Has Quebec entered a new era of drug-related deaths?

For the last decade, people who use drugs in Quebec have been partially sheltered from Canada's drug overdose epidemics. But since 2020, the picture has changed.

The contamination of the drug market is now present in Quebec, and what happened in British Columbia and Ontario is now happening here, says expert Sarah Larney.

In a recent study published in Drug and Alcohol Review, the Université de Montréal researcher analyzed datasets of accidental deaths between 2012 and 2021 that were determined by the coroner to be due to opioids or stimulants.

And what she found is worrying: the drug-related mortality rates in Quebec increased over time, peaking in 2020 and remaining high in 2021.

In addition, fentanyl and new synthetic opioids are on track to soon become the most commonly detected substances in opioid poisoning deaths. These drugs often contain adulterants, active pharmaceutical ingredients added to enhance or mimic the expected effects of the illicit substance being used.

"In the recent past, people used to buy heroin and there were adulterants in it, but those adulterants didn't kill you," said Larney, a professor in UdeM's Department of Family Medicine and Emergency Medicine.

"Now you can only buy fentanyl, which is far more potent than heroin, and the adulterants are much more deadly as well," said the professor, an investigator at the Canadian Research Initiative in Substance Misuse (CRISM).

On the eve of International Overdose Awareness Day, we asked Larney to tell us more about what her study revealed.

The drugs currently offered on the illegal market in Quebec (fentanyl and derivatives) are not the same as in 2019. How do you explain this market shift when Quebec traditionally differentiated itself from British Columbia?

It coincides with the COVID-19 pandemic, even though there were signs that fentanyl was on the rise before that. The opioid overdose epidemic has been made worse in Canada by this "big event," which had escalated from approximately 3,700 drug poisoning deaths in 2019 to more than 7,300 deaths in 2022.

The pandemic disrupted the drug market, catalyzing and accelerating the change in what people were buying and using. In fact, a key change is the greatly increased presence of fentanyl and new synthetic opioids in opioid poisoning deaths recorded in Quebec since 2020.

Toxicological findings from drug-related deaths suggest that Quebec potentially may have entered a new era of elevated overdose mortality at this time.

You also found that deaths were often due to a combination of opioids and benzodiazepines. Why is this a concern from a public health perspective?

Most overdoses involve more than one drug. For a long time, overdoses in Quebec involved well-known benzodiazepines like Valium. But now we are seeing potent new benzodiazepines (synthetic tranquilizers) being combined with opioids, intentionally or not.

This novel combination is of particular concern. The sedative effects of benzodiazepines, combined with the tendency of opioids to slow the central nervous system and respiratory system, increase the risk of overdose and reduce the effect of naloxone to wake someone up.

The risk of overdose is higher than before; the risk of not recovering from an overdose is also higher. It is a very scary situation.

Despite all the overdose prevention campaigns, overdose mortality rates have gone up. What do you think should be done to tackle this issue more effectively?

With nearly 45,000 opioid overdose deaths recorded between 2016 and 2023, Canada continues to grapple with a drug poisoning epidemic.

Interventions are essential. Naloxone, safer supply, and accessible supervised consumption sites are part of the answer, but they are not enough today even though we know harm reduction works.

Now, with the lethality of the drug supply, we need to look at drug law reform, such as drug decriminalization or even legalization. We can take inspiration from a fairly successful model in Portugal, which has reduced overdoses and HIV cases, and try it at the city level in Montreal, for example.

Moreover, the literature tells us that criminalization and punishment do not work. Instead, we should invest in social policy reforms that address the root causes of problematic drug use: poverty, income inequality, and the housing crisis.

Our study draws attention to what the most recent data say, things have changed and we need to respond.