Circumstances surrounding opioid toxicity deaths within shelters in Ontario, Canada, before and during the COVID-19 pandemic: a population-based descriptive cross-sectional study

Introduction — Evidence suggests growing opioid-related toxicity deaths within shelters that has been exacerbated by the COVID-19 pandemic. We sought to characterise opioid-related toxicity deaths within Ontario shelters before and during the pandemic.

Methods — A descriptive cross-sectional study of people who died of an accidental opioid toxicity, where the location of the incident (ie, toxicity) was within a shelter in Ontario, Canada, was conducted. The primary analysis was restricted to conventional shelter spaces as classified by the coroner (ie, excluding temporary COVID-19 emergency shelters in hotels). Characteristics, circumstances surrounding death and patterns of healthcare use preceding death in the pre-pandemic period (1 January 2018—16 March 2020) and the COVID-19 pandemic period (17 March 2020―31 May 2022) were summarised.

Results — Overall, opioid-related toxicity deaths within Ontario shelters more than tripled when comparing the pre-pandemic (n=48) with the pandemic period (n=162). Fentanyl directly contributed to the majority of these deaths, and its role as a direct contributor to death rose during the pandemic (from 85.4% to 94.4%; p=0.04), as did those of any stimulants (from 43.8% to 71.0%; p< 0.001). Moreover, benzodiazepine detection in opioid-related toxicity deaths increased during the pandemic (from 27.1% to 56.8%; p<0.001). In both the pre-pandemic and pandemic periods, more than half of the recorded deaths occurred among people with a diagnosis of an opioid use disorder (59.6% vs 53.5%; p=0.46), and a large percentage of people had a healthcare encounter in the week before death (46.8% vs 43.9%; p=0.73).

Conclusions — Opioid-related toxicity deaths within Ontario’s shelters have increased rapidly over the study period, with notable changes in the circumstances of death and patterns of non-pharmaceutical opioid involvement during the COVID-19 pandemic period. This study demonstrates the urgent need to expand programme and policy interventions tailored toward harm reduction within Ontario’s shelter system.