This story originally appeared on VICE Quebec
Fentanyl has rapidly transitioned from a pain relief medication to a source of public health catastrophes across North America. Being a part the opioid family, fentanyl is a drug prescribed to relieve chronic pain, 40 times stronger than heroin.
However, its consumption goes well beyond the medical world. On the streets, we often find medicinal gel patches which can be grated and smoked, or diluted and injected. Fentanyl can also be purchased in its powdered form, which is a bootleg, non-pharmaceutical version, and "this is what we've seen happening in the last few years," observed Jean-François Mary, general director of L'Association québécoise pour la promotion de la santé des personnes utilisatrices de drogues (AQPSUD, a health promotion association for drug users in Quebec).
Fentanyl powder can be pressed into counterfeit pills or used as a cheap way to cut drugs, such as heroin. We have seen "a little bit" of it in Montreal, confirmed Royal Canadian Mounted Police (RCMP) investigator Jacques Théberge when he spoke to VICE. But in Western Canada and Ontario, a crisis is raging: All sorts of drugs are cut with fentanyl, often unknowingly to the consumer, who, without knowledge, consume a substance can result in an overdose.
British Columbia declared a state of emergency last April after at least 488 deaths were caused by overdoses since the start of the year. As of the end of September, that number had risen to 555. A preliminary analysis from the province's coroner's office revealed that 60 percent of the drug overdoses deaths that occurred between January and July were linked to fentanyl. The situation is equally critical in Alberta and Ontario (though, little information is available in the latter because the government isn't properly tracking it).
Is it as bad in Quebec?
From 2010 to 2014, 191 overdose autopsies revealed the presence of fentanyl, according to Quebec's coroner's office. Of these deaths, 46 were directly caused by this powerful drug, which works out to about a dozen deaths per year. And while there here have been a few notable busts in Quebec this year, including one massive seizure in Quebec City worth $1.5 million, the situation in Quebec has not yet felt the full intensity of the overdose wave which has plagued other provinces.
According to David Champagne-Turcotte, responsible for AQPSUD's communications, Montreal's drugs are not being cut with fentanyl like they are elsewhere.
"The people that will consume fentanyl know what they are looking for, therefore they are more careful. But you have to be careful, because there are counterfeit [tablets]," he told VICE.
These tablets, which come from clandestine laboratories or are smuggled in from China, are extremely dangerous. "Anybody can pretend to be a chemist, order ingredients, order a press, and fabricate their own tablets in a basement. Nobody checks the quantity of fentanyl contained inside them," warned Geneviève Fortin, communication organizer at Cactus Montréal, the city's largest community group working with IV drug users. According to the RCMP, the lethal fentanyl dose hovers around two milligrams.
For Fortin, what seems most common in Quebec are clandestine tablets that are passed off as other opioids. She explained: "We have observed that many people thought they were getting OxyContin, when it was actually fentanyl."
Opioid consumption is on the rise
"We know that people [in Quebec] are consuming fentanyl, but we have no data on its consumption or presence on the streets," said Fortin. Reluctantly, Corporal Théberge confirmed to me that the RCMP is investigating the presence of fentanyl in Quebec, but won't confirm how many investigations are underway, nor their scope.
What we know for sure is that two years ago Quebec's Public Health Institute reported an increase in intentional and accidental overdoses caused by opioids. Generally, the sale and the consumption of medicinal opioids are on the rise.
The Collège des médecins du Québec is worried: according to them, there is no control on the prescription of opioids and on who is prescribing them. The organization fears that the situation is deteriorating like in British Columbia. "We know some of our doctors have prescribed as many as 3,000 opioid pills per month. To our knowledge, there's no medical reason to be prescribing 3,000 tablets per month to one patient. We know that there are certain patients that have access to a couple hundred, if not thousands of tablets per month," said Yves Robert, the secretary of the Collège de médecins, in an interview with Radio-Canada.
On the topic of why there's less fentanyl in Quebec than elsewhere in Canada, opinions among those who work in the field were all over the place.
For some, like Carole Morissette, consulting physician to Montreal's public health department (Direction de la santé publique de Montréal) it is first a question of supply. "The consumers purchase what is on the market, and thankfully drugs that contain high quantities of fentanyl are not available at this time, unlike what we see in western Canada," she told VICE.
For others, it is also a question of demand, because for the moment, it is not opioids that are consumed most in the city. Geneviève Fortin said that, "it continues to be marginal. We see a lot more cocaine and crack. But among users of heroin and other opioids, more and more people are turning to fentanyl or OxyContin because they are cheaper than heroin."
Different cartels, different markets
"The thing with drugs is that there are no places where they are distributed the same way," Julie Soleil, director of Montreal's Group for Research and Psychosocial Intervention (GRIP) told VICE. According to her, the large variations in the presence of fentanyl across Canada can be attributed to the different cartels that control drug trafficking in those areas.
Soleil went on to explain: "[In Quebec], crime is organized either by [the mob] or bikers, but it is not the same in all provinces. In the west, we find different cartels, notably Asian cartels that have many links to China where fentanyl comes from."
Jean-François Mary supports this hypothesis: "It is certain that the availability of fentanyl [in Quebec], compared to British Columbia, is really different. They have strong links to Chinese drug trafficking networks that has been established for a very long time, which is not the case here."
RCMP Inspector Jacques Théberge did not want to confirm the cartel theory. He stated: "It is something that I cannot openly discuss."
Fentanyl is also being purchased on the dark web, which adds a further complication to tracking its distribution.
Another hypothesis that could account for the weak presence of fentanyl in Quebec, is that drug users and traffickers might simply be coming to the game later than the other provinces.
"Everything that happens out West eventually makes it to Quebec, but there's a lag," said Geneviève Fortin. "Crystal meth came to Vancouver ten, 15 years ago, but we're only starting to see a lot of it in Montreal. We expect it will take ten or so years before crystal meth consumption in Montreal reaches the levels we're currently seeing in Vancouver."
Théberge disagrees fentanyl will inevitably make inroads in Quebec. "For years, we kept hearing that crystal meth was coming to Montreal, but it never happened." Théberge nonetheless concedes fentanyl consumption patterns could more closely resemble those for crack, which is widely used in Montreal. It could go either way, he says.
Quebec is preparing
Though Quebec has managed to avoid the crisis up until now, it remains crucial that the province prepares for such an eventuality. Théberge warns that, "We must not forget that Montreal is a hub for drug trafficking, therefore we must expect to also see fentanyl."
The Direction de la santé publique de Montréal has put in place many measures to prevent and deal with the eventual crisis after a brief wave of 79 overdoses in 2014, which caused the deaths of 28 people in Montreal. The powerful opioid was detected in the analysis of one of the first overdoses, but "the inquiry permitted us to conclude that fentanyl was not the cause in all cases," corrected Carole Morissette, who participated in writing the inquiry's report.
Fentanyl or not, the Direction de la santé publique de Montréal has since proceeded to institute an oversight group tasked to quickly repair problematic situations and to transmit information in real time. The Direction has also been working on awareness tools that can prevent or recognize overdoses and also raise awareness about prevention. She has also pressed for the implementation of a program for access to naloxone, an injectable antidote that stops an overdose.
"In 2014, only a dozen paramedics had access to naloxone in pre-hospitalization services in Montreal. Now, almost all medical emergency paramedics are trained to use it," said Morissette. "Our goal, is to make sure that all persons susceptible to overdoses have access to this life-saving injectable."
The consulting physician added that since June of 2015, 350 people were trained to administer naloxone and that it has successful been administered 23 times.
Still a long way to go
Resources are still lacking with the—imminent or not—coming of fentanyl. Fortin pleads for legislation supporting testing services, which are permitted in many European countries. This would allows for the detection of fentanyl in drugs unbeknownst to consumers. In other words, she does not accept that naloxone "hasn't been made available to enough people," even if many field practitioners and users already have their naloxone kit.
For his part, David Champagne-Turcotte criticizes Quebec's tardy implementation of supervised injection sites, a service that has been in the works for 20 years. "It's been years now that we've been hearing that it would come in the spring… Now, they are conducting interviews for nurses. We hope that it will be here in next spring," he said with a sigh.
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