Drug Prohibition Is Making the Overdose Crisis Worse

By Drs. Kora DeBeck and Perry Kendall

Should heroin and cocaine be legally available to people who need and want them? If we are serious about stopping the crisis of drug overdose deaths, that is exactly the kind of profound change we need. Yes, extensive regulations would be necessary. In fact, the whole point of regulating drug production and sales is that we can better control what is being sold and to whom.

After British Columbia’s Provincial Health Officer Dr. Bonnie Henry testified to the all-party health committee in Ottawa in May that regulating these controlled drugs would minimize harms, B.C. Premier David Eby said he disagreed. He is quoted saying “in a reality-based, real-world level, (it) doesn’t make any sense.” But does our current approach of drug prohibition “make sense?”

Since the overdose crisis was declared in 2016, illicit drug toxicity deaths have become the leading cause of unnatural death in B.C. and the leading cause of death from all causes for those aged 10 to 59. More than 44,000 people have died from drug poisoning in Canada since 2016, and more than one-third of those were in B.C. An average of 22 people are dying every day in Canada because the illicit supply of drugs is toxic.

Toxic Drug Supply

Why is the drug supply so toxic? Because we are letting organized crime manufacture drugs instead of regulated licensed industries that are required to follow health and safety standards.

In the context of drug prohibition, organized crime and drug cartels are incentivized to make highly potent products because it is cheaper and hence more profitable. This is what happened during alcohol prohibition in the 1920s. Organized crime ran rampant, and people were poisoned because there were no health and safety standards for production.

The failure of alcohol prohibition in meeting its key objectives of eliminating the supply and demand of alcohol are the same failures of drug prohibition. Illegal drugs are easy to find regardless of their illegal status. Reliable estimates are that 225,000 people are using illegal substances in B.C.

What is the way out? Our knowledge of research evidence and decades of collective experience — including as a researcher (Kora DeBeck), a B.C. provincial health officer (Perry Kendall) and chief coroner (Lisa Lapointe) during the overdose crisis — brings us to drug regulation. When we regulate a substance, we have the most control over its production, distribution and consumption.

Lessons From Tobacco

Some may argue that regulating drugs sends the “wrong message” and will encourage drug use, most concerningly among young people. However, if we look to lessons from tobacco regulation, we can see that public health-based regulations can actually be strong and effective substance-use deterrents.

By strictly controlling tobacco marketing, packaging, purchase price, purchase age and consumption locations alongside educating people about the health risks, tobacco consumption and associated health harms have been significantly reduced without all the additional risks of banning tobacco products (for example, criminal black markets controlling production and sales).

The same kinds of regulatory tools would be available to control the use of currently illegal drugs if we moved from prohibition to regulation.

Addiction Treatment Not Enough

But what about addiction treatment? Isn’t that what we really need? While it’s true that eliminating wait times and increasing access to effective, evidence-based treatment are critically important and much needed, the reality is that many people who use drugs don’t have an addiction and many others are not currently seeking treatment. Yet all people who use drugs face the deadly consequences of an unregulated toxic drug supply.

It is also important to remember that addiction recovery is complex and relapse is common in the recovery journey. In today’s toxic drug environment, people who relapse after a period of abstinence face a significantly higher risk of death due to their reduced tolerance. We also know that substance treatment is not regulated or standardized, and treatment outcomes are not reported.

While supporting people to recovery is important and can be lifesaving, addiction treatment is not the straightforward solution many believe it should be. Thousands of lives remain at risk every day.

A Regulated Drug Supply

Taking the production and sale of currently illegal drugs away from organized crime and drug cartels is the most promising way to keep our kids and communities safe. With strict health and safety standards for the production of these drugs and stringent public health-based regulations on their distribution and sale, we have the best shot at reversing the carnage of overdose fatalities and managing drug-related harms.

Regulating drugs may seem to some like a radical proposition but governments regulate the production and distribution of potentially dangerous goods all the time. The regulation of firearms in Canada includes licensing that requires passing a firearms safety course. Mandatory ingredient lists that disclose the amount of sugar, sodium and fat in the foods we eat is another example of a government regulation that is designed to protect the public and provide information that may shape consumption patterns and reduce health risks.

Implementing an effective regulatory framework for currently illegal drugs will be a complex undertaking requiring close monitoring and evaluation and inevitably corrections and revisions along the way. While the task may appear daunting, allowing overdose deaths to continue at the current rate is unconscionable.

Transformational and life-saving drug regulation is urgently required because, borrowing terminology from Premier Eby, at the “reality-based, real-world level,” our current approach is a catastrophic failure.

Kora DeBeck, PhD, is a Distinguished Associate Professor in the School of Public Policy at Simon Fraser University and a Research Scientist at the BC Centre on Substance Use.

Perry Kendall is a Clinical Professor in the Faculty of Medicine, School of Population and Public Health at the University of British Columbia. He is also a former Provincial Health Officer for BC

This article was also co-authored by Lisa Lapointe, who was BC’s Chief Coroner from 2011 to 2024.

This article originally appeared in The Conversation and is republished with permission.

‘Safe Supply’ of Rx Opioids Saved Lives in British Columbia

By Pat Anson, PNN Editor

Prescribing opioids and other medications to people with substance use disorders significantly reduces their risk of dying, according to a large new study in British Columbia. The findings add weight to efforts to create a “safe supply” of legal medications for patients at risk of an overdose from increasingly toxic street drugs.

Vancouver, British Columbia was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, a potent synthetic opioid. That led Vancouver to become a laboratory for harm reduction programs and safe supply sites offering prescription opioids and injectable heroin to drug users.  

How effective have those programs been?

A study by the B.C. Centre for Disease Control, recently published in the British Medical Journal, found that prescribing opioids, stimulants and anti-anxiety medication to nearly 6,000 drug users dramatically reduced their risk of death.

The Risk Mitigation Guide (RMG) program was initially launched in early 2020 to help drug users going through withdrawal while isolated by the COVID-19 quarantine. A year later, the program was extended, allowing doctors and nurse practitioners to prescribe hydromorphone, morphine, oxycodone, fentanyl, benzodiazepines and stimulants to drug users.

People who were given an initial dose of prescription opioids had a 61% lower risk of death from any cause the following week, and were 55% less likely to die of a drug overdose.

The protective effect of a safe supply increased as more doses were provided. Drug users who received four or more days of opioids were 91% less likely to die from any cause and 89% less likely to die from an overdose.

"We saw a profound impact on reduction in somebody's overdose death risk the week after they picked up these drugs, to a degree that is really surprising and has enormous potential," co-author Paxton Bach, MD, an addiction medicine specialist, told CBC News. "This paper is the strongest evidence we have so far, by a large margin, supporting the idea that this can be an effective strategy for reducing overdose death risk."

But critics of safe supply programs say they don’t really reduce drug abuse. An investigation last year by the National Post found that hydromorphone pills given to drug users in Vancouver were being sold to other addicts, with the sellers then using the money to buy more potent street drugs that were often laced with fentanyl.

A new study in JAMA Internal Medicine also found that opioid-related hospitalizations rose sharply in British Columbia after safe supply programs were launched there, although there was no significant change in overdose deaths. The spike in hospitalizations may have been due to more potent street drugs and counterfeit pills on the black market.

Since a public health emergency was declared in British Columbia in 2016, over 13,000 people have died from drug overdoses. A 2020 analysis found that only about 2% of the B.C. opioid-related deaths were caused by prescription opioids alone. The other overdoses mainly involved illicit fentanyl and other street drugs.  

Illicit Drug Users Turn to Cannabis as ‘Safe Supply’ Option

By Pat Anson, PNN Editor

The cannabis industry and its advocates have long said that medical marijuana could help solve the opioid crisis by reducing demand for prescription opioids. While the evidence for that claim is somewhat mixed, a new study suggests that cannabis may be useful in reducing demand for illicit opioids, such as fentanyl.

Researchers at UCLA and the British Columbia Centre on Substance Use surveyed 205 people in Vancouver, BC who use cannabis and “unregulated opioids” obtained on the black market. In recent years, Vancouver has become a laboratory for harm reduction programs aimed at reducing overdoses, such as “safe supply” sites that offer prescription opioids and injectable heroin to drug users.  

The survey findings, published in the International Journal of Drug Policy, found that almost half the participants used cannabis to manage their opioid cravings and nearly 58% reported decreasing their opioid use. Researchers say the association between cannabis and harm reduction was “mainly driven by those living with moderate to severe pain.”

“These findings indicate that cannabis use to manage opioid cravings is a prevalent motivation for cannabis use among PWUO (people who use unregulated opioids) and is associated with self-assessed reductions in opioid use during periods of cannabis use,” wrote lead author Hudson Reddon, PhD, a Postdoctoral Fellow at the BC Centre on Substance Use.

The study is believed to be the first to investigate if illicit drug users can successfully manage their opioid cravings with cannabis. If the findings are confirmed, it could broaden access to cannabis as a harm reduction measure.

A previous survey of illicit drug users by the BC Centre on Substance Use found that about 1 in 4 used cannabis for harm reduction. About half used cannabis as a substitute for cocaine, methamphetamine and other stimulants (50%) and nearly a third used it as a substitute for illicit opioids (31%). Other reasons for using cannabis include coming off of other drugs (25%), substitution for a legal substance (15%), and as a treatment for withdrawal (15%).

“Given the increasing harm of the drug toxicity crisis and ongoing maturation of the regulated cannabis market in Canada, evaluating how cannabis use patterns, such as substitution, impact opioid use behaviours will be important to inform public health and policy responses to mitigate the harms of opioid use and evolving cannabis access,” Reddon wrote.

“Increasing the accessibility of cannabis products for therapeutic use may be a useful supplementary strategy to mitigate exposure to unregulated opioids and associated harm during the ongoing drug toxicity crisis.”

Stopping Rx Opioid Therapy Raises Risk of Overdose

By Pat Anson, PNN Editor

Discontinuing opioid therapy for people with chronic pain raises the risk of a patient dying from an overdose, according to a new Canadian study that calls for better guidance for healthcare providers on the risks associated with abrupt tapering.

Researchers analyzed the medical histories of over 14,000 pain patients in British Columbia who were on long term opioid therapy from 2014 to 2018 – a period when physicians in Canada and the United States were being urged to restrict opioid prescriptions due to a worsening overdose crisis. The vast majority of patients studied were either tapered to a lower dose or their opioid treatment was discontinued, regardless of whether they showed signs of opioid use disorder (OUD).  

The study findings, published in PLOS Medicine, show that discontinuing opioid therapy for pain was associated with increased overdose risk. The association was even stronger for the small minority of patients diagnosed with OUD. In total, 530 people in the study (3.8%) experienced either a fatal or non-fatal overdose, with 120 of them dying.

“Our findings underscore the need for healthcare providers and policymakers to carefully consider potential unintended adverse effects of discontinuing opioid treatment for chronic pain when developing prescribing interventions and making practice decisions,” wrote lead author Mary Clare Kennedy, PhD, a Research Scientist with the BC Centre on Substance Use and a Research Fellow at the University of British Columbia.

“Given the harms of opioid treatment discontinuation identified in this and past studies, non-consensual and abrupt discontinuation of opioid treatment for pain is contraindicated in almost all instances.”

Kennedy and her colleagues were unable to determine what substances were involved in the overdoses, but they believe some patients who had their opioid therapy stopped may have resorted to illicit fentanyl and other street drugs to manage their pain, withdrawal and other symptoms. Over 73% of the overdose deaths that occurred in British Columbia during the study period involved fentanyl.

Previous studies have also found that opioid tapering raises the risk of an overdose and mental health crisis. A study published last year in JAMA found that tapered patients were 68% more likely to be treated for opioid withdrawal, drug overdose or alcohol intoxication, and they were twice as likely to experience depression, anxiety or a suicide attempt.

The FDA warned in 2019 that rapid tapering or abrupt discontinuation of opioids could result in serious harm to patients, including withdrawal, uncontrolled pain, psychological distress and suicide.

‘Reckless Mistreatment of Patients’

Despite this growing body of evidence, forced tapering and opioid discontinuation continues – some of it caused by the heavy-handed tactics of law enforcement. Over 200 pain patients were recently cut off from opioids after their California doctor had his DEA license suspended without warning. One patient and his wife died by suicide within a week of the DEA’s action.

“Not only are we collectively causing harm, we are failing to stop causing harm even when we agree that we're causing it, which is actually worse,” says Stefan Kertesz, MD, an associate professor at the University of Alabama at Birmingham, who is leading a study of pain patient suicides.

Kertesz says regulators, insurers, journalists and law enforcement have misinterpreted overdose studies to suggest that opioid prescribing, particularly at higher doses, was the root cause of the overdose crisis.  

“Many clinicians and policymakers engaged in aggressive extrapolation that went far beyond the data. Many journalists and legal plaintiffs described the prescriptions in a way that aggravated matters. They made dose into a fetish, a performance metric, and a threshold for law enforcement,” Kertesz told PNN. “Dose based quality metrics, payor standards and legal investigation thresholds incentivize reckless mistreatment of patients.

“My ultimate question is when will agencies like the National Committee for Quality Assurance, the Office of Inspector General, and law enforcement actually come to appreciate the evidence in play?”

It took six years, but the CDC recently revised its 2016 opioid guideline to include specific language warning of the dangers of tapering or discontinuing opioids.

“Clinicians should avoid abrupt discontinuation of opioids, especially for patients receiving high dosages of opioids, should avoid dismissing patients from care, and should ensure appropriate care for patients with pain and patients with complications from opioid use,” the revised guideline states.

Opioid Prescribing Limits Failed to Reduce Overdoses in British Columbia

By Pat Anson, PNN Editor

British Columbia’s opioid guideline failed to have any significant impact on overdoses, hospital admissions or deaths in the year after it was adopted, according to new research published in CMAJ Open. The study is the latest to show that opioid prescribing limits have been misdirected and ineffective in slowing North America’s opioid crisis.

The College of Physicians and Surgeons of British Columbia released strict professional guidelines for the “safe prescribing” of opioids and sedatives in 2016, after the Canadian province was hit by a wave of overdoses and deaths. The BC guidelines, which are similar to the CDC’s opioid guideline in the United States, warn doctors to be cautious about opioid prescribing and to avoid increasing doses over 90 morphine milligram equivalents (MME) per day.

Researchers at the University of British Columbia wanted to see how effective the BC guideline was in reducing overdoses, so they analyzed health data on over 68,000 patients on long term opioid therapy. A previous study by the same research team found a “modest” reduction in opioid use in the 10 months after the guideline was introduced, as well as more tapering.

Did the reduced prescribing result in fewer overdoses?  No.

Researchers found no significant change in opioid overdose hospital admissions, opioid overdose mortality, all-cause emergency department visits, all-cause mortality, or all-cause hospital admissions after the BC guideline was adopted. They also found no evidence that pain patients turned to street drugs after their opioid prescriptions were reduced or stopped.

“Concern has been expressed that policies focused on reducing prescribing of opioid analgesics could increase opioid-related deaths if patients unable to access prescription opioids for adequate pain relief turned to street drugs and were exposed to dangerously high levels of synthetic opioids. Our study did not find evidence that the standards and guidelines had the unintended consequence of increasing opioid overdose hospital admissions or opioid overdose mortality,” wrote lead author Richard Morrow, a senior research analyst at UBC.

Critics say the lack of evidence is proof that opioid prescribing has little to do with British Columbia’s overdose crisis.   

“The results are not unexpected and demonstrate the folly of limiting opioids to pain patients in a futile attempt to deal with overdoses from illicit street drugs. The policy has created considerable pain and anxiety along with a worsening quality of life for nothing,” said Marvin Ross, a patient advocate with the Chronic Pain Association of Canada. 

British Columbia’s Coroners Office expects 2020 to be a record breaking year for overdoses in the province, with about five drug deaths every day. A recent study found that the vast majority of BC’s overdoses involved illicit fentanyl and other street drugs. Only 2.4% of the nearly 1,800 fatal overdoses in BC from 2015 to 2017 involved opioid medication alone.

Stricter opioid prescribing policies have also been ineffective in slowing the overdose crisis in the United States. Prescription opioid use in the U.S. is at its lowest level in 20 years, while more Americans are dying from overdoses than ever before.

Can Cannabis Be Used to Treat Opioid Addiction?

By Pat Anson, PNN Editor

Canadian researchers – with funding from U.S. taxpayers – are proposing a novel treatment for opioid use disorder: Cannabis.

In a paper published in the journal Drug and Alcohol Dependence, researchers from the University of British Columbia (UBC) and the BC Centre on Substance Use (BCCSU) say cannabis could help people being treated for opioid addiction by reducing their risk of exposure to illicit fentanyl and other street drugs.

The finding is based on urine drug tests of 819 people being treated for opioid addiction in Vancouver, BC, the first major city in North America to experience an outbreak of fentanyl-related overdoses. Addiction treatment usually involves taking opioid agonist drugs (OATs) such as buprenorphine or methadone.

The researchers found that over half the participants (53%) tested positive for fentanyl, suggesting they were still using street drugs. Those who tested positive for THC -- the psychoactive compound in cannabis -- were about 10 percent less likely to have fentanyl in their urine.

"These new findings suggest that cannabis could have a stabilizing impact for many patients on treatment, while also reducing the risk of overdose," said lead author Eugenia Socías, MD, a clinician scientist at BCCSU. "With overdoses continuing to rise across the country, these findings highlight the urgent need for clinical research to evaluate the therapeutic potential of cannabinoids as adjunctive treatment to OAT to address the escalating opioid overdose epidemic."

Socias and her colleagues say cannabis may play an important role in keeping people in addiction treatment programs. Previous research at BCCSU found that drug users initiating OAT who used cannabis daily were about 21 percent more likely to be retained in treatment after six months than non-cannabis users. People who stay in treatment face much lower risks of dying from an overdose, acquiring HIV or suffering other harms of drug use.

‘Gateway Drug’

The research at UBC and BCCSU was funded, in part, by grants from the U.S. National Institute on Drug Abuse, which is part of the National Institutes of Health (NIH).

The NIH has taken a dim view of cannabis in the past, calling marijuana a “gateway drug” for some users, particularly adolescents. A 2015 study funded by NIH found that nearly a third of those who use marijuana develop some degree of marijuana use disorder.

“Whether smoking or otherwise consuming marijuana has therapeutic benefits that outweigh its health risks is still an open question that science has not resolved,” said Nora Volkow, MD, Director of the National Institute on Drug Abuse.

Public health officials in British Columbia have proposed some controversial solutions to the opioid crisis, including decriminalization of all illicit drugs. A treatment center in Vancouver currently provides diacetylmorphine -- prescription heroin – to drug users to keep them from using street heroin that is often laced with fentanyl, a synthethic opioid that is 50 to 100 times more potent than morphine.

The Canadian Institutes of Health Research recently approved funding for a pilot study in Vancouver to evaluate cannabis as an adjunct therapy to OAT.

"Scientists are only just beginning to understand the role cannabis might play in supporting people's well-being, particularly those who use other substances," said co-author M-J Milloy, PhD, the Canopy Growth professor of cannabis science at UBC. "This study will help us understand if and how cannabis might have a role in addressing the overdose crisis."

Only 2% of British Columbia Overdoses Linked to Prescription Opioids

By Pat Anson, PNN Editor

A new analysis of fatal opioid overdoses in British Columbia found that only about 2% of the deaths were caused by prescription opioids alone. The other overdoses mainly involved illicit fentanyl and other street drugs or a combination of illicit drugs and other medications, which were often not prescribed.

“Our data show a high prevalence of nonprescribed fentanyl and stimulants, and a low prevalence of prescribed opioids detected on toxicology in people who died from illicit drug overdose. These results suggest that strategies to address the current overdose crisis in Canada must do much more than target deprescribing of opioids,” researchers reported in the Canadian Medical Association Journal (CMAJ).

Vancouver, British Columbia was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, a potent synthetic opioid. A public health emergency was declared in BC in 2016 and strict guidelines were released to limit opioid prescribing. Although prescriptions dropped dramatically, fatal overdoses in BC continued to rise.

Researchers looked at 1,789 fatal overdoses in BC from 2015 to 2017 for which toxicology reports were available and found that 85% of them involved an opioid. Of those, only 2.4% of the deaths were linked to opioid medication alone. Another 7.8% of cases involved a combination of prescribed or non-prescribed opioids.

The findings are similar to a 2019 study of opioid overdoses in Massachusetts, which found that only 1.3% of the people who died had an active prescription for opioid medication.   

“Pain patients and their medications have never been responsible for overdose deaths – not then or now. Will the anti-opiate zealots, with all their data-dredged studies be taken to task for all the unnecessary suffering, disability, and premature deaths they have contributed to within the Canadian pain population?” asked Barry Ulmer, Executive Director of the Chronic Pain Association of Canada, a patient advocacy group.

“The ‘prohibition’ approach that has wrongly been applied for years that focused on reducing access to pharmaceutical products directly contributed to exposure to higher risk illicit substances, which put people at risk of overdose.”

Most Overdoses Linked to Illicit Fentanyl

Researchers say efforts to reduce opioid prescribing in Canada were “insufficient to address the current overdose crisis” because street drugs are involved in the vast majority of deaths. They also warned against the forced tapering of patients on opioid pain medication.

“The risk of harms from these medications must be balanced with the potential harms of nonconsensual discontinuation of opioids for long-term users, including increased pain, risk of suicide and risk of transition to the toxic illicit drug supply,” wrote lead author Alexis Crabtree, MD, resident physician in Public Health at the University of British Columbia.  

Crabtree and her colleagues found that most overdoses involved a street drug, with fentanyl or fentanyl analogues linked to nearly 8 out of 10 overdose deaths. Many of the deaths involved multiple substances, including medications such as stimulants, anti-depressants, benzodiazepines, antipsychotics and gabapentinoids, which were often not prescribed to the victim.   

Over 7% of the overdoses involved methadone or buprenorphine (Suboxone), opioids that are used to treat addiction. About a third of the people who died had a diagnosis of substance use disorder in the year before their overdose.

In a commentary also published in CMAJ, a leading public health expert said it was time to decriminalize drugs and offer a “safe supply” to illicit drug users.

“Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated. It is time to scale up safe supply and decriminalize drug use.”

— Dr. Mark Tyndall

“Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated. It is time to scale up safe supply and decriminalize drug use,” wrote Mark Tyndall, MD, Executive Director of BC Centre for Disease Control and a professor at the School of Population and Public Health, University of British Columbia.

Tyndall says blaming the opioid crisis on excess prescribing by doctors and the unethical marketing of opioids by pharmaceutical companies fails to address the reasons people abuse drugs in the first place.

“While having a cheap and ready supply of opioid drugs does allow for misuse and addiction, this narrative fails to acknowledge that drug use is largely demand-driven by people seeking to self-medicate to deal with trauma, physical pain, emotional pain, isolation, mental illness and a range of other personal challenges and these are the people overdosing,” Tyndall wrote.

(Update: Canada’s Chief Public Health Officer, Dr. Theresa Tam, issued a statement August 26 saying the COVID-19 pandemic is contributing to an increase in drug overdoses and deaths across Canada.

“There are indications that the street drug supply is growing more unpredictable and toxic in some parts of the country, as previous supply chains have been disrupted by travel restrictions and border measures. Public health measures designed to reduce the impact of COVID-19 may increase isolation, stress and anxiety as well as put a strain on the supports for persons who use drugs,” Tam said.

“For the third consecutive month this year, the number of drug overdose deaths recorded in British Columbia has exceeded 170. These deaths represent a 136% increase over the number of deaths recorded in July 2019. There are news reports of an increase in overdoses in other communities across the country.” )

Arizona Drug Bust Shows Fentanyl Crisis Growing

By Pat Anson, PNN Editor

In one of the largest fentanyl busts in state history, nearly 170,000 counterfeit pills made with illicit fentanyl have been seized in Phoenix, Arizona. A DEA task force and Phoenix police seized the pills during a traffic stop on January 22, arresting two suspects who were under surveillance.

The blue pills were stamped with an “M” and a “30” – distinctive markings for 30mg fake oxycodone tablets known on the street as “Mexican Oxy” or “M30.” The total street value of the drugs was estimated at $3 million.

"These 169,000 pills, it can have a varying amount of fentanyl. They have no quality control, and what makes them that much more deadly is they look like legitimate oxycodone pills. They don't contain an active ingredient. It is just fentanyl with other ingredients," said DEA Spokesperson Erica Curry. 

"We are talking about a very deadly substance in such small quantities it can be lethal to anyone who doesn't have an opioid tolerance built up."

DEA PHOTO

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. Counterfeit pills laced with illicit fentanyl have been appearing around the country and are linked to thousands of overdose deaths. In 2019, law enforcement agencies seized over 1.4 million fentanyl pills in Arizona alone.

According to a recent DEA analysis, about one in every four counterfeit pills have a potentially lethal dose of fentanyl.

Street Drug Users Aware of Fentanyl

Who would be foolish or desperate enough to take a street drug that might kill them? Do overdose victims even know the fake pills they’re buying contain fentanyl?

The answer in many cases is yes, according to a new study of street drug users in Vancouver, British Columbia – the first major North American city to see an influx of illicit fentanyl.  

The study drew on data collected from over 300 people recruited at drug treatment sites in 2018. The participants completed a brief survey on their drug use and provided a urine sample that researchers tested for fentanyl and other substances.

About 60 percent of those tested had fentanyl detected in their urine. Of those, nearly two-thirds (64%) knew they had taken fentanyl.

"This research shows the majority of people who use fentanyl know they're doing so," says Dr. Jane Buxton, an epidemiologist and professor at the University of British Columbia, who is corresponding author of the study published in the International Journal of Drug Policy.

"Making people who use drugs aware of the presence of fentanyl in the drug supply isn't enough; we need harm reduction services, substance use treatment, overdose prevention resources, and pharmaceutical alternatives to the toxic drug supply to reduce the devastating impact of fentanyl and its analogues on our communities."

The fentanyl crisis in British Columbia is growing worse by the year.  A similar study in 2015 found only 29% of participants tested positive for fentanyl, with only 27% aware that they'd used it.

When fentanyl first appeared in the illicit drug supply, many users took fentanyl unknowingly because dealers secretly added it to heroin, counterfeit pills and other street drugs. It’s no secret today. According to preliminary data from the BC Coroner, fentanyl or its analogues were found in 85 percent of fatal overdoses in 2019.

Researchers do not fully understand the reasons people knowingly take fentanyl. Some users are aware it is present in the illicit supply of opioids and have no other choice, while others may prefer the experience of taking fentanyl.

"This research lays groundwork that will help us learn more about why fentanyl use is increasing," said lead author Mohammad Karamouzian, a PhD student at UBC's School of Population and Public Health. "These findings will also contribute to more effective messaging campaigns and harm reduction strategies to help reduce preventable deaths and support the health of people who use substances, their families, and their communities."

Another key finding of the study was that people who used fentanyl were more likely to have also recently used heroin or crystal meth.  Those who used cannabis were less likely to use fentanyl.

Would Decriminalization Solve the Overdose Crisis?

By Pat Anson, PNN Editor

Vancouver, British Columbia was the first major North American city to be hit by the overdose crisis. In 2016, after a wave of overdose deaths involving illicit fentanyl and even more deadly synthetic opioids like carfentanil, the western Canadian province declared a public health emergency.

Despite efforts to decrease the supply of prescription opioids in BC, over 3,600 more people have overdosed since the emergency was declared, with fentanyl detected in 87% of the deaths last year.

So when BC’s largest healthcare system recommends some radical solutions to the overdose crisis, it’s worth noting. Vancouver Coastal Health (VCH) released a report last month recommending that illegal drugs be decriminalized and that drug users be given access to prescription opioids as an alternative to the black market.

"Legalization and regulation of all psychoactive substances would reduce people's dependence on the toxic illegal supply, criminal drug trafficking and illegal activities that people with addictions must engage in to finance their drug use," said Dr. Patricia Daly, VCH’s chief medical health officer.  

Some Canadian drug policy experts think the idea makes sense.

"The illegal market is an absolute toxic mess right now," Donald MacPherson, executive director of the Canadian Drug Policy Coalition, told the CBC. "It's really in line with consumer protection strategy ... just like we do with every other substance that we ingest, whether it be food or drugs."

Also notable about the VCH report is that – unlike most regulators and politicians in Canada and the U.S. – prescription opioids are not singled out as the root cause of the overdose crisis. Instead, opioid medication is seen as part of the solution.

The report recommends pilot programs to see if prescription fentanyl and other opioid medications made available at supervised consumption sites could help high-risk illicit drug users “transition” to legal opioids.

“Piloting legal access to opioids is different from OAT (opioid agonist therapy) as treatment and would be low-barrier and flexible. Initial pilots would include observation of consumption, followed by pilots allowing distribution of opioids for people to take away for later consumption,” the report recommends.

The idea is controversial, but some doctors are warming up to it. A pilot program recently began at a Vancouver clinic, where hydromorphone tablets are given to about 50 patients who ingest them on site under staff supervision. In Ontario, over 400 healthcare providers and researchers recently signed an open letter asking that high dose injectable hydromorphone be made widely available to illicit drug users.

Substance Abuse and Socioeconomic Problems

The primary cause of the opioid crisis, according to the VCH report, is a “complex interaction” of socioeconomic problems, such as unemployment and homelessness, combined with substance abuse and an increasingly dangerous black market supply.

VCH analyzed the deaths of 424 overdose victims from 2017 and found that less than half (45%) even sought treatment for acute or chronic pain. They were far more likely to be unemployed (72%) and have a substance abuse problem (84%). About four out of ten overdose victims used opioids, alcohol or stimulants daily.

“Most of those who died used multiple substances including opioids, alcohol and stimulants such as cocaine and crystal meth. A significant percentage of those who died of opioid overdoses had primary alcohol use disorder and/or stimulant use disorder,” the report found.

Importantly, most of those who died were no strangers to the healthcare system. The vast majority (77%) had seen a healthcare provider in the year before they overdosed and one out of five (21%) had seen a provider a week before their death. Six out of ten (59%) had received Suboxone or methadone to treat opioid addiction, but the medications were either not effective or they dropped out of treatment.

In addition to decriminalization, the VCH report recommends improving access to addiction treatment, better substance abuse training of healthcare providers, and increased access to the overdose reversal drug naloxone.

Fake Norco Nearly Killed California Woman

By Pat Anson, Editor

An article published online in the Annals of Emergency Medicine shows just how easy it is for someone to be fooled – and nearly killed – by counterfeit pain medication.

It tells the story of an unnamed 41-year old California woman who treats her chronic back pain with regular doses of Norco, a prescription medication that combines acetaminophen and hydrocodone.

She was one of dozens of people who died or were hospitalized in northern California after ingesting counterfeit Norco bought on the street that was laced with illicit fentanyl – a synthetic opioid that is 50 to 100 stronger than morphine.

"Street Norco is almost indistinguishable from brand-name Norco in appearance but can be lethal," said lead author Patil Armenian, MD, of the University of California San Francisco-Fresno.

"This new street drug's toxicity led to an unexpected cluster of fentanyl deaths in California this spring. These deaths in our area combined with an emergency patient who was concerned about pill appearance and exceedingly sleepy after her usual dose of medication led to our investigation."

The woman in question suffers chronic pain from a herniated disc and normally buys the Norco illicitly, 2 to 3 tablets at a time. The article does not explain why she buys them off the street.

The woman felt sleepy and became unconscious within 30 minutes of taking three of the counterfeit tablets. She next remembered waking up in a hospital emergency room. She told hospital staff the pills had the markings of Norco, but were beige in color instead of the usual white.

A blood serum analysis revealed the woman had significant amounts of fentanyl and U-47700, another type of synthetic opioid. Neither drug is an ingredient in brand-name Norco.

“Toxic effects of these compounds are similar to those of other opioids, namely, miosis, respiratory depression, coma, and possible death. To our knowledge, this is the first reported opioid toxidrome case with confirmed serum concentration of U-47700,” said Armenian, adding that the woman was discharged from the hospital and has completely recovered.

“This case highlights that fentanyl-laced Norco is spreading to other regions and may contain psychoactive ingredients other than fentanyl, such as U-47700, prompting emergency providers to remain vigilant in their care.”

As Pain News Network has reported, the Drug Enforcement Administration is warning the U.S. faces an unprecedented “fentanyl crisis” that is growing worse as drug dealers ramp up production of counterfeit medication. Dozens of Americans have died this year after ingesting counterfeit versions of oxycodone, Norco and Xanax that are virtually indistinguishable from the real medications. Even a few milligrams of fentanyl can be fatal.

Fentanyl is legally prescribed in patches and lozenges to treat severe chronic pain, but the DEA said “hundreds of thousands of counterfeit prescription drugs” laced with illicit fentanyl are on the black market. The agency predicts more fake pills will be manufactured because of heavy demand and the “enormous profit potential” of fake medication.

Canada’s Fentanyl Crisis

Canada – which has been dealing with its own fentanyl crisis – may provide a preview of what’s in store for the U.S. Overdose deaths from fentanyl have reached such an urgent level that British Columbia Premier Christy Clark asked the federal government last week to restrict access to pill presses and to start screening “all small packages” entering the province for fentanyl. 

Earlier this year British Columbia declared a public health emergency and adopted new opioid prescribing guidelines that are even more stringent than those released by the Centers for Disease Control and Prevention.  

While the CDC’s guidelines are voluntary and intended only for primary care physicians, British Columbia’s guidelines are legally enforceable for all opioid prescribers because they set a “minimum standard of professional behaviour and ethical conduct.” The guidelines state that opioids should not be prescribed to treat headaches, fibromyalgia and low back pain.

In Ontario, the backlash against opioids has reached a point that palliative care doctors are worried they will no longer be able to give high doses to their patients – many of whom are dying from cancer and other chronic illnesses. Ontario’s Ministry of Health said public health plans next year would stop paying for high doses of hydromorphone, morphine and fentanyl patches.

“Our patients under palliative care deserve better than this,” Stephen Singh, MD, director of the Canadian Society of Palliative Care Physicians, told The Globe and Mail, adding that he was “appalled” by the government’s decision.

Canadian Province Adopts CDC Guidelines

By Pat Anson, Editor

Less than three months after their adoption in the United States, the CDC’s opioid prescribing guidelines are now being implemented in Canada.

The College of Physicians and Surgeons of British Columbia has released new professional standards and guidelines that are closely modeled after the CDC’s guidelines.

One key difference is that while the CDC’s guidelines are “voluntary” and intended only for primary care physicians, British Columbia’s standards of care are legally enforceable for all opioid prescribers because they set a “minimum standard of professional behaviour and ethical conduct.”

“The public health crisis of prescription drug misuse has developed in part due to the prescribing of physicians. The profession has a collective ethical responsibility to mitigate its contribution to the problem of prescription drug misuse, particularly the over-prescribing of opioids, sedatives and stimulants,” the college said.

"Every physician is professionally responsible for the prescription that they provide to a patient."

Like the CDC guidelines, the college discourages the prescribing of opioids for chronic pain, but goes even further by saying they should not be used to treat three specific health conditions: headaches, fibromyalgia and low back pain.

Opioids for acute pain should be limited to three to seven days’ supply, and when prescribed for chronic pain should be limited to only a month’s supply at a time. British Columbia physicians are also warned not to prescribe opioids concurrently with benzodiazepines and other anxiety medication.

Doctors are also cautioned to carefully document their reasons for increasing doses over 50 morphine milligram equivalents (MME) per day and to avoid increasing the dose to over 90 MME per day.

The British Columbia standards are more strict than Canada’s national guidelines, which have not been revised since 2010, “leaving them out of date with current research associated with taking painkillers,” according to The Globe and Mail.

“While Canada’s guidelines for opioid-prescription are expected to be updated in January, the death toll is mounting too quickly to wait,” said the Toronto Star in an editorial urging Ontario’s College of Physicians and Surgeons to adopt guidelines similar to British Columbia’s.

“B.C. has shown the way for other provincial regulatory bodies. Colleges across the country, including Ontario’s, should follow its example and set informed rules now. Injudicious prescriptions have already destroyed the lives of too many Canadians.”

Like the United States, Canada is one of the top opioid prescribing countries in the world and is struggling with an “epidemic” of addiction and overdoses. A growing number of deaths, however, can be attributed to illegal opioids such as fentanyl and heroin, and it remains in doubt whether restricting access to prescription opioids will lessen the problem or only make it worse by forcing legitimate patients to turn to the streets for pain relief.

As Pain News Network has reported, Canadian drug dealers are now selling counterfeit painkillers laced with fentanyl, an opioid that is more potent and dangerous than most pain medications.

The Star sees the problem differently, blaming doctors for Canada's opioid problem.

“It’s hard to believe that a large part of the blame for Canada’s latest drug-addiction crisis lies not with dealers, but with doctors. That is the conclusion of a growing number of health experts across the country who say our ballooning opioid problem can’t be solved until physicians stem the flow of prescriptions for the highly addictive painkillers,” the newspaper said in its editorial.