Little pills, big trouble

How Alberta's fentanyl crisis escalated despite years of warnings

Addiction experts tried to warn the Alberta government years ago that fentanyl abuse was about to become a crisis.

"We were aware that this was a problem that was hitting the fan," said Michael Trew, the province’s former chief addiction and mental health officer.

A document released to CBC News under access-to-information laws shows that Trew's office asked for a bigger role in battling opioid abuse in July 2014.

"While other provinces have made a clear priority of the issue, it languishes in Alberta," according to the memo, titled Advice to the Deputy Minister.

Trew was appointed in July 2013 under the province's former PC government. But when his contract expired in September 2015 under the current NDP government, it was not renewed.

Instead, the Office of the Chief Addiction and Mental Health Officer was disbanded — a decision Trew calls "short-sighted."

"We would have been at least two years ahead of where we are now in terms of organization," Trew told CBC News.

The addictive and widely prescribed narcotic OxyContin was pulled off the Canadian market in 2012, and each year since has seen a steady and startling increase in the number of Albertans dying from overdoses of drugs that contain fentanyl or other opioids.

(File\/CBC Vancouver)

(File/CBC Vancouver)

Given how fast the fentanyl crisis is growing, most Albertans have been touched by it in some way: They know someone who has taken the drug, or overdosed on it, or they know someone who knows someone who has.

Deadly pills containing fentanyl began to show up en masse in Alberta shortly after OxyContin was removed from pharmacy shelves. Around that time, the drug became prevalent in British Columbia as well.

(File\/CBC Vancouver)

(File/CBC Vancouver)

Faced with a rising death toll, the B.C. government declared a public health emergency in April 2016. Numbers continue to rise in Alberta, but the province's NDP government has resisted going down the same road.

Critics say that's a dangerous mistake.

"I don't think that there's any good explanation for why B.C. has gone that way and Alberta has not," said Dr. Hakique Virani, a public health and addiction specialist at the University of Alberta.

Virani has lobbied governments past and present to declare a public health emergency.

"When you find that the measures that you're taking are not keeping up with the public health need, and that extraordinary measures are going to be required to deal with an extraordinary problem, that’s when you declare a public health emergency."

Dr. Hakique Virani, addiction specialist, U of A

Front-line workers saw the crisis coming a decade ago.

They tried to sound the alarm, but their concerns were ignored by the politicians in a position to do something.

Marliss Taylor, the longtime manager of Edmonton’s Street Works needle exchange, knew by 2006 that fentanyl abuse was becoming "an absolute epidemic" in major cities along the northeast coast of the United States.

"We just knew it would be coming here," she said. "We just knew, and we tried to raise flags."

But at the time, alerting authorities in Alberta’s then-Progressive Conservative government about a seemingly non-existent problem proved fruitless.

"It would be like saying, 'You guys, pay attention: There's martians coming, there's martians coming.' Well, there were no martians here," Taylor said. "And so it was harder, I think, for people to get their heads around."

Marliss Taylor, manager of Street Works, talks about foreseeing the rise of fentanyl in Alberta

It was Taylor's needle exchange that pioneered the life-saving front-line response. Between 2004 and 2007, Street Works partnered with the federal government on a program to widely administer an antidote called naloxone (which, at that time, required a prescription) to people who had overdosed.

Naloxone kit (File\/CBC)

Naloxone kit (File/CBC)

Successive provincial governments have not been nearly as innovative in finding ways to deal with the crisis, though the NDP has now implemented an Alberta-wide version of the naloxone program started under Street Works.

Fuelling an addiction

Opioids were commonly used to treat acute pain or given to terminally ill patients until the 1990s, when pharmaceutical manufacturers began marketing the drugs they insisted were non-addictive. As doctors began prescribing those supposedly low-risk opioids for chronic pain, more and more Canadians became dependent on them.

In 2007, the manufacturer of OxyContin, Purdue Pharma, pleaded guilty to misrepresenting the risk of abuse and agreed to pay $600 million US in fines.

By 2010, the number of Canadians using prescription opioids had increased by 203 per cent, compared to a decade earlier.

OxyContin was taken off Canadian shelves in April 2012, replaced by the manufacturer with a substitute that didn’t give the same high. That’s when the trouble really started.

Within two weeks, Taylor said, there was more heroin on the streets of Edmonton — and more fentanyl.

The situation went from bad to worse, and by the end of 2013, officials in Alberta were alerted to an impending problem.

On Dec. 24, 2013, two Calgary doctors signed off on a memo, released under the Freedom of Information and Protection of Privacy Act, that warned two patients had experienced cardiorespiratory failure after taking fake OxyContin bought on the streets.

It was laced with fentanyl.

The accompanying Urgent Notification to an Emerging Issue Report from Alberta Health Services advised: "If additional cases occur, consideration should be given to issuing a public advisory similar to B.C."

Adding fentanyl to the equation

In B.C., toxic street drugs have long been a concern, particularly on Vancouver's infamous Downtown Eastside.

The B.C. Centre for Disease Control and the coroner's office have been tracking drug-related overdose deaths for years. In 2010-11, they noticed a spike, which led to the creation of a task force that included police and emergency services, researchers, addiction treatment specialists and drug users.

(File\/CBC Vancouver)

(File/CBC Vancouver)

The group issued alerts about bad batches of drugs and started a program to increase access to naloxone, similar to the one in Edmonton.

Despite those efforts, the number of overdose deaths continued to climb in B.C.

B.C.'s first public health emergency

Before 2011, fentanyl wasn’t a factor in fatal drug overdoses, said Perry Kendall, B.C.'s provincial health officer.

"If you took fentanyl out of the equation, you basically had a relatively stable illegal drug overdose rate," Kendall said.

After a "particularly bad set of numbers" in early 2016, Kendall said the task force contemplated declaring a public health emergency, which, under the Public Health Act, is typically reserved for outbreaks of communicable diseases.

B.C. Health Minister Terry Lake supported the idea, Kendall said, and in April 2016, the call was made. In July 2016, Premier Christy Clark announced the solicitor general's office would be officially focusing on the crisis as well.

"It was the first time a public health emergency had been declared in British Columbia, so it focused a lot of attention on the issue, and we were able to engage more readily with the local health authorities," Kendall said.

In addition to raising the profile of the problem, Kendall said the big advantage of the declaration was that it allowed more — and more frequent — data collection, including from ambulances and emergency rooms. It has also helped more people get into opioid replacement therapy. When under a public health emergency, governments are able to reallocate resources, including money and physicians, to deal with the epidemic.

After the call was made in B.C., many wondered why Alberta did not follow suit.

The Alberta government had launched a provincewide take-home naloxone program in July 2015.

But a memo to the minister, dated Dec. 1, 2015, acknowledged the government’s response to fentanyl-related overdose deaths had been widely criticized.

“Advice to the minister: If pressed on declaring a public health emergency … declaring a public health emergency would not remove barriers for Alberta to provide naloxone without a prescription,” the memo read.

As a public health and addiction specialist, Virani also runs a treatment clinic where he regularly works with patients trying to recover from opioid abuse.

"This is not the time for key messages," he told CBC News in April, speaking about the NDP government’s approach to the problem. "And it's certainly not the time for passing the buck.

"When asked why we've not declared a public health emergency, to me the only reasonable answer is, 'I don't know.' "

In March 2016, the federal government announced naloxone would be deregulated and made available across Canada without prescription.

Critics pushed the federal government to do more, and last week, Health Minister Jane Philpott announced a series of legislative changes to speed up the process for opening safe-injection sites.

Those same critics also want to see a more centralized solution in Alberta, as the number of deaths continues to rise. In the first quarter of this year, 113 people fatally overdosed — a sharp increase over the first quarter of 2016.

In February 2017, Brandy Payne, associate minister of health, announced that naloxone would be available from Alberta pharmacies without prescription. In April, she said in a statement the province is "multiplying its efforts" and will spend $56 million to "help Albertans get the treatment that they need to reduce the harm of substance abuse and raise public awareness."

That's in addition to the $6 million the federal government gave the province in March to battle the opioid crisis. At the time, federal Health Minister Jane Philpott said: "Alberta, like British Columbia, has been disproportionately affected by overdose deaths and so we agreed to support Alberta in those emergency needs."

'This is an emergency situation'

Alberta's opposition parties have pushed the government in the legislature to declare a public health emergency.

Payne has repeatedly said that declaring an emergency "would not give us any additional surveillance tools that we are not already using." When her office was asked about the situation again last week, her communications team said her stance hasn't changed.

Widespread fentanyl abuse is "clearly not an infectious disease," said Liberal Leader David Swann, a former medical officer of health in southern Alberta. But Swann said he believes it should be treated as a public health emergency.

"This is an unprecedented amount of life lost and family tragedy in this province."

David Swann, Alberta Liberal leader

"I think if anything else was causing this number of deaths — up to two a day now in Alberta — there would be a declaration of an emergency to address it as comprehensively and in as co-ordinated a fashion as possible," Swann said.

Citing the government's repeated insistence that it has the resources to deal with the crisis, Swann said he'd like to see more proof that declaring a public health emergency wouldn’t change the province's plan.

"If that's the case, then show us the evidence that they're getting ahead of it," Swann said. "If we're not getting ahead of it, then it needs more attention, more urgency and more leadership."

Documents released under FOIP show that in October 2015, the Alberta government began to receive daily briefings on the fentanyl abuse. It put together a working group that met weekly, a cross-ministerial roundtable that met monthly and a task force that included police and other first responders, as well as social services, First Nations and other stakeholders.

Wildrose mental health critic Mark Smith said the government's slow response means there's even greater need now to focus on root causes of addiction.

"We would have argued that they should have known that this should have happened sooner. It is an emergency situation."

Mark Smith, Wildrose opposition MLA

Smith said addiction and its causes are not new challenges, but there are new challenges associated with them.

"I believe the seriousness of the opioid crisis is new to this country and new to this province," Smith said. "It just takes so little for people's lives to be shattered."

A decade in the making

Edmonton nurse Heather Stanchfield started her career at Insite, Vancouver's supervised injection site. Like Marliss Taylor, she first became aware of the power of fentanyl in 2006, when she saw someone fatally overdose in the middle of the road.

"How can this really actually be happening," Stanchfield recalled thinking. "How can people be dying so rapidly from something that's so preventable?"

"Had that person been using in ... the safe consumption site, the outcome would have been entirely different."

Heather Stanchfield, former Insite worker

Today it's widely known that even a small amount of fentanyl — the size of a grain of rice — can kill.

Though Stanchfield thinks Alberta's response has been slow, she said she feels B.C. hasn't done enough, either.

Declaring a public health emergency in B.C. ultimately hasn't helped curb the number of overdose deaths. Kendall said he has no idea how long that province's public health emergency will last.

Perry Kendall, B.C.'s provincial health officer (Government of B.C.)

Perry Kendall, B.C.'s provincial health officer (Government of B.C.)

"Once you're aware that it can become a crisis like this, you can take steps," he said. "You don't need to declare an emergency. An emergency happens when you haven't taken sufficient steps, because you weren't aware that it was going to get to the state that it's in.

"If we've got fentanyl and carfentanil now replacing heroin and other safer opioids on the streets, then this might be the new normal in terms of danger and a toxic drug supply."

Producer: Rick McConnell
Design and Multimedia: Sam Martin
Photo Credits:
Marliss Taylor (Peter Evans/CBC)
Perry Kendall (Province of British Columbia)
Mark Smith (Wildrose.ca)
Heather Stanchfield (Roberta Bell/CBC)