The fentanyl crisis in Vancouver is splashed over the media every few days and news articles are popping up with alarming regularity, reporting the increasing rate of overdose deaths. At Her Vancouver we believe that if something is labeled a crisis it should not only spark our curiosity and voyeurism on the subject but also a desire to learn about and encourage solutions.
We quickly found ourselves buried deep in information on a difficult, multifaceted problem. Vancouver is a complex city where having a neighbourhood like the Downtown Eastside can cause us to automatically compartmentalize issues of drug use, addiction, and overdose deaths to one small zone. It’s easy to feel untouched and safe when problems appear concentrated in the DTES but Her Vancouver has begun to question these artificial boundaries; not only geographically because opioid addiction extends far beyond the DTES but also societally, how do we determine the value of a human life based on resource allocation?
This post is a reflection of our navigation through the fentanyl crisis from its root cause to current state. To help us in our navigation we started a conversation with an old friend and current addictions specialist, Dr. John Koehn.
“Over the last 20 years there has been a major shift in the way the medical establishment looked at painkillers and looked at pain in general and it led to an increase of prescription opioids, not just to people dying of cancer or other diseases, they just had chronic pain. The view that we have to obliterate all pain through the use of these medications has led to many more people being on opioids in general. Probably the chief culprit in terms of pharmaceutical companies was Perdue in terms of their marketing of OxyContin. They marketed it to doctors saying that it’s a safer option than morphine, that it’s not addictive or very few people get addicted to it and it treats chronic pain. We know differently now that a much higher percentage have a dependence and that when doctors realized that and cut them off, they turned to heroin and now fentanyl.”
Perdue introduced OxyContin to the public in around 1997. More accurately, it was introduced to Canadian doctors as a, ‘Safer alternative to even Aspirin and Tylenol and good for anyone who needed pain relief for “several days” or more (National Post, November 2011).’ The drug was promoted for it’s continuous-release convenience and it’s supposedly low potential for abuse. In Canada it is illegal to directly market pharmaceuticals to the public and so drug companies go the clever and not so discreet route of targeting doctors with office visits, sponsored talks and advertisements in medical journals. We highly recommend reading this National Post article for a detailed overview of Perdue’s quick and effective promotion of OxyContin to Canadian doctors and medical students, the resulting over-prescribing of the drug by Canadian doctors and the opioid addiction crisis it spawned. By 2000 it was widely known that OxyContin was being hugely abused.
In 2007 the U.S. branch of Perdue pleaded guilty to “misbranding” and came to a $635-million dollar settlement with the federal government. However, according to this Forbe’s article from July 1, 2015, Perdue’s annual revenues are about 3 billion, still mostly from OxyContin. We’ll get to the current Canadian class-action suit against Perdue in a while but for now we want to follow the path towards the emergence of illicit fentanyl as the opioid of choice.
In 2012 Purdue Canada replaced OxyContin with OxyNEO. According to Dr. Koehn,
“It’s another long acting form of opioid pain relief which is in a very hard form. It’s hard to crush but you still can if you freeze it or put it in a vice grip, this kind of thing. But it’s meant to be less abusable. More importantly: Why would you need that when you have something much more potent, much more cheap available?”
Enter fentanyl. The fentanyl we’re hearing about in the news is not coming from medical sources. Dr. Koehn tells us,
“There is a fentanyl patch. It’s the only kind available to be prescribed and it was largely used in palliative care patients, people dying of cancer. Sure people might have been abusing their fentanyl patch at times but the fentanyl that you’re hearing about is illicit, made in clandestine labs in China. It could be produced locally too. It was put into a powder and then in Canada they were taking that powder and pressing it into pills, painting them green to look like OxyContin. But now nobody has to make them look like OxyContin, it sells just as well on it’s own.”
To rehash: Pain patients become addicted to OxyContin, OxyContin becomes more regulated in Canada due to wide spread abuse (read harder to get a prescription) and takes the form of OxyNeo, which is less “abuser-friendly.” Users discover fentanyl as a non-prescription way to get pain relief and fuel their addiction.
But why fentanyl? What makes its properties lucrative to sellers and users alike?
For starters fentanyl is 100 times more potent than morphine.
“A kilogram of fentanyl will be cut 26 times with other stuff (like icing sugar) and still be as potent as a kilogram of heroin. If they’re about the same price you can make fentanyl go much further to sell more. It makes sense from a business perspective. You have a cheaper product that you can sell and make more money for yourself at the same time.”
Then there’s the transportation of fentanyl that makes it highly appealing for seller and users alike. Because a little fentanyl goes a long way, very small amounts can be funneled through regular mail delivery.
“It’s probably going through some of the typical ways like through the ports but I know some of my patients order it online. If a letter is less than 30 grams it is not subject to random custom checks. They don’t have the same ability to open and search. You could bring fentanyl over in a plastic cell phone case for example. Some of these companies that will do these online shipments will say, ‘look, if it gets complicated for any reason, we’ll just send you more.’”
If you’re looking for access to opioids, fentanyl is a win-win economic situation. But here is where everyone loses; not only making overdoses a near inevitably but targeting addicts and recreational users alike; not only killing people in the DTES but killing Joe Blow with the white collar job next door.
“Because it’s cut, it’s an unreliable amount and potency. People use the measures of a point (point one of a gram), so 100 milligrams, but one point for someone who is opiate naive can be too much for them. That’s the fine line and that’s why there are overdoses because it’s so potent it’s being cut with other substances that melt at the same degree and kind of look the same as other opioids to stretch it further.”
This made us consider who else could be affected by the fentanyl crisis outside the more obvious high-risk neighbourhoods like the DTES. Many health care providers and other front line workers believe we have not hit rock bottom in regards to this crisis. What would that look like?
For example, according to a Canadian Drug Use and Monitoring Survey from 2012 the use of opioid pain-relievers (OxyContin), stimulants and tranquilizers and sedatives, by youth age 15-24, increased from 17.6% in 2011 to 24.7% in 2012. Prevalence was higher among females. In 2012, of this population of young females who, “indicated they had used a psychoactive pharmaceutical in the past year, 6.3% (or 410,000 Canadians, corresponding to 1.5% of the total population) reported they abused such a drug (i.e. used it for the experience, the feeling it caused, to get high or for “other” reasons).”The practice of mixing fentanyl with other opioids puts all drug users at risk, regardless of age or degree of use.
More current data specifically focusing on overdose deaths was recently provided in a PDF from BC Coroners Service titled: Illicit Drugs Overdose Deaths in BC. From January-October 31st. The document reports, “There were 622 apparent illicit drug overdose deaths from Jan to Oct 2016. This is a 56.7% increase over the number of death occurring during the same period in 2015 (397). Fentanyl–detected deaths appear to account largely for the increase in illicit drug overdose deaths since 2012.” The chart paints a grim picture showing fentanyl deaths on a massive rise. Vancouver has the highest rate of overdose deaths in the province.
Society is now scrambling to put forth solutions to the fentanyl crises before we find out what rock bottom really looks like. While no solutions come easy, Dr. Koehn and many others in health care and addiction services believe there are ways to proactively address the crises. We mentioned earlier the class-action suit currently under way in Canada against the pharmaceutical company, Purdue. Launched by Wagners Law Firm. The suit is titled Bellefontaine & MacGillivray v. Purdue Pharma Canada et al. The suit was launched in September of 2007 and from our latest search we found that a 2nd Fresh Amended Statement of Claim was made on August 26th 2015. In eights years, the case is moving forward at a snails pace.
In a text conversation with Dr. Koehn we wrote, “I was thinking about Purdue and correct me if I’m wrong but even if a class action suit was won in Canada, the problem extends way beyond Oxycontin now. It would be like retroactive punishment without changing much in the current crisis with Fentanyl.” His response was, “Yes, exactly. The train has left the station.” So while we still hope Perdue pays for any wrongdoing, there’s no nipping this one in the bud. Instead, proposed solutions point towards pruning away at the fentanyl crisis, albeit with a heavy-hand by focusing on methods of harm-reduction, abstinence based therapy, and a combination of both.
The most common harm-reduction methods in Vancouver centre on safe-injection sites and supplying healthcare providers, street-workers and users with Naloxone as an antidote to a fentanyl overdose. An injection of Naloxone can save a life. However as Dr. Koehn points out,
“You can have a paramedic give Naloxone and it brings them back to life but it just allows them to overdose another day.”
Harm-reduction has an important place in coping with the fentanyl crisis but the underlying issue of addiction can not be ignored.
“I think at the basic level, addiction is a treatable disease. One that people can get better from and that access to treatment in a variety of forms is crucial. So with opiate addiction, first stabilization methadone or Soboxone have been shown to be effective for treating this disease. And then also psychosocial interventions, like for some people who are very unstable, inpatient treatment goes a long ways to helping people get their lives back and access to these treatments is absolutely crucial so while the government has focused largely on putting a cork in the dam, just trying to stop people from dying, underneath that you have a disease that needs treatment. Perhaps the longer term solution is to treat the disease not just the symptoms of the disease.”
As the case of Amelia and Hardy Leighton has demonstrated, one of the characteristics of the overdose deaths in BC is that it is not just street-entrenched users who are dying.
“They are people in the suburbs, what we would consider to be recreational, intermittent users who then overdose because they don’t know what they’re taking or what they’re taking is so much more powerful then what they had been used to.”
As it currently stands, there are not many treatment programs for those suffering with addiction both inside and outside the DTES. A valuable point made by Dr. Koehn is that recreational users outside the DTES are not going to come into the city to use at a safe-injection site.
“I don’t think there’s enough focus put on abstinence based therapies with the goal of not using drugs altogether. So sometimes people on those medications need in-patient treatment, access to counseling, detox programs where you’re part of programming every single day. Outside of the Lower Mainland access is very limited. So I think there’s not nearly enough treatment options for patients. It’s not a one approach versus another, but that’s what it’s become in some ways. These are all important things but not one of them is going to solve the whole problem. From the way I see it, focusing only on harm-reduction might be harmful too.”
Like so many societal issues, government money is a factor. It is not only necessary for creating more programs that focus on helping people hurt themselves less but also for funding programs that help treat addiction. Amelia and Hardy Leighton would surely have benefited from both.
We also asked Dr. Koehn about current educational campaigns about drugs, targeted at youth and adults.
“I think some of the educational campaigns that have gone to the people in general have been ‘Don’t use alone,’ ‘Know who you’re buying from,’ but again they’re kind of band-aid solutions. The answer is not just, ‘Don’t do drugs,’ but it kind of is. It is very risky behaviour and there’s no way of putting a needle in your arm in a completely safe way. There are safer ways. That’s what we would be talking about when we say harm-reduction, you can protect yourself from overdosing if you use in a safe-injection site or use clean needles but there’s no 100% safe way of using fentanyl.”
As we look back at the beginning when OxyContin was first introduced to treat pain it causes us to reflect on the question of does it work? OxyContin and now OxyNeo and fentanyl numb the physical experience of pain but what Dr. Koehn suggests is a redefinition of what “works” means.
“Usually when people say it works they mean something that makes my pain go away for a time. But I think maybe a better way of looking at treatment of pain is asking: Is your life getting better? With opiote medications the answer is often no. Life isn’t better. Objectively a better life means a return to some of the normal activities like being around your family, being able to do things that you need to do like cooking, cleaning, working. That becomes the framework. It’s harder to make that up. Your life is either better or it’s not.”
*For those struggling with addiction or who know someone who is there is the BC211 Helplines. Through BC211 it’s possible to find phone numbers for detox, treatment centres and counselling. Mutual support groups through Alcoholics Anonymous and Narcotics Anonymous are also available in most cities.