A recent death review panel by the BC Coroners Service recommended that everyone who’s been released from incarceration and under corrections supervision in the community have access to a take-home naloxone kit, given how significantly overrepresented these individuals are in overdose death statistics. A program in the United Kingdom that gives prisoners these kits upon release was found to significantly reduce opioid overdose deaths among that population.
Remember Brandon Jansen? He was the 20-year-old who died of an illicit drug overdose at the Sunshine Coast Health Centre after being released from jail. I was shocked to read in the coroner’s inquest that naloxone wasn’t available at the recovery centre at the time he overdosed. The coroner’s inquest jury recommended that all substance use treatment centres educate clients with opioid use disorder about the risks of relapse, ensure they understand about tolerance levels, provide training for staff on administering naloxone, and give patients a take-home naloxone kit when they’re discharged.
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Despite all the evidence that naloxone saves lives and that it’s cost-effective and safe, I was surprised to find that some people are still opposed to making it widely available.
“Naloxone does not truly save lives, it merely extends them until the next overdose,” said Paul LePage, Maine’s Republican governor. In April 2016 he vetoed a bill to make naloxone available over-the-counter to people at risk of overdosing, or to their family members. It “serves only to perpetuate the cycle of addiction,” LePage said.
That’s like saying giving CPR to someone suffering a heart attack merely extends their life to their next heart attack. By LePage’s logic, we should just let those people die too. Restricting access to a critical life-saving medication like naloxone is heartless and cruel. The research is clear: delaying the rapid distribution of take-home naloxone costs lives.
Likewise, an article recently made its way around the Internet claiming that naloxone encourages riskier drug use as a result of “risk compensation,” the argument being that, given naloxone’s availability, people will engage in riskier drug use because they perceive the chances of dying from an overdose as lower. The argument, along with the methodology behind the article, was thoroughly dismantled by numerous experts.
Indeed, researchers found that naloxone does not encourage increased drug use. To the contrary: there are studies showing the opposite. In one study, intravenous drug users who were educated and trained in how to respond to an overdose with CPR and naloxone saved the lives of their peers while decreasing their own drug use over a six-month period. Medical experts say that “this is likely because people who use opioids are very averse to naloxone induced opioid withdrawal, and opioid overdose education may reduce incremental risky behaviors.”
Even Dr. Jerome Adams, the U.S. Surgeon General appointed by President Donald Trump, recently issued an advisory calling for naloxone to be made widely available to patients prescribed high doses of opioids, illicit drug users, people abusing prescription opioids, healthcare practitioners, family and friends of people with opioid use disorder, and community members. The simple message from Dr. Adams is this: “Be Prepared. Get Naloxone. Save a Life.”
Another concern people might have about helping someone they believe is overdosing is that they could be sued if the person is injured or dies, even though they were just trying to help. But most provinces, including BC, have civil “good Samaritan” laws so that laypeople can’t be sued for damages if they provide help during an emergency, unless they’re grossly negligent.
Many public places now have automated external defibrillators (AEDs) to save the life of a heart attack victim when there’s no time to wait for professional first responders. The same should be the case with naloxone. That means making naloxone, and people trained to use it, available at all venues where there’s a chance of an overdose occurring. When UBC recently hosted a roundtable on the opioid crisis attended by people who use drugs (who sat at the table as experts alongside physicians and professors), it had several naloxone kits on hand for anyone to access. It wasn’t promoting drug use—the medication was there for those who were already using or had in the past as a way to make sure they were safe.
Saving lives has to be our top priority.
“It was not a great leap for us to, for example, put naloxone in the hands of front-line police officers. They didn’t need a lot of convincing,” said Clayton Pecknold, assistant deputy minister and director of police services in BC. “That’s not the case in Ontario, for example. The chiefs of police back in Ontario were resisting it. Surprising to me. Shocking to me, frankly.”
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“Addiction doesn’t need to be a death sentence.” It’s a powerful declaration from PHS Community Services Society. And one aspect of that is educating the public in overcoming any reluctance to call for emergency aid.
Studies have found that bystanders often don’t call 911 or seek medical help during a drug overdose because they’re afraid of the police coming and the potential for criminal charges being laid. To reduce that barrier, on May 4, 2017, the federal Good Samaritan Drug Overdose Act became law in Canada. If someone experiences or witnesses an overdose and calls 911, this new law provides them with some limited legal protection: the police can’t charge them with simple possession of illegal drugs, or for breaching conditions related to simple possession of illegal drugs (e.g., pre-trial release, probation orders, conditional sentences, or parole conditions).
“It’s very recent. I mean, we saw these laws in the United States—I don’t know how many dozens of States have a law like this—but in a lot of cases nobody knows about it,” said Jordan Westfall, president of the Canadian Association of People Who Use Drugs. The police agree that many people, including some first responders, don’t know about the law or are confused about how it applies. At least one senior official I met with in BC, who was responsible for overseeing training for front-line first responders in a major city, had never even heard of the federal Good Samaritan legislation. Research has shown that drug overdose Good Samaritan laws don’t help much without effective education campaigns about their existence and scope. So there’s much more work to be done to raise awareness about this new law.
There are also concerns that the federal Good Samaritan Drug Overdose Act is too narrow. “In theory,” said a representative of Pivot Legal Society, “the principle behind the Act—to encourage calls to 911—is a good one, but if that actually is the goal, we feel that the way that the law is under this Act is inadequate. It provides actually quite minimal legal protections for people. It protects them [only] in instances of simple possession.”
Indeed, the Act doesn’t protect people from being arrested for offences other than simple possession, such as theft or possession for the purpose of trafficking—the latter a complex charge that involves a lot of police discretion and isn’t well understood by people on the street. Nor does the Act cover those who’ve been charged with a criminal offence (other than simple possession) and are released on bail before their trial, or those who’ve been convicted and put on probation: these people will frequently have to respect a range of conditions (such as abstaining from drugs or alcohol). The Act doesn’t provide any legal protection against charges for breaching those conditions or for outstanding arrest warrants (such as for missing a court appearance).
As Westfall told me, “I think they started with just simple possession, and I think it needs to include breach charges if people have outstanding warrants for non-violent acts. Those things would make people feel a lot more comfortable.” Lawyers and healthcare advocates agreed that the legislation needs to be expanded to encourage people to call 911 during an overdose. “People who use drugs, particularly those who are street involved, still feel marginalized and vulnerable when they deal with police,” pointed out Dr. Bonnie Henry, BC’s chief medical officer.
There are also concerns about police attending non-fatal overdoses (where a person is experiencing an overdose but has not died) when all that’s needed is medical intervention. If it’s just a medical situation and no violence is taking place, there’s arguably no public safety reason for the police to be there. And if people think police will come to a non-fatal overdose, that can deter them from calling 911 for help.
“People will not call 911 because they fear police attendance. It doesn’t need to result in a charge. It’s just a relationship of bad history with police—and it’s fear of what could happen that oftentimes drives people into incredibly dangerous behaviour and cuts them off from the services that they need,” said Pivot Legal Society. Police attendance at a non-fatal overdose could also be a problem for undocumented immigrants who fear deportation if they call 911—another issue that Good Samaritan laws often don’t address.
“I think a lot of police departments throughout the country are still responding to non-fatal overdoses, and that’s a deterrent for people to call 911, even with the Good Samaritan Act,” conceded Inspector Spearn. “In Vancouver, we stopped going to non-fatal overdoses in 2006 as a policy. The only time we’ll attend an overdose is if Fire or Ambulance request our presence for safety reasons, if it’s an attempted suicide, and, of course, if it’s an overdose death.”
The VPD’s approach made sense to me. The opioid epidemic is a public health emergency. Our criminal laws and criminal justice system have to get out of the way of first responders whose job it is to save lives and let people call 911 without fear. I was also convinced that we need to increase awareness of the Good Samaritan Drug Overdose Act and expand its legal protection to include immunity from prosecution for any non-violent offence and for related breaches of condition and warrants.
What’s the whole point of our criminal law anyway? It’s intended to save lives and protect people. We can’t forget that.
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Naloxone is a miracle drug that saves lives during an overdose emergency, but it’s not a silver bullet for singlehandedly solving the opioid crisis. There are four reasons why.
First, giving someone who’s overdosed an excessive quantity of naloxone puts them into withdrawal. And as we’ve seen, avoiding withdrawal is one of the primary drivers of opioid use by people with opioid use disorder. The naloxone that has saved their life can simultaneously compel them to quickly use again, even though they just about died. It may be hard to understand, but some people who are revived from an overdose can be angry because the naloxone has abruptly ended the pain-relieving effects of opioids that their body craves and that they’ve spent their scant money for. This need to stave off withdrawal symptoms, even at the risk of their own life, blatantly reinforces the fact that opioid use disorder is a relentless condition that effectively robs many users of their autonomy.
“It’s one of the hardest things when we treat someone. In essence, you reverse their overdose with the naloxone, but they don’t want to go anywhere,” said Vancouver Fire Chief Reid. “They don’t want to go to the hospital. It’s exceptionally hard to have the same person overdose three times in a day and die on the fourth.”
“That’s happened?” I asked, finding it hard to believe.
“Yeah. And it’s really frustrating,” said Reid, referring to the strain on front-line firefighters who live the opioid crisis day in and day out. “They develop relationships, too. They have regulars.”
Second, once someone has had a non-fatal overdose, they’re at greater risk of overdosing again and dying. “I think a huge number of lives have been saved by take-home naloxone,” said Dr. Evan Wood, executive director of the BC Centre on Substance Use. “Though that’s resuscitating people in the moment. But if you don’t offer other things, then obviously they remain at high risk of a subsequent fatal overdose. Actually, there’s literature to show that individuals who have had a non-fatal overdose are at extremely high risk of subsequent fatal overdose.”
Third, people may simply administer naloxone without other necessary medical interventions, such as rescue breathing. Unless an overdose victim receives sufficient oxygen to their brain during the time it takes naloxone to begin working, they can suffer permanent brain damage even if they’re revived.
“Naloxone is unfortunately all too commonly considered just this panacea for the opioid crisis,” said Staff Sergeant King. “In an acute situation, it should have been used together with rescue breathing and supportive CPR and all those other factors. Even our own police officers think, ‘Oh, just administer naloxone and let it do its stuff.’ People can suffer brain damage and other really terrible medical side effects.”
As Dr. Bonnie Henry told me, “Opioids, artificial or natural, are respiratory depressants. People stop breathing, which is why we teach rescue breathing when we’re teaching the use of naloxone. Until somebody comes back up with the naloxone, you want to make sure their brain is still getting oxygen. One of the biggest risks is an anoxic brain injury—brain tissues don’t like being without oxygen and can die off very quickly. So there is a potential for permanent brain damage, depending on the individual. That can mean visual, that can mean cognitive, that can mean behavioural change and other changes as a result of that injury.”
A senior health official in BC, who asked to remain anonymous, told me that there have been situations where patients can’t get into an ICU in Vancouver because it’s full of people who didn’t quite get resuscitated or had too much brain damage due to overdosing.
While many medical experts I spoke to raised concerns about the long-term effects of repeated non-fatal overdoses, they noted that there has yet to be a definitive clinical study confirming the phenomenon. But social services providers and the courts are already seeing what they suspect is a link. “Every time the brain is deprived of oxygen, brain cells start to die,” said Jennifer Breakspear. “We’re starting to notice within our buildings and within the neighbourhood some folks who are deteriorating physically—with balance issues, with other issues, but also cognitively—and I raised this with the health authority.”
“What we’re seeing now are more and more people with significant cognitive impairment because they’ve got brain damage,” said Judge Elisabeth Burgess with Vancouver’s Downtown Community Court. “We’ve always had people with cognitive impairments and different kinds of organic brain damage: FASD [fetal alcohol spectrum disorder], things like that, that aren’t really treatable. They’re not going to get better. They come through the court repeatedly. There’s not much we can do for them. Sometimes housing and other healthcare will stabilize them a little bit and they’ll commit fewer offences, but you can’t really cure that kind of thing. We’re adding to that population because of this overdose crisis that’s happening.”
Fourth, while take-home naloxone is saving lives, it’s meant a recent notable decline in 911 calls and emergency rooms visits for overdoses. Everyone I spoke to was quick to point out that this is the result not of fewer overdoses but rather of an increasing number being dealt with by naloxone alone. BC’s Take Home Naloxone program estimates that 911 was called in only about half of overdose events, even though it’s the first and most important step in responding to an overdose. One of the reasons to call 911 is that naloxone wears off in 20 to 90 minutes, after which an overdose can return.
“Not everyone wants to be in the emergency department,” said Dr. Aamir Bharmal, medical health officer and medical director of communicable disease and harm reduction with Fraser Health. For example, about one-third of overdose patients leave St. Paul’s Hospital in downtown Vancouver before they’ve been discharged. It’s a lost opportunity to help them. “What we’d like to do is try to ensure that people who are overdosing obviously have as many opportunities and access points for treatment.”
Naloxone is an essential life-saving medication during an overdose emergency. But if we want to keep people with opioid us
e disorder alive longer and have them get into treatment if and when they want to, a lot more is needed.
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DON’T SUPERVISED INJECTION SITES ENABLE DRUG USE?
One has a moral responsibility to disobey unjust laws.
—Martin Luther King, Jr.
Sarah Blyth doesn’t let rules get in the way of helping people. During the opioid crisis, it’s rebels like her who’ve been challenging the status quo in order to save lives. I first heard about Blyth in the fall of 2016. She’d apparently set up a tent in a Downtown Eastside alleyway with a bucket of naloxone and was reviving people who were overdosing from fentanyl-contaminated street drugs. The media was calling it an unauthorized “pop-up” supervised injection site. I had to meet her.
After a few months of trying to pin down a time, we did finally meet one morning at Blyth’s street-level office on East Hastings—the headquarters of the Overdose Prevention Society that she founded and leads as its executive director. We sat in a couple of mismatched chairs around a simple desk. She was wearing a light grey zipped-up hoodie and her hair was tied back with several wisps sneaking out. After she took a sip of coffee, she let out a yawn.
“I heard a bit from media stories, but I wanted to hear from you,” I began. “How did you get started doing this?”
“Well, I worked for the Portland Hotel Society for 10 years,” said Blyth. “In the very beginning of that I worked as a manager of a shelter called the New Fountain. It was created during the Olympics to get people off the street, into shelters.” At the time, activists claimed that Vancouver was trying to brush the city’s visible homeless population under the rug during the 2010 Winter Olympic Games. Sure enough, when the games were over and all the international visitors and media had left, they tried to shut the shelter down that summer. Blyth was having none of it. “We said no,” she told me. “We kept it open.”
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