The lessons learned from the fentanyl overdose crises in British Columbia, Canada

Sir: In 2016, more than 900 people in British Columbia (BC), Canada, lost their lives due to unintentional drug overdoses, attributed mainly to illegal drugs mixed with ultrapotent opioids, such as fentanyl groups, which marked an 80% increase compared to the previous year 1, 2. Since 2016, the health authorities and various levels of government in BC have worked together on implementing different methods to control the epidemic 3-7. There have been some important strategies used in the city of Vancouver which, in our opinion, have been novel in their approach. These strategies included a multi-sectoral approach that involved drug-user community engagement by increasing accessibility, distribution and training in the use of naloxone in addition to early public health crisis declarations, law enforcement engagement, establishment of overdose prevention sites and health-care policy shifts 8, 9. In addition to operating the only legally sanctioned supervised injection facility in North America, Vancouver has benefited from numerous community harm reduction consumption facilities that previous research has shown to have clear benefits 8-12. Moreover, the harm reduction program in Vancouver has focused on utilizing peer drug user networks 12-14 which has proved to be extremely effective in reducing mortality rates in Vancouver 15-17. Vancouver is also the only city in North America that has been implementing heroin-assisted treatment 18. Despite the relative success in controlling the epidemic in Vancouver, the overdose crisis continues to take lives. This could be due to the direct link between the epidemic and the stigmatization and demonization of substance use disorders; a chronic–relapsing medical condition that has traditionally received harsh criticism through its criminalization and massive drug-related incarcerations, rather than supportive health-care evidence-based models. The current drug policies that affect men and women unequally are comparable to the ‘discourse of disposal’, a social milieu for ‘getting rid’ of certain segments of society (reflected in policy), such as homosexuals and sex workers 19. These unjust drug policies are also reinforced by perceived devaluation and discrimination associated with substance use disorders. In our opinion, there is no straight path forward; however, acknowledging the complexities of relapsing nature of addiction as a chronic illness and working with the reality that some people are not willing or ready to stop using drugs is certainly a good start. To many members of the community, including the physicians and researchers, the legalization and regulation of illegal drugs seem to be the only sustainable fix to the acute and potent action of fentanyl, as more than 60% of illegal drug-related deaths occurred in private rooms in 2016 4. In the meantime, governments need to expand evidence-based harm reduction programs, including peer-run supervised consumption facilities, opioid agonist substitution treatment, full cost coverage for the naloxone kit and other evidence-based primary care models that include supportive housing and peer-harm reduction engagements. The current epidemic can be addressed only if key harm reduction players such as people with lived experiences, physicians, nurses, social workers, law enforcements, academics and government officials work together collaboratively. The views expressed by E.J. in this letter are those of the authors, and they may not necessarily express the views of the Canadian Institutes of Health Research (CIHR) or the BC Centre for Disease Control. We would like to thank the Vancouver Area Network of Drug Users’ (VANDU) board members for reading and approving the earlier draft of this letter. Moreover, we would like to thank Dr Jane A. Buxton for providing feedback on this letter. The contribution by E.J. was supported by the Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship (201511MFE-358449-223266). The contribution by M.K. was supported by the Vanier Canada Graduate Scholarship.

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