Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data.

BACKGROUND: Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase. METHODS: Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance. RESULTS: Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05). CONCLUSIONS: Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Towards cross-Canada monitoring of the unregulated street drug supply.

BACKGROUND: The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions. METHODS: The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018-March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use. RESULTS: The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal. CONCLUSIONS: This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.

Attributable fractions for substance use in relation to crime.

AIMS: Building upon an existing methodology and conceptual framework for estimating the association between the use of substances and crime, we calculated attributable fractions that estimate the proportion of crimes explained by alcohol and six other categories of psychoactive substances. DESIGN: Cross-sectional surveys. SETTING: Canadian federal correctional institutions. PARTICIPANTS: Canadian men (n = 27 803) and women (n = 1335) offenders who began serving a custodial sentence in a Canadian federal correctional institution between 2006 and 2016. MEASUREMENTS: Offenders completed the computerized assessment of substance abuse, a self-report tool designed to assess (1) whether the offence for which they were convicted would have occurred had they not been intoxicated from alcohol or another substance, (2) whether they committed the offence to support their alcohol or other substance use and (3) whether they were dependent on alcohol (alcohol dependence scale) or another substance (drug abuse screening test). Offences were grouped into four mutually exclusive categories: violent crimes, non-violent crimes, impaired driving and substance-defined crimes. This study focused on violent and non-violent crime categories. Substances assessed were: alcohol, cannabis, opioids, other central nervous system (CNS) depressants, cocaine, other CNS stimulants and other substances. FINDINGS: According to offender self-report, 42% of all violent and non-violent crime would probably not have occurred if the perpetrator had not been under the influence of, or seeking, alcohol or other substances. Between 2006 and 2016, 20% of violent crimes and 7% of non-violent crimes in Canada were considered attributable to alcohol. In contrast, all other psychoactive substance categories combined were associated with 26% of all violent crime and 25% of non-violent crime during the same time-frame. CONCLUSIONS: Attributable fraction analyses show that more than 42% of Canadian crime resulting in a custodial sentence between 2006 and 2016 would probably not have occurred if the perpetrator had not been under the influence of or seeking alcohol or other drugs. Attributable fractions for alcohol and substance-related crime are a potentially useful resource for estimating the impact of alcohol and other substances on crime.