Public Safety Canada and CCSU Law Enforcement Round Table

Petra was invited to present to the Law Enforement Round Table in Ottawa on March 19, 2018. The presentation given was a slightly abbreviated version from the text below. 

Our youngest child Danny died from accidental drug poisoning in 2014. Danny was 25 years old.  

Danny was in recovery when one more pill, which he thought was a fake OxyContin, but was in fact Fentanyl, took his life.  We did not know about the increased risk in recovery, when the person’s tolerance for the drug is lowered and when they are less informed about the scene and dangerous drugs.  He was one of the early victims, before Fentanyl made the news, and before there were any health warnings. Those came several months after his death.

After Danny died we decided to be open about the cause of his death. We wanted to end the silence and the stigma. Friends and family, and his workplace were surprised. Danny did not look like an “addict” - a word I don’t care for much.  How does a person who struggles with substance use look like? In most cases, it is an invisible condition. When Danny died, he had been in recovery for a year and a half. He was a chef in one of Edmonton’s best restaurants, and he lived in a downtown apartment.

What worked for Danny was opioid agonist treatment with Methadone combined with counselling, which we paid for  privately. The only thing the public health system offered at the time was a list of 12 step groups, that are not evidence based and would not have taken him on methadone.

What did not work was the fact that both he and we were keen to have him “drug free” and he did not stay on the Methadone long enough to be stable.

For a while it seemed that we had the old Danny back, the kid we knew before he became dependant on drugs. On the outside, he looked like a successful young man, but he was struggling. His addiction started as his way of dealing with his severe social anxiety, but there were other risk factors: A learning disability, being gay, working in an environment were drug use is prevalent. Being impulsive and risk seeking.

He told me once that after he took an opioid he could just walk into any room and be himself, and I wondered if being yourself is too much to ask. Should we not help people to deal with their mental health issues, before they turn to drugs?

What I have since learned is that one of the greatest barrier to providing more effective supports is the stigma of mental health and substance use. 

It is because of stigma that people, like Danny, use and die alone.

These are the photos of some of the loved ones MSTH members mourn. The images we see in the media are mostly from Vancouver’s  DTES – of people who are living  with multiple risk factors besides substance use. These individuals been underserved for a long time and an effect of this crisis is the fact that this population finally gets attention and services, such as supervised injection.

People from all socioeconomic, ethnic or cultural backgrounds and all regions are affected by the drug poisoning crisis, but if there is one demographic  that is at high risk and difficult to reach:  men age 25 to 39 who use alone (80+%, BC and AB stats), mostly indoors (80%), in their own homes (65%)

The reasons why people use vary widely, but there are some common themes, especially for those where the use becomes problematic: physical or mental pain (mental health), trauma and adverse childhood experiences (ACEs), and a lack of hope. For many sexual exploitation causes and contributes to use.

In Canada this is slowly changing, but people are dying faster than we can respond, and our response to date does not match the magnitude of the crisis.

All too often the focus of information for parents and users is still to get “clean” - another term I don’t care for much. People relapse and we did not learn about potential lifesaving solutions, such as Naloxone and how opioid agonist treatment should work, until it was too late. 

Danny was as safety conscious as he could be, doing something very dangerous. He always bought new needles, but that day he was home alone, so nobody could assist him when he overdosed. I can’t tell you how many times I imagine myself finding him in time with a Naloxone kit in hand -  I always keep one with me now. I can visualize what I would have done, but never got a chance to do.  Before his death we had never heard of Naloxone, a safe medication that can reverse an opioid overdose, if  administered in time.

Anybody who takes drugs from the illicit market, including those who do so casually  and even those who take prescription opioids should have Naloxone on hand, and make sure that their friends and family know how to use it.

Ideally you should not use drugs alone, but if you must, always let others know and never take them in a place where you can’t be found, such as stairways or locked cubicles in public washrooms. We have mothers in our group whose children were found in those locations after it was too late.

These rules are like basic first aid, more important since the arrival of new and more toxic drugs, such as Fentanyl, and Carfentanil. Before Fentanyl, the people who were most at risk were people like Danny, injection drug users dependant on opioids.

For casual users, the situation has drastically changed, as Fentanyl and other toxic substances are contaminating drugs that should not contain an opioid, such as cocaine, methamphetamine and ecstasy.

Contrary to common assumptions not all drug use is problematic, and most people who use substances  do so without developing an addiction. I had a glass of wine last night and I will be ok tonight if I go without one.

What substances are currently legal, such as alcohol and Cigarettes and soon cannabis, and what is illegal  is not always based on evidence. Alcohol is  dangerous and causes tremendous harm, such as family violence, and motor vehicle collisions, as well as a host of potentially fatal health conditions.

How drugs are regulated should be based on the best possible evidence on their harm and with a population health approach. Using substances is as old as the human race and, some people will always use.

Does arresting dealers help keep us  safe and save lives? Some dealers, who are part of large criminal networks,  yes, but the street-level dealer who is a user needs a different, more creative and compassionate approach. If more arrests and stricter punishment would keep us safer, the US would be one of the safest countries. 

Why do people deal?  Many of our children who used have also been involved in trafficking, mostly to finance their use, or to pay back dealer debt. People who use have also told us that the street level dealer who uses has a safety role, as they can advise on the strength and/or toxicity of a batch. You probably know of the turf wars that erupt when a dealer is taken out.

As a society, we need a paradigm shift away from treating substance use as a criminal justice problem, to approaching it as a health and human rights issue. Our mothers group calls for the decriminalization of the personal possession of illicit drugs. This is a big shift for Canadian society and probably for many of  you, but it has been shown to save lives and reduce crime in several European countries, where it is practised.  Since decriminalization in Portugal, rates of drug use have not increased, far fewer people arrested and incarcerated for drugs, more people receive drug treatment, and  incidence of HIV/AIDS, as well as drug-induced deaths have been significantly reduced.

How can we expect people to seek help for doing something that could result in a life altering criminal record?

For those within the criminal justice system we need to provide harm reduction (needle exchanges or naloxone), and evidence based treatment and effective follow-up services for substance use disorder (SUD) when the person is released. Loved ones of our members have overdosed in or right out of jail. Their tolerance is lowered and the addiction has not been addressed.

Locking people up for using drugs causes tremendous harm to the individuals, their families and to society, while it does nothing to help those in need of treatment nor to  reduce the supply of illicit drugs.

This young woman is was in recovery when she died in 2017. She did not die from the drug use itself,  but from endocarditis, caused by the dirty needles she shared and repeatedly used. She did not have access to a needle exchange, and the city where she lived still does not offer supervised injection services.  If she would have had access to both, she would not have had to die.

Prohibitive drug policies based on the false assumption that needle exchanges and supervised consumption encourages drug use, are causing harm.  These services keep people as healthy as possible and data from BC shows that those who have access to SCS are 30% more likely to seek addictions treatment. This young woman's ultimate cause of death should read bad drug policy.

The picture on the right is a vile o OxyNeo. When it be became clear that we were duped by Purdue pharma regarding their claims of the  “non-addictive & slow acting” properties of Oxycontin, and when the extend of the misuse and addiction attributed to prescription medication, Oxycontin was reformulated into a “tamper proof version” and rebranded at OxyNeo.

But users were left stranded. Nobody thought to combine the measures that influenced the supply with measure that addressed demand. When you are dependant on opioids you don’t just stop to take them because your supply has changed. Opioid dependence is a chronic condition and people need medical help to stop using.

Criminal networks quickly filled the void left with the reformulation with drugs that are easy to smuggle and can be sold with a huge profit.  Poorly planned and executed drug policy brought us fentanyl and other synthetic drugs.

Danny’s substance use started on prescription Oxycontin, readily available on the streets of Edmonton,  and ended with a fatal dose of fentanyl.

People do recover from substance use if we use evidence based (proven) treatment approaches, combined with harm reduction measures to keep them alive. Some people simply outgrow their dependence when they mature or life circumstance changes.

Our expectations of recovery have to change. These photos are from the SALOME study in Vancouver, where individuals, who have not succeeded with other treatment approaches, have access to injectable prescription hydromorphone. The results have been amazing and the stabilizing effect in people’s life is evident.

Without having to seek the illegal fix, people found housing, work, reconnected with loved ones, and most importantly have found hope for the future, some have moved to OAT or even stopped using.

People I know take a daily dose of Methadone or Suboxone, but you would never know. It is part of their health regime, just like some people take blood pressure meds or insulin.

Recovery does not have to mean to be or drug free. Recovery means being free from the chase of buying drugs on the street and all the activities that come with getting the money to do so. Activities that keep you busy.

For some people it may mean drug free, but making “clean” the benchmark has cost  the lives of many people for whom this was an unrealistic goal.

In my advocacy work  I am always amazed at the time, creative energy and a money spent on keeping people safe from a toxic illicit drug supply. Would it not be so much easier if giving safe drugs on prescription, to those who are addicted, could be a first line of defence rather than a last resort?

Living with substance use disorder should not have to come with a risk of sudden death.

Danny came close to reaching recovery. He had hopes and dreams.  He is on our mind every day and I try to think about the loving, caring son he was and the great meals he cooked. I can’t help to also think about how different the outcome could have been.

The lack of health warnings (Letter to Dr. James Talbot), the rising number of deaths and our experience with the health system lead me to speak out and find like minded individuals. Lorna Thomas, Leslie McBain and I founded MSTH in 2016 and today there are close to 400 Canadian families in our group and 3500 followers on  our Facebook  page

We have learned much about the challenges our families experience trying to help their loved ones. Families struggle with:

Personal Safety – setting healthy boundaries, protecting the child who is using, other children and the rest of the family, personal threats from dealers over debt, dealing with sexual exploitation.

Economic strains – lost time of work, paying for drugs (while waiting for treatment), paying off dealers, paying treatment, paying lawyers and ultimately funerals

Social isolation from family and peers due to stigma –  Before Danny died not even his grandparents new about his addiciton.

[last slide for law enforcement round table]

As you have heard drug policy has four distinct pillars : prevention, treatment, harm reduction and enforcement. Your concern is the fourth pillar, but if we do not invest in the other 3,  we will not be successful and you are not able to do your job effectively.

I would like to quote Sargent Jason Walker, one of my fellow members from the AB MOERC, who works for Calgary Police services: He has learned that “We can’t arrest ourselves out of this problem”. We have to look for solutions in the other 3 pillars. 

As mothers and families we want to keep our loved ones  alive and as healthy as possible until they can arrive at a place in their lives where treatment or abstinence works for them. Please help us achieve that outcome!

[Text I used in my last slide for a healthcare audience]

In closing, I would like to share this final message to you: When a person with SUD presents in to you, remember how hard it is come forward and ask for help. Welcome them, thank them, and be kind. Watch not only your words but also your body language. Check the person’s knowledge of harm reduction. Do they know that all pills and power may contain Fentanyl? Do they know not to use alone, but to have a safe observer? Do you and your loved ones have Naloxone?

Most of all welcome the person, tell them that you are glad they are here and help keep them alive. Someone’s mom will thank you for it. 

[This slide was not part of the law enforcement round table, but is included in most presentations - it is included here to show the complete talk]

I am part of a research project on mothers advocacy (with Dr. Hyshka from the school of public health and others) and in our project we are examining what a family centred approach to substance use could look like. We have learned that families have a central role in keeping  people alive and helping them reach recovery, but our system neither recognizes nor encourages that role. Not considering the needs of families can have negative health outcomes both for the individual in treatment as well as other family members.  Affected family members can develop chronic medial and psychiatric conditions and become high users of health services

Evidence based interventions for families have been shown to improve health outcomes not only for other family members, but also for the individual receiving treatment.  A paradigm shift is required to move to a family centred model. (1)

(1) Ventura, A.S. To Improve Substance Use Disorder Prevention, Treatment and Recovery: Engage the Family. Journal of Addiction Medicine. Volume 11, Number 5, September/October 2017