisis, said the solution is not "one size fits all."

"This is multi-factorial. I think this stretches from everything from political will to social change," he said.