655 West 12th Avenue

Vancouver, BC V5Z 4R4

Tel: 604-707-2500
Fax: 604-707-2441
www.bccdc.ca

BC DOAP Opioid Overdose Response Strategy (DOORS)

Background
Since2010,accidentalillicitdrugoverdosedeathshavecontinuedtoincreaseattheregional,provincialand
nationallevels.In2015,therewere465deathsapparentillicitdrugoverdosesinBC,a27%increasefrom366
deathsin2014andthehighestnumberofillicitdrugoverdosedeaths(IDD)since1998.iAlthoughmostIDDare
duetotheconsumptionofmultiplesubstances,preliminarydatafromtheBCCoronersServiceshowthatthe
proportionofIDDwherefentanylisdetected(aloneorincombinationwithotherdrugs)hasincreasedfrom
lessthan5%in2012toapproximately30%in2015.

TheannualmortalityrateduetoillicitdrugoverdoseinBChasrisenfrom4.7per100,000in2010to9.9per
100,000in2015.This100%increaseinthemortalityrateistroubling,giventheincreasingexpansionofaccess
toharmreductionservicesincludingoverdosepreventiontrainingandtakehomenaloxone.Incomparison,the
motorvehiclefatalityrateinBCin2012was6.2per100,000,therateofdeathsduetoHIVdiseaseinBCfrom
19962011was3.03per100,000,andtherateofaccidentaldeathsrelatedtoprescriptionopioidsinBCfrom
20052010was1.1per100,000.ii,iii

Death,severebraindamageandotherharmsduetooxygendeprivationduringanopioidoverdosehavebeen
showntobereducedthroughoverdoseeducation,supervisedconsumptionfacilities,ivandcommunitybased
naloxone1programs.v,viNaloxoneprogramshavebeenoperationalintheUSandEuropesincethelate1990s;
Canadasfirstprogrambeganin2005andtheBritishColumbiaTakeHomeNaloxoneprogramstartedin2012.
Key Immediate Recommendations for Action
Inresponsetothispublichealthcrisis,theBCDrugOverdoseandAlertPartnership(DOAP)membershave
identifiedanumberofkeyactionsthatmunicipal,provincialandfederalagenciescantaketohelpaddressthis
crisis:

1. IncreaseAccesstoNaloxone,anOpioidOverdoseAntidote,ThroughChangesinPractice

HealthauthoritiesshouldexpandtheBCTakeHomeNaloxone(THN)programsitesforatriskgroups
andthegeneralpublic:
o Incommunityhealthcentres,FirstNationshealthcentresandcommunitybasedagencies
o Inacutecaresettingsincludingemergencydepartments(EDs)(currently8EDsitesinBC2)
o Insubstanceusewithdrawalmanagementandtreatmentfacilities(includingOpioid
SubstitutionTreatmentclinics)
ProvincialandfederalcorrectionalfacilitiesshouldexpandaccesstoTHNprogramsonrelease
(currentlyapilotin2provincialinstitutionsinBC)
Provideaccesstonaloxonefornonmedicalstaffworkingincommunitysettingswhereoverdoses
occur(e.g.inshelters,temporaryhousing,dropincentres,etc.)
Healthcareprofessionalscollegesandassociationsshouldencouragephysicians,nursepractitioners
andnursestoprescribeand/ordispensenaloxoneincludingasacoprescriptiontopeoplewhoare
receivingopioidsandmaybeatriskforanoverdose

1
2

Naloxoneisanopioidantagonistwhichcanquicklyrestoresbreathingduringanopioidoverdose
EnrolledinBCTakeHomeNaloxoneprogramasofFebruary3,2015

2. IncreaseAccesstoNaloxoneThroughChangesinPolicy

HealthCanadashouldchangenaloxonetoanonprescriptionmedicationtoincreaseaccessto
naloxoneforthepublic,familyandfriendsofpeopleatriskofoverdoseandnonmedicalstaffworking
incommunitysettingswhereoverdosesoccur
CollegeofPharmacistsofBCandtheBCgovernmentshouldactquicklytochangedrugscheduling,to
providetheleastbarrierstoaccessnaloxonewhileensuringproperconsumereducation,whenthere
arechangesinfederalschedulingorchangesinavailableformulations
BCMinistryofHealthshouldexpediteprovidingcoveragefornaloxoneunderBCsPharmaCare
MunicipalfiredepartmentsshouldsignconsentagreementswithBCEmergencyHealthServicesto
allowtheirfirefighterstoreceivetrainingandapprovaltoadministernaloxonewhenrespondingtoan
overdoserelatedcall
Lawenforcementagenciesshouldreviewcurrentpoliciestoensurethebestandmostrapidmedical
responsetoanopioidoverdose.
Encouragepharmaceuticalmanufacturerstosubmitapplicationsfortheuseofintranasal(IN)naloxone
toHealthCanada(INadministrationismoreacceptabletoresponderswhodonotinjectdrugsandis
usedbymanyUSlawenforcementagencies)
HealthCanadashouldexpeditetheapprovalprocessforanynaloxonerelatedapplications

3. ImproveOverdosePreventionEducation,TrainingandServices
Healthcareandalliedhealthprofessionalsaswellasprovincialandregionalorganizationswithmandates
topromotepublichealthandsafetyshouldworktogetherto:
Providetrainingforstafftohavetraumainformed3discussionswithindividualswithknowncurrentor
recentsubstanceuseproblemsabouthowtoprevent,recognizeandrespondtooverdoses
Encouragehealthcareandsocialserviceproviderstoworkfromatraumainformedviilensto
strengthenclientproviderrelationshipandfosteropendialoguesaroundsubstanceuse
Increasephysicianawarenessofbestpracticesforopioidprescribingandencouragephysiciansto
carefullyreviewpatientsmedicalandmedicationhistoriesandconsiderrelationshipwiththepatient
whenprescribingopioids.viiiForexample:
o Opioidnavepatients(i.e.whohavenotbeenprescribedopioidsbefore)shouldbeprescribed
alowerdoseorashortcourseofopioids
o Avoidcoprescribingopioidswithbenzodiazepinesorothersedatingmedications
o Patientsreceivingcontinuous/ongoingprescriptionsofopioidsshouldnothavetheir
prescriptionssuddenlystoppedorhavetheirdoseofprescriptionopioidsabruptlyreducedas
thismayresultinpatientsmanagingwithdrawalandpainsymptomsthroughillicitmeans.
Suspicionsofdivertedmedicationsoraddictionshouldbeconfirmedthroughacandid
conversationwiththepatient,randompillcounts/urinedrugtestinganddaily
dispensing/witnessedingestion.Optionsforwithdrawalmanagementandopioidsubstitution
treatmentshouldbediscussedwiththepatient.

Traumaisdefinedasexperiencesthatoverwhelmanindividualscapacitytocope.Traumainformedservicesworkat
theclient,staff,agency,andsystemlevelsfromthecoreprinciplesof:traumaawareness;safety;trustworthiness;choice
andcollaboration;andbuildingofskillsandstrengths.AdditionaldetailscanbefoundintheTraumaInformedPractice
GuideendorsedbytheBCMinistryofHealthandtheBCMentalHealthSubstanceUseServices.

EstablishaprofessionalpracticestandardrequiringtheprescribertoreviewPharmaNetbefore
prescribingopioids(orbenzodiazepinesandstimulant)medications
Inform/trainstaffonoverdoseprevention,recognitionandresponsestrategies
Providetrainingtolaypersons,patientsandtheirsocialnetworkthatistraumainformedandteaches
themhowtorecognizeandrespondtooverdoses
Raiseawarenessaboutoverdosesymptomsandresponseindifferentaffectedpopulationsbyplacing
relevantmessagesin:
o Areaswithhighvisibility(publictransitvehicles&shelters)
o Areaswherepeoplearelikelytousedrugs(publicwashrooms,clubs,etc.)
o Targetedoutreachtoatriskgroups
Provideevidenceinformed,factbasededucationtoyoungeradultsaboutoverdoseprevention,
recognitionandresponse(includingcalling911immediately)throughschoolsandpostsecondary
institutions
Includeoverdoseprevention,recognitionandresponsetrainingaspartofstandardfirstaidtraining
RequireBCHousingandallHealthAuthoritieswhocontractwithsupportivehousingnonprofitsto
haveanopioidoverdosepolicyincluding,butnotlimitedtonaloxone.
ExpandaccesstosupervisedconsumptionservicesinregionsofBCwhereoverdosedeathsareapublic
healthconcerniv
Workwiththefederalgovernmenttofacilitateapprovalsfornewsupervisedconsumptionservicesin
BC
Expandaccesstoevidencebasedwithdrawalmanagementandsubstanceusesupportservices,
includingopioidsubstitutiontherapywhichreducesopioidoverdoseriskbyalmost90%ix

4. EnhanceSurveillanceandUtilizationofOverdoseData

Provincialandregionalorganizationswithmandatestopromotepublichealthandsafetyshouldtake
leadershipandprovideresourcesto:
Increasethetimelycollection,analysis,anddisseminationofdataondrugoverdoseeventsin
collaborationwithregionalandprovincialpartners
Improvedatasharingbetweenlawenforcement,publichealth,researchers,coronersservice,drug
analysisandtoxicologylabstoimproveresponseplansandearlywarningtoreduceharms
Improvetheformatofsurveillanceandalertdatadisseminatedtothepartners
Reviewtheevidenceformakingoverdosesareportableconditiontoallowfollowupbypublichealth
agenciesandimprovethequalityofdatacollected
Supportincreasedcommunicationaboutunexpected/unusualdrugrelatedeventswithinandbetween
governmentagenciesandwiththegeneralpublic
Conductareviewofoverdosedeathstoinformrecommendationstopreventandreduceharms
Developsystemforcommunitylevelreportingofunexpected/unusualdrugrelatedeventsasanearly
warningsysteme.g.developinganonlinetool
Improveaccesstodrugchecking(testing)capacityincommunitiestoincreaseaccuracyofrealtime
surveillanceasissuesarise

AboutUs:
TheBCDrugOverdoseandAlertPartnership(DOAP)isamultisectoralcommitteethatwasestablishedto
preventandreducetheharmsassociatedwithsubstanceuse.Thegroupidentifiesanddisseminatestimely
informationaboutharmsrelatedtosubstanceuseincludingoverdose,adversereactionstocontaminated
products,andotheremergingissues.DOAPischairedbytheHarmReductionLeadattheBCCentreforDisease
Control.Memberagenciesinclude:

ProvincialHealthServiceAuthorityagencies:
o BCCentreforDiseaseControl
o BCEmergencyHealthServices
o BCDrugandPoisonInformationCentre
o BCProvincialToxicologyCentre
BCCentreforExcellenceHIV/AIDSUrbanHealth
ResearchInstitute
BCCoronersService
BCRegionalHealthAuthorities
o FraserHealth
o InteriorHealth

o NorthernHealth
o VancouverCoastalHealth
o IslandHealth
BCMinistryofHealth
CentreforAddictionsResearchofBC,Universityof
Victoria
FirstNationsHealthAuthority
HealthCanadaDrugAnalysisService
VariouslawenforcementagenciesinBC
VancouverAreaNetworkofDrugUsers

WeacknowledgeandthanktheCollegeofPhysiciansandSurgeonsofBCandtheCollegeofPharmacistsofBC
fortheircollaborationindevelopingtheserecommendations.

References
i

BCCoronersService.IllicitDrugOverdoseDeathsinBC:20062015*.AccessedJanuary12,2015,from:
http://www.pssg.gov.bc.ca/coroners/reports/docs/statsillicitdrugdeaths.pdf
ii
CanadianCouncilofMotorTransportAdministrators.CanadianMotorVehicleTrafficCollisionStatistics2012.AccessedFeb3,2016,
from:https://www.tc.gc.ca/media/documents/roadsafety/cmvtcs2012_eng.pdf
iii
TannerZ,MatsukuraM,IvkovV,AmlaniA,BuxtonJA.BritishColumbiaDrugOverdoseandAlertPartnershipreport.BCDrugUse
Epidemiology(September2014)BCCDC.
iv

Marshall,B,Milloy,MJ,Wood,E,Montaner,J,andKerr,T.2011.Reductioninoverdosemortalityaftertheopeningof
NorthAmericasfirstmedicallysupervisedsaferinjectingfacility:aretrospectivepopulationbasedstudy.Lancet,377:1429
37
v
WorldHealthOrganization.2014.Communitymanagementofopioidoverdose.AccessedDecember11,2015,from:
http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/
vi
EuropeanMonitoringCentreforDrugs&DrugAddiction.2015.Preventingfataloverdoses:asystematicreviewofthe
effectivenessoftakehomenaloxone.AccessedDecember11,2015,from:
http://towardtheheart.com/assets/naloxone/emcddanaloxonejan2015_152.pdf
vii
Arthur,E,Seymour,A,Dartnall,M,Beltgens,P,Poole,N,Smylie,D,North,N,andSchmidt,R.2013.TraumaInformed
PracticeGuide.Accessed,December12,2015,from:http://bccewh.bc.ca/wpcontent/uploads/2012/05/2013_TIP
Guide.pdf
viii
PrescriptionReviewPanelPrescribingPrinciplesforChronicNonCancerPain.2015.CollegeofPhysiciansandSurgeonsof
BC.RetrievedDec21,2015,from:https://www.cpsbc.ca/files/pdf/PRCPrescribingPrinciples.pdf
ix
WorldHealthOrganizationUnitedNationsOfficeofDrugsandCrime.2013.Opioidoverdose:preventingandreducing
opioidoverdosemortality.Accessed,February5,2016,from:https://www.unodc.org/docs/treatment/overdose.pdf