canadas-health-crisis-opioid-addiction-in-alberta-and-british

Canada’s Health Crisis:

Profiling Opioid Addiction in Alberta & British Columbia

Report for the Stanford Network on Addiction Policy (SNAP) by:

Blair Gibbs

Ryan Workman

Jake Kiefer

Chosen Canlas

March 2023

Background

This project was commissioned by Professor Keith Humphreys of Stanford University and was funded through the

Stanford Network on Addiction Policy (SNAP).

Purpose of Study

The purpose of this report is to investigate the current state of the opioid addiction crisis in Canada. The report gives

specific attention to Alberta and British Columbia, the two provinces in Canada with the highest rates of opioid-related

overdose deaths. The report seeks to identify drivers of the crisis and key features of the provincial policies, along with the

makeup of the addicted populations and overdose victims.

Methodology

This report utilized publicly available data at both the federal and provincial level applying both quantitative and qualitative

research methods. All data was retrieved between September 2022 and February 2023. Access to certain datasets was

refused in the absence of an ethics approval.

Executive Summary

Canada’s drug addiction crisis has been mounting for two decades, and shares many of the same features as the

well documented experience of the United States. In both countries, the COVID-19 pandemic exacerbated the health

harms, with rates of drug mortality in areas like British Columbia (BC) in 2022 as high as the worst affected parts of the

USA.

There is more political attention on the issue compared to a decade ago, but a situation that warranted a

declaration of a public health emergency in BC in 2016 has not improved since then – in fact the crisis has

escalated. As of December 31, 2022, the rate of illicit drug toxicity deaths in BC has more than doubled since the

emergency was first declared in 2016.

This report explores what is behind this dramatic deterioration and focuses on the characteristics of the crisis in

British Columbia and Alberta – two neighbouring provinces in Western Canada that are home to a disproportionate

share of the harm caused by opioid addiction today.

Key Findings

Canada’s addiction crisis in context

• The scale of drug-related harms in Canada are significant, dramatically outpacing comparator jurisdictions in

places like Europe. The death rate in Canada’s worst affected province – British Columbia – has risen from 5.8 per

100,000 in 2000 to 44.2 per 100,000 in 2021. In Canada, the number of accidental apparent opioid toxicity deaths

(AAOTDs) per 100,000 was 20.2 per 100,000 in 2021. For comparison, in 2019, England and Wales had a drug-

related mortality rate of 7.7 per 100,000.

• BC’s AAOTD rate in 2021 was more than double the national average, and Alberta was not far behind at 36 per

100,000. Ontario had the most total AAOTDs (2,772) but had a lower death rate of 19.4 per 100,000.

• Between them, BC and Alberta accounted for a quarter of Canada’s population but almost half (49%) of drug

deaths (3,804). To put this another way, 1 in every 7 Canadians live in BC and 1 in every 9 live in Alberta, but 1 in

every 4 AAOTD in 2021 was a British Columbian and 1 in every 5 was an Albertan. The share of AAOTDs held by

Alberta and BC has actually decreased slightly from 54% in 2016.

• In Canada overall, in 2020 and 2021, opioids caused nearly half as many deaths (13,815) as COVID-19 over the

same period (29,985), and were responsible for five times the number of lost life years. The COVID-19 pandemic

caused approximately 90,000 lost years of life in 2020 and 2021. Over that same period, premature deaths from

opioids caused nearly 450,000 lost years of life. The crisis has gotten so severe that it halted the increase in Canadian

life expectancy between 2016 and 2017, the first time that Canadian life expectancy has decreased in over four

decades.

• Opioid addiction is now at a scale that makes it a general public health concern. Alcohol and tobacco kill more

Canadians than illicit drugs, however those who overdose on opioids are usually far younger than those who die of

alcohol or tobacco. Because the chronic health impacts of alcohol or tobacco consumption manifest over decades of

use, opioids are responsible for more life years lost than tobacco, and nearly as many life years lost as alcohol, despite

not having the same level of general use in the population.

Opioid addiction in Canada

There are many dimensions to opioid-related-harms, but this report focuses on deaths, hospitalizations, lost life years, and

drug-related crime. Key findings regarding opioid-related harms include:

• Although illicit drug use often begins in adolescence or young adulthood, the people most impacted by

AAOTDs in Canada are those aged between 30 and 49. In 2021, middle-aged Canadians aged 30-49 represented

27% of the population and over half (52%) of all AAOTDs. Two other cohorts – 20-29-year-olds and 50-59-year-olds –

together represent 26% of the population and 38% of AAOTDs.

• The impact of opioid addiction is not evenly spread, and the concentration is significant. Geographically, the

harms are concentrated in Alberta and BC, and there is a disproportionate impact according to age and sex. Over half

of those suffering from opioid harms in Canada are 30-59-year-old men, though in BC the most impacted group is 50-

59-year-old-men.

• Indigenous people in Canada are also over-represented in terms of opioid harms. In Alberta, First Nations

individuals were dying at a rate nearly 7 times that of non-first nations in the first six months of 2020. In BC, between

January and June 2021, 14% of overdose deaths were among First Nations peoples despite them representing only

3.3% of the population. First Nations people had an illicit drug-related death rate 4.8 times greater than other BC

residents in 2021.

• Low income and lack of employment were also key drivers of opioid harms. The BC Coroners Service found that

only 35% of those who suffered illicit drug toxicity deaths between August 2017 and July 2021 were employed at the

time of their death. Data for BC shows income levels were also correlated with opioid-related mortality and

hospitalization, with those in the lowest quintile being 3.8 times more likely to suffer opioid-related mortality and 4.3

times more likely to be hospitalized for opioid-related reasons.

• Drug addiction often compounds other health issues, with poor mental health a common aggravating factor. In

BC, between August 2017 and July 2021, 62% of people who died of illicit drugs were experiencing mental health

issues. Those who die have often been in contact with the health system. Decedents had a higher number of health

visits, and 30% had had a previous paramedic attended non-fatal illicit drug related event.

Key drivers of drug deaths

Fentanyl is a synthetic opioid that can be up to 50 times stronger than heroin and 100 times stronger than morphine, but it

was not a feature of the drug market even 10 years ago. Fentanyl and its analogues have played an important role in the

opioid crisis because they are significantly cheaper to produce per dose and much harder to detect illicit supply routes.

This makes them more widespread in illicit drug markets and harder for law enforcement to trace and detect, and it is also

more likely that a dose will be too potent and cause people who use these drugs to overdose:

• The single factor that best explained the distribution of drug harms in Canada, based on published data, was

the prevalence of fentanyl. Though the populations of drug users were highest in Alberta and BC, the difference was

not substantial enough to explain why these provinces have approximately double the rate of deaths than Canada as a

whole, and eight times the AAOTD rate compared to jurisdictions such as Quebec and Newfoundland.

• Fentanyl was detected much more frequently in samples seized by law enforcement in Western Canada than in

Eastern Canada. Based on data from Health Canada’s Drug Analysis Service (DAS), this indicates a preponderance

for more toxic drug supply in these provinces, and marked correlations in other parts of Canada.

• In Alberta, in 2021, fentanyl was detected in 81% of all accidental drug poisoning deaths. In BC between 2019 and

2022, fentanyl was detected in 85% of all illicit overdose deaths. Further, fentanyl detection in BC has risen in tandem

with the death rate.

• Increased harms are not the result of an increase in the user base for illicit drugs. When considered alongside

survey data on self-reported drug use, it appears the increase in opioid-related harms in Canada is being driven by the

increased toxicity of the supply, rather than an increase in the number of drug users in the general population.

Other possible drivers of the higher rates of drug harm in Alberta and BC not considered in detail for this report include

access to treatment and rates of attrition in recovery services; inward migration of drug users; income and socio-economic

inequality; distribution of ethnicities within provinces; housing access and stability; and prescribing and dispensing

practice.

Drug crime in Canada

Crime associated with illicit drug markets is a further cause of harm to communities. Compared to twenty years ago, the

emphasis in Canada has shifted away from punishing users and sanctioning possession to deter drug use. However, as in

the USA, the fentanyl causing overdoses in Canada are supplied by an illegal market where addicted drug users are

exploited by organised crime and their international suppliers, who are still subject to serious penalties when they are

caught and prosecuted. The current state of this activity is hard to gauge, but our research found:

• Enforcement against drug crime has reduced in recent years. For Canada overall, sentencing volumes for drug-

related crime have dropped by over 50% in the past decade. Convictions for crime overall in Canada have also

dropped, but not to nearly the same extent, indicating a general lessening of criminal justice enforcement against drug

offences in Canada during the escalating health crisis of opioid addiction.

• The majority of reported opioid-related offences occur in BC. In 2021, BC – comprising approximately 13% of

Canada’s population – had nearly half of all police-reported opioid trafficking, production, and distribution (TPD)

incidents in Canada (drug offences that do not encompass personal possession). BC’s rate of opioid-related police

recorded incidents in 2021 was more than four times the recorded incident rate in Alberta.

• Despite the high volume of drug violations in BC, criminal charges for these offences are low, and appear

disconnected from incident rates. By contrast, charges for serious drug-related crimes are much higher in Alberta,

and increases in charges broadly tracked the trend in incidents, with rising rates after 2012 and reductions more

recently.

• In BC, drug possession incidents have increased significantly in the last decade, and TPD incidences have also

increased after 2016, but charge rates for both categories have remained broadly flat or even fallen over the same

period, suggesting a lack of interest by law enforcement in traditional prosecution for these offences.

• Crime incident data confirms BC is the epicentre of drug-crime in Canada, reporting 57 opioid-related incidents

per 100,000 population, compared to 13 per 100,000 in Alberta. Vancouver also has much higher numbers of drug-

related violations than anywhere else, and significantly higher than large cities like Calgary or Edmonton.

• In BC, drug users caught in possession have not been routinely charged by police in recent years,

foreshadowing the formal decriminalisation of drug possession in BC that came into effect on 31 January 2023.

However, this does not seem to reflect a law enforcement focus on upstream interdiction instead. When considering

the more serious drug offences involved in supply and profiting from the illicit market, the gap between TPD incidents

and charges in BC, however, is significant (80 per 100,000 incidents vs. 22 per 100,000 charges in 2019). In contrast,

Alberta charges far more people for TPD relative to the incidents detected (46.6 per 100,000 incidents vs. 38 per

100,000 charges).

Provincial comparison

Drug addiction affects every community but there is also a geographic concentration in western Canada. For more than a

decade, Alberta and BC have been Canada’s opioid hotspots, but there are some differences in how the crisis has

presented in the two provinces.

• British Columbia has a much longer history with substance harms than Alberta, and volume of harm is much

higher in BC, measured according to deaths and hospitalisations. However, the rise in AAOTDs in Alberta during

the pandemic has been steeper relative to its pre-pandemic levels.

• BC’s opioid addiction crisis skews older and more male – for reasons that have not been closely studied. On

age, Alberta is similar to the Canadian average, with 30-49-year-olds representing 30% of the population and 54% of

deaths. Those dying in BC, however, tend to be older: 50–59-year-olds represented only 13% of the province’s

population in 2021, but account for 28% of all AAOTD deaths.

• The ratio of male to female deaths in Alberta was in line with national averages, but was more acute in BC,

where 80% of all AAOTDs in 2021 were men. This could indicate that the resident base of drug users in BC – which

itself may explain the elevated number of deaths there - is being supplemented by inward migration from other

provinces.

• The impact on emergency dispatch caseloads from the addiction crisis is much higher in BC. Looking at

ambulance data, Emergency Medical Service (EMS) responses to suspected opioid-related overdoses are highest in

BC (24,152 responses) – three times the volume of such incidents in Alberta (8,215 responses).

Policy Responses in Western Canada

Strategies and municipal initiatives have been launched to addressed the crisis, beginning with the landmark ‘Four Pillars’

strategy published by the City of Vancouver in 2000. Major funding commitments have been made by the provincial

governments; however, the addiction crisis continues in both provinces, with 2022 being the second-deadliest year ever

for drug harms in both jurisdictions.

Both Alberta and BC deploy elements of harm reduction along with recovery. This report found that there was a significant

degree of overlap between the policy approaches and services provided by the two provinces, however the policy framing

and direction are not the same:

• Both provinces support harm reduction activity such as Naloxone distribution to emergency services and

community providers. In recent years, there has been a dramatic upswing in naloxone kit distribution in Alberta

where in 2022 there was approximately 135,330 kits distributed compared to only 32,140 in 2017, and 6,181 in 2016.

In BC, over one million naloxone kits were distributed between 2012 and 2021.

• Both provinces also fund and permit syringe exchange programs, and supervised consumption sites (SCS) in

multiple locations, with Vancouver being the location for the first such facility that opened in 2003.

However, there are some notable differences between Alberta and British Columbia:

• The provincial government and health providers in BC have placed a stronger emphasis on harm reduction,

with ‘safe supply’ for users of illicit drugs, and the recent decriminalization of drug possession, approved by the Federal

Government, in order to further reduce stigma and protect drug users from enforcement.

• Alberta has weighted their response more towards investment in rehabilitation beds and spaces, such as

therapeutic communities. Alberta has also not adopted the models of ‘safe supply’ – including proposals for

automated dispensing – that have been setup in BC. In addition to investments in treatment and new community

dispensing of licensed medicines like Sublocade, the province has also committed capital to building new recovery

communities.

• Published data implies that there is more residential recovery bed provision in Alberta than BC today, but

comparisons are hampered by a lack of consistent recording. It is currently not possible to compare the two provinces

on the politically salient issue of treatment and recovery outcomes based on the available data.

• The most apparent difference in policy between the provinces is BC’s recent decriminalisation of substance

possession. Alberta, while, bolstering funding and support around its recovery model, is maintaining current

approaches to law enforcement around illicit drugs.

• Enforcement appears to be a more integral part of the response in Alberta, although the province has also seen a

reduction in its incident caseload. The ratio of serious drug incidents to charges was nearly 1:1 in Alberta, compared to

BC where the ratio of incidents to charges was about 4:1.

There is a lack of policy innovation in BC on the issue of drug addiction, although a growing political interest in finding

sustainable solutions. Alberta’s nascent ‘Recovery-oriented System of Care’ model has new investment and political

leadership but has not yet had time to fully deliver results, with recovery communities still being constructed.

As the implementation of these neighbouring strategies advances, ongoing scrutiny of their impacts and effectiveness is

required to inform policymakers across Canada and other jurisdictions. Close engagement between policymakers and

service leads in both provinces will be important to allow sharing of learnings, especially in those areas where provincial

practices begin to diverge.

Headline conclusions

Despite the urgency of this crisis, and the many years to make the necessary investments, some basic information

architecture is still not in place to support policymakers or to guide those practitioners on the ground working to help

users suffering from drug addiction. This means that the impact of many policies in Canada to reduce harms and to aid

recovery cannot be properly evaluated.

Canada’s experience could provide lessons to other countries like the USA, but only if governments at all levels

commit to a consistent suite of reporting measures that accurately describes the progress being made, and one that

counts more than caseloads, inputs, or a series of ‘harm’ metrics.

Given the significant public funds that continue to be spent, it is time for provincial and federal policymakers to

urgently agree upon what success looks like and how it will be measured. In the absence of robust metrics around

treatment and pathways for recovery, the ‘harm’ metrics around deaths and hospitalisation become the only marker of

policy progress.

Of the two provinces studied for this report, Alberta is currently experiencing a reduction in key addiction-related

harms; however, it is based on two quarters of data, and would need to be sustained through 2023 to represent an

established trend. Our research indicates that Canada overall, and BC in particular, is not yet showing the progress that

the public and those impacted by drug addiction deserve.

Widespread public concern about this challenge is likely to continue and as death rates remain high, more

transparency, innovation and new policy responses are therefore needed. The current political attention on how two

provinces are choosing to respond to the opioid addiction crisis provides a window of opportunity to embrace new

solutions with focused political leadership in order to finally see Canada’s harmful trends around opioid addiction

reversed.

10 
Contents 
 
Background ......................................................................................................................................................................... 1 
Executive Summary ............................................................................................................................................................. 2 
Contents ............................................................................................................................................................................. 10 
Foreword ............................................................................................................................................................................ 14 
Introduction ....................................................................................................................................................................... 17 
CHAPTER 1: Defining the Problem ................................................................................................................................... 21 
Opioids: their function and role ....................................................................................................................................................... 21 
Benefits and Harms........................................................................................................................................................................... 22 
Risk and Context ............................................................................................................................................................................... 23 
CHAPTER 2: History of Canada’s health crisis ................................................................................................................ 26 
Overview ............................................................................................................................................................................................. 26 
Wave 1 (1980s – 2010) .................................................................................................................................................................... 27 
Wave 2 (2010 – 2014) ...................................................................................................................................................................... 27 
Wave 3 (2014-2019) ......................................................................................................................................................................... 28 
Wave 4 (2020 – Present) .................................................................................................................................................................. 29 
What Comes Next? ........................................................................................................................................................................... 29 
CHAPTER 3: Data ............................................................................................................................................................... 30 
Deaths, Hospitalizations and EMS .................................................................................................................................................. 30 
Population of People who Use Illegal Substances in Canada .................................................................................................... 31 
Fentanyl and Overdose Deaths ....................................................................................................................................................... 33 
Policing and Criminal Justice .......................................................................................................................................................... 34 

11 
Multi-Drug Use ................................................................................................................................................................................... 37 
Risk Factors........................................................................................................................................................................................ 38 
Sex ................................................................................................................................................................................................. 38 
Age ................................................................................................................................................................................................. 39 
Age and Sex ................................................................................................................................................................................. 40 
Ethnicity ......................................................................................................................................................................................... 40 
Employment and Socio-Economic Status ................................................................................................................................ 42 
Location of Death and Household Characteristics ................................................................................................................. 43 
Marital Status ................................................................................................................................................................................ 44 
Area-Level Characteristics ......................................................................................................................................................... 44 
Mental Health and Contact with Healthcare System .............................................................................................................. 44 
Education ...................................................................................................................................................................................... 45 
Summary: Canada, Alberta, BC ...................................................................................................................................................... 45 
CHAPTER 4: Policies and Services in Alberta and British Columbia ............................................................................. 47 
Provincial Contrast? .......................................................................................................................................................................... 47 
Enforcement and Decriminalization ................................................................................................................................................ 47 
‘Safer Supply’ and Harm Reduction ............................................................................................................................................... 48 
Recovery ............................................................................................................................................................................................ 50 
Services .............................................................................................................................................................................................. 50 
Supervised Consumption Sites ................................................................................................................................................. 50 
Rehabilitation ..................................................................................................................................................................................... 52 
Naloxone ............................................................................................................................................................................................. 54 

12 
Opioid Agonist Treatment ................................................................................................................................................................ 55 
Technology ........................................................................................................................................................................................ 56 
Summary ............................................................................................................................................................................................ 57 
CONCLUSIONS .................................................................................................................................................................. 58 
Alberta and BC .................................................................................................................................................................................. 58 
Policy Recommendations................................................................................................................................................................. 61 
Bibliography ...................................................................................................................................................................... 63 
Appendix A: Calculations for COVID-19 and Opioid Life Years Lost, 2020-2021 .......................................................... 72 
COVID-19 ........................................................................................................................................................................................... 72 
Opioids ................................................................................................................................................................................................ 73 
Appendix B: Estimating Drug User Population based on CADs data ............................................................................. 74 
Appendix C: Terminology for Different Indigenous Groups in Canada ......................................................................... 75 
Appendix D: Drivers of the Opioid Crisis ......................................................................................................................... 76 
Increased Toxicity ............................................................................................................................................................................. 78 
Improved Product ............................................................................................................................................................................. 79 
Policing and Enforcement ................................................................................................................................................................ 80 
Prescribing and Dispensation ......................................................................................................................................................... 82 
Technology ........................................................................................................................................................................................ 83 
Point of Entry ..................................................................................................................................................................................... 84 
Criminal Networks ............................................................................................................................................................................. 85 
Immigration ........................................................................................................................................................................................ 86 
Gender/Age ........................................................................................................................................................................................ 87 

13 
Income and Inequality ...................................................................................................................................................................... 88 
Housing and Homelessness ............................................................................................................................................................ 89 
Ethnicity .............................................................................................................................................................................................. 90 
Marriage Rates .................................................................................................................................................................................. 91 
Drug Culture and Stigma ................................................................................................................................................................. 92 
Physical and Mental Health ............................................................................................................................................................. 93 
Driver Summary ................................................................................................................................................................................ 94 
 
   

Foreword

The United States and Canada continue to experience high rates of opioid-related mortality and other harms associated

with opioid and drug misuse. As neighbouring jurisdictions, these two countries have faced similar challenges in respect of

over-prescribing of opioids, and the problematic impact of new illicit substances in the community, such as fentanyl.

Canada’s opioid addiction crisis has been mounting for two decades, and the COVID-19 pandemic has exacerbated the

health harms, with rates of drug mortality in areas like Greater Vancouver in 2022 as high as the worst affected parts of the

USA. Despite very different healthcare models, both countries have endured a level of adverse population impact from

drug addiction that has not been experienced in other developed nations.

Two decades ago, the City of Vancouver in British Columbia set out their four-pillar strategy (harm reduction, prevention,

treatment and enforcement) to address drug addiction and associated challenges, and the province has attempted to be a

leader in how it innovates to respond to the evolving crisis ever since. It was outside the scope of this project to evaluate

the efficacy of interventions over that period, but nonetheless a clear conclusion is that the collective impact of drug harms

has significantly increased since that comprehensive strategy was announced.

More recently, opioid addiction was declared a ‘public health emergency’ in BC in 2016, and although the nature of the

problem remains essentially unchanged, interventions since that time to address the challenge have not reduced the

societal impact in communities. Judged only by one key metric, the scale of the harms to individuals in BC has actually

grown significantly – with the number of deaths doubling by 2022 compared to when the emergency was first declared.

Drug policy failure doesn’t just harm people who use drugs. The collateral consequences are myriad, and include crime,

family violence and divorce, community disorder, degraded public spaces, lost business investment, and depressed tax

revenue. As such, the wider public is entitled to challenge public health and safety approaches that policymakers have

adopted if they appear to be limited in impact, or potentially exacerbating the problem.

A generalised commitment to ‘harm reduction’ predominates in Canada, and as such, key metrics are viewed more

narrowly as a collection of statistics referring to negative outcomes and harms experienced by individuals who use drugs.

This makes the wider societal impact of drug addiction and the harm reduction policies adopted in response to it, much

harder to track.

For example, the evidence base in criminology is clear that addiction drives much offending behaviour, and that a minority

of offenders are responsible for a disproportionate amount of crime, but rarely does research attempt to quantify the

public impact and cost of elevated crime levels associated with drug-addicted offenders or the continuation of addiction in

these populations.

A narrow focus on ‘harm’ to the individual user also provides no framework for measuring success in line with what the

relatives or friends of those suffering from drug addiction might want as an outcome for their own loved one – that is, to

escape addiction and to desist from behaviour that may lead to premature death.

There is an emerging perception in the media and public debate that the strategies adopted in Canada to address the

problem have not yielded sustained improvements across a range of key metrics. The result has been an increase in

public concern and political attention on the issue, and there is a renewed debate about the merits of different policy

responses in Canada.

In recent months, the salience of this issue has increased, with both BC and Alberta seeking to justify and promote their

respective approaches and their record to date. There is however an ongoing lack of good data on key outcomes and

even a consensus on what success would look like in this policy arena.

There is a general acceptance that the harms inflicted by drug misuse, combined with mental health and homelessness,

are ‘wicked’ problems requiring complex and multi-layered responses. In this respect, drug addiction and its

consequences are re-emerging as a key test of the effectiveness of evidence-based urban policymaking in cities across

North America. What can the situation in two of Canada’s worst affected provinces teach us?

The concentration of this crisis in Western Canada is clear, with BC and Alberta comprising half (49%) of all opioid-

overdose deaths in 2022. Below the provincial level, there is a further geographic concentration in major urban areas,

even if victims of opioid overdoses can be found in small towns and rural communities all across Canada. There is also a

strong perception that BC’s crisis is highly concentrated not just in one city (Vancouver), but in one neighbourhood of that

one city centre – the Downtown Eastside.

In Canada more generally, attention of politicians has tended to be dominated by a range of policy and legislative

responses focused on drug users – rather than drug markets or suppliers – that are intended to reduce infectious disease

acquisition, accidental deaths and overdoses. In addition, there has been new steps taken in recent months to further

reduce ‘stigma’, including the enactment of decriminalisation of drug possession in British Columbia. This is the first time

that anywhere in Canada has adopted an approach pioneered in just a few other jurisdictions, most famously by Portugal.

This research project, commissioned in Fall 2022, is designed to give an overview of the current drug addiction crisis in

Canada, with a special focus on two neighbouring provinces – British Columbia and Alberta – and to describe its key

features. The goal of the project was to outline the scale and nature of the drug harms affecting these two provinces, to

outline the policy approaches adopted by both provincial governments, and to explore the most likely drivers of the high

death and hospitalisation rates.

It was outside the scope of this report to evaluate the efficacy of different policy responses adopted by each province, or

to make recommendations for how policymakers in both places might respond. Our recommendations – outlined in the

Conclusion – are restricted to those that arise from the research undertaken and relate to how the response to the

challenge might be understood and evaluated more effectively in future.

In terms of years of productive life lost, the sheer scale of the drug addiction challenge makes it the most critical health

crisis for Canada. It demands a sober, non-ideological assessment of what policy responses are working, which

interventions are worth trialing, and how we should judge success when it comes to public policy around drug addiction.

This report provides a summary of where we begin in pursuing answers to those critical questions.

Introduction

Canada is in the midst of an opioid overdose crisis.

Though there is not reliable country-wide data on

overdose harms dating back further than 2016, British

Columbia’s death rate due to illicit drugs rose from 5.8

per 100,000 in 2000 to 44.2 per 100,000 in 2021.

This is

comparable to some of the worst affected states in the

US. In Canada, the number of accidental apparent opioid

toxicity deaths (AAOTDs) per 100,000 was 20.2 per

100,000 in 2021.

For comparison, in 2019, England and

Wales had a drug-related mortality rate of 7.7 per

100,000,

and in 2020 the European Union had a drug-

induced mortality rate of 1.5 per 100,000.

Illicit Drug Toxicity Deaths in BC: January 1, 2012—December 31,

2022. (2022). British Columbia Coroners Service.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

* All countries other than Canada measure total drug-related mortality

Fig. 1. Data sourced from the BC Centers for Disease Control (2023), Office

of National Statistics (2020), Government of Canada (2022) and European

Monitoring Centre for Drugs and Drug Addiction (2022).

Deaths related to drug poisoning in England and Wales. (2020).

Office for National Statistics.

Frequently asked questions (FAQ): Drug overdose deaths in

Europe. (2022). European Monitoring Centre for Drugs and Drug

Addiction.

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

Deaths per 100,000

Opioid Overdose Deaths* in Canada

compared to select jurisdictions

USA Canada European Union England and Wales

The only G7 country that has a similar rate of overdose

deaths is the United which had 25.4 drug overdose

deaths per 100,000 in 2020 (age-adjusted rate).

In 2020 and 2021, there were 13,815 deaths attributed to

accidental opioid poisoning in Canada.

This is almost half

the death toll that COVID-19 had over the same period

(29,985).

Considering the relative ages of those killed,

however, the opioid crisis has caused a far greater loss in

years of life. COVID-19 caused approximately 90,000 lost

years of life in 2020 and 2021.

Over that same period,

opioids caused nearly 450,000 lost years of life (see

appendix A).

CDC Wonder. (2023). CDC Centers for Disease Control and

Prevention.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

COVID-19 daily epidemiology update. (2020). Public Health Agency

of Canada.

Fig. 2. Data sourced from Government of Canada (2022) and Public Health

Agency of Canada (2022).

The crisis has gotten so severe that it halted the increase

in Canadian life expectancy between 2016 and 2017, the

first time that Canadian life expectancy has decreased in

over four decades.

COVID-19 daily epidemiology update. (2020). Public Health Agency

of Canada.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Changes in life expectancy by selected causes of death, 2017.

(2019).

100,000

200,000

300,000

400,000

500,000

7,000

14,000

21,000

28,000

35,000

COVID-19 Opioids COVID-19 Opioids

Deaths Life Years Lost

Life-years lost - COVID-19 vs.

Accidental Opioid-Related Overdoses

32%

22%

46%

28%

21%

51%

Alberta and BC's Share of Canada's

AAOTDs, 2016 and 2021

BC Alberta Other Provinces and Territories

Addressing opioid addiction in BC and Alberta

Though opioid overdose deaths have been increasing

across the country, they have been most concentrated in

BC, Alberta, and Ontario. BC’s AAOTD rate in 2021 was

more than double the national average, and Alberta was

not far behind at 36 per 100,000. Ontario had the most

total AAOTDs (2,772) but had a lower death rate of 19.4

per 100,000. Between them, BC and Alberta accounted

for only 25% of the population but 49% of AATODs

(3,804). To put this another way, 1 in very 7 Canadians

live in BC and 1 in every 9 live in Alberta, but 1 in every 4

AAOTD in 2021 was a British Columbian and 1 in every 5

is an Albertan. The share of AAOTDs held by Alberta and

BC has actually decreased slightly from 54% in 2016.

In response to the crisis, both BC and Alberta have made

new investments in addiction services. BC’s 2021 budget

earmarked $0.5 billion for mental health and addiction

services over the next three years

and its 2023 budget

marked over a billion

, while Alberta’s 2022 budget

included $1 billion for addiction and mental health care

with an additional $60 million over three years to build a

recovery-oriented system of care.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Grochowski, S. (2021). B.C. announces historic half-billion-dollar

funding for overdose crisis, mental health. Maple Ridge - Pitt

Meadows News.

Fig. 3. Data sourced from Government of Canada (2022).

In recent months, certain policy differences between

Alberta and BC have become politically salient in Canada.

This report found there to be similarities between the two

provinces’ strategies, but also significant differences.

Both provinces support harm reduction activity such as

Naloxone distribution to emergency services and

community providers, syringe exchange programs, and

licenced overdose prevention provision (SCS) in multiple

locations to provide drug users with a safer, regulated

environment to consume. Each province has also shifted

away from police enforcement against drug possession

More than $1B announced for mental health, addictions support in

2023. (2023). CBC.

Toward an Alberta model of wellness. (2022). Government of

Alberta.

2016

2021

and towards diversion to treatment and education for

drug users.

BC’s approach places a stronger emphasis on stigma

reduction and decimalization, with a greater policy focus

on harm reduction, conceptualised as overdose

prevention and access to safer supply (i.e., prescribed

medical alternatives to toxic illegal drugs) including

through automated dispensing. In addition, BC has with

federal consent – as of 31 January 2023 – removed

criminal penalties for possession of illicit drugs.

Alberta,

in contrast is pursuing a ‘recovery-oriented system of

care’

and has emphasized the importance of community

support, treatment pathways, and more regulation over

and higher standards for SCS.

There also appears to be

a generally higher rate of enforcement against drug

trafficking, production, and distribution in Alberta,

although arrest rates for possession have dropped in both

provinces in the last decade.

Alberta and BC are relatively similar geographically and

culturally, are approximately equal in population, and the

factors driving their respective opioid crises seem

comparable. This makes them interesting neighbours for

a jurisdictional comparison; however, the difference in

policy approach is still developing. In time, the outcomes

achieved in AB and BC will provide an important

Judd, A., & Zussman, R. (2022, May 31). B.C. becomes first

province to remove criminal penalties for possession of some hard

drugs. Global News.

dimension to the political debate over the right response

to the problem Canada-wide. For now, it is too soon to

analyse the relative progress of each province as it

attempts to address opioid harms; nevertheless, this

report will draw attention to some key differences that

should be monitored going forward.

Toward an Alberta model of wellness. (2022). Government of

Alberta.

Impact: A Socio-Economic Review of Supervised Consumption

Sites in Alberta. (2020). Government of Alberta.

CHAPTER 1: Defining the Problem

In considering the current state of Canada’s opioid crisis,

for this chapter we summarise the role of opioids in

society, and how they may cause harms, either in

isolation, or in conjunction with other addictive

substances.

Opioids: their function and role

Opioids are a group of analgesic (pain relieving) drugs

commonly used in clinical practice. In addition to

providing pain relief, opioids trigger the release of

endorphins, reducing an individual’s perception of pain

and creating feelings of pleasure. Importantly, opioids

also slow multiple biological functions, including

breathing, which is why they can be fatal.

Opioids are used in both legal and illegal contexts. Legal

opioid use is restricted to medical contexts in Canada, as

it is in most countries, and a range of licensed medical

products contain opioids. Individuals may also use

opioids illegally for purposes of managing physical or

psychological pain or for the pleasurable affects of the

drug itself. People can also combine their use of

Felbab-Brown, V. (2020). Fentanyl and Geopolitics. Brookings

Institution.

Fentanyl Facts. (2022, February 23). Centers for Disease Control

and Prevention.

prescription opioids with other addictive substances or

opioids sourced from the illicit market.

Though certain opioids are primarily used in an illegal

context (e.g., heroin), for many types there is no chemical

difference between the substance being used in legal and

illegal contexts (e.g., fentanyl). Sometimes drugs may

even be sourced from the same production facilities.

Some types of opioids are more potent than others.

Fentanyl is a synthetic opioid that can be up to 50 times

stronger than heroin and 100 times stronger than

morphine.

Fentanyl and its analogues have played an

important role in the opioid crisis because they are

significantly cheaper to produce per dose. This makes

them more widespread in illicit drug markets, but it is also

more likely that a dose will be too potent and cause

people who use these drugs to overdose.

There are drugs in Canada that kill more people per year

than opioids. Purely in terms of deaths, the two most

lethal substances in the country are alcohol and

tobacco.

Canadian Substance Use Costs and Harms. (2020). Canadian

Centre on Substance Use and Addiction.

Fig. 4. Data sourced from Canadian Centre on Substance Use and Addiction

(2020).

Nonetheless, those who overdose on opioids are usually

far younger than those who die of alcohol or tobacco,

because the chronic health impacts of alcohol or tobacco

consumption manifest over decades of use. Opioids are

responsible for more life years lost than tobacco, and

nearly as many life years lost as alcohol, despite not

having the same level of general use in the population.

Canadian Substance Use Costs and Harms. (2020). Canadian

Centre on Substance Use and Addiction.

* Productive Life Years lost defined as years lost before the age of 65

Fig. 5. Data sourced from Canadian Centre on Substance Use and Addiction

(2020).

Benefits and Harms

Like many other drugs in modern society, opioids can be

both beneficial and harmful. They are a valuable tool for

the management of acute and chronic pain, and have

clear clinical efficacy and well-established prescribing

guidelines for use. At the same time, opioids are an

addictive substance, and rapid expansion of prescribing

by the medical profession occurred before some of the

10,000

20,000

30,000

40,000

50,000

60,000

2015 2016 2017 2015 2016 2017 2015 2016 2017

Alcohol Tobacco Opioids

Deaths by Substance Type, 2015-2017

20,000

40,000

60,000

80,000

100,000

120,000

2015 2016 2017 2015 2016 2017 2015 2016 2017

Alcohol Tobacco Opioids

Productive Life Years* Lost by

Substance Type, 2015-2017

risks of addiction were properly understood. When

someone takes opioids, their body can become

dependent, making it more challenging to desist, or to

reduce their use of the drug over time. Taking too strong

a dose can have immediate, negative health

consequences, up to and including death.

The policy debate about addiction is complicated by the

nature of the behaviour. Unlike most other illnesses or

adverse health conditions (e.g., cancer), opioid addiction

makes users complicit in their own injury, and unlike most

diseases, subjects do derive some enjoyment from the

use of opioids, which acts as a strong incentive to

continue using.

The debate over how to address drug addiction of all

kinds is a legitimate matter of public policy because of the

harms suffered by users, but also because of the wider

societal impact of the behaviour. Opioid use may not only

be harmful to the person themselves – impacting their

employability, housing, and relationships with dependents

– but can also cause harm to those around them. Friends

and family may struggle to help users manage their

addiction, addicts may resort to theft or fraud to sustain

their addiction, children may suffer neglect or separation,

and the broader public may suffer from the crime and

disorder impact of drug addicted populations, including

degradation of the public realm and drug paraphernalia

Humphreys, K. (2022). Testimony to the Oregon Senate

Committee on Judiciary and Ballot Measure 100 Implementation.

proliferating in parks or other public spaces. These

broader societal impacts can be exacerbated if drug

using populations are concentrated in certain urban

neighbourhoods where their behaviour is highly visible

and especially when combined with open drug markets

and street dealing of illicit drugs.

Risk and Context

Risk of harm from opioids is highly dependent on why

and how opioids are acquired. The safest context for

mitigating the risks associated with opioids is when they

are used for medical purposes for in-hospital treatment.

The patient does not have unsupervised access to

opioids, the opioids are unlikely to be diverted to an

unintended recipient, and the treatment is closely

monitored and is usually time-limited.

Risk contexts for opioid use

Fig. 6. Risk is an interaction between Why and How.

Despite being one of the largest consumers of opioids in

the world, Germany has relatively low overdose rates,

and this has been attributed to the fact that opioids are

primarily prescribed in-hospital and in other 24-hour care

settings.

Opioids prescribed by medical practitioners are also

relatively low risk. The majority of people who are

prescribed opioids use them for their intended purpose,

and benefit from the resulting pain relief; however, the

opioid crisis in the USA and Canada had its origins in the

over-prescribing of regulated opioid treatments. The

lower the threshold for opioid prescriptions, the greater

the risk for the recipient and those around them.

It is significantly riskier to use opioids for pleasure, even if

the opioids being used are prescription opioids. Like

many other substances (alcohol, cannabis, nicotine),

opioid use carries a number of potential health

implications, such as addiction, liver damage, and

overdoses. The risk of using opioids for pleasure goes up

considerably if the opioids are diverted from an intended

recipient or otherwise acquired via the illicit market or

other unregulated source, where dosage and purity are

not controlled or guaranteed. Self-medicating, either with

diverted prescriptions or illegally sourced substances, is

risky for these same reasons.

Felbab-Brown, K. H., Jonathan P. Caulkins, and Vanda. (2020).

What the US and Canada can learn from other countries to combat

the opioid crisis [Brookings].

CHAPTER 2: History of Canada’s Health Crisis

Overview

Canada’s opioid addiction crisis can be traced back two decades, and divides into four successive waves, each

representing a significant transition or evolution with an escalation of harms each time. The opioid crisis in the United

States has followed a similar trajectory, and has been included in the below table for comparison. Note that these phases

are a useful heuristic, rather than definitive and discrete categories.

Fig. 7. Data sourced from CDC Centers for Disease Control (2023), Government of Canada (2022), and BC Coroners Service (2022).

Wave 1 (1980s – 2010)

The reason that Canada and the USA have such

significant levels of opioid harms compared to other

countries has its origins in their relatively high

consumption of prescription opioids. Though

consumption has decreased in recent years, Canada was

once the second-largest consumer of opioids in the

world.

Currently, Canada is the fourth largest per-capita

consumer of controlled opioids, behind only Germany,

Iceland, and the USA.

This disproportionate consumption of opioids began as

far back as the 1980s, when opioid manufacturers began

campaigning for the increased utilization of opioids in

healthcare.

Since the 1980s, the volume of opioids sold

to hospitals and to pharmacies for prescription increased

by more than 3,000%.

As controlled opioid consumption

increased, so did the misuse of opioids. Patients either

used prescriptions for non-medical purposes, or

prescriptions were diverted from their intended

Lisa, B., & Jessica, H. (2018). Evidence synthesis - The opioid crisis

in Canada: A national perspective. Health Promotion and Chronic

Disease Prevention in Canada : Research, Policy and Practice, 38(6),

224–233.

Richards, G. C., Aronson, J. K., Mahtani, K. R., & Heneghan, C.

(2022). Global, regional, and national consumption of controlled

opioids: A cross-sectional study of 214 countries and non-

metropolitan territories. British Journal of Pain, 16(1), 34–40.

recipients. This was the first wave of the opioid crisis in

Canada and the USA.

It was during this period, in 2001, that Vancouver

implemented its four-pillar drug strategy of Prevention,

Treatment, Enforcement, and Harm Reduction, which

guided the approach in the early stages of what would

later become a much more serious public health crisis.

Wave 2 (2010 – 2014)

The first wave resulted in a large base of opioid users in

the general population, even if the majority were not

suffering from addiction or abusing other substances. The

second wave was characterized by the rise of

unregulated opioids from the illicit market, as dealers

responded to the demand for cheap and potent opioids

such as heroin and began to expand distribution.

This trend may have been encouraged by measures

taken by health authorities in Canada and the USA to limit

the supply of medical opioids and tackle over-prescribing

by some clinicians in an effort to reduce the number of

Meldrum, M. L. (2016). The Ongoing Opioid Prescription Epidemic:

Historical Context. American Journal of Public Health, 106(8), 1365–

1366.

Lisa, B., & Jessica, H. (2018). Evidence synthesis - The opioid crisis

in Canada: A national perspective. Health Promotion and Chronic

Disease Prevention in Canada : Research, Policy and Practice, 38(6),

224–233.

Framework for Action: A Four Pillar Approach to Vancouver’s Drug

Problems. (2001). City of Vancouver.

people becoming addicted. According to one source,

medical opioid consumption in Canada declined by

36.8% between 2009 and 2019.

Though this drop in

medical opioid consumption may have reduced the

number of people suffering addiction for the first time, it

may also have pushed existing dependent users to seek

out riskier alternatives. This likely consequence was

acknowledged at the time and became part of the policy

response to over-prescribing.

Wave 3 (2014-2019)

The second wave began transitioning into the third wave

as the toxicity of the drugs in the illegal market began to

increase, with deaths rising accordingly. In BC, in 2012,

fentanyl – at that time, the most potent opioid in

circulation – was detected in about 5% of all illicit drug

toxicity deaths. BC Coroners’ Service data shows the

rapid increase in subsequent years, with a sustained rise

in fentanyl detection among deaths over the past

decade).

When considered in tandem with the rise of deaths in BC

(see below) it is difficult to dispute that the increased

availability of fentanyl has resulted in a significant

increase in fentanyl consumption and fentanyl-related

Jayawardana, S., Forman, R., Johnston-Webber, C., Campbell, A.,

Berterame, S., Joncheere, C. de, Aitken, M., & Mossialos, E. (2021).

Global consumption of prescription opioid analgesics between 2009-

2019: A country-level observational study. EClinicalMedicine, 42.

deaths. More evidence regarding the role of fentanyl is

reviewed in section 4.

Fig. 8. Drug Types Relevant to Death, 2012-2021. From Illicit Drug Toxicity

Deaths in BC: January 1, 2012—October 31, 2022. (2022). British Columbia

Coroners Service.

It is unclear why deaths dropped between 2018 and

2019. One possibility is that use declined because supply

was restricted due to regulatory changes in China that

banned the production and sale of some types of fentanyl

without a license.

However, the decline in deaths would

soon reverse.

Illicit Drug Toxicity Deaths in BC: January 1, 2012—October 31,

2022. (2022). British Columbia Coroners Service.

Felbab-Brown, V. (2020). Fentanyl and Geopolitics. Brookings

Institution.

Drug Types Relevant to Death in BC, 2012-2021

It was in 2016 that the provincial government in BC

declared a state of medical emergency regarding drug

toxicity deaths, and greater political attention on the issue

and government funding began.

Wave 4 (2020 – Present)

With the onset of the COVID-19 pandemic, the number of

AAOTDs in Canada began to increase again, reaching

their highest levels ever in 2021. The rise in AAOTDs

would have been caused by a confluence of factors, but

three of what are likely the most prominent drivers are

listed below.

First, social distancing and isolation would facilitate a

riskier environment for drug use. As will be discussed in

section 4, most AAOTDs happen while someone is alone

in a private residence.

Second, the stress of the pandemic caused increase drug

use. Surveys conducted by the Canadian Centre on

Substance Use found that drug users, particularly those

with a history of substance use disorder, reported

Provincial health officer declares public health emergency. (2016).

Government of British Columbia.

Mental Health and Substance Use During COVID-19. (2023).

Canadian Centre on Substance Use and Addiction.

Moallef, S., DeBeck, K., Fairbairn, N., Cui, Z., Brar, R., Wilson, D.,

Johnson, C., Milloy, M.-J., & Hayashi, K. (2022). Inability to contact

increased stress and substance use with the onset of the

COVID-19 pandemic.

Third, some health and treatment services were more

difficult to access throughout the pandemic. For example,

one study found that many users had difficulty accessing

their prescriber to access Opioid Agonist Therapy (OAT)

medication.

What Comes Next?

Across Canada, AAOTDs have fallen from their record

2021 high, but not by much. Both BC and Alberta are

now making significant investments in tackling the crisis.

In the next section, we will review data on the current

state of the crisis in Canada overall, and then the two

worst affected provinces of Alberta and British Columbia.

opioid agonist therapy prescribers during the COVID-19 pandemic in

a Canadian setting: A cross-sectional analysis among people on

opioid agonist therapy. Addiction Science & Clinical Practice, 17(1),

73.

Illicit Drug Toxicity Deaths by Year in BC

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

270

334

369

529

994

1495

1562

987

1774

2306

CHAPTER 3: Data

This project describes the current state of Canada’s

opioid crisis based on quantitative analysis of official

(federal and provincial) data sources. Some municipal

data sources also exist, but they are not widespread and

are not recorded with standardised definitions or to the

same level of assurance.

Deaths, Hospitalizations and EMS

Canada-wide data regarding opioid-related deaths and

hospitalization only begins in 2016. British Columbia does

publish data regarding illicit drug toxicity deaths going as

far back as 1996, but there is not comparable historical

data from other provinces (see fig. 7, pg. 26). To facilitate

comparisons between Canada-wide and BC data, this

report will primarily refer to accidental apparent opioid

toxicity deaths (AAOTDs), which excludes suicides. This

does not significantly impact the analysis because

intentional opioid toxicity deaths represent only a small

portion of all opioid toxicity deaths. In 2021, only 3% (268

out of 7993) of all apparent opioid toxicity deaths were

identified as non-accidental.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Population and dwelling counts: Canada, provinces and territories.

(2022). Statistics Canada.

The health crisis of drug addiction in Canada is

concentrated in BC, Alberta and Ontario. In 2021, there

were 7,725 AAOTDs in Canada. 49% of those deaths

(3,804)

occurred in Alberta and BC, despite the two

provinces representing only 25% of Canada’s

population.

Ontario had the highest number of AAOTDs

(2,772), but had a comparably low death rate of 19.4 per

100,000 compared to Alberta’s 36.2 and BC’s 41.9.

The

Yukon technically had the highest AAOTD rate at 53.2

per 100,000, but due to its low population this

represented a total of only 23 deaths.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Fig. 9. Data sourced from Government of Canada (2022)

Hospitalization and EMS rates followed a similar trend. Of

the 4,433-accidental opioid-related poisoning

hospitalizations (AOPHs) in Canada, 2,351 (53%) of them

occurred in Alberta and BC.

Looking at ambulance data, the impact on emergency

dispatch caseloads from the addiction crisis is much

higher in BC. Emergency Medical Service (EMS)

responses to suspected opioid-related overdoses are

highest in BC (24,152 responses) – three times the

volume of such incidents in Alberta (8,215 responses),

Opioid- and stimulant-related harms. (2022). Government of

Canada.

Fig. 10. Data sourced from Government of Canada (2022).

though not all provinces shared EMS data and EMS

responses will be highly impacted by provincial

infrastructure.

Population of People who Use Illegal

Substances in Canada

It is important to assess opioid harms against the

estimated population of people who use substances. The

best source of data to estimate such figures in Canada is

the Canadian Alcohol and Drugs Survey (CADS), a

biennial general population survey of alcohol and drug

use amongst Canadians 15 and older. The CADS breaks

down drug use in several ways. For the purposes of this

Opioid- and stimulant-related harms. (2022). Government of

Canada.

report, population estimates are based on the ‘illegal drug

use, any of 5 drugs’

category for 2013, 2015 and 2017

data, and the ‘any of 6 drugs’

category for 2019 data

(see appendix B for details).

Any of 5 drugs:

2013, 2015, 2017

Cocaine/crack, speed/methamphetamine/crystal

meth ecstasy, hallucinogens (excluding salvia), and

heroin

Any of 6 drugs:

2019

Cocaine/crack, speed/methamphetamine, ecstasy,

hallucinogens, heroin, salvia

Based on the CADS figures, in 2019 16.1% of Canadians

(c.5 million people) had used at least one of the 6 select

drugs in their lifetime, while 3.5% had used at least one in

the past year (c.1 million). Prevalence of use was highest

in Alberta and BC, the two provinces who had the highest

percentage of past-year users, with 4.8% (170,800) of

Albertans and 3.8% (157,300) of British Columbians

having used at least one of the drugs in the past year.

Use of at least one of six illegal drugs, 2019

Canada

Alberta

Past year

3.5%

4.8%

3.8%

Lifetime

16.1%

18.0%

17.8%

* Any of 6 drugs in 2019

Cocaine/crack, speed/methamphetamine/crystal meth, ecstasy,

hallucinogens (excluding salvia), and heroin

Cocaine/crack, speed/methamphetamine, ecstasy, hallucinogens,

heroin, salvia

Canadian Alcohol and Drugs Survey (CADS): 2019 detailed tables.

(2021). Government of Canada.

** No data was available for BC in 2017

Fig. 11. Data sourced from Government of Canada (2021).

Past year drug use appeared to increase between 2013

and 2019 in Canada and Alberta. The number of lifetime

users appeared to drop between 2017 and 2019 in

Canada, Alberta, and BC,

but this may be attributable to

changes in the survey.

Due to sample size, it cannot confidently be said that past year

drug use was higher in Alberta and lower in BC in 2019 (the only

year for which confidence intervals were provided).

Canadian Alcohol and Drugs Survey (CADS): 2019 detailed tables.

(2021). Government of Canada.

2013 2015 2017 2019*

Percentage of past year users,

any of 5* drugs

Canada Alberta British Columbia

* Any of 6 drugs in 2019.

Fig. 12. Data sourced from Government of Canada (2021).

Fentanyl and Overdose Deaths

The single most significant factor that seems to affect the

number of people dying due to drug overdoses across

Canada’s provinces is the degree to which fentanyl is

present in the drug supply. Based on data from Health

Canada’s Drug Analysis Service (DAS), which identifies

substances contained in samples seized by law

enforcement, fentanyl was detected much more

Adulterants, Contaminants and Co-occurring Substances in Drugs

on the Illegal Market in Canada. (2020). Canadian Centre on

Substance Use and Addiction.

Substance use surveillance data. (2023). Government of Alberta.

frequently in Western Canada than in Eastern Canada.

The table below compares the rate of fentanyl detected in

seized samples in different regions and their respective

AAOTD death rate.

In Alberta, in 2021, fentanyl was detected in 81% of all

accidental drug poisoning deaths.

In BC, between 2019

and 2022, fentanyl was detected in 85% of all illicit

overdose deaths.

Further, fentanyl detection in BC has

risen in tandem with the death rate (see fig. 8, pg. 28).

When considered with the previously reviewed CADS

data, it appears the increase in opioid-related harms in

Canada are driven by the increased toxicity of the supply,

rather than an increase in the number of drug users in the

general population.

Illicit Drug Toxicity Deaths in BC: January 1, 2012—October 31,

2022. (2022). British Columbia Coroners Service.

Illicit Drug Toxicity Deaths in BC: January 1, 2012—October 31,

2022. (2022). British Columbia Coroners Service.

2013 2015 2017 2019*

Percentage of lifetime users, any of 5*

drugs

Canada Alberta British Columbia

Region (2021)

Canada

Ontario

Quebec

Fentanyl

detection

69%

91%

55%

14%

Deaths per

100,000

20.2

42.2

18.7

5.2

Policing and Criminal Justice

Illicit drug markets are a key aspect of the addiction crisis

in Canada, being responsible for the supply of

unregulated opioids into communities and with criminals

based in Canada and those overseas exploiting users

suffering addiction. Organised crime understands that

addiction makes their ‘customers’ desperate to maintain

access to drugs, even if this means buying them illegally

from street dealers, or becoming indebted to them. As

the opioid crisis has unfolded, enforcement by the police

and prosecutors has continued, but the true picture of

how drug markets are addressed by law enforcement

agencies is difficult to determine.

Canadian criminal justice and policing statistics are not

sufficiently granular to make comparisons between

municipalities on how cases are processed. Data at the

Greg Moreau. (2022). Police-reported crime statistics in Canada,

2021. Canadian Centre for Justice and Community Safety Statistics.

provincial level and reported to StatsCan provides a high-

level summary of drug crime across the country, and

incident data is also available for larger census areas.

Police department data (where such city police

departments exist) is not consistent or comparable.

The majority of reported opioid-related offences occur in

BC. In 2021, BC – comprising approximately 13% of

Canada’s population – had nearly half of all police-

reported opioid possession, trafficking, production, and

important/exportation incidents in Canada. BC’s rate of

opioid-related police reported incidents was more than

four times the recorded incident rate in Alberta.

Fig. 13. Data sourced from Statistics Canada (2022).

Glossary of Criminal Justice Terminology and Acronyms:

Incident: a set of connected events usually constituting an

occurrence report. An incident may involve

multiple perpetrators and victims.

Charge: When a person is charged, they are formally

accused of committing an offence. Charges are

made on an individual basis.

Convictions: Guilty outcomes in court.

TPD: Trafficking, production, and distribution

586

2,970

5,996

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Number Rate Number Rate Number Rate

Alberta British Columbia Canada

Rate per 100,000

Number

Police-Reported Opioid-Related Incidents,

Number and Rate per 100,000, 2021

Fig. 14. Data sourced from Statistics Canada (2022).

For all drug violations, Vancouver reported 374 incidents

per 100,000 compared to 99 in Edmonton and 162 in

Canada.

Enforcement to suppress illicit drug markets and to

address unregulated supply requires police incidents to

result in charges and convictions. Given the high volume

of drug violations in BC, it is noteworthy that charges are

low, and are disconnected from charge rates. Meanwhile

charges for drug-related crimes are much higher in

Incident-based crime statistics, by detailed violations, Canada,

provinces, territories, Census Metropolitan Areas and Canadian

Forces Military Police. (2022). Statistics Canada.

Alberta for TPD and increases in charges broadly tracked

the trend in incidents, with rising rates after 2012 and

reductions more recently.

Fig. 15. Data sourced from Statistics Canada (2022).

In BC, drug possession incidents have increased

significantly in the last decade, and TPD incidences have

also spiked after 2016, but charge rates for both

categories have remained broadly flat or even fallen over

the same period.

100

200

300

400

500

600

700

800

1,500

3,000

4,500

6,000

7,500

9,000

10,500

12,000

Number

Per 100,000

Total

Per 100,000

Total

Per 100,000

Total

Per 100,000

Total

Per 100,000

Vancouver Kelowna Edmonton Calgary Lethbridge

Rate per 100,000

Number

All Drug Incidents,

Select Albertan and BC Cities,

Number and Rate per 100,000, 2021

120

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

Alberta drug incidences vs. charges

(excl. cocaine)

Drug possession, incidences Drug possession, charges

Drug TPD, incidences Drug TPD, charges

Fig. 16. Data sourced from Statistics Canada (2022).

For Canada overall, sentencing volumes for drug-related

crime have dropped by over 50% in the past decade.

Adult criminal courts, guilty cases by type of sentence. (2012).

Statistics Canada.

Fig. 17. Data sourced from Statistics Canada (2022).

Convictions for crime overall in Canada have also

dropped, but not to the same extent, indicating a general

lessening of criminal justice enforcement against drug

offences in Canada during the escalating health crisis of

opioid addiction.

120

150

180

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

BC drug incidences vs. charges (excl.

cocaine)

Drug possession, incidences Drug possession, charges

Drug TPD, incidences Drug TPD, charges

2,000

4,000

6,000

8,000

10,000

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Guilty Drug Cases in Canada,

Possession and Other

Drug, Possession Drug, Other

Fig. 18. Data sourced from Statistics Canada (2022).

Multi-Drug Use

Though fentanyl now dominates drug toxicity deaths in

BC and Alberta, many drug samples were found to

contain other substances, and many of those who died of

overdoses were found to have other substances in their

system.

In their national review of submitted opioid samples,

Health Canada’s Drug Analysis Service found that only

31% contained only opioids. 13% contained other

psychoactive substances, and most samples contained

cutting agents (non-psychoactive adulterants or co-

Adulterants, Contaminants and Co-occurring Substances in Drugs

on the Illegal Market in Canada. (2020). Canadian Centre on

Substance Use and Addiction.

occurring substances). In BC, 15% of submitted samples

contained other psychoactive substances, the highest in

the country.

In both BC and Alberta, it appeared that drugs other than

fentanyl frequently contributed to the deaths of drug

users. As can be seen in the below table, a significant

proportion of all fentanyl deaths would have involved

another substance.

Percentage of deaths involving specific substances

Substance

Alberta (2021)

BC (2019-22)

Fentanyl

81%

86%

Methamphetamine

57%

42%

Cocaine

24%

45%

Alcohol

23%

26%

Substance use surveillance data. (2023) Government of Alberta.

Illicit Drug Toxicity Deaths in BC: January 1, 2012—October 31,

2022. (2022). British Columbia Coroners Service.

50,000

100,000

150,000

200,000

250,000

300,000

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Guilty Cases in Canada for all crime,

Total Offences

Risk Factors

Opioid harms are not distributed evenly across different

groups in Canada. Some are far more likely to suffer

opioid-related harms than others.

Sex

Men are significantly more likely to suffer opioid-related

harms in Canada than women.

Fig. 19. Data sourced from Government of Canada (2022).

In 2021, three quarters (74%) of all AAOTDs and 65% of

all accidental opioid-related poisoning hospitalizations

(AOPHs) were men. The ratio of male to female deaths in

Alberta was in line with national averages, but was more

Opioid- and stimulant-related harms. (2022). Government of

Canada.

acute in BC, where 80% of all AAOTDs in 2021 were

men. Though the proportion of men to women dying of

AAOTDs has remained relatively stable in the past few

years (2017-2021), the proportion of men to women

being hospitalized for AOPHs has been rising steadily.

CADs data did not break down responses by both

province and gender, so it is not possible to evaluate

whether the ratio of men to women in BC’s drug using

population differs from other provinces.

Fig, 20. Data sourced from Government of Canada (2022).

20%

40%

60%

80%

100%

Deaths Hosp. Deaths Hosp. Deaths Hosp.

Canada Alberta BC

Male vs. Female Proportion of Opioid-

Related Deaths and Hospitalizations, 2021

Male Female

10%

20%

30%

40%

50%

60%

70%

80%

Canada Alberta BC

Percentage of Men Hospitalized for

Accidental Opioid-Related Poisonings

2017 2018 2019 2020 2021

Age

Drug use often begins in adolescence or young

adulthood. However, the ages most impacted by AAOTDs

in Canada are those between 30 and 49. In 2021 30-49-

year-olds represented 27% of the population and over

half (52%) of all AAOTDs. 20-29-year-olds and 50-59-

year-olds together then represent 26% of the population

and 38% of AAOTDs.

Alberta is similar to the Canadian average, with 30-49-

year-olds representing 30% of the population and 54% of

deaths. Those dying in BC, however, tend to be older.

50–59-year-olds represented only 13% of the population

in 2021 but account for 28% of all AAOTD deaths.

Fig. 21. Data sourced from Government of Canada (2022).

Population estimates on July 1st, by age and sex. (2022). Statistics

Canada.

Those in middle age – 30-49-year-olds – then represent

42% of deaths (and 27% of the population).

Similar to gender, AOPH rates for different age groups do

not entirely align with AAOTD rates. Most notably, those

who are over 60 are hospitalized at a much greater rate

than the rate at which they are dying, while those 50-59

are dying at a greater rate than they are hospitalized.

Fig. 22. Data sourced from Government of Canada (2022).

Opioid- and stimulant-related harms. (2022). Government of

Canada.

<19 20 to 29 30 to 39 40 to 49 50 to 59 60+

Percentage of Accidental Apparent Opioid

Toxicity Deaths by Age Group, 2021

Canada Alberta BC

20%

40%

60%

80%

100%

Deaths Hosp. Deaths Hosp. Deaths Hosp.

Canada Alberta BC

Proportion of Opioid-Related Deaths

and Hospitalizations by age, 2021

0-19 20-29 30-39 40-49 50-59 60+

As with sex, however, the age of those being hospitalized

has increasingly come to resemble the age of those dying

of opioid overdoses.

Fig. 23. Data sourced from Government of Canada (2022).

Age and Sex

Taken together, age and sex are major determinants of

AAOTDs. In Canada 30-59-year-old men represent 54%

of all AAOTDs but only make up 20% of the total

population (2021). The next two most significant

categories are 20–29-year-old men (12% of deaths, 7% of

the population) and 30-39-year-old women (8% of deaths,

Alberta Opioid Response Surveillance Report: First Nations People

in Alberta. (2021). The Alberta First Nations Information Governance

Centre.

7% of the population). Taken together, these groups

represent 74% of all AAOTDs but only 34% of the

population.

Ethnicity

There is a lack of data regarding ethnicity and opioid

harms in Canada. Four sources of data were identified.

Reports were published in both BC and Alberta analyzing

the impact of the opioid crisis on First Nations

populations (note that this does not encompass all

indigenous peoples in Canada, see Appendix C), and the

BC Coroners Service analyzed the representation of

indigenous peoples in illicit overdose deaths.

In Alberta, First Nations individuals were dying at a rate

nearly 7 times that of non-first nations in the first six

months of 2020.

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hosp.

Deaths

Hosp.

Deaths

Hosp.

Deaths

Hosp.

Deaths

Hosp.

Deaths

Hosp.

Deaths

2016 2017 2018 2019 2020 2021

Age Ratios of AAOTDs and

AOPHs over time

0-19 20-29 30-39 40-49 50-59 60+

Fig. 24. Data sourced from The Alberta First Nations Information Governance

Centre (2021).

In BC, between January and June 2021, 14% of overdose

deaths were among First Nations peoples despite them

representing only 3.3% of the population, resulting in a

death rate 4.8 times greater than for other BC residents.

The third identified source was a report analyzing the

demographic characteristics of people hospitalized

across Canada (excluding Quebec) due to opioid

poisonings between 2011 and 2016.

The report found

that those who self-identified as visible minorities had a

hospitalization rate of only 2.6 per 100,000, compared to

people who did not identify as a member of a visible

minority who had a hospitalization rate of 13.2 per

100,000. Self-identified indigenous peoples were found to

have significantly higher rates of hospitalization due to

opioid poisoning.

Rates of Hospitalization Due to Opioid Poisoning by Self-Identified Ethnicity, 2011-2016

Group

Not visible

minority

Visible

minority

First Nations

On Reserve

(First Nations)

Off reserve

(First Nations)

Métis

Inuit

Crude Rate

per 100,000

13.2

2.6

34.1

47.6

26.4

24.8

22.7

BC Coroners Service Death Review Panel: A Review of Illicit Drug

Toxicity Deaths. (2022). BC Coroners Service.

Gisèle Carrière, Rochelle Garner, & Claudia Sanmartin. (2018).

Social and economic characteristics of those experiencing

hospitalizations due to opioid poisonings. Statistics Canada.

100

120

2016 2017 2018 2019 01-06/2020

Alberta First Nations Mortality Rates

per 100,000

First Nations Non-First Nations

Employment and Socio-Economic Status

Though there was not Canada-wide data available on

employment status and opioid-related deaths, the BC

Coroners Service found that only 35% of those who

suffered illicit drug toxicity deaths between August 2017

and July 2021 were employed at the time of their death.

Of those employed, over half worked in the trades, in

transportation, or as equipment operators.

When it comes to hospitalization, research found that

unemployment correlated with opioid-related incidents.

Those under 65 who were not in the labour force were

most likely to be hospitalized (30.8 per 100,000), while

those who were employed were least likely to be

hospitalized (6.5 per 100,000).

Other research also found that income levels were also

correlated with opioid-related mortality and

hospitalization.

Those in the lowest quintile were 3.8

times more likely to suffer opioid-related mortality

and

BC Coroners Service Death Review Panel: A Review of Illicit Drug

Toxicity Deaths. (2022). BC Coroners Service.

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-

and-divorce/deaths/coroners-service/death-review-

panel/review_of_illicit_drug_toxicity_deaths_2022.pdf

Gisèle Carrière, Rochelle Garner, & Claudia Sanmartin. (2018).

Social and economic characteristics of those experiencing

hospitalizations due to opioid poisonings. Statistics Canada.

https://www150.statcan.gc.ca/n1/pub/82-003-

x/2018010/article/00002-eng.htm

Wasem Alsabbagh, Martin Cooke, Susan J. Elliott, Feng Chang,

Noor-Ul-Huda Shah, & Marco Ghobrial. (2022). Stepping up to the

4.3 times more likely to be hospitalized for opioid-related

reasons.

Average Opioid-related mortality

by income quintile, 2000-2017

Income

Quintile

Death

Cases

Population

Adjusted

rate

Rate Ratio

1 (highest)

1,585

4,923,280

18.9

1.0 (reference)

2,325

5,115,515

26.4

1.4

4,035

6,070,270

38.5

2.0

4,960

6,086,520

48.2

2.6

5 (lowest)

5,955

4,792,290

72.1

3.8

The death rate ratio between the highest and lowest

quintile has been decreasing over time (having gone from

4.33 in 2000 to 2.15 in 2017), but the hospitalization ratio

has not changed significantly.

Canadian opioid crisis: A longitudinal analysis of the correlation

between socioeconomic status and population rates of opioid-related

mortality, hospitalization and emergency department visits (2000–

2017). Government of Canada. https://www.canada.ca/en/public-

health/services/reports-publications/health-promotion-chronic-

disease-prevention-canada-research-policy-practice/vol-42-no-6-

2022/canadian-opioid-crisis-longitudinal-analysis-correlation-

socioeconomic-status-population-rates-mortality-hospitalization-

emergency-department-visits-2000-2017.html

2000-2017

2000-2013, age- and sex- adjusted rate.

Average Opioid-related hospitalization

by income quintile, 2000/01-2012/13

Income

Quintile

Hosp.

cases

Population

Adjusted

rate

Rate Ratio

1 (highest)

4,520

4,923,280

96.5

1.0 (reference)

5,835

5,115,515

138.9

1.4

9,020

6,070,270

203.8

2.1

15,785

6,086,520

284.7

3.0

5 (lowest)

21,855

4,792,290

413.2

4.3

Location of Death and Household Characteristics

There is no Canada-wide data on location of death, and

there is no published geographic mapping of deaths

below provincial level, however both BC and Alberta have

category data.

In both BC and Alberta, the majority of drug overdose

deaths occurred in private residences. In BC, between

August 2017 and July 2021, 65% of all illicit drug toxicity

deaths occurred in private non-subsidized residences,

and a further 19% occurred in subsidized housing, hotels

or shelters.

In 2021, in Alberta the average quarterly

death rate in private residences where the decedent lived

long-term was 68% of all deaths.

Research found that the most common living

arrangements of those being hospitalized were those

BC Coroners Service Death Review Panel: A Review of Illicit Drug

Toxicity Deaths. (2022). BC Coroners Service.

Substance use surveillance data. (2023) Government of Alberta.

living alone (25.1 per 100,000) and single parents (25.5

per 100,000). They were also far more likely to be in band

housing (53.8 per 100,000) or renting (21.3 per

100,000).

Though Canada-wide data was not available on the

relationship between opioid harms and homelessness,

the BC Coroners Service found that 12% of those who

died of illicit drug toxicity between 2017 and 2021 were

homeless.

Gisèle Carrière, Rochelle Garner, & Claudia Sanmartin. (2018).

Social and economic characteristics of those experiencing

hospitalizations due to opioid poisonings. Statistics Canada.

BC Coroners Service Death Review Panel: A Review of Illicit Drug

Toxicity Deaths. (2022). BC Coroners Service.

Marital Status

Data from BC found that, in 2016 and 2017, 65% of those

who died had never been married, and 18% were

separated or divorced.

Comparable data was not

available elsewhere in Canada, but is mirrored by

statistics from the United States.

Fig. 25. Data sourced from BC Coroners Service (2022).

Area-Level Characteristics

A study found that in 2016-2017, the majority of deaths

occurred in major population centres (30% of all deaths

occurred in metropolitan zones with 1,500,000+

residents), but the highest rate of deaths occurred in

Illicit Drug Overdose Deaths in BC. (2018). BC Coroners Service.

The Numbers Behind the Opioid Crisis. (2017). Social Capital

Project.

smaller centres (15.9 deaths per 100,000 occurred in

zones with 100,000-499,999 residents. 1,500,000+ zones

only had a death rate of 10.7).

Mental Health and Contact with Healthcare System

Though there is not Canada-wide data on the intersection

between opioid harms and contact with the healthcare

system, both Alberta and BC report on whether those

who suffer from AAOTDs had contact with the healthcare

system prior to their death.

In Alberta, January to June 2022, 56% of those who

suffered a non-pharmaceutical opioid-related death had

received at least one health service within 30 days of

death, 34% had been dispensed an antidepressant, 18%

had had a mental health visit, and 16% had a visit related

to chronic pain.

In BC, between August 2017 and July 2021, 62% of

people who died of illicit drugs were experiencing mental

health issues. 50% had a mental health diagnosis, while

12% and anecdotal evidence of a mental health disorder.

43% had a health visit related to mental health in the year

prior to their death, compared to 14% of the B.C.

population. 72% of those who died had a visit with a

health professional less than three months before their

death, and 87% had a visit within one year of their death.

Canadian area-level characteristics of substance-related acute

toxicity deaths, 2016 to 2017. (2022). Government of Canada.

Substance use surveillance data. (2023) Government of Alberta.

0% 10% 20% 30% 40% 50% 60% 70%

Unknown

Widowed

Separated/divorced

Married (incl. common law)

Never Married

Marital Status of Those Suffering from Illicit

Drug Overdose Deaths in BC, 2016-2017

Decedents had a higher number of health visits, and 30%

had had a previous paramedic attended non-fatal illicit

drug related event.

A prior BC report looking at 2016

and 2017 data found that 45% of decedents had sought

assistance for pain-related issues in the year prior to their

death.

Education

Education was highly predictive of risk of hospitalization

due to opioid poisoning. Those with no credentials were

hospitalized at a rate of 23 per 100,000, while those with

a university degree were hospitalized at a rate of 5.5 per

100,00.

Rate of hospitalization due to opioids by education level,

2011-2016

Highest level of education

attainment

Crude rate per

100,000

No certificate, diploma, or degree

23.0

High school diploma and/or trade

certificate

14.3

College Diploma or university

below bachelor

12.7

University degree

5.5

BC Coroners Service Death Review Panel: A Review of Illicit Drug

Toxicity Deaths. (2022). BC Coroners Service.

Illicit Drug Overdose Deaths in BC. (2018). BC Coroners Service.

Summary: Canada, Alberta, BC

The published data enables a summary of differences

between Alberta and BC, Canada’s two opioid hotspots.

Over half the people suffering AAOTDs in Canada are

30–59-year-old men, and the majority of deaths have

occurred in Alberta and BC. Though there appear to be a

higher prevalence of drug use, and more drug users in

the two provinces than in other Canadian provinces, this

factor is insufficient for explaining why deaths are so

concentrated in the two provinces. Instead, deaths seem

concentrated in Alberta and BC because of the relative

toxicity of the drugs being supplied and consumed there.

Those dying were generally poorer, unemployed,

unmarried, and less educated. For those that were

employed, they were most commonly working in the

trades, transportation, or as equipment operators. They

often would have had recent contact with the healthcare

system, mental health issues, and/or have sought

assistance for chronic pain.

First Nations peoples suffer disproportionally high levels

of opioid harms. Other visible minorities are significantly

less likely to suffer opioid-related harms than the general

population.

Gisèle Carrière, Rochelle Garner, & Claudia Sanmartin. (2018).

Social and economic characteristics of those experiencing

hospitalizations due to opioid poisonings. Statistics Canada.

The majority of deaths occurred in large population

centres with populations over 1.5 million, but the highest

rate of deaths occurred in smaller population centres.

Alberta and BC are Canada’s opioid hotspots, but there

are some differences in how the crisis has presented in

the two provinces. First, BC has a much longer history

with substance harms with Alberta, and volume of harm is

much higher in BC, measured according to deaths and

hospitalisations. However, the rise in AAOTDs in Alberta

during the pandemic has been steeper relative to its pre-

pandemic levels.

Fig. 26. Data sourced from Government of Canada (2022).

Those dying of AAOTDs in BC are notably older than

those dying in Alberta and the rest of the country. They

are also the most likely to be male, with 80% of all deaths

being men (vs. 74 % in Canada and 73% in Alberta).

Finally, police incident data confirms BC is the epicentre

of drug-crime in Canada, reporting 57 opioid-related

incidents per 100,000 vs. 13 in Alberta. In terms of the

major cities, Vancouver also has significantly higher

numbers of drug-related violations than either Calgary or

Edmonton, which could be a reflection of police activity,

as opposed to underlying prevalence. Despite this, there

are significantly fewer arrests for drug-related crime in

the BC, and a low charge rate despite rising rates of

incidents.

Considering the recent decriminalisation of possession in

BC it is perhaps unsurprising that drug users have not

been routinely charged by police when caught in

possession in recent years; however, this does not seem

to reflect a law enforcement focus on upstream

interdiction against dealers and traffickers instead. When

considering the more serious drug offences involved in

supply and profiting from the illicit market – namely

importing and trafficking – the gap between TPD

incidents and charges, however, is significant (80 per

100,000 incidents vs. 22 per 100,000 charges in 2019). In

contrast, Alberta charges far more people for TPD

relative to the incidents detected (46.6 per 100,000

incidents vs. 38 per 100,000 charges).

2017 2018 2019 2020 2021 2022 (Jan-

Jun)

Deaths per 100,000

Alberta and BC AAOTDs

Canada Alberta British Columbia

CHAPTER 4: Policies and Services

in Alberta and British Columbia

This chapter summarises the respective programs that

Alberta and BC have implemented to address the

addiction crisis. The backdrop is stark: BC in 2022

experienced its second worst year of overdose deaths

ever (2,272), just behind the 2021 total (2,306).

Alberta

too went through its second worst year of overdoses

(1,346) in 2022, compared to its worst total the preceding

year (1,621).

Nevertheless, the recent annualised

decline in deaths of 17% in Alberta – if sustained in 2023

– would be the start of a positive trend.

Provincial Contrast?

The two broad policy approaches explored in this section

include both harm reduction, which dominates the

approach in BC, and recovery-oriented care, which is the

model being pursued in Alberta since 2019.

Some observers have suggested that Alberta’s emphasis

on recovery (inspired by ‘Towards an Alberta Model of

Wellness’) represents a new model of care in Canada and

a departure from the harm reduction policies embraced

in British Columbia.

This is an oversimplification as it

Wells, V. S. (2023, January 31). 2022 was second deadliest year

for toxic drug deaths ever. The Georgia Straight.

Substance use surveillance data. (2023). Government of Alberta.

presupposes that Alberta’s current service approach is

wholly distinct from British Columbia’s, which it is not. For

example, harm reduction efforts are also undertaken in

Alberta, and BC funds residential recovery provision.

Nevertheless, there is a distinct contrast in the strategic

emphasis that is placed on recovery in Alberta, compared

to what is currently guiding all policy in BC, and as of

January 2023, both provinces take different policing

responses to drug possession.

Enforcement and Decriminalization

In an attempt to further reduce the potential for drug

users to be subject to enforcement, the BC Government

has advocated decriminalisation of drug possession in the

province. As of 31 January 2023, and following approval

from the federal government in November 2022, BC has

now adopted a decriminalization policy that prevents law

enforcement from arresting individuals aged 18 or above

for possessing minor quantities (2.5g) of illicit

substances.

Given that charges for possession were

already low, this could also be viewed as the formalization

and codification of current practices. Possessing drugs

for the purpose of trafficking, possessing drugs at

schools, child-care facilities and airports remains illegal

and several municipalities have local bylaws prohibiting

Alberta, B.C., and two different approaches to fight Canada’s

epidemic of drug deaths. (2022, October 11). The Globe and Mail.

Kulkarni, A. (2023, January 31). What you need to know about the

decriminalization of possessing illicit drugs in B.C. CBC.

drug use at public facilities and in private spaces like

shopping malls.

Meanwhile, Alberta is maintaining conventional

enforcement pertaining to possession of illicit substances.

The Alberta Association of Chiefs of Police has stated that

it is too soon to look at decriminalization in Alberta

because the necessary levels of support, including

addiction treatment services, are unavailable.

Despite

this position, as recently as last year the city of Edmonton

passed a motion to develop its own decriminalization

strategy to reduce future harm from toxic drugs.

Along with the rest of Canada, with the exception of BC,

drug possession remains illegal in Alberta without a

prescription. Alberta police officers can now offer

diversion to treatment to individuals caught with illicit

substances; however, drug possession is not

decriminalised and individuals can still be arrested,

charged, and processed for possession. Overall incident

rates for possession in Alberta have reduced in recent

years, though this is probably best attributed to the

COVID-19 pandemic.

Kulkarni, A. (2023, January 31). What you need to know about the

decriminalization of possessing illicit drugs in B.C. CBC.

Graveland, B. (2022, January). It’s too soon to support drug

decriminalization: Alberta police chiefs. Global News.

Amato, S. (2022, April 11). Edmonton moves forward on

decriminalizing ‘simple personal possession’ of drugs. CTV News.

Hyshka, E., Anderson-Baron, J., Karekezi, K., Belle-Isle, L., Elliott,

R., Pauly, B., Strike, C., Asbridge, M., Dell, C., McBride, K., Hathaway,

The next section will explore elements of harm reduction

and recovery-oriented models of care.

‘Safer Supply’ and Harm Reduction

The origins of harm reduction in British Columbia can be

traced to the first needle exchange and distribution

programs in 1988 and 1989 aiming to limit the reuse and

sharing of needles to help address the AIDS epidemic.

The federal government then adapted harm reduction as

part of its drug policy and introduced further measures

such as attempts to decriminalize cannabis possession

and providing for exemptions to criminal prosecution to

open Insite in 2003 in BC, which was the first supervised

injection facility to exist in North America.

Since this time BC embraced more elements of harm

reduction, including investments in naloxone distribution,

Opioid Agonist Therapy (OAT), supervised drug

consumption services, overdose prevention technology,

‘safer supply’ distribution and most recently,

decriminalization of illicit substances.

A., & Wild, T. C. (2017). Harm reduction in name, but not substance:

A comparative analysis of current Canadian provincial and territorial

policy frameworks. Harm Reduction Journal, 14(1), 50.

Hyshka, E., Anderson-Baron, J., Karekezi, K., Belle-Isle, L., Elliott,

R., Pauly, B., Strike, C., Asbridge, M., Dell, C., McBride, K., Hathaway,

A., & Wild, T. C. (2017). Harm reduction in name, but not substance:

A comparative analysis of current Canadian provincial and territorial

policy frameworks. Harm Reduction Journal, 14(1), 50.

In March 2020, BC rolled out the first ‘safer supply’ pilot

program to residents.

According to Dr. Thomas Kerr, a

senior scientist at BC’s Centre on Substance Use, safe

supply is defined as a legal supply of drugs that enables

individuals to use regulated substances as opposed to

toxic supplies from the illicit market.

As part of its 2021

budget, BC increased funding to expand the program and

as of February 2022, at least 12,000 citizens have

accessed prescribed safer supply.

There is no way of

tracking who is in receipt of drugs via these channels,

what proportion of these drugs are given or sold to others

not enrolled in the program. Note also that drug users

enrolled in ‘safer supply’ may choose to continue to

source drugs from the illicit market.

The many dimensions of harm reduction in BC have

become a defining strategy for how the province

addresses the addiction crisis. Below, BC lists specific

examples of harm reduction measures currently

practiced in the province.

This represents an overview

of how BC is defining harm reduction and what types of

service provisions the province has adopted in response

to the opioid crisis.

Grochowski, S. (2022, February). What is safe supply? A look at

what B.C. drug users, advocates are demanding. Vancouver Sun.

Grochowski, S. (2022, February). What is safe supply? A look at

what B.C. drug users, advocates are demanding. Vancouver Sun.

Components of Harm Reduction in BC

▪ Supply distribution and needle recovery programs

▪ Options for opioid substitution (agonist) therapies

such as methadone or suboxone

▪ Take home naloxone kits. The kits include

medication to reverse an opioid overdose

▪ Supervised consumption/injection services and

overdose prevention services

▪ Mental wellness and healing support programs

and centres

▪ Outreach and support programs

▪ Information and resources on safer ways to use

substances

▪ Public awareness campaigns to support de-

stigmatisation of drug use

▪ Peer support programs run and attended by

people with experience using substances

Alberta also has elements of harm reduction present in its

public policy approach to substance use and addiction.

The province distributes naloxone, offers OATs –

including the rapid deployment of new therapies like

Sublocade since late 2021 – and hosts SCS across the

province.

B.C. introduces new prescribed safer supply policy, a Canadian

first. (2021, July 15). BC Gov News.

Understanding Harm Reduction: Substance Use. (2020).

HealthLinkBC.

Recovery

The origins of the recovery-orientated model in Alberta

can be tracked back to 2019 when the United

Conservative Party (UPC), under Jason Kenney, entered

office. The party’s election platform at the time promised

to prioritizing investments in rehabilitation beds and

spaces that could help expand treatment capacity and

support more drug users to recover, as a key strategy to

reverse the opioid crisis in Alberta.

According to Alberta Health Services, recovery-oriented

care providers work with individuals in their current state,

respect autonomy and dignity and place an emphasis on

individual safety and providing support for harm

reduction, positive risk taking and continual personal

growth.

Moreover, recovery seeks to transcend

symptom management and cravings and instead aims to

support the development of a return to social,

psychological, cultural, sexual, and spiritual aspects of

life.

The following reflects some of the key features of the

recovery-oriented model of care in Alberta.

How Alberta is tackling its toxic drug crisis. (2022). The Drug and

Alcohol Testing Association of Canada.

Recovery Oriented Care. (2020). Alberta Health Services.

Components of Recovery Oriented Care in

Alberta

▪ Individual, family, or group therapies

▪ Professional/clinician-led or peer-led therapies

▪ Privately or publicly managed

▪ Formal or informal settings

▪ Wellness-focused or treatment-focused

▪ Prevention-focused or action-focused

▪ Cultural interventions

Alberta Health Services includes harm reduction

references within its definition of recovery-oriented care,

and drug users can still access many services that are

also available in BC.

Services

The following section aims to investigate what services

are available to citizens within the scope of each

province’s overarching policy model.

Supervised Consumption Sites

Currently, both Alberta and BC deploy SCS in each

province as reflected in the table below. Each province

hosts sites that offer a variety of services to visitors, but

data on capacity or current service caseload is not

published:

Recovery Oriented Care. (2020). Alberta Health Services.

Supervised Consumption Sites in Alberta and BC

Province

City

Location

Authorized services

Alberta

Calgary

Sheldon M. Chumir Health Centre (Alberta Health Services)

1213 4

St SW

Injection

Intranasal

Oral

Alberta

Edmonton

Boyle McCauley Health Centre (Boyle McCauley Health Centre) 10628

96th St

Injection

Intranasal

Oral

Peer assistance

Alberta

Edmonton

George Spady Centre Society (George Spady Centre Society) 10015

105A Ave NW

Injection

Intranasal

Oral

Peer assistance

Alberta

Edmonton

Royal Alexandra Hospital

(Alberta Health Services)

10240 Kingsway Ave

Injection

Intranasal

Oral

Alberta

Grande Prairie

Northreach Mobile Supervised Consumption Service (Northreach

Society) 10101 97A St

Injection

Intranasal

Oral

British

Columbia

Vancouver

Dr. Peter Centre (Dr. Peter AIDS Foundation)

1110 Comox St

Injection

British

Columbia

Vancouver

Hope 2 Health

(BC Centre for Excellence in HIV/AIDS)

611 Powell St

Drug content checking

Injection

Intranasal

Oral

British

Columbia

Vancouver

Insite (Vancouver Coastal Health)

139 East Hastings St

Drug content checking

Injection

Intranasal

Oral

Safer supply prescription fulfillment

British

Columbia

Victoria

The Harbour Supervised Consumption Service (Island Health) 941A

Pandora Ave

Drug content checking

Injection

Intranasal

Oral

Peer assistance

No representative could be reached from the Dr. Peter Center who would confirm whether they fulfilled safer supply prescriptions.

Insite, being North America’s first legal SCS, still operates

in Vancouver’s Downtown Eastside. Since its inception in

2003, funding has been expanded to other sites

throughout the province. These sites provide hygienic

environments to consume drugs without fear of arrest for

possession and to help improve the integration of care for

individuals who use substances.

In Alberta, the first permanent SCS in Calgary began

operations in 2018 and rapidly expanded services to

additional sites in Edmonton, Lethbridge, and Grand

Prairie. Currently, Alberta has five sites in operation that

are authorized by the same valid exemption from the

federal government under section 56.1 of the Controlled

Drugs and Substances Act.

Alberta previously hosted an additional site in Lethbridge

which saw the highest volume of visitors in North

America

but this site has subsequently closed.

According to a government audit, the site closed due to

the discovery of misappropriated funds.

100

It is not possible to determine the number of clients that

the network of consumption sites supports in each

province, although given their longer history, it is likely

that the four sites in BC have a higher caseload. What is

Supervised Consumption Services: Operational Guidance. (2017).

British Columbia Centre on Substance Use.

Lethbridge supervised consumption site shutting down at month’s

end. (2020, August). Calgary Herald.

Lethbridge supervised consumption site shutting down at month’s

end. (2020, August). Calgary Herald.

apparent is that the only services unique to BC are drug

checking and safer supply prescription fulfillment. All

other authorized services are available in each province

depending on the site.

It is argued by advocates that there have not been fatal

overdoses at drug consumption sites in BC and this is

proof that the model is working. However, there is no

published operating criteria for these sites and no means

to hold providers accountable, and the expansion of drug

consumption sites has occurred in parallel to continued

increases in drug deaths in the community. There is also

a lack of evidence that supervised consumption sites

reduce mortality.

101

Data is not publicly available that demonstrates the

impacts of SCS on drug harms. It is possible that while

these sites were initially effective for their intended

purpose to limit the spread of HIV and other

communicable diseases, they are not generating the

same success in reducing overdose deaths.

Rehabilitation

In 2019, the Government of Alberta, in support of the

recovery model, announced $140 million of spending

100

Lethbridge supervised consumption site shutting down at month’s

end. (2020, August). Calgary Herald.

101

Panagiotoglou, D. (2022). Evaluating the population-level effects of

overdose prevention sites and supervised consumption sites in

British Columbia, Canada: Controlled interrupted time series. PLoS

ONE, 17(3), e0265665.

over four years with an additional $20 million investment

in 2022, including 8,560 new treatment and recovery

spaces, which would reportedly increase available spaces

to over 27,000 from 19,000 spaces in 2019.

102

As part of

this they are the first province to eliminate fees for

addiction recovery programs.

103

Part of this investment is directed towards creating

communal settings for care that are defined as

‘rehabilitation/therapeutic communities.’ These

communities enable individuals to receive treatment that

focuses on many facets of the individual and their overall

lifestyle changes that prepare them for a return to normal

life.

104

The treatment is funded by the provincial

government and is a gradual recovery program that

assists individuals returning to full community living on

their own.

BC points to treatment and supportive recovery services

as either live-in or bed-based substance use services

offering a variety of programs that can be shorter or

longer depending on individual need. The amalgam of

102

Johnson, L. (2022, March). Toxi-City (Part 3): Deadly drugs in

Edmonton — How is the Alberta government tackling the problem?

Edmonton Journal.

103

French, J. (2020, November 7). Financial hurdle gone: Alberta first

province to eliminate fees for addiction recovery programs. CBC.

104

Recovery Community Operations Competitive Grant. (n.d.).

Government of Alberta.

services and models of care differ depending on the

individual as well.

In 2016, in BC, the number of rehabilitation beds totaled

approximately 2,547.

105

Currently, the province has a total

of 3,261.

106

In 2022, the government announced the

investment of $164 million to build more complex-care

housing.

107

Making accurate inter-provincial comparisons on

treatment beds and spaces is not possible because

Alberta and BC do not use common definitions. It

appears that Alberta has significantly more spaces

dedicated to rehabilitation than BC, but its numbers

encompass both ‘live in’ and ‘communal’ settings.

Additionally, it appears BC does not currently offer any

therapeutic community settings as defined in Alberta.

When it comes to wait times to access rehabilitation

spaces and beds, while provincial health authorities like

Island Health suggest waitlists for existing rehabilitation

beds in BC is typically about five weeks,

108

Albertans face

105

McElroy, J., & Clancy, N. (2016, September). Are there enough

beds for drug treatment in B.C.? CBC.

106

Russ, G. (2022, September 27). A tale of two provinces: Assessing

the opioid crises in BC and Alberta. Macdonald-Laurier Institute.

107

Cowie, A. (2022, May 21). Powell River and Bella Coola to receive

funding for complex-care housing. CityNews.

108

Dickson, L. (2022, August 28). People seeking detox treatment

face weeks-long waits. Times Colonist.

a waitlist to access beds that can range between six

weeks and twelve months depending upon location.

109

Moreover, the definition of rehabilitation beds in each

province is not uniform. This is particularly important

because Alberta is charting a comparatively new path

when it comes to creating rehabilitation communities,

which encompass rehabilitation beds in a manner that

does not appear to exist in BC.

Ultimately, despite funding announcements around

creating new rehabilitation spaces and beds in Alberta,

demand is still exceeding supply and it is therefore too

early to conclude whether the expansion in rehabilitation

beds is impacting the opioid crisis.

Naloxone

Naloxone provision is another service that is offered in

both Alberta and BC. Naloxone is an opioid antagonist

medication that can temporarily reverse the effects of an

overdose and allow time for help to arrive by blocking the

effects of opioids and restoring normal breathing.

110

Antagonist medications bind to the same brain receptors

as opioids, which stops the receptor from producing the

suppressed respiratory response.

109

Bhatti, A. (2017, October 16). Waitlists Are Growing in Alberta for

Treatment Centres. Andy Bhatti.

110

Naloxone. (n.d.). CAMH.

111

Get Naloxone. (n.d.). Alberta Health Services.

In Alberta, there are currently over 2000 sites that

provide naloxone kits free of charge for individuals to take

home.

111

In BC, there are approximately 1800 currently

on record.

112

In recent years there has been a dramatic

upswing in naloxone kit distribution in Alberta where in

2022 there was approximately 135,330 kits distributed

compared to only 32,140 in 2017, and 6,181 in 2016.

113

BC, over one million naloxone kits were distributed

between 2012 and 2021.

114

With clear efficacy, both

provinces continue to increase the number of naloxone

kits distributed in recent years. However, the increase in

distribution in Alberta has been particularly rapid.

*2022 Q4 data not yet available. Chart uses average of prior three quarters.

Fig. 27. Data sourced from Government of Alberta (2023).

112

Take Home Naloxone. (n.d.). Towards the Heart. Retrieved 6

March 2023, from https://towardtheheart.com/naloxone

113

Substance use surveillance data. (2023). Government of Alberta.

114

More than one million naloxone kits shipped in B.C. as overdose

crisis continues. (2021, June). BC Centre for Disease Control.

50000

100000

150000

200000

2016 2017 2018 2019 2020 2021 2022*

Naloxone Kit Distribution in Alberta by year

Opioid Agonist Treatment

OATs are defined as agonist medications, which are

drugs that produce a similar response to illicit opioids, but

in a safer and more stable fashion.

115

Agonist

medications bind to the same brain receptors as illicit

opioids, reducing withdrawal symptoms and creating

biological and emotional stability for the patient.

116

This is

different from naloxone, which is an antagonist drug

designed to rapidly reverse the effects of opioid

overdoses.

The process for engaging in an opioid agonist treatment

plan in BC does not involve a referral and most OATs are

covered for all provincial residents who have sought

treatment from a doctor to explore their options.

117

The

Island Health Authority in BC is careful to point out that

these treatments often require a combination of individual

and group counselling.

Similarly, the Government of Alberta defines opioid

agonist therapy as taking medications to treat opioid use

disorder by reducing cravings and helping to manage

withdrawal symptoms.

118

These types of medications are

prescribed to be taken daily and treatment plans exist

within a long-term or short-term context depending on

each individual.

115

Opioid Agonist Therapy. (n.d.). Island Health.

116

Pharmacological Treatment. (n.d.). Indian Health Services.

117

Opioid Agonist Therapy. (n.d.). Island Health.

The process for engaging in an opioid agonist treatment

plan in Alberta requires the acquisition of a prescription

and dispensation by a pharmacist. The associated

dispensing fees can provide a barrier to individuals

without health benefits coverage.

119

However, the OAT

coverage program offered by the Government of Alberta

aims to eliminate the gap in coverage by offering OAT to

individuals for up to 120 days free of charge for those

with a valid prescription and a current provincial health

card identification number.

Clearly, the role OATs play in reducing or eliminating

cravings is significant. Nonetheless, it does not appear as

though it is more difficult to gain access to this type of

treatment. In Alberta, there has been a rapid deployment

of Sublocade – an injection that can satiate cravings for

30 days – and which was licensed in Canada in 2018.

118

Opioid Agonist Therapy Gap Coverage Program. (n.d.).

Government of Alberta.

119

Opioid Agonist Therapy Gap Coverage Program. (n.d.).

Government of Alberta.

*2022 Q4 data not yet available. Chart uses average of prior three quarters.

Fig. 28. Data sourced from Government of Alberta (2023)

Technology

Alberta has recently emerged as a leader on the

technology front when it comes to addressing the opioid

crisis.

In 2017, the government introduced the virtual opioid

dependency treatment program (VODP), utilizing

telehealth infrastructure to support the provision of OATs

to Albertans.

120

The Virtual Opioid Dependency Program (VODP). (n.d.). Health

Standards Organization.

121

Digital Overdose Response System. (n.d.). DORSAPP.

122

Digital Overdose Response System. (n.d.). DORSAPP.

Additionally, the Digital Overdose Response System

(DORS) app allows Albertans using opioids or other

substances to rely on automated alerts to summon

emergency response to their location if they become

unconscious.

121

The DORS app also provides information on national and

provincial addiction recovery supports and services, such

as the Addiction Helpline, to ensure a range of support is

available to individuals using the app.

122

Another

supporting piece of technology deployed in Alberta is an

online too called My Recovery Plan, which offers

assessment tools, generates recovery goals, monitors

progress, and helps with challenge management.

123

This

platform, developed in partnership with the treatment

provider Last Door, and derived from their own in-take

assessment system, is geared around tracking not just

interventions, but the drug users ‘recovery capital’, as a

individualised metric of their place on a recovery journey.

The tool has become the basis for tracking policy impact

beyond ‘harm’ metrics, and the expansion of MRP is

underway.

BC, on the other hand, has technology available such as

Lifeguard.

124

This is a smartphone app, like DORS in

Alberta, which alerts first responders by automatically

dialing 911 during a suspected overdose event. Another

123

My Recovery Plan. (n.d.). Government of Alberta.

124

Two years later, Lifeguard App continues to save lives. (2022,

May). BC Emergency Health Services.

500

1000

1500

2000

2500

3000

2016 2017 2018 2019 2020 2021 2022*

Unique Individuals Prescribed

Sublocade in Alberta by year

smartphone app that exists in BC is the Brave App, which

acts as a panic button for individuals using substances

and at risk for overdose.

125

In an effort to prevent

overdoses in the first place, a piece of technology

currently being tested is a portable drug checking

machine called a Fournier-Transform Infrared

Spectrometer, which would be the first piece of

technology of its kind in Canada.

126

Though both provinces are investing in and deploying

technology to support users, Alberta has married the

investment in this area with a plan to track and eventually

publish more data on the whole addiction journey,

including the progress being made towards recovery.

With technology in Alberta integrated into this coherent

structure of services, in years to come it will be possible

for policy-makers to evaluate the province’s impact on

improving recovery capital as well as addressing drug

harms – a first of its kind in the developed world.

Summary

Both Alberta and BC deploy elements of recovery and

harm reduction. The most apparent difference in policy

between the provinces is BC’s recent decriminalization of

substance possession. Alberta, while, bolstering funding

and support around its recovery model, is maintaining

current approaches to law enforcement around illicit

125

Overdose Detection Saves Lives. (n.d.). Brave.

drugs. Alberta continues to invest in rehabilitation beds

and spaces, such as therapeutic communities and has

not adopted the models of ‘safer supply’ – including

proposals for automated dispensing – that have been

setup in BC.

New policy innovation in BC is not currently apparent on

the issue of drug addiction, whereas Alberta’s nascent

model has not yet had time to fully deliver results, with

recovery communities still being constructed for example.

In a similar way, though BC has emphasized harm

reduction for two decades, its safer supply strategy only

reached the implementation phase 2021.

As the implementation of these strategies advances,

ongoing scrutiny of their impacts and effectiveness is

required to inform policy-makers in Canada and other

jurisdictions. Close engagement between policy-makers

and service leads in both provinces will be important to

allow sharing of learnings and best practice, especially in

those areas where provincial practices diverge.

126

Overdose prevention. (n.d.). Government of BC; Province of

British Columbia.

CONCLUSIONS

Canada has been grappling with a worsening opioid crisis

for over two decades. The harms caused by the crisis are

substantial, causing half as many deaths in 2020 and

2021 as COVID-19 and five times as many life years lost.

The problem is particularly acute in Alberta and BC,

which together account for 50% of all AAOTDs in Canada

despite representing only 25% of the population.

The data reviewed for this project gives a broad picture of

why drug harms are so high in Alberta and BC and who is

bearing the brunt of these harms. Harms are highest in

Alberta and BC principally because in these two

provinces the drug supply is most toxic. Though there are

likely more drug users in these two provinces, the

difference in self-reported drug use is insufficient to

explain the concentration of harms on the west coast.

Though a number of other factors may contribute to the

crisis (e.g., innovation in the illicit market, inward

migration of drug users

127

, and access to housing), their

impact is likely to not be as significant as the toxicity of

the drug supply itself.

127

Somers, J. M., Moniruzzaman, A., & Rezansoff, S. N. (2016).

Migration to the Downtown Eastside neighbourhood of Vancouver

and changes in service use in a cohort of mentally ill homeless

adults: A 10-year retrospective study. BMJ Open, 6(1), e009043.

128

Substance use surveillance data. (2023). Government of Alberta.

129

Illicit Drug Toxicity Deaths in BC: January 1, 2012—December 31,

2022. (2022). British Columbia Coroners Service.

Alberta and BC

As the opioid crisis in Alberta and BC have intensified, so

have comparisons of their respective policy platforms. In

particular, a number of commentators have held up

Alberta’s recovery-oriented system of care as a new

alternative for BC’s harm-reduction oriented approach.

This report makes three observations on this subject.

First, though there was a greater decline in Alberta’s

overdose-related deaths compared to British Columbia’s

between 2021 and 2022 (17%

128

vs. 1.4%

129

respectively)

it is still Alberta’s second most deadly year on record with

regards to drug-related harms.

130

Sustained reductions in

the opioid mortality rate in 2023 would be needed to

confirm a positive trend in Alberta. Also of course,

overdoses are not the only indicator of success of drug

policy.

Second, however much differences are emphasized

between the provinces, both utilize harm-reduction and

recovery-oriented interventions. Alberta, for example,

distributes more naloxone than BC.

130

Substance use surveillance data. (2023). Government of Alberta.

Third, data gaps and differences in definitions in certain

key areas makes effective comparisons across the two

provinces harder. For example, different definitions

prevent comparisons of recovery beds and spaces

available in the two provinces.

It is too soon to determine if Alberta’s recovery-oriented

system of care is delivering better results than BC’s more

harm-reduction centred approach, however BC’s

longstanding approach has been the subject of the most

intense criticism, given the scale of drug harms there.

The rate of drug deaths in the province has been

increasing for two decades, and 2022 only saw a very

modest decline, so it is unclear whether further

investment in the same harm-reduction efforts will

improve this state of affairs.

The differences between Alberta and BC’s policies are

real, but in terms of provincial approaches, their service

offerings are more similar than they are different. As

Alberta’s recovery-orientated model is implemented, it is

possible that the differences in approach will become

clearer.

The two provinces studied for this project have made

some progress in becoming more transparent, and have

also pioneered new prescription treatment programs.

Compared to a decade ago, there is more information in

the public domain, and more system-wide performance

data being published. In recent months, Alberta has

launched a detailed online data dashboard that allows the

addiction crisis and other interventions there to be

tracked, with an innovative ‘recovery capital’ scoring

matrix to track more than harmful episodes or agency

demand.

However, key metrics are still difficult to evaluate given

gaps in reporting and the lack of data collection. Alberta

has the more comprehensive dataset to report on current

performance, although some of British Columbia’s data –

though harder to access and compare – is more granular

and has a longer time series. The two provinces are

suffering the same public health crisis, and as

neighbouring jurisdictions, their respective approaches

warrant further investigation. Primary research, supported

by comprehensive government data, is required to

extract identifiable best practices from comparisons

between the two, and this is the type of activity that a

Federal Government study could seek to evaluate.

Where Next?

There is an ongoing public health emergency of drug

addiction in Canada. The Covid-19 pandemic and its

consequences exacerbated the harms associated with

the pre-existing challenges around poly-drug use

combined with mental illness, and homelessness among

a cohort of individuals suffering from low levels of social

capital.

Our research indicates that current approaches in both

provinces, based on the available data, are not yet

showing the progress that the public and those impacted

by drug addiction deserve. Of the two provinces, Alberta

is currently experiencing a reduction in key addiction-

related harms, however it is based on two quarters of

data, and would need to be sustained through 2023 in

order to represent an established trend.

Politicians, the public and practitioners working in the

field across both provinces want to see better progress to

mitigate the health harms from addiction. And although

the pandemic was an accelerant to some negative trends,

and despite major investments in services, the Federal

Government has not undertaken an intervention to

properly score the impact of provincial and municipal

responses in Western Canada. Given the scale of the

crisis and the number of lives lost, and set against the

assertive role played by Health Canada and other national

agencies in responding to the pandemic, this reticence is

hard to explain.

In both provinces, and in Canada overall, the biggest

impediment to an informed public policy debate is the

lack of data around long-term treatment outcomes,

desistence, and recovery. This is one area where a set of

nationally agreed definitions and counting rules would

benefit everyone. Overdoses are relatively easy to count

but cannot be the only metric by which drug policy is

judged.

The lack of good data on the downstream interventions

and the addiction recovery journey may be the symptom

of a wider problem in that public health practitioners and

provincial and federal policy-makers do not share a single

view on the evidence base around intervention efficacy,

nor the best pathways towards, effective recovery from

drug addiction.

Public concern about this challenge is likely to continue

and as death rates remain high, more transparency,

innovation and new policy responses are therefore

needed. Alberta Government’s development of a

‘recovery-orientated system of care’ provides an

important example of how political leadership and a

comprehensive strategy are necessary conditions for

success. Combined with new technology and data

tracking that captures a drug user’s recovery potential, it

may provide a collective impetus to widen the policy

agenda across Canada as a whole from a narrow goal of

reducing fatal overdoses.

Whatever new policy responses take hold in either BC or

Alberta, it is not constructive for the wider debate in

Canada for the media and researchers to be hampered

by a lack of coherence around policy goals combined

with inadequate data collection and publication.

Drug addiction and its consequences are problems

shared across many jurisdictions, but provinces like BC

and Alberta, and Canadian policy-makers in general,

should be well placed to develop an evidence-based

policy framework that is comprehensive for the whole

addiction journey, and supported by the best data. Such

a robust policy framework would encompass prevention,

enforcement and interventions, through to treatment and

recovery.

Canada’s experience could provide lessons to other

countries like the USA, but only if governments at all

levels commit to a consistent reporting measure that

accurately describes the progress being made, and one

that counts more than caseloads, inputs, or a series of

‘harm’ metrics. Despite the urgency of this crisis, that

basic information architecture is still not fully in place and

as a result, the impact of many policies in Canada to

reduce harms and to aid recovery cannot be properly

evaluated.

With COVID-19 we have recently seen the kind of

mobilization that both the Federal and Provincial

governments are capable of when they actively

cooperate. The scale of opioid-related harms in Canada

warrants major coordinated action of this kind, led by

Ottawa, with much more focus on how progress at all

levels will be measured, and much greater transparency

around what outcomes are being pursued.

Policy Recommendations

Agree what success looks like.

• Given the significant public funds that continue to be

spent, provincial and federal policy-makers should

now urgently agree what success looks like and how it

will be measured.

• The Federal government should agree with Canadian

provinces a core set of performance metrics that will

be routinely collated and published, and fund a full

evaluation of the provincial policy framework in British

Columbia, where the crisis is most acute;

• Health Canada should publish a comprehensive policy

briefing that summarises the international evidence-

base for all currently funded addiction services,

including innovative models like ‘safer supply’;

• Key national metrics must be developed

collaboratively and in a way that covers all provinces

and encompasses the full spectrum from prevention,

through enforcement and other interventions, to

treatment and recovery, with a balance between

positive and negative outcomes where possible.

• Alberta and British Columbia should work together to

share learnings as new approaches are adopted in

each province, such as recovery communities in

Alberta, the use of treatment interventions using

Sublocade, or the impact of decriminalisation in BC.

Collate and publish more, better data.

• All public authorities and those service providers

funded by the government, should be obliged to

monitor and report on the full set of outputs at every

stage and in a standardised format. Better data that is

published in a more accessible way will aid the media

and public to understand trends and to gauge whether

current approaches are working.

• Existing data that relates to harms should be

augmented with new data relating to benefits, such as

long-term recovery rates and first-time entrants. BC

would benefit from adopting a platform similar to MRP

in Alberta where recovery capital is scored and

tracked.

• Standardised counts are needed for intra-provincial

comparisons, especially of activity-based measures

like safer supply prescribing behaviour, attendance at

overdose prevention sites, and capacity and utilisation

of treatment spaces.

• Data that is not currently published, but which would

enhance public debate, such as the geographic

concentration of drug deaths below the provincial

level, or the costs associated with treatment

programmes, should be released.

• Local population and user surveys that would inform

public understanding of areas like Vancouver’s

Downtown East Side should be commissioned,

including documenting the residency history of drug

users in that area to determine the level of inward

migration.

• Collect and publish more federal and provincial data

on enforcement and criminal justice caseloads related

to drug crime. This would enhance the policy debate,

especially in the context of decriminalisation now

underway in BC, which is affecting possession but is

not meant to lead to a reduction in enforcement

against drug traffickers and those detected and

charged at a local level with more serious offences

like importation or distribution of illicit drugs.

63 
 
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Appendix A: Calculations for COVID-19 and Opioid Life Years Lost, 2020-2021

COVID-19

Age distribution estimates were made based on Canada’s COVID-19 statistics on November 22, 2022.

131

Age

Deaths

Proportion of total

0 to 11

0.09%

12 to 19

0.05%

20 to 29

144

0.31%

30 to 39

335

0.73%

40 to 49

720

1.56%

50 to 59

2061

4.48%

60 to 69

4889

10.62%

70 to 79

9875

21.45%

80+

27939

60.70%

Total

46029

100.00%

A midpoint was then assigned for each age group (e.g., 20-29 was assigned 25), and subtracted from 75 (e.g., 20-29 that

died of COVID-19 lost an average of 50 life years).

The total number of deaths as of January 1, 2022 (30,145) was assigned the above age distribution and the estimated

number of deaths in each age group multiplied by the midpoint of LYL. The sum of LYL was then taken for the report.

Age

Deaths

LYL by age (75 - midpoint)

Sum of LYL Lost

0 to 11

26.85144148

1879.600904

12 to 19

16.37283017

982.3698103

20 to 29

94.30750179

4715.37509

30 to 39

219.3959243

8775.836972

40 to 49

471.537509

14146.12527

50 to 59

1349.776119

26995.52239

60 to 69

3201.870668

32018.70668

70 to 79

6467.267918

80+

18297.62009

Total

30145

N/A

89513.53712

131

COVID-19 daily epidemiology update. (2020). Public Health Agency of Canada.

Opioids

Statistics were provided for both the number and distribution of accidental-apparent opioid toxicity deaths in 2020 and

2021, and these were combined to determine the number of deaths per age group.

132

A midpoint was assigned for each

age group and subtracted from 75, and the estimated number of deaths in each age group multiplied by the midpoint of

lost life years. The sum of lost life years was then taken for the report.

Distribution by age

2020 deaths:

6090

2021 deaths:

7725

2020, %

2021, %

2020, #

2021, #

Total Deaths

LYL by age (75 -

midpoint)

Estimated LYL by