As health officials in Canada's western provinces scramble to get a grip on the rampant opioid crisis, addictions experts in Ontario — the country's most populous province — say they have no idea what the exact scope of the problem is around them.
British Columbia and Alberta have ramped up their efforts to inform frontline workers about the overdose rate of fentanyl, the highly potent synthetic opioid that's 40 to 50 times stronger than heroin, with BC releasing overdose data almost in real-time and Alberta doing so at a faster rate than ever. But the latest data in Ontario is currently two years old.
Many public health experts in the province say this makes it difficult to tackle the problem quickly and efficiently.
A big part of the issue is that the Canadian federal government does not track opioid overdoses nationally, resulting in a patchwork of data available by province that makes it impossible to get a coherent snapshot of the crisis.
"I flagged fentanyl for the Ontario provincial government in 2008 after I started seeing it move into Michigan," said Michael Parkinson, coordinator for the Waterloo Region Crime Prevention Council. For him, there's a lack of political will from government officials to jump into action to count and adequately respond to opioid-related deaths and addictions.
"And now, we're in the middle of an opioid crisis, the worst drug safety crisis in Canadian history, compounded by the fact that bootleg fentanyl crisis is present coast to coast to coast," he said.
Preliminary figures on opioid-related fatalities released this February by the office of the coroner for Ontario show that fentanyl overdoses are now the leading cause of opioid deaths in the province, killing 174 people in 2014, up 28 percent from the year before. There were a total of 663 opioid overdose deaths that year.
But public health experts say this is likely the tip of the iceberg as these numbers — the most recent data available in the province — are from 2014 and obviously way out of date. Part of the reason for delay is the high volume of deaths the coroner investigates in Ontario, as well as other delays from toxicology labs and law enforcement.
One of the biggest challenges for Parkinson and those working to stem overdoses in Ontario is the lack of statistics on overdose deaths, something that comes only from the provincial coroner's office, which investigates deaths. He pointed to the US where, although the national overdose data isn't published in real time, many states such as Rhode Island, are releasing data on fentanyl overdoses sometimes on a monthly basis.
In April, BC's provincial health officers declared a public health emergency following an unprecedented rise in drug-related overdose deaths, a first for any province in Canada. The latest numbers from the BC coroner showed that fentanyl was present in 56 percent of all drug overdose deaths in the province — up 31 percent from the same time late year. And from January to May of this year, the number of overall illegal drug overdose deaths in the province jumped up 75 percent from last year, a trend that's expected to continue.
Invoking a state of emergency has granted the BC coroner new powers to collect and release drug overdose statistics almost in real time and identify overdose "hot spots." The office has been releasing monthly data, based on preliminary results from investigations, and this could go up to weekly in the near future.
"One of the big things we've seen recently is that the situation is not entirely centered on the lower mainland of BC anymore or the suburbs," Barb McLintock, a spokesperson for the BC coroners service, said in an interview. "Service providers now know for example, that they need to adjust how they target those areas."
Even though Alberta is facing similar levels of fentanyl overdoses — with nearly 300 deaths linked to the drug in 2015 alone — the provincial government declined to follow BC's lead in declaring a public health emergency because it received legal advice that it could handle the crisis without doing so. Alberta's justice department vowed to ramp up its surveillance of fentanyl overdose deaths, and that the stats on them will be even more detailed.
Parkinson believes Ontario's growing fentanyl problem likely mirrors that of BC, and that paints a grim picture for the future. "A 75 percent rise in Ontario would put us on pace for 1,200 opioid-related deaths here, but we won't know if that's the case until 2018," continued Parkinson. In the absence of good data, his group has created an online alert system to track opioid use and overdoses in the Waterloo, Ontario region.
The website is updated with any numbers on overdoses coming from provincial coroners across the country, as well as local media reports and police warnings on illicit fentanyl and other street drugs, and information on how to obtain naloxone kits to reverse overdose deaths.
"It's questionable whether there are any adults in charge in Ontario. It's not a recent crisis," said Parkinson. "Programming should be based on good data, good evidence so you can craft appropriate interventions and in the absence of any interest in collecting good data, it becomes much more difficult on a population health level to design those interventions."
'It's questionable whether there are any adults in charge in Ontario. It's not a recent crisis.'
For Dr. Rosana Salvaterra, the medical officer of health for Peterborough, north of Toronto, the Ontario coroner would do well to take a page from BC. For months, she has been urging the provincial government to streamline its response to the opioid crisis.
"What we need are preliminary toxicology data from the coroner, both on a monthly basis as well as whenever there's a cluster of deaths," said Salvaterra, adding that while there is a surveillance system in place for emergency departments when it comes to opioid overdoses, it's only one piece of the puzzle. "In Peterborough, if we have three deaths in a week related to overdoses, that's a cluster and it should be a red flag. We should be able to do a deep dive into the circumstances to look for common threats, whether there's something there that needs immediate attention, and whether we need to send a warning out."
But, Salvaterra also said it's important to tread carefully around preliminary data, which could be inconclusive.
Dr. Reuven Jhirad, the deputy chief coroner for Ontario, defended the office's ability to release data, saying in an interview that Ontario has the largest death investigation system in North America — dealing with about 15,000 death investigations in one year.
The nature of these non-natural investigations, including overdoses, involves multiple stages, and pathology assessment with multiple layers, he said.
"Let's say we do a toxicology and it shows a couple of drugs … what we have to say in those scenarios is that the drugs are implicated in the deaths, but we can't say which drug in particular was actually the cause," he said.
"We have to provide data when it's definitive, when we know it. We can try in certain circumstances to release certain things to agencies when they are looking for things, with the provision they know the numbers aren't finalized."
But for Parkinson, that isn't good enough. "I haven't seen any data fresher than 2014," he said. "If we have to declare a state of emergency so we can count the dead bodies in real time, then so be it."
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