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In the absence of widespread safe supply, drug checking is saving lives
In the absence of widespread safe supply, drug checking is saving lives
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In the absence of widespread safe supply, drug checking is saving lives
On April 14, the front steps of the BC Legislature building were heavy with the collective grief of more than 7,000 lives lost to BC’s opioid crisis.
To mark five years since the province declared a public health emergency, families joined Moms Stop the Harm at the BC parliament buildings, immortalizing their victims on poster boards, the abbreviated dates of their lives marked below young, promising faces.
“The government can no longer ignore the number of deaths, the number of our children, our loved ones who are dead because they could not find safety in the drugs they needed,” Leslie McBain, the group’s co-founder, told the small crowd.
“Keeping people who use drugs alive and free is our job and we will succeed. And let me tell you, and everybody up there,” she added, gesturing to the legislature, “there is no rest. We are all warriors, and we will win this.”
The sombre anniversary was particularly painful after a year of staggering death rates. When COVID-19 cases started growing, so did overdose fatalities—in 2020, 1,724 people died from illicit drug toxicity deaths, a 75% increase from 985 deaths in 2019.
And 2021 is already on track to outpace what was a horrific year in 2020, with 174 overdose deaths in January and 155 in February, putting the rate of deaths per 100,000 people at 38. That’s more than three times the rate of overdose deaths in 2015.
In Victoria, 24 people died from overdoses in the first two months of 2021.
Experts are connecting the dots of those startling numbers with the “new realities” imposed by the pandemic. Not only was drug supply interrupted, but the “when, where, and how” of drug use changed too. More isolation and less certainty often equals more overdoses.
“It's incredibly frustrating to be where we are, which is the worst it's been at any point in time,” says Fred Cameron, operations manager with SOLID, a Victoria peer-based harm reduction non-profit. “Because in the months prior to COVID, the numbers were actually turning for the better.”
But the virus, and the restrictions that came with it, flipped the world upside down.
“The drug supply was interrupted. The producers and suppliers were all different. People didn’t know how to [process drugs] because the numbers were up and down so much, there was no regularity,” Cameron says.
“It was Russian roulette, basically, for people using on the street.”
Every time the drug market gets interrupted—be it the COVID-19 pandemic or a highly publicized fentanyl bust—the supply chain shifts, and experts believe that as a result, the toxic supply changes and gets stronger.
“The more we criminalize people who use drugs, the more innovative drug manufacturers will get in making sure that they can get drugs into Canada,” says Corey Ranger, the clinical nurse lead for AVI Health and Community Services and SAFER. “We got into this problem because of the prohibitive criminalization of substances, de-prescribing of oxycodone, all that did was create demand [and] fentanyl filled that gap.”
Currently, an influx of carfentanil and benzodiazepine is wreaking the most havoc on regional supply, prompting Island Health to post online alerts and install bus shelter signs imploring people to “buddy up” or visit supervised overdose prevention sites. Carfentanil, a fentanyl analogue, is used typically as a sedative for large animals like elephants. Not surprisingly, it can be 100 times more deadly than fentanyl, which is prescribed medically for human pain relief. Benzodiazepine—or “benzos”—are sedatives used to treat depression and anxiety. Overdoses are extremely difficult to reverse, even more so if the substance is mixed with opioids.
Bruce Wallace, a scientist with the Canadian Institute for Substance Use Research and co-lead for the Vancouver Island Drug Checking Project, says those drugs aren’t inherently toxic. It’s the uncertainty around the substances that makes them deadly.
“People consider alcohol a toxic substance also, and so there’s always levels of risk and harm in different substance use,” Wallace says. “It’s the unpredictability of the supply that makes it toxic.”
“It’s either the potency or that it was not intended to be purchased,” he adds.
And responding to toxic supply is complicated—Ranger says benzodiazepine doesn’t respond to Naloxone, the life-saving overdose response toolkits that have reversed an estimated 48,000 to 96,000 overdoses in BC since March 2017.
“When you add a depressant with a sedative, what you get is a synergistic effect,” Ranger says. “And overdose risk is incredibly high, even for people who have high tolerances for opioids.”
Adding to that is the impairment of judgment that these drugs also elicit. “The inhibitions and decision-making are so poor when someone's in that state that they're going to keep trying to use again,” Ranger says. “And so it just leads to an entire 24-hour period where that person is at an incredible risk of overdose.”
From 2016 onwards, overdose has been the most common cause of unnatural death in BC, and now, illicit fentanyl and analogue drugs are, undoubtedly, the leading cause—accounting for 87% of illicit drug deaths from 2018 to 2020. Death rates from other opioids fall behind cocaine and methamphetamines—in fact, at this point experts say heroin is practically a relic. And it isn’t just because it’s hard to find—people aren’t looking for it. They want fentanyl, heroin’s powerful and potent synthetic relative, which packs a far more serious—and dangerous—high.
“There’s no heroin on the streets,” Ranger says. “Anyone who thinks they’re getting heroin is actually just getting fentanyl.”
Safe supply, a legal, regulated alternative to dangerous, illicit drug supply, was introduced to Canada in 2019, with support from many in the harm reduction community, including AVI, which operates SAFER: a “community-based, safe supply model with health care provider oversight.” The project’s goal is to save lives by providing safer, pharmaceutical alternatives to the currently toxic supply.
But Ranger says over time, tolerances have increased so much that fentanyl is the only drug meeting people's needs. Safe supply, which is distributed via a prescriber model, may offer Oxycodone or Dilaudid.
“Our ability to keep people alive and safe through a safe supply model is being outpaced by people's growing tolerances—so the drugs the government has made available aren't effective enough,” Ranger says.
Every morning, Dave Keeler, a mobile outreach worker with SOLID, picks up his prescribed Methadone and Oxycodone. But Keeler also buys drugs from his connections in the community on a daily basis. For him, the clean, prescribed medication from his doctor does little to meet his needs.
“What they have me on every day doesn’t work,” he says. “I have to go and use every day or every second day. And I’m saying every day, because it’s rare to get through the day without it.”
Keeler started using when he was about 13 years old to cope with abuse and trauma. In the 33 years since, he’s built up an ironclad tolerance to opioids.
“I can remember the first time I did it. It was after a big fight with my family, I was kicked out of the house and I ran away and the cops wanted me,” Keeler remembered. “I sunk into a chair… I was in such a good place.
“I’ve been chasing that forever.”
But using isn’t just an escape anymore—it’s a physical dependency. Without the right dosing, Keeler experiences depression, sweats, anxiety, restlessness, and pain—physical and emotional.
“Anybody who gets addicted to any kind of drugs or opiate has gone through massive amounts of [post traumatic stress disorder],” he says. “And they're trying to kill pain from something. When I take that, my heart pain goes away. I take that, my emotional pain goes away, my mental pain. Everything. All kinds of pain. It doesn’t matter.”
Even if safe supply was powerful enough, it’s reaching only a fraction of the people who need it. Roughly 4% of the 88,000 British Columbians at risk of overdose are able to access safe supply, according to Ranger.
“It is in the hands of individual prescribers to make the decision on what people can and can't get,” Ranger says. “And what we found is that there's a lot of unintentional gatekeeping from prescribers. They don't necessarily want to be the gatekeepers of the situation, but they are, and it's leading to gross inequities in access for folks who really, really need it right now.”
The dust is still settling on Victoria’s first official drug testing site, located on the corner of Cook and North Park Streets, a block or two away from hip coffee shops, a bagelry and an elementary school. The location is next to SOLID headquarters.
The Vancouver Island Drug Checking Project—a collaboration between the University of Victoria, Health Canada, SOLID, AVI, and others—opened Substance in March. The project operated for several years out of overdose prevention sites, but COVID-19 complications meant rethinking service delivery. So, the project opened its own space, a move that’s seen a massive uptick in community buy-in. In March alone, Substance checked 155 samples—a 388% increase in service uptake from 2020.
Papered windows maintain a sense of privacy for clients, who come in, drop off a rice-sized sample of their drugs, and leave with a numbered ticket they use to identify themselves when they call in or return for the results. The entire process typically takes under 20 minutes.
Technicians use several technologies: Raman spectroscopy, test strip, and an Infrared Absorption (IR) spectroscopy, which reads the specific identity of each sample. The IR spectroscopy measures infrared radiation and produces a graphing for each sample, matching its unique radiation levels to a library of other substances. The machine reacts almost with a fingerprint for each drug—for instance, a sample of a white substance might match almost perfectly to cocaine, but beneath the top match are other substances with similar characteristics.
It gives the user a better grasp of what clients are about to take, and a higher degree of certainty that there aren't toxic or unknown substances in their drugs. But it doesn’t eliminate the risk entirely.
“If someone had a larger baggie… we can only comment on the speck we've tested,” explains Jarred Aasen, a Substance UVic checking technician. “So that's just inherent. We can do multi-sampling, especially if it looks different, or there's different colours or textures happening, then we will kind of draw multiple samples (and) try to be representative, but it is a limitation.”
Certainty decreases further for drugs known as ‘opioid-downs’—like heroin and fentanyl—where researchers are seeing more irregularity.
“We're noticing with the down supply that there's a large variance in fentanyl concentration,” Aasen says. “As well as benzodiazepine adulteration. So even within the same sample, there could be variants, and that's something we're looking into.”
Regardless of what they’re using, drug testing gives people vital information and agency, Wallace says.
“We’re trying to put some of that information and control into it so that people can have greater expectations of what’s being consumed,” he says. “People think the value of drug checking is to find out if there’s an unexpected or dangerous substance, [and] I think it’s just as valuable to confirm the substance they have is the substance they intended to have.”
Data collection has been a core component of the project too. The Vancouver Island Drug Checking Project releases quarterly and annual reports on its findings, as well as regular interpretations on its blog.
Some of the high-level analysis is done through a partnership with researchers from Vancouver Island University, who have access to a paper spray mass spectrometer, which offers immediate, accurate details on both the type and quantity of potentially deadly substances, something Substance’s instrument can’t do as accurately.
However, that instrument is more expensive and less mobile than the IR spectroscopy, which instead offers fast, inexpensive testing on-site.
In March, Substance reported that amongst opioid-downs, 93% contained fentanyl, and 59% contained benzodiazepines and/or etizolam, a drug clinically regarded as a benzodiazepine and with similar tolerance and dependence properties.
The BC NDP government’s 2021 budget included $500 million towards the continued expansion of mental health and addictions services, including $152 million for opioid treatment, and 195 new substance-use treatment and recovery beds across the province.
In addition to funnelling millions into youth and adult treatment beds, BC Minister of Mental Health and Addictions Sheila Malcolmson announced April 14 that the province would formally seek a provincewide exemption from the Controlled Drugs and Substances Act, eliminating criminal penalties for people who possess a small quantity of drugs for personal use.
Advocates are adamant and unwavering on this point: criminalization pushes drug-users into solitude, desperation, and death.
“You can't destigmatize somebody who you're criminalizing,” Wallace says.
But he says a fulsome public health approach folds in sellers and dealers, who generally want to avoid toxic supply, and may not have a full picture of what they’re selling. Many are operating survival-based dealing and trading with friends and acquaintances.
“The decriminalization that is often talked about is only limited to personal possession, and… often at the same time, demonizes people who sell drugs and trafficking,” Wallace says. “If we look at drug checking as an upstream public health action, rather than a downstream, Band Aid approach, I think it would be that we're… working with people who produce themselves and sell drugs.”
Keeler says the government’s announcement is a start, but it isn’t going to bring the meaningful change that’s needed. Many of the people selling drugs in small quantities are also using them.
“The police will always look at something as, ‘oh the dealers, they’re all feeding off everybody’s weakness [but] in actual fact, that dealer is in the same position, and needing to do this so he can keep his head up.”
Keeler has witnessed dozens of deaths and overdoses in his life. He says drugs don’t stop people from living functional lives, but pain and trauma do. At the end of the day, he wants access to safe, effective supply.
“People say, ‘you’re the problem because you’re doing drugs.’ No, I’m doing drugs because of the problem,” Keeler says.
“People have their heads up their asses, and they don’t think they can learn anything from people who have been through hell. You can learn a lot from people who have been through hell.”
