Background: Ontario continues to face a substantial burden of harms related to substance use, driven by a highly toxic and unpredictable unregulated drug supply. Importantly, these harms vary significantly across the population, with emerging evidence highlighting important differences by occupational and employment conditions. However, little is known about how these harms have evolved since the COVID-19 pandemic, or how they vary across a broad range of occupational groups.

Objective: We sought to assess the circumstances surrounding opioid toxicity deaths across occupational groups to identify sectors where individuals may be experiencing disproportionately high rates of harm.

Methods: We conducted a descriptive cross-sectional study of trends and circumstances surrounding opioid toxicity deaths across individuals in multiple employment sectors in Ontario, Canada between January 1, 2018 and December 31, 2024. We captured all people who died of an opioid-related toxicity during the study period. An opioid toxicity death was defined as an acute toxicity death resulting from the direct contribution of consumed substance(s), where one or more of the substances was an opioid, regardless of how the opioid was obtained.

Results: Our findings demonstrate that opioid toxicity death rates vary across occupational sectors in Ontario, with the highest burden observed among workers in Construction & Trades and Natural Resources & Agriculture. Across all sectors, deaths commonly involved multiple substances and frequently occurred in private residences when individuals were alone. Over one-third of decedents were unemployed at the time of death, suggesting that workforce detachment may represent a period of elevated risk of substance-related harm.

Conclusion: Our findings demonstrate that opioid toxicity death rates vary across occupational sectors in Ontario, with the highest burden observed among workers in Construction & Trades and Natural Resources & Agriculture. The findings in this report highlight the continued need to address underlying structural factors that increase the risk of experiencing substance-related harm, including housing instability, income insecurity, and insufficient access to pain management, mental health care, and treatment. Strategies to improve the standard of care following an initial opioid prescription need to be implemented to reduce longer term harms and mitigate the risk of developing an opioid use disorder.