Alberta's Fentanyl Crisis

"We're dealing with a large number of cases [and] it's through all the units of our office that the workload has increased and there is a stress and pressure there."
"The fentanyl [we] were seeing in the lab back then [2011] -- it was present in the bloodstream but it didn't kill them [elderly patients], it just happened to be in the background."
"Then all of a sudden, you get a 20-something-year-old in their basement who is dead -- who suddenly has a spike of fentanyl with no reason for it to be there."
"I just remember nights and nights of going through charts and tables and reading these stories: 20-something-year-old person found in a hotel, 30-something-year-old person found in a basement, 20-something-year-old person had a party the night before."
"So it was almost like an overload of story after story after story, and then checking them up against the list of toxicology results and trying to just see the pattern and trend."
Dr. Elizabeth Brooks-Lim, chief medical examiner, Alberta

"We started to measure the concentrations in those pills and they were significant. We were seeing fentanyl, we were seeing young people dead who were probably abusing it, but what we were not able to judge at that time was the scale of the problem."
Dr. Graham Jones, chief toxicologist, Alberta

"The fentanyl-related overdoses tend to be more related to illicit drug use and illegal products, whereas the non-fentanyl could be more related to prescription drugs that are being taken."
"What we've consistently seen in our reports is that young males, or young adult males, are dying [from fentanyl] at a higher rate than other age groups and genders."
"We're seeing a lot more EMS [emergency medical services] responses for overdoses in the more centralized neighbourhoods compared to the more suburban areas." 
"That's concerning to the ministry because we don't know why these people are not being seen by EMS -- if they're just using alone and so no one is there to call for an ambulance, or if they are hesitant to call for help in those areas."
Dr. Kristin Klein, deputy chief medical officer of health, Alberta

Still from video: First responders reacting to fentanyl overdose: Global News

In the province of Alberta, fentanyl-related deaths doubled each year, between 2011 and 2015. Dr. Brooks-Lim was newly invested as acting chief medical examiner by the summer of 2016, reporting to her new position only to discover a full-blown crisis. Frequent updates on the escalating number of opioid deaths were  being provided to Alberta Health by the staff at the Office of the Chief Medical Examiner. Quite an introduction to a harried and desperate situation for someone just entrusted with the office.

Dr. Brooks-Lim has a fuzzilyunclear memory of working late into the night hours attempting to discover the whys and wherefores of these runaway death statistics, exploring 'reams and reams' of data. Five years earlier the Office of the Chief Medical Examiner had an investigative load of between 1,900 to 2,000 cases of unexplained deaths annually. Since then the caseload has leaped forward representing between 2,500 to 2,600 of these drug-related morbidities, most of which are attributable to fentanyl.

Fentanyl, before 2011, would be detected in explicable ways when victims of car crashes or elderly patients showed up with traces of fentanyl in their blood. In the case of the former it was because the drug had been legally administered in an emergency to reduce pain associated with injuries sustained in the crashes; in the instance of the latter, it was because the elderly had been prescribed fentanyl patches when the pain of advanced cancers had to be managed.

And then, startlingly, the OCME's laboratory noticed an inexplicable rise in deaths where fentanyl in surprisingly high amounts was identified in the blood of those who had succumbed. That finding was soon linked with OCME investigators and police coming into possession of illegal and sizable amounts of pills appearing similar to 80 mg OxyContin tablets but which laboratory testing revealed to contain not oxycodone, but the more potent opioid fentanyl.

This graph breaks down the overdose deaths for 2016 by quarter. (Alberta Health)

Last May, in response to the growing epidemic of opioid deaths in the province, the Minister's Opioid Emergency Response Commission was created, adding another analyst to the OCME to correlate data on the opioid deaths. There is a consensus of opinion among health authorities in the province that this emergency is proving to be intractable and efforts are being extended to try to understand why people were using fentanyl and risking death, so interventions could take place.

The Alberta Health ministry has taken to mapping the appearances of death from opioids, noting a pattern in the ratio of deaths to calls made to EMS for overdose aid in various areas of major cities. More than a thousand Albertans died from fentanyl overdosing since 2011, with hundreds more dying from opioids besides fentanyl. The steps that authorities have attempted to date appear to have done little to curb the crisis, leading to frustration as the deaths spiral to an average of 120 per quarter.

According to Alberta addictions specialist Dr. Hakique Virani the province's opioid crisis is "completely out of hand. It's frustrating that the drug trade is more creative, nimble, and quick to respond to demand than public health is", he observed.