He noted that one of their recent convictions for fentanyl trafficking had netted a 12-year prison sentence. But King is under no illusions about what he and his policing colleagues are up against. “Well, I’m not entirely sure that what we’re doing is working, because our sole goal is to stop overdose deaths,” he conceded.
King and all the other law enforcement and border officials I spoke with were clearly dedicated to their work. They were committed to doing what they could to address the opioid crisis. But they also frankly admitted to me, to varying degrees, that trying to have any major impact on the opioid crisis by waging a war on the supply of illicit fentanyl is not going to work. Period.
With a synthetic drug like fentanyl that can be made anywhere on the planet, it’s all the more impossible to stamp out the supply. Add the dark web, cryptocurrencies, and a lack of legal tools to the mix, and you’ve got a seemingly insurmountable task.
“Am I a believer that we’re going to be able to turn off the tap of illicit fentanyl?” King asked. “We haven’t been able to turn off the tap of cocaine or heroin for 60 years.”
–9–
WHAT IS NALOXONE AND IS IT THE SOLUTION?
Any other time a regular citizen saved 148 lives, they’d be in the national news and get a medal from the Governor General. We’d all know their name. A school, park, or city street would probably get named after them too.
Surrey’s 135A Street—known locally as “the strip”—is a place few Canadians have heard of. On any given night in early 2018, there were 80 to 90 tents with 90 to 140 people living in them on this derelict side street that’s about 40 minutes from downtown Vancouver. Nearby there’s a corner store, a thrift shop, a pawnbroker, fast food restaurants, a food bank, and some low-rent hotels. The homeless residents of this tent city, which stretched for three blocks, included people with mental health and substance use issues. The RCMP got involved because of increasing property crime in the area and violent crimes being committed against these vulnerable homeless people.
“The violence in that community from drug dealers was huge, it was astronomical,” said Inspector Shawna Baher with the Surrey RCMP detachment. Among other responsibilities, she heads up the drug section, criminal intelligence section, and gang task force as well as the auto crime and property crime units. Talk about having a lot on your plate at work. Baher has short, straight brown hair and has worked undercover. I’ve met other undercover officers before and, like Baher, you’d never know they were cops if you saw them on the street.
“What kind of offences were you seeing at 135A Street?” I asked her.
“Beatings, stabbings, robberies, a lot of intimidation, sexual assault on females.”
I met Baher and her boss, Assistant Commissioner Dwayne McDonald, at the Surrey RCMP headquarters, just across the street from the busy provincial courthouse. McDonald, who has 26 years of policing experience, was promoted in November 2016 to officer in charge of the Surrey RCMP—essentially the chief of police. Nothing could have quite prepared him for taking on that role in the midst of the opioid crisis. Seeing the rising overdose death count across Surrey and the ongoing crime happening on 135A Street, McDonald and his team had to try something different.
“We developed the Surrey Outreach Team,” he told me. “We basically placed 16 regular RCMP members in a portable office, for lack of a better word, or trailer, and we’ve partnered with Fraser Health, with BC Housing, with bylaws, and with the Front Room [a non-profit community agency]. Our main mandate in that area is to develop relationships with the people there, try and help them transition from 135A to housing, to treatment, to rehab, to anywhere other than having to be homeless.”
When McDonald arrived, the situation on the strip was downright dystopian.
“People would be vacating their bowels in buckets in tents and then just throwing them out on the street,” he said. “We put in some bathrooms. Well, I think we’ve gone through two service providers already who have refused now to continue because it’s so filthy. In agreement with the City and bylaws, we’ll go in every morning and do a cleanup. Everyone brings out their junk and stuff they don’t want anymore. Everyone will take their tents down and we’ll power wash the street every two weeks now, just because it’s necessary.
“We’ll do a tent count and a person count every day, usually at night. Last night we had 82 tents. The number of people sleeping in tents were 115, and I think there was maybe one arrest because of a fight.”
Another purpose of the Surrey Outreach Team’s daily walk-around is to get to know people on the strip, especially newcomers, and try to direct them to services. Peer-based support is also part of 135A Street.
And given the massive number of overdoses in the area, naloxone, which can reverse an opioid overdose, has been handed out widely. “With the advent of the use of naloxone and the fact that, especially in some of the higher-risk areas, it’s provided free to the clients, we find out that a lot of them are reviving each other and aren’t calling police, fire, or ambulance,” said McDonald. The widespread free distribution of naloxone to the residents of 135A Street is credited with saving countless lives.
One person living there even took it upon himself to help out.
“We had one guy, what was his name? Jim,” said Inspector Baher. “He was a homeless guy, and he rode his bicycle up and down 135A Street. Doug, that was his name. Just driving around with a little take-home naloxone kit and administering it. You have people like that, who are taking responsibility. He’s not only educating. He’s out there helping people, and he’s trying to do it from that grassroots movement.”
I wanted to find out more about Doug.
Coincidentally, as I was doing some further research, I visited the BC Centre for Disease Control’s naloxone website (www.towardtheheart.com). At the bottom of the page was a video about someone named Doug. Could it be the same guy? I clicked on the link.
“They call me ‘Little Doug’ on the street,” said the man in the video. He had a kind, gentle voice. Hazel eyes, a weathered but friendly face. A reddish beard and wavy, shoulder-length hair. “I carry naloxone in Surrey,” he said. “Since I was homeless and in that neighbourhood where the demand was, I thought I could do something useful. That’s what it’s all about, is preventing death.
“Fentanyl is a new addition causing a lot of overdoses. There are no sure ways to reverse an overdose other than naloxone. It’s the wonder drug that changes the event.”
It turns out that “Little Doug” is Douglas Nickerson. He’s the guy Inspector Baher was talking about—the guy driving around 135A Street on his bicycle, saving lives with naloxone all on his own.
All told, Little Doug reversed 148 overdoses. He was honoured with Surrey’s “Heart of the City” Award a few days before he died from pancreatic cancer on October 28, 2017. He was 59 years old. I don’t know exactly why, but watching him share his story in that video, in his own words, brought tears to my eyes. Maybe it was the small glimmer of hope that I finally saw shining through after weeks of hearing about little else but death and hopelessness.
Little Doug’s selfless heroism and gentle humility, all the while himself homeless and having struggled with opioid addiction, were so inspiring. I wish I could have met him while he was alive. I wanted to do something to recognize what he and countless other unsung heroes have done during the opioid crisis, and so that’s why I’ve dedicated this book to his memory. Now you know the name of this hero too.
* * *
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“It’s a miracle drug,” said Linda Lupini. Naloxone has a remarkable ability to seemingly resurrect people who are barely breathing, or not breathing at all—just a few minutes later they’re walking around and talking. That’s the reason it’s sometimes called the “Lazarus” drug, alluding to the Biblical account of Jesus raising Lazarus from the dead. It’s no exaggeration to call it an “antidote” to an opioi
d overdose.
Naloxone is an “opioid antagonist” medication, meaning that it blocks opiate receptors, temporarily reversing the effects of opioids like fentanyl, heroin, and oxycodone. During an overdose, opioids are telling your brain to breathe less, or to stop breathing altogether. Naloxone works by temporarily stopping those signals, which can be life-threatening. It can take three to five minutes for naloxone to take effect, so overdose victims may need to be given rescue breathing to ensure that enough oxygen is reaching the brain. In serious cases, an overdose victim may go into cardiac arrest and also need CPR. If you don’t have naloxone, you can still try to save someone’s life by breathing for them and calling 911 until help arrives.
Sold under the brand name Narcan, naloxone is the number one emergency response for keeping people alive during an opioid overdose. For that reason, Health Canada “delisted” naloxone in March 2016, meaning it can now be obtained over the counter, without a prescription.
Naloxone is typically administered through an intra-muscular injection (into the muscle of the arm, thigh, or buttocks) or as a nasal spray. It’s safe and can be given by someone who has minimal training—studies have shown naloxone to be 94% effective when administered by laypeople. There are no known negative consequences of giving someone naloxone if they’re not, in fact, experiencing an opioid overdose. And there’s no potential for it to be abused. So experts say that when someone is exhibiting signs of an overdose and you’re unsure whether opioids were the cause, it’s still safe to administer naloxone.
The more potent the opioids, the greater the quantity of naloxone may be needed to reverse the overdose. Many overdose victims require several doses in order to be revived. If carfentanyl caused the overdose, it can reportedly take nine to ten naloxone doses to revive someone—and that’s several take-home naloxone kits’ worth of medication, so one kit wouldn’t be enough.
There’s something ironic about the fact that naloxone was developed at almost exactly the same time as fentanyl, but on different continents by two different teams of scientists.
“I look at that almost in a weird way—like if we were to believe for a second that there’s this kind of yin and yang, as it were, for the universe,” said Staff Sergeant Conor King. “Just when fentanyl came along, naloxone had been around for years but it became more widely available, and it’s like the two fit together in this weird kind of way.”
Indeed, the original patent for naloxone was filed in 1961. Its original aim was to deal with one of the less serious side effects of opioid addiction: constipation. Its inventor, Jack Fishman, had no idea that it would come to save hundreds of thousands of lives during the opioid crisis for its ability to reverse the effects of an opioid overdose. He died in 2013 at the age of 83, never having profited from the life-saving drug he invented because the patent had expired. Tragically, his own stepson died from a heroin overdose in Florida when naloxone was still tightly controlled and hadn’t yet been made available to the public.
* * *
——
“Someone’s down!”
“People would literally be yelling at paramedics,” said Lupini. “We had bike paramedics to go through alleys and lanes, and that worked really well because they’ve got all their equipment with them. Otherwise they’re parking, they’re running quite a distance with drug kits and all sorts of things.”
In the early days of the opioid crisis, as overdose rates skyrocketed, Lupini’s ambulance service had to split up paramedic teams to patrol solo on bikes, roving around high-risk areas rather than waiting for 911 calls. The bike paramedics were literally waiting for someone else to drop to the ground, no longer breathing, their skin quickly turning blue.
The first emergency response to the opioid crisis is to keep people alive who have overdosed. Since every second counts during an overdose and naloxone is the antidote, it must be freely available and widely distributed anywhere an overdose has occurred or is likely to occur. People need to be trained and know how to administer it during an emergency. That training is available for free online at www.naloxonetraining.com and takes only 10 to 15 minutes.
In addition to all the paramedics, firefighters, and police officers carrying and being trained in how to administer naloxone, it should be widely distributed for free to the general public, including people who use drugs, their families and friends, and people being released from custody. These take-home naloxone kits should also be renewed as they’re used or expire. Because of the stigma around drug use and its ongoing criminalization, there can’t be any barriers around accessing this lifesaving drug.
A BC Centre for Disease Control study published in The Lancet Public Health journal found that the rapid, wide-scale distribution of naloxone kits has prevented even more overdose deaths from occurring in BC. Between January and October 2016, 298 deaths were averted—over a quarter (26%) of all possible overdose-related deaths—by the administration of naloxone by drug users, community organizations, and concerned citizens—people like “Little Doug” Nickerson. Tragically, the same Lancet study found that if the take-home naloxone program had been ramped up earlier, an additional 118 lives would likely have been saved.
“People self-report back and say, ‘I used my kit. I saved my friend,’ ” said Inspector Bill Spearn. “Take-home naloxone was probably one of the most successful harm reduction initiatives we’ve had.”
As I walked through the Downtown Eastside to meet with various people for this study, I saw the distinctive kits everywhere I turned, often dangling from backpacks. They look like a black sunglasses case with a zipper, bearing a cross emblazoned with the word “NALOXONE.” These kits contain naloxone itself (either in a nasal spray or in ampoule vials with syringes) along with alcohol swabs, protective gloves, a breathing mask for providing mouth-to-mouth resuscitation, and a card describing exactly what to do in the event of an overdose. They’re distributed by pharmacies and various organizations, many of which have weekly standing orders for them.
“We are the first first responders,” said Shelda Kastor. “We’re the ones who keep them alive. Those are our friends, they’re people we know.” Kastor has personally administered naloxone 14 times to help people who’ve overdosed.
“The first one is always very scary,” she told me. “I was working the window at Washington Needle Depot and somebody came to the window and said, ‘We need the kit! We need the kit! Somebody’s OD’d.’ I was there by myself, so I locked up the place, grabbed the kit, and went running out. Just as I saw the guy, I realized there’s a cop car at the end of the alley.” She threw the naloxone kit she had at the person who’d come asking for it so that they could get started. “I ran down to the cop and said, ‘There’s a guy OD’ing! There’s a guy OD’ing!’ The cop says, ‘Go run down to Insite and get a nurse.’ I said, ‘Are you fricking kidding me?’ ”
There was no time to get a nurse. Kastor left the police officer and ran back to the person who’d overdosed. She readied a naloxone dose in a syringe for the first time. “When I went to puncture his thigh, I was like ‘Oh my God, am I going to go too deep and get him in the bone or something?’ It was very scary.”
“What happened?” I asked.
“He died.
“They all survived after that. One time it was so cold out my fingers got numb, and I was trying to snap that little vial. And those things can snap and break and can cut your hands, cut your fingers. My fingers were so, so cold I couldn’t even snap the thing. All I’m worrying about is, ‘I gotta get this open so I can help this person.’ ”
“The people carry naloxone on the streets, and everyone has their needles out when somebody ends up in a perceived or real overdose event,” said Vancouver Fire Chief Darrell Reid. “A lot of times, our crews are finding that the person’s received naloxone even before we’ve arrived a minute later, a minute and a half later. Our specialty in patient management has actually become early managemen
t. That’s the life-saving skill, more so than the administration of naloxone. It’s a real basic resuscitative skill.”
That’s been the experience in Victoria as well. As Daniel Atkinson, deputy fire chief for operations with the Victoria Fire Department, told me, “What we’re seeing now is that because there is such a saturation of naloxone on the street and available to the end user, there’s more self-administering or partner administering and less activation of first responders as a result of that, because I think it’s being managed at the street level. Our guys arrive on site, and it would be another user who has already actually administered the naloxone on the street. They’re so much better at it, we don’t do it a ton. I guess these guys, they’re pretty versed with the needle.”
Unfortunately, not all jurisdictions that are in the midst of the opioid crisis have made naloxone widely and freely available. Shockingly, there are media reports that individual pharmacists who’ve taken the initiative to get naloxone out into affected communities have faced censure. A comprehensive review by the Canadian Pharmacists Association in November 2017 found that improvements must be made to increase access to naloxone across Canada. At the time of their review, only Alberta, Ontario, Quebec, Nova Scotia, the Northwest Territories, and Yukon were providing free, unrestricted access to naloxone—and even then there were some barriers (e.g., in Ontario a valid health card had to be presented, which presents an impediment for some vulnerable populations). BC has since joined the list.
“Naloxone should be readily available to all Canadians at no cost, regardless of where they live,” said the Canadian Pharmacists Association. “We therefore recommend that all provinces implement publicly-funded Take-Home Naloxone programs to ensure that naloxone is available to all residents without restrictions on eligibility, supply or cost. Furthermore, naloxone should be available through a variety of providers, including community pharmacies, community health centres, and first responders.”
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