PUBLICATION DATE: December 16, 2022
This publication may be reproduced for personal or internal use only without permission provided the source is fully acknowledged.
Suggested citation: Government of Manitoba, Department of Health, Performance and Oversight Division, Epidemiology and Surveillance. (2022). Take Home Naloxone Program and Substance Surveillance Report: December 2022.
We acknowledge our office is located on Treaty 1 Territory and that Manitoba is located on the Treaty Territories and ancestral lands of the Anishinaabeg, Anishininewuk, Dakota Oyate, Denesuline and Nehethowuk Nations.
We acknowledge Manitoba is located on the Homeland of the Red River Métis.
We acknowledge northern Manitoba includes lands that were and are the ancestral lands of the Inuit.
We respect the spirit and intent of Treaties and Treaty Making and remain committed to working in partnership with First Nations, Inuit and Métis people in the spirit of truth, reconciliation and collaboration.
We would also like to acknowledge the important efforts of staff members involved in the follow-up of overdose/ poisoning events in Manitoba, and the reporting of this information to the provincial substance harms surveillance system.
Substance overdose, toxicity, and poisoning has become a growing concern in Manitoba. Though this is not a new problem, it has worsened with the changes in potency in the unregulated and diverted pharmaceutical drug supply over the last few years.
The objective of this report is to provide program evaluation information on how the take home naloxone program operates in the community by analyzing the data provided to MB Health through the Overdose Response Form (MHSU-6836). This form is filled out in an anonymous and confidential manner, when a participant reports using a take home naloxone kit in a suspected opioid toxicity event. This form is an integral part of the Provincial substance use and harms surveillance system, and provides an insight into the experience of using take home naloxone kits during suspected opioid toxicity events that occur in community settings. Data are analyzed by age, setting, month, substance type, naloxone usage, and other actions taken to reverse the effect of the overdose event.
This is the first edition of this report, and includes data from all forms submitted to MB Health in the year 2021. Future versions will be released on a quarterly basis, and will be expanded to include data from the Public Health Information Monitoring System (PHIMS) which will provide data on all Take-Home Naloxone (THN) program kits being distributed within the Province.
For the current edition of this report, there is one data source:
The Overdose/Poisoning Response Form (MHSU-6836) is anonymous, confidential, and collected voluntarily from the participant. When a service recipient/ participant reports using a take home naloxone kit in an apparent opioid overdose/poisoning event, the distribution site staff member will ask if the participant is willing to provide anonymous information about the event.
Completion of this form is voluntary and refusal to provide information about the overdose/poisoning event will not affect participants’ access to services or THN kits. This form is not linked to personal health records or health information. Whether or not the client is willing to provide information about the event, the distribution site is expected to track the number of THN kits reported used, and report these numbers to the province using the take-home naloxone kit tracking reporting form.
Note, that these reports are generally a second hand account of someone who witnessed or was involved in an opioid toxicity response where take home naloxone kit was used. The information about the person who experienced the opioid toxicity cannot be verified.
Link to the form: https://www.gov.mb.ca/health/publichealth/surveillance/docs/mhsu_6836.pdf
Link to form instructions: https://www.gov.mb.ca/health/publichealth/surveillance/docs/mhsu_6836_ug.pdf
This report contains data from Overdose/Poisoning Response Forms submitted between January 01, 2021 and December 31, 2021. This is a small sample, and may not be representative of the whole Provincial picture, but can provide insight into suspected opioid toxicity events in which a take home naloxone kit was reported used by a community organization that submitted data to MB Health.
A substance related toxicity event is the ingestion or application of a substance in quantities much greater than is therapeutic or recommended. A toxicity event can lead to serious medical complications, including death. The severity of a substance related toxicity event depends on the substance, the quantity, and the physical and/or medical history of the person who experienced the event.
Each substance has a different effect, function, and purpose. Substances can be organized based on their chemical structure, effect, and drug scheduling. We classified the substances reported into the following categories:
Depressants are drugs that impair the functioning of the central nervous system. They can cause side-effects such as slurred speech, dizziness, and loss of coordination. In the cases of high doses or frequent use, they have the potential to lead to dependence and dangerous drug toxicity.
Stimulants:
Naloxone is an antidote to opioid toxicity. During an opioid toxicity event, naloxone can be injected into a muscle, vein, or under the skin, or sprayed into a nostril (nasal naloxone kits). Naloxone is only active in the body for 20-90 minutes and temporarily reverses the effects of opioid toxicity. Therefore, it may need to be used again, depending on the amount or type of opioid taken.
The Manitoba Take Home Naloxone program provides free take home naloxone kits (through registered distribution sites) to members of the public who are at risk for experiencing or witnessing opioid toxicity. A Manitoba take home naloxone kit includes 4 ampoules/doses of 0.4 mg/ml injectable naloxone, 4 Vanish Point® 3 ml syringes with 1 inch needle, 4 plastic ampoules breakers, one pair of non-latex gloves, 2 alcohol swabs, a breathing mask, and instructions for opioid toxicity response. Training is provided with kit distribution.
Link to the Manitoba THN Program: https://www.gov.mb.ca/health/publichealth/naloxone.html
Link to THN kit training manual: https://www.gov.mb.ca/health/publichealth/docs/training_manual_overdose.pdf
Overall, 122 suspected opioid toxicity events were identified by the Overdose/Poisoning Response forms in 2021. The majority of these forms were submitted by naloxone distribution sites within Winnipeg, with a small number being submitted by distribution sites in rural Manitoba.
The next two figures denote form submissions by month in 2021, grouped by each THN distribution site that submitted at least one form. The first figure shows this as a count and the second provides these counts as percentages. Overall the highest number of forms (22) were submitted in July.
WRHA Health Sexuality and Harm Reduction/ Street Connections has submitted forms continuously throughout 2021 except for September. The highest number of their monthly submissions (13) were reported in July. Youth Addiction Stabilization Unit, Parkwood Centre, Northway Pharmacy Broadway, Nine Circles Community Health Centre, and Carman Community Health Services have submitted forms in only one month in 2021.
Over half of the reported suspected opioid toxicity events (56.4%) were among the 19-30 age group in 2021, with 87.1% of all reported overdoses being aged 40 or less. This is consistent with other data sources and other jurisdictional reporting, showing that the substance harms epidemic affects the younger age groups disproportionately.
The following figure depicts the suspected opioid toxicity events reported by overdose setting. In 2021, a majority (68.1%) of suspected opioid toxicity events took place in private residences (private home/ apartment). Approximately 19.8% of suspected opioid toxicity events have taken place in outdoor public spaces such as street, alley, and park. This shows a mix between private and public settings for substance use, with private settings taking the majority of overdose cases. This can be problematic if the person is using drugs alone and unable to call for aid, which will often lead to more acute outcomes (i.e. hospitalization) and death [1].
Breaking the data down by age and setting, it is shown below that private residence settings have the highest proportion for all age groups. One core difference between age groups however, is that the street/ alley/ park (public) settings are more commonly occurring in the older age groups (i.e., 31-50), than in the younger. This appears to give, at first glance, the younger aged victims more risk for an acute overdose event, due to the increased likelihood of using alone within these private residences [1, 2]. However, we do not know the proportion of private setting events which consisted of the victim using alone or with another person.
This section breaks down the different substances that participants self-reported on the form. This may not be a true indication of what substances were actually taken, but what the participant thought they were taking or was aware of taking.
The first table lays out each individual choice a participant has when reporting the substance they believe the person was using. Note, that participants can select more than one substance, and so may be included in more than one row.
The second table displays the number of suspected opioid toxicity events by drug category. Note, that we have listed the drugs which were unable to identify by the user (Unknown) and not willing to say (Prefer not to say) as unknown substances. Additionally, the drug called “down” has also been included in the opioids category as it has historically been a mix of strong opioids such as heroin and fentanyl. Recently however, down has been found to contain benzodiazepines and stimulants to varying degrees alongside strong opioids.
Again, a participant may be included in more than one row depending on what they selected in the form as substances they were aware of taking.
The third table in this section breaks this down into distinct categories. The intention here is to show the percentage of participants that reported taking only opioids, only non-opioids, or opioids and another type of substance.
The table below displays the distribution of naloxone doses being used. For some suspected opioid toxicity events, the participant was unaware how many doses were used.
| Number of Doses Being Used | Number of Events | Number of Events as a Percentage (%) |
|---|---|---|
| 1 | 17 | 13.9 |
| 2 | 43 | 35.2 |
| 3 | 24 | 19.7 |
| 4 or more | 18 | 14.8 |
| Prefer not to say | 3 | 2.5 |
| Unknown | 17 | 13.9 |
The following table has listed the other actions that were taken to minimize the opioid effect in addition to administering naloxone. It is important to note that chest compressions and rescue breathing which have reported as the most frequent additional interventions according to the following table, are challenging skills that take time to master and are developed through CPR training. Training offered with take home naloxone kit distribution is focused primarily on safe and appropriate naloxone administration.
| Intervention | Number of Events | Number of Events as a Percentage (%) |
|---|---|---|
| Chest Compressions | 46 | 37.7 |
| Rescue Breathing | 41 | 33.6 |
| Other Intervention | 30 | 24.6 |
| Unknown Intervention | 14 | 11.5 |
| Prefer not to Say | 6 | 4.9 |
The table below shows the suspected opioid toxicity events based on whether the emergency medical services (EMS) were called (calling 911). This shows roughly a half and half split between calling and not calling EMS, with the slight majority not calling.
| Emergency Called | Number of Events | Events as a Percentage of Total Events (%) |
|---|---|---|
| No | 61 | 50.0 |
| Yes | 47 | 38.5 |
| Unknown | 12 | 9.8 |
| Prefer not to say | 2 | 1.6 |
Following a “no” response when asked if the participant had contacted EMS, the participant was then asked what the reason for not contacting EMS was. The most common reason for not calling EMS was that they were worried the police would come at 44.3% of all suspected opioid toxicity events where EMS was not called. This indicates participants are fearful of what might happen if the police were to show up during an overdose event, making them less likely to call EMS and increasing the probability that a person does not receive adequate care during a medical emergency.
Take home naloxone kit training includes introduction to the Good Samaritan Drug Overdose Act which has been implemented by the federal government to reduce the fear of police attending overdose/ toxicity events and encourage people to call 911 [3]. This act can protect people from charges for possession of a controlled substance under section 4(1) of the Controlled Drugs and Substance Act and breach of conditions regarding simple possession of controlled substances in pre-trial release, probation orders, conditional sentences, and parole. Despite training and communication of this act, there appears to be continued reluctance to involve EMS in opioid toxicity events.
Breaking this down by age, being - “worried police would come” is the most common reason for not calling EMS in all 19+ age groups. This percentage increases in the older age groups, with 80.0% of “no” reasons in the 41-50 age group reporting they were worried about the police. “Thought the person would get better on their own” was another commonly used reason, especially in the younger age groups.
The table below shows the distribution of the number of naloxone doses administered by whether the EMS were called or not. Number of events denotes the suspected opioid toxicity events for each response category by the number of naloxone doses administered. These counts include the people who called EMS, did not call EMS, did not mention whether they called EMS (unknown), and were not willing to say whether they called (prefer not to say).
This shows that there is a relationship between the number of naloxone doses administered and EMS being called, with higher number of doses corresponding to a higher likelihood that EMS would be called. This is understandable, as more doses being administered likely means the victim was at higher levels of distress. What is still surprising is that even when 4 or more doses were administered, in 38.9% of these events EMS still was not called.
| Number of Doses Being Used | Number of Events | Yes | No | Yes | No |
|---|---|---|---|---|---|
| 1 | 17 | 5 | 8 | 29.4 | 47.1 |
| 2 | 43 | 14 | 25 | 32.6 | 58.1 |
| 3 | 24 | 11 | 13 | 45.8 | 54.2 |
| 4 or more | 18 | 10 | 7 | 55.6 | 38.9 |
| Prefer not to say | 3 | 0 | 3 | 0.0 | 100.0 |
| Unknown | 17 | 7 | 5 | 41.2 | 29.4 |
| a Note: The number of events include all the overdosed cases, including the ones who did not know whether they called emergency services or not (unknown) and not willing to say (prefer not to say) |