Between July 2017 and June 2021, the number of opioid toxicity deaths in Ontario increased across all ethno-racial groups. Although white people accounted for the highest proportion of deaths, this trend showed a slight decline over the study period, while the percentage of deaths affecting Non-Black People of Colour (Asian people and Latin American people) increased considerably and remained relatively stable among black people. Moreover, there were marked ethno-racial differences in patterns of opioid toxicity death by key demographic and clinical characteristics, as well as in the circumstances surrounding death, including the types of opioid and non-opioid substances involved, the incident location and the prevalence of naloxone use. Notably, we observed considerable ethno-racial disparities in healthcare access during the week and month prior to death, and in rates of diagnosis and treatment for opioid use disorder, particularly among black people. These findings have important implications for determining the best approaches to tailoring and providing access to prevention, treatment and harm reduction services that meet the needs of different ethno-racial groups.
Comparison with other studies
The number of opioid toxicity deaths among Non-Black People of Colour (Asian people and Latin American people) in Ontario more than doubled over the study period, and this population accounted for nearly 6% of deaths by the second quarter of 2021. Notably, a recent report from the Fraser Health region of British Columbia revealed a tripling in the number of drug toxicity deaths among South Asian people,31 a group that accounted for almost 40% of Non-Black People of Colour in our study. Among black people, we observed a modest increase in the number of opioid toxicity deaths across the study period, and this group represented 4% of deaths by the second quarter of 2021. These findings differ slightly from recent data indicating that the most pronounced increases in overdose deaths in the USA have occurred among Black people.22 23 32 Moreover, we discovered distinct ethno-racial differences in the characteristics of Ontarians who died of opioid toxicity. On average, Asian and black people died 3–5 years younger than white people, and there was greater male predominance in deaths among racialised people relative to white people. Similar findings were reported among South Asian people who died of drug toxicity in the Fraser Health region,31 and among black and Hispanic people who died of opioid toxicity in Kentucky.24 Furthermore, we observed that black and Latin American people were more likely than white people to reside in the lowest income neighbourhoods, while Asian people were more likely than white people to live in middle-income neighbourhoods. These findings illustrate that the context and risk factors for substance use and overdose are population-specific and region-specific, and emphasise the intersectional nature of the drug toxicity crisis. To effectively address the crisis, discourse and research must move beyond the historical focus on white people as the sole or primary group impacted, and root causes, such as economic and material disadvantage, substandard living and working conditions, poverty, and adverse childhood experiences,33 must be tackled across society.
Relative to white people, fatal toxicity incidents among black people in Ontario were more likely to arise from opioids with a non-pharmaceutical source, and deaths among both black and Asian people were substantially more likely to involve cocaine. Notably, the USA has seen a recent rise in mortality due to combined opioid and cocaine toxicity, and these increases have disproportionately affected black, Hispanic and Asian Americans.34 35 Ethno-racial differences in cocaine involvement in opioid toxicity deaths may only be partially explained by variations in the prevalence of cocaine use across groups, as a US study found that although the percentage of people reporting past-year cocaine use was similar across ethno-racial groups, the rate of cocaine overdose death among black people was more than double that of white people.36 Future work must investigate whether other factors, such as the frequency of cocaine use, route of administration or type of cocaine used, can, at least in part, explain the differences we observed in cocaine involvement in deaths across groups. Additionally, qualitative research is needed to uncover the drivers of combined opioid and cocaine use among racialised people, and the degree to which combined use is intentional versus inadvertent. Furthermore, given the high involvement of non-pharmaceutical opioids and non-opioid substances in opioid toxicity deaths among racialised people, there is an urgent need for research to understand patterns of drug access and use across ethno-racial groups, and for governments to fund equitable and low-barrier access to drug checking services, safe spaces to use drugs and a safe supply of drugs. In addition, these results highlight the need for overdose prevention and harm reduction measures that are targeted to all people who use drugs, not just those who primarily use opioids.
Black and Asian people in our study were less frequently administered naloxone, even though the likelihood of a bystander being present was similar across ethno-racial groups. This finding may be partially explained by the patterns we observed in cocaine involvement in deaths, as stimulant use may mask symptoms of opioid overdose. Further, people who intend to primarily use stimulants may not expect or recognise symptoms of opioid toxicity, which may reduce the likelihood of these individuals or bystanders carrying or administering naloxone.35 Another barrier may stem from stigma and a resultant lack of communication around substance use in racialised communities. For instance, the analysis of drug toxicity deaths among South Asian people in British Columbia revealed that decedents’ loved ones were often unaware that they used unregulated substances. Consequently, naloxone kits were rarely available in the home, and families seldom recognised the overdose or understood how to respond.31 Furthermore, racialised people face many barriers accessing harm reduction services, such as the persistence of culturally embedded notions of stigma and shame surrounding substance use, addiction and harm reduction; lack of diversity among service users and providers; displays of overt racism within services; limited outreach of, and lack of representation in, promotional campaigns for services; and regular police presence near services.37 38 Resultantly, racialised people who use drugs are less likely than white people to have received or used naloxone or to have received overdose prevention training.39 40 These findings support the need for allocation of specific funding for harm reduction facilities in racialised communities that are accessible, culturally appropriate and are led or staffed by, tailored for, and targeted to members of those communities.
Over two-thirds of white decedents in our study had a history of opioid use disorder, compared with approximately half of those who were black or Asian. These findings may suggest that a substantial proportion of opioid toxicity deaths among racialised people affect those using opioids intermittently, or they could reflect an underdiagnosis of opioid use disorder among racialised people. Notably, less than two-thirds of white people with opioid use disorder received opioid agonist treatment in the 5 years before death, and this treatment gap was even larger for Asian people and black people, among whom approximately half and one-quarter of individuals, respectively, had received treatment. Therefore, our findings are likely also suggestive of substantial ethno-racial disparities in access to healthcare more generally, and in the diagnosis and treatment of opioid use disorder specifically. In particular, the differences we observed in healthcare utilisation were primarily driven by lower rates of outpatient care among black people, fewer hospital-based interactions among Asian people, and lower rates of prior hospital-treated opioid toxicity incidents among both black and Asian people. These findings likely reflect patterns of healthcare use among these groups more generally, and as such, prevention and harm reduction initiatives must take this into account in the planning of outreach and support strategies for racialised people. Moreover, our data build on US studies that have demonstrated significant disparities in rates of treatment for opioid use disorder by race and ethnicity, with white people being more likely to be treated.41–43 These disparities are likely multifactorial, and drivers may include a lack of confidence in the medical system and treatment process arising from higher rates of incarceration and societal marginalisation faced by racialised people who use drugs; cultural and language barriers; and limited ethno-racial diversity in the medical system and in promotional materials for treatment.18 44 45 In addition, US studies have shown that racialised neighbourhoods have less treatment facilities and fewer options for treatment,46–48 and there are well-documented disparities in the prescribing of opioids by race and ethnicity.11 49 These systemic factors, along with fears of stigma, rejection, discrimination and social judgement are likely responsible for the differences we observed in healthcare use more generally and in opioid use disorder diagnosis and treatment more specifically across groups. Our results emphasise the need for a multipronged response to the drug toxicity crisis that incorporates input from racialised communities and includes strategies such as decriminalisation, building diversity in the healthcare and harm reduction workforce, enhancing access to treatment and harm reduction facilities, and community-led initiatives to reduce stigma around substance use and boost education on naloxone.
Strengths and limitations
This study has several strengths, including its use of medical coroner’s data to identify all opioid toxicity deaths in Ontario, and the use of linked administrative data to allow for a comprehensive investigation of the characteristics and circumstances surrounding death. Furthermore, the study was conducted in a multicultural setting, which enhances its generalisability to culturally similar regions with diverse populations. However, several limitations warrant discussion. First, misclassification and under-reporting of ethno-racial identity is possible because this information was missing for approximately 13% of the cohort and relied on details gathered by the coroner during the death investigation. Moreover, socially ascribed ethno-racial classifications may not reflect culturally embedded notions and patterns of substance use and treatment as accurately as classifications based on self-identified race. Although our use of coroner’s records precluded the measurement of self-identified race, the coroner’s process of determining ethno-racial identity involved talking to the deceased’s family, friends and acquaintances, and as such, our measure of ethno-racial identity likely aligns closely with self-identified race/ethnicity. Second, because of the small number of Latin American people in our study, we had to aggregate data across diverse cultural backgrounds for some analyses, which may have masked some variation in the patterns and circumstances of death. Relatedly, there are also distinct cultural differences across ethnic groups within a given race; however, the approach taken in our analyses prevented us from highlighting any heterogeneity in findings within the groups of Asian, black and Latin American people. Furthermore, we were unable to include Indigenous people in our analyses, who have faced disproportionately high rates of drug toxicity death, and yet have not been prioritised in the response to the crisis.50 Future studies should use ethno-racial identities that are more reflective of modern Canadian society. Third, we did not have access to population data by ethno-racial group, and therefore we were unable to estimate rates of opioid-involved death by ethno-racial group. Moreover, we did not have access to data on the sexual identities of people in our cohort, and therefore we cannot comment on circumstances surrounding opioid toxicity deaths among people with intersecting marginalised identities. Finally, we relied on prior healthcare encounters related to opioid use disorder and claims for opioid agonist treatment to identify people with an indication of diagnosed opioid use disorder. However, not everyone with opioid use disorder will seek diagnosis and treatment, and there may be variations in the recording of this diagnosis, both of which may particularly impact racialised people. Therefore, it is likely that we have not identified all people with opioid use disorder, and the data we present may be underestimated.
Conclusions and policy implications
In Ontario, circumstances surrounding opioid toxicity deaths differ substantially by ethno-racial group, with deaths among racialised people predominantly affecting younger males with a lower prevalence of opioid use disorder. Furthermore, relative to white people, deaths among racialised people in Ontario are more likely to arise from the use of non-pharmaceutical opioids such as fentanyl and its analogues, commonly involve cocaine, and less frequently involve attempts to administer naloxone. Notably, black and Asian people with opioid use disorder are considerably less likely to receive opioid agonist treatment compared with white people. To reduce drug toxicity deaths, there is a need for integration of black, brown and Indigenous people into the discourse surrounding the opioid overdose crisis, including the development of culturally informed policies and programmes that address the social drivers and impacts of the crisis, and are led by, tailored for and targeted to racialised people.
