Strategies for Reducing Opioid-Overdose Deaths — Lessons from Canada

published on April 26, 2018 in The New England Journal of Medicine

North America is in the midst of its most serious drug-overdose crisis in history. From 1999 through 2015, drug-overdose deaths approximately tripled in the United States, and the majority of such deaths now involve an opioid. In 2016 alone, there were 64,000 drug-overdose deaths in the United States — more than the total number of U.S. military deaths during the Vietnam War. As a result, and despite gains in other areas of medicine and public health, the United States recently experienced its first major decline in life expectancy since 1993.

The origins of the opioid epidemic can be traced to overprescription of narcotic analgesics. But in recent years, deaths due to illicit synthetic opioids have outstripped deaths due to heroin and prescription painkillers. According to the Centers for Disease Control and Prevention, deaths involving synthetic opioids (excluding methadone) doubled between 2015 and 2016 (see graph). This upsurge can largely be attributed to the emergence of fentanyl and related analogues (e.g., carfentanil) in the illegal-drug supply. An examination of data from 10 U.S. states found that more than half the people who died of opioid-related overdoses during the second half of 2016 tested positive for fentanyl.

As the United States faces this unprecedented epidemic, there are lessons to be learned from Canada, which has taken bold action on a number of fronts with the aim of reducing deaths related to fentanyl, fentanyl analogues, and other opioids. For instance, in March 2016, the Canadian government made the overdose-reversal drug naloxone available without a prescription. Although naloxone is also increasingly available in many regions of the United States, laws in 14 states provide no immunity from criminal prosecution for health care providers who prescribe or distribute it to laypersons. Furthermore, in 36 states, existing laws make possession of naloxone without a prescription illegal.

The Canadian government has also passed legislation aimed at facilitating the development of medically supervised injection facilities, where people who use drugs can inject opioids they buy on the street under the supervision of health care staff. Although research has found that supervised injection facilities can reduce rates of fatal overdoses by more than 30% in communities with high rates of drug use1 and can help facilitate greater uptake of addiction treatment, there are few, if any, such programs in the United States. In recent months, however, public health officials in several U.S. cities, including San Francisco, Seattle, and Philadelphia, have endorsed plans to open pilot supervised injection programs to address increasing rates of overdose deaths.

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