Changing nature of Canada's overdose crisis calls for more aggressive response, experts say

An evolving mix of opioid cocktails and changing consumption habits mean governments must now respond more aggressively to the overdose crisis, experts say.

More than 32,000 Canadians have died of toxic drug overdoses since 2016, according to data released by Health Canada last month.

Over 3,500 people died of overdoses in the first half of 2022 (data is available only up to June). That's almost 20 people per day, and more than half the number of people who died of overdoses during the first year of the pandemic.

The federal government has spent hundreds of millions of dollars to combat the crisis by funding community-led projects such as safe consumption sites and safe supply programs and improving access to naloxone, medication that can reverse the effects of an opioid overdose.

Fentanyl remains a driving factor in overdose deaths; Health Canada says that 76 per cent of all overdose deaths involve that opioid. But an increasing number of overdose deaths involve more than one substance.

Health Canada said just under half of the 3,556 overdose deaths that occurred in the first half of last year involved a stimulant such as cocaine or methamphetamine. At the same time, health services are increasingly warning of illicit opioids being contaminated with depressants such as benzodiazepine or "benzos."

Tara Gomes of the Ontario Drug Policy Research Network said the two trends are likely linked.

"What we're seeing more and more is benzodiazepines in the opioid supply. So they're actually mixed in with the fentanyl," she said.

That means the people who use these drugs aren't necessarily aware that they're taking benzo along with the opioid, she said.

But Gomes said some are intentionally using stimulants in an effort to counteract the sedative effects of an opioid and benzo cocktail.

"Oftentimes what they're looking to do is counteract those effects, try and moderate the effects of the opioid so that they don't get too sedated," she said.

Benzodiazepines are dangerous when paired with an opioid like fentanyl because the added sedation increases the risk of an overdose, says Health Canada.

And the lifesaving medication naloxone does not work on benzos.

"It makes it more challenging for already burdened overdose prevention services," Cheyenne Johnson, executive director of the British Columbia Centre on Substance Use, told CBC News.

Johnson also said a mix of opioids and benzos can also complicate substance use treatment by intensifying withdrawal symptoms. Such symptoms can include extreme anxiety, sweats and dangerous seizures.

"It makes it very complicated in terms of managing their cravings and withdrawals when there's multiple types of potentially unknown substances like benzodiazepines" she said.

Fentanyl and benzodiazepines on their own can be used in clinical settings, but Johnson said substances never meant for human consumption are appearing in the illicit drug supply.

Xylazines, an animal sedative, and nitazenes — a synthetic opioid that is estimated to be several times more potent than fentanyl — are two such drugs, Johnson said.

"The sky is the limit on what is coming next," she said.

Karen McDonald, head of Toronto's Drug Checking Service, echoed Johnson's point, saying that the illicit drug supply "is increasingly more contaminated, more toxic and less predictable."

"[It's a] recipe for disaster," she said.

McDonald's organization tests samples from the illicit drug supply to warn people who use drugs about what is being mixed in. But while the technology her organization uses is quite sophisticated, she said the illicit supply changes so fast that it feels like they're "constantly playing catch-up."

"By the time we've maybe improved our method so that we can better identify or provide better information to a service user, that drug may actually have come and gone from the supply and something else that is potentially more harmful has come along," McDonald said.

Many harm reduction services don't have access to the same technology McDonald's organization uses. Johnson said most use only low-cost mechanisms meant to detect fentanyl alone.

"We don't have these types of low cost solutions for things like nitazene and trying to keep up with this designer drug opiate market and contamination is nearly impossible," Johnson said.

More people dying after smoking

In 2021, up to three quarters of people killed by B.C.'s toxic drug supply in parts of the province had smoked — not injected — their fatal dose, according to figures from the coroner's service.

Gomes and some of her colleagues released a report this past November that found a similar trend in Ontario. Between January 2018 and June 2021, half of the opioid toxicity deaths in the province were linked to smoking or inhalation.

The trend makes things difficult for safe consumption programs, which are geared more toward needle users, Gomes said.

"It's very difficult within these settings because if you're smoking a drug, it's a lot more difficult to contain that substance," she said.

Johnson said many safe consumption programs are struggling to keep up with the trend because adapting to inhalation consumption could put them at odds with zoning restrictions and other laws or bylaws.

"It's a bit more of a complicated process but by no means is it insurmountable," Johnson said.

The safe consumption site in Whitehorse, for example, opened for inhalation consumption in May.

LIberal MP Brendan Hanley, who previously served as Yukon's chief medical officer of health, said smoking has generally been the preferred method of consumption in the territory and so the switch was necessary.

"That is where you see people going. We have very few going to the injection table, but we have many going and actually lining up for the inhalation room," he said.

Experts call for expansion of safe supply

While improving access to safe consumption sites would help, McDonald said a more permanent and less ad-hoc strategy is needed to address the root cause of the crisis.

"These services, they're still viewed as temporary, which just doesn't work when you're in the midst of a crisis and you're losing this many individuals," she said, adding that governments need to look at formalized arrangements for harm reduction services.

Johnson said she thinks Canada needs to move more swiftly away from a prohibition policy toward a health-oriented model for illicit drug use.

The federal government's Bill C-5, which became law in November, gives police officers the option of diverting those found in possession of illicit drugs to health services instead of laying charges. The federal government is also granting B.C. a Criminal Code exemption to decriminalize the personal possession of illicit drugs within the province.

But a federal expert task force on substance use unanimously recommended in May that the decriminalization of personal possession be applied to the whole country.

"Criminalization of simple possession causes harms to Canadians and needs to end," the task force report said, citing issues such as stigmatizing people who use drugs and burdening the health and criminal justice systems.

While B.C.'s exemption will begin at the end of January, Toronto is still waiting for a response to a similar decriminalization request.

A briefing note prepared for Minister of Mental Health and Addictions Carolyn Bennett suggests another 55 municipalities have expressed interest in decriminalization.

But Johnson, who was a member of the federal expert task force, said while decriminalization on a national scale would be a "good first step," it wouldn't go far enough.

"Decriminalization does not have any impact on the toxicity of the supply," she said.

Hanley agreed and said Canada needs to offer a regulated and stable alternative to the illicit drug supply.

"We need to have safe supply as one of the options and we're not seeing that enough," he said, adding that it would complement treatment programs.

The expansion of safe supply programs was included in the federal task force's list of recommendations.

CBC asked Bennett's office and Health Canada if the government intends to follow the task force's recommendations. A government official told CBC on background that the government "agrees with the spirit" of the recommendations and is using them to inform its current approach to the crisis, but didn't specifically say what recommendations, if any, would be fully implemented.

NDP MP Gord Johns says the government isn't acting quickly enough and has called on the auditor general to probe the government's response to the overdose crisis.

"Canadians have every right to start to lose faith in what this government's doing and what the minister's doing in response to this crisis," he said. "It's a lot of talk and very little action."