QUESTIONS YOU HAVE ABOUT OPIOIDS — ANSWERED
Bootleg fentanyl is so powerful that a tiny amount could be fatal
Late last year, health officials and first responders teamed up to warn Ottawans that bootleg fentanyl is so powerful that an amount the size of two grains of salt could be fatal, and also to promote naloxone kits that can save the life of someone who’s overdosing.
Then earlier this month, Ottawa Public Health and city police sent out an alert that counterfeit prescription drugs containing fentanyl were turning up in the capital — and were suspected in life-threatening overdoses.
That warning took on heartbreaking meaning the very next day when 14-year-old Chloe Kotval died from what’s believed to have been a drug overdose. While toxicology tests could take months, her parents said the Kanata girl’s death was the result of taking a pharmaceutical drug of unknown origin and called on authorities to address the “devastating impact” of “high-grade counterfeit pharmaceuticals.”
Two days later, Ottawa police announced the biggest fentanyl seizure in the city’s history and a dozen arrests.
WHAT’S AN OPIOID?
Opioids include drugs such as heroin, morphine, fentanyl, methadone and codeine. Some, such as morphine and codeine, are natural, derived from plants including the opium poppy. Some are created in a lab from natural ingredients such as oxycodone, better known as OxyContin, and heroin. Totally man-made opioids include fentanyl and methadone.
Opioids bind to receptors in the body, mimicking natural “feelgood” chemicals produced by our bodies such as endorphins but with much, much more powerful effects.
That’s why they’re prescribed to suppress pain but they can also induce euphoria like “your best feeling ever — nothing is hurting, everything is great,” explained Pam Jackson, director of patients services for substance use and concurrent disorders at the Royal.
On the flip side, when users stop taking opioids cold-turkey, withdrawal is like the worst flu you’ve ever had, Jackson said.
“You feel like you’re dying,” she said. “To make that stop you can take one little pill.”
DRUGS HAVE ALWAYS BEEN WITH US. WHAT’S DIFFERENT ABOUT THESE ONES?
They’re incredibly powerful. Fentanyl is 50 to 100 times stronger than morphine.
While recreational users in the past had to scrape it off patches prescribed to pain patients, it’s now so cheap and readily available that drug dealers are using it to lace street drugs or make knock-offs of prescription drugs.
That means that people the experts dub the “opioid naive” are at risk but may not recognize the drowsiness, difficulty breathing and slowed heartbeat that signal a potentially fatal overdose.
Even regular users of opioids — and for some fentanyl is the drug of choice — can get far stronger doses than they’re expecting.
The Ottawa drug squad keeps getting reports back from Health Canada’s lab showing that seized drugs contain fentanyl, said Staff Sgt. Rick Carey.
“Submit a cocaine sample, it’s got fentanyl in it,” Carey said. “Submit a heroin sample it’s got fentanyl in it. Submit what we thought was Ecstasy, it’s got fentanyl in it. Submit Percocets, it’s got fentanyl in it. Submit methamphetamines, it’s got fentanyl in it.”
“That’s what we’re telling people: You think you’re getting one (drug), there’s no guarantee, there’s no control system, it’s an unknown.”
Looming on the horizon is carfentanil, a drug intended for use on large animals, that is 10,000 times stronger than morphine and has already caused deaths in western Canada.
WHAT’S A ‘COUNTERFEIT’ DRUG?
These are drugs made illicitly in labs to mimic prescription pills but actually contain a totally unpredictable amount of synthetic opioids, most often fentanyl.
“You think you’re getting a prescription drug but it’s not the drug you think you’re getting,” Jackson said. “It may look exactly like what you just got from your doctor.”
Patients will tell treatment staff that they don’t use fentanyl but it shows up in a urine test.
“You’re playing Russian roulette,” Carey said, explaining that one pill could contain nothing but an inert filler and another all fentanyl and a third any mix in between.
“It’s completely unknown as to when that deadly shot will hit you.”
WHERE ARE OTTAWANS GETTING THIS STUFF?
There’s no one, simple answer, Carey said. It’s bought from traditional drug dealers connected with cross-border and interprovincial networks, shared between friends and even ordered online.
Citing the RCMP, the Canadian Centre on Substance Abuse notes that fentanyl, for example, is finding its way to the Canadian illicit drug market through two means. It used to be the diversion of pharmaceutical fentanyl products, typically skin patches, from sources within the country. Now it’s also smuggled from outside Canada, notably from China. Fentanyl and its analogues arrive in powdered form, and Canadian organized crime groups use them to create illicit products.
Police are making major busts but struggle to connect an overdose death to the supply that caused it.
“The difficulty is trying to say this person, unfortunately, passed away as a result of this drug. Well, where did that come from?” Carey said.
“People think, ‘I’m at a party with my friends and it’s my friend who gave it to me so it should be OK,’ but you have no idea where they got it from either.”
BOTH PROVINCE AND FEDS PROMISE ‘STRATEGIES’ ON OPIOIDS. WHAT ARE THEY?
Ontario launched its first opioid strategy last fall, including measures to prevent people from becoming addicted to prescription opioids, boost treatment and head off overdose deaths. The province appointed the chief medical officer of health as the first overdose coordinator to launch new surveillance to figure out how care should be directed.
New standards on opioid prescribing will be released by the end of next year. High-strength forms of long-acting opioids will be delisted and $17 million will be spent on chronic pain treatment. Access was expanded to life-saving naloxone kits so they’re free for patients and families through pharmacies.
The federal government, meanwhile, announced this month $65 million over five years to combat the opioid crisis. The cash could go to boost drug lab testing capacity, launch a nationwide awareness campaign and fund grants to communities in need.
The government had already made naloxone readily available and simplified the application process to open supervised injection sites.
It has proposed changes to the Customs Act that would allow border authorities to open and inspect mail weighing less than 30 g if they have reasonable grounds to suspect it may contain contraband. Currently, if they don’t have permission from the sender or recipient, all they can do is send suspicious envelopes back to the sender, so drug traffickers send substances, including pure fentanyl, in separate, small envelopes knowing some will get through and there will be no legal consequences.
The RCMP also recently inked a deal with Chinese authorities to work together to disrupt the supply of fentanyl and other synthetic opioids.
WILL SUPERVISED INJECTION SITES HELP IN THE OPIOID CRISIS?
Proponents of the sites, such as Marilou Gagnon, who teaches at the University of Ottawa’s School of Nursing, say they’re one piece of a solution but not a panacea for the problem. The Sandy Hill Community Health Centre has submitted an application to the federal government to open a supervised injection site at its Nelson Street building.
“Everyone who’s working on this topic recognizes that supervised injection sites are one piece of the puzzle, one piece of a comprehensive health-care strategy around harm reduction,” she said.
Supervised injection sites help head off overdoses from powerful or tainted drugs and connect drug users with medical care and support, Gagnon said, but they target people who inject their drugs, typically the most vulnerable, not those who sniff, smoke or ingest them and not recreational users.
However a University of Ottawa research scientist has asked for funding to evaluate technology that could instantly check street drugs for potentially deadly substances like fentanyl with an eye to including it at the city’s first supervised injection site. That way, officials could help prevent overdoses and issue speedy warnings about “bad drugs” on the street.
It’s something advocates have been suggesting for years. The AIDS Committee of Ottawa, for example, offers cheap kits that allow users to test their own drugs but they don’t work well with opioids, unlike the high-tech spectrometers, costing $30,000 to $100,000, which have been used at events like music festivals around the world.
HOW DO OPIOIDS TIE INTO THE DISCUSSION ABOUT LEGALIZING MARIJUANA?
There have been warnings that marijuana could be laced with fentanyl.
But police and health officials in B.C., for example, said late last year that there was no evidence to back up Premier Christy Clark’s comments that fentanyl-adulterated pot had been found in the province, which Clark said made regulating marijuana “even more important now than ever.”
Vancouver police, at the centre of the opioid crisis, said in November that they’d never found marijuana laced with fentanyl, though the province’s public safety minister noted that, given seizures of pot and fentanyl from locations where drugs are packaged, cross contamination posed a threat.
Researchers have wondered if medical cannabis might reduce mortality from opioids because both are used for chronic pain. A 2014 study in the Journal of the American Medical Association found that states with medical cannabis laws had a mean of nearly 25 per cent fewer deaths from overdoses of opioid painkillers. Medical marijuana has also been touted as a treatment for patients with opioid addictions.
Gagnon, an advocate of decriminalizing drugs so that efforts can focus on the need to reach users with medical care and support, thinks that legal pot could spur debate.
“I’m sensing in Canada a momentum for more discussion around decriminalization,” she said.
WHAT ARE THE LATEST NUMBERS WE HAVE ON OPIOID OVERDOSES AND DEATHS?
Statistics on overdose deaths this year and in 2016 aren’t yet available, according to Ottawa Public Health. They’re collected and distributed by the province’s Office of the Chief Coroner. Currently, overdoses aren’t “reportable” to public health like cases of everything from food poisoning to whooping cough to HIV.
In the meantime, Ottawa Public Health is part of the Overdose Prevention and Response Task Force, including partners such as hospitals, paramedics and police, which collects real-time statistics overdoses to plan their response to the crisis.
In 2015, a total of 48 Ottawa residents died of unintentional drug overdoses, which was an increase of a third over 2014. Almost twothirds of the deaths were from opioids and more than one in four from fentanyl.
But the overall overdose deaths in 2015 may reflect something very different than the alarm now being raised in Ottawa.
Only one of the deaths was a child or teenager in 2015. Only six were people in their 20s. Twentythree of the dead were people over 50, reflecting a cohort that is more likely to experience chronic pain and to take multiple medications that may not interact well with each other.
Older people are more likely to take opioids prescribed for pain, and the risks increase if they’re mixed with alcohol, Jackson said.
While our minister of health says, “Canada faces a serious and growing opioid crisis,” there are no national statistics on the death toll.
The British Columbia Coroner’s Service reported that the arrival of fentanyl pushed the death toll to a high of 914 overdose deaths in 2016 — nearly 80 per cent higher than in 2015.
The only statistics available for Ontario are from 2015, when 707 people died from opioid-related overdoses.
Fentanyl was detected in almost one in three of the opioid-related deaths but it’s not known how many of these deaths are due to bootleg versus pharmaceuticalgrade fentanyl.