Pubdate: Sun, 30 Apr 2017
Source: Toronto Star (CN ON)
Copyright: 2017 The Toronto Star
Author: Sandro Contenta
Page: A1


Mark Baratta works with drug users on the front lines of Ontario's
opioid epidemic. But as deaths mount, Baratta's story illustrates how
far society has to go to end the crisis . . . if it so chooses

Like most people who might be called heroes, Mark Baratta shies away
from the label. A lean and purposeful man, Baratta has saved 17
people, each on separate occasions. He chalks it up, with a shrug of
his shoulders, to keeping his head in the presence of death.

"I've always been that sort of person who doesn't panic," he says.

Under normal circumstances, you can imagine Baratta being honoured at
a civic ceremony. Instead, Toronto police want him jailed.

The rub for Baratta is that he's saving lives on the front lines of
the opioid epidemic, an area where public health clashes with the
Criminal Code, and with policies that infuriate outreach workers as

The day of the interview, Baratta sat on a flat rock in the garden of
the Parkdale Community Health Centre, the sun warming his back. His
presence was appreciated, judging by the people who stopped to say
hello and gladly hand over cigarettes. He's one of three "peer
ambassadors" reaching out to drug users in a pilot project recently
launched by the centre. It's a shoestring operation, with Baratta
barely getting $45 a week. But with lives lost daily to the "opioid
crisis," as Canadian health ministers have jointly declared it, the
centre needed Baratta's experience as a self-described "off and on
user for 24 years."

A new study by leading medical researchers found that in 2015, 734
people in Ontario died of opioid-related causes, 80 per cent of which
were accidental, according to data from the Office of the Chief
Coroner. Preliminary figures indicate that 135 of the deaths occurred
in Toronto - an increase from 44 in 2004.

By all accounts, thousands more in Ontario are overdosing and being
saved each year. Experts expect a higher death toll when more recent
data is collected.

Overdose rates in British Columbia, where the epidemic is most severe,
continue to rise despite a public health emergency declared a year
ago. When an epidemic isn't caught early enough, "it needs to run
itself out," says Benedikt Fischer, a senior scientist at the Centre
for Addiction and Mental Health.

In late March, Toronto's Board of Health adopted a drug overdose
action plan that includes sites to inject drugs safely, and greater
support services for people treated with methadone and Suboxone,
opioid substitutes that prevent dangerous withdrawal symptoms. Harm
reduction workers generally applaud the plan while calling for greater
and more stable funding for their programs.

Baratta never overdosed, although he once "went on the nod" while on
heroin and woke up to a pillow set ablaze by his cigarette. Now 43 and
on methadone - a treatment used by 50,000 Ontarians in 2014 - he
remembers his overdose rescues with eerie precision.

"I've brought back 18 people, technically 17, because one of them was
the same person twice," he says. "Eleven of those I know if I wasn't
there, they would be gone. The other seven, someone else was in the
room and might have helped them.

"Of those 18, nine or 10 are all in the last two years, including one
who was twice in four months," he adds. "It is, sadly, becoming a
little routine, and that's what bothers me. It bothers me that it
doesn't bother me more."

In the early years, his rescues were physical and intense: "screaming,
keeping them on their feet, dumping ice on them and slapping them and
being actually quite violent, and forcing them to stay conscious."

More recently, they involved naloxone, an antidote to dangerous doses
of opioids, a class of painkillers that includes fentanyl, morphine,
oxycodone and heroin. Naloxone is so effective at bringing people back
from comas that Toronto's board of health wants the provincial
government to make it available far more widely.

The last time Baratta saved someone with naloxone was April 3, three
days before this interview. Normally, one injection of the antidote is
enough, sometimes reversing the opioid's effect so completely the user
experiences withdrawal, a tortuous combination of vomiting, diarrhea,
stomach cramps, high anxiety and cravings. The last person Baratta
rescued needed three shots.

"He was on his knees with his forehead on the floor. He started to
raise himself up slowly and we said, 'Hey, you were as good as dead a
couple of minutes ago,'" Baratta recalls. "And I couldn't believe it
because after three doses of naloxone, he's still high."

He posted a warning about that batch of heroin at Parkdale's harm
reduction program, in a room where users can pick up clean needles.

Baratta and other outreach workers are convinced that illicit street
drugs laced with fentanyl, an opioid that can be 100 times more potent
than morphine, is a major reason the death toll has

Fentanyl has become the drug most commonly involved in opioid-related
deaths in Ontario, but data on the impact of illicit drugs is
non-existent. In B.C., more than 900 people died from an overdose of
illicit drugs in 2016, an almost 80-per-cent increase from 2015.
Fentanyl was responsible for much of the increase.

Fentanyl is cheap and easy to produce illegally. That has made it the
adulterant of choice during the past two years, showing up in street
batches of cocaine, oxycodone, ecstasy and heroin.

"People don't die on fentanyl when they know they're doing fentanyl,"
Baratta says. "The problem is when they're told something is heroin
and it has fentanyl in it. So they do their normal heroin dose and
they die."

The danger is increased by a growing number of inexperienced dealers
entering the illegal market and assuming heroin with an extra kick
will keep customers coming back for more. "Except they don't because
they die," Baratta says.

Baratta steers users to treatment programs if they express the desire.
But the realities of his world are sledgehammer hard, and he's not
there to judge.

"When a person is an addict," he says, "they don't want you to do them
the favour of helping them abstain. They want you to do them the
favour of helping them get dope so they can get well, because they're
in hell while they're in withdrawal."

In January, he got a call from someone claiming to be an acquaintance
in desperate need of a hit. Baratta says he turned to a friend he
thought might have a safe supply of heroin, and delivered it himself
when his friend wouldn't. He walked right into a police sting.

He is charged with trafficking heroin and with possession of property
obtained by crime. The property obtained, according to court
documents, is the $250 police used to buy the heroin.

"It's an absolute travesty," says Natalie Kallio, head of the harm
reduction program running Baratta's pilot project, referring to his

"They went through all that effort to catch someone who was trying to
help a friend who was sick," she says of police. "It's crazy. They
want to take off the streets someone who is saving lives every day."

Baratta's lawyer, Ari Goldkind, asks: "Was he entrapped into doing
something he otherwise would never have done, or was he set up?"

Goldkind says he's not calling on police to turn their backs on heroin
dealers, but he expects the Crown attorney to consider Baratta's
community work before proceeding with the case.

Kallio blames Prohibition-era morality around drug use for what she
describes as timid political reaction to the opioid epidemic. She
supports the decriminalization of all drugs for personal use, a call
echoed by many workers in Toronto's harm reduction programs, which in
2016 issued 2.1 million needles and other sterile injection supplies
to clients that made 139,000 visits.

"People are using drugs; they always have and always will. When you're
scared of being thrown in jail for what you need to do, everything
becomes less safe," Kallio says, referring to the dangers of illicit
drug markets.

Toronto Public Health, which reports to the board of health and is
mandated with improving the health of Toronto residents, touted the
advantages of decriminalization in a 52-page report that outlines
Toronto's overdose action plan, which the board adopted in late March.

The report notes that in 2001, Portugal legalized the possession of up
to 10 days' worth of all drugs for personal use while increasing
investment in health services. Police focus on grabbing big drug
traffickers and refer people with personal amounts allowed by the law
to a commission that gauges interest in treatment. Studies have since
noted significant decreases in the number of people who inject drugs,
in overdoses and in HIV infections.

"The harms associated with the criminalization of drugs are well
documented, and include high rates of incarceration for nonviolent
drug offences," the public health report says.

"The lack of support and compassion for people is perhaps the greatest
harm of our current approach to drugs," it adds. "People face profound
stigma and discrimination, from society as a whole and from family and
friends. This stigma is entrenched in our culture. There is no other
group of people who are treated so poorly because of a health issue.

"Further, until such time as our drug laws are changed, more must be
done for people who come into conflict with the law because of their
substance use. People need support not punishment."

And yet, Toronto Public Health stopped short of calling for
decriminalization as part of its overdose plan.

"There is a lot of stigma still out there and I don't think as a
society we're ready to move towards that yet," says Dr. Rita Shahin,
an associate medical officer of health at the municipal agency.

Toronto Public Health's plan relies mostly on action from the federal
and provincial governments. The city now provides $1.4 million a year
for harm reduction programs and city council will be asked for a
$374,000 increase only if the province refuses to hand over that amount.

The federal government has yet to approve key aspects of the plan,
including the opening of three sites where users can inject illegal
drugs in the presence of medical staff ready to intervene in case of
overdose, the testing of street drugs before use, and giving drug
users access to prescription heroin.

The only place in Canada where users can get prescription heroin is at
a site in Vancouver.

"Prescription heroin should be available everywhere," says Craig
Stephen, with the Toronto Harm Reduction Alliance.

"We know people are dying from contaminants or unknown quantities (of
fentanyl), so why not make available an alternative that is safe?"

For its part, the provincial ministry of health has said it is willing
to fund the three safe injection sites, but has yet to announce how
much of the $3.5 million requested it will provide.

"The response is slow and the need is urgent," says Sarah Greig, who
heads a harm reduction program in Etobicoke.

"My guys are dying on the streets or in their apartments and people
don't care."

She notes that harm reduction programs operate on shoestring budgets
that are usually pieced together with short-term grants from different
governments to prevent HIV or hepatitis C.

"Every frontline harm reduction worker I know is facing burnout," she
says. "People aren't paid well, there is a lack of resources, and a
lot of people, including peer workers, don't know if they'll have a
job one year to the next."

The previous Conservative government, under prime minister Stephen
Harper, spent years trying to shut down a supervised injection site in
Vancouver. Harper also passed the Respect for Communities Act,
requiring 26 criteria to be met, including consultations with police
and local community groups, before any other site could open.

Last December, the Liberal government introduced C-37, a bill that
makes it easier to open drug injection sites. In February, it approved
three sites in Montreal. C-37 also makes it harder to import bootleg
fentanyl into Canada, partly by allowing customs agents to open
couriered or mailed packages of less than 30 grams.

Mike McCormack, president of the Toronto Police Association, has
called injection sites "a Band-Aid solution," and warned of increased
crime in neighbourhoods that host them, including "break and enter,
shoplifting, theft from auto, fraud, prostitution, panhandling (and)
selling of stolen property."

The Centre for Addiction and Mental Health has long argued that people
dependent on drugs should not be criminalized for possessing drugs for
personal use. "That should be considered and be dealt with, first and
foremost, as a health issue," says Benedikt Fischer at CAMH.

Fischer also backs safe injection sites and access to prescription
heroin as part of a comprehensive public health response to the opioid
crisis. But while those policies would help users of street heroin, he
says they won't help the larger number of opioid addicts who never buy
street drugs.

"The main problem is prescription opioids. For many, many years, the
medical system overprescribed them," says Fischer, who calls for more
refined, long-term programs to treat dependency.

In 2007, the makers of OxyContin, Purdue Pharma, pleaded guilty to
criminal charges of "misbranding" the painkiller as less addictive and
less subject to abuse than other opioids. It agreed to pay a $600
million fine.

Particularly at risk are people who suffer what are commonly called
the "social determinants of health," including poverty, homelessness
and unemployment. The emotional and physical pain this group numbs
with opioids runs deep.

The new overdose study, by researchers at the Ontario Institute for
Clinical Evaluative Sciences, St. Michael's Hospital and the Ontario
Drug Policy Research Network, found that 51 per cent of Ontario
residents who died of opioid overdoses in 2015 lived in low-income

Twenty-six per cent lived in high-income ones.

The study, funded by Ontario's health ministry, also noted a spike in
heroin-related deaths and called for more research to determine
whether policies restricting access to prescription opioids had the
unintended consequence of steering people to the dangerous illicit

In 2012, the health ministry acted to reduce opioid dependency by
removing OxyContin from the Ontario Drug Benefit program, and did the
same in 2016 with fentanyl patches of 75 and 100 micrograms. Harm
reduction workers say the delisting had the unintended consequence of
pushing low-income people dependent on those opioids, and without
private insurance plans, to turn to street supplies.

Along with the death toll, another 600 people ended up in Toronto
hospital emergency departments due to opioid poisoning in 2015. It's
about the same number that visited in the first nine months of 2016.
At St. Michael's hospital, five to 10 overdose victims arrive each
week, says Glen Bandiera, chief of emergency medicine.

Hundreds more are overdosing in Toronto each year without ever being
taken to hospital, according to harm reduction workers.

Mark Baratta notes that drug users are reluctant to call 911 when
someone they're with overdoses, fearing police will show up and lay
charges. He knows of overdose victims dragged out of apartments and
onto the street before 911 was anonymously called. Toronto's overdose
plan calls for swift passage of the federal Good Samaritan Drug
Overdose Act, a private member's bill that would prevent people who
call 911 from being charged with drug possession.

What's clear is that the number of people suffering multiple overdoses
is shockingly high. They're easily found, for instance, during drop-in
hours at Sarah Greig's harm reduction program in Etobicoke.

One of them asked the Star to use only his middle name, Robert,
although his friends know him best as Juice.

He overdosed eight times in the past year.

"My psychiatrist says, 'You won't make it to your 55th birthday," says
Robert, who has a few months to go before that milestone. "I don't
know; I get stupid. I just want to get high and forget my troubles."

Robert is tall, with long brown hair and a clean-shaven face that
looks stern and confident. He's not proud of being hooked on fentanyl,
but he won't easily give up his dignity, either.

"I'm tired of the judging and the crap like that, because I'm not a
bad guy," he says.

He's been with the same woman for decades. They have a son and two
grandchildren. He used drugs on and off for years, and worked at a
tile-making factory until losing his job in 2013, the year he started
on fentanyl. He and his wife spent the next three years homeless.

He was prescribed fentanyl for a bad knee and quickly developed a
dependency. His prescription is for 10 fentanyl patches a month. The
first day he met the Star he was high on both crystal methamphetamine,
a stimulant, and fentanyl, a depressant. He was a controlled bundle of

Robert lifted his left sleeve and revealed half of a 50-microgram
fentanyl patch glued to his arm, the prescribed way a full patch
should be used. The other half got the street treatment: he had placed
it in a spoon, released the opioid by "cooking it" and then injected
it, the route to a more powerful and immediate high.

He then lifted his right sleeve to reveal a string of needle marks
running along the exterior of his forearm, from his wrist to his elbow.

Recently, Robert's doctor found crystal meth in his urine and had him
sign a contract swearing off the stimulant, or risk losing his
fentanyl prescription. So Robert now buys clean urine from street
contacts, at $25 a cup.

Also causing him difficulties is the medical policy around fentanyl
patches: to renew his prescription of 10 he has to return 10 used
patches. If he shares three with friends, or they get stolen, he'll
only get seven when he renews. To make up the difference he buys off
the street, either fentanyl or heroin.

That's how he overdosed the last time on heroin, and it took two
naloxone shots to revive him.

"I'm tired of doing this," he says. "I don't know what's keeping me
going. My family is like, Robert, what are you doing? My cousins are
like, Robert, you're a loser. I've heard it all, and they're right.
What have I done? I haven't done s---. You try to regroup, you hear
your grandson's voice. . . ."

"We need a little more compassion, a little more sensitivity, and not
so much judging. I'm not going to be a poster boy, but walk a mile in
my shoes, man."
- ---
MAP posted-by: Matt