Overdose

by Benjamin Perrin

  Adkin was in cardiac arrest and having seizures. He was taken to the Intensive Care Unit, but never regained consciousness. He died at 3:00 a.m. on September 28.

  “A friend reported that Mr. Adkin purchased what he thought was cocaine from a dealer who delivered it to the hotel,” wrote Jacqueline Couch, the coroner who investigated Adkin’s death. “Each of the friends used the drugs from the same delivery.” Adkin was an occasional user of cocaine and cannabis. The post-mortem toxicology exam found cocaine, a heavy level of alcohol intoxication, and fentanyl. Ms. Couch determined Adkin’s death to be caused by anoxic brain injury (lack of oxygen to the brain) due to cardiac arrest caused by mixed alcohol and drug toxicity (cocaine and fentanyl).

  All of Adkin’s four friends who overdosed that night survived. Fentanyl poses a particularly significant risk to recreational or occasional illicit drug users, like Adkin, who often don’t know that the drugs they’ve purchased contain illicit fentanyl—a substance that their body hasn’t developed any tolerance to process.

  “Rarely did you see Paul without a smile, or rather a grin, on his face,” shared his family. “He was extremely loyal and had a host of close, close friends who will miss him deeply—but will never forget him.”

  * * *

  ——

  Vancouver’s Downtown Community Court is located in the heart of the Downtown Eastside, often called the country’s poorest postal code. As I arrived at the courthouse at 7:45 a.m., just across the street someone was sleeping outside in the rain under a makeshift shelter. Old tents, tarps, and cardboard boxes. That’s what passes as a home in one of the wealthiest countries on earth.

  The innovative court was designed to help the criminal justice system recognize that there are underlying health and social issues, including alcoholism and drug addiction, that contribute to offending. It has social workers, mental health workers, and other professionals on site—but it’s still a criminal court.

  “I have seen, with my own eyes, people in the back alleys in this neighbourhood drawing water into their syringe from a puddle in the lane and injecting it,” said Judge Elisabeth Burgess. Using filthy water to dilute powdered drugs so that they can be injected exposes people to risks of disease and infection.

  It was clear to me that Judge Burgess has tried to see the world through the perspective of those she judges. When I met with her in a small boardroom before her morning court session began, I asked about her experience with the opioid crisis and the people who end up in her courtroom facing criminal charges.

  “I’ve got a few regulars here—all of them happen to be First Nations—who witnessed their father murdering their mother as small children,” said Judge Burgess. “A couple of them actually were so small that they were left with the body for days before anybody discovered it. And, yeah, they’re addicts now.”

  It was a horrific story that transformed the image in my mind of a chronic adult offender, driven by drug addiction to commit petty crimes, into the image of a frightened young child.

  Traumatized. Alone. Terrified.

  “It’s not just that you’re necessarily an addict if you had some horrible tragedy in your life. They’ve got no support,” said Judge Burgess. “They’ve never been diagnosed. They’re severely mentally ill. Never seen a doctor. That happens in this city.

  “It’s a miracle what some of them have been through, but there’s that old cliché, and it strikes me every day: the biggest lottery in life is the family you’re born into. It’s nothing to your credit. You’re not better.”

  I wanted to know more about what role childhood trauma can have on substance use as an adult, and several experts pointed me to the Adverse Childhood Experience (ACE) questionnaire. It asks just 10 yes/no questions about your childhood, but it can tell you a lot about your risk of experiencing a host of challenges later in life. There are questions about physical, emotional, and sexual abuse as well as neglect, parental divorce or separation, incarceration of a parent, and exposure to domestic violence, substance abuse, and mental illness. Each of the 10 questions to which you answer yes counts as a point. These points add up to your ACE score (which ranges from 0 to 10).

  Traumatic events and experiences in childhood can lead to social, emotional, and cognitive impairment, which can in turn lead to high-risk behaviours that increase the risk of health problems and premature death. And these harmful childhood experiences can have cumulative effects. For each ACE point, a person’s risk goes up for a range of challenges, including poor academic achievement, poor work performance, mental health issues, certain diseases, suicide attempts, and illicit drug use and substance abuse.

  A massive study published in the journal Pediatrics found that people with an ACE score of 5 or greater (those who’d experienced at least half of the childhood trauma asked about) were seven to ten times more likely to have an illicit drug use problem than someone who had an ACE score of 0. Each ACE point represents a two- to fourfold increase in the likelihood of early use of illicit drugs.

  Many people in our society are living with deep pain and unresolved trauma. They need our compassion, not our condemnation. Yet condemnation is precisely how people who use illicit drugs are treated. As social outcasts. We insist that they accept “personal responsibility” while we ignore our own moral responsibility to help them. More than anything, they’re blamed. Blamed for the “bad decisions” or “poor choices” they’ve made, with no understanding or empathy for how they came to arrive at that place in their lives. They’re even blamed for dying.

  “People think, ‘If you’re gonna do drugs, you’re asking for it,’ ” said Shelda Kastor. “ ‘If you’re gonna do drugs, tough on you if something happens,’ you know what I mean?”

  The image of those young children being left alone with their murdered mother for days is etched in my mind. And it speaks of an even longer-term intergenerational trauma that contributed to such a horrific event.

  “Their life hasn’t worked well. They’ve had, typically, some blunt-force trauma early in their life and that blunt-force trauma while they’re a kid is physical abuse, sexual abuse, verbal abuse,” said Bill Mollard, president of Union Gospel Mission (UGM). His organization runs a network of hot meal programs, shelters, and substance use programs in and around downtown Vancouver. “The drugs, at that point, aren’t about partying. They aren’t about having a good time. It’s about anaesthesia. They use these drugs to mitigate those emotional stresses they have.”

  Mollard was making a powerful point that’s been lost in the public perception of illicit drug use. Synthetic opioids like fentanyl were created to help people endure immense pain as they lay in bed dying. They were intended to numb and block out pain to make life bearable—and that’s how people are using them today in the illicit market, too. In other words, absent a properly functioning mental health system and support services, many are self-medicating the pain in their lives.

  “Most of the people that I’ve dealt with in my career have been street entrenched drug users,” said Conor King, staff sergeant with the Victoria Police Department. “Almost all of them will tell you a story of things like abuse as kids, disconnection with parents, poverty, trauma in childhood, trauma in adolescence—whether that’s domestic violence, sexual abuse, injury or illness when they were in the workforce as a young man or young woman. Despair.”

  That’s where opioids can come into the picture.

  “It’s got a reputation as something that feels good to take,” said Vancouver Fire Chief Darrell Reid in describing fentanyl. “Our patients call it a ‘warm hug.’ ”

  Opioids are powerful painkillers. And, unfortunately, there are many, many people with tremendous pain and trauma in our society. We see them now as grown adults, but when we step back and see them as people with lives that are often full of traumatic and painful experiences, holding on to memories that have been unaddressed, and with untreated mental heal
th challenges, we can start to realize that they need our love and compassion.

  “There’s always this gaping hole in their history that just was not filled by a supportive network—and when later on in life, whether it was as a teenager or as a young adult, they were looking in some way to deal with their trauma, drugs were the answer,” said King.

  “The intervention that you need for early childhood experience is proper trauma counselling,” explained Linda Lupini. “It’s not even just ‘Mom and Dad think we should all go to see a family counsellor,’ because that’s happening. It’s really good trauma counselling, and that will help mitigate the high risk you’re at for addiction.”

  * * *

  ——

  What are other factors that help us understand why people use illicit drugs?

  “We look at early drug use, peer influence, trauma, genetics, psychosocial, and mental health concurrent disorders,” said Dr. Ronald Joe. “So we can’t say that there’s a single causative factor. It really depends on each individual person’s resilience to trauma and other influences.”

  I noticed that something was missing from Dr. Joe’s list of what causes people to use illicit opioids. Aren’t the substances themselves highly addictive? That’s always how I’d heard them talked about: the warning to not try them even once or you’ll get hooked.

  “The vast majority of individuals who take opioids don’t have any problems,” said Dr. Joe. “The typical person would go for surgery and take some morphine for pain, acute pain, and then we’re finding that they don’t need to take it anymore.”

  I had a flashback to when I was in hospital for almost a week as a McGill grad student. I had excruciating abdominal pain. They ruled out appendicitis, but test after test came back inconclusive. Eventually the pain was so bad that they gave me morphine. To me, it felt like an alien presence in my body. I absolutely hated the feeling. The next day, when the pain was resuming, I refused to take it again. Maybe there was something to what Dr. Joe was saying about opioid addiction being much, much more complex and nuanced than the simplistic view we often hear in the media about opioids being “highly addictive” in a physical sense.

  “If you put five people on opioids, one person may have an addiction problem. That’s based on medical studies,” said Dr. Joe. “Nicotine, for instance, is higher. Opioids are actually at the lower end of the spectrum for substances that are potentially habit forming.”

  The idea of people becoming addicted to drugs based on trying them once, or that there are “chemical hooks” in these substances which are the primary cause of addiction, is a popular urban legend that has been substantially undermined in recent decades. The reasons behind addiction are complex, and our understanding of it is continuing to evolve.

  Dr. Joe is quiet-spoken and unassuming. But his low-key demeanour is deceiving: he’s a walking encyclopedia when it comes to substance use disorders. He’s seen them firsthand, both as a practising physician and now as the medical director of substance use programs for the Vancouver health authority during the opioid crisis.

  “I started practising in the Downtown Eastside in the early nineties,” said Dr. Joe. “Back then, of course, it was called opioid dependence. It related to the weakness of one’s personality and it was a moral issue, and it was something that many of the people who suffered from the condition had control over. Our understanding of it certainly has changed over time.”

  I’d been struggling to understand why the response to the opioid crisis had been so muted. Why didn’t more people care that thousands were dying, and why weren’t governments doing more about it? Dr. Joe had just hinted at one compelling reason. Most people don’t care about “addicts” (a hurtful and stigmatizing label) overdosing from illegal drugs. They believe that drug users are to blame for harming themselves by “choosing” to use these dangerous illegal substances in the first place: if they overdose and die, it’s their own damn fault. It’s a harsh form of victim blaming that I started to notice in conversations with even some friends and family members. And it has roots in thoroughly debunked but persistent theories about why people use illicit drugs.

  “The Canadian Society of Addiction, the American Society of Addiction, and the [BC] Ministry of Health have all proclaimed opioid use disorder and other addictions as a chronic disease,” said Dr. Joe. “That’s the best model we have. [And yet] addiction is more stigmatized than the other chronic conditions. We have people who are still of the old mindset and don’t really understand the nature of addiction as we currently understand it.” Opioid use disorder—characterized by a compulsive and prolonged pattern of problematic use of opioids—is classified as a mental disorder by the American Psychiatric Association in its authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM-5, published in 2013).

  “There’s this whole moral construct around drug use—that the person must be lazy or the person must be weak,” said Leslie McBain. “ ‘Why can’t they just pull up their socks and get over it and stop?’ All of these myths around drug use. We’re hoping this is changing. I think it is: slowly in Canada, in BC. Not other places, unfortunately—not south of the border.”

  “I think we’re past thinking that addiction is a moral failure,” Bill Mollard told me. “I think we’re well past that. I hope we are, because addiction is a medical issue. It is a physiological issue, but it’s not solved just by that.” Mollard emphasized that many people with substance use disorders are suffering. They need care and compassion, not blame and judgment.

  * * *

  ——

  Why can’t people who are addicted just stop using illicit opioids?

  “I think we have to recognize that problematic substance use is a chronic relapsing condition,” said Dr. Aamir Bharmal. “To suddenly say that you’re just going to be able to get them out and then you’ve solved the problem—[that] just doesn’t happen.”

  Opioid use disorder is considered to be a compulsive mental disorder. It can start at any age, but it commonly first arises in the late teens and early twenties. It can last for years, even a lifetime. That’s because, once people are addicted to illicit opioids, they’ve lost the ability to simply stop using. They’re essentially on autopilot. Their condition is characterized by a strong desire to stop or cut back but an inability to do so. The disorder causes people to take more opioids over a longer time than they intended. Attempts to briefly abstain are typically and quickly followed by relapses.

  The condition causes people to use opioids even when it’s hazardous to their health and even though they know they’re bad for them—which goes a long way towards explaining why so many people are continuing to use street drugs when they know they’re likely to be contaminated with fentanyl and fentanyl analogues.

  Over time, people with opioid use disorder develop a tolerance to these drugs. That means they need increasingly more to feel the same way. They need greater quantities of the drugs, or more potent opioids. For some long-term daily illicit opioid users, they may actually want fentanyl. “People seek out fentanyl because that’s what they know, for one, and then you have a tolerance that develops to a drug that’s more potent,” said Jordan Westfall. “Basically, when you get used to that, you’re going to seek it out because the other stuff isn’t going to work for you.”

  The flip side to developing a tolerance is that if users cut back or stop using for a time, either because they try to abstain or are forced to (e.g., due to being incarcerated), they’ll go into withdrawal and their tolerance will reduce rapidly. And when they almost inevitably relapse, their reduced tolerance makes them significantly more likely to overdose. For that reason, abstinence on its own is not recommended as a form of treatment for someone with opioid use disorder.

  “If you’re an opioid-addicted individual and you’re trying very hard to go to recovery, you’re at high risk of actually dying,” said Dr. Joe. “It’s a really cruel chroni
c disease.”

  The life of someone with opioid use disorder can be debilitating, and includes being unable to meet major responsibilities at work, school, or home; spending an inordinate amount of time seeking, using, and recovering from using opioids; causing serious problems in relationships with friends and family; and giving up or reducing social, work, and recreational activities.

  * * *

  ——

  “The kid wanted to get out of this,” Leslie McBain told me. Her son, Jordan Miller, had used illicit drugs and was addicted to a mix of prescription opioids. He was trying desperately to stop. “That period between detox and relapse, his girlfriend and I just stuck with him. He had nausea, he had diarrhea, he was trying so hard just to get through it. He had restless arms and legs where his limbs would just fling out. I said, ‘Can’t you just hold it in?’ and he’s like, ‘No, you can’t imagine what it feels like.’ You need to do that to release the tension. There’s sleeplessness, horrible mood swings. It’s nasty.”

  As McBain put it, “I can imagine people going through withdrawal just giving up and thinking, ‘Give me what I need.’ Get me that heroin, that fentanyl, that whatever it is, because I can’t do this. If you imagine the sickest you’ve ever been in your entire life, sometimes we say, ‘I just wanna die, this is so terrible.’ Well, I think multiply that by 10 and you probably have some idea of what it feels like.”

  Opioid withdrawal typically occurs after someone who’s been using opioids for several weeks or more stops or reduces their use. Withdrawal can also be triggered when naloxone (a drug that can reverse an overdose) is given after someone has used opioids. Opioid withdrawal symptoms can occur within minutes and up to several days. They can “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,” and can include the following, according to the DSM-5: