Why the Overdose Crisis in BC will not end

The Overdose Crisis in BC

Approximately six people die every day in British Columbia, according to the BC Coroners Report (2021) these deaths are caused by individuals accidentally overdosing on an illicit and toxic drug supply.

Historically in BC fatal “unintentional illicit drug toxicity deaths” averaged about 250 individuals annually going back to 1995 (BC Coroner’s Report, 2021).  While substance use and the connected risk of overdose have always existed, a dramatic change happened in British Columbia beginning around 2015.  By April of 2016, the “Provincial Health Officer declared an opioid overdose public health emergency” due to the astonishing and sudden increase in fatal overdoses (Lee V. 2018). The BC Coroner had reported that Illicit drug toxicity deaths accelerated rapidly to 992 deaths in 2016, 1493 in 2017 and 1551 in 2018.  2020 is currently the worst year on record with 1736 recorded deaths and the latest data is anticipating 2021 will even surpass that (BC Coroner’s Report 2021).

Fentanyl

The shocking increase in fatal overdoses is explained by a change in the illicit drug supply where heroin has been replaced by potent “synthetic opioids such as fentanyl” (Lee V. 2018).  The BC Coroner’s Report (2021) reveals that more than 7953 individuals have lost their lives in BC since 2016 to what is now often referred to in the media as a ‘toxic drug supply’ crisis.

Fentanyl is a very potent synthetic opioid, as much as 30-40 times stronger than heroin (Mars et al., 2018).  Individuals accessing the illicit supply are unaware of the quality and quantity of the substance they are purchasing.  There is no regulation, there are no labels.  While street drugs have a long history of contamination, and the potency of a single dose is unknown to users, with the introduction of fentanyl into the supply the risk of overdose has increased to a level never before seen.

A dramatic way of understanding how the drug supply has changed is that in 2012 only 4% of fatal overdoses detected the presence of fentanyl.  By 2018 that number had climbed to 87% (BC Coroner’s Report 2021).  Mars et al. (2018) determined that the appearance of fentanyl in the drug supply is not about consumer demand, but rather is ‘supply-led’, “suppliers are able to lower their costs of production by finding a cheaper input. … When one proposes that fentanyl’s emergence was ‘supply‐led’, we take that to mean that it was adopted to reduce the costs of production and/or distribution.”

The Media

It has taken time for the general population to feel this crisis is relevant to them.  The initial framing (an unintentional consequence of mainstream media’s need for accompanying visual content) often showed us pictures of Vancouver’s downtown east end, homeless individuals, back alleys, and needles on the ground.  As a result, we conclude that these are the individuals affected and at risk, and that the people who are dying must have substance use disorders (addictions).  When the overdose crisis was first reported people remained unaware of the fact that this was impacting people from all demographics and regions throughout BC.  By digging into the BC Coroner’s Report (2021) we see that ~72% of fatal overdoses are happening in private residences, throughout the province.  This simple statistic breaks through the mindset that this is a crisis affecting only homeless or addicted individuals.

When it comes to substance use society has a long and complex relationship with both legal and illegal drugs.  Perceptions that everyone who does drugs is a criminal, or will end up homeless, in jail or dead are rampant.  Understanding stigma and its impact on individuals is necessary to fully comprehend the overdose crisis.  According to Fischer (2020) stigma “indicates the ascription of negative attributes or assumptions (or ‘stereotypes’ or ‘mark of disgrace’) on a person because of certain properties or behaviours outside their control, and consequential loss in social status, opportunity, and care or support (including possible ‘discrimination’)”.  If we view people who use drugs as ‘less than’, and see drug use itself as a moral failure, then we are less likely to take this crisis and the accompanying death toll seriously.  The sentiment that some members of our society are ‘disposable’ exists. 

Who is at Risk?

The BC Coroner’s Report (2021) notes that cross-contamination of fentanyl throughout the illicit powdered and pills drug supply is a significant issue.  The initial framing ‘opioid crisis’ could perhaps lead us to believe that the  individuals who are at risk are all opioid users.  However, fentanyl has been regularly detected in non-opioid street drugs, for instance, “Methamphetamine (deaths) [have] also increased from 14% in 2012 to 43% in 2020.  Cocaine and other opioids have steadily declined from 2012 to 2020; however, cocaine was involved in 45% of illicit drug toxicity deaths in 2020” (BC Coroner’s Report 2021).  The BC Centre On Substance Use has a web drug checking dashboard that reveals information about the drug supply in BC.  Their dashboard shows that 21% of tested samples in the last three years did not contain the expected drug.  In addition, 87 out of 6287 stimulant samples tested positive for fentanyl (BCCSU drug checking dashboard 2021).

It’s important also to understand that not everyone dying has a problematic substance use disorder, neuroscientist Carl Hart (2020) noted that “most people—70% to 90%—who use even the most stigmatized drugs, such as heroin and methamphetamine, do not meet criteria for a substance use disorder.” This important fact alerts us to the significance of the overdose crisis as a social problem for our society.  The impact is broad and varied, whether it is an individual from any walk of life, accessing illicit drugs whether for recreation or to maintain an addiction, whatever the reason, they now find themselves at heightened risk of accidental overdose.  The fallout from these deaths is widespread impacting loved ones and their communities; every death is someone’s son, daughter, husband, wife, friend or co-worker, the pain and consequence are far-reaching throughout the province. 

Five years of collecting data on the individuals who have died have revealed that those at risk of dying as a result of the toxic drug supply are all around us.  Some notable demographic data from the BC Coroner states that men are disproportionately at risk, four out of five fatal ODs are male.  Additionally, “the proportion of deaths that are 50+ years of age has steadily increased year after year for the past 6 years” (BC Coroner’s Report, 2021).

Another significant layer to this crisis is the incommensurate way First Nations people are impacted. “According to the First Nations Health Authority, Status First Nations people are five times more likely to have an overdose event and three times more likely to die than non-First Nations people” (Lee V. 2018).

The Government’s Response

With the declaration of a public health emergency on April 14^th, 2016, by provincial health officer Dr. Perry Kendall, the government of BC began to roll out varied responses to address the crisis and attempt to reduce deaths.  At the time of the emergency declaration, we were losing an average of 2.7 people per day (BC Coroner’s Report 2021).  Now, the latest data shows the number has climbed to over 5 per day it’s clear that despite the following efforts this crisis is not improving.

The government response identified six key areas to focus on, “saving lives, ending stigma, building a network of treatment and recovery services, creating a supportive environment, advancing prevention, improving public safety” (Ministry of Mental Health & Addictions, 2020). 

An emphasis has been placed on a harm reduction approach,  “Harm reduction signals itself as pragmatic in contradistinction with prevailing moral (criminal) and disease policy models which have dominated since the twentieth century. Now the primary alternative to those prohibitionist and abstinence oriented policy models, harm reduction begins from the starting point that drug use is an “inescapable fact rather than a moral issue”, and therefore seeks to reduce negative consequences of drug use rather than to eliminate it” (Klein A. 2020).

One of the most notable life saving, harm reduction tools is the community-based distribution of free take home naloxone (THN) kits to virtually anyone in BC who would like one (Wallace & Kennedy, 2020).  According to Tsang & Buxton (2021), the government acted quickly to make a “series of regulatory changes in 2016 and 2017 [to] reduce barriers to naloxone access”.  As of 2020, there have been 75,888 THN kits used to reverse an overdose (Tsang & Buxton, 2021).  One can only imagine what the fallout may have been if the government had not acted quickly to get naloxone into the hands of the general public.  Within all levels of response, the opportunity to reduce stigma is always sought, it’s recognized that the practical offering of THN kits could be paired with stigma reduction as Tsang & Buxton go on to say that “offering THN kits is an easy way to create safe spaces for clients to discuss drug consumption practices. Medical students, physicians, and other providers should be encouraged to provide training, carry a THN kit, and act as champions to reduce drug-related deaths in their communities.”

Overdose prevention sites, brick & mortar facilities that have spaces where drug users can consume their substance of choice and be monitored and responded to in case of overdose have also been setup throughout the province (though not without push back from many communities).  However, at the mandate of government “sites were operational within weeks and in the first year there were approximately 550,000 visits and no overdose deaths recorded at any of the prevention sites” (Wallace & Kennedy, 2020).

Provincial funds were made available to the hardest hit communities throughout BC.  One of the grassroots responses was the creation of local “Community action teams” (CATs), that work within their communities to provide education, stigma reduction, harm reduction resources and other creative initiatives.  “Community Action Teams play a crucial role in targeting local resources where they are needed most and in strengthening local partnerships” (Community Action Teams, n.d).  There are 35 community action teams throughout the province (Ministry of Mental Health & Addictions, 2020).  As an example, the Ministry of Mental Health & Addictions states Langley has a CAT that developed the “We All Play a R.O.L.E. project (responding to overdose in Langley through education) and “hosted 40+ education sessions with various local business/groups” training “several hundred Langley participants in stigma awareness/OD response (naloxone)” in 2018 & 2019.  The CATs are made up of community members, people with lived/living experience (PWLLE), firefighters, police, doctors, community health specialists and social workers (Ministry of Mental Health & Addictions, 2020).

The role of social workers in the crisis can not be understated.  “Social workers are among the front-line responders employed by organizations using harm reduction strategies… notably with regard to new and emerging overdose responses such as naloxone administration, supervised injection, drug checking, and more” (Wallace & Kennedy, 2020).

Next Steps

Advocates are pushing forward innovative policies in an attempt to actually make a difference in the death toll.  As a result, their efforts have recently influenced the provincial government to take a dramatic step by “applying to the federal government to remove criminal penalties for people who possess small amounts of illicit drugs for personal use” (B.C. applies for decriminalization in next step to reduce toxic drug deaths, 2021).  The BC gov news release goes on to state “Substance use and addiction is a public health issue, not a criminal one,” said Sheila Malcolmson, Minister of Mental Health and Addictions. “B.C. is adding new health and substance-use care services almost weekly, but we know shame prevents many people from accessing life-saving care. That’s why it’s crucial to decriminalize people who use drugs.”

Civil disobedience from activists plays a crucial role in shifting the narrative as policy changes can not happen quickly enough.  Headlines were made in the summer of 2021 when journalist Vincent Plana wrote about Vancouver’s Drug User Liberation Front (DULF) and their very public “safe supply protest” in which illicit drugs sourced from the dark web were tested for purity and then distributed to users for free.  “Among the participants was city councillor Jean Swanson, who shared photos online of her participation in the parade, as well as distributing a package that reportedly contained heroin” (Plana, 2021).

Conclusion

None of the approaches by government or community groups are truly able to effectively address the organized crime controlled illicit drug supply.  While Canada has historically focused on enforcement and efforts to intercept drugs and prevent them from entering our borders, sentiment about this costly approach is shifting.  With the supply-led change from heroin to fentanyl and its significant profitability over the former, fentanyl and its analogues are likely here to stay.  If we conclude that drug use is a fact of life and a permanent part of society, then it becomes necessary to consider alternative approaches and policy changes that will ultimately address the drug supply and make substance use safer for all who partake.  The majority of the local community responses and that of municipal governments have been reactionary, working on the frontlines and focusing on individuals, and harm reduction; ways to make drug use safer, education programs, drug testing, ideas like don’t use alone, or smartphone apps like “lifeguard” that will “automatically contact emergency responders if a user becomes unconscious or unable to function in the event of an overdose” (Lifeguard App: Lifeguard Digital Health 2021).

The Provincial government has provided funding, it’s hard to figure out just how much but one report shows that as of “September 2017, the provincial government had allocated $322 million over three years” (Ministry of Mental Health & Addictions, 2020).  BC is also responsible for limited policy interventions (such as the aforementioned decriminalization exemption request to the federal government). 

The Federal government has been relatively silent and unwilling to consider the aggressive policy changes that might actually address the root of the problem, the illicit drug supply.  Advocates such as Donald MacPherson, the Executive Director of the Canadian Drug Policy coalition who is on record stating, “Drugs that are currently illegal, we should make them legal, then we can focus on problematic substance use and issues like dependency and addiction” (Crosby J. 2018).  The Canadian Drug Policy coalition is actively exploring solutions to the overdose crisis with their “Getting to Tomorrow” initiative which is collating “Studies and evidence in support of harm reduction and public-health based drug policies” (Studies and evidence in support of harm reduction and public health-based drug policies 2021).  MacPherson goes on to say “If we were to just legalize these substances and put our resources to helping people who develop problems with them, we’d waste less money and have much better outcomes.  Laws change, bad laws get changed.  We do that all the time.  Those drugs are illegal, but we made them illegal.  We can change it up.”

We are now more than five years into this health crisis and fatal overdoses continue to increase.  One thing is certain, we must be open to innovative solutions that will likely be a dramatic departure from the status quo.

References

BCCSU drug checking dashboard. BCCSU Drug Checking dashboard-. (2021, October 22). Retrieved November 23, 2021, from https://drugcheckingbc.ca/dashboard/.

BC Coroner’s Report, Illicit drug toxicity deaths in BC. (2021, July 31). Retrieved October 28, 2021, from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf.

BC Mental Health and Addictions. (2021, November 1). B.C. applies for decriminalization in next step to reduce toxic drug deaths. Retrieved November 28, 2021, from https://news.gov.bc.ca/releases/2021MMHA0059-002084.

Coalition, C. D. P. (2021, June 4). Studies and evidence in support of harm reduction and public health-based drug policies. Getting to Tomorrow. Retrieved November 28, 2021, from https://gettingtotomorrow.ca/2021/05/04/studies-evidence/.

Community action teams. Community Action Initiative -. (n.d.). Retrieved November 28, 2021, from https://caibc.ca/grants-training/oerc-cai-stream-grants/oerc-cai-stream-1/.

Crosby, J. (2018, May 11). Canadian drug policy expert says it’s time to legalize all drugs. Global News. Retrieved November 28, 2021, from https://globalnews.ca/news/4202577/legalize-drugs-opioid-crisis-health-addiction/.

Fischer, B. (2020). Some notes on the use, concept and socio-political framing of ‘stigma’ focusing on an opioid-related public health crisis. Substance Abuse Treatment, Prevention, and Policy, 15(1). https://doi.org/10.1186/s13011-020-00294-2

Government of Canada, S. C. (2018, November 13). Drug overdose crisis: Socioeconomic characteristics of those dying of illicit drug overdoses in British Columbia, 2011 to 2016. The Daily – . Retrieved November 22, 2021, from https://www150.statcan.gc.ca/n1/daily-quotidien/181113/dq181113a-eng.htm.

Hart, C. (2020, July). Exaggerating harmful drug effects on the brain is killing black people. Neuron. Retrieved November 2021, from https://pubmed.ncbi.nlm.nih.gov/32615067/.

Klein, A. (2020). Harm reduction works: Evidence and inclusion in drug policy and Advocacy. Health Care Analysis, 28(4), 404–414. https://doi.org/10.1007/s10728-020-00406-w

Lee, V. (Jan 2018). The hidden epidemic: The opioid overdose emergency in Fraser Health. Retrieved November 21, 2021, from https://www.fraserhealth.ca/media/Project/FraserHealth/FraserHealth/Health-Topics/Overdose/20180122_hidden_epidemic_overdose_emergency.pdf.

LifeguardApp: Lifeguard Digital Health, powered by evan. (2021, June 24). Retrieved November 28, 2021, from https://lifeguarddh.com/products/lifeguard-app/.

Mars, S. G., Rosenblum, D., & Ciccarone, D. (2018). Illicit fentanyls in the Opioid Street Market: Desired or imposed? Addiction, 114(5), 774–780. https://doi.org/10.1111/add.14474

Ministry of Mental Health & Addictions. (2020). Overdose emergency response centre community action teams. Community Action Initiative. Retrieved November 28, 2021, from https://caibc.ca/wp-content/uploads/sites/3/2020/09/Community-Action-Team-Synopses-20192020-.pdf.

Ministry of Mental Health & Addictions. (Feb 2020). Escalating BC’s response to the overdose emergency.  Retrieved November 28, 2021, from https://www2.gov.bc.ca/assets/gov/overdose-awareness/mmha_escalating_bcs_response_report_final_26feb.pdf

Plana, V. (2021, July 16). Vancouver city councillor hands out heroin during safe supply protest. Retrieved November 28, 2021, from https://dailyhive.com/vancouver/jean-swanson-drugs-safe-supply-protest-vancouver.

Province of British Columbia. (2018, July 16). How the province is responding. Province of British Columbia. Retrieved November 24, 2021, from https://www2.gov.bc.ca/gov/content/overdose/how-the-province-is-responding.

Tsang, V.W.L., & Buxton, J.A. (2021). History of naloxone kits in BC: From inception to expansion: The Take Home Naloxone program’s history, how far we’ve come since its inception, and the work yet to be done. British Columbia Medical Journal, Apr 2021, Vol 63, No. 3 – p122-125

Wallace, B., & Kennedy, J. (2020). Journal of Social Work Values & Ethics, Spring 2020, Vol. 17, No. 1 – page 63 An Environmental Scan of Social Work’s Regulatory Response to the Illicit Drug Overdose Crisis in Canada. Journal of Social Work Values & Ethics.