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In the shadow of COVID-19, Canada’s opioid epidemic has suddenly become deadlier

In the shadow of COVID-19, Canada’s opioid epidemic has suddenly become deadlier
Canada
Bonn has been using fentanyl, a powerful synthetic opioid, since 2012, but he said this time hit him unlike anything before. It forced him to face a reckoning about his drug use.

“I just realized I have so much to lose ... I didn’t want to become a statistic.”

Bonn, a harm reduction advocate in Halifax, could easily have become one of Canada’s record number of overdose deaths — a trend that, like every aspect of life in the past six months, has been impacted by the COVID-19 pandemic.

But as the attention of governments and policy-makers is focused on the toll the virus has taken on hospitals and long-term-care homes nationwide, the opioid epidemic continues to kill in the shadow of the COVID-19 pandemic — and it’s now outpacing the virus in monthly deaths in Canada.

Since 2016, when British Columbia declared the opioid epidemic a public health emergency, more than 15,000 Canadians have died of opioid overdoses. But it appears the COVID-19 pandemic is making things worse. Both B.C. and Ontario recently saw the most opioid overdose deaths ever in a single month, in June and April respectively, with B.C. recording 175 deaths (compared with 76 in June 2019) and Ontario, 201 (compared with 173 in April 2019).

In July, of its own with 27 overdose deaths, compared to 18 from COVID-19 complications. Nationwide, the coronavirus pandemic has claimed more than 9,000 lives.

To some, such as Gillian Kolla, a Toronto-based researcher with the Canadian Institute for Substance Use Researc h, the way public officials in Canada have handled the opioid crisis versus the COVID-19 pandemic is telling.

“Seeing the way the medical system, the public health system and politicians across the country of all stripes came together to address the COVID pandemic, and then contrasting that to the slow, anemic response to overdose deaths across the country … is rather shocking to me,” Kolla said.

Harm reduction advocates say the recent rise in overdose deaths can be attributed to two main factors: more people using in isolation because of the COVID-19 pandemic and a highly contaminated illicit drug market.

In Bonn’s case, both factors affected the outcome of his recent overdose; using around other people saved his life, after a friend injected him with naloxone, a drug that can reverse opioid overdoses.

“If I wasn’t open about my drug use and comfortable sharing it with people, I would have used that fentanyl alone in my room,” Bonn said. “Stigma is the driving force to why people use alone, and using alone is the driving force as to why people die.”

It was also the unpredictable strength of street fentanyl that led to his overdose. In its pharmaceutical form, fentanyl is prescribed by doctors to treat severe pain, often in late-stage cancers. It is about 100 times stronger than morphine and 50 times stronger than heroin. Because fentanyl is so potent, it is usually mixed and diluted with other substances in its illicit form. The lack of quality control in the street version means one grain can be much deadlier than the next. A fatal dose for people with no tolerance can be equivalent to about a grain of salt.

Bonn believes that third line of fentanyl he did had a much higher concentration of the drug, which he says reflects the danger of an unregulated drug market. He said it highlights the need to increase access to a safe supply of drugs, especially pharmaceutical-grade opioids that can be prescribed in a clinical setting.

“It’s really about knowing the dose, knowing the quality and knowing the quantity. But if you have no idea … you’re very much playing Russian roulette any time you use.”

In Ontario, chief coroner Huyer said overdose deaths increased by about 35 per cent in April to July, compared to the same period in 2019.

Meanwhile, the number of people dying from COVID-19 complications has dropped significantly since April and May, he said.

Huyer noted that nearly 60 per cent of people dying from overdoses are between the ages of 25 and 44.

“If you look at the number of life years lost, it’s substantial,” he said. “And these people are in what many would say the prime of their lives. And to see that loss, it’s such a significant thing for them, but also for their families and society in general.”

In Alberta, there were 142 opioid overdose deaths in the first three months of 2020, a drop from 151 in the same period last year. There are indications the second quarter was worse, although official figures have not yet been released.

The rise in overdose deaths during the pandemic is a reversal of a trend observed in March 2019, when deaths were slowly but consistently decreasing.

“As soon as the COVID restrictions were put in place, we saw an uptick in the number of people dying of overdoses in Toronto, which went against the trend over the past year, from March 2019 to March 2020, where we actually started seeing declines … That essentially has evaporated,” said Daniel Werb, executive director of the Centre on Drug Policy Evaluation in Toronto.

“The main issue right now that we’re facing and one of the drivers of overdose is the fact that the unregulated drug market is so unpredictable,” Werb added. “And that makes it extremely hard for people to stay alive.”

Guy Felicella is a harm reduction worker who used heroin for more than 20 years in Vancouver’s Downtown Eastside. But he never experienced an overdose until he started doing fentanyl in 2012. He would end up being brought back to life six times in nine months before he went into detox and recovered from his addiction.

These days, heroin is almost impossible to find on the streets, according to Felicella and other drug experts who spoke to the Star. The illicit opioid market in nearly every major city in Canada has been completely contaminated by fentanyl. In B.C., Alberta and Ontario, the three provinces that have been hit hardest by the opioid epidemic, fentanyl has been detected in 70 to nearly 90 per cent of opioid overdose deaths.

“(Practically) nobody’s dying of heroin because there is none,” he said. “It’s all fentanyl.”

The pervasiveness of fentanyl in Canada’s illicit opioid market shows how prohibition and the lack of regulation have created a toxic drug supply, Felicella said. Or as he puts it: the harder the enforcement, the harder the drugs.

One step towards reducing the number of opioid overdose deaths? Bring back heroin, at least in its pharmaceutical form, Felicella says.

“If we bring heroin back, that’ll actually give drug users a legitimate choice, where they can say, well, I can go do fentanyl, or I can go to a clinic and get heroin and not die,” Felicella said, acknowledging that people can also die from a heroin overdose, but it’s much less common.

“Heroin is one of those interesting concepts that I think can really help save, not just some lives, but many, many lives.”

The idea of prescribing people heroin may seem strange, but in its pharmaceutical form, diacetylmorphine, it’s not much different from the morphine used in hospitals across Canada for pain management, according to Werb.

“Heroin-assisted treatment is a really widely accepted internationally practised treatment … really what it is is a clinical intervention,” Werb said.

For people with substance use disorder, complete abstinence is rarely an option. The safe supply of prescription-grade opioids such as methadone or buprenorphine, which are provided in a clinical setting to wean people off more dangerous opioids such as fentanyl, is common in Canada, but those treatments are not always effective for everyone, particularly those with high tolerance to opioids.

Heroin-assisted treatment has not been embraced in the same way, despite evidence of its efficacy, Kolla said.

“I can’t think of another area of medicine or public health where there’s so much reluctance to put in place evidence-based solutions to a public health crisis,” she said.

But things are changing.

The widespread acknowledgment that Canada’s illicit, unregulated drug market is highly toxic is spurring more people — including the police — to push for decriminalization of all drugs and easier access to a safe supply of pharmaceutical-grade opioids.

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It was early in Abbotsford, B.C., police Chief Mike Serr’s career when he realized taking people’s drugs from them wasn’t solving any problems. He recalls an incident when he was patrolling Vancouver’s Downtown Eastside in the mid-1990s and saw a sex worker he was familiar with using heroin in a laneway.

He confiscated her drugs, as his job required. That’s when she broke into tears and told him she would have to engage in more sex work to avoid going into withdrawal.

“All I was doing was putting her back (on the street),” Serr said.

Serr is the chairperson for the Canadian Association of Chiefs of Police Drug Advisory Committee. In July, he added his voice to a list of police chiefs calling for the decriminalization of possession of illicit drugs.

“What we’ve been doing since I’ve been a police officer for 30-plus years has not worked … We’re not going to be able to ever stop the supply of drugs,” Serr said.

He believes the focus needs to be on the demand. He supports the safe supply of prescription opioids such as methadone and buprenorphine, comparing them to a nicotine patch for someone who wants to quit smoking.

“Police officers are still going to be aggressively going after the people that are trafficking and importing and producing … at the end of the day we’re trying to save lives.”

Like others, Serr has observed the COVID-19 pandemic worsening the opioid epidemic. The police chief suggests several reasons for this, including that enforcement strategies have been tapered down and the virus has increased stressors in people’s lives.

Furthermore, more people have been using drugs alone during the pandemic due to factors such as reduced capacity at supervised consumption sites and policies such as hotels limiting rooms to one person.

There are some who believe Canada’s drug supply has become more toxic during the pandemic, due to border closures, leading to higher drug prices and the introduction of more adulterants by dealers.

The Canada Border Service Agency told the Star it does not comment on seizure trends or fluctuations, but a look at activity so far in 2020 shows agents have seized less than a third the amount of fentanyl this year compared to the same period in 2019. In April, June and July, they didn’t seize any fentanyl at the border, unlike the first six months in 2019.

This could indicate fentanyl is getting into Canada via other means, such as the mail system. It also shows how even with borders closed, drugs will still find their way into the country.

Allen Custance, a technician with the organization Get Your Drugs Tested in Vancouver, said in the initial months of the pandemic, they were hearing of a fentanyl shortage. But it didn’t last long.

“Fentanyl didn’t really take too long to come back. And when it did come back, it seemed like we’re seeing a lot more stronger mixes of dope,” he said.

The type of fentanyl on the streets seems to be different, in that it’s a different colour and less pure.

“We kind of hypothesize it was a transfer between largely supply coming from China, Chinese pharmaceutical fentanyl, to illicitly made fentanyl coming from Mexico and South America,” Custance said. “Because it kind of changed.”

This illicit fentanyl may be harder for drug dealers to accurately measure. Because fentanyl is so potent, it’s usually mixed with other substances.

It’s not just the opioid supply that is growing more toxic, said Andy Watson, a spokesperson for the B.C. coroners office.

“We’re also seeing high levels of cocaine and methamphetamine in our post-mortem testing, too, so it’s not just an opioid epidemic — this involves mixed-drug toxicity and multiple types of drugs. All that said, we are seeing extreme levels of toxicity in the fentanyl we test (more than 50 micrograms/L) in recent months,” he said in an emailed statement.

One clear and concerning trend is an increase in the amount of benzodiazepines, a class of tranquilizer, in opioid samples. The organization Get Your Drugs Tested said it has seen this increase, as has Werb in Toronto.

Werb said in late March there was a cluster of overdoses in downtown Toronto and when they checked the samples, they found a “clinically significant” rate of benzodiazepine adulteration.

“This is really difficult from a public health perspective because if people take a combination of benzos and opioids and overdose, naloxone is not going to revive people necessarily,” he said.

“I think this is one of the reasons why we’re seeing an uptick in overdose deaths in Toronto right now.”

These days, people don’t go out and ask for heroin or fentanyl. All opioids fall under the generic term “down,” reflecting how unchecked the market has become.

“You’re essentially just trusting the market,” Werb said. “And trusting the market is deadly.”

As the number of people dying every week from opioid overdoses eclipses those who are succumbing to complications from COVID-19, Felicella says the government must urgently consider decriminalizing drugs and providing safe, pharmaceutical-grade opioids in a clinical setting.

“They say the difference between COVID and the overdose crisis is that people aren’t making a choice to get COVID,” Felicella said. “Well, nobody makes the choice to die of a drug overdose, either.”
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