British Columbia is gripped in an overdose crisis never before seen in our history. The number of known overdose deaths across the province has now reached at least 755, with 128 in November alone.
The synthetic opiate fentanyl, which has contaminated the street drug supply, appears to be responsible for the overdoses. Now carfentanil — a more potent form of fentanyl that can kill a person with a dose no larger than a grain of sugar — is being detected in the province.
This is not our first crisis: In the 1980s, the Downtown Eastside experienced a surge in overdoses caused by the arrival of a highly potent form heroin. We are not alone: In the 1990s, cities such as Zurich, Amsterdam and Hamburg experienced a series of overdose crises that were no different from what we are experiencing across our province today.
What is different is how B.C. and European cities have dealt with their crises. In Europe, they became a major turning point in the overall approach to drug treatment and addiction medicine. In contrast, our approach has been entirely reactionary, with a response plan that focuses on the symptoms of addiction as opposed to the causes or a cure.
A case in point is how we are dealing with the fentanyl crisis today. The primary response largely focuses on the widespread distribution of naloxone and its administration to anyone experiencing an overdose. Naloxone works by “knocking off” the opiates from the receptors in the body’s central nervous system that control basic functions like breathing.
However, a little mentioned side effect of naloxone is that after a person is revived, it precipitates painful withdrawal symptoms including anxiety, restlessness, agitation, cramping, nausea, vomiting, rapid heartbeat, muscle aches and hot and cold sweating. The more naloxone is required to revive a person, the greater these withdrawal symptoms. As a result, addicts who have been revived with doses of life-saving naloxone immediately begin searching for their next hit to stave off these very painful withdrawal symptoms, starting the overdose and revival cycle over again.
This revolving door is playing havoc with hospitals and first responders. Emergency room beds are being tied up so other medical emergencies have to be diverted or wait, while ambulance and fire and rescue service shifts are so taken up with overdose calls that staff are hard pressed to respond to calls for other medical conditions or patient transfer.
How did European cities in Germany and Switzerland tackle their crises? Firstly, they invested significantly in treatment on demand. This means that as soon as an addict expresses any interest in getting off street drugs, they are immediately able to enter addiction and mental health treatment. Currently, it takes eight days to access a treatment bed in B.C., so the addict never makes it into treatment.
Another form of treatment on demand is to provide clean drugs to addicts, specifically opiate substitution drugs such as slow-release morphine, hydromophone or polamidone that are readily available to addicts to replace contaminated street drugs. What is killing people are drugs contaminated with unknown quantities of fentanyl. Providing a clean alternative will save lives. These substitution drugs can be therapeutically administered and monitored in supportive housing units, pharmacies, overdose response centres and clinics. Indeed, Vancouver has one such clinic and it is overwhelmed.
However, the approach in B.C. so far has been to go after pill presses and the importation of fentanyl. While these measures will reduce some of what is available on the street, it does nothing to stop addicts from seeking drugs and buying whatever is available, regardless of its composition.
Another practice that should be adopted is the testing of all drug seizures by police and the immediate publication of the results on easily accessible websites. This is the basis for informed decision making. Important information on purity and the addition of ingredients like synthetic opiates and their proportions, including an expert interpretation of the results and their assessment of the risk and impacts to a user, should be included.
This testing should be done regularly, not just during times of crisis, so that all stakeholders — from health officials and patient advocacy groups to the police and social service agencies — can see emerging trends and prepare long in advance.
Moreover, all fatal overdose cases need to be examined by a forensic pathologist/toxicologist to understand the actual factors leading to fatal outcomes. An addict’s death is rarely caused by a single drug or a single factor, but multiple causes and factors. Understanding what these are is central not only for the timely shaping of the immediate response to mass overdoses, but for health-care reform to deal with addiction and mental health proactively as opposed to reacting to the latest crisis.
Finally, what is critical is a coordinated emergency response group that should have a command centre, daily meetings, real time data, dedicated project support and clear accountabilities. It should include greater representation from the front-line staff, drug user advocacy groups and municipalities, as opposed to mostly provincial bureaucrats, as it is now. Much of the current response has not been coordinated, contributing to its slow and disjointed nature.
Recent announcements by the B.C. and federal governments to increase the number of supervised injection sites, repeal Stephen Harper’s flawed Bill C-2, and adding a mobile medic unit in the DTES are good steps and are urgently needed.
But the lack of investment in treatment on demand, drug substitution, an early-warning monitoring system and a coordinated response has severely limited our ability to address the current overdose crisis and prevent future ones. The experiences in Europe, and in Vancouver’s past, show us what needs to happen. We just need the political will to make it happen.
Michael Krausz is a Professor of Psychiatry, Faculty of Medicine, UBC and the UBC-Providence Leadership Chair for Addiction Research.
Kerry Jang is a Professor of Psychiatry, Faculty of Medicine, UBC and a Vancouver City councillor.
William MacEwan is a Clinical Professor of Psychiatry, Faculty of Medicine, UBC.
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