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The government of Ontario recently announced plans to improve \"convenience and choice\" for consumers starting in early 2026, by expanding alcohol sales into 8500 new privately operated stores and decreasing the price of alcohol. Alcohol currently results in an estimated 17,000 deaths in Canada annually and creates a larger health system burden and overall cost to society than any other substance. The proposed changes represent the most substantial alcohol deregulation policy in Canada in decades, and a large body of Canadian and international research cautions that these changes may lead to increased alcohol consumption and associated harms. They propose instituting mitigation policies at the provincial and federal level -- including strengthening minimum pricing on alcohol, mandating warning labels on all alcoholic beverages, and increasing access to screening and treatment for alcohol use disorders -- in anticipation of potential harms and costs related to the policy change.

Alcohol use causes a large burden on the health of Canadians, and alcohol-related harms appear to be increasing in many high-income countries. We sought to analyze changes in emergency department visits attributable to alcohol use, by sex, age and neighbourhood income over time. All individuals aged 10 to 105 years living in Ontario, Canada, between 2003 and 2016 were included in this study. The primary outcome was age-standardized rates of emergency department visits attributable to alcohol use, defined using diagnostic codes from the Canadian Institute for Health Information Health Indicator “hospitalizations entirely caused by alcohol.” We compared rates of these visits using a retrospective population-level design. Among 15 121 639 individuals, there were 765 346 emergency department visits attributable to alcohol use over the study period. Between 2003 and 2016, the age-standardized rates of these visits increased more in women (86.5%) than in men (53.2%), and the increase in rates of emergency department visits attributable to alcohol use was 4.4 times greater than the increases in the rates of overall emergency department visits. Individuals aged 25–29 years experienced the largest change in the rate of emergency department visits attributable to alcohol use (175%). We found evidence of age-cohort effects, whereby the rate of emergency department visits attributable to alcohol use at age 19 years increased on average by 4.07% (95% confidence interval [CI] 3.71%–4.44%) per year for each cohort born between 1986 and 1999. Individuals in the lowest neighbourhood income quintile had 2.37 (95% CI 2.27–2.49) times the rate of emergency department visits attributable to alcohol use than those in the highest income quintile. This disparity increased slightly over the study period. Although men and lower-income individuals have the highest burden of emergency department visits attributable to alcohol use, the largest increases in visits have been in women and younger adults. Further research should focus on potential causes of these trends to provide guidance on how to reduce alcohol-related harms.

Five things to know about cannabis and psychosis are presented. The tetrahydrocannabinol (THC) content of cannabis has roughly quintupled in the past 2 decades, from around 4% in the 2000s to more than 20% in most legal dried cannabis in Canada by 2023. The lifetime occurrence of cannabis-induced psychosis symptoms is estimated to be 0.47% among people who use cannabis. A population-based retrospective cohort study of 9.8 million people in Ontario, Canada, found that people with an emergency department visit for cannabis use or cannabis-induced psychosis were at a 14.3-fold and 241.6-fold higher risk of developing a schizophrenia-spectrum disorder within 3 years than the general population, respectively. Ongoing cannabis use after first-episode psychosis is associated with a greater incidence of return of symptoms. Motivational interviewing can increase treatment engagement, while cognitive behavioral therapy can build skills to resist cravings and urges to use cannabis.

AbstractObjectiveTo analyse the association between survival from critical illness and suicide or self-harm after hospital discharge.DesignPopulation based cohort study using linked and validated provincial databases.SettingOntario, Canada between January 2009 and December 2017 (inclusive).ParticipantsConsecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period.Main outcome measuresThe primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models.Results423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56).ConclusionsSurvivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Hallucinogen use for both recreational and medical purposes is rapidly increasing globally, raising concerns about potential adverse effects. This study examined the risk of incident mania or bipolar disorder (BD) diagnosis associated with having an emergency department (ED) visit or hospitalization involving hallucinogens. We used a population-based cohort study of all individuals aged 14-65 years with no baseline history of BD and registered in the Ontario Health Insurance Plan in Ontario, Canada, between 2008-2022. Incident mania (primary outcome) and incident BD (secondary outcome) were compared between individuals with acute care (an ED visit or hospitalization) involving hallucinogens and the general population using overlap propensity score weighted Cox proportional hazard models. Models were adjusted for age, sex, rural residence, income quintile, recent documentation of homelessness, and healthcare encounters for mental health or other substance use in the past five years. The study included 9,311,844 individuals of which 7,285 (0.08%) had acute care involving hallucinogens. Within 3-years of acute care involving hallucinogens, 1.43% (n = 104) of individuals had an incident episode of mania requiring acute care compared to 0.06% (n = 41) of individuals in the age-sex matched general population, a 25-fold increase in risk. After weighting, acute care for hallucinogens was associated with a 6-fold (weighted Hazard Ratio [HR] 5.97, 95% CI 3.29, 10.82) increase in risk of incident mania relative to individuals without hallucinogen acute care who had otherwise similar demographic and mental health histories. Associated increases were also observed for risk of an incident diagnosis of BD (HR 3.75 95%CI 2.49, 5.65, absolute proportion 2.50% versus 0.11%). The main limitation of the study is the risk associated with the exposure examined in this study may not generalize to the majority of people who use hallucinogens who do not require acute care. These findings suggest the need for ongoing caution regarding hallucinogen use in individuals at risk of bipolar disorder. They also have potential implications for clinical practice, research, and public health policy, including substance regulation and targeted education for high-risk groups in the context of rising hallucinogen use.

ABSTRACTBackgroundAlthough clinical trials involving psychedelic-assisted psychotherapy have not observed short-term increases in the risk of death, limited data exist on mortality associated with hallucinogen use outside of controlled trial settings. We sought to determine whether people with an emergency department visit or hospital admission involving hallucinogen use were at increased risk of all-cause death compared with the general population and with people with acute care presentations involving other substances. MethodsWe conducted a retrospective cohort study using linked health administrative data on all people aged 15 years and older living in Ontario, Canada, from 2006 to 2022. We compared overall and cause-specific mortality between members of the general population and people with incident acute care (an emergency department visit or hospital admission) involving hallucinogens and other substances. ResultsWe included 11 415 713 people; 7953 (0.07%) had incident acute care involving hallucinogens. In a matched analysis with 77 101 people with a median follow-up of 7 (interquartile range 3–11) years, acute care involving hallucinogens was associated with a 2.6-fold (hazard ratio [HR] 2.57, 95% confidence interval [CI] 2.09–3.15) increased all-cause mortality within 5 years ( n = 482, absolute risk 6.1%) relative to the general population ( n = 460, absolute risk 0.6%). Analyses excluding people with comorbid mental or substance use disorders showed similar elevations in mortality risk for acute care involving hallucinogens relative to the general population (HR 3.25, 95% CI 2.27–4.63). People with acute care involving hallucinogens were at a significantly elevated risk of death by unintentional drug poisoning (HR 2.03, 95% CI 1.02–4.05), suicide (HR 5.23, 95% CI 1.38–19.74), respiratory disease (HR 2.46, 95% CI 1.18–5.11), and cancer (HR 2.88, 95% CI 1.61–5.14) relative to the general population. InterpretationRequiring hospital-based care for hallucinogen use was associated with increases in risk of death relative to the general population, particularly from suicide. These findings should be considered in clinical and policy decision-making, given the increasing use of hallucinogens and associated problematic use.

The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians and non-physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non-physicians, before and during the COVID-19 pandemic. We conducted a population-based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario's universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non-physicians. We compared the first 18 months of the COVID-19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID-19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in-person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre-pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non-physicians. During the first 18 months of the COVID-19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person-years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non-physicians (615.5 pre versus 675.9 during per 1,000 person-years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non-physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non-physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access. The first 18 months of the COVID-19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non-physicians. These findings suggest physicians may have had larger negative mental health during COVID-19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness.

Background Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors. Methods We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time. Results During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (−$59.80, 95% CIs: − 78.47, − 41.03) and non-essential sales (−$308.70, 95% CIs: − $326.60, − 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels. Conclusion During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms.

The impact of coronavirus disease 2019 (COVID-19) on unintentional pediatric poisonings is unclear. We examined changes in emergency department (ED) visits and hospitalizations for poisonings before and during the COVID-19 pandemic. We compared changes in cannabis vs non-cannabis poisoning events given the recent legalization of cannabis in October 2018 and cannabis edibles in January 2020. Interrupted time-series (ITS) analyses of changes in population-level ED visits and hospitalizations for poisonings in children aged 0–9 years in Ontario, Canada (annual population of 1.4 million children), over two time periods: pre-pandemic (January 2010–March 2020) and pandemic (April 2020–December 2021). Overall, there were 28,292 ED visits and 2641 hospitalizations for unintentional poisonings. During the pandemic, poisonings per 100,000 person-years decreased by 14.6% for ED visits (40.15 pre- vs. 34.29 during) and increased by 35.9% for hospitalizations (3.48 pre- vs. 4.73 during). ED visits dropped immediately (Incidence Rate Ratio [IRR], 0.76; 95% CI, 0.70–0.82) at the onset of the pandemic, followed by a gradual return to baseline (quarterly change, IRR 1.04, 95%CI 1.03–1.06), while hospitalizations had an immediate increase (IRR 1.34; 95% CI, 1.08–1.66) and no gradual change. The only increase in poisonings was for cannabis which had a 10.7-fold for ED visits (0.45 to 4.83 per 100,000 person-years) and a 12.1-fold increase for hospitalizations (0.16 to 1.91 per 100,000 person-years). Excluding cannabis, there was no overall increase in poisoning hospitalizations. The COVID-19 pandemic was not associated with increases in any type of unintentional pediatric poisonings, with the exception of cannabis poisonings. Increased cannabis poisonings may be explained by the legalization of non-medical cannabis edibles in Canada in January 2020. •Pediatric poisoning ED visits decreased by 14.6% in the COVID-19 pandemic.•Critically, the only increase in ED poisonings was a 10-fold increase from cannabis.•Pediatric poisoning hospitalizations increased by 35.9%.•Cannabis became the leading cause of pediatric hospitalization from poisonings.•Excluding cannabis there was no overall increase in hospitalization from poisoning.

ObjectivesTo characterize the distribution of vaping retailers and examine the association between neighbourhood income and vaping retailer availability in Ontario prior to and after regulatory changes to the vaping market in 2018.MethodsWe quantified vaping access by number of vaping retailers for 19,964 dissemination areas (DAs) in Ontario and percentage of schools near a vaping retailer. We used mixed-effects regression models to examine the associations between vaping access and neighbourhood income in 2018 and 2019.ResultsBetween 2016 and 2019, the number of vaping retailers in Ontario increased by 22.6% (5999 to 7355), despite a mild drop from 2016 to 2018. In 2019, 59.7% of urban neighbourhoods had one or more vaping retailers within 1000 m of their geographic centre, and 79.4% of elementary, 82.8% of secondary, and 84.2% of post-secondary schools had at least one within 1000 m. Neighbourhood income was associated with access to vaping retailers, with a greater number in low-income regions. In 2019, neighbourhoods in the lowest income quintile had over twice the number of vaping retailers per capita within 1000 m compared to the highest income quintile (adjusted incidence rate ratio 2.40; 95% CI 2.24–2.58). Increases over time in access to vaping retailers did not differ by geographic region, neighbourhood income quintile, or school type.ConclusionWe observed a substantial increase in access to vaping retailers in Ontario including proximity to elementary and secondary schools following the 2018 provincial marketing regulations and federal nicotine regulations. Access to vaping was greatest in low-income neighbourhoods and may contribute to established inequities in vaping-related adverse events.