Far and Wide: Canada’s Opioid Overdose Crisis Is Destroying Lives Across the Country
Co-author: Viktor Elias
Canada’s opioid overdose crisis has touched lives across the country. In May 2022, the federal government announced it would decriminalize possession of small amounts of hard drugs, such as cocaine and methamphetamine, in a move that could be the first step towards solving the crisis. (Jonathan Gonzalez/ Unsplash)
Canada’s opioid overdose crisis is “really a crisis of failed drug policy,” said Garth Mullins.
Mullins, an advisor to the B.C. government representing the Vancouver Area Network of Drug Users, says people are dying from contaminated street drugs because of the war on drugs.
"The reason drugs are contaminated is because, for over a hundred years, police have been trying to chase, stop, and enforce them at the border," he said. "And, so, it's just been this long arms race of drugs getting more and more stronger, more and more contaminated."
Mullins grew up in Yellowknife before moving to B.C. He's an activist for decriminalization and a safe supply, saying he spent much of his adult life using heroin but is now on methadone.
“Methadone definitely helps and it really shows you the principle of what a safe supply could look like,” he said. “Methadone is just an opioid that’s legal and the molecule isn’t all that different from heroin or fentanyl. And, so, if we can substitute one drug for another and call that legal treatment, why not with other drugs?”
In November, a spike in suspected fatal opioid overdoses in Toronto prompted the city to issue a warning to drug users, with harm reduction advocates saying the situation highlighted the need for decriminalization and a widespread regulated supply.
Toronto Public Health’s alert cited the rise in suspected opioid deaths and a reported increase in the potency of the illicit fentanyl supply, saying paramedics had responded to at least 15 suspected fatal overdose calls over the past four weeks, including at least five calls within four-day spans on three separate occasions.
In an interview with the Toronto Star, Toronto’s medical officer of health Dr. Eileen de Villa said the latest string of suspected overdoses was “higher than the historical average,” adding that their interest is in “making sure that people who use drugs, and the people who served them are aware of this and can take action to protect the health of people who use drugs.”
Harm reduction advocates said the alerts will continue without urgently needed changes.
Toronto's drug alert was its first since July when paramedics responded to 10 overdose deaths in five days. With the latest alert, Toronto Public Health said several drugs were involved and the overdose took place in neighborhoods across the city.
Hayley Thompson, a project manager at Toronto’s Drug Checking Service, a Health Canada backed project that tests illicit drugs from across the city, says “in the absence of a regulated market, people really don’t know what it is they’re purchasing.”
Thompson says the lab-based technologies the service uses, which are provided to them by St. Michael’s Hospital, can give them a better picture of what is in Toronto's unregulated supply and ensure drug users are provided with information on what is exactly in their drugs, so they can make informed decisions, in a de facto policy response.
Harm reduction advocates have long pushed governments to offer widespread, low-barrier access to a regulated, pharmaceutical-grade supply of drugs.
“171 people died in British Columbia in September,” said Leslie McBain. “That’s 171 families in deep chaos, in deep grief. And this is unconscionable.”
McBain, who co-founded Moms Stop the Harm, says a safe supply will at least stop the deaths.
“I think the government not allowing a safe supply, in a widespread, low-barrier way, has made a decision to let people die,” she said. “How can you look at it any differently? They say they’re working on it, but it’s been almost seven years now since a public health emergency has been declared in B.C., around this crisis.”
While a select number of Toronto health centres offer prescribed opioids to those with severe dependencies, say referrals are hard to come by and application criteria are too narrow.
“Right now, our criteria is anyone who uses the street supply five times a week or more,” Gab Laurence said. “And we have a quite involved process to work towards equitable enrollment” because, traditionally, services and supports have not been accessible to marginalized persons.
Laurence, who is the manager of harm reduction services at Parkdale Queen West Community Health Centre, outlined how these difficult choices are made “We really consider identity markers, someone's geography, and someone's attachment to other services as factors for enrollment into the program.”
She also says the provincial government’s own Ontario Drug Formulary, a list of covered drugs for individuals on ODSP and Ontario Works, is limiting her organization’s work to match individuals’ street supply with a safe one, and dictating how they do their jobs.
“Currently the medications that are available for prescription are not strong,” Laurence said. “Another point of advocacy right now is updating the formulary to make more medications available to people in order to really be able to have more success in safer supply because we’re really limited with what’s available.”
In January 2022, Toronto Public Health submitted a preliminary request asking the federal government to decriminalize the possession of illicit drugs for personal use in the city — a move that British Columbia also requested, and was granted, in May.
Toronto’s top doctor said in November of 2022 that the city’s request had yet to be finalized.
“We want to make sure that when we submit that we’re putting in something that is going to be successful. So that does take time. But that doesn’t mean that we’re not concerned, we’re actively working on this,” de Villa said in an interview with her.
Toronto laid out a model as part of that request that supports expanded safer supply programs and increased access to social supports, including housing.
More than 1,000 people died from overdoses in Toronto in 2020 and 2021, nearly double the number reported in the previous two years, according to the city's own data. Despite this, the rate of opioid overdose deaths decreased by more than 10 per cent in the first two quarters of 2022 compared to the year before, according to Ontario's chief coroner.
Preliminary data from the coroner's office show 1,278 people have died from opioid toxicity in the first six months of 2022. There were 1,487 deaths in the same period last year.
“This is a significant tragedy that is ongoing and continuing, which requires a much deeper, broader response in my mind,” Dr. Dirk Huyer said in an interview with the Canadian Press. “The way I’ve always looked at the word crisis is it’s a terrible situation, a bad circumstance, that is short-lived. And, for me, this is sustained and this is an ongoing, significant public health problem.”
Opioids continue to kill Ontarians at a rate 55 per cent higher than in 2019, before the pandemic hit. Nonetheless, the comparative 13 per-cent death rate decline in the first six months of this year has given Huyer some hope.
“Is it hopeful that that’s a trend downwards? That’s certainly a hope, but it’s still a 55 per cent higher mortality rate than the 2019 range,” he said.
Opioid overdose deaths increased dramatically since the pandemic began, killing 2,492 people in 2020 and 2,911 people last year.
With lockdowns and most public health measures against COVID-19 ending this spring, people have returned to their social networks and services for those who use drugs have become more available — factors that may be playing a role in the decrease, Huyer said.
“That’s the hope of what’s going on,” Huyer said. “But it’s still incredibly tragic and difficult.”
The provincial average is 19.7 deaths per 100,000 people.
Those aged 30 to 59 remain the most affected, accounting for 71 per cent of opioid deaths between April and June this year.
But the coroner saw some shifts in the age demographics.
Deaths among those aged 20 to 49 have decreased by 13 per cent, but they’ve shot up among those aged 60 and older by 44 per cent.
Men continue to account for 75 per cent of opioid toxicity deaths.
Fentanyl remains the major contributor, with the substance found in 85 per cent of deaths. Other drugs like cocaine, methamphetamine and non-pharmaceutical benzodiazepines are also found in a significant number of deaths.
Decriminalization in B.C. is an important step
Following years of advocacy by people who use drugs and their families, the federal government announced in May that it will exempt British Columbians from criminal charges for possessing small amounts of drugs beginning next year.
The announcement was made by Bennett alongside her B.C. counterpart, Sheila Malcolmson.
“For too many years, the ideological opposition to harm reduction has cost lives,” Bennett said at the same news conference. “While approving this request is significant, it must be seen as one additional tool to be used in the ongoing comprehensive response to the crisis.”
The announcement was made a day before the House of Commons voted against a bid to pass an NDP bill that would decriminalize drug possession nationwide.
“I have some discomfort with the bill because I think it doesn’t put in place the guardrails around implementation, and so I will not be voting for the bill,” Bennett said.
The exemption will begin on January 31, 2023, and will be in place for three years.
Canada’s former health minister Dr. Jane Philpott said other measures the government is taking are not going to be enough without “wrapping around all of the other things that are necessary to make decriminalization successful.”
Philpott suggests the government's three-year timeline is insufficient.
"I worry a little bit that it won't be set up for success and then three years from now, there's not enough evidence and the idea will be tossed out because it wasn't implemented in the right way," Philpott said. "It's a little risky, I would say, it's not necessarily being done in a way that will make it most likely to succeed."
Federal and provincial officials said they need time to work on implementation, including a public education campaign and developing a monitoring and evaluation plan.
“If you just decriminalize, then what happens is the illegal market explodes,” Mark Haden said.
Haden, an adjunct professor at UBC's School of Population and Public Health, says “a medical approach — the safe supply approach — is actually legalization.”
The exemption means that no adult in B.C. will be charged with drug possession if they have a cumulative total of 2.5 grams of drugs or less. They will also not have their drugs confiscated.
"In the past, we would typically seize illicit drugs from an individual and we know from experience that those individuals may turn around and commit crime to support their habit to replace the drugs, essentially, that the police have just taken," BC Association of Chiefs of Police Executive Vice-President Fiona Wilson said. "In a worst-case scenario, you have people, typically women, who are working in the sex trade to support their habit."
Those drugs include cocaine, MDMA, methamphetamine and opioids like heroin and fentanyl.
Health Canada is still reviewing exemption applications from Toronto and Vancouver, although the B.C. exemption will automatically apply to Vancouver once it comes into effect. Edmonton city council also recently voted to submit an exemption request.
“Shame and fear keep people from accessing the care that they need, and the fear of being criminalized has led many people to hide their addiction and use drugs alone, and using alone can mean dying alone,” Malcolmson said at the same news conference.
B.C. applied to Health Canada for the exemption in November 2021, in the face of a worsening drug toxicity crisis in the province. More than 9,000 overdose deaths were recorded in B.C. between April 2016 and March 2022, according to the Public Health Agency of Canada.
Gord Johns, a B.C. MP, said in an interview with the Toronto Star that the announcement was made a day before the vote on his bill to “soften the blow” of the government voting against it.
His bill required the support of Liberal MPs to ensure its passage at second reading so that it can be sent to committee where Parliament would hear from experts on decriminalization.
Johns said that Bennet should have sent the bill to committee if she had concerns with the current wording, so it could be amended.
"We're hoping they'll change their mind tomorrow, that the prime minister will stop picking and choosing when he wants to listen to evidence," Johns said. "I don't know what it's going to take, how many thousands of lives before they take a comprehensive approach."
Bennett said in an interview with the Toronto Star that the NDP bill lacks an implementation plan and wording around thresholds. She argued that making such amendments at committee would be declared out of order because they would change the intent of the bill. She also said a nationwide approach requires buy-in from the provinces and territories.
“We actually need a partner with which to do this, so that is the reason that I think that it’s not really possible for us to vote for this bill in principle because putting all those safeguards on after the fact would not be in order,” she said. The government, however, is “receptive” to other jurisdictions considering an exemption request.
Harm reduction experts have, too, called decriminalization an important tool in tackling Canada’s opioid overdose crisis, alongside a safe drug supply and greater access to treatment and social support. They argue that decriminalization reduces stigma, ensuring that fewer people use drugs alone and that more people who use them feel comfortable seeking help.
“Stigma is so rooted in our society around drug use,” McBain said. “I don't even think in my lifetime it's gonna happen where people accept drug use as substance use disorder. It's a disorder like anything else like heart disease or diabetes and so on, so forth.”
"I would dream that when people are addicted they could go to the ER and they could find a doctor. They could find medical help where they could if they wanted it. They could get safe drugs and a safe supply, or they could get treatment and/or opioid agonist treatment without barriers, without stigma," McBain said.
B.C. had requested an exemption for those found in possession of up to 4.5 grams of drugs, but Health Canada’s decision is limited to 2.5 grams. Advocates have argued that the threshold is far too low, and not in line with drug using and purchasing patterns.
More than 20 organizations, including the HIV Legal Network and groups representing people who use drugs, wrote to Bennett and federal Health Minister Jean-Yves Duclos in April 2022, saying there is “no legal evidentiary basis” for a threshold of 2.5 grams.
“A 2.5 grams threshold flies in the face of your government’s commitment to evidence-based drug policy, anti-racism, and reconciliation with Indigenous communities,” said the letter. “It sets a dangerous precedent for other municipalities across Canada seeking an exemption.”
The exemption does not apply on the premises of schools, child-care facilities and airports.
B.C. can learn from Portugal’s drug policy model
More than two decades ago, when Portugal was in the throes of a drug crisis, Dr. João Goulão was tasked with helping to do something about it, and one of the central measures taken was to decriminalize certain amounts of hard drugs.
During the dearth of the crisis, the country had an estimated 100,000 heroin users and HIV was raging, whereas it has 25,000 today. Now, with decriminalization coming to B.C., it will take more effort than that to make an impact, Goulão says.
“I believe decriminalization is an important step, but it's only one of the components.”
Goulão, who is Portugal’s director-general for intervention on addiction, said that the decision presents an opening for B.C. to mitigate the damage drugs inflict on people.
Advocates say the move will result in fewer overdose deaths by people using alone in secret for fear of being judged. Vancouver, which has long struggled with the opioid overdose crisis, has seen nearly 3,000 deaths since 2012, according to the B.C. Coroners Service.
Decriminalizing drugs alone is not the answer, Goulão said.
“What, in my view, is needed is to provide safer substitution opioids, such as methadone, and having naloxone easily accessible and distributed among users, with users trying to use it on their peers,” Goulão said. “And treatment easily accessible for detox for free, with no constraints or waiting lists” could go a long way to solving the crisis.
In Portugal, habitual users are pressured to go into treatment if they are caught with small amounts of drugs too often — something Goulão thinks would be a good supplement to decriminalization in B.C.
When apprehended — and assuming the drugs are below the decriminalized limit, which varies depending on the substance and is calculated based on personal use over 10 days — the person has a meeting with an administrative authority to discuss their drug use and needs.
If they are found using drugs again or in possession within a certain time frame and refuse treatment, the law stipulates they may face consequences, including losing the ability to travel abroad and their driver’s licence, Goulão said. It may also be necessary that they prove they are attending counselling sessions.
Most, though, are not found to be “problematic” drug users, Goulão said.
Treatment facilities, which typically try to help people stop using drugs, are mostly free, government-run and open-door, meaning spontaneous decisions to get into treatment are well-supported within the health care system and wait lists are rare.
On visits over recent years to Toronto and Vancouver, Goulão said certain tools were missing.
“If addicted people are in need of treatment, you should escort people to the appropriate response,” he said. “And, if someone — and the vast majority of people that we have in those conditions nowadays are not problematic users, such as people who use drugs recreationally and in recreational settings, occasionally — says ‘drugs are not a problem in my life’ in a discussion, we assume there are other things going on their lives, so we can invite these people to join other responses, to help them deal with the difficulties.”
Not everyone will want help, at least at first, Goulão said.
“I can’t go into the street, pick up someone sleeping on the street and say ‘let's go to a treatment facility,’ that simply won’t work,” he said. “But if I work on a daily basis for a while, then it’s possible it will work and be successful in changing that person’s lifestyle and getting this person once again functional and able to contribute to society.”
Ottawa’s exemption through Health Canada was also received begrudgingly by advocates for drug users who say the amount is not high enough.
"2.5 grams is a tiny amount, especially for people who are dependent," McBain said. "We were blindsided by the feds. We thought we had all agreed on 4.5 grams, and then at the 11th hour, it came out to be 2.5 grams. And we're just like, what the hell?"
The 2.5-gram threshold will not likely affect opioid overdose deaths, as the priority needs to be getting a safe supply into the market, McBain said. She cautioned Canadians not to be distracted from finding ways to save lives by the decriminalization news.
“Decriminalization only means decriminalizing people who carry illicit drugs. It's not the drugs,” McBain said. “While decriminalization is a great step, it will have very little impact” in B.C.
In terms of solutions, Mullins says the Portuguese model is not without its flaws, as it can end up forcing people using substances, such as marijuana, into its system.
"I thought Portugal was pretty cool before I went there," Mullins said. "What I saw, on the one hand, was something that felt like the principal's office, so you get called in there and 90% of the people going through are like kids who were caught with a joint or some hash."
Even though drug possession is not criminalized in Portugal, he still saw “regular, criminalized drug users who were smoking and shooting dope in a broken down old machine shop.”
“Occasionally, they have real dope fiends like me, and they get a lecture,” he said. “The more serious people may get administrative penalties or sort of compelled along, nudged along into something more.”
In a statement, B.C.’s Ministry of Health and Addictions and Mental Health Minister Sheila Malcolmson said moves post-decriminalization are “...”
“British Columbia requested an exemption related to the personal possession of small amounts of certain illegal drugs as one part of the province’s comprehensive approach to address the overdose crisis,” Charlaine Sleiman, a media relations advisor at Health Canada, said in an email. “This time-limited exemption will be supported by rigorous monitoring and a third-party evaluation to gather evidence and data on the impact and outcomes of the exemption and help to inform Canada’s comprehensive approach to addressing substance use harms.”
Whatever direction B.C. and the rest of Canada take after the exemption takes effect next year, Goulão said it is important that the approaches recognize that drug users are human beings living with challenges, including addiction, not unlike others — and to listen to them.
"It's not enough to give drug users a piece of paper with a phone number and tell them 'you can find treatment there,'" Goulão said. "You need to motivate them, you need to be with them, you need to escort them to those facilities. And, with this approach, I believe it's possible to minimize a difficult situation. I believe in involving people who use drugs in designing the responses as well since they are the people who best know what they need and what is the best way to help them to deal with the difficulties they face."
