The rapid rate of deaths caused by the opioid drug carfentanil has coroners speaking out in an urgent attempt to stop the harm.
Carfentanil is a veterinary medication meant for very large animals, such as elephants – not humans. Though it’s another form, or analogue, of the painkiller fentanyl, carfentanil is 100 times more potent.
“At the current rate of this crisis, everyone in Ontario is going to know someone who’s died of opioid drug toxicity in the near future, if not already,” Dr. Paul Dungey, Ontario’s regional supervising coroner.
“Unfortunately I think it’s going to take that to make people realize how serious this is,” said Dungey. He oversees the eastern region bordered by Peterborough, Haliburton, Prince Edward County and Kingston.
Starting in January 2019, he said, the number of opioid-related deaths in Ontario spiked sharply, with 142 deaths caused by carfentanil between January and April compared to 95 in all of 2018.
“It was like somebody flipped a switch,” Dungey said.
“Whoever’s controlling the illicit drug trade made a conscious decision that, ‘OK, we’re switching to carfentanil,’” he said, calling the change “staggering.”
While the increasing use of fentanyl sparked similar concern, authorities are now even more worried about carfentanil.
Dungey’s rough tally of deaths related to fentanyl analogues found there were 69 confirmed cases in 2018 and 45 to date this year.
And since February, he continued, 11 of the last 13 toxicological tests made during coroners’ investigations in the eastern region detected the presence of carfentanil.
Dungey is also mindful of the discrimination toward people who die of opioid toxicity. He uses the term “toxicity” instead of “overdose.” He also does not refer to people as “addicts,” saying such terms are prejudicial.
“It’s a chronic illness: substance use disorder,” Dungey said.
“Every person who dies of accidental drug toxicity was someone’s family member and their tragic death should be remembered in that context.”
He and Dr. Jessica Ladouceur, a Belleville family doctor since 2015 and coroner since 2017, were
adamant the victims are often not who many might expect.
“They’re moms with kids. they’re people who have jobs. They’re from all walks of life,” Ladouceur said.
“It really does affect everyone.”
A 2018 report by the Canadian Institute for Health Information found Belleville’s rate of hospitalization due to opioid poisoning between 2013 and 2018 was the sixth-highest in Canada.
Need for education
Ladouceur also investigates deaths in Quinte West, Prince Edward County and the western Napanee area.
She said she’s seen the lack of opioid awareness and the need for more public education.
“Any time I get called and it’s a young person, it’s typically related to opioids,” Ladouceur said. Their ages make their cases “the most challenging” she sees.
“I think they take the most emotional toll on me because they’re so preventable and it’s such a loss.
“These are people who had their whole lives ahead of them to contribute to society and now that’s been cut short.”
She said the victims’ “devastated” families are sometimes left with many questions.
“They don’t know why their loved one has passed away. When I tell them this is an opioid-related death, they say, ‘Why isn’t this on the news? Why aren’t people more aware of this?’
“I think the public wants to know.”
Ladouceur said carfentanil is “often mixed in with other drugs so there’s a very good chance that people are thinking they’re buying something else” and not realizing it contains more potent drugs.
In the last few months she’s investigated two confirmed carfentanil-related deaths; she’s waiting on laboratory test results in other cases. Local police have also charged people in connection with opioid-related deaths.
“There’s no quality control in the illicit drug trade,” Dungey said. As dealers mix opioids with other drugs, he said, they can’t control the concentration. One hit may kill; the next may not.
Dr. William Bates was a Belleville-area corner from 1968 until 2017. He said opioid-related deaths “hastened my retirement” by causing an “overload” of investigations, mostly in the Quinte West area.
“I had 16 of those cases in one month,” he said, referring to October 2016.
“They were all younger people who were sudden unexpected deaths,” including suicides.
In general, he said, “Financial problems and substance abuse go hand-in-hand with sudden unexpected death.”
Bates said the expectation that people with substance abuse disorder will simply stop is “sort of like a police officer standing on the road” expecting impaired drivers to stop at checkpoints. Neither may be able to stop, he said.
When someone becomes addicted to a substance, he said, using it “becomes an automatic process” caused by the body’s dependency, not a choice.
Dungey compared it to the effects of alcohol.
“Some of us can have one or two drinks. Some of us, it ruins your life.”
Linked to prescriptions
“Upwards of 80 per cent of people who have an opioid addiction started off with an opioid prescription,” Dungey said.
He said those workers may have had legal prescriptions for painkillers, perhaps due to back pain.
But when prescriptions can’t be refilled, some people turn to street drugs.
“When I started practising, physicians were fairly stingy with opioids,” said Dungey, who began practising about 30 years ago.
Then, following pressure from major pharmaceutical companies and “questionably-produced studies and evidence,” he said, doctors prescribed opioids much more frequently.
“No one was allowed to have pain.”
The profession has since reversed course, with campaigns urging doctors to stop prescribing opioids to some patients and reduce other patients’ use.
“We’re not trying to punish people. We’re trying to save their lives,” said Dungey.
“We have to have a multi-pronged, multi-faceted approach” to solving a problem which has developed over decades, he said.
Dungey would not comment directly on public policy but said there is a need for a “properly-funded harm-reduction strategy accessible to everyone across the province.”
Kingston, for example, has a street-health clinic providing services which aren’t available in Belleville, he said.
He said harm reduction includes rehabilitation but may also include safe injection sites, substitution therapy using the drugs suboxone and methadone, improving access to services and ensuring clinics are funded appropriately.
Though the threat of carfentanil is growing, Ladouceur said she’s seeing signs of hope in the medical field. Suboxone is now being prescribed in hospital emergency rooms, she said.
“We have lots of physicians that have taken an interest in addiction medicine and are providing services.”
Health units, too, are increasing their awareness campaigns and free distribution of naloxone, a temporary antidote for opioid toxicity. It’s also available for free in many pharmacies.
Ontario Provincial Police have begun their own campaign.
Jury cites urgency
Last year’s inquest into the 2015 Toronto death of Bradley John Chapman ended with the jury recommending 55 steps for governments of Ontario and Toronto plus police, nurses and others to address the opioid crisis.
Chapman, 43, died of accidental acute opiate toxicity.
“All recipients of these recommendations should recognize the urgent nature of the opioid overdose crisis and should consider and implement recommendations with the utmost urgency,” reads the jury’s verdict.
Jurors ruled Ontario should assign a provincial coordinator from the health ministry to respond to the crisis. They recommended the government “develop a comprehensive provincial strategy” which “addresses the social determinants of health” and “takes a non-discriminatory approach to drug overdose prevention and harm reduction.”
The jury also recommended anti-discrimination training for all professional organizations, including the Ontario Medical Association, Registered Nurses’ Association of Ontario and the Toronto Police Service, with regard to people who use drugs and those who are homeless.
Ontario’s Office of the Chief Coroner requested Ontario respond to the jury’s recommendations to the government by Sept. 7. A spokesperson for the chief coroner’s office said government officials have acknowledged receipt of the verdict. Government letters indicate the ministries of health and of community safety and correctional services are to study the jury’s recommendations.
Jury calls for action
The following are excerpts from the Ontario Opioid Mortality Surveillance Report, June 2019.
Some have been condensed for brevity.
Between July 2017 and June 2018, there were 1,337 confirmed opioid-related deaths in Ontario. Investigations revealed:
• The majority of opioid-related deaths were accidental (90.4%), occurred among males (72.0%) and most often occurred among individuals between the ages of 25 and 44 (50.2%).
• Among suicide deaths, nearly half (47.5%) occurred among females and more often occurred among individuals aged 45 to 64 (55.6%).
• Among accidental opioid-related deaths (N=1,209):
• Fentanyl and fentanyl analogues directly contributed to death for almost three-quarters (71.2%).
• The non-opioid substances that most often directly contributed to death were cocaine (33.9%), methamphetamine (14.6%), alcohol (13.2%) and benzodiazepines (11.0%).
• Almost one-third (31.8%) of deaths occurred among people who resided in neighbourhoods with the highest material deprivation (measure of inability to attain basic resources and services).
• Sixty-two per cent of deaths occurred among individuals who resided in large urban population centres.
• Nearly half (46.8%) occurred among people who were unemployed. Where employment industry information was available, nearly one-third (31%) of those employed worked in the construction industry.
• Nearly 74 per cent occurred among people living in a private dwelling and 9.8% occurred among people experiencing homelessness; 59.6% occurred in a deceased person’s own private residence.
• Nearly half (48.6%) of deceased persons were alone at the time of incident.
• Almost 48 per cent involved a resuscitation attempt and 22.2% had naloxone administered by a first responder, hospital staff or bystander.