With fentanyl's rise, race is on to save lives
Narcan training follows spike in opioid deaths in other parts of the country
 | Killer on the streets Part I of IV:
Yellowknifer is investigating fentanyl's toll. |
Shane Magee
Northern News Services
Friday, April 15, 2016
SOMBA K'E/YELLOWKNIFE
At first, fire chief Darcy Hernblad thought Yellowknife was insulated from the deadly drug fentanyl.
"We knew it was around, but you know, the thinking was 'Yellowknife? We're immune to this sort of stuff because we're so far in the North,'" said Hernblad about the painkiller deadly in even small amounts and about 100 times more potent than morphine.
After three suspected fentanyl overdoses, his perspective changed.
"It was the later part of last year that all of a sudden we realized ... this is fentanyl used by the patients they're picking up."
In the months that followed, the department, which operates the ambulance service, trained its members to use Narcan - a drug that temporarily blocks the effects of opioids like fentanyl.
It's one of a number of steps governments have taken in response to the drug, a Yellowknifer investigation into the rise of fentanyl has found using access-to-information requests and more than a dozen interviews with doctors, firefighters, corrections officials, police and addictions treatment providers.
Deaths attributed to the drug have been steadily climbing in Canada. In Alberta, the toll has increased to 272 last year from six in 2011. The loss of life in the NWT remains in the single digits, based on available data.
The warnings about fentanyl first began in early 2014 as police alerted users about fake oxycontin pills laced with it. Since then there's been a steady drumbeat of health warnings and drug busts. This month police seized 1,200 fentanyl pills from an alleged drug network distributing in the city.
Users cross all demographics - teens, people in their 50s, men and women, Yellowknifer was told by police and doctors.
"It's highly addictive," said RCMP Sgt. Dean Riou with the G Division federal investigations unit. "Once people try it, it becomes a drug of choice."
Debbie DeLancey, the territory's deputy Health and Social Services minister, told another media outlet the fentanyl "crisis" is on the department's radar.
Limited information prevents a broader assessment of the drug's impact beyond deaths and police busts. For example, the health department can't provide specific data for hospital emergency room visits caused by fentanyl.
The number of people who have died with fentanyl in their system, called a toxicity death, isn't anywhere near what's occurring in B.C. and Alberta. But the number has risen, according to NWT Chief Coroner Cathy Menard. Menard said she typically investigates about 100 deaths per year, which would include suicides, homicides, accidental deaths as well as toxicity deaths.
At least one person has died with fentanyl in their system each year between 2012 and 2015.
Most had a mix of fentanyl and at least one other drug.
The total for 2015 may still rise as it can take up to six months to get the results of tests carried out after death.
In B.C., a testing system is in place that can provide a much faster indication of what was in a person's system when they died. However, Menard said it's not precise and could lead to misinterpretation because it only says what's there, not what quantities.
She said fentanyl and other powerful drugs aren't going away and will be something communities have to grapple with.
"I don't think we're seeing the last of these powerful drugs," Menard said, applauding the city for stocking Narcan on its three ambulances.
On the front lines of the crisis are the firefighters, who double as paramedics. Three quarters of all calls for service between October and December last year were for medical issues. While that isn't broken down by type of medical call, the fire chief says ambulances frequently respond to overdoses, including alcohol. The cost to add Narcan to the city's ambulances is estimated at $5,000 to $10,000 annually.
Training began for how to inject Narcan at the fire hall Jan. 27, where deputy fire chief Mike Hoffman explained how it works to two firefighters. The drug blocks the receptors opioids use in the brain. Narcan has few side effects and Hoffman said if there's a suspicion a patient is experiencing an opioid overdose, Narcan should be given. The idea is to get the person breathing again, then start transporting them to hospital.
Hoffman attended an RCMP workshop on fentanyl. He said emergency responders have to be cautious about the drug because they may end up responding to clandestine labs manufacturing the pills. No labs have been found here so far, according to RCMP.
"If we don't open our eyes, if we don't get busy with this, we're probably going to start seeing people dropping like flies," Hoffman said.
At a news conference this month, RCMP Superintendent Michael LeSage, criminal operations officer, suggested paramedics have saved lives.
"Police are aware of several incidents in Yellowknife in recent months in which medical professionals and emergency service personnel were required to perform live-saving interventions on people who have overdosed with fentanyl," LeSage said.
The fire chief said the city won't release data on Narcan's use.
"I don't want to get something out there that the public gets fearful about (saying), 'Oh my God, how much is going on this town?' or whatever," Hernblad said.
The story of fentanyl's rise cannot be told just through deaths. Medical providers have said the size of the city means overdose patients can typically get to the hospital and be treated faster than other cities.
For the doctors seeing those entering the ER - often unconscious - it can be difficult to determine exactly what caused an overdose. That usually only happens through talking to the patient when they wake up or through what information paramedics have gathered.
Dr. Hannah Shoichet, an emergency room physician at Stanton Territorial Hospital, said she's seen a handful of fentanyl overdose patients in her two and a half years there.
She sees mostly young people coming in with fentanyl overdoses, she said. Keeping them alive brings a sense of both accomplishment and the realization of how close they came to death.
"It's tough to see lives almost destroyed by such a tough drug, a non-discriminating drug," Shoichet said.
If the person is quickly found and Narcan used, the hospital stay could be as short as six to eight hours.
But if they've had more time without oxygen going to the brain, she said the stay could be days. The hospital has seen various levels of severity, including patients who have had seizures and choked on their own vomit, she said.
"Anytime you have a drug on the street that can kill with one dose and regardless of who is taking it - whether they're naive to all narcotics or they've used before - it doesn't differentiate between those people. It can kill anybody," she said. "In a small population, each overdose is going to cause a great impact to the community."
In Alberta, the government has moved toward harm reduction by increasing the availability of Narcan.
That province has a web page laying out what fentanyl is, the death toll, how to seek help and its effort to put Narcan in the hands of addicts so it can be used quickly in overdose situations.
In contrast, the only fentanyl information on the GNWT Health and Social Services website is a 2015 warning about it from the chief public health officer.
Asked about the availability of Narcan in the territory, health department spokesperson Damien Healy told Yellowknifer by e-mail it is stocked in all health centres and hospitals.
"We currently have no plans to expand access to this drug but we will continue to monitor what is happening in other jurisdictions, while reviewing the extent of this problem in our own context," he wrote in January.
In Yellowknife, Inuvik, Hay River and Fort Smith, where there are doctors, a prescription is required to access the drug, according to a bulletin by the Canadian Centre on Substance Abuse. In the other NWT communities, a nurse can administer one dose of Narcan.
In March, Health Canada removed naloxone, the generic name for Narcan, from a list of drugs requiring a prescription. However, each province or territory must also approve the change. Days after it was de-listed, B.C. became one of the first jurisdictions to remove the prescription requirement, which allows people to go to a pharmacist and get the drug and training to administer it for someone experiencing a suspected overdose.
"I encourage parents and friends of people who use drugs to visit their local pharmacist for training and include naloxone as part of their first aid kit," stated Provincial Health Officer Perry Kendall in a news release.
Asked whether the territory would also remove the restriction, Healy wrote in an e-mail it's already available here and "we are closely reviewing practices in other jurisdictions before we look at any changes."
Next week, Yellowknifer examines suspected fentanyl overdoses at the secure North Slave Correctional Centre and how fentanyl has driven changes to addictions services in the city.
What is fentanyl and where does it come from?
Fentanyl wasn't always the killer it's become. The synthetic opioid was developed to treat severe pain, such as that associated with cancer. Opioids such as fentanyl, heroin and morphine work by binding to receptors in the brain that control pain and emotions, increasing dopamine levels, which produce a state of euphoria and relaxation, according to the U.S.-based National Institute on Drug Abuse. Repeated use can lead to addiction.
Taken in sufficient doses, it causes drowsiness, coma and death. As little as two milligrams can be lethal for a 200 lbs person.
Although the medically prescribed form is often administered by injection, patch or lozenge, illicit fentanyl is often taken in pill form - either swallowed or crushed and snorted.
A Canadian Centre on Substance Abuse bulletin on the drug states RCMP found fentanyl making its way into the illicit drug market through diversion from legal channels or smuggling the powdered form into the country.
A kilogram of pure fentanyl powder, purchased for about $12,000, is diluted about 100 times to produce roughly a million pills, according to documents obtained from the GNWT Department of Justice through access-to-information legislation.
The pills can sell for between $30 and $80, depending on where they are bought.
"The profit margins are extremely high," the document states.
RCMP Sgt. Dean Riou, a federal investigations unit officer in Yellowknife, said in Western Canada the drug is often imported as a powder from China and then diluted and pressed into green pills resembling OxyContin.
In Eastern Canada, more often it's medical-grade fentanyl diverted from pharmaceutical supply chains. The medical form is manufactured in a quality controlled lab, unlike the pills made to be sold on the street.
RCMP and the coroner's service in the territory have said when dealing with a street drug, users have no idea how it has been made or what's in it. Police in other parts of the country have seized drugs that actually were up to 89 per cent fentanyl.
Dr. Hannah Shoichet, an emergency room physician at Stanton Territorial Hospital, said it's important for people to realize that the amount of fentanyl in one pill may not be the same in a second pill.
"People can very easily get into trouble with it because they don't know how much they're taking," she said.
According to a Health Canada news release from last summer, its Drug Analysis Service labs have detected fentanyl more often in street drugs being sent for testing by police.
It analyzed 29 samples found to contain fentanyl in 2009. That increased to 894 two years ago - a 30-times increase.
Most of the large-scale drug seizures by RCMP in Yellowknife in the past year have swept up cocaine and its dealers, although there have been busts with hundreds of fentanyl pills. The latest bust was announced earlier this month.
At a meeting organized by RCMP in January here in Yellowknife, health officials, firefighters and others were warned of a new form of fentanyl considered 10,000 times stronger than morphine, said Hoffman. Police at the time declined an interview about the presentation.
Earlier this year, lab testing confirmed the presence of W-18, an opioid 100 times more powerful than fentanyl, after a drug raid in Calgary, Alta., according to media reports.
