Pubdate: Sat, 31 Dec 2016
Source: Vancouver Sun (CN BC)
Copyright: 2016 Postmedia Network Inc.
Contact:  http://www.canada.com/vancouversun/
Details: http://www.mapinc.org/media/477
Authors: Michael Krausz, Kerry Jang and William MacEwan
Page: F5

OVERDOSE RESPONSE KEY

Learning from Europe, Vancouver's past is critical write Michael
Krausz, Kerry Jang and William MacEwan.

British Columbia is gripped in an overdose crisis never before seen in
our history. The number of known overdose deaths across the province
has now reached at least 755, with 128 in November alone.

The synthetic opiate fentanyl, which has contaminated the street drug
supply, appears to be responsible for the overdoses. Now carfentanil -
a more potent form of fentanyl that can kill a person with a dose no
larger than a grain of sugar - is being detected in the province.

This is not our first crisis: In the 1980s, the Downtown Eastside
experienced a surge in overdoses caused by the arrival of a highly
potent form of heroin. We are not alone: In the 1990s, cities such as
Zurich, Amsterdam and Hamburg experienced a series of overdose crises
that were no different from what we are experiencing across our
province today.

What is different is how B.C. and European cities have dealt with
their crises. In Europe, they became a major turning point in the
overall approach to drug treatment and addiction medicine. In
contrast, our approach has been entirely reactionary, with a response
plan that focuses on the symptoms of addiction as opposed to the
causes or a cure.

A case in point is how we are dealing with the fentanyl crisis today.
The primary response largely focuses on the widespread distribution of
naloxone and its administration to anyone experiencing an overdose.
Naloxone works by "knocking off" the opiates from the receptors in the
body's central nervous system that control basic functions like breathing.

However, a little mentioned side-effect of naloxone is that after a
person is revived, it precipitates painful withdrawal symptoms
including anxiety, restlessness, agitation, cramping, nausea,
vomiting, rapid heartbeat, muscle aches and hot and cold sweating. The
more naloxone is required to revive a person, the greater these
withdrawal symptoms. As a result, addicts who have been revived with
doses of lifesaving naloxone immediately begin searching for their
next hit to stave off these very painful withdrawal symptoms, starting
the overdose and revival cycle over again.

This revolving door is playing havoc with hospitals and first
responders. Emergency room beds are being tied up so other medical
emergencies have to be diverted or wait, while ambulance and fire and
rescue service shifts are so taken up with overdose calls that staff
are hard-pressed to respond to calls for other medical conditions or
patient transfers.

How did European cities in Germany and Switzerland tackle their
crises? Firstly, they invested significantly in treatment on demand.
This means that as soon as an addict expresses any interest in getting
off street drugs, they are immediately able to enter addiction and
mental health treatment. Currently, it takes eight days to access a
treatment bed in B.C., so the addict never makes it into treatment.

Another form of treatment on demand is to provide clean drugs to
addicts, specifically opiate substitution drugs such as slow-release
morphine, hydromorphone or polamidone that are readily available to
addicts to replace contaminated street drugs. What is killing people
are drugs contaminated with unknown quantities of fentanyl. Providing
a clean alternative will save lives. These substitution drugs can be
therapeutically administered and monitored in supportive housing
units, pharmacies, overdose response centres and clinics. Vancouver
has one such clinic and it is overwhelmed.

However, the approach in B.C. so far has been to go after pill presses
and the importation of fentanyl. While these measures will reduce some
of what is available on the street, it does nothing to stop addicts
from seeking drugs and buying whatever is available, regardless of its
composition.

Another practice that should be adopted is the testing of all drug
seizures by police and the immediate publication of the results on
easily accessible websites. This is the basis for informed decision
making.

Important information on purity and the addition of ingredients like
synthetic opiates and their proportions, including an expert
interpretation of the results and their assessment of the risk and
impacts to a user, should be included.

This testing should be done regularly, not just during times of
crisis, so that all stakeholders - from health officials and patient
advocacy groups to the police and social service agencies - can see
emerging trends and prepare long in advance.

Moreover, all fatal overdose cases need to be examined by a forensic
pathologist/toxicologist to understand the actual factors leading to
fatal outcomes.

An addict's death is rarely caused by a single drug or a single
factor, but multiple causes and factors. Understanding what these are
is central not only for the timely shaping of the immediate response
to mass overdoses, but for health-care reform to deal with addiction
and mental health proactively.

Finally, what is critical is a co-ordinated emergency response group
that should have a command centre, daily meetings, real-time data,
dedicated project support and clear accountabilities. It should
include greater representation from the frontline staff, drug user
advocacy groups and municipalities, as opposed to mostly provincial
bureaucrats, as it is now. Much of the current response has not been
co-ordinated, contributing to its slow and disjointed nature.

Recent announcements by the B.C. and federal governments to increase
the number of supervised injection sites, repeal Stephen Harper's
flawed Bill C-2, and adding a mobile medic unit in the DTES are good
steps and are urgently needed.

But the lack of investment in treatment on demand, drug substitution,
an early-warning monitoring system and a co-ordinated response has
severely limited our ability to address the current overdose crisis
and prevent future ones. The experiences in Europe, and in Vancouver's
past, show us what needs to happen. We just need the political will to
make it happen.

Michael Krausz is a professor of psychiatry, Faculty of Medicine, UBC 
and the UBC-Providence leadership chair for addiction research. Kerry 
Jang is a professor of psychiatry, Faculty of Medicine, UBC and a 
Vancouver city councillor. William MacEwan is a Clinical Professor of 
Psychiatry, Faculty of Medicine, UBC.
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