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    First stop the dying


    Judith Lavoie

    Experts agree that bold moves are essential to reducing the deaths from opioid use.

     

    SOME MEMORIES make David Clarke feel ashamed, such as stealing from family and friends when he was addicted to crack cocaine.

    “I would do anything, anything to get it,” says the 35-year-old Vancouver Island resident who switched from crack to heroin in an attempt to modify his behaviour—a shift that meant he changed to stealing from stores or dealing drugs to feed his habit. “I felt I had gained some morals,” says Clarke.

    However, like many others struggling with addiction, the switch to heroin put Clarke at increased risk of inadvertently taking fentanyl, which is found in most illicit opioids sold in BC. Some also actively seek out fentanyl after finding it offers a more intense high. Four years ago, Clarke overdosed on fentanyl and was brought back by a naloxone injection.

    He was one of the lucky ones. The latest figures from the BC Coroners Service show that 690 people died in BC from illicit drug toxicity in the first eight months of 2019.

    There is growing pressure to replace a poisoned supply of street drugs with a safe supply. Advocates also want decriminalization of small amounts of drugs for personal use, a move that would reduce the stigma and persuade more people to seek help.

    Leslie McBain, co-founder of Moms Stop The Harm, a network of families who have lost members from drug use or have loved ones struggling with substance use, in common with institutions such as BC Coroners Office and BC Centre on Substance Use, believes that the urgent priority is to stop the deaths. Arguments that money should be put into enforcement and recovery, rather than a safe supply, ignore the realities of addiction, McBain says.

     

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    Leslie McBain

     

    “A person who dies from a toxic drug supply will never go into recovery. People who don’t understand the concept of safe supply also don’t understand what addiction is and how people have to live their lives when they are addicted. People are forced to go to the toxic supply on the street. It’s Russian roulette,” she says.

    Safe supply and decriminalization, although politically controversial, are far from fringe concepts.

    The BC Centre on Substance Use (BCCSU) has issued a paper suggesting heroin compassion clubs be established, and Provincial Health Officer Dr Bonnie Henry has called for decriminalization, urging politicians to regard the overdose crisis as a public health issue, not a criminal justice matter.

    Safe supply and decriminalization would keep people out of the justice system; public benefits would include a reduction in criminal activity and wresting control of the drug trade—and resultant money-laundering activities—from organized crime.

    Coroners Service statistics show that fentanyl was detected in more than 85 percent of illicit drug toxicity deaths in 2018 and 2019. Carfentanil, an animal sedative many times more powerful than fentanyl, was found in more than 100 cases this year—an increase of 240 percent over the previous year.

    Andy Watson, spokesperson for BC Coroners Service, says, “Sadly, fentanyl continues to be the main issue, leading to the existence of a toxic drug supply across British Columbia. In fact, four in every five illicit drug toxicity deaths in BC have fentanyl detected in the post-mortem testing.” That’s why the Coroner is advocating for access to safe supply: “If you provide a safe drug supply for people who use substance, there is less risk,” says Watson.

    The 690 deaths actually represent a 33 percent decrease over the 1,037 deaths in the same eight months last year, but it is not necessarily an indication that the opioid crisis is easing, notes former Provincial Health Officer Dr Perry Kendall, now interim co-executive director at the BC Centre on Substance Use. “If you look at the actual number of overdoses that are being attended, we are not seeing a drop in overdoses and we are not seeing a drop in the severity of overdoses. What you are seeing is that we are getting pretty good at pulling people back from an overdose,” says Kendall.

    Kendall acknowledges that a safe supply of drugs is not a cure-all, and must be combined with new programs to build resilience against drugs, particularly among young people, and better intervention, treatment and recovery systems. “But, if we don’t stop people dying, there won’t be people able to go into recovery. It’s not one or the other,” he says.

    Watson also noted that harm reduction measures are partially responsible for the drop in the number of deaths. “If it was not for the treatment and harm reduction measures in place, we understand from our partners there would have been at least twice the number of deaths since 2016 when the public health emergency was declared,” he says.

    Among the most important of those harm reduction measures are supervised consumption and overdose prevention sites—there have been no deaths reported after more than 300,000 injections at such facilities. And more than 1,000 overdoses were reversed. Understandably, most advocates want to see such services expanded.

    Victoria has seen 35 deaths so far this year, compared to 98 for the same period in 2018, but the City remains in the top three drug death communities in BC. Northern Vancouver Island has seen an increase in the number of deaths.

     

    ADDICTION TO THE POWERFUL DRUGS is often fast and unanticipated. “Choice is only in the first few times. Addiction happens and then it’s often no longer a choice for a person,” says McBain.

    And there is no easy way out.

    Clarke has tried methadone and suboxone programs and spent time at Guthrie House Therapeutic Community at Nanaimo Correctional Centre and several other treatment and rehabilitation centres to try and quit his drug use—with no long-term success.

    Jail time, sometimes with involuntary periods of cold turkey, taught him how to commit crimes such as credit card fraud, and put him in touch with groups involved in the drug trade. “I found new, innovative ways to get my fix,” admits Clarke, whose drug use started after childhood abuse and family addiction problems.

    Few people are likely to kick their addiction while in jail or while they are homeless, so new approaches are needed, says McBain, who also advocates for more harm-reduction services and increased help in homing people and addressing poverty.

    Reverend Al Tysick of the Dandelion Society, who works with Victoria’s most vulnerable population, cautions that, although decriminalization and safe supply would help, long-term solutions must prioritize housing, better access to mental health care, well-regulated treatment centres, and giving people on welfare sufficient money to live on. “We’ve tried to tackle it piece by piece and it hasn’t solved the problem. We’ve never looked at it as a whole…It’s a vast puzzle, and one piece of the puzzle cannot solve the issues we are facing,” says Tysick, acknowledging that a multi-faceted approach would be extremely expensive. But, he adds, “I think we are wealthy enough to solve it.”

    Access to well-regulated, intense treatment centres is essential, says Martin (last name withheld), a 20-year-old who has been clean for 10 months after a downward spiral into drugs and crime that started in high school.

    After several failed attempts, Martin checked in to a privately-run recovery home, based on the 12-step program, that counselled and mentored him 24 hours a day over nine months—in contrast to some government-funded recovery homes where treatment can be minimal, with no daytime supervision.

    The only problem is cost, as most people cannot afford the treatment, says Martin, whose family has helped financially.

    One of Clarke’s biggest regrets is the effect on his family the night he overdosed on fentanyl, shortly after being released from jail, and was found on the floor of his family home by his niece.

    “I thought all the kids had gone to bed and I decided to do fentanyl. I knew people were dying all over the place, but I didn’t think anything of it. I went from sitting on a chair to being on the floor of the kitchen with all the kids surrounding me and crying. I could hear someone screaming,” says Clarke, who was given naloxone by ambulance attendants.

    Naloxone, which reverses the effect of overdoses from opioids such as heroin and fentanyl, has saved thousands of lives, and is another vital part of BC’s harm-reduction strategies, with take-home kits widely distributed around the province.

    For Clarke, that night proved that BC’s harm-reduction policies are working. “I probably wouldn’t be here today if it wasn’t for harm reduction,” he says.

    However, like many others in BC, treatment options for Clarke have failed, and his worries about being returned to jail are sometimes overwhelming. Yet, as a continuing drug user, he remains at risk from a tainted drug supply.

    In addition to the death toll, an increasing concern among first responders and medical professionals is the after-effects of naloxone, which can be followed by an overwhelming need to find another fix to avoid going into withdrawal.

    “It’s like, ‘I almost died that time, but I needed another fix right now,’” says Clarke, who is continuing to use crystal meth and fentanyl, obtained from a dealer who he believes is providing safe doses. He then treats his anxiety with Ativan and Xanax.

     

    ISLAND HEALTH CHIEF MEDICAL OFFICER Dr Richard Stanwick worries that, combined with an upsurge in the use of crystal meth, which also affects the brain, long-term care facilities are going to be needed for people who have survived overdoses.

    “Sometimes people are being brought back five times in a single day, which is not necessarily going to be good for your brain, because of episodes of oxygen starvation,” Stanwick says. “There are some really disturbing trends. It’s a very fluid drug scene.”

     

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    Dr Richard Stanwick

     

    Island Health walks a tightrope when it comes to innovative measures, as there are no government policies promoting safe supply or decriminalization. “But, on a trial basis, and under the auspices of the state of emergency, it does appear we are going to continue to look at alternative ways of saving lives,” Stanwick says.

    More than 3,000 individuals on Vancouver Island are receiving methadone or suboxone. And, under tight control, a new injectable pharmaceutical-grade opioid treatment for chronic, severe opioid addiction is being offered to some residents of Johnson Street Community at 844 Johnson. The twice-daily injections are offered to those who have not benefitted from options such as methadone. It is likely another Vancouver Island centre will open shortly.

    Stanwick describes it as pushing the boundaries in an effort to save lives. “It is increasing our menu of options. It is life-saving because the risk out there is so severe, but…we’re not giving out free drugs to anyone. That’s the last thing anyone wants to do,” he says.

    Despite the success of supervised consumption sites, the latest statistics show that the majority of deaths occur in private residences, hotels or shelters, and that is a major concern, notes Stanwick.

    “Somehow, we are still not breaking that stigma barrier where people are dying alone. It’s so hard to figure out what to do,” he admits.

    Kendall points to the all-too-common attitude that people who abuse drugs are responsible for their own problems—and that it is a moral failing rather than a chronic health problem—lying at the root of the inadequate response to the situation.

     

    DESPITE MORE THAN 12,800 OPIOID-RELATED DEATHS across Canada between January 2016 and March 2019, the issue has gained remarkably little political traction, although provision of harm- reduction services has required municipal, provincial and federal governments to work together. At times, health authorities in BC have pushed the limits legally to provide safe injection sites, such as when faced with opposition from former Prime Minister Stephen Harper, who unsuccessfully tried to shut down Vancouver’s Insite.

    BC declared a public health emergency in 2016, but the federal government has not followed suit. Decriminalization technically falls under federal laws, although enforcement varies widely in different communities, with de facto decriminalization already being practiced in some communities. In Victoria, police rarely prosecute cases of minor drug possession.

    The provincial government has said it cannot change the law, but Dr Henry noted in her “Stopping The Harm” report that the Province could amend the Police Act to achieve the objective. “This could include declaring a public health and harm-reduction approach as a provincial priority to guide law enforcement in decriminalizing and de-stigmatizing people who use drugs,” says Henry’s report.

    Portugal, which adopted a decriminalization approach in 2001—switching simple drug possession from a criminal to an administrative offence—is held up as an example of how decriminalization can work, especially when linked to intensive treatment strategies and harm reduction. The strategy has resulted in more people seeking treatment, fewer deaths, and no increase in drug use.

    Kendall says he would favour a similar system. “We decriminalize, and we find people who are at risk, and they would get an assessment by a physician or a nurse,” Kendall suggests. “Then, if we had something similar to the Portuguese system, you could be offered a treatment program—whether for alcohol or stimulants or opioids or, if you were deemed to be at ongoing risk of death or brain damage from illegal drugs, you would be eligible to pick up a certain amount of pharmaceutical opioids,” says Kendall.

    In the hyper-heated political atmosphere of the recent federal election campaign, the Conservatives described decriminalization and adding more safe consumption sites as “terrible” ideas, while the Liberals promised more treatment services and an expansion of programs such as safe consumption sites, but avoided commitments to safe drug supply or decriminalization. The NDP supported decriminalization and expanded treatment options, while the Greens promised decriminalization and “access to a screened supply.”

    “It seems to be a political third rail for almost every party,” says Kendall, speculating that the issue is too hot to touch politically.

    McBain is exasperated that governments are failing to recognize the severity of the public health crisis. “The people in power, who hold the purse strings, have not got the will or courage to make the really hard decisions, some of which are decriminalization and implementing safe supply,” she says. “We are in the middle of a wildfire and we do have access to water…The solutions are right in front of us and we can’t access them,” says McBain, who lost her only child, 25-year-old Jordan Miller, to an accidental opioid overdose five years ago after he became addicted to pain killers prescribed for a back injury.

    The figures should speak for themselves when it comes to the need to stop the deaths, according to Kendall. Last year, 4,488 Canadians died from opioid overdoses—which translates into about one death every two hours. “A Boeing Max 737 carries about 220 people, and when two of those go down in the world, every Max 737 is grounded. Then look at the number of people that are dying in BC and Canada—it’s planeloads,” says Kendall, adding, “Stop the deaths, stop the brain damage. As a humanitarian, I think it has to come, unless we are content to continue to see this kind of damage happening. It’s not just legalization, it’s building an evidence-based accessible continuum of care that includes effective recovery as well as maintenance programs.”

    Judith Lavoie is an award-winning journalist specializing in the environment, First Nations, and social issues. Twitter @LavoieJudith

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