The day this article was written marks the eighth anniversary since a public health emergency was declared in British Columbia to address the alarming increase in overdose deaths in recent years. Little did we know the devastating wreckage that would ensue and how the political division that is being pushed is contributing to the crisis. My hope is that this article can shed a little bit of light from my battle weary retired substance use clinician’s perspective.
We are the proverbial frogs in the water. The temperature has slowly been increasing. And we have become indifferent and even careless towards people who use substances and the people who are dying from the toxic drug poisoning crisis that is the underlying cause of the overdose deaths of the last decade. We will die in this water if we don’t get out of it quick! But that doesn’t seem too likely.
April 14 2016, The BC Provincial Health Officer at that time declared a public health emergency. B.C. was the first Province to do so. It was declared because the number of overdoses and overdose deaths increased over the previous years at an alarming trend. In 2009 there were just over 200 overdose deaths recorded in BC – far far too many. We could not have imagined even at that time, how incredibly overwhelming this would become. How low that number seems now. The water simmers.
Six years later in 2015, 474 overdose deaths occurred in this province. That is a 237% increase in 5 years. In January of 2016 there were already 74 beautiful people who died from overdose. That rocketed upwards to 995 preventable deaths in 2016. Thus even before the end of that year, we knew we were in for an unimaginable storm. But we had no idea even then how horrifying it would be for people in all stages of life who would experiment for the first time, have a weekend bash, relax or party after work. We had assumed that this would likely only hit those who were suffering from substance use disorder, or addiction as we traditionally know it. This is one of the most difficult health conditions to address. We assumed this would be a street and/or a homelessness problem. But the numbers are telling a different story.
We had naturally moved into a triage wound care type of action through harm reduction while continuing to moderately support recovery based solutions. And as a treatment provider and outreach clinician working in a street clinic, I saw a slowly growing response as deadly policies were being repealed preventing harm reduction strategies from being implemented alongside counselling/outpatient treatment strategies. I am not going to go into all of the things that were put into place in detail but here is a few of the things that happened…
Regulations and prescriptions for naloxone were axed in 2016 and policy put in place to allow anyone to administer the life saving antidote for overdose. Today, anyone can administer naloxone after a brief training is available in health centres and available through youtube and towardstheheart.com and many other sites now. I personally witnessed so many lives saved on sidewalks and back alleys due to the growing and now widespread availability of naloxone.
Supervised consumption sites (SCS) were finally deregulated enough in 2017 to be set up across the country. But not after a huge push back by conservative members of the federal government actually stalled the bill for about a year; as over 3500 more people in Canada died during the debates that year. Viewing this and operating from a street perspective, in my last years in my career, I witnessed hundreds of people use our mobile SCS everyday. To date, no one has died at a supervised consumption site in the world. One death has occured at an overdose prevention site. These are different than SCS.
Community Action Teams were put in place around the province. These teams were designed to address the unique needs of every community and region. They were and are still tasked with creating solutions to the toxic supply and overdose death crisis.
Outreach policies from health authorities loosened up so that we could meet people where they were at instead of waiting for them to crawl through our door.
The distribution of all harm reduction supplies was loosened and expanded for safety and in hopes of connecting with people and helping when their opportunities were open.
Our detox adopted a medical assisted model to provide suboxone and methadone for those struggling with opioid use disorder rather than depending on the old and dangerous cold turkey detox that typically resulted in relapse.
Our secular residential treatment provider began to accept people who were on opiate replacement therapies with the recognition that treatment can begin when people are stable, not necessarily abstinent from all substances.
Historically, all treatment centres required 3-7 days abstinence, from all substances, before acceptance into their programs. For many then, and too many now, this is still the admission criteria. As you can imagine, this makes it difficult for people to enter a residential treatment program regardless if they are coming from a tent or a mansion.
There were many many changes made to the continuum of care that were of benefit and started making a difference. But the number of deaths continued to increase in BC; 1,495 in 2017, 1,561 in 2018. Finally in 2019 we saw the first significant decrease in overdose deaths. many of the harm reduction initiatives were put in place at that point and functioning regularly. Slightly lower than 2016, numbers in 2019 as only (only lol) 990 people perished due to overdose deaths. So much pain still but a glimmer of hope. Then the pandemic hit.
I was retired just months before the shut downs so I could only watch and listen as the system we had so carefully built and showed so much potential, broke down. We all know how the shut downs affected us personally. What we don’t maybe know is that all of the face to face contact needed to address harm reduction, treatment and anything health related really came to a grinding deadly halt.
A safer supply policy was put into place and a restrictive program was initiated in Vancouver in response to the pandemic. Only those formerly diagnosed with Opioid use disorder were eligible for the medical assistance. Less than 5% of people who are estimated to use opioids in BC have access to this safer supply. Yet the police and politicians keep claiming the streets are flooded with safe supply.
Well, you know, if only that were true. We’d see a significant decrease in overdoses and overdose deaths. No, not in addiction, in overdose deaths. These are separate issues with different solutions.
By the time shut downs were ended, the momentum of death was out of control. Every year since 2019, after all of our efforts were showing some promise, grim death records were broken every year after that and the deaths continue to increase.
The lack of a supposedly less toxic product available over the border led to increases in additives in the available local supply. So not only are we dealing with fentanyl now but substances that are immune to naloxone. Benzodiazepines and their analogues, animal tranquilizers like Xylazine. Other nervous system depressants to mimic the effects of opioids that are immune to naloxone are all very prevalent in a typical “pick up”. No one knows what they are getting. And the impact of substance use disorder, the “using despite the consequences”, the part of the disorder that we are so quick to dismiss as choice, has a most definite impact on the overdose crisis.
However, these deadly cocktails are also known to be the direct result of the “Iron Law of Prohibition”: an unwritten law that states that the tougher the sanctions on substances, the more toxic they become and not only more crime but more violent crime increases. We are certainly witnessing that. The Iron law of prohibition is believed to be the underlying cause of the deadly trend of toxicity leading to the overdose deaths.
And guess who is getting scapegoated for this? The people struggling with substance use disorder. They are getting it from all sides; the legal system, organized crime, and yes, even the health system. Stigmatized left right and centre it is not surprising in the least that people do not reach out. And even then they are blamed.
The water is reaching peak boiling point.
All of our harm reduction responses were aimed at the person suffering from substance use disorder. They were also targeted at people who were on the street. SCS, drug testing, harm reduction, and street counselling clinics were all set up for the people that are struggling the most with their health and social concerns. Just as all of our scapegoating for society’s ills are mis aimed at that group. What we have totally missed the target on is all of those people who don’t fit into our concept of addiction.
Consistently throughout this other “pandemic” the numbers have revealed trends and issues we have not really even touched. Consistent again with previous years, 70% of those dying were aged 30-59 and 72% of those people were men.
So far this year and in every other year the highest group represented are not those who are living on the street but those who are actually living in a residence. Fourty six percent of those people were living in private residences. Another 38% lived in supportive housing or in rented rooms or hotels etc.
Only 13% of deaths occurred on the street. Now that might be due to the availability of harm reduction programs readily available to those who are nearby or most likely easier access to said resources. But what about the rest?
What about the men in trades who have among the highest rates of opioid overdoses in Canada? According to health Canada, trades workers are more impacted by substance use and addiction than other fields of work. Up to half of those employed were employed in the trades at the time of their overdose death.
Workplace culture has a huge impact on mental health, especially amongst men as we can see by this alarming stat. Many men are subject to and at least complicit in unwritten workplace rules such as “don’t talk about your feelings” “suck it up” “man up”. Unhealthy coping through substance use is encouraged and often considered a must and rite of passage to belong to the crew.
Many men are injured at work. If it isn’t debilitating, men continue their work with the help of prescriptions. These can (but not always) lead to dependency and eventually to “addictive” behaviours especially when doctors titrate or wean their patients too quickly because, you know, we wouldn’t want addiction. Yet it is mishandled way more often than not. A titration done too quickly and the withdrawal and dependency are not addressed properly. This has historically and has currently led to “addictive” and sometimes criminal behaviours; almost always out of desperation and pain.
Stigma is the leading cause of resistance to help. The people that walked through my door for help, when I wasn’t directly dealing with street issues, did so with the utmost embarrassment and shame. (Two of the biggest using triggers by the way). It took immense courage for them to to seek out help and go against the culture that they had to succumb to day after day.
Most people outside of the targeted street population will not access any resources associated with mental health or substance use issues. That my friends is all on all of us! That is not denial! That is not “they’re not ready”! That is risking a fundamental basic need of a sense of belonging. That is about the stigmatization of substance use imposed on people by the criminalization of substances and even the misinformation about health, especially about addiction, that we bestow on people. In short, our attitudes suck when it comes to people who use drugs.
The water is boiling rapidly now.
So the deaths increase. The nay sayers are kind of right when they say what we are doing isn’t working. Except that it is working! But only with a select group of people who use drugs. It isn’t working with the huge numbers of others who are outside our assumptions and conceptions of people who use drugs.
To get to a big part of the solution to all of this, two things have been proposed; the popular bolstering of recovery aka abstinence based programs to make them more available to people who are able to get through that window; and a safer supply to make available a far less toxic supply of substances to those who struggle with opioid use disorder. One seems to make sense, the other seems like the antithesis of support, at least to the general public. An understanding of all the nuances of treatment and the iron law of prohibition is crucial now more than ever. In truth, both are needed.
In short, this is history repeating itself. Both with opiates from the past and with alcohol from the early 20th century. Both were prohibited. Both resulted in the increase of toxicity of the substances themselves and the increase in violent criminal behaviour. We like our booze so we repealed prohibition. Everyone was still drinking anyway so might as well regulate it and put it in the hands of those who will market it safely.
Hmmm, sounds like the mess we’re in right now. Imagine that for just a moment. I’ll wait…
Just in case that was hard, imagine that all substances were regulated. Yes, there would certainly still be addiction. People would still suffer with many of the consequences of that health and social issue, like they do with alcohol. But like alcohol they would not be dropping dead from an unregulated cocktail of poison happily slapped together by organized crime. At least, realistically, there would be a choice.
People would not have their futures uprooted with criminal records. Nor would crimes to obtain substances be near as prevalent as they are now. And again, you would not be dead from an overdose. This has already been demonstrated in a study included here in the resources.
Think if alcohol were still illegal today. Where would you be on the criminal spectrum? A little “stil” on the side in your basement perhaps? A speak easy every week or month hidden in an alleyway somewhere? And how would we toast the bride and groom? With apple juice? How would we unwind at the end of a stressful day? Imagine what would happen if you got busted; to your family, your job, your home. And, you risk overdose, Oh sorry, “alcohol poisoning”, from the toxic brews produced by organized crime or even just hacks in the back alleys. Hospitalizations and deaths would increase incrementally the tighter the laws.
Imagine what would happen if cannabis had not been legalized in Canada. There would be no choice but to still obtain it from organized crime, directly or indirectly like all other illegal substances. You would get a criminal record for a plant or two in your home. On it goes.
So we debate and argue about how much treatment should be available: and I agree we need much more truly evidenced based treatment rather than the moralistic abstinence only based treatment programs that we have at the moment. And some of us scream out about a safer supply enabling addiction and we can’t have that so….
So what then? We continue with prohibition? At best we medicalize a safer supply but only make it available to a select few who are covered by medical and/or who have the doctors willing to prescribe it? Medicalization will make a difference. But not enough.
Let’s not forget that the goal of abstinence as a measure of success in treatment programs is less than half most of the time. So that leaves half or more people still accessing a toxic supply as they try to manage their disorder and the debilitating withdrawals that come with it. And most people attend programs multiple times before significant periods of abstinence occur.
And just as importantly, the people that do not seek access to a treatment program, or even qualify as having the disorder that still partake in their weekend enjoyments: Does that warrant a death sentence?
We have been the proverbial frogs in boiling water through this crisis. We have become numb to the numbers and slaves to old ways of thinking that no longer work, if they did at all, when it comes to substance use issues. Yet for some of us, there is the abject horror, as we do everything we can think of, and still the majority or at least the loudest of society resist the change. They are comfortable in the boiling water and you know where that leads.
I will not boil with the blind and the ignorant.
As long as society exists as it does; as long as our economy discriminates as it does, as long as substances are available in nature and the laboratory; people will use substances. And we will use them for our many personal reasons. And some of us (about 15-20%) will have just the right risk factors that will lead to health and social issues if we continue to use substances. We actually live in a perfect storm for mental health and substance use disorders to flourish. There is no such thing as an addiction free community contrary to what some Albertan politicians are trying to sell. That is a complete fairy tale as I have written before. But there is the potential for a different approach to addiction.
A prohibition free society with the most up to date treatment services might be at least part of an answer to the devastation that has been occurring in the last 8 years. There are still the end stage capitalist economic factors that are contributing to the state of our collective mental health right now as well. But that will take a profound shift in our pious, self righteous, myopic thinking about what is important to us as humans and towards people who use drugs.
Oh ya! Most of us do use drugs by the way so be careful who you are judging. It might just be yourself.
Resources
(https://drugdatadecoded.ca/city-of-recovery/ )
https://www.canada.ca/en/services/health/campaigns/men-construction-trades-overdose-crisis-canada/men-trades-substance-use.html
https://app.powerbi.com/view?r=eyJrIjoiOGJmNzZmOWQtMjcxMy00ZTFhLTlkZWQtOWM3YmMxZjc1NWNlIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9
(https://www.ncbi.nlm.nih.gov/books/NBK235506/)
https://www.sciencedirect.com/science/article/pii/S095539592400015X
https://www.canada.ca/en/health-canada/services/canadian-alcohol-drugs-survey/2019-summary.html