To Reduce Drug Overdose and Public Drug Use, Close Supervised Injection Sites

Bill 103 bars supervised drug use sites from operating within 150 metres of a school or daycare.  The bill will require two of these sites to move, including the Maison Benoît-Labre in Montreal. CBC

 

"Within 50 metres of Maison Benoit Labre, emergency calls were up 1,967 percent [from six calls to 124] after the facility opened. Within 250 metres of the centre, mischief calls were up 800 percent [and there was] a 93 percent increase, or near doubling, in crimes against people."

"Even overdose incidents were up 300 percent. Giving the lie to the claims from Maison Benoit Labre that they went to where the need was already existing and are preventing overdoses in the area."

Michael MacKenzie, professor of social work and pediatrics, McGill University, Canad Research Chair in child well-being 

 

"Remarkably, the fact that overdose rates in Toronto have gone down, not up, since four of the city's drug-use sites closed at the end of March was completely absent from a recent story in the Toronto Star about a  'staggering increase' in overdoses at ten of the city's drop-in centres since those closings."

"Arguing that consumption sites are reducing overdoses and public drug use while neglecting to mention that they are also facilitating it on a large scale is a misleading representation of the facts to those who live, work and raise children near these facilities." 

Derek Finkle, National Post 

Maison Benoît-Labre, a supervised drug inhalation site, in Saint-Henri on April 13, 2024. (Gareth Madoc-Jones, CityNews)

 

Last summer, Victor-Rousselot Park in Montreal was at the centre of the national debate over supervised injection sites. Maison Benoit Labre, a facility including drug consumption services along with a drop-in centre for homeless people had opened mere metres from the park. This is a park that serves as a playground for an elementary school located nearby where students at recess and lunch breaks view it as their outdoor recreational centre.

 

It took just weeks for the newly-located facility to attract new drug activity and with that, assaults and public sex acts. The extent to which was sufficiently intimidating and alarmingly dangerous that police escorts were required to enable the children to access the park in safety. Then in May of 2024 the Quebec government tabled legislation to prevent drug-consumption sites from opening within 150 metres of schools and daycares; a similar set of laws had been passed in law in Ontario the year before. 

 

What Quebec did to prepare for the legislation was to consult with the public, as stakeholders who should have a say in the proceedings. One resident of the impacted St.Henri neighbourhood who spoke before Social Services Minister Lionel Carmant, was area resident Professor Michael MacKenzie of McGill University. Professor MacKenzie introduced the committee in his presentation to a 2021 systematic review of injection site literature which found a mere 22 studies "that examined actual outcomes".

 

Social Planning Toronto

 

"Within the program evaluation field, it is notable that 22 studies does not represent a deep evidence base". Just one site -- Vancouver's Insite -- took up 15 of those 22 studies with another three of a site in Australia. "In other words, 19 of the 22 studies (86 percent) represented just two sites, neither of which were located near schools and daycares". Insite "was in deep and protracted community crisis before the centre was implemented", explaining why "any intervention in a neighbourhood in the throes of real crisis was likely to show some positive short-term change". 

 

As for Toronto, overdoses dropped noticeably in April once half of the city's drug-use sites were ordered closed by the province. Toronto Paramedic Services reported that fatal and non-fatal overdoses were about 50 percent lower than what was reported in 2024. There were more people using outside the site than within it, particularly in warmer months, admitted the former chief executive of the closed South Riverdale drug-consumption site in east-end Toronto. Evidently about "400 to 500 sterile crack kits a day" were distributed against expectations that users would opt for supervision.

 

"More people are choosing to use outside", as the site has three booths for supervision which can "sometimes lead to longer wait times", according to the manager of the South Riverdale drug-consumption site in Toronto. As well, at the Toronto Kensington safe-consumption site, visits for drug equipment for use off-site vastly outnumbered the number of visits for supervised consumption; only 64 of 413 visits were for safe consumption in July of 2024.  

 

Staff at the site noted: "We are still seeing clients coming in for supplies rather than using the site. Many of those visits were for supplies." Their argument remains that consumption sites reduce overdoses and public drug use -- somehow overlooking any mention that drug use is being facilitated on a large scale -- a misrepresentation of facts familiar to those who live, work and raise children close to these facilities. 

 

A board showing drug checking information is displayed in the consumption room at the Parkdale Queen West Community Health Centre in Toronto days before the site transitioned into a homelessness and addiction recovery hub. (Chris Young/The Canadian Press)

Canada's Shortage of Child-Centric Pharmaceuticals

"As a clinical pharmacologist and someone who is married to a pediatrician, we had a difficult time trying to figure out how to divide adult doses."

"And I figured that if we were having a hard time doing this, and my colleagues with young kids were having a hard time doing this, I can only imagine the impact on the greater Canadian population."

"We may be missing some of the possible harms, because we only know about the cases where people call."

Dr. Jonathan Zipursky, clinical pharmacologist, Sunnybrook Health Sciences Centre, Toronto

"I think it would be very fair to say that if  you talk to the other medical directors of the poison centres in British Columbia, Quebec and Halifax, that they would anecdotally say the same thing -- that they also received a change in calls."

"I think that it really highlights for  us is in some cases how reactive the system is as opposed to how proactive it is."

"Everyone, including health-care professionals and government as well as pharmaceutical companies, we really do need to continue to work together and we need to have even earlier warnings ... so that the right authorities can take action."

Dr. Mark Yarema, medical director, Alberta Health Services' Poison and Drug Information Service

"You can call this the canary in the coal mine. It just speaks to how precarious our supply chain is in Canada. Children are at greater risk in general [particularly young children who require liquid formations they can swallow and who make up a very small market compared to adults and older kids who can take tablets]."

Dr. Stephen Freedman, pediatrician

 

Canada last year saw an alarming and acute unavailability of children's painkillers from pharmacy shelves. A new study verifies what every parent already knew, the shortage of Tylenol and Advil frightened parents and it wasn't unusual for parents under frantic duress to reduce the pain their children were suffering to travel to the U.S. where there was no shortage, to buy up enough painkillers to share with their friends and family members. 

 

Between August and December of 2022 there was a sudden surge of viral illness and that was the time when supplies of children's pain and fever medication dropped precipitously.

Pharmacy shelves bare of these basic over-the-counter necessities to treat children, greeted parents. Which left them with another option that turned out to be fairly troublesome; either to hope they could accurately translate the dose their children usually took by cutting up adult tablets to approximate the formulation and dosage required, or simply to throw up their hands in desperate resignation and decide to forego painkillers completely.

A new study published in the New England Journal of Medicine of which Dr. Zipursky was the lead author, concluded that calls to the Ontario Poison Centre for accidental painkiller overdoses in children more than doubled throughout the shortage. Dr. Zipursky and his co-authors decided they would study Poison Centre data through this period motivated by the reality that they too were parents of children who were affected by the shortage and the potential for well-meaning solutions that sometimes led to overdoses and trips to hospital emergency rooms.

The research team included doctors and scientists from Sinai Health, Sick Children's Hospital in Toronto, Public Health Ontario and others, collected over five years of data from the Ontario Poison Centre servicing 15.6 million people across Ontario, Manitoba and Nunavut, representing over 40 percent of the Canadian population.  Calls to the Poison Centre for acetaminophen and ibuprofen dosing errors in children during the 2022 shortage were compared to the 4.5 years previously and two months immediatly after.

Of the total calls, close to 80 percent involved children aged five or younger. The centre received a median of 44 calls monthly before the shortage of children's painkiller. That number more than doubled during the shortage, to 107 calls monthly; while calls about children in duress for all other reasons remained static. Adjusting for the very high levels of viruses in circulation at the time and the season, the number of calls was significantly higher than what might be expected, it was found.

The researchers assessed severity by analyzing how many children affected by dosing errors were referred to hospital, finding the proportion of calls stayed the same compared to the pre-shortage period. The data did not reflect a large increase in hospitalizations, pointing to the importance of Canada's five poison centres and the role they play through counselling caregivers and health-care providers. Dr. Yarema of Alberta Health Services pointed out that although the study covered mostly Ontario "this truly was a national issue".

While the shortage of children's painkillers was stressful and difficult for children and caregivers alike, pointed out pediatrician Stephen Freedman, it was less concerning than was the shortage of antibiotics immediately following the painkiller shortage. Amoxicillin, a first line of defence for bacterial infections in kids' shortage was particularly disturbing in its unavailability.

"Parents were using adult medications anyways to treat their children’s pain and fever. I do think it was the right call. Unfortunately, the issue with the guidance is imperfect because some parents and families don’t understand English or French. Some parents and families may still make mistakes with the cutting up of the medications."

"Canada is, by all accounts a small drug market, but it sources a lot of its medications from abroad. Perhaps this sheds light on the importance of producing some medications here and not only producing medications at home but also building in systems where we can increase production during times of need."

Dr. Jonathan Zipursky

There are alternatives to provide relief for kids with colds and flus, be it compounded medication from a pharmacist or fractional dosing. (George Rudy/Shutterstock)

Canada's Hard Drugs Problem

"The Drugs Store will provide customers with reliable access to safe, tested drugs, harm reduction supplies such as unused sterile needles, pipes, etc., and educational information."

Basically, allowing medical storefront access has been the main goal all along."

"I would risk my freedom all over again and lose everything, give up everything to change the law so that people could get help medicinally."

Jerry Martin, "king of compassion", Vancouver, British Columbia

Tents remain on East Hastings in Vancouver's Downtown Eastside a week after city staff began the process of removing them, citing a fire department order that the structures constitute an extreme fire safety hazard. (CBC News)

Personal-use quantities of heroin, fentanyl, methamphetamine, cocaine and MDMA is set to be provincially decriminalized in British Columbia at the end of this month. Beginning on January 31, possession of fewer than 2.5 grams of any of these drugs will no longer be classed as illegal.

 

Although this verges on Federal territory since criminal status of drugs is a federal responsibility, British Columbia was successful in obtaining a two-year "time-limited exception" to the Controlled Drugs and Substances Act. The emergency measure is purposed to "reduce the barriers and stigma" attached to drug addiction in hopes of achieving a reduction in the province's huge rates of fatalities due to overdose.

 

Even so, while personal-use possession of drugs will for the next two years, become decriminalized, the federal law remains unchanged; selling or trafficking in any of these drugs will remain illegal. "Under this exemption, illegal drugs ... will not be legalized and will not be sold in stores", according o a provincial background policy document.

 

Despite which a Vancouver entrepreneur is preparing to open a storefront for the sale of illegal drugs. The store to be named The Drugs Store. It is unknown where the business plans to source its inventory. Vancouver is known for its clinics that prescribe medical-grade opioids to drug users, but it is unknown whether The Drugs Store plans a similar service to its clients.

 

The soon-to-be proprietor of The Drugs Store was on trial recently to face charges regarding operation of an illegal cannabis dispensary in Whitewood, Saskatcewan. Jerry Martin's dispensary, Martin Medical Services, had been raided in 2016 by the RCMP two years before the legalization in Canada of retail sales of recreational cannabis.

 

Prior to the legalization of marijuana in 2018, Vancouver hosted over three dozen cannabis "dispensaries", all of them with no legal status since their very existence was in direct contravention of the Controlled Drugs and Substances Act. Vancouver police wee open about their refusal to shut down these dispensaries.

 

"We do have a priority-based approach to policing here in Vancouver, and we do have other priorities", stated Vancouver police spokesman Constable Brian Montagne. That changes when a dispensary was viewed as a conspicuous threat to public safety or violated the rules by selling to minors, and that would warrant a visit from police.

 

It's a different story altogether with regard to selling drugs linked to the overdose crisis. Before Christmas the Vancouver Police Service made public a major bust of a drug ring funneling fentanyl into Vancouver's infamous Downtown Eastside. Mr. Martin's scheme however, is to get arrested, to draw attention to a charter challenge against the federal prohibition on hard drugs.

 

Essentially the plan is to present a case arguing that banning retail sales of hard drugs is itself a contravention of the charter-guarantee of the right to "life, liberty and security of person", since it causes people using drugs to search for illegal sources of drugs carrying a higher overdose risk.

 

The Drugs Store is the brainchild of Vancouver's Jerry Martin, a self-proclaimed “king of compassion.” Photo by Facebook

In An Ideal World....No Death Wishes

"You'd be foolish to use opioids and not grab a naloxone kit."
“All you can think of is getting your next fix [after two of three times receiving naloxone, feeling 'horrible', as in withdrawal]."
Leon "Pops" Alward, Toronto

"Naloxone can't be seen as this wonder drug, that if we had naloxone in everyone's hands all opioid overdoses would go away."
"Right now, the focus is trying to get naloxone in our community and people using it ... so if there is an overdose there's a naloxone kit there to be used."
"If you think of first aid and CPR classes, nobody really tracks who takes that training and because naloxone can't really be harmful, there's no need to monitor it. It's not unusual. It just makes it more challenging to really understand whether naloxone is working."
Tara Gomes, epidemiologist, St.Michael's Hospital, Toronto

"Naloxone is equipping thousands of people in our community to recognize an emergency and respond in an appropriate way when that emergency happens. That's not just a band aid, that's a community-wide change."
"In an ideal world, 100 percent of people who died would have been given something to help."
"Deaths happen when people are alone. We need to get serious about asking, are people dying from being marginalized more than they're dying from an opioid overdose?"
Dr. Aaron Orkin, emergency department physician, Mount Sinai Hospital, Toronto

"They have to be very vigilant and cognizant of the fact that when the naloxone wears off, the chance of the opioid coming back is still there."
"Other people need to be with them to monitor their well-being so if they overdose again someone can call 911 and they can get more definitive treatment."
Adam Thurston, commander, Toronto Paramedic Services

In an ideal world it is not that people dying of narcotic overdoses being helped to survive them would represent a wonderful benefit, rather in an ideal world people would be bypassing entirely the use of such drugs altogether unless prescribed for a definite purpose and even then both prescribing physician and patient would have to be aware of limiting use as well as ensuring that use is carefully structured for a specific purpose for a limited time-frame.

And then there is the larger issue of non-prescription opioids whose popularity has risen monumentally to include fentanyl and now carfentanil, both most frequently used supplementally, mixed in with heroin  and other opioids for greater profitability, both of which are exponentially more powerful than conventional drugs. Education is said to be the key to ensuring that people know the dangers inherent in their use of such drugs.

Information is widely available, including in screaming headlines, about the dangers of street drugs being laced with fentanyl and its even more knock-out cousin carfentanil, but the allure, despite the now-very-well-known dangers lurking behind their use in soaring rates of overdose and death, appears to knock sense out of users. Who also at the back of their minds may rely on the assurance that naloxone is now so widely available, someone will inject it and save them.

Part of an emergency kit includes several bottles of Naloxone (blue caps)  Bernard Weil/Toronto Star

In Mr. Alward's case, it was his roommate who used naloxone to revive him when he first overdosed in 2017. Out of that experience he's become a devoted naloxone carrier himself, using it to save others from overdose deaths. Between May and October of 2017, 564 people in Ontario died of opioid overdoses. Of that total number, ninety-six had been administered naloxone by hospital staff, emergency responders or bystanders, representing 17 percent of all opioid-related deaths.

One Toronto paramedic, Jason Benaim, speaks of arriving on scene to find someone in cardiac arrest, injection needle in his arm, no longer breathing. Arriving ten minutes after a patient has stopped breathing, he stresses, negates administering naloxone; nothing will bring that person back to life. "It's frustrating because this (death) is something that could be prevented)".

Even when paramedics are certain an injection is too late to reverse an overdose, the province still requires that naloxone be used.

In the first half of 2017, Toronto Paramedic Services administered on average naloxone 32 times monthly; that number leaped to 54 times in the second half of the year. It is an aid, but no cure, viewed by government, cities and public health units, police, firefighters, paramedics, pharmacists and doctors as the only reactive tool at their disposal in dealing with the opioid crisis across the country.

Four British Columbians die every day; over 1,400 people died of opioid overdoses in 2017 in British Columbia, according to the province's coroner's office. Half that number -- still a substantial number of people -- died of the same cause in Alberta last year. Ontario's Ministry of Health and Long-Term Care ordered naloxone administered by needle to be available free of charge in pharmacies across the province.

Leading 333 Toronto pharmacies to hand out over 12,000 kits to anyone who asks for one. Recently, naloxone administered by nasal spray has been added to the province's distribution program. Toronto Public Health itself distributed 9,000 kits to partner agencies and the public. During an overdose with an opioid like fentanyl difficulty breathing can result and breathing can be stopped altogether, causing cardiac arrest, explained Adam Thurston.

Paramedic Jason Benaim holds a syringe using an intravascular method of administering naloxone to a patient. Bernard Weil/Toronto Star

What naloxone does, is reverse the overdose for about 30 minutes, but since opioids remain in the system for a much longer time, the risk of over-dosing after the naloxone has worn off remains. If, explained Mr. Thurston, someone was revived, then used opioids and once again overdosed shortly afterward, naloxone will have failed to succeed.

"People will keep on using their drug even though they've had an overdose and been revived. Naloxone is not enough", explained Dr. Meldon Kahan, substance use director, Women's College Hospital, Toronto. He feels that Suboxone, a prescription drug used to treat opioid addiction, should be more widely available and increased numbers of supervised injection sites established over the four currently in operation in Toronto.

Coping With a Deadly Public Menace: Opioid Overdoses

"Data imply some saving of auto occupants' lives at the expense of more pedestrian deaths and more nonfatal accidents: 'The Effects of Automobile Safety Regulation'."
Sam Peltzman, economist, University of Chicago, 1975

"We find that broadening Naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality."
"Our findings do not necessarily imply that we should stop making Naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose. They do imply that the public health community should acknowledge and prepare for the behavioural effects we find here."
Researchers Jennifer Doleac and Anita Mukherjee, professor, Wisconsin School of Business

"Patients occasionally tell me that having naloxone on hand has served as insurance against overdose. So, in some instances, it enhances risk-taking."
"That said, we must use it to save people in the immediate term."
Sally Satel, psychiatrist, drug-policy scholar, American Enterprise Institute

Naloxone is a medication that quickly reverses the effects of an overdose from opioids such as heroin, methadone, fentanyl and morphine. It is available in without a prescription and often given as an injection into a muscle.

Governments, in the 1960s, appalled by the growing carnage on highways related to drivers' inattention to driving safety coupled with automobile manufacturers' disinterest in building safety features into their products, began to press those same automakers to begin looking at investing in safety technologies to be built into their cars and trucks in an effort to make vehicles safer to drive. It has often been observed that drivers, instead of honing their driving skills with a view to driving more safely, simply became more reckless with the new assurances of safety built into their vehicles.

This had the perverse effect of saving the lives of drivers, but sacrificing the lives of pedestrians. Safety features in vehicles produced the desired result in reducing driver deaths due to the new regulations, but the tendency of drivers to drive with increased recklessness had its unanticipated costs. When locomotives were killing cattle straying onto train tracks, farmers were dismayed and angered by their financial losses. A cage-type device called a cow-catcher was attached to train engines that would scoop up the stray cow, not kill it. Imagine designing a passenger vehicle with a similar device and how popular that would be with consumers.

Drivers who feel it is their entitled right to drink and drive, drive while impaired by drugs, or impair their driving skills by diverting their attention to ubiquitous cellphones don't so much endanger their own lives as they do the lives of other drivers and pedestrians through inexcusable habit unconstrained by either conscience or consequences. In these instances far more severe penalties for flouting the law should be imposed in recognition of the fact that people who behave in this way have no regard whatever for the safety and security of others.

The drug overdose scenario that now haunts North America with the growing use of dangerous opioids, the appearance of powerful drugs like fentany and carfentanil and the penchant of drug dealers using these inexpensive, readily-available more powerful opiates as fillers with other drugs so that people often have no idea what they're using, ending up with drug overdoses, has led public health agencies to recognize the need to have the opioid-antagonist naloxone readily available to reverse a deadly overdose.
 Overdose deaths per day in Alberta ... Source: Alberta Health, Opioids and Substances of Misuse, Alberta Report, 2017 Q4

The very same kind of human reaction has been recognized linked with opioid overdose rescues with naloxone. Users of fentanyl and other similar drugs have developed a degree of confidence in knowing that naloxone is in the possession of a wide range of emergency responders; health workers, firemen, police, even librarians and relatives and friends of those known to be drug-addicted to enable them to respond with an overdose antidote. That confidence has led them to relax their own vigil against overdose; in other words choosing to continue endangering themselves.

Of course, in making that choice it is they alone who after a series of overdoses successfully treated with naloxone, stand a good chance of not surviving another and last one. They are, in the final analysis, harming themselves. They pose no threat to anyone else, other than leaving bereaved relatives suffering, deprived of the presence of a loved one. It simply is not morally feasible to withdraw that support from those reckless enough to keep gambling with their lives, caught in the spiral of their unappeasable addiction.

For a lot of people, it is difficult-to-impossible to ignore the pleas of homeless people, begging for 'spare change'. Some of that 'spare change' will be used for the acquisition of drugs or alcohol. These are people living desperate, dysfunctional and dangerous lives. If a cash pittance from those whose lives are so completely dissimilar can bring a little relief into such dismal lives why not dispense whatever help one can? Moralizing simply results in smoothing balm on one's own conscience.

Until such time as governmental social services are capable of extending useful programs to assist addicts to shed their habits, as well as setting aside the needed funds to provide decent housing to those living rough on the streets in wasted lives, wasted tax dollars on emergency relief, hospital services, police responses, these issues plaguing societies and laying waste to peoples' lives will not be resolved.

A fentanyl overdose will result in several characteristic physical symptoms. These symptoms will be easily observed by those who know what to look for, and include:^3,4,5

• Confusion.
• Dizziness.
• Difficulty thinking, speaking, or walking.
• Pale face.
• Blue- or purple-colored lips, fingernails, or extremities.
• Throwing up.
• Choking sounds.
• Pinpoint pupils (pupil size reduced to small black circles in middle of eyes).
• Seizures.
• Low blood pressure.
• Slowed heart rate.
• Excessive drowsiness.
• Frequent fainting spells (nodding off).
• Limp body.
• Unresponsive.
• Coma.
• Difficulty breathing.
• Hypoventilation (slow, shallow breathing).
• Respiratory arrest.
• Death.

What’s in a naloxone kit

Province of Ontario

Injectable kits    

Each injectable naloxone kit includes:

• 1 hard case
• 2 (0.4 mg/1 ml) vials or ampoules (a small glass container) of naloxone
• 2 safety-engineered syringes with 25g, 1” needles attached
• 2 devices (known as “breakers,” "snappers,” or “openers”) for opening ampoules safely
• 1 pair of non-latex gloves
• 1 card that identifies the person who is trained to give the naloxone

Preventable Deaths

"These are unimaginable tragedies and, make no mistake, an overdose death is a preventable death."
John Tory, Toronto Mayor

"What we're hearing is that there are people overdosing regularly on the street."
"It seems to be increasing."
Shaun Hopkins, manager, The Works, needle exchange

"There's people OD'ing in the hallways here left, right and centre."
"People are dropping dead for $20 [price of a heroin hit]."
"It's ridiculous."
Moss Park recovered addict

Many, but not all, of Ontario’s opioid-related deaths have taken place in lower-income neighbourhoods like Toronto’s Moss Park.    Laura Pedersen/National Post/File

A still unidentified woman overdosed near Toronto's Moss Park in the stairwell of an apartment, last week. It's a safe bet she was far from whatever could be considered her original home, a lost soul, addicted to drugs, living off the street, just like thousands of others in Canada's cities. In the week just passed, however, six people died in Toronto of suspected Fentanyl-related overdoses.

City Hall in Toronto was the site of an emergency meeting with first-responders: police, paramedics, the fire department and representatives from public health all in attendance. Exchanging experiences, thoughts and frustrations, but clearly no one knowing exactly how to move forward from this expanding crisis, reflected in cities everywhere in North America, with Vancouver representing the worst-case scenario in Canada.

There are never any shortages of vows by public officials to accelerate efforts in prevention and overdose treatments. More training for city staff, wider distribution of Naloxone kits -- and a stepped-up opening of planned supervised injection sites which supporters are convinced help immensely to persuade users that they can continue their fatally addictive habits in a safe environment overseen by prepared-to-react health professionals.

The contents of a drug overdose rescue kit at a training session on how to administer Naloxone. (Carolyn Thompson/AP Photo)

In the first four months of 2017, no fewer than 101 people died of Fentanyl-linked overdoses in the city of Vancouver, while British Columbia in its entirety saw 935 people expiring from opioid overdoses in 2016. Figures for 2015 in Ontario show that 734 people died from opioid-related causes, according to the Ontario Drug Policy Research Network. This represents the deaths of two people daily, with 253 of those deaths taking place in Toronto.

Over 80 percent of the deaths were deemed to have been accidental, most of them occurring in lower-income neighbourhoods of which Moss Park is one, in the city of Toronto. And as far as health professionals and social workers are concerned the problem is getting more out of hand with each passing day, as Fentanyl becomes more commonly encountered.

And nor are the overdose concerns concentrated just among street users. Recreational users from all walks of life are increasingly vulnerable. They are sufficiently alert and determined not to succumb, to acquire Naloxone kits, but in the communities in which they move, fewer people are likely to recognize the symptoms of overdose and how best to respond.

VELD Music Festival at Toronto's Downsview Park in 2012. (Constance Chan)

Festival-goers in Toronto allowed to bring overdose-countering drug

Society's Killers-by-Default?

Photo: The Atlantic

Big Pharma is being introduced through the courts to the power of public concern over their products. The drugs, OxyContin, Percocet, Opana and a generic version of oxycodone are not illegal, they have a place in responsible use by medical professionals when the attributes they are capable of are called upon to ease peoples' suffering and pain. But their manufacturers deliberately and with the prospect of enriching themselves, launched public relations blitzes convincing prescribing doctors that these opiates are 'less addictive' than others which have been a bane to society, not a boon.

Public authorities are alarmed throughout North America at the carnage that the drugs' dependencies are wreaking through drug overdose deaths. The general public has been made aware that they live in a time where the "culture of drug dependence, dysfunction and death" has affected the larger society, not only drug addicts dealing with mental instability, crime and profit, feeding addictions, but ordinary, middle-class and upper-middle class professionals who have lost their way, becoming hopelessly in the thrall of death-delivering medications.

"[The opioid epidemic was produced by a] fraudulent scheme [engineered by Purdue Pharma, Mallinckrodt Pharmaceuticals and Endo Pharmaceuticals] to mislead doctors and the public about the need for, and addictive nature of opioid drugs."
"They put millions of dollars into advertising. They put lots of sales forces out there. And they supported legislation that made this stuff far more available than it was before. And it's not enough to say, 'Well, people misused it'."
"When you put way too many drugs, for way too many bad reasons, into way too many people's hands, prescribed by way too many people, you get what we have in our area, which is an epidemic."
Barry Staubus, District Attorney, Sullivan County, northeast Tennessee

Photo: The Atlantic

The entire world knows about the legal battles undertaken by various governmental bodies to punish tobacco manufacturing giants in 1998 when they were accused on the evidence which revealed they were in the business of deceiving the public trust about tobacco addiction. They were ordered to pay out over $200-billion in fines to aid government in cost outlays associated with providing health care to smokers whose lung cancer was directly attributable to scientifically validated and acknowledged carcinogens present in cigarettes.

A new battle  has been mounted by public authorities whose areas have been hit with the still-emergent epidemic of drug overdoses. Attorneys general of Ohio, Missouri, Mississippi and Oklahoma, along with counties in California and New York among others, have launched lawsuits against the offending pharmaceutical giants. This is just the beginning. There will be an increasing number of lawsuits. And, as with the battle against tobacco manufacturers when those suits have been settled, individual civil suits will be launched.

In 2015, opioid overdoses caused the deaths of 33,000 people in the United States. This is fast becoming a crisis of intense and untenable proportions, no little of the sense of urgency to do something to ameliorate the situation and name and punish the perpetrator, that white-middle-class suburbanite communities with political influence, has persuaded politicians of all stripes to become involved, as the issue keeps gaining momentum.

There is no disagreement among public health experts to the obvious; that legal painkillers are the cause of a crisis where prescription opioids steadily gained prominence through wide prescription practices, habituating users to search out ever more powerful drugs, leading them on to heroin. OxyContin maker Purdue was persuaded to plead guilty in 2007 to a criminal felony, admitting to fraudulent practices, inaccurately promoting its product as less likely to be abused than other drugs, leading to a $600-million settlement.

"The drug companies are not utterly defenceless. There are issues they can raise and they're pretty good at it", observed University of Kentucky law professor, Richard Ausness. All they have to do is point out that prescription opioids have a distinct purpose, aiding patients in coping with pain issues, as long as they are used responsibly, and therefore they have a place for good health reasons in the prescription pharmacopoeia.

Prescription and illegal opioids are commonly abused because they are so addictive, binding to areas of the brain that control pain and emotions. Photo CNN

They were given a scientifically-approved clean bill of  health when government health regulators themselves studied, then endorsed prescription opioids, releasing them for wide use. In any event, it is medical professionals themselves who stand between the manufacturers and the patients. "Unlike tobacco companies, our products are medicines approved by the FDA, prescribed by doctors, and dispensed by pharmacists, as treatments for patients suffering pain. [The company] vigorously [denies allegations, and is] committed to working collaboratively to find solutions [to the crisis]", Purdue huffed righteously.

The maker of Percocet and Opana, Endo Pharmaceuticals, chooses to side-step any awkward acknowledgement of impending litigation: "Our top priorities include patient safety and ensuring that patients with chronic pain have access to safe and effective therapeutic options". How can any one argue with that selfless, public-service-focused statement, of a totally innocent manufacturer whose only interest in producing drugs is to serve the public?

Ohio Attorney General Mike DeWine announced Wednesday the state is suing five pharmaceutical companies, claiming the companies knowingly understated the addiction risks of prescription opioid medication.(Jackie Borchardt, cleveland.com)

The Savage Myth of Opioid Non-Addiction

"The new guidelines are basically an attempt to turn around a huge freighter ship that's moving in one direction, and now we're doing a 80-degree turn."
"All of a sudden they're [prescribing doctors] dropping all these patients or cutting them off their opoids."
"I see more people dying."
"What really most urgently needs to happen in our system, Canada-wide, is system-management."
Benedikt Fischer, senior scientist, Centre for Addiction and Mental Health, Toronto

"I started with heroin because I couldn't stand the pain. Everybody was croaking [people dying of fentanyl-laced street drugs]."
"I told him [her doctor], 'I'm shooting up powder now, cocaine, because that's what kills the pain."
"Sometimes it's hard just to get to the place where you buy your stuff. You can hardly wait to get that needle, just to get that sense of relief."
"It's awful to have somebody hold you and have to walk you there. And then you're doubled up in pain."
Lorna Bird, 60-year-old grandmother, Vancouver

A man walks past a mural by street artist Smokey D. about the fentanyl and opioid overdose crisis in the Downtown Eastside. DARRYL DYCK / THE CANADIAN PRESS

A 60-year-old drug addict? What would her grandchildren think? She's thought about that. Thought about what it might be like for her grandchildren to discover that their grandmother was one of those addicts that the infamous Downtown Eastside streets of Vancouver -- home to people with mental problems, the homeless and the addicted; petty criminals who commit crime to pay for their next fix -- is known for.

She faced a dilemma when her doctor decided he would stop prescribing an opioid; his personal response to new standards and guidelines among medical professionals reacting to the epidemic of overdoses caused by the deadly opioid fentanyl and its even deadlier cousin carfentanil being used by unscrupulous and profit-driven drug dealers to cut more common street drugs with, to substantially increase their profit margin.

Lorna Bird had surgery in December of 2014, when the prescription opioid hydromorphone (five times more potent than morphine) had been prescribed to numb the intolerable pain she suffered with. However, despite the ongoing pain her doctor began by decreasing her prescription and then finally stopping it altogether. Presumably in an effort to wean her off dependence on the pain \-relieving effects of the opioid, but delivering her straight into the hands of street drug dealers, to cope on her own with the Russian roulette of fentanyl overdosing.

She, according to experts in the field, ranks among thousands of other Canadians with their predicament involving the acquisition of pain-numbing street drugs in the face of having become addicted to the opioids they were originally prescribed for their pain. Lorna Bird was spending $100 daily on cocaine, hoping that she wouldn't be acquiring contaminated heroin instead. Because of her concerns of overdosing should fentanyl be added, she has someone with her when she takes it.

Her doctor had responded to his patient's plea by referring to the College of Physicians and Surgeons of British Columbia having issued new standards as his primary motivation to alter his prescription methods. He finally agreed to allow her to resume a lower dose of hydromorphone, along with methadone. Yet she finds this insufficient to adequately dull her incessant pain, so she continues with both drugs while also injecting cocaine.

The recently updated guideline for prescribing opioids released by the National Pain Centre at McMaster University in Hamilton urges doctors to limit dosages of drugs like hydromorphone, oxycodone and the fentanyl patch to no more than 90 milligrams of morphine daily. They recommend as well that physicians taper medications, even discontinue prescribing the drugs that have led, with long-term use, to dependence in their patients.

According to the Public Health Agency of Canada, close to 2,500 people have lost their lives to opioid overdoses last year. Approximately 20,000 Canadians, according to Dr. Fischer, have overdosed fatally on the potent narcotics being prescribed for them. He urges non-pharmaceutical pain-management strategies be implemented as  systemic changes to prevent the over-prescribing epidemic of opioids.

A public health emergency was declared in British Columbia in reflection of the fatal-overdose crisis that has taken more than 1,400 lives there, between January of 2015 and March of 2017.

The number of overdose calls Vancouver firefighters deal with on a daily basis can be overwhelming, but are becoming routine. Pictured are firefighters and B.C. Ambulance paramedics taking a woman who suffered a fentanyl and heroin overdose to the hospital. Jason Payne / PNG

Overdose Capital of the U.S.

"Heroin is the devil's drug, man. It is."
"No one wants their family to find them face down with a needle in their arm."
"But no one stops until they're ready."
Cliff Parker, 24, heroin user, Akron, Ohio

"July 5, 2016 -- that's the day carfentanil hit the streets of Akron."
Captain Michael Shearer, commander, Narcotics Unit, Akron Police Department

Drugs seized by Montgomery County (Ohio) Sheriff's officers  (Montgomery Sheriff's Office)

Akron, Ohio got their initiation into the devastating effects of a powerful sedative used to sedate huge beasts like elephants, when it appeared on their streets likely sourced from China through the Internet and being used to adulterate more expensive drugs for higher profitability. People using illicit street drugs looking for a kick, and a high more dramatic than the ones they'd become accustomed to and were dissatisfied with, began to get more than they'd bargained for.

On the day that Captain Shearer was commemorating with huge regret, 17 people overdosed, with one of them dying over a tortuous nine hours. The following six months saw 140 overdose deaths of people testing positive for carfentanil, verified by the county medical examiner. With fentanyl, the still-highly-dangerous but more moderate of the two drugs and carfentanil, overdoses can present as sufficiently severe that even multiple doses of naloxone -- the anti-overdose medication -- can barely rescue people from death.

Fentanyl has been around for awhile. Its legitimate use in the medical community is that of a pain reliever. It is commonly prescribed in amounts carefully judged by those skilled in pain management for people suffering pain. It is also used in hospital settings during surgery and following surgery to help manage the pain that accompanies surgical intervention and its follow-up recovery. As such its use is monitored and carefully gauged and stopped once its work is deemed to have succeeded.

But it is also a drug that has been seen more and more frequently during drug seizures over the past three years across North America. Most frequently fentanyl is sold as heroin on the street. Alternately drug traffickers make use of it to produce cheap counterfeit prescription opioids. Its cousin carfentanil is 5,000 more powerful than heroin, and it is well known that a few grains of the drug can be lethal.

Lisa Roberts gives a naloxone auto-injecter to a group of women who live under a bridge in Portsmouth, Ohio. (Jon Castell/CBC)

So much so that the requirement of multiple applications of naloxone to save a life has become common. Rescue crews (first-responders) "are hitting them with 12, 13, 14 hits of Narcan with no effect", observed Doyle Burke, the chief investigator at the Warren County coroner's office in Ohio. And this situation is only  going to become more common, with overdose deaths continuing to spiral upward, according to Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention.

As Dr. Frieden points out, this represents the sole aspect of American health becoming significantly worse over accelerated time. In excess of two million Americans are thought to be dependent on opioids, with another 95 million who used prescription painkillers in the past year. "This epidemic, it's got no face", commented Chris Eisele, president of the Warren County Fire Chiefs' Association. Lawyers, accountants, young adults and teens from middle-class backgrounds attend Narcotics Anonymous meetings in Deerfield Township.

There has been 312 drug deaths in Summit County in 2016 alone, a 45 percent increase from 2015, and over triple the 99 cases that the medical examiner's office saw just two years earlier. Last year -- according to Gary Guenther, chief investigator of the county medical examiner's office -- saw so many deaths that the county was forced to have refrigerated trailers brought onto site to store bodies when the morgue had run out of space, on three occasions.

"The problem is getting worse every day. We don’t have enough police resources to combat it. We work very hard, it’s changed our jobs."
"We’re trying to be proactive. People say to us: ‘We didn’t know, we don’t understand’ the scope of the crisis."
"I don’t know, with everything that’s out there, how some people still don’t know [about the epidemic]."
"They're overdosing in the jails and in courtrooms."
Montgomery County Sheriff Phil Plummer

Public health nurse Lisa Roberts leads Project DAWN, the first program in Ohio to put the anti-overdose drug naloxone into the hands of users. (Jon Castell/CBC)

Detecting : Avoiding Fentanyl

"We're hoping to give community members a free and simple way to find out whether or not they've been exposed to fentanyl through recent substance use and we're also hoping, if we can, to collect a bit of data on what those results might be."
"We really need to start talking about pre-use interventions."
"Naloxone is great but it's after the fact. The issue isn't just fentanyl, it's that people don't know the content and strength of the drugs that they're consuming."
"That's where the analysis is necessary. We're seeing the public health benefit from other jurisdictions."
"[If people who use the strips are] angry, scared, confused [about the results] talk to us first! We strongly encourage people not to use these test results to accuse or threaten someone you may have gotten the drugs from. Your safety is important!"
Caleb Chepesiuk, member, AIDS Committee of Ottawa 

The fentanyl test will look like the one shown here and will reveal a coloured line if the drugs are positive for fentanyl. (Courtesy Mark Lysyshyn, Vancouver Coastal Health)

"We've heard from clients that they want to know what's in their drugs. With the number of overdoses rising, it's critical to empower people to learn about their risk of being exposed to this toxic substance."
"We're hoping this will encourage them to use our harm reduction services like take-home naloxone kits, consider undergoing addiction treatment and take precautions like decreasing their dose or not using alone."
Dr. Mark Lysyshyn, Vancouver Coastal Health

"It's a sociological phenomena." There's the contention that it's not a drug, just a tablet."
"These tablets mimic the appearance of the legal product. It started as a marketing tool. We have seen a lot of drugs that were pressed with a brand name and logo. But we are also seeing a new generation of drug consumers who have a large appetite for drugs in tablet form. There's the feeling that you're not a drug user because socially it's OK to take medication. I was talking to some kids near Quebec City and they were telling me it's OK to take tablets, because it's not smoking or injecting something."
"There used to be a point of human contact at every level of a [drug] transaction. The connection doesn't exist anymore. Now, chemicals are being produced by people with chemical know-how for anyone who wants them, anywhere in the world. This is large-scale and detached. We've seen an organization sell 5,000 to 10,000 packages a week. They are selling it with no remorse."
Sgt. Luc Chicoine, national drug program coordinator, RCMP

Phoro: Travis Lupik, Last June protesters marched through Vancouver's Downtown Eastside with a coffin, to bring attention to fentanyl-overdose deaths

Throughout Canada, community organizers and aid groups are attempting through all manner of creative means to help 'do something' positive about the fentanyl crisis that has hit communities and led to the deaths of so many people of all ages, from teens experimenting to hard-core drug users and potentially, patients suffering pain for whom doctors prescribe opioids as pain-relievers, who end up possessing drugs from unauthorized sources which have adulterated them for higher profit and the filler just happens to be deadly fentanyl.

A new program has been launched by the AIDS Committee of Ottawa, offering urine test strips whose purpose is to chemically interpret what's in the chemical mixture that people may have unknowingly used; whether the powerful opioid fentanyl has been used as a 'filler'. ACO has named their project "Where's the Fent?" A free-of-charge, completely anonymous method for concerned individuals to ascertain whether they have been exposed to this killer drug. At the same time ACO is hoping through this process to be able to gather useful statistics from anyone willing to complete a short questionnaire.

Ottawa police have discovered that fentanyl has been used to lace street drugs, from heroin to cocaine in pharmaceutical knock-offs like counterfeit Percocets. The ACO office makes the test strips along with a urine cup available so that users can choose to take the test discreetly right there at their office, or take it home with them, where results are revealed mere minutes once the strip is dipped in urine. The chemical formula of the strip is geared exclusively to the detection of fentanyl and its analogues.

Negative tests do not mean that exposure to another opioid or adulterant is also negative. The presence of the even deadlier high-strength carfentanil, or U-4770, for example is not picked up by the test. Ottawa Public Health and city police responded to a series of local overdoses by working as a team to warn the public about counterfeit pills appearing identical to prescription opioids like OxyContin and Percocet, but containing fentanyl, 50 to 100 times more powerful than morphine.

Insite is one of only two legal supervised injection sites in the country, both of which are in Vancouver. The publicly-funded health centre is now offering users tests to determine if their drugs are laced with fentanyl. (Radio-Canada)

Seized drugs have been sent to Health Canada laboratories where they are identified as containing fentanyl, though appearing to present as cocaine or heroin. The same urine test strips have been used in other jurisdictions. Vancouver's Insite, the first supervised injection site in North America, used the urine strips for drug testing directly last year. Their finding was that 90 percent of tests in a single month last summer tested positive for fentanyl.

There has also been an eightfold rise in the number of times nurses have used naloxone to counter overdoses, in the first six months of 2016.

The Death Drugs

"Submit a cocaine sample, it's got fentanyl in it. Submit a heroin sample it's got fentanyl in it. Submit what we thought was Ecstasy, it's got fentanyl in it. Submit Percocets, it's got fentanyl in it. Submit methamphetamines, it's got fentanyl in it."
"That's what we're telling people: You think you're getting one [drug], there's no guarantee, there's no control system, it's an unknown."
"The difficulty is trying to say this person, unfortunately, passed away as a result of this drug. Well, where did that come from?"
"People think, 'I'm at a party with my friends and it's my friend who gave it to me so it should be OK', but you have no idea where they got it from either."
Staff Sgt. Rick Carey, Ottawa Police drug squad

Vancouver firefighters Jason Lynch and Jay Jakubec try to revive an addict who has already had two doses of Narcan after overdosing on fentanyl in Vancouver’s downtown eastside. (CBC)

The Coroner's Service of British Columbia has reported that since the arrival of fentanyl on the scene, the death toll in that province has been elevated to 914 documented overdose deaths for the year 2016, representing a figure that exceeds the overdose death statistics for 2015 by 80%. British Columbia's problems with this laboratory-created chemical opioid leads the nation, but other provinces are realizing high death figures due to opioid overdoses as well.

Older people are viewed as likelier to use opioids that have been prescribed for pain. Their risks increase if they mix those drugs with alcohol. But what has really raised the alarm stakes is not only the drug users on the street who have been overdosing in records numbers resulting from the street drugs they use which have been adulterated with cheaper 'fillers' -- primarily fentanyl, a far more powerful drug, 50 to 100 times stronger than morphine -- is that teens have now begun to die from fentanyl overdoses.

No one is, at this time, ignorant of the fact that fentanyl is hugely dangerous, that it shows up regularly in unknown quantities in drugs sold as being known substances. No one using these drugs doesn't know of the growing number of fatalities due to overdoses. But they are propelled by their addiction and their self-assurance that these fatalities occur to others, nothing untoward will happen to them; the world they inhabit is absent of concern.

Ottawa police several days after the deaths of two teens in that city, conducted the largest fentanyl seizure yet, along with arrests of a dozen people. What that translates to is a temporary plug in a flood of illicit drugs reaching an eager and easy market. The known antidote to these overdoses, nalaxone, has been made available through the Province of Ontario in a kit, made available at drugstores free of charge to anyone wanting to become proactive among the general public or within the drug-using community.

Fentanyl, primarily sourced through the Internet from China (China has just recently placed fentanyl on its proscribed list of drugs), is popular with organized crime groups in Canada for the creation of their illicit products, irresistible to those addicted to pain killers. There are also local labs producing fentanyl. At this point, fentanyl is a known and dangerous substance circulating widely, damaging peoples' lives and creating fear among parents of teens.


The eventual, inevitable introduction of its more powerful cousin carfentanil, meant for the control of large animals like elephants, brings shudders of apprehension to the minds of those having to deal with this disastrous turn of events.

Health promotion specialist Samira Walji demonstrates how opiate users would draw drugs through a filter into a syringe before injecting them.  FRED LUM/THE GLOBE AND MAIL

Of course, parents and users can always seek help. Say, from addiction counselling services. In Canada, unfortunately, it is an unregulated field. Anyone, irrespective of their backgrounds, can claim themselves to be a reliable counsellor in addictive behaviour. And that concerns Crystal Smalldon, executive director of the Canadian Addiction Counsellor Certification Federation.

"All you have to say is, 'I'm an addiction counsellor' and people believe you. You could go hang up a sign on Bank Street and the next day you could probably see ten people a day at $200 a pop. We regulate taxi drivers. We regulate hairdressers. We don't regulate addiction counsellors. It makes no sense. If you have $25,000 you could get treatment right now. But the problem is, you don't know who's doing the treating. You can pay the money and send your daughter to any facility that has a bed for a teenager right now, but if you walk in you just trust they know what they're doing", she argued.

Coincidentally, a substance-abuse counsellor in California was sentenced to 25 years to life in prison in California, She had pleaded no contest to second-degree murder and two drunken driving counts. Sherri Lynn Wilkins hit and killed a 31-year-old man, driving with his body embedded in the windshield of her vehicle, his upper body faced down on the hood of her car until other drivers stopped her.