Why is Canada's illicit drug supply so deadly and what's being done about it?
'On any given day, nobody knows what they're using,' says one addiction medicine physician
Canada's overdose crisis has worsened during the pandemic, with the number of people dying from illicit drugs soaring to new heights in many provinces.
The Public Health Agency of Canada (PHAC) says 2020 was the deadliest year for overdose deaths since it started recording the numbers in 2016. From January 2020 to June 2021, more than 9,800 Canadians died from an opioid overdose.
According to those who research and work with drug users, the country's increasingly toxic drug supply is to blame.
Why is Canada's illicit drug supply increasingly deadly?
Data suggests that the pandemic has a part to play in how toxic the supply has become. Supply volatility increased dramatically once pandemic lockdowns were declared in March 2020, according to the Canadian Centre on Substance Use and Addiction (CCSA).
"The entire drug supply has gotten a lot more messy since COVID started.… The borders closed, and the drug supply routes aren't the same and people are just using what they can," said Doris Payer, a co-ordinator and researcher with the CCSA.
Prescription opioid OxyContin was introduced in 1996 and is widely seen as a catalyst to the opioid crisis that has claimed hundreds of thousands of lives across North America. Drug manufacturers marketed opioids aggressively, particularly OxyContin, which lawsuits claim they falsely suggested was safer and less prone to misuse than other opioids.
However, as more people began using the drug, more people started misusing it. Dealers turned huge profits as the painkiller became a popular street drug, and OxyContin eventually made its way from cities into remote communities.
In 2012, the manufacturers of OxyContin, Purdue Pharmaceuticals, reformulated the drug to make it harder to crush or melt down, with the intent of discouraging abuse. But making pharmaceutical opioids less available didn't change the fact that thousands of people were addicted to them, so many people turned to the streets and to other opioids, including heroin.
As the demand for illicit opioids increased, drug dealers began adding the powerful synthetic opioid fentanyl to the illicit supply of heroin to maximize profits.
In 2016, a study by Public Health Canada found that fentanyl was fuelling a rise in opioid-related deaths. The study said fentanyl, which was becoming more prevalent on the illegal drug market, was being increasingly mixed in with other illicit drugs, increasing the risk of an overdose.
Much more potent than oxycontin, the relatively cheap-to-make opioid has been increasingly mixed into other street drugs, killing hundreds of people across Canada, but particularly in B.C. and Alberta. In 2016, PHAC recorded more than 2,800 opioid-related deaths.
Data from drug-checking services Toronto and B.C. that test the substances used by people and inform them on what they contain shows fentanyl now dominates the market.
In 2020, 69 per cent of opioids seized by law enforcement agencies across Canada consisted of fentanyl or fentanyl analogues, according to Health Canada's Drug Analysis Service (DAS).
But Paxton Bach, an addiction medicine physician and co-medical director of the B.C. Centre on Substance Use, said fentanyl itself isn't the only reason people are overdosing and dying.
Rather, it's because "on any given day, nobody knows what they're using" or how much they're using, Bach said.
Fentanyl is still detected in an overwhelming majority of illicit drug deaths in Canada, according to PHAC, but the unpredictability and potency of other substances mixed in with the fentanyl are making the supply more dangerous.
The latest drug health authorities are sounding the alarm about is benzodiazepines.
According to a recent report by the B.C. Coroner Service, the number of drug samples in which benzodiazepines were detected in B.C. went from 15 per cent to 53 per cent in a little more than a year.
Benzodiazepine, which is typically prescribed as a sedative, is dangerous when paired with fentanyl because the sedation increases the risk of an overdose, according to Health Canada.
Pat Fifield, an overdose prevention support worker at a supervised consumption site in Toronto, said the illicit drug market has been flooded with new substances for years.
Over the past two years, Fifield said almost all fentanyl tested at supervised consumption sites in Toronto also contains synthetic cannabinoids, benzodiazepines or psychoactive substances. Toronto's drug-checking program shows a similar plethora of substances.
Synthetic cannabinoids are manufactured chemicals that affect the brain in a similar way to cannabis plants. Psychoactive substances are chemical substances that change a person's mental state by affecting the way the brain and nervous system work.
Often, people are using these new substances unintentionally — and that's what makes the current situation so deadly, said Bach.
"The speed at which the unregulated drug supply is evolving and getting more unpredictable and dangerous is outstripping our response."
How did we get here?
Canada's unpredictable drug supply has roots that extend far beyond the country, said Martin Raithelhuber, an illicit synthetic drugs expert working with the United Nations Office on Drugs and Crime (UNODC) in Vienna, Austria.
"The development you're seeing in Canada has a global dimension," said Raithelhuber.
Since 2008, more than 1,000 new psychoactive substances have been reported to the UNODC.
Raithelhuber said this is largely because information on how to synthesize drugs is widely available online.
"A lot of these substances first appeared in pharmaceutical research — they're so-called failed medicines. But the literature is there and it becomes accessible through the internet."
He also said the rise of cryptocurrencies and the dark web have made it easier to sell drugs anonymously.
Raithelhuber said that it is easier and cheaper to produce synthetic drugs than to produce organically derived drugs such as heroin, which involves growing and harvesting the poppy.
How are people being affected?
Fifield said the changes in the illicit drug supply have made harm-reduction work more difficult and the lives of drug users more precarious.
Naloxone, a fast-acting antidote that reverses the effects of an opioid overdose, doesn't act on benzodiazepines or on most other synthetic substances found mixed in with opioids.
Similarly, the increasingly toxic drug supply is complicating medical care for drug users.
"On the medicine side of things, we're seeing a lot more unpredictable withdrawal and unpredictable response to our traditional medications," said Bach.
For people who use drugs, it can mean life or death.
Frank Coburn, 70, has been using opioids and cocaine for more than 20 years and works as a harm-reduction worker in Toronto.
"You pray to God or whatever force is there that rules the world that this is not going to kill you," he said.
"The tainted drug supplies are killing people all over the place."
What's being done?
Harm-reduction services have become more widely available in recent years.
Supervised consumption sites have started popping up in most urban centres in Canada. They provide a safe, clean space for people to bring their own drugs to use in the presence of trained staff.
There are 38 federally authorized supervised consumption sites offering services in Canada, according to Maja Staka, press secretary for the office of the federal minister of mental health and addictions.
Naloxone distribution programs, public awareness campaigns and addiction treatments to help wean people off of certain drugs have also ramped up in the past few years.
Coburn said a safe supply is the only thing that will curb the number of illicit-drug-related deaths in Canada.
People who use drugs have been calling for safe and regulated drugs for decades. The goal is to enable people who use drugs to access regulated substances, such as medical-grade heroin, from a legal source, rather than toxic versions from illicit markets
So far, safe supply programs have limited scope. The programs exist in a handful of cities in B.C., Ontario, Quebec and New Brunswick and users need a doctor's prescription.
For Bach, the only way to curb overdose deaths is by expanding the availability of safe-supply programs and reducing barriers to accessing them.
"The No. 1 thing that we can do to curb overdose deaths is provide a predictable, safer alternative to a poisoned, volatile, unpredictable drug supply that's continuing to evolve much faster than we can keep up."
David Golesworthy uses opioids and lives in London, Ont., one of the first cities in Canada to put in place a prescription-led safe supply programs.
But he hasn't been able to sign up to the program run through the London Intercommunity Health Centre because demand far outstrips availability and there's a waiting list.
Carolyn Bennett, the federal minister of mental health and addictions, told CBC she agrees that safe supply "is going to be the way that we will save the most lives," but remained vague on a possible timelines for the expansion of safe supply programs across Canada.
"I'm interested in learning more about and putting in place the research to firstly do no harm and to make sure that the [safe supply] proposals are effective, because only then can they be sort of scaled up and used in other parts of the country."
Meagan Jasper, a recovering methamphetamine addict and harm reduction worker based in Moose Jaw, Sask., said more funding for harm reduction services is desperately needed.
Saskatchewan saw its deadliest year in terms of overdose deaths in 2021 with 464 people confirmed or suspected to have died from drug toxicity.
"We are so far behind other provinces," said Jasper. 'Until the long-term solutions are there, like the treatment beds, housing, things like that, we need to keep people alive long enough through harm reduction until we're ready to help them."
Coburn and Fifield believe decriminalizing illegal drugs would lead to a safer supply because all substances would be federally regulated.
They both noted that after Portugal decriminalized the personal possession of all drugs in 2001, overdose deaths and rates of drug use fell. They have since remained consistently below the EU average.
The federal NDP party, the Toronto Board of Health and health practitioners in B.C. are pushing the federal government to decriminalize illicit drugs.
Bennett said the government is "looking very carefully" at decriminalization proposals, but said "we need to make sure there's a good implementation plan."
With files from Nicole Ireland and Adam Miller