The Story of the Opioid Epidemic

“We need […] all of the folks within an ecosystem to work together, to think through a systems lens and get outcomes for the entire system.”

INTRODUCTION

The opioid crisis is one of Canada’s most pressing public health issues. Between January 2016 and September 2024, nearly 51,000 apparent opioid toxicity deaths were reported across the country (Public Health Agency of Canada, 2025). Thousands more are living with a substance use disorder, and the services available to help fall woefully short. 

How did we allow this crisis to thrive? And what do we need to do now to help those living with an opioid addiction? In a special three-part series of the Public Health Insight Podcast, the team sits down with Dr. Jennifer Loeffler-Cobia, Director of Justice and Public Health Policy and Practice at the WestEd Justice and Prevention Research Centre. Together, they walk through the story of the opioid crisis in North America, and discuss tools and strategies decision makers can use to effectively address the issue. 

Today’s blog post will cover:

• Beginning of a Crisis: The Three Waves
• Current Situation: In The Midst of the Fourth Wave
• Where To Go From Here: Re-Framing, Systems Thinking and Political Buy-In

Beginning of a Crisis: The Three Waves

Experts typically describe the opioid crisis as having unfolded in three distinct waves. The first wave began in the 1990s with an increase in the prescription of opioid medications, particularly OxyContin. 

Prior to the 20th century, opioids had been used widely for centuries to treat all kinds of ailments – from battle wounds to the common cold (Loeffler-Cobia, 2023). As doctors came to understand the addictive properties of the substance, they began to limit its use to patients experiencing acute pain (i.e. short-term pain with a specific cause) from things like surgery, injury, cancer treatment, etc. (Congressional Budget Office, 2022).

As the average lifespan increased and more people lived longer with chronic pain (i.e. long-term pain that persists beyond normal recovery periods), experts began looking for new management solutions. This spurred a new wave of research into opioids in the late 20th century, and the results suggested the drugs were not as addictive as previously believed (Loeffler-Cobia, 2023). 

Pharmaceutical companies thus began producing new opioid-derived drugs for chronic pain management. OxyContin and similar drugs were widely marketed to doctors and patients as non-addictive, “safer” opioid medications suitable for long-term use (Sun, 2024). However, these claims proved quickly to be untrue. Misuse and overuse of prescription opioids became common as people developed a dependence on the substance, and a black market for opioid pills quickly grew (Congressional Budget Office, 2022). 

In response to this problem, new measures were put in place to limit the prescription and distribution of opioids. Decision makers implemented prescription drug monitoring programs (PDMPs) to allow doctors to keep track of patient opioid prescription history and assess patient risk of developing a substance use disorder (Centers for Disease Control and Prevention, 2024). Doctors were also properly educated on the risks of opioid use, and moved away from prescribing them for chronic pain. But while these new policies did lead to a drop in opioid prescriptions – resulting in fewer people being exposed to the drugs in the first place – they did not support those who had already developed a substance use disorder.

This laid the groundwork for the second wave of the crisis to unfold. Beginning in the 2010s, the second wave was characterized by a shift away from opioid pills and an increase in heroin use and overdoses. Heroin is an illicit semi-synthetic opioid made from opium poppies, and was widely present in the street supply (Congressional Budget Office, 2022). As people were cut off from their prescription opioids, many resorted to using heroin as a replacement.

Compared to prescription opioids, heroin use comes with a host of additional risks. For one, it is not a regulated substance, so users can never be sure of quality or safety. As well, because heroin is administered intravenously, the risk of developing blood-borne infections, such as hepatitis and HIV, is elevated. As more and more people became reliant on the street supply, these factors contributed to an increase in opioid-related hospitalizations and deaths.

The third wave of the opioid crisis was characterized by an increase in the use of synthetic opioids in the street supply in the mid-2010s, specifically fentanyl. Fentanyl is an extremely potent opioid substance. It is estimated to be between 20 to 40 times more potent than heroin and 100 times more potent than morphine, making it incredibly addictive and dangerous. In fact, just a few grains of fentanyl is enough to cause an overdose and possibly death (Health Canada, 2024). 

Since its introduction into the supply, fentanyl has become a main driver of opioid-related hospitalizations and deaths. There were 3.5 times more deaths involving fentanyl than non-fentanyl opioids in 2020 (Hatt, 2022), and in 2024 nearly 3 in 4 opioid toxicity deaths involved the substance (Public Health Agency of Canada, 2025).

Current Situation: In the Midst of the Fourth Wave

In the present day, hospitalizations and deaths from opioid toxicity remain high. In 2024, more than 7,100 deaths linked to opioid toxicity were reported in Canada – an average of 20 deaths per day. 

In the midst of this fourth wave, several new challenges have emerged. In addition to fentanyl, several new toxic substances are becoming increasingly present in the drug supply. Common additives (or “adulterants”) in the current Canadian supply include benzodiazepine – a nervous system depressant – and xylazine – a veterinary tranquilizer. The effects of these substances cannot be counteracted using Naloxone (a common medication used to temporarily reverse an opioid overdose), making them especially dangerous (Health Canada, 2024).

The COVID-19 pandemic has also caused complications. From 2020 to 2022, the rate of death due to apparent opioid toxicity increased by 91% across Canada (Canadian Centre on Substance Use and Addiction, 2022). The pandemic affected people who use substances in a variety of ways, including the loss of social support/safety measures due to physical distancing, loss or reduction of health services, and increased vulnerability to contracting the disease (Canadian Centre on Substance Use and Addiction, 2020). These factors have had a lasting impact in the post-pandemic period.

Stigma and stereotyping have always been a barrier to progress on the opioid crisis and continue to persist today. Individuals struggling with opioid addiction have long been perceived as “bad people” who are solely to blame for their situation. Harm reduction practices, such as safe injection sites and needle exchange programs, are also highly controversial, with many believing they enable individuals with substance use disorders to continue using. As a result of this stigma, advocates often have a hard time convincing decision makers and the public to dedicate extensive resources to helping people affected by the crisis. 

Where to Go From Here: Re-Framing, Systems Thinking, and Political Buy-In

It is clear that current efforts to mitigate the opioid crisis are barely scratching the surface. So what is it that needs to change, and how can governments and other experts work more effectively? Dr. Loeffler-Cobia had the following insight to share with the PHI team:

Re-Framing the Crisis

A foundational step, says Dr. Loeffler-Cobia, is to re-frame the perception of the opioid crisis. Messaging is an incredibly important tool for shaping the public’s understanding of an issue, which in turn impacts the types of solutions they are willing to accept. 

Historically, the opioid crisis has been framed as a criminal issue and/or a moral failing. People who use drugs are highly stigmatized and generally viewed unfavourably by members of the public. Under this conceptualization, the general public has been willing to accept restrictive and punitive policies to address the opioid crisis, such as reduced opioid prescribing, criminalization, and incarceration. 

Public health experts, on the other hand, understand the crisis as a social issue. They argue there are a multitude of factors that may drive a person to use opioids including income, education level, mental health, past trauma, etc. They advocate for substance use to be understood as a complex health disorder – much like other well-known chronic disorders like diabetes and heart disease. And just as we treat those ailments in a clinical setting, we also have tools available to treat substance use disorder. 

When we understand substance use as a complex social and public health issue, we are more inclined to advocate for supportive, evidence-based interventions focused on treatment and harm-reduction such as safe injection sites, counselling, housing support, etc. The way we conceptualize the issue is thus an important tool for swaying public opinion and generating support, and efforts to humanize people who use drugs must be prioritized.

Systems Thinking Approach

In her work with WestEd Justice, Dr. Loeffler-Cobia advocates for systems thinking to effectively address the opioid crisis. In a systems thinking approach, various sectors and/or organizations work collaboratively with one another to identify needs, brainstorm solutions, and coordinate actions to address a common problem (WestEd Justice and Prevention Research Center, 2023). This stands in contrast to a siloed approach, where the various sectors work independently.

The opioid crisis is a multi-layered issue that touches many different sectors including public health, health care, criminal justice, housing, and mental health, among others. Each of these sectors have their own set of outcomes they wish to achieve – for instance, the criminal justice system seeks to charge drug vendors and shut down toxic drug production to uphold public safety; while the healthcare system focuses on providing care to opioid users and reversing overdoses to keep them alive. Both outcomes are important pieces of the bigger puzzle, and the two sectors ought to work together to ensure effective cooperation, communication, and resource management to reach their goals.

Political Support

Finally, on a political level, Dr. Loeffler-Cobia stresses the importance of gaining buy-in from decision makers. While advocates may possess the expertise on the crisis, it is ultimately politicians who make the final decisions. To make a lasting difference, advocates need to build partnerships with these individuals.  

To get the issue on the agenda, she recommends seeking out a political figure to champion the issue. This person can act as a voice in government to advocate for the issue, and may even encourage others in their party to get on board. 

Conclusion/Key Takeaways

There is no silver bullet solution to the opioid crisis. The issue is multi-faceted, requiring cooperation across a wide array of sectors and stakeholders.

Dr. Loeffler-Cobia reminds us that there is a person with a story behind every statistic. People living with opioid addictions are just that: people. And despite their circumstances, they deserve the same level of compassion and empathy as anybody else. 

In today’s blog, we have discussed:

• How the modern-day opioid crisis came to be via three distinct waves;
• The current situation and prevailing issues; and
• Foundational steps to enacting change, including re-framing the issue, adopting a systems thinking approach, and gaining support at the political level. 

Written by: Maddie Burnett, BSc, MPH