Carolyn Sinclair is the manager of the BC Provincial Overdose Mobile Response Team, which provides crisis support to professional first responders. I first met Sinclair several years ago in her previous role as head of Police Victim Services of BC. She knows about supporting people in traumatic situations and she knows law enforcement. That, combined with her positive outlook and cheerful attitude, made her the perfect person for this new job. Her team was set up when it became clear that the relentless trauma of the opioid crisis was hitting first responders hard.
“In April 2018 we had 27 completed suicides by first responders,” said Sinclair. It was a startling figure, one that she believes is directly linked to the opioid crisis. I asked her to tell me about some of these individuals so that I could get a better idea of how this public health emergency was affecting them. In one instance, she said, “the firefighters arrived at the house and found a mom down. The first person in was a young firefighter. They didn’t realize that there was a little four-year-old girl that had also gotten into Mom’s drugs and that she’d crawled behind a chair. They didn’t know she was there until later. The little girl is still in an induced coma, and there are some firefighters that are visiting her every day. The first firefighter to that scene committed suicide.”
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The opioid epidemic has spread across the continent like wildfire. In the United States, more than 500,000 people died from drug overdoses between 2000 and 2015. And those figures have been accelerating, as they’ve been in Canada, owing to a dramatic increase in synthetic opioid–related deaths. In 2017, an estimated 70,237 people died from illicit drug overdoses in the U.S. That’s more than the total number of American troops, 58,220, who died between 1961 and 1975 during the entire Vietnam War.
In response, on October 26, 2017, the United States declared the opioid crisis a national public health emergency. Canada has yet to take that step. But despite the U.S. declaration, even the most rudimentary medical interventions that have been proven to save lives (such as “take-home” naloxone—the antidote to an opioid overdose—and supervised consumption sites) have faced roadblocks. President Donald Trump has instead insisted on building a wall on the US–Mexico border to deal with the problem—an idea that experts agree would do nothing to address it.
What’s responsible for causing this carnage?
The opioid crisis has many complex and interrelated causes. But the immediate starting point is a drug I’d never heard of until it started popping up in news reports about overdose deaths: fentanyl.
“The main driver of the crisis that we’re in is the contaminated drug supply, and we have little to no control over it,” said Chris Buchner, director of communicable diseases and harm reduction at Fraser Health, which covers the sprawling suburbs outside of Vancouver and has the unfortunate distinction of having the highest number of illicit drug overdose deaths of any health authority in the province.
“It’s horrendous. I hate people calling it ‘overdose,’ because people are being poisoned. ‘Overdose’ means they used too much. They’re using what they normally would,” said Shelda Kastor with the Western Aboriginal Harm Reduction Society. Indeed, Kastor’s explanation is backed up by data from the coroner’s office.
In 2012, fentanyl was found in just 4% of post-mortem toxicology investigations of illicit drug overdose deaths in BC—a negligible amount that no one really paid much attention to. Since then, illicit drug overdose deaths where fentanyl has been detected (on its own or combined with other drugs, such as cocaine, methamphetamine, and heroin) jumped to 15% in 2013, 25% in 2014, 29% in 2015, 67% in 2016, 82% in 2017, and a staggering 87% in 2018. Multiple drug use, including alcohol, is frequently identified in these cases, with fentanyl as a common denominator.
When you look at the annual number of illicit drug overdose deaths over the last decade—taking out those where fentanyl was detected—you see a relatively stable rate. In 2007 and 2017 alike, there were roughly 200 illicit drug overdose deaths in BC that did not involve fentanyl. Illicit fentanyl is clearly the immediate cause of the dramatic rise in overdose deaths. But, as I would find out, there was plenty of blame to be shared for this crisis.
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WHY IS FENTANYL KILLING SO MANY PEOPLE?
“I don’t have to breathe.”
That’s the thought that passed through Laurence Rankin’s mind as fentanyl began to cause him respiratory depression.
“Breathe. Don’t forget to breathe,” the nurse reminded Rankin, who was recovering from surgery in the hospital and had been given fentanyl to relieve the pain.
As deputy chief constable of the Vancouver Police Department, Rankin oversees the force’s response to the opioid crisis. His experience in the hospital helped him understand some of what’s going on when a person overdoses from illicit fentanyl. Fortunately for Rankin, who’d been given precisely titrated quantities of the potent painkiller and under medical supervision, he was fine. Illicit fentanyl has neither of those safeguards.
Canada’s illicit drug supply is contaminated. Experts say that fentanyl has been found in all street drugs except cannabis (contrary to some erroneous media reports), and that it has saturated the illicit opioid market. What’s sold as heroin in Vancouver often contains little, if any, pure white heroin. Instead, it’s a toxic cocktail that can consist of nothing more than “buffers,” like table salt and caffeine, with a few grains of fentanyl mixed in.
“The drug supply is shifting rapidly,” said Dr. Evan Wood, executive director of the BC Centre on Substance Use and a practising physician. “In clinic, we would see people and tell them that their urine toxicology screen had fentanyl, and they’d be surprised because they thought they were using other opioids, like heroin or OxyContin [a synthetic opioid pain-relief medication].”
Pure fentanyl comes in the form of tiny crystals or a white powder. Mixed into other substances, it’s invisible to the naked eye, odourless, and tasteless. There’s no way to tell whether a substance contains fentanyl without testing it. And even then you won’t know how much of the drug is mixed in.
“As long as we’re asking people every day to play Russian roulette with these drugs, people are going to continue to die,” said Dr. Mark Tyndall with the BC Centre for Disease Control.
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What is fentanyl, exactly? It’s a synthetic opioid, meaning that it’s not naturally occurring. Rather, it’s made through a chemical process—and, as a result, it has a potentially limitless supply.
“Fentanyl was originally developed for palliative cancer patients, and then it started to be used in some other kinds of pain management,” explained Linda Lupini, executive vice president of the BC Provincial Health Services Authority and BC Emergency Health Services. We were sitting in her seventh-floor office in downtown Vancouver. Lupini has thick, black-rimmed glasses and short dark hair. She was eager to help me understand the scope of the problem. Her experience with the opioid crisis is invaluable, as she’s run the province-wide ambulance service since 2014. Her team of analysts figured out that there was an epidemic of illicit drug overdoses, and they alerted the BC Ministry of Health back in 2015—the year before the public health emergency was declared. The team, which rapidly deploys resources to respond to clusters of overdoses, has had to develop innovative ways to reach vulnerable people. Every morning when she wakes up, Lupini told me, she checks her phone to see how many overdose calls and deaths there were the night before. It sounded like a horrible way to start the day.
Fentanyl’s intended medical purpose is as a powerful painkiller, sedative, and anaesthetic. A key feature is its potency: fentanyl is 30 to 50 times more potent than heroin and 50 to 100 times more potent than morphine. For most people, as little as two milligrams of fentanyl is a lethal dose. How small is that? Imagine just a few grains of table salt.
How exactly does a fentanyl overdose kill some
one?
“Fentanyl turns off the receptors that make you breathe,” said Lupini. “They slowly turn them off and you just literally go to sleep, but then you stop breathing in your sleep and you’re dead, essentially.”
It surprised me when I learned that fentanyl isn’t a new drug. In fact, it was invented in 1959 by Dr. Paul Janssen, a Belgian physician; in the 1960s it began to be used to treat people in medical settings as well as animals in veterinary medicine.
I was curious about when fentanyl made the leap to being used as an illicit narcotic outside these legal settings, so I did some case law research to see when it first made it onto the radar of the criminal justice system. It turns out that a veterinary office in Beauharnois, Quebec, just south of Montreal on the St. Lawrence River, was the unlikely location of Canada’s first reported fentanyl trafficking case. On October 17, 1980, Dr. Jules Blanchette, a 36-year-old veterinary surgeon, sold Inovar-Vet—an anaesthetic for animals containing fentanyl—for $200 to an undercover RCMP officer. Blanchette also purchased 63 grams of cocaine from a pharmacist he knew for resale on the black market. Blanchette was convicted.
The first time fentanyl is mentioned in any reported judicial decisions as being mixed or cut into street drugs was in a 2008 decision in Nova Scotia, where an expert identified fentanyl as one of a long list of illicit drugs that had been found in what was being sold as Ecstasy pills. So there’s some evidence of at least experimental diversion of licit fentanyl dating back almost 40 years and fentanyl being cut into street drugs over a decade ago. However, illicit fentanyl in street drugs doesn’t appear to have become widespread in the drug supply in BC until 2012–2013.
Dr. Janssen, who invented fentanyl, died in 2003, while he was attending a scientific conference in Rome. He never lived to experience the bitter irony that the drug he’d created to alleviate pain and suffering would ultimately bring so much misery and death.
If fentanyl sounds formidable, even more potent illicit drugs are now being detected in post-mortem exams. Carfentanyl is a chemical variation, or “analogue,” of fentanyl that was never intended for human consumption; it’s used in extremely small doses to sedate large animals like elephants. (In the movie Jurassic World, carfentanyl is used to sedate a Tyrannosaurus rex.) Carfentanyl is 100 times more potent than fentanyl and 10,000 times more potent than morphine. In fact, it’s so powerful that security experts are concerned that terrorist groups could use it in aerosol form as a weapon of mass destruction.
We don’t yet know how long carfentanyl has been part of the opioid crisis, since the BC Coroners Service started standard toxicology testing for it only in June 2017. Prior to that, it would have simply been identified as fentanyl. But since then, in just 10 months carfentanyl was detected in 81 illicit drug overdose deaths in BC. A batch of street drugs containing the substance is what keeps first responders up at night. Remarkably, though, some people, likely long-term drug users, are consuming it and surviving. They’ve developed a tolerance to it. “What’s amazing is the degree of carfentanyl positivity in living men that are giving urine drug screens that are getting analyzed,” said Dr. Wood. “You see 20% of fentanyl-positive samples that are actually carfentanyl positive.”
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But how did we end up with illicit fentanyl becoming so widespread in street drugs?
“The current situation is very scary,” said Oren Bick, senior counsel with the Public Prosecution Service of Canada. “I don’t know if it has an end. I think it’s a continuation of a historical cat-and-mouse game where people who want to sell narcotics, controlled substances, continue to find more unusual, more innovative ways of doing it.”
Bick is an experienced federal drug prosecutor. I first met him over 15 years ago when we were law students at the University of Toronto. He was friendly, bright, and the kind of guy who’d happily share his notes with you if you missed a lecture. Bick and I would occasionally discuss cases from our criminal law class, sometimes over a beer or two. Unlike me, he didn’t seem to have aged at all in the intervening years. I’d seen his name in the media as the lead prosecutor on a big fentanyl trafficking case, so I’d decided to reconnect with him.
“Every action has an equal and opposite reaction,” said Bick, explaining why illicit fentanyl started to become widespread around 2012. Back then, the big concern in Ottawa was prescription drug abuse. A growing number of pharmaceutical opioids were being misused, and an increasing number were finding their way onto the streets. The knee-jerk solution was to crack down on those drugs. It seemed to make sense at the time.
Most notoriously, OxyContin was widely available in the black market. It was being crushed, mixed with water, and then injected by people who use intravenous drugs as an alternative to illicit opioids like heroin. In 2012, the drug manufacturer responded by transforming OxyContin into a different drug, OxyNeo, which was designed to be “tamper-resistant”: it reportedly turned to a flat pancake when crushed and into a gel when it got wet, making it much harder to inject.
But that transformation had its own effects. “When you have this crisis of people abusing OxyContin and the response is to change the formulation of OxyContin to OxyNeo, which is supposedly less susceptible to abuse, enterprising drug dealers find a way to address that by manufacturing their own OxyContin out of fentanyl, with little regard to the consequences, obviously,” Bick told me. “Then when that’s so financially successful, they start to realize, ‘Hey, why are we even selling heroin anymore? Why on earth are we risking our necks to bring heroin in from Asia when we can get fentanyl so much easier, so much cheaper, and make our own heroin?’ So once the OxyContin opening hit, that made people understand that fentanyl could be used as a substitute for other opiates. There was no going back.”
Bick’s explanation of the tectonic shift that’s taken place since 2012 in the illicit drug market represents quite a paradox. The attempt to crack down on prescription drug abuse had backfired, and it was this unintended consequence that prosecutors, police, and groups that represent people who use drugs all pointed to as one of the main catalysts for the current crisis.
“The government had no exit strategy once they took OxyContin off the market,” said Jordan Westfall, president of the Canadian Association of People Who Use Drugs. “Those people still needed to use drugs. Watching this happen, it’s traumatic, it’s horrific. It just confirms that this whole approach is not working.”
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I wanted to know what role, if any, the alleged overprescription of opioids by doctors has played in the opioid crisis. In the United States, there’s strong evidence that in recent years it has directly and indirectly contributed to an increasing number of overdose deaths. As a result, there have even been criminal charges against doctors in the U.S. and lawsuits against pharmaceutical companies.
“To some extent the medical profession has brought this upon us by not very responsible prescribing, and the pharmaceutical industry by overselling and misleading,” said Dr. Richard Frank, a professor of health economics at Harvard. Dr. Frank worked in President Barack Obama’s administration coordinating the Department of Health & Human Services’ response to the opioid epidemic.
Purdue Pharma introduced OxyContin in the mid-1990s, claiming that its delayed absorption was “believed to reduce the abuse liability”; in other words, allegedly suggesting that it was less addictive. Physicians were allegedly the target of aggressive marketing, including OxyContin-branded swag like fishing hats and stuffed toys, along with “starter coupons” that would give patients a free initial supply of the opioid medication. Medical residents were allegedly taught that, if the patient was in true pain, they didn’t need to worry about the potential for addiction. Opioid prescription rates skyrocketed, with drug overdose deaths in the United States steadily increasing from 1999 to 2012. And since then, as illicit fentanyl became widespread, there has been an even greater i
ncrease in drug overdose deaths.
In February 2018, after making more than US$35 billion from selling OxyContin, Purdue Pharma announced that it would no longer market opioids to doctors in the United States and that it was cutting its sales force in half. The company has denied deceptive marketing in numerous lawsuits brought against it. In September 2019, the company filed for bankruptcy due to a growing number of lawsuits for its alleged role in the opioid crisis.
“The fact is that we are awash with more opioid pills than we need,” said Dr. Frank, “and, at least in the United States, [for] most people who wind up misusing pain medication, the prescription typically wasn’t for them. It was for somebody else. We’re just allowing a lot of extras to be floating around, which then creates this secondary market.”
In central and eastern Canada, there appears to be a clear link to pharmaceutical products playing a role in the black market, particularly fentanyl patches prescribed for pain management. Those patches have been cut up and have made their way onto the illicit market, leading to requirements that patients return used patches before getting another one from their pharmacist. Some people have even chewed used fentanyl patches, trying to suck out that last bit of fentanyl.
A CBC investigation found that an average of half a million doses of prescription drugs are stolen every year from pharmacies, and that the majority of these are opioids. Prescription drug theft has been increasing in provinces like Ontario, but has substantially declined in BC since 2012. Indeed, all the BC-based experts I interviewed agreed that there isn’t any noticeable quantity of prescription fentanyl products being diverted to the black market. Some pointed to a study by the BC Coroners Service which found that relatively few overdose deaths—about 75 annually—are caused directly by prescribed opioids.
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