Ayah El-Hajj, Sophia Burns, Jazlyn Chan, Nabeel Khan, Justina Wong (senior author)

Youreka Edmonton | yourekacanada.org

2nd Place in the Youreka Canada National Competition

Edited by Nina Acharya

The implementation of COVID-19 restrictions has exacerbated the existing national opioid crisis by increasing social isolation and limiting dependency program access. This study examines the impact of COVID-19 restrictions on opioid overdose rates by analyzing opioid-related mortalities and Emergency Medical Service (EMS) responses in Alberta and Ontario. A month-by-month count of opioid-related deaths and EMS responses between January to June 2020 were retrieved from Health Analytics Alberta and Public Health Ontario, with demographic data retrieved from Public Health Canada. Two-way ANOVA tests with replication were performed with a p-value of <0.05 defined as statistically significant. When standardized for population, the rate of opioid-related mortality per 100 000 people is 10.36 in Alberta and 7.15 in Ontario. ANOVA analyses showed that restriction level severity had a significant effect on opioid-related mortalities (F(2,6) = 8.76, p = 0.017). Additionally, there was a significant difference in both mortality (F(1,6) = 64.97 p = 0.00020) and EMS responses (F(1,6) = 107.12, p = 0.000048) between Alberta and Ontario. The prominent demographic of opioid overdoses was from males aged 30-39 using non-pharmaceutical fentanyl. The results from this study illustrate the effect of restriction severity on individual mental health and wellbeing. This emphasizes the need for harm reduction programming amidst lockdown restrictions to limit disease transmission.

INTRODUCTION

Opioids are highly addictive medications prescribed for severe body pain (American Society of Anesthesiologists [ASA], 2021). They attach to receptors in the brain causing the release of dopamine which stimulates a euphoric feeling and may lead to addiction (ASA, 2021). The widespread misuse and subsequent overdose of opioids have resulted in a national opioid crisis which has only worsened with the advent of the COVID-19 pandemic (Province of Alberta, 2020). This study focuses primarily on the provinces of Ontario and Alberta to compare how implementing restriction of differing severities worsened the existing opioid crises. Prior to 2020, Alberta had an annual average of 806 overdoses and Ontario had an average of 1512 deaths yearly (Ontario Drug Policy Research Network [ODPRN], 2020; Province of Alberta, 2020). With the start of the pandemic in 2020, opioid related deaths rose by 43% in Alberta and overdoses increased by 38.2% in Ontario (Province of Alberta, 2020). The implementation of various lockdown restrictions aimed to reduce the spread of the virus may have worsened mental health and exacerbated the existing opioid crisis. A systematic review by Richardson et al. (2020) concluded that COVID-19 necessitated social isolation and had an overall negative impact on mental health. Additionally, Xiong et al. (2020) noted a connection between psychiatric illnesses and increased overdose rates during the pandemic.

During the first few months of the COVID-19 pandemic, both Alberta and Ontario varied their restriction severity depending on the number of cases, hospitalizations and mortalities. When the state of emergency was declared in March 2020, Alberta's social gatherings were limited to a maximum of 15 people indoors and outdoors, while Ontario had a limit of 10 people (Province of Alberta, 2020), (Province of Ontario, 2020). In addition to these social gathering restrictions, opioid dependency programs which aided in addiction management were suspended or shut down. As the stage one plan slowly eased restrictions starting May 2020, social gatherings in Alberta expanded to a limit of 15 people indoors and a maximum of 50 people outdoors, while Ontario permitted gatherings of 10 people indoors and 25 people outdoors. Dependency programs were slowly re-opened with restrictions on visitations (Alberta Health Services, 2020). The fluctuation of lockdown restrictions over the course of the pandemic may have influenced individual struggles with mental health and drug use. Analyzing public health data during the COVID-19 pandemic period will provide better insight on the relationship between restriction severity and opioid overdose.

This study aims to examine the impact that COVID-19 restrictions of varying severities have on rates of opioid overdoses through analyzing rates of opioid-related mortalities and Emergency Medical Service (EMS) responses. Comparing the impact of the severity restrictions between Alberta and Ontario will provide greater insight as to how provincial differences in restriction implementation may affect opioid usage and overdose. Additionally, both Ontario and Alberta had similar timelines implementing initial restrictions and reopening phases, making analysis feasible. Researching the effects of COVID-19 restrictions on the opioid crisis can better inform effective COVID-19 restrictions which limit the transmission of the disease while promoting individual mental health and protecting against illicit drug use.

METHODS

Three databases informed this study: Public Health Ontario under the jurisdiction of the Government of Ontario, Health Analytics Alberta under the Provincial Government of Alberta and Public Health Info Base under the Federal Government of Canada (Health Analytics Alberta, 2016; Ontario Agency for Health Protection and Promotion, Public Health Ontario, 2020; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2021). The Health Analytics Alberta Database collected the EMS data from the Alberta Health Services (AHS) EMS direct delivery and most AHS Contractor-ground ambulance services. The mortality data for Alberta was obtained from the Alberta Office of the Chief Medical Examiner. The Ontario opioid-related deaths database, tracking mortality rates from January 2020 until June 2020, was obtained from the office of the Chief Coroner for Ontario. The Ontario emergency department visits preliminary was gathered from the National Ambulatory Care Reporting System (NACRS), with data from April 2020 to June 2020, under the Ontario Ministry of Health and Long-Term Care and the Health Analytics Branch, extracted on August 26, 2020. The Public Health Ontario database and the Health Analytics database provided a month-by-month breakdown of the data, and the Public Health Infobase supplied demographic characteristics of the populations observed.

Opioid overdose-related mortality and EMS data for Alberta and Ontario were recorded on a month-to-month basis from January to June 2020. This time frame was divided into three two-month stages, based on the major changes in COVID-19 restrictions. The January to February stage represents a baseline before the implementation of COVID-19 related restrictions. The March to April stage begins with the declaration of the state of emergency and is used to highlight the implementation of more extreme restrictive measures in Alberta and Ontario, including the shut-down of in-person opioid dependency programs and clinics. The May to June stage indicates when stage one reopening in both Alberta and Ontario ensued. The total number of opioid-related mortalities and EMS responses were adjusted using the population sizes for Alberta and Ontario published by Statistics Canada for Q1 (January to March) and Q2 (April to June) of 2020. The mean of the Q1 and Q2 population sizes was used to obtain the rate of opioid-related mortalities and EMS responses per 100 000 people. For opioid-related mortalities in Alberta, demographics were collected on sex, age, types of opioids and origin of opioids used. For EMS responses, demographics were collected on sex and age.

A two-way ANOVA with replication was performed twice to analyze the effect of the two independent variables (province and time frame) on two dependent variables (opioid-related deaths and EMS responses). A p-value of <0.05 was defined as statistically significant, and the Tukey post hoc test was run to identify the significant relationship if needed. All statistical tests were performed using the XLMiner Analysis ToolPak on Google Sheets.

RESULTS

For opioid-related mortalities, the total number of deaths between January to June 2020 was 457 in Alberta and 1052 in Ontario. In Alberta, there were 85 deaths between January and February, 145 deaths between March and April, and 227 deaths between May and June. In Ontario, there were 285 deaths between January and February, 373 deaths between March and April, and 394 deaths from May to June. When adjusted for population, the rate of opioid-related mortality per 100 000 people was 10.36 in Alberta and 7.15 in Ontario. The overall numbers and population-adjusted rates of opioid-related mortalities for both provinces over the six month period are summarized in Figure 1 (see Appendix).

For opioid suspected EMS responses, the total number between January to June 2020 was 2105 in Alberta and 5789 in Ontario. In Alberta, there were 363 EMS responses between January and February, 574 EMS responses between March and April, and 1168 EMS responses between May and June. In Ontario, there were 1818 EMS responses between January and February 2076 EMS responses between March and April, and 1895 EMS responses between May and June. When adjusted for population, the rate of opioid-related EMS responses per 100 000 people was 47.74 in Alberta and 39.36 in Ontario. The overall numbers and population-adjusted rates of opioid suspected EMS responses for both provinces over the six month period are summarized in Figure 2 (see Appendix).

The monthly counts of apparent opioid-related deaths above accounted for both accidental and intentional mortalities, however, demographic information was only provided for accidental deaths. Of the total 457 opioid-related deaths and 2105 EMS responses in Alberta, demographics were collected for 448 (98%) of deaths and 1966 (93%) of EMS responses. From the total 1052 opioid-related deaths and 5189 EMS responses in Ontario, demographics were collected for 1035 (98%) of deaths and 1675 (32%) of EMS responses. The demographics collected are summarized in Tables 1-2 and Figures 3-14 (see Appendix).

The two-way ANOVA results are summarized in Table 3. Of the deaths analyzed, the two-way ANOVA results indicated a significant difference in opioid-related mortalities between provinces (F(1,6) = 64.97, p = 0.00020). There was no significant interaction between province and restriction level (F(2,6) = 0.51, p = 0.62). There was a significant effect of restriction level on opioid-related mortalities (F(2,6) = 8.76, p = 0.017). Further testing showed a difference between the January to February stage and the May to June stage. Of the EMS responses analyzed, the ANOVA results indicated a significant difference in EMS responses between the provinces (F(1,6) = 107.12, p = 0.000048). There was no significant effect of restriction level on EMS responses (F(2,6) = 4.61, p = 0.061). There was no significant interaction between province and restriction level (F(2,6) = 4.47, p = 0.065).

DISCUSSION

The overall number of opioid-related mortalities and EMS responses was much lower in Alberta when compared to Ontario, as Alberta had approximately half the number for deaths and one-third for EMS responses. However, as Alberta has a population of 4.4 million that is roughly one-third of Ontario, it was useful to adjust both mortality and EMS response rates per 100 000 people. When adjusted for population, Figures 1 and 2 show similar mortality and EMS response rates for Alberta and Ontario in the January to February stage before the implementation of COVID-19 restrictions. By the May to June stage, however, Alberta has exceeded Ontario in both mortality and EMS response rates, resulting in a higher overall rate for January to June 2020 altogether. The significant difference between Alberta and Ontario mortalities and EMS responses was confirmed by the ANOVA results obtained. Additionally, the Tukey post hoc test demonstrated that the significant effect laid between the January to February (prior to COVID-19 restrictions implementation) and May to June (stage one reopening) periods, but not elsewhere. This may be attributed to differences in restriction severity between Alberta and Ontario. For example, Ontario’s stage one reopening plan included addiction counselling services and outdoor recreational amenities, while these were not included in Alberta’s plan (Government of Ontario, 2020). These are services that may impact mental health, well-being and substance abuse in opioid users, which may correlate to the comparatively lower mortality and EMS response rates in the May to June stage.

From this study, opioid overdose-related mortalities and EMS responses occurred most commonly for males from ages 30-39. The prominent young male demographic of opioid users aligns with a previous study by Jeanne C. Marsh et al. (2018) who noted nonmedical opioid prescription use as more prevalent among men than women. Additionally, the prominent age demographic of 30-39 confirms the results of a previous study by Belzak & Halverson (2018) who noted that opioid-related deaths are most common among this age group in Canada. The exception to the male demographic majority in this study was in Ontario EMS responses which showed a female majority of 73.6% (Figure 13). However, as demographics were only collected for 1675 of the 5189 EMS events (32%), this female majority may not be an accurate representation of the true Ontario EMS response demographic.

It was also noted from our results that opioid-related mortalities resulted most commonly from non-pharmaceutical fentanyl. Compared to other types of opioids, fentanyl has a high potency of 50 to 100 times more than morphine (Ramos-Matos et al., 2017). This potency is often associated with increased addiction and severity in withdrawal symptoms, which make it extremely difficult for users to stop using fentanyl. The prominent non-pharmaceutical origin of fentanyl can be linked to the re-selling of legal prescription opioids in secondary markets (National Academy of Sciences [NAS], 2017). Fentanyl can also enter illegal drug markets through illegal imports from other countries, production from illegal laboratories, and theft of medical fentanyl products (eg. skin patches) (Government of Canada, 2020). Additionally, illicitly manufactured synthetic opioids remain less expensive to purchase than most analgesics opioids leading to growth in illegal opioid markets and increased accessibility to non-prescription fentanyl (NAS, 2017). The greater accessibility to the cheaper and more potent non-pharmaceutical fentanyl may account for the increase in opioid-related mortalities.

The ANOVA results in our study showed that opioid-related mortalities were significantly affected by COVID-19 restrictions, while EMS responses were not. To account for this result, it is useful to understand the public health response to opioid overdose (Government of Canada, 2020). The first point of medical intervention for suspected overdose are EMS responders. They can administer life-saving treatments such as Naloxone and transport patients to hospitals to receive further treatment. At the hospital, patients may receive immediate care in the emergency department or become admitted as an inpatient. Death may result at any point depending on the severity of opioid-related poisoning. The significant increase of opioid-related mortalities unaccompanied by EMS responses could indicate a greater degree of severity in opioid poisoning. Alternatively, it could indicate that the greater number of opioid overdoses with the advent of the COVID-19 pandemic has resulted in a shortage of EMS responses. It should also be noted that data for emergency department visitations and opioid poisoning hospitalizations was not available on a month-to-month basis and subsequently excluded from this study. Future studies could include analysis of hospitalization data for a more comprehensive understanding of the impact of COVID-19 restrictions on the entire opioid overdose response pipeline.

Other limitations to this study include the limited time frame which spans January to June 2020 only, thus the results obtained may not be indicative of recent changes in COVID-restrictions. In addition, the two-month increments used in our study may have been too long as COVID-19 restrictions have changed quickly over a small course of time. Due to the limited demographic information from our databases, our study also did not consider the special populations present in Alberta, for example Indegenious populations. A published report highlighting the impact of opioids on First Nations communities from January 2016 to March 2017 found First Nations people were three times more likely than their non-First Nations counterparts to die from an opioid-related overdose (Belzak et al., 2018). In addition, this study did not account for opioid seizures across Canada which would have an impact on the circulation and increased accessibility of non-pharmaceutical fentanyl (Canadian Border Services Agency, 2021). Future directions for this study can include expanding analyses to present-day COVID-19 restrictions, and investigating the EMS response, hospitalization and mortality rates in additional Canadian provinces. Furthermore, as COVID-19 restrictions begin to ease with increased vaccination rates, the impacts of the re-opening of opioid dependency programs can be researched.

CONCLUSION

This study analyzed the effects of COVID-19 restrictions on opioid overdoses in Alberta and Ontario. The severity of restriction levels demonstrated a significant effect on opioid-related mortalities but not on EMS responses, which could indicate a greater degree of severity in opioid poisoning during the pandemic period. The results also demonstrated significant differences in opioid-related deaths and EMS responses between Alberta and Ontario, which could possibly be attributed to provincial differences in easing restrictions and resuming addiction services. Additionally, this study characterized the prominent demographic of opioid overdoses being young males using non-pharmaceutical fentanyl. By comparing the impact of restrictions between Alberta and Ontario and characterizing the demographic most at-risk for opioid overdose, this study provides greater insight on how varying implementations of restrictions may affect individual opioid usage and overdose. This can better inform restrictions which limit disease transmission while taking into account individual mental health and well-being, such as structuring harm reduction programming amidst public health crises.

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