Taking stock of fixing fentanyl nine months into the public health emergency

B.C.'s provincial health officer says there's no easy solution to the province's ongoing fentanyl crisis.

B.C. provincial health officer says unless more is done, the burden of death and injury will continue

Fentanyl is estimated to be 40 times more potent than heroin on its own. (CBC)

In B.C., between 2000 and 2010 there were around 200 unintentional deaths from illicit drug overdoses annually.

In 2011 these numbers began climbing, more than doubling by the end of 2015, leading to the declaration of a public health emergency in April 2016. By Dec. 31, 2016 the toll reached 914.
This increasing toll parallels the increasing detection of the opioid fentanyl in the victims, which went from 5 per cent in 2011, to over 60 per cent in 2016. Take fentanyl out of the equation and the death toll would have been within the historic range.

No single cause, no easy solutions

Who is dying? Mostly younger adult males (80 per cent). While most may be described as regular users, no demographic or age group has been spared. Twelve of the deceased were younger than 19.
So what have we learned nine months into the emergency? This is an extremely complex problem which has no single cause, no easy solutions and requires a sustained, multi-sectoral, collaborative and innovative response.

Society's relationships with psychoactive drugs are complex. Policies and strategies have historically been largely values-driven, rather than evidence driven and fraught with the unintended consequences of well-intentioned decisions, hobbled by stigma, and suffering from an historic divide between legal and illegal substances. 

Victims are our families and friends

The criminalization approach condemns many of the most vulnerable in our society to discrimination, lack of compassion, lack of evidence based interventions and social and legal marginalization.
We have also learned that this is not a problem that just affects "them": "bad" or "weak" people who made poor decisions. Our families, children, friends and people we know are the victims.
Addictions treatment in Canada, long the poor relation of mental health care, itself the poor relation in the healthcare family, is now better understood. 

People suffering from substance use disorder are now recognised as having a chronic health condition.  Like many other chronic health conditions addiction has underlying social causes, identifiable and modifiable physiologic changes, and like any chronic condition, without medical and social support, is prone to relapses and treatment failures.

Stigma has blunted our compassion

The marginalization of people who use illegal drugs has blunted our compassion. Unintentionally, our policies of prohibition as the primary response to preventing or stopping illicit psychoactive experimentation, use or dependency have placed experimenters, users and addicts increasingly in harm's way.
Driven in part by overzealous promotion of prescription opioids a perfect storm has emerged. Attempts to curb inappropriate opioid prescribing and use resulted in unintended consequences. Inadequately addressed demand, driven by inadequately treated physical, psychological and emotional pain fuels the illegal market.

Convenient internet-based access, an ever growing compendium of increasingly potent (and toxic) psychoactive drugs, air-mailed in small packages rapidly around the globe, further drives this epidemic.

Limiting the burden of death

The response to this crisis — involving thousands of individuals, family members, emergency responders, front line health professionals, policing and elected officials has been heartening. Increased education, overdose response and reversal, opioid substitution therapy, psychosocial supports, withdrawal management and treatment beds are all appropriate and necessary, but do not fully address the underlying causes of this problem.
Consequently many of those engaged in the response believe that unless more is done, this burden of death and injury will be with us for longer than anyone would wish.
We need, therefore, to review and critically evaluate our approach to psychoactive substances and envision creating a regime in which human frailty, experimentation, drivers of demand and periodic or long term use for non-medical purposes are acknowledged and addressed through evidence informed interventions and system redesign.  

This could lead us to a future in which harms to individuals, families and society are minimized, and in which assistance and care for people having problems with their use of drugs are readily available, without stigma or marginalization.  

Such a dialogue may not be easy, but it is necessary and will be life-saving. 

Perry Kendall is B.C.'s provincial health officer.

This story is part of CBC's Opinion content. For more information, please read this editor's blog and our FAQ.