This is the fifth in a seven-part series. For Part 4, click here.
"Frightening" is the first word that comes to mind for an emergency physician at the Barrie hospital when asked to describe the current opioid crisis.
Dr. Chris Martin, an emergency and intensive-care physician at Royal Victoria Regional Health Centre (RVH) in Barrie, has been a doctor for eight years and he has seen the drug problem change rapidly.
"The first word I would say is 'frightening,'" Martin told BarrieToday during an interview in RVH's emergency department. "The reason is that the overdoses we're seeing are not your typical, chronic drug users. This is affecting recreational drug users and people who are just experimenting.
"It's really picked up quickly," he added. "I would definitely not call it gradual. Synthetic fentanyl has come on the scene in, I would say, the last three years. It's really skyrocketed."
The root of the problem is that fentanyl can be found in "almost everything now," Martin said.
"First of all, it was just volume," he said. "A lot of people seemed to be overdosing on narcotics that weren't your typical patient population. And the spike's been going up ever since."
It has led to doctors, nurses and paramedics dealing with many more drug cases from a wider range of people.
"Whereas before we would just see heroin addicts taking too much heroin, now we're seeing people trying cocaine for the first time on a weekend, it being filled with fentanyl and not waking up," Martin said.
In November 2018, there were 39 opioid overdose emergency-department visits at hospitals in Simcoe Muskoka and 35 opioid overdose emergency department visits among Simcoe Muskoka patients visiting any hospital in Ontario, according to data from the Simcoe Muskoka District Health Unit.
Over the first six months of 2018, statistics also indicate there were 31 confirmed and four probable opioid-related deaths in Simcoe Muskoka, which was similar to the 33 opioid-related deaths in Simcoe Muskoka from January to June 2017.
Statistics also show that the crude rate (per 100,000 people) for opioid overdose ER visits in 2017 was highest locally in Barrie, Penetanguishene, Orillia and Midland, based on 2016 population estimates. Barrie led the way with 204 opioid overdose visits, followed by Orillia (42), Midland (22), Innisfil (19) and Bradford West Gwillimbury (15). Penetanguishene had 13.
Martin, who is also the director of intensive care at RVH, said that's a "scary" prospect, because it sometimes involves young people.
The patients Martin sees on a daily basis cover a whole spectrum.
"Unfortunately, it's a lot of younger people who are, again, not chronic users," he said. "But we're also seeing even hardcore users, who know their drug limits and usually don't overdose, who are coming in because they don't even know what's in their supply."
There is a toxic supply of drugs on the street, where experts say even a grain of fentanyl could be potentially deadly.
"The synthetic fentanyl has made traditional heroin even more dangerous, because a lot of it has fentantyl in it," Martin said. "It's also in the cocaine; almost all of the cocaine samples are having fentanyl traces in them. So, as unsafe as recreational drugs are, they're really unsafe now. It's 10 times worse."
It was about two years ago that the level of the growing opioid problem -- which Martin and others in the local medical community now refer to bluntly as a 'public health crisis' -- really started to become noticeable. That also coincided with the arrival of carfentanil, which is an even more potent and deadly synthetic opioid, and other fentanyl derivatives.
Opioids can include substance such as fentanyl, oxycodone, morphine and codeine, and can be found either through prescription or on the black market.
Because of the growing crisis, the Simcoe Muskoka District Health Unit is a key backer of the Gilbert Centre’s application to the province to open a Consumption and Treatment Services (CTS) facility in Barrie.
Associate medical officer of health Dr. Lisa Simon said the health unit will also be taking part in the consultation process this year to receive feedback on the application.
“It is clear that the opioid crisis has hit Barrie very hard and there are pockets of high use in the city that would benefit from (a supervised consumption site),” she said.
Simon said the evidence shows that such facilities decrease overdose deaths and hospital visits, as well as being “pivotal avenues” to allow people to access treatment and social services “when they are ready.”
HOW OPIOIDS AFFECT PEOPLE
When medical professionals are handling a suspected overdose, the patient's symptoms can be wide-ranging, but the tell-tale signs are pupil size and their breathing rate.
"The most common case is a decreased level of consciousness," Martin said. "Basically, they can't be woken up and paramedics are called. ... The EMS will use Narcan, or naloxone, the reversal agent, and then they're brought in (to the hospital).
"Sometimes, if they haven't had too long a period where their oxygenation was low, they are awake but they become drowsy again and have to be put on an infusion. Those people tend to do OK, but could be in emerg for hours and hours," he added.
"The other end of the spectrum is they come in with a decreased level of consciousness, no obvious cause found and they have had a brain injury from low oxygen, and only on subsequent (toxicology) testing do we find fentanyl in their system."
Martin said the Barrie hospital can't test for fentanyl specifically and samples have to be sent to Sick Kids Hospital in Toronto. The results typically come back the next day.
"It's almost becoming expected, that if you're in a certain age group and you come in (with a loss of consciousness and not yet diagnosed), it's fentanyl," he said. "So if we have someone who's in a coma and we don't know why, if you're under the age of around 60, it's almost now assumed to be fentanyl. That's how bad it is."
Many times when people are found without vital signs and paramedics administer Narcan or naloxone, it may have no effect.
"Once your heart has already stopped, the Narcan doesn't really do anything," Martin said. "You have to get to it before that, otherwise they are just terminated on scene.
"There's a lot of people that aren't even making it into emerg; they're just dying in their homes or dying on the street," he added. "I would say the majority of the deaths happen like that. They don't even come (to the hospital), because we can pronounce them on scene."
Overdose patients tend to come into the hospital in the evening and overnight.
"But shockingly, we see people coming in at 10 in the morning," Martin said. "You think that's crazy. Who's doing drugs at 10 in the morning, but that's the life. The chronic users come in at all hours, but most times the recreational, first-time users are coming in weekend evenings and overnight."
"Whatever the public health strategy is, whether it's methadone or whether it's safe injection sites, which is a separate argument, that's what we need to invest in right away," Martin added. "Just giving out Narcan is like shuffling deck chairs on the Titanic. It saved people and it's a very short-acting drug. People don't realize they get a false sense of security with it."
Martin said there have been overdose patients coming into the hospital with their Narcan kits, "not knowing that when you pass out, you can't give yourself Narcan."
The next steps, Martin said, should include more investment in fixing the problem.
"I think prevention is going to be the key," he said. "The thing I always remind people of is that Narcan is only a small Band-Aid on a massive wound. It buys you time, but often these people are dead before we get to them."
"I really think this is going to take a big investment and a big shift in the way we think about things," Martin said. "It's not just addiction as a punishment; they need our support. It's a public health crisis."
According to recently released report from the Canadian Institute for Health Information (CIHI), rates of hospitalization from opioid poisoning have increased 27 per cent over the last five years.
Additionally, between 2016 and 2017, opioid-related ER visits rose by 73 per cent in Ontario.
In the CIHI report, Dr. Jeff Eppler, an emergency-room physician in Kelowna, B.C., said there are some positive signs, such as people wanting to seek treatment and better access to such services.
Locally, Meredith Fryia, co-ordinator of the opioid treatment program with the Canadian Mental Health Association (CMHA), said data around emergency-room visits continues to show the impact the opioid crisis is causing.
“I would say our region became more aware of the local impact of the opioid crisis in October of 2016 and rates of opioid-related emergency department visits and hospitalizations increased significantly shortly after that time,” Fryia said.
“This issue is certainly a challenge and therefore we needed a system response to address it,” Fryia added. “It will take time to see the results but our community is very committed to this work.”
Fryia says there has also been an increase to our community counselling resources.
The local health unit also launched its Simcoe Muskoka Opioid Strategy (SMOS) in May 2018, which includes a five-pillared plan focused on prevention, treatment, hard reduction, enforcement and emergency management.
SMOS’s short-term goals were expected to be in place by the end of the year, while the long-term goals are expected to be fully implemented by December 2020.
Simon said the SMOS approach has been “very active” with regular meetings to discuss its ongoing implementation.
Under SMOS’s prevention pillar, Simon said health officials have also been working with local school boards on the topic of education to equip teachers with information. Anti-stigma campaigns have also been started in the community.
A workshop is being planned for May 2019 in Barrie to promote the Alberta Family Wellness Initiative, focusing on the importance of early brain development and building resiliency as a means of preventing addiction, Simon said.
In June 2018, the North Simcoe Muskoka Regional Rapid Access Addiction Medicine (RAAM) clinic, located at 70 Wellington St. W., opened in Barrie. The facility offers help for people to reduce cravings, avoiding withdrawal symptoms and a place to talk about substance use.
RAAM is designed primarily for people who are seeking help to get clean right now. It doesn’t require physician’s referral and there is no fee.
Fryia says volumes at the RAAM clinics and other addiction services in the community show there is a definite and ongoing need.
“Prescribing rates in our region suggest that primary care is working towards learning new skills to manage addictions,” she said, “and from what we hear from primary care and emergency medicine, addictions continue to impact their daily practices.”
In addition to RAAM clinics around the county, Simon said the Barrie Drug Awareness Partnership also meets quarterly to discuss the city’s issues specifically.
For more information on SMOS, visit preventOD.ca.
Watch for Part 6 tomorrow.