As the number of deaths linked to fentanyl and carfentanil in 2016 continue to rise in British Columbia and Alberta, the "unprecedented drug safety and public health crisis" is "spreading like a cancer" across Canada, a prominent drug expert says.
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"There has never been a more dangerous time to source drugs on the street," said Dr. David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, and a researcher with the Institute for Clinical Evaluative Sciences (ICES).
The federal government has acknowledged the threat. In November, Health Minister Jane Philpott, along with many of her provincial and territorial counterparts, jointly committed to respond to "a serious and growing opioid crisis," including an Opioid Action Plan in 2017.
How did we get to this crisis point?
Juurlink, who is on a steering committee to change the guidelines for prescribing opioids in Canada, says a massive increase in prescriptions for narcotic painkillers that started 20 years ago paved the way for today's fentanyl and carfentanil crisis.
Opioids, including morphine, OxyContin and fentanyl, work by binding to receptors on cells in the brain and spinal cord, blocking the perception of pain. But up until the mid-1990s, Juurlink said, they were usually prescribed only for acute pain (such as a broken bone), pain caused by cancer or for palliative care.
That attitude changed when medical students and doctors were told that opioids could also be used to treat chronic pain, and that the risk of addiction for their patients was low.
But by the mid-2000s, when medication like OxyContin was being widely prescribed, it became clear that many chronic pain patients were on a "spiral into addiction."
The sheer amount of painkillers being prescribed also "put a lot of opioids into medicine cabinets that otherwise wouldn't have been there," Juurlink said, which in turn led to teens experimenting with their parents' drugs, and "millions" of tablets also falling into the wrong hands.
When the medical community started to recognize the damage being done, the culture of prescribing opioids began to shift and many doctors stopped giving them to their chronic pain patients.
In 2012, Purdue Pharma replaced its OxyContin pills in Canada with a different formula approved by Health Canada that was supposed to make the tablets more difficult to abuse by crushing, injecting or snorting.
But making pharmaceutical opioids less available didn't change the fact that thousands of people were addicted to them — and the withdrawal symptoms were unbearable.
"I can't tell you how many people I've looked after over the years who say, 'I've tried quitting, I just can't do it,'" said Juurlink, an internal medicine physician. "Imagine the worst flu you've ever had, multiply it by 20 and you are miserable."
Desperate people turned to the streets to get their hands on whatever opioids they could to avoid those withdrawal symptoms, he said — and that option was often heroin.
The "sheer enormity of the market" of people addicted to opioids has led drug dealers to maximize their heroin supplies as much as they can, Juurlink said, and that's where fentanyl — and more recently, carfentanil — come in.
Fentanyl is cheap and "incredibly potent," so drug dealers add it to heroin to multiply the effects and increase their profits, he said. But because "quality control isn't exactly their thing," how much fentanyl they add varies widely, and even a tiny bit too much kills.
In addition to contaminated heroin, there are reported cases of fentanyl-laced cocaine. Police have also started to find tablets that look exactly like OxyContin — but really contain fentanyl.
People using street drugs "literally have no clue what they're getting," Juurlink said.
But what alarms him even more than fentanyl is the recently discovered presence of carfentanil, which was never intended to be consumed by humans, in other drugs.
Carfentanil, also an opioid, is chemically related to fentanyl, but is 100 times more potent and used in veterinary medicine to sedate large animals.
It's "one of the most frightening drugs I can imagine in circulation," said Juurlink. "It's only a matter of time before it is detected in every province in Canada."
Who is affected by this crisis?
When it comes to carfentanil, "nobody is safe from this stuff," Juurlink said. "This could literally kill anybody who comes into even just casual contact with the powder."
Both fentanyl and carfentanil pose enormous danger not only to people with addictions, he said, but also to anyone — including kids — who might try a pill or drug at a party that isn't what they think it is.
"This happens. And those people fall asleep, and they stop breathing and they die."
How many Canadians have died?
Because the consumption of carfentanil by humans only became apparent relatively recently, some provinces have just started testing for it in post-mortem toxicology screens, so little information is available.
Some provincial chief coroners' offices have information about fentanyl-related deaths, but there is no national data. According to a British Columbia Coroners Service report, fentanyl was detected in 374 illicit drug overdose deaths in that province between January and October 2016.
A report from the Office of the Chief Coroner in Ontario cites fentanyl as a factor in more than 150 deaths in that province in 2014.
Juurlink estimates fentanyl and carfentanil will kill at least 2,000 people in a year, and that the number will only go up without drastic action.
How can those deaths be prevented?
Experts, including Juurlink, are calling on the federal government to support safe consumption sites, where people suffering from addiction are supervised, and can be resuscitated if the drug they take is contaminated with fentanyl or carfentanil. In addition, those sites can provide a gateway to addiction counselling and anti-withdrawal drugs that can help someone stop using illicit substances.
Juurlink also says people need to be able to easily access naloxone — medication that reverses the effects of an opioid overdose — in the same way that cardiac defibrillators are found in public places for use on someone suffering a heart attack. Naloxone is available in pharmacies, but Juurlink wants to see it in places like public bathrooms and nightclubs.