by Danny Zanbilowicz
When and how did this become a crisis?
“There have always been deaths from drug overdoses, and one is too many,” says Dr. Charmaine Enns, a Medical Health Officer with Island Health. ”We normally experience four to five deaths a year from overdoses for all of the north island. The rate rose slightly in 2014, and again in 2015, but it skyrocketed last year and continues to increase this year, in spite of everything we are doing.”
According to statistics released by the BC Coroners Service, from January 1, 2016 through June 30, 2017 there were 48 overdose deaths in the North Island. Fentanyl was detected in 78% of these deaths. Compared with 2016, there are almost as many deaths to date in 2017 as there were last year. In 2017, an average of four people are dying in BC every day. In 2016, 978 in BC died of drug overdose- almost a thousand.
Enns explains that the crisis is driven by the introduction of fentanyl and its synthetic analogues.
Fentanyl is legal and was first prescribed for use for cancer pain, and worn in patches. Sarah Sullivan, Manager of AIDS Vancouver Island in Courtenay and Campbell River says “The challenge is that it is not illegal to manufacture the drugs in other countries. They are controlled here, but not other places. People can order them online from countries such as China, where most of the supply comes from. Because the drug is so concentrated, it can be shipped in small packages, under the size which Canada Post is allowed to open and inspect.”
Fentanyl was first cut into heroin, a fellow opioid, for two main reasons- to make the drug more addictive, and because it costs significantly less. Now fentanyl may be cut into virtually every illicit drug on the market – heroin, cocaine, crack, methamphetamine or ecstasy; and an overdose can occur whether its injected, inhaled, ingested, snorted or smoked.
So what is going on- why are so many people dying? The answer is not that dealers and sellers are trying to kill off their customers, but sloppiness when it comes to preparing the drug.
For it to be safe, when fentanyl is mixed in, it must be evenly distributed across the batch, but this takes some expertise. “There is no quality control in the illicit drug supply,” Enns says.
What’s worse, a customer can test a sample and it may be fine, while the next one, because of uneven preparation may contain a deadly dose of fentanyl. This is the problem with the illicit drug supply- every time you use, you are playing Russian roulette.
“People who have been using for decades are now not getting what they thought they were getting,” says Enns.
Teaching illicit drug manufacturers how to make better drugs would save lives, and while this does not seem a likely solution, some front-line advocates believe that we need a major overhaul of our policy towards drug use and legalization.
Dr. Enns says: “There needs to be societal discussions. The subject is highly stigmatized- there are so many biases. Are people “making a choice to die”? No. We think of it as legal/illegal, moral or immoral, right or wrong, instead of a chronic health problem. We need to reframe (the issues), and this will move us miles ahead. We need to have conversations with families to remove the stigma and deal with prejudice across the societal system. This is not just a health systems issue – the stigma is entrenched across all facets of our society. We need to overcome barriers, and this is everybody’s job. It is impossible to live in BC and not know someone impacted by this crisis.”
Enns continues “We need to take a “prevention to treatment approach. The best interventions for prevention- vulnerable youth need supportive adults in their lives. In Scandinavian countries youth are involved in groups of accountability, to prevent them experimenting with illicit drugs. The fact is, if illicit drugs were decriminalized there is no question that the rate of overdoses would plummet. Portugal decriminalized the use of drugs in 2001. This means that the drugs are still illegal but those who consume the drugs are not treated as criminals but rather as individuals with a medical condition. This model has significantly reduced drug use in the country and now rarely anyone dies of an overdose.”
Could we imagine such an approach in North America? Sarah Sullivan thinks so. She espouses a radical tolerance for people’s rights to intoxicate themselves as they wish:
“Many species use intoxicants as a form of pleasure. We live in a system where certain drugs are legal and the government makes money on them, despite the evidence that they are harmful. Other pleasurable drugs are illegal. If I want to go home every day and have a glass of wine, there is nothing wrong. If there was a safer supply of the drugs that people like or need, we wouldn’t have the fentanyl crisis. If anything will push drug policy it is people dying.”
Sarah Sullivan can imagine, instead of lonely overdose deaths: “Communities of families where people who use drugs are accepted, employed, make reasonable money, have food, recreation, and are a meaningful part of society.”
Crisis Disproportionately Affects Men
Of fentanyl-related overdose deaths, a startling 82% are men. The majority are men aged 30-59.
“All of us need to be aware- this is the canary in the coal mine in terms of men’s health,” says Enns. We need to be more aware of the challenges for boys and men. The health system, for example, is not always accessible or safe for many men. We should be outraged at the amount of deaths happening to men in the prime of their lives. It should get our attention- why not?”
Sarah Sullivan adds: “Men with chronic pain start using opioids. Society should talk- what do we expect of people, and at what cost? There is psychic pain- sending men and women to war with no follow-up services. These are men in their prime of life- its tragic, often dying alone in residences. These are people who are part of families- husbands, fathers, sons- real people that matter.”
In our resource-based communities, many men have acquired chronic ailments from a lifetime of working in dangerous industries. Many require help coping with pain.
“Canada has the second highest opioid prescription rate in the world, after the States,” says Enns. “As a result, there has been lots of pressure on physicians to stop prescribing.”
Coping with chronic pain while being cut off from prescribed medications is what drives some otherwise law-abiding people to the illicit drug market.
Sullivan says- “This in spite of the evidence that opioid use for chronic pain is not that useful. But other methods such as acupuncture and massage can be too expensive. Even someone with a medical marijuana prescription has to pay for it- costing some as much as $1,000/month. The challenge is how to manage chronic pain- physical, depression, PTSD, trauma. How do people manage mental health? It is a long-term journey.”
In the meantime, health professionals are scrambling to come up with ways to reduce overdose deaths.
Overdose prevention sites are a big part of the solution. There is one in the Comox Valley located at AIDS Vancouver Island, open from 9-11, 12-3 Mon to Thursday and 11-2 Friday, Saturdays, Sundays and statutory holidays (250-338-7400).
The statistics around these facilities are remarkable. Eight sites opened through Island Health between December 2016 and June 2017. During this time there were 26,600 visits by 970 different people. Of the three hundred and ten overdoses that occurred, zero people died.
Sullivan says- “People can bring their drugs, use them, and if they overdose, someone is here to help, with training on naloxone kits.”
Opioids are depressants. An overdose occurs when the body is so relaxed that it forgets to breathe, or the heart slows down so much it stops beating. To save a person’s life, it is necessary to keep the breathing going.
Naloxone is “the only known and proven antidote to opioid overdose”. Naloxone pushes opioids off the nervous system’s receptors. This means that the desired drug effect will stop, and the user will be tempted to reuse. The effect wears away after twenty minutes or so, and users need to be patient to wait that long.
Users, caregivers, family members- anyone can come in to AIDS Vancouver Island, and after quick training, get a kit. Other sites which have the kits are Mental Health and Substance Abuse, Public Health, the Nursing Centre, hospital emergency, and Careavan. You can purchase one in a first aid kit sold at London Drugs for $50.
If you are a user-
-Know your dealer, know your source.
-Don’t use alone. Go to an overdose prevention site, or a safe place where you can use testers and people will check on you.
-If you are going to use, tell someone in your house, or call a friend and ask them to “check on me in ten minutes”.
-Use small amounts.
For friends, relatives and caregivers-
-Be trained on naloxone. Learn to recognize signs of overdose, and what to do: Call 911, start rescue breathing, continuing to maintain a supply of oxygen.
– check for a pulse, if there is not a pulse, do chest compressions. All of the community should be trained in first aid and CPR.
-Naloxone only lasts twenty minutes. It is important to go to emergency.
“What does a person with substance use disorder look like? The answer is- Look in the mirror.”
“The opposite of addiction is not abstinence, it is connection.”
Sarah Sullivan, and many others