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Karen Ward is exhausted.
“The fact is, after 2,500 days of this, the people who are actually trying to work on the so-called front lines here are falling apart,” she says. The long-time drug policy advisor and anti-poverty advocate speaks so fast that it feels like the words tumble out of her.
“God—the fact that it’s still an emergency. This is just destroying people. This is grinding people down. This is ruining lives of people who are surviving. Certainly, it’s crushed me.”
We’re speaking the day that the BC Coroners Service has announced the poisoned drugs death toll for 2022: 2,272 deaths across the province. That’s 2,272 lives cut short, and countless thousands more who are now left to wrestle with the reality that their coworker, their kid, their parent, their friend, is gone: killed by the unregulated toxic soup that circulates on the illicit market. And it was only the second deadliest year on record.
How do we grasp grief that big?
In response to spiking death rates from fentanyl, the provincial government declared drug poisoning deaths a public health emergency on April 14, 2016. February 17 marks 2,500 days of a drug poisoning emergency in BC.
The numbers of deaths are so big as to almost lose all meaning. And the scale is unprecedented. In 2016, 994 people died from toxic unregulated substances. More than 11,098 people have died since the emergency was declared almost seven years ago; more than 6,300 of them in the last three years alone.
In the Vancouver Centre North health delivery area, encompassing Ward’s home in the Downtown Eastside, there were 319 deaths last year. The toxicity rate was 470.8 per 100,000 person-years. The next highest is Terrace, at 110.5 per 100,000. The city as a whole saw 562 deaths in 2022, up from 542 in 2021.
“‘Oh, why is the Downtown Eastside all messed up?’ I think it’s the death,” Ward says. “People used to say, ‘Oh, the community is so connected.’ No, the connections between us are gone…
“It’s not that easy for people to make friends in Vancouver. But it’s like, we actually make a friend and find a home, after a life that has been marked by trauma and violence. And then you finally feel like you’re at peace, and you’ve got people you trust and connect to.
“And then they die.”
An endless emergency
How can an emergency last this long?
Caitlin Shane, a drug policy staff lawyer at Pivot Legal Society, says that declaring an emergency gave the provincial health officer, or any medical health officer in a health authority, the power to take any action they deem necessary.
Since the emergency declaration, there has been a single ministerial order issued in relation to it: a December 2016 order from then-health minister Terry Lake, ordering health authorities to “assess the need in their region” and provide overdose prevention sites (OPSs) as needed.
“Need is important, because it is the sole criteria for establishing sites. If there is a need, a site arguably must exist,” Shane explains. “And the health authorities have demonstrably failed in fulfilling that order.”
There are 42 OPSs across BC, but they tend to cluster in cities. There’s also some glaring practical problems: while inhaling, not injecting, is responsible for the majority of illicit drug-related deaths, only 13 sites allow smoking, with none north of Campbell River or east of Abbotsford.
“This order exists. It’s required by law, and yet we see terribly low numbers of overdose prevention sites, astronomical death rates,” Shane says.
It’s not just geographical need. Kali Sedgemore, a peer harm reduction worker who focuses on youth, says different communities need safe consumption sites that cater to their specific needs.
“A lot of youth don’t feel comfortable in [OPSs] because they’re very adult-oriented or very high-barrier,” they say, adding that sometimes youth are turned away from OPSs for being “too young to be here.”
In a paper Sedgemore co-authored last year, one important point is that young people fear consequences for trying to use illicit substances more safely. “Younger youth, and in particular younger Indigenous youth, may fear that accessing harm reduction supplies will precipitate a call to child protective services and removal from their families of origin,” the paper reads.
Youth have been left out of the recent decriminalization of small amounts of certain illicit substances, as the province seems concerned about doing anything that could be even vaguely painted as “encouraging young people to use drugs.” But, as Sedgemore points out, young people do use drugs, and denying them access to harm reduction services is dangerous.
Last year, 34 children under 19 died from toxic unregulated drugs.
Tyson Singh Kelsall, an outreach social worker in the Downtown Eastside, says that problems arise from assuming that all people who use unregulated drugs speak English or live in one part of the city. There simply need to be more resources, made by people from different communities who have lived experience of using drugs.
“We know that a lot of South Asian people have died in the Fraser Health Region, but we don’t have any Punjabi-led harm reduction services,” he tells the Straight from Simon Fraser University, where he’s studying for a PhD in the health sciences department. “Although a lot of [toxic drug overdoses] happens in the Downtown Eastside, there’s also a lot of life-saving interventions that happen. A lot of other neighbourhoods simply don’t have that kind of safety net.”
Even though OPSs do important work, they are still predominantly run by people who use drugs. The labour of saving lives—and the trauma of dealing with overdoses, fatal or not—still falls on community members.
“The ripple effects of the overdose crisis are much more complex than just the fatalities, losing people you care about,” Singh Kelsall continues, with a heavy sigh. Before moving to Vancouver, he helped open an OPS in Victoria in 2017. “Continuing to try and keep people alive can be exhausting and traumatic, and it has become even more so.”
The eight-month fight for the ministerial order permitting (and demanding) OPSs was “excruciating,” Ward says. “But what’s worse is the fact that’s the only thing that [the province] has significantly done. Since then, it’s been avoidance.”
The provincial government created the Ministry of Mental Health and Addictions in 2017, ostensibly to build better mental health and addiction services and “lead the response to the toxic drug crisis.” But, in Ward’s words, mental health and addiction “specifically are not the emergency.”
The emergency isn’t that people use illicit drugs to cope with poor mental health, or that some people develop addictions to illicit drugs. These deserve time and attention, of course, but the emergency—the thing that’s been raging for 2,500 days and far longer before that—is the toxic drug supply.
“We know that the vast majority of people who use drugs are not addicted,” Ward says. “They die too. Everyone dies in this situation.”
“Relapse is often fatal”
BC, and governments at other levels, has consistently been conflating the toxic drug supply crisis with almost anything else involving drugs. As a result, many of the steps they’ve been championing—increasing publicly funded treatment beds, limited decriminalization, even OPSs—are designed with the idea of “recovery” in mind. That if people would just stop using drugs, they wouldn’t die.
Guy Felicella, a former illicit substance user who now works in public speaking, says it took him several attempts over many years to stop using illicit drugs until he found something that worked for him. That was a decade ago.
“The drug supply has gotten way worse from 2012 and 2013. What it is today, I mean, it’s just a whole new level,” he tells the Straight.
One of the big problems is that the illicit drug supply is more volatile than ever. 2019 saw a considerable reduction in the number of deaths, but then in 2020 the COVID-19 pandemic hit. Supply chains everywhere broke—and that included illicit drugs.
Cutting product with synthesized drugs became a way for dealers to stretch their supply further. People were alone, cut off from their friends and family and seeking comfort, at the same time as the kind of product on the illicit market completely changed.
Fentanyl is still present in 88 per cent of fatal overdose samples, but there are other substances as well. Carfentanil, a synthetic opioid around 100 times stronger than fentanyl, went from being found in 23 per cent of substances in April 2021 to six per cent in December 2022. Benzodiazepines went from 15 per cent of samples in July 2020, to 52 per cent of samples in January 2022, to 19 per cent in December 2022. Stimulants were present in 68 per cent of all deaths. “Down,” the general name for any depressant, could have any kind of mix of substances present: the Vancouver Island Drug Checking Project’s monthly report for December found 80 per cent of down had additional active substances beyond fentanyl or heroin. (One of Ward’s friends has taken to calling illicit substances “mystery chemicals.”)
Benzos present a big problem for drug users. For one, overdoses are harder to respond to: people don’t get up and walk away from an overdose anymore. Naloxone, the drug that’s reversed thousands of overdoses, specifically works on opioids. Benzos make naloxone less effective; someone who’s overdosed on benzo-dope will probably wake up in hospital after naloxone treatment. Coming around from non-lethal doses takes way longer. If you happen to pass out somewhere in public, you’re more vulnerable to being robbed or sexually assaulted.
And for people who might want to change or lower their drug consumption, benzos are one of only two substances where detoxing can kill you. (The other is legally regulated: alcohol.) Currently, there is only one facility in Vancouver that’s equipped to deal with people coming off benzos or alcohol—which isn’t a lot of beds, when one in five street samples has benzos in it.
“To come off benzos, we’re talking about medical detox or a hospital. And then if you’re looking at a medical detox, there’s a waitlist there as well,” Felicella says. “If you go through all those challenges, and trying to get into detox and you finally get in and then for whatever reason, it takes a while… it becomes dehumanizing. The waitlist essentially becomes a death sentence.”
Singh Kelsall says that treatment can also be problematic in other ways. Even if someone manages to come off illicit drugs when they’re in treatment, long-term success rates are low: it typically takes multiple tries for an abstinence-based model to permanently work. And any time away from taking illicit substances can affect your tolerance.
“Even for people who adhere to the government strategy of abstaining from using the street supply, we’re in a context where relapse is often fatal,” he says.
Singh Kelsall points to a study showing that people who have been forced into treatment often die soon afterwards. Similarly, people in BC who have recently been released from prison died from poisoned drugs at seven times the rate of other residents.
His job is to help people; how can he, in good faith, recommend that they take part in a program that will probably not cause them to immediately stop using illicit drugs, but probably will increase the likelihood that their next hit kills them?
“It becomes ethically fraught to be a social worker, who is working within a system that incentivizes treatment, knowing that you might be guiding someone to increase their chance of overdose risk.”
Cutting out the poisoned supply
Felicella believes the answer lies in a full spectrum of care: more treatment beds, more support for people coming out of treatment programs to be able to access continuing care, more connection with harm reduction services to ensure any return to using drugs happens safely. Secure housing, too: “Why would anybody go to treatment just to go back to what they’re trying to escape?” And—importantly: a safe supply of substances.
The exact mechanics of what a safe supply would look like differ. For Felicella, it would have two streams. One part would be scaling up what we already have, a medicalized supply for people who have been diagnosed with an addiction; the other would be providing pure, regulated substances for occasional, casual, or recreational users.
“In order for us to save significant lives, we have to really have those two models: a medical model, and one outside of the medical model as well,” he says.
Humans will always use drugs. We use caffeine to wake up, or alcohol to celebrate, or cannabis to chill out, or psilocybin to expand our mind. But the current model, which criminalizes specific substances, means that the only way to get a hold of them is through the illicit market. There’s no regulation, so people don’t know what exactly they’re using. And it only takes one time using something toxic to potentially kill us.
The alternative, radical as it sounds, is to do the opposite: provide a way to access regulated substances.
Shane, the lawyer, says that the nature of the public health emergency declaration means there shouldn’t be legal barriers in creating a large-scale framework to legally regulate currently illicit substances.
“The beauty of legal regulation is it’s endlessly flexible,” she says. “You can make it whatever you want it to be, if you are the person in charge of regulating the thing.”
Setting rules that decide how people can consume substances is far safer than just closing your eyes and wishing people didn’t do drugs. Cannabis and alcohol are two obvious points of comparison, but all kinds of substances are legally regulated in all sorts of different ways.
“Do we want them to be adults only before they get this substance? Do we want them to consume it on site? Like literally whatever you want, however you want to control it, you can,” Shane says. “We relinquish all of that control under prohibition, because we just say ‘No,’ knowing full well that people are just going to go to the illicit market and get a totally unregulated drug that may well kill them.”
Things didn’t used to be this way. The illicit drug supply didn’t used to be so toxic. And the stuff we’ve banned didn’t used to be illicit at all.
Habit-forming drugs like cocaine, amphetamines, or opium used to be widely available in pharmacies, and were only legislated into prohibition in the early 1900s through a mixture of anti-Chinese racism, and paternalistic concern that people were using medical drugs recreationally. Alcohol was also banned at various times: in the anti-Indigenous Indian Act of 1876, which banned Indigenous people from being allowed to drink it, and provincewide in BC between 1917 and 1921. And just as prohibition did little to stop people drinking booze, banning drugs did little to stop people doing them: it just moved the market underground.
“Prohibition itself is a historical anomaly in the history of human societies. It’s a weird thing that we invented 100 years ago,” Ward says. “[Access to illicit drugs] was totally available. You didn’t have to, you know, drop out of society to actually access things.”
But the provincial government shows little interest in committing to a safe supply that would save lives. Change is too dramatic, too radical, too likely to cost voters.
“Every policy choice they make is intent on preserving the status quo,” she says. Safe supply “would mean a shift away from that, and there would be implications that would mean larger changes, because this isn’t about drugs. It’s about structural inequality.”
Treatment beds and limited decrim and tiny pilot models of safe supply for people with the most severe opioid addiction will not stop six people dying.
Sedgemore, the youth peer worker, says people in power don’t take drug users seriously.
“They don’t think that we have the capability of actually talking about it in an ethical way,” they say. “They think that we’re all dumb, and we don’t understand certain things, when we do understand things. We get it.”
Overdose prevention sites were spearheaded by people who use drugs, and continue to save thousands of lives every year. Decriminalization, even in its current watered-down capacity, was advocated for by people who use drugs, for decades. When the communities most affected by an emergency tell us what would help, we should listen to them.
Safe supply opponents worry that the government would be “encouraging” drug use, that suddenly everyone will just quit their jobs and rush to get high on heroin. But is that worse than the world we currently live in, where six people every single day are dying?
“I would love to go have a decent life and do something interesting and build better futures,” Ward says. “But instead I’m just calling people going, ‘Death is bad. Death is bad. Death is bad.’
“It really messes—it really fucks you up. It really takes over your whole mind, the fact of having to resist and fight against mass death, and then having people say you’re wrong to do that. That’s wild.”
February 17 marks 2,500 days of the toxic drug deaths emergency. More than 11,098 people have died since it began.
How many more will there be?