Opioid-Related Deaths Have Surged in Ontario Shelters

The number of accidental opioid-related toxicity deaths more than tripled in shelters across Ontario, Canada, during the COVID-19 pandemic, according to a new study.

Between January 2018 and June 2022, 210 accidental opioid overdoses occurred in shelters. Of these events, 48 occurred before the pandemic and 162 occurred during the pandemic. During the study period, the annual number of emergency beds in Ontario grew by only 15%.

“Our report highlights the need for improved and expanded harm reduction approaches, overdose response, and staff training and supports within shelters,” study author Tara Gomes, PhD, an epidemiologist and principal investigator with the Ontario Drug Policy Research Network and a scientist at St. Michael’s Hospital’s Li Ka Shing Knowledge Institute in Toronto, Ontario, Canada, told Medscape Medical News.

“Additionally, improved connection to community-based healthcare, treatment programs, and mental health supports is needed for people experiencing homelessness and housing instability,” she said. “In combination, we need efforts to address upstream factors such as more accessible housing, income and employment supports, and community-based social supports across the province.”

The report was published online on June 18 by the Ontario Drug Policy Research Network.

Analyzing Opioid-Related Deaths

The investigators conducted a cross-sectional descriptive study of data from ICES and the Office of the Chief Coroner of Ontario to examine the trends and characteristics of healthcare use among patients who died of an opioid-related toxicity in Ontario shelters between January 2018 and June 2022. They also analyzed the differences in these variables before and during the COVID-19 pandemic.

Forty-eight deaths occurred before mid-March 2020 and 162 after mid-March 2020. The quarterly number of deaths nearly quadrupled from eight deaths in the second quarter of 2018 to 31 deaths in the second quarter of 2022. The rapid increase in deaths began in 2021, when 82 deaths occurred, compared with 38 in 2020.

During the pre-pandemic and pandemic periods, about half of overdose deaths occurred in patients aged 25-44 years. The second highest proportion (about a third) occurred in patients aged 45-64 years. Fewer than 10% of deaths were among patients under the age of 25 years and those aged 65 years or older. More than three quarters of deaths occurred among men.

Most opioid-related toxicity deaths in shelters involved nonpharmaceutical opioids such as fentanyl. The proportion of deaths resulting from nonpharmaceutical opioids increased during the pandemic from 85.4% to 94.4%. The proportion of opioid-related deaths in which stimulants, particularly cocaine and methamphetamine, were a direct contributor significantly increased during the pandemic as well, rising from 43.8% to 71%.

Only one in seven of these deaths, however, occurred in the presence of someone who could intervene, which means that most people used the drugs alone, the study authors wrote. This rate was lower than that in Ontario overall, where about one in four opioid-related overdoses occurred in the presence of someone else.

In the week before death, about half of the people who died in a shelter had contact with someone in the healthcare system. In the 5 years before death, 80% had a hospital visit related to a mental health diagnosis, which was higher than the rate of 56% of people with such a visit in Ontario overall.

“People who use Ontario’s shelter system are not only facing housing instability but also have complex healthcare needs and unique barriers to accessing treatment and harm reduction programs, which underscores the disproportionate impact of the opioid crisis on this population,” study author Bisola Hamzat, an epidemiologist at the Ontario Drug Policy Research Network, told Medscape Medical News.

Healthcare System Resources

Ontario continues to experience an opioid-related toxicity crisis, with more than 2500 deaths reported in 2022, which represents a 63% increase from 2019, the study authors wrote.

“The report highlights what we have witnessed the last few years in Timmins,” said Jason Sereda, president of the board of directors for DIY Community Health Timmins, who contributed to the report.

“It demonstrates the need for comprehensive support across the spectrum of care for unhoused community members and the importance of shelter design and management to ensure that services are accessible and safe for people who use drugs,” he said. “An increase in deaths in the Timmins shelter system over the past 2 years serves as a stark reminder of this importance.”

Environmental factors and perceived safety can play a role as well. During the pandemic, both the general population and patients in shelters reported feeling more alone, more unsafe, and more likely to use fentanyl from the unregulated drug supply.

“Drug overdose mortality rates among the homeless population have increased over the past two decades and risen rapidly during the COVID-19 pandemic,” said Nick Kerman, PhD, an associate scientist at the Centre for Addiction and Mental Health in Ontario.

Kerman, who wasn’t involved with this report, has researched overdoses, safety, and shelter-based victimization before and during the pandemic. He and his colleagues found that shelter policies and the environment shaped perceived safety and overdose risk.

“Given the critical role of shelters in addressing unmet basic needs among people experiencing homelessness, it is essential that these services be perceived and experienced as safe by those who access them, as well as the staff who work in these settings,” said Kerman. “As the homeless population is highly heterogeneous, safety in shelters may be experienced differently by service users, yielding potentially unique support considerations and needs.”

The study was funded by the Canadian Institutes of Health Research and the Government of Ontario through Public Health Ontario. Gomes, Hamzat, Sereda, and Kerman reported having no relevant financial relationships.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.