Harm reduction agency urges Quebec to get naloxone into hands of more opioid users

"I've overdosed several, several times," says Raymond Horan, standing in the graffiti-painted alleyway behind CACTUS Montreal, a needle-exchange centre and safe injection site.

"I can't remember how many times I've woken up in the hospital on a gurney."

Naloxone, a fast-acting antidote to opioids, is what saved his life every time, he said.

"Your whole body feels like it's being jolted," said Horan."It's an extremely weird kind of feeling."

Whenever Horan is in Montreal now, he picks up a few naloxone kits at CACTUS Montréal, one of 15 community organizations in the city that gives out free kits without asking questions.

This past autumn alone, he saved the lives of four people with naloxone, Horan said. Among those who take opioids, he said, overdoses are going to happen, no matter what.

Horan has dealt with drug addiction for a big part of his life. He remembers a time when no one knew about the powerful synthetic opioid, fentanyl, or naloxone. He said he's noticed how easy it has become to overdose, ever since fentanyl came on the scene.

Kits 'without questions'

Between January 2016 and March 2019, there were more than 12,800 opioid-related deaths nationwide, according to Statistics Canada — many due to the growing availability of fentanyl and its analogues.

Quebec has so far escaped the worst of the carnage. In 2018, there were 1,546 deaths in British Columbia, compared to 424 deaths in Quebec. That figure for Quebec is a 70 per cent increase over the previous year: there were 250 deaths in 2017.

In an effort to prevent a full-blown opioid crisis, in November 2017 the Quebec government made naloxone kits freely available through 1,900 Quebec pharmacies across the province.

The injectable antidote was to be made available to anyone over the age of 14 with a Quebec health card, "without questions and without an investigation," said Gaétan Barrette, the health minister at that time.

However, pharmacies ask those who request a kit to identify themselves. That deters a lot of drug users, says the executive director of CACTUS, Jean-François Mary.

"People need to register in the pharmacy, open an account there. They need to have their health insurance card — it's a lot of constraints."

"Most marginalized people wouldn't go through that," said Mary. "Non-marginalized drug users also do not want to be registered as a drug user."

Mary believes naloxone must be made more accessible — distributed anonymously and on a larger scale.

Reaching the hidden 80 per cent

Community groups like CACTUS have been distributing the kits freely and anonymously since May 2018, after a lot of lobbying and conversations with Health Ministry officials. But Mary says naloxone should be available everywhere.

"There should be naloxone everywhere where drugs users are," he said. "And drug users are everywhere."

"We are in touch with ten to 20 per cent of the drug users — the most problematic ones — but what about those 80 per cent that face overdose risks as well?" asked Mary. "We know that the people who are dying are not only the marginalized ones."

Anonymity is important, said Mary, because opioid use is so highly stigmatized. Many drug users are afraid if they have naloxone listed on their health care file, it could have an impact on the way they're treated by health professionals.

Dikran Karlozian, a pharmacy owner in the Ville-Marie neighborhood, said that should not be a concern. He said information divulged in a pharmacy remains confidential and is only used by health care professionals to assess a patient's medication profile.

"In this sense, it helps us to make a more informed decision on whether they're at high risk, or if they're users, or if certain medications or products that they take put them at high risk for overdose," said Karlozian.

Quebec's Health Ministry says people who request naloxone from pharmacies are "not absolutely required" to present their health care card.

"It can be anonymous in certain conditions (e.g. in case of emergency or homelessness)," said a ministry spokesperson, Noémie Vanheuverzwijn, in a statement. "Additionally, confidentiality is guaranteed by the pharmacists' code of ethics."

INSPQ's most recent statistics indicate that 14,021 naloxone kits have been distributed through pharmacies since the naloxone distribution program began, with a noticeable increase since July 2018.

There are no statistics on the number of naloxone kits distributed by community groups, but CACTUS and another group advocating for the health of street drug users, AQPSUD, both said they each distribute around 300 kits per month.

According to the Quebec public health institute, INSPQ, from January 2016 to June 2019, the number of opioid-related emergency visits remained steady, with an average of 99 visits per month.

"We need to scale up in terms of giving access to naloxone everywhere where drugs users feel at ease to ask for it," said Mary. That includes soup kitchens, homeless shelters, university campuses and bars.

Naloxone is safe and poses no health risks to opioid-intoxicated people nor to someone who does not have opioids in their system, Mary points out. It has no potential for abuse.

"This is a public health crisis," he says. "We have to saturate our communities with naloxone."

This is not a big deal, you know. A vial of naloxone costs $1. This $1 can save a life. It's cheap for a life … not even [the price of] a coffee."