Pubdate: Sun, 03 Sep 2017
Source: Edmonton Sun (CN AB)
Copyright: 2017 Canoe Limited Partnership.
Author: Meghan Potkins
Pages: 12-13


Chief medical examiner's office pores over deaths in opioid fight

EDMONTON - In the Office of the Chief Medical Examiner each morning,
medical examiners, investigators, and morgue staff divide the stack of
files containing unexplained deaths that have come in from the night

Five years ago, this department, headquartered in a low-slung grey
building in Edmonton, investigated between 1,900 to 2,000 cases a year.

But in the last couple of years the caseload has jumped to between
2,500 to 2,600 annually - the bulk of that increase, officials say, is
due to fentanyl and other opioid deaths.

"We're dealing with a large number of cases (and) it's through all the
units of our office that the workload has increased and there is a
stress and pressure there," says Dr. Elizabeth Brooks-Lim, the
province's chief medical examiner.

As early as 2011, the OCME'S laboratory began to notice a curious
increase in the number of deaths where fentanyl was found in
significant amounts in the blood.

Before, fentanyl would occasionally turn up, but in ways that
investigators could account for: victims of car crashes who had been
administered the drug in an emergency setting; or among elderly
patients using transdermal patches to manage the pain of advanced
forms of cancer.

"The fentanyl (we) were seeing in the lab back then - it was present
in the bloodstream but it didn't kill them, it just happened to be in
the background," Brooks-Lim recalls.

"Then all of a sudden, you get a 20-something-year-old in their
basement who is dead - who suddenly has a spike of fentanyl with no
reason for it to be there."

At the same time, OCME investigators and police were seizing large
amounts of emerald green pills that looked very similar to authentic
80 mg Oxycontin tablets. But in the laboratory, testing showed the
pills did not contain oxycodone as would have been expected, but the
vastly more potent opioid fentanyl.

"We started to measure the concentrations in those pills and they were
significant," says Dr. Graham Jones, the province's chief

"We were seeing fentanyl, we were seeing young people dead who were
probably abusing it, but what we were not able to judge at that time
was the scale of the problem."

Counting the dead

Between 2011 and 2015, fentanyl-related deaths in Alberta more than
doubled each year.

By the summer of 2016, when Brooks-Lim had stepped into the role of
acting chief medical examiner, the crisis was in full swing and staff
at the OCME were in constant communication with Alberta Health to
provide frequent updates on the number of opioid deaths.

Almost as soon as she took the helm, Brooks-Lim recalls a blur of late
nights spent going over "reams and reams" of data on deaths.

"I just remember nights and nights of going through charts and tables
and reading these stories: 20-something-year-old person found in a
hotel, 30-something-year-old person found in a basement,
20-something-year-old person had a party the night before," Brooks-Lim

"So it was almost like an overload of story after story after story,
and then checking them up against the list of toxicology results and
trying to just see the pattern and trend."

The work was overwhelming at a time when the OCME had enough on its
plate with its regular case work. The Jordan decision, a Supreme Court
of Canada ruling that targeted unreasonable court delays, sent
shockwaves through the judicial system by limiting the amount of time
an accused can await the start of their trial - putting additional
pressure on the OCME to move quickly to conclude death

The province sent an analyst with Alberta Health to the OCME just to
assist in correlating the data on the opioid deaths. And last May,
along with the creation of the Minister's Opioid Emergency Response
Commission, a second analyst was dedicated to the effort.

They wanted to learn as much as possible about the people that were
dying from fentanyl, in hopes of figuring out ways to intervene in the
lives of those who might be careering down the path towards overdose.

What the dead can tell us

Slowly, a picture is emerging from the data that points to important
differences among the people who are dying from opioid overdoses.

"The fentanyl-related overdoses tend to be more related to illicit
drug use and illegal products, whereas the non-fentanyl could be more
related to prescription drugs that are being taken," says Dr. Kristin
Klein, deputy chief medical officer of health for the province.

"What we've consistently seen in our reports is that young males, or
young adult males, are dying (from fentanyl) at a higher rate than
other age groups and genders."

Alberta Health has also been mapping the deaths from

The ministry has also noted a concerning pattern in the ratio of
deaths to the number of calls made to EMS for overdose in different
parts of major cities.

"We're seeing a lot more EMS responses for overdoses in the more
centralized neighbourhoods compared to the more suburban areas," Klein

"That's concerning to the ministry because we don't know why these
people are not being seen by EMS - if they're just using alone and so
no one is there to call for an ambulance, or if they are hesitant to
call for help in those areas."

But the most staggering data is still the number of overall deaths:
more than 1,000 Albertans dead from fentanyl since 201 and hundreds
more from opioids other than fentanyl.

Finding carfentanil

For the medical examiners, compounding the difficulty in the sheer
volume of deaths is the complexity of the opioid cases.

Overdose deaths involving fentanyl often involve more than one
fentanyl analogue and such other illicit drugs as heroin, cocaine and
methamphetamines; blood tests often find anti-depressants, anxiety
medications and sleeping pills in the mix as well.

Determining exactly what drugs contributed to someone's death from the
cocktail of narcotics found in the blood can be difficult.

"These are more complex, more challenging cases," Jones says. "We've
got sheer numbers that have increased, plus the complexity has increased."

And staying ahead of illicit drug manufacturers who are synthesizing
fentanyl analogues at a remarkable pace is nearly impossible.
Toxicologists at the OCME keep in touch with law enforcement to find
out what drugs are being seized at the border and from clandestine

In the fall of 2016, one drug the OCME was bracing for was
carfentanil. An opioid 100 times more potent than fentanyl, developed
by the Janssen laboratory in the '70s, it was found to be too potent
for humans and so it was marketed for use in large animal veterinary

Staff at the OCME knew it had been found in drug seizures by police,
but it still came as a surprise when they found traces of carfentanil
in drug paraphernalia seized in a death investigation.

"It was still almost disbelief that somebody was actually taking this
stuff," says OCME toxicologist Dr. Russell Handy, recalling the
discovery last fall.

Then in October, Handy and his colleagues were the first in Canada,
and possibly North America, to develop a test that could reliably
detect carfentanil in a routine blood screen - a huge accomplishment
given how minute the amounts are found in the blood.

The deaths of two men in their 30s, one from Calgary and one from
Edmonton, quickly returned tests positive for carfentanil.

Subsequent testing has linked carfentanil to 82 deaths in Alberta
since 2016.

"After that, nothing really surprises me anymore," Handy

"There are so many different fentanyls out there with varying degrees
of potency. I don't know if people necessarily know that they're
getting carfentanil. It really comes down to whether or not (the) drug
dealers are mixing this stuff in low enough concentrations."

Fentanyl not letting up

Frustrating authorities is the fact that the steps taken so far to
curb the crisis seem to have done little to reduce the number of drug

Fentanyl deaths escalated rapidly in Alberta in recent years, with the
number of fatalities reaching an average of around 120 deaths per
quarter since late 2016, and officials say the numbers aren't declining.

"What's discouraging is the backbone of the current opioid crisis is
still fentanyl," Jones says.

"We're seeing a number of carfentanil cases, we occasionally see other
fentanyl analogues, but there's no real indication that the absolute
number of fentanyl-related deaths is going down."

Families and frontline healthcare workers who spoke to Postmedia say
public health authorities will have to go beyond education campaigns
and hand out naloxone kits to stem the tide of deaths.

"As a physician and even as a human being, I'm disappointed, I'm sad,"
says Dr. Mark Yarema, medical director of the province's poison and
drug information service.

"It also highlights just how prevalent the disease of addiction is and
how if somebody is intent on using these drugs, that simply telling
them to stop and telling them to abstain is going to fall on deaf ears."

Criticism of health authorities for responding too slowly and calls
for more harm reduction measures, treatment services and changes to
drug policies are mounting.

Alberta addictions specialist Dr. Hakique Virani says Alberta's opioid
crisis is "completely out of hand."

"It's frustrating that the drug trade is more creative, nimble, and
quick to respond to demand than public health is."
- ---
MAP posted-by: Matt