To start with, Egilson confirmed what researchers had been saying for years, even before the opioid crisis: people released from jail are at high risk of dying from a drug overdose. The first two weeks after release are especially dangerous.
“Their tolerance is lowered,” said Linda Lupini with BC Emergency Health Services. “So, now what? So now they go straight to where they buy something on the street, not knowing what’s in it. Their tolerance is lower, and they die unless somebody sees them or we get called. So we do see a high proportion of people coming out of correctional facilities.”
The same phenomenon has been observed in the United States. “While there is access, obviously, to drugs in prisons, it’s not the same as on the street,” said Dr. Richard Frank. “People were used to using certain doses when they go into prison. They’re not getting that anymore, and then they come out and go back to their old dose—and they basically immediately overdose because their bodies haven’t been acclimatized to that anymore.”
In his medical practice in the Downtown Eastside, Dr. Ronald Joe, medical director for substance use services at Vancouver Coastal Health, has seen many people with opioid use disorder who’ve recently been released from jail. He told me about the lengths to which one of his recent patients went to get help after being tossed out of pre-trial custody without any support whatsoever. “He had a few scratches on his face,” Dr. Joe told me. “I said, ‘How are you feeling? You look a little bit ruffled up,’ and he said, ‘Yes. I’m a bit ruffled up. I was released from prison and I actually hiked here from Coquitlam to the Downtown Eastside. I know all the special trails. That’s why I have some scratches—from a few branches here and there.’ ”
I asked Dr. Joe why this man had hiked over 30 kilometres to come to his clinic.
“He was released without a prescription,” he responded. “So he just came for a prescription.”
“For what?”
“Opioid agonist,” said Dr. Joe, referring to Suboxone or methadone—medications that would help prevent his client from going into withdrawal, which would have made him more likely to use illicit opioids and overdose.
It’s remarkable what people like Brandon Jansen and Dr. Joe’s patient will do to seek help for their opioid use disorder. It upset me to hear how the corrections system was leaving them at greater risk of overdosing just when they want to get help. And the risk of a fatal overdose after release from custody actually persists for years. According to Egilson, 44% of those who fatally overdosed and had been in custody died within two years of being released. So much for helping people reintegrate into society and rehabilitate.
People in custody should have equal access to the medical interventions and evidence-based treatment options discussed later in this book. It’s in their best interest, and it’s in society’s best interest. Right now, though, they’re basically tossed out with little, if any, support. And like Brandon, each of them is somebody’s son or daughter.
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East Hastings and Main streets intersect at the epicentre of Vancouver’s Downtown Eastside, where one of the most visible homeless populations in Canada can be found. Many here suffer from serious untreated mental health issues, fetal alcohol spectrum disorder, physical disabilities and injuries, and substance use disorders. There’s also a notable proportion of Indigenous people.
Groups of people mill around while others sit on pieces of cardboard. The long lines are for warm meals offered by local charities. Parts of syringes litter the sidewalks despite efforts to clean them up. There are people in wheelchairs struggling to cross the busy streets in time—one man backs his wheelchair across, kicking the ground with his foot to slowly propel him along. Shopping carts are filled with a person’s earthly belongings. A man rocks rhythmically back and forth facing a brick wall. There’s the acrid smell of urine near the alleyways. Others lie on the hard concrete, wrapped up in distinctive thin white blankets with blue lines; I recognize these from the hospital.
“Most of us are just a couple of paycheques, one injury on the job, or one mental health crisis away from homelessness,” said Jennifer Breakspear, executive director of PHS Community Services Society.
Places like the Downtown Eastside and the tent cities found in many other places are Canadian skid rows. I’m always baffled—and annoyed—when some journalists call these homeless people “campers,” as if they’re on some sort of pleasant vacation with campfire singalongs and marshmallows.
Despair and drug use are frequent companions. It’s not surprising that there are so many overdoses among people who are homeless or living in precarious housing, whether these be emergency shelters, temporary housing, or ultra-low-rent (and often derelict) single room occupancy (SRO) facilities.
“Welfare Wednesday” is a day that first responders in these areas dread. They know that it brings a spike in illicit drug overdose calls, and that more people will die. It’s the day when monthly income assistance cheques are given out in BC—cheques that barely cover a rundown room and subsistence expenses. The amount of money for food works out to just $19 a week, less than $1 a meal. Try living on that. I did, as part of the 2017 annual #welfarefoodchallenge organized to raise awareness. I lost several pounds and felt lethargic. I was constantly hungry, unproductive at work, and cranky at home. And that was after just a week. In 2018 the challenge was cancelled because rising costs meant that the amount of money left over for food would be just $6 a week—less than a dollar a day. Living long-term on that pittance would lead to countless health problems and affect you in myriad ways. But even food takes a backseat when you have opioid use disorder. That’s how powerful it is.
“When you get money as an addicted substance user, it’s your first thought,” said Troy Balderson, downtown projects manager with Lookout Society. “It really is. Before food. Before anything, you want to take that pain away, whether it’s traumatic pain, whether it’s emotional pain, or whether it’s physical pain.”
As Andy Watson with the BC Coroners Service told me, “On the five days that follow income assistance payments, we’re seeing almost double the number of deaths per day than we do on other days of the month. For 2017 alone I believe it was almost six deaths per day…whereas in the rest of the month we were closer to three.”
“This past Wednesday,” said Linda Lupini, “we did 104 overdoses.” She explained that, right across the province, there’s usually double the number of 911 overdose calls on income assistance Wednesdays (a typical day will see 50 to 60 overdose calls). “Sometimes we start to see people the day before because sometimes they go to Money Mart.”
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Coastal BC’s temperate climate is a draw for homeless people from across the country. After all, it’s next to impossible to live outdoors in the frigid weather most of the rest of Canada endures during its snowy winters. Another prominent reason the Downtown Eastside always seems to be attracting people is the access to services. The fact that a sizable proportion of Downtown Eastside residents have serious mental health challenges is partly related to the 2012 closure of nearby Coquitlam’s Riverview mental health facility, which advocates say occurred without any real plan to help patients afterwards.
“Somewhere between 20 to 30% of the folks who come to access care are newcomers to the Downtown Eastside. It’s up each and every year,” said Dr. Joe. “They come from adjoining jurisdictions, whether it be proximal—Burnaby, Surrey, and further north, Prince George and so on—or from back east. You have people from Alberta, Saskatchewan, and Ontario. The issue of the Downtown Eastside isn’t an issue of the residents of the Downtown Eastside. It’s actually a Canadian issue.”
At Vancouver’s Downtown Community Court, that’s been Judge Elisabeth Burgess’s experience, too. “This is a place that’s been made more supportive, and services are available. You can live here on the street,” she pointed out. “It’s not so
mething I’m recommending, but it’s doable, and of course our climate makes a difference to that as well. There have been estimates of how much money gets poured into the Downtown Eastside on a daily basis, and the lowest I’ve seen is a million dollars a day for services.
“Every day in court I listen to people talking about how ‘I came here from’—naming the other province—‘because I thought it would be easier.’ But a lot of them say their life’s just gone to hell because drugs are so much more easily accessible here—illegal street drugs. They want to go back home, and they’ve gotten in terrible trouble. These are people with no criminal record usually. They come here and they just start cycling through the courts and developing serious health problems along with the addictions as well.”
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Indigenous Canadians have been hit particularly hard during the opioid crisis. I wanted to understand why, and what’s being done to help.
Shelda Kastor, who is 55 years old and living in the Downtown Eastside, is from the Ochapowace Nation, part of the Cree First Nation. “I was born in Saskatchewan,” she told me. “My parents kept me till I was 18 months old before I got scooped, and then I went through living hell until I got adopted, two weeks before I turned seven.”
As a toddler, Kastor was one of thousands of Indigenous children taken from their homes as a result of child welfare policies established in the 1960s. These racist policies involved transferring Indigenous children to typically white homes, in some cases relocating them to other provinces or countries without their parents’ consent.
The “Sixties Scoop,” as it’s known, represents a shameful period of Canadian history, one that Kastor and others say hasn’t really ended. Indeed, Statistics Canada data reveals that although Indigenous people comprise 4.3% of Canada’s population, almost half (48.1%) of all children 14 years and under in foster care are Indigenous. Moreover, compared with only 0.3% of non-Indigenous children, almost 4% of all Indigenous kids are in foster care.
“I’m surprised I even made it,” Kastor said. “I’m surprised I’m as sane as I am. I couldn’t do anything about it then, but I sure the hell can now. I’m a real little fighter,” she added with a grin. “I was adopted by a well-off white family. I was always the only Native, and I was always so ashamed. I always had to fight.”
“Do you know anything about your birth parents?” I asked.
“I do, actually. I have an unbelievable memory, and I’ve always known my real birth name, which is totally blacked out on my adoption papers. I just sort of got into contact with my tribe, and the chief said my real mom is still alive. Apparently she tried to phone here once, but she didn’t leave a number, so I couldn’t call her. Meanwhile, while that happened, my son died. He didn’t get to meet his grandmum.”
Today, Kastor is a board member and secretary of the Western Aboriginal Harm Reduction Society (WAHRS), which has about 300 members and operates out of the Vancouver Area Network of Drug Users (VANDU) headquarters on East Hastings Street. When I went to meet her there a huge lineup of people were outside, filling the main entrance. I assumed it was for a free meal or something, which is a common sight in the Downtown Eastside. I didn’t want to look as if I were jumping the queue, so Kastor managed to wiggle through the mass of people to find me on the sidewalk outside, her eyeglasses pushed up on top of her long dark hair. I was surprised when she told me that everyone was there for a weekly education meeting. I felt guilty about the assumptions I’d made.
“We’re the only Aboriginal harm-reduction group in the entire world,” said Kastor. “The other thing I like to say is we’re the newest tribe, because we’re all products of residential schools or the Sixties Scoop. We’re Natives from all over. We’re just trying to find our way. We basically lost our culture, and because we’ve been discriminated against and everything like that for years, it’s a way of bonding together. One of the main things is to empower our people and have a voice.
“There’s underlying issues why people use to begin with—you don’t just go ‘Yeah, I want to use drugs.’ It’s to stop the pain, especially for Native people. Not only the pain from residential schools or the Sixties Scoop; it’s everything about losing their family. They thought their parents deserted them when they got scooped. They couldn’t figure out why their parents didn’t come get ’em. And then the parents felt bad because they let the kids get scooped.
“We have our ‘One Heart’ healing circle,” Kastor told me. “It’s just a circle—there’s two facilitators, there’s an Elder. You can talk about whatever you want, like what’s hurting you. They’re very, very powerful. A lot of crying, a lot of laughter. People just love being there.
“We need healing, especially with the opioid crisis going on.”
Data from the First Nations Health Authority shows that although Indigenous people comprise 3.4% of the population in British Columbia, they account for 10% of all illicit drug overdose deaths and 14% of all overdose events in the province. “Indigenous people are disproportionally represented in people who overdose, people who are addicted, people who die,” said Dr. Bonnie Henry, BC’s chief medical officer.
“People who are self-declared as First Nations were three times more likely to die of an illicit drug overdose than non–First Nations British Columbians,” confirmed Andy Watson with the BC Coroners Service.
What’s driving such disproportionate numbers?
“Many of the roots of the problems are related to colonization and intergenerational trauma and lack of community and culture supports,” said Dr. Henry. The horrific legacy of the residential school system is continuing to be felt today in many ways. Indigenous youth who had a parent attend residential school have an increased risk of substance use. Indeed, intergenerational trauma can be a huge driver of substance use. So instead of blaming Indigenous people for using illicit drugs, we should be taking a look in the mirror at how our country has directly caused their precipitating trauma in the first place.
“I think it’s a very complex picture,” said Dr. Shannon McDonald, acting chief medical officer with the First Nations Health Authority. “We have a pain problem, not just a drug problem. Many individuals with histories of trauma, with histories of poverty, with histories of being dealt with in our systemic racist society are more likely to be in the category of somebody who needs help, who needs support. And instead they’re often pushed away, labelled, and poorly treated when it comes time to access healthcare and other services to change that trajectory.
“In working with some of the individuals I’ve met who have a history of use, they often talk about very painful histories, personally in their family, nation, and the situations of their childhood. For example, many of them have been children in care. Come from abusive situations. The use of opioids, alcohol, and other mood-altering drugs helps them cope with systemic painful situations.”
“There’s a huge role in trauma in the Indigenous population,” said Dr. Joe, who has treated many Indigenous people with substance use disorders over the last several decades. “It’s very difficult to digest. They’re using substances as a means to take away the pain and, more so, to make a bit of their current life less painful. It’s very difficult to hear. It affects a lot of people—not just opioids, but other substances as well.”
As I looked more closely at the impact of the opioid crisis on Indigenous people, two other aspects came to the surface. One was gender.
“We saw that four in every five deaths across the province involved males,” Andy Watson told me. “Well, in the First Nations communities the number was closer to being equally split [between men and women].”
“The gender flip was surprising to me,” said Clayton Pecknold. “We’re all scratching our heads on that.”
Compared with non-Indigenous women, Indigenous women were eight times more likely to overdose, and five times more likely to die from an illicit drug overdose. “
We know that many young Indigenous women have been left without the protections of family and community for different reasons in their lives, and have been victims for much of their history,” Dr. McDonald explained. She spoke about how Indigenous women in the Downtown Eastside have been treated as disposable to society, as found by the BC Inquiry into Missing and Murdered Women. “There isn’t a lot of value placed on them as human beings in those circumstances. It’s quite tragic.”
“The rate of Aboriginal girls dying is phenomenal,” said Shelda Kastor. “They get used and dumped on from the minute they sort of end up on the street. The dealers, everybody uses the girls. That’s one of the reasons Native women go missing so often. They think we’re disposable for some reason. We gotta make sure that they know that they are somebody. That they can be somebody. We’ve started, with money from the city, to do an outreach thing to go and connect with those girls down there. Try and keep our girls safe.”
The second aspect that struck me about the opioid crisis as it affects Indigenous communities is social dislocation.
“About 90% of the deaths of status First Nations individuals in the opioid crisis have occurred away from home,” said Dr. McDonald. “People who are regularly using opioids often have trouble accessing those drugs in their communities and have left home in order to sustain that habit.”
Many Indigenous communities have grappled with alcohol abuse for a very long time. The dominant treatment model has been abstinence. However, as we’ve seen, opioid use disorder is a very different condition—one in which abstinence actually increases the risk of an overdose death when a relapse occurs.
“There are practical things, in that the response to alcohol in First Nations communities in particular has always been very much an abstinence-based program, and it’s been a challenge to talk about addictions to opioids and how that’s not necessarily the best approach,” said Dr. Henry.
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