Vancouver's top doctor opens up about late nights through the fentanyl crisis and B.C.'s next steps

Five days before Christmas last year, Dr. Patricia Daly was working with provincial colleagues on a problem no civil servant ever wants to have.

“Seems there is a challenge at VGH [Vancouver General Hospital] which may have further impact on the already increasingly ‘creative’ Coroners Service approach to locating crypt spaces”, reads an email she received at 11 a.m. that morning.

The previous month, 128 people had died of illicit-drug overdoses, an all-time high in records going back to 1989. The following month, 142 died.

The fentanyl epidemic had caused the city’s morgues to run out of space to store the bodies.

Daly, chief medical health officer for Vancouver Coastal Health (VCH), replied in less than 20 minutes.

“Please call me on my cell phone,” she wrote. “I’ll connect you with the right person once I know the details about what’s needed.”

Those emails are included in hundreds of pages of government correspondence obtained by the Straight through more than a half-dozen freedom-of-information requests. In a telephone interview, Daly discussed the December 20 exchange.

“With the number of deaths, there are a lot of bodies, and part of the issue is they need to be stored while toxicology tests are pending. It’s become a challenge,” Daly told the Straight. “It really brings home the reality of what is going on with the number of deaths that we’ve seen.”

The emails show government staff and health-care workers working on the problem from early in the morning to late at night.

Daly acknowledged the monthly death tolls are likely to remain high (at more than 100 deaths per month for four months now, compared to an average of 41 per month through 2015).

“I’ve been in public health 20 years in this city and this is certainly one of the most stressful crises,” she said. “When we were getting SARS cases, I was getting calls all through the night. But that was for a short period of time and this has been going on for a while now. So it’s stressful. We continue to have too many deaths.”

Working day and night

The documents, which the Straight began reporting on March 21, depict officials with the city, VCH, and the provincial government working frantically to slow the rapidly rising body count associated with B.C.’s overdose crisis.

Daly said the health authority is now moving into phase two of its response. Last year, it worked to significantly expand access to naloxone, the so-called overdose antidote. And then in December, the provincial government and local partners established 20 overdose-prevention sites, where people can inject drugs under the supervision of staff trained in overdose response.

Those efforts were significant. With the help of provincial and federal partners, naloxone was stripped of prescription requirements and made available for free at dozens of locations around B.C. It went from being a drug that very few people could readily access to one that’s now a common sight on the streets of Vancouver, or at least the Downtown Eastside.  And the overdose-prevention sites operating today see between 500 and 600 people every day. Not one death has occurred at any of those 20 locations.

Phase two, Daly continued, will focus on opioid-agonist therapy, which means expanding access to drugs that block opioid receptors in the brain. This help people addicted to heroin and fentanyl transition to treatment medications like Suboxone.

For entrenched addicts, the emails reveal that the provincial government is also looking at a similar but more controversial category of opioid-substitution therapy: prescription heroin, which is already offered on a small scale at Crosstown Clinic in the Downtown Eastside.

“Can you please give me the total costs of crosstown,” reads one email. “Patty Daly wants to know as the MOH [Ministry of Health] is thinking of using a Crosstown model to address the OD crisis.”

Daly said that VCH continues to work with the B.C. Ministry of Health to expand access to prescription heroin, but there are challenges.

“There aren’t a lot of neighbourhoods like the Downtown Eastside where you have a concentration of people who could benefit from this,” she explained. “But the province is looking at it. We all know that this is a part of what we need to offer. The questions are: How do we do it? And how should it be expanded?”

Bureaucratic stumbles

The emails also include evidence of disagreements and tensions between some agencies.

For example, in a December 16 email, Daly expressed her disapproval of remarks made earlier that day by Mayor Gregor Robertson and Vancouver police chief Adam Palmer. At a news conference, they made an impassioned plea for the province to spend more on addiction treatment and specifically for easier access to detox.

In an email to the province, Daly expressed concern over Robertson and Palmer’s emphasis on detox, explaining that from a medical perspective, that could actually be dangerous.

“Our addictions experts would not have called for an immediate expansion of detox beds as you know, since people coming out of detox currently are at a very high risk of overdoses and death,” she wrote. “Many of our docs won’t refer those with opioid addiction to detox for this reason.”

Speaking to the Straight, Daly explained that there was a concern for unintended consequences.

“If people detox successfully, they get off their drugs, but there is a very high rate of relapse with opioid addiction. And they’ve lost some of their tolerance to the drug, and so they may be at greater risk of overdose when they come out if they relapse,” she said. “I understand the motivation of police and the city at the time, to say that we need detox and treatment on demand, but they are not the addictions experts, and what our addictions doctors tell us is that detox without a comprehensive system of care could actually be more dangerous right now.”

She said communication between agencies has since improved, and that conference calls now happen at least once every two weeks in order to ensure coordination.

In another flap with the city, which occurred last summer, VCH filed federal applications to open two additional supervised-injection sites in Vancouver. But the process was slowed by the city’s permits process for building renovations.

“Both [proposed supervised-injection] sites required renovations, and the permits have been delayed due to CoV’s [City of Vancouver’s] permit requirements,” an email reads. “Very frustrating in the midst of a true crisis.”

Daly acknowledged bureaucratic stumbles at every level of government have slowed some specific responses to the fentanyl crisis.

“Health Canada, before they will approve [a new supervised-injection facility], they have to inspect the site, and that means you have to do the renovations first,” she explained. “And while the city has been very supportive of the whole opioid response crisis, it takes a while to get permits. So that was frustrating. We did raise it with the city right to the highest, to the city manager, and they committed to doing whatever they can to expedite that process going forward.

“The city is a big government structure and they have their own processes for construction permits," Daly continued, "and Health Canada is working through their processes, so all of these things take time, which is why we still want the whole process revised.”

Last year, there were 922 overdose deaths in B.C. That was up from 513 in 2015 and 366 in 2014.