At least 22 people died from suspected opioid overdoses in the city in March, up from 18 in February, according to paramedic records published by Toronto Public Health.

This is the highest monthly total recorded since September 2017, which saw 27 deaths amid the city’s worst period on record for opioid-related overdoses.

Paramedics last month also reported 452 calls for non-fatal suspected opioid overdoses. That number, exactly 150 more cases than in February, is the most since Toronto Public Health first began reporting paramedics’ data in August 2017.

The spike in both fatal and non-fatal overdoses in March comes as activists and city officials warn more people may die following the province’s announcement last week that two Toronto supervised drug-consumption sites will lose their funding and legal status.

“I expect you will see deaths,” Dr. Eileen de Villa, Toronto’s medical officer of health, said at a Monday news conference at city hall. “I don’t think that’s hyperbole nor do I think that’s exaggeration. I think it’s calling the facts as they are.”

The paramedic count of suspected opioid overdoses is preliminary and subject to change, and therefore may underestimate the true number of overdoses in the city, according to Toronto Public Health’s Overdose Information System.

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That’s in part because not all opioid overdoses in the city result in a 911 call involving paramedics. Any patient who dies in hospital after first being transported alive by paramedics might also be recorded as a “non-fatal” overdose in the data.

A paramedic’s assessment of an opioid overdose may also differ from a hospital’s ultimate diagnosis, or the coroner’s call on cause of death.

According to separate data maintained by Public Health Ontario, Toronto saw 308 deaths and 1,694 emergency room visits due to opioid-related causes in 2017.

Public Health Ontario has not yet released its count of 2018 overdose deaths in the city.

The Overdose Information System’s preliminary findings reported 146 deaths from suspected opioid overdoses in 2018.

Toronto Public Health launched the Overdose Information System in August 2017 at a time when opioid-related deaths in the city were spiking to the highest levels the city has seen. Paramedics reported 24 deaths due to suspected opioid overdoses and 396 non-fatal calls that month.

The greatest density of overdose calls is in the city’s downtown core.

Toronto Public Health released its first report on a full year’s worth of paramedic data in November. It found in part that the city is best-equipped to prevent deaths from opioid overdoses downtown due to the prevalence of treatment services such as overdose prevention sites.

Overdose prevention sites, like the two facilities threatened with closure in Toronto, are meant as an emergency solution to a mounting crisis. Workers at the sites monitor for signs of infection or overdose and are trained to reverse an overdose in progress.

Ottawa has granted these sites the right to stay open on a temporary emergency basis, but they will have to come up with their own source of funding.

A third Toronto facility, the city-run safe-injection site The Works, is also in limbo as the province announced it is reviewing its legal status.

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Safe injection sites offer similar services as overdose prevention sites but are meant to be permanent. A lengthy application process must take place before the sites can open.

The Works, on Victoria St. near Yonge-Dundas Square, is the busiest such site in the province, recording over 40,000 visits since August 2017. Some 750 overdoses have been reversed at the site since opening.

A total of 15 safe-consumption sites were approved for continued operations after Minister of Health Christine Elliott announced a new program and set of criteria to judge the sites this past summer. Six are in Toronto.