“Overdose is a necessary and searching investigation into a devastating epidemic that should never have happened. Benjamin Perrin painstakingly shows that it need not continue if we, as a society, heed the evidence.”
—Gabor Maté M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
An astonishing and powerful look at the ongoing opioid crisis
North America is in the middle of a health emergency. Life expectancies are declining. Someone is dying every two hours in Canada from illicit drug overdose. Fentanyl has become a looming presence—an opioid more powerful, pervasive, and deadly than any previous street drug.
The victims are many—and often not whom we might expect. They include the poor and forgotten but also our neighbours: professionals, students, and parents. Despite the thousands of deaths, these victims have remained largely invisible.
But not anymore. Benjamin Perrin, a law and policy expert, shines a light in this darkest of corners—and his findings challenge many assumptions about the crisis. Why do people use drugs despite the risk of overdosing? Can we crack down on the fentanyl supply? Do supervised consumption sites and providing “safe drugs” enable the problem? Which treatments work? Would decriminalizing all drugs help or do further harm?
In this urgent and humane look at a devastating epidemic, Perrin draws on behind-the-scenes interviews with those on the frontlines, including undercover police officers, intelligence analysts, border agents, prosecutors, healthcare professionals, Indigenous organizations, activists, and people who use drugs. Not only does he unveil the many complexities of this situation, but he also offers a new way forward—one that may save thousands of lives.
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What Is the Opioid Crisis?
“I don’t think anybody really saw this coming.”—Dr. Mark Tyndall, Executive Director, BC Centre for Disease Control
A sleepy suburb on the outskirts of Greater Vancouver was about to get a wake-up call—in more ways than one. At 1:30 a.m., the stillness of a balmy late-summer night in Delta was shattered by the blaring siren and f lashing lights of an ambulance racing to a family home.
“The paramedic walked up to a house in Delta because a friend of somebody called 911 saying this guy’s passed out; he’s not breathing,” said Linda Lupini, who heads BC Emergency Health Services. “Before they got into the house there were two kids who’d overdosed on the front stairs. So they thought they were at the address—the kids are overdosed; that’s the call.”
The paramedics began working frantically to help resuscitate them. The tell-tale signs of a drug overdose include unresponsiveness, blue lips, and difficulty breathing—or not breathing at all. The outcome can be fatal.
“Are you coming upstairs?!” someone screamed from inside the house.
“What do you mean?” replied a confused paramedic.
“The kid we called for is upstairs.”
There were three simultaneous drug overdoses at the house that night—and that was just the beginning. Within 26 minutes the 911 switchboard lit up like a Christmas tree. Drug overdose calls kept coming in. Paramedics would revive someone only to learn from them that someone else had taken drugs at the same party and could be at risk.
“Then we were working with dispatch, trying to find all these kids,” said Lupini.
In total, 11 young people who were at the party overdosed the night of September 1, 2016, after taking what they thought was a small amount of cocaine. What they didn’t know was that it had been laced with fentanyl—a potent opioid drug. One went into full cardiac arrest.
“We had parents doing CPR on the front lawn on their kids,” said Lupini. “We had 11 teenagers literally not breathing. They were all resuscitated, but barely. A few came close to not making it. It was so traumatic for the front-line staff. We just didn’t have the resources to respond to something like that.
“The problem for an ambulance service is that the increase in calls are your highest acuity—Code 3,” she continued. “They’re gonna die in minutes.”
Between January 2016 and June 2019, a record-shattering 13,913 people across Canada died f rom opioid-related drug overdoses. In 2018, when the annual death count hit 4588, a life was lost every two hours. According to Dr. Theresa Tam, Canada’s chief public health officer, opioid-related overdoses have become the leading cause of death for 30- to 39-year-olds. And although every part of the country has been affected by the opioid crisis, British Columbia, Alberta, Ontario, Saskatchewan, and Manitoba have been the hardest hit.
On April 14, 2016, British Columbia declared the opioid crisis a public health emergency after illicit drug overdose deaths began sky-rocketing. Historically, about 200 to 300 people a year had lost their lives this way, but by 2015 the number of overdose deaths had risen to 530. Worst was yet to come. By 2018 that number had almost tripled, reaching 1542. It hit me just how serious the situation was when the BC Coroners Service announced that illicit drugs were claiming more lives than murder, suicide, and car accidents combined. By 2019, the number of overdose deaths in the province finally started to decline as thousands had already died and the response to the crisis ramped out, even as the number of 911 overdose calls continued to grow to almost 25,000.
“For the longest while we said it’s a crisis,” said Jennifer Breakspear, executive director of the Portland Hotel Society (PHS) Community Services Society, which provides supportive housing for over 2000 people in Vancouver and Victoria as well as various programs and services. PHS also operates Insite, North America’s first supervised injection site. Breakspear was hired to head up PHS in January 2017. And although she’d had experience in leading a non-profit focused on reproductive health, she described the transition to PHS as a real “crash course.”
As I sat on a couch in Breakspear’s office on East Hastings Street, fire truck and ambulance sirens kept interrupting her—a constant reminder that Vancouver’s Downtown Eastside is ground zero in this crisis. “The soundtrack of my workday,” she remarked as another emergency vehicle raced by. Without a doubt, several of them that hour would have been heading to overdoses in the immediate area.
When the public health emergency was declared in 2016, Breakspear told me, everyone thought it was the height of the crisis. Since then, though, “the numbers have continued to worsen. I don’t want to say it’s become the normal—the new norm. That sounds so offensive,” she said. “This is still a situation in which people are dying every day, and I don’t know how you could ever wrap your head around calling it ‘normal.’”
That harsh realization is especially disturbing for the loved ones of those who’ve died during this overdose crisis. “The thought that it’s the new normal is just crushing,” said Leslie McBain, co-founder of Moms Stop the Harm, a national advocacy group of families that have lost loved ones to drug overdoses, including her own son. “Fentanyl is still out there; it’s still killing people. People have no alternative.”
“Crisis” is the word that everyone I spoke to used to describe this state of affairs, including police officers, medical experts, and groups of people who use drugs alike. And BC is like the canary in a coal mine; the problem has spread across the rest of the country, too. The only place you’d see more body bags would be in an actual war. But even that’s not an entirely accurate comparison: 159 courageous Canadians died during the conflict in Afghanistan, and 516 died during the Korean War. Combined, those losses are significantly lower than the number of Canadians who died f rom fatal overdoses in 2018 alone.
Given the massive fatalities during the opioid crisis, Vancouver’s morgue has been filled to capacity and the BC Coroners Service has been forced to develop extraordinary plans to store bodies while the coroner investigates. “We are in urgent need of temporary body storage owing to the public health emergency,” wrote Aaron Burns with the BC Ministry of Justice in a December 19, 2016, email plea to funeral home directors in the BC Lower Mainland. (The email was released under the Freedom of Information and Protection of Privacy Act.) “Bodies are kept at hospital morgues or funeral homes while the coroner conducts the investigation,” Burns continued. “It would only be situations where those places are overwhelmed by volume that storage would pose a problem for us. That being said, we’ve come close to that point in the recent past and looked into refrigerated shipping containers as a contingency.”
The impact of the opioid crisis is widespread. For people who use drugs, it means never knowing whether they’ll be next. It means being blamed. It means being treated like criminals and lowlifes. This crisis continues to catastrophically affect families, friends, and loved ones of those who have died or are using substances and are at risk. And it’s had a devastating impact on those working hard to save lives, including “peers”—people with lived experience using drugs—and professional first responders like paramedics, firefighters, and police officers.
Carolyn Sinclair is the manager of the BC Provincial Overdose Mobile Response Team, which provides crisis support to professional first responders. I first met Sinclair several years ago in her previous role as head of Police Victim Services of BC. She knows about supporting people in traumatic situations and she knows law enforcement. That, combined with her positive outlook and cheerful attitude, made her the perfect person for this new job. Her team was set up when it became clear that the relentless trauma of the opioid crisis was hitting first responders hard.
“In April 2018 we had 27 completed suicides by first responders,” said Sinclair. It was a startling figure, one that she believes is directly linked to the opioid crisis. I asked her to tell me about some of these individuals so that I could get a better idea of how this public health emergency was affecting them. In one instance, she said, “the fire-fighters arrived at the house and found a mom down. The first person in was a young firefighter. They didn’t realize that there was a little four-year-old girl that had also gotten into Mom’s drugs and that she’d crawled behind a chair. They didn’t know she was there until later. The little girl is still in an induced coma, and there are some fire-fighters that are visiting her every day. The first firefighter to that scene committed suicide.”
The opioid epidemic has spread across the continent like wildfire. In the United States, more than 500,000 people died f rom drug overdoses between 2000 and 2015. And those figures have been accelerating, as they’ve been in Canada, owing to a dramatic increase in synthetic opioid–related deaths. In 2017, an estimated 70,237 people died f rom illicit drug overdoses in the U.S. That’s more than the total number of American troops, 58,220, who died between 1961 and 1975 during the entire Vietnam War.
In response, on October 26, 2017, the United States declared the opioid crisis a national public health emergency. Canada has yet to take that step. But despite the U.S. declaration, even the most rudimentary medical interventions that have been proven to save lives (such as “take-home” naloxone—the antidote to an opioid overdose—and supervised consumption sites) have faced roadblocks. President Donald Trump has instead insisted on building a wall on the US–Mexico border to deal with the problem—an idea that experts agree would do nothing to address it.
What’s responsible for causing this carnage?
The opioid crisis has many complex and interrelated causes. But the immediate starting point is a drug I’d never heard of until it started popping up in news reports about overdose deaths: fentanyl.
“The main driver of the crisis that we’re in is the contaminated drug supply, and we have little to no control over it,” said Chris Buchner, director of communicable diseases and harm reduction at Fraser Health, which covers the sprawling suburbs outside of Vancouver and has the unfortunate distinction of having the highest number of illicit drug overdose deaths of any health authority in the province.
“It’s horrendous. I hate people calling it ‘overdose,’ because people are being poisoned. ‘Overdose’ means they used too much. They’re using what they normally would,” said Shelda Kastor with the Western Aboriginal Harm Reduction Society. Indeed, Kastor’s explanation is backed up by data f rom the coroner’s office.
In 2012, fentanyl was found in just 4% of post-mortem toxicology investigations of illicit drug overdose deaths in BC—a negligible amount that no one really paid much attention to. Since then, illicit drug overdose deaths where fentanyl has been detected (on its own or combined with other drugs, such as cocaine, methamphetamine, and heroin) jumped to 15% in 2013, 25% in 2014, 29% in 2015, 67% in 2016, 82% in 2017, and a staggering 87% in 2018. Multiple drug use, including alcohol, is frequently identified in these cases, with fentanyl as a common denominator.
When you look at the annual number of illicit drug overdose deaths over the last decade—taking out those where fentanyl was detected—you see a relatively stable rate. In 2007 and 2017 alike, there were roughly 200 illicit drug overdose deaths in BC that did not involve fentanyl. Illicit fentanyl is clearly the immediate cause of the dramatic rise in overdose deaths. But, as I would find out, there was plenty of blame to be shared for this crisis.
Table of Contents
1 What is the Opioid Crists? 7
2 Why Is Fentanyl Killing So Many People? 15
3 Why Do People Start Using? Why Can't They Stop? 27
4 Has Criminalizing Drugs Failed? 49
5 Why Are Dealers Killing Their Customers? 57
6 Can We Stop Fentanyl At Its Source? 65
7 Who's Been Hardest Hit? 83
8 Can We Prosecute Our Way Out? 99
9 What Is Naloxone and Is It The Solution? 121
10 Don't Supervised Injection Sites Enable Drug Use? 141
11 Is Providing "Safe Drugs" Giving Up On People? 163
12 How Can We Help People Stop Using? 177
13 Won't Decriminalization Make Things Worse? 193
14 How Can We Solve This Crisis? 219
Appendix: Vancouver Declaration On Responding To The Opioid Crisis 235