Canada is reeling from the opioid crisis. It's a complex issue that has developed into epidemic proportions in past years, leading to a troubling increase in drug-related deaths. It's not a situation that will be easy to get out of. But if you're reading this article, you probably already knew that.

When OxyContin was pulled from pharmacy shelves in Canada in 2012 and replaced with a "safer" alternative, the result was far more deadly than anyone could have predicted. Fentanyl, an opioid many times stronger than heroin and morphine, appeared on the black market when the illicit drug market saw an opening. While the drug is available as a prescription, much of what appeared on the streets was a bootleg version.

As fentanyl continues to flow into Canadian cities, it has already killed thousands. We don't have a complete picture, but here's what we do know from a couple of provinces that have been hit hardest by the worst drug safety crisis in Canadian history. So far in 2016, British Columbia has reported a record 555 drug overdose deaths, up from 508 from all of last year. In Alberta, the number of fentanyl-related deaths hit 153 at the end of June. And the year is not over yet.

Unfortunately, as you're reading this, the death toll has already increased. The federal government has called a national opiate summit in Ottawa on November 18 and 19, but ahead of that, we wanted to allow some of those who have ideas for solutions to speak. Because the opioid crisis is a complicated, multi-faceted problem, we asked people from a variety of disciplines to voice their recommendations.

Frontline staff, like medical and emergency room staff, should have more training—and better training. [There's a] lack of empathy and knowledge they always seem to have. If somebody has a really bad experience there, most times they're not going to go back and seek treatment anywhere else. I was treated like I was a criminal, not like I was somebody with a disease or somebody who was trying to better myself. I remember the doctors saying, "Oh, you know, you just gotta suffer for a couple days." There's no need for anyone to ask you to do that.

In Alberta especially, [there are] very few treatment options. And any good treatment centres you have to pay for. Most treatment centres are 21 days. In 21 days you're not going to be feeling better. You're still sick. The first thing you're gonna do is go back and use because you're still not even feeling 100 percent.

It's not a very positive experience. I don't really like methadone, like at all. There's side effects. But when you have no other options… And if you're on welfare, your medication is covered. If you're not on welfare, I was paying like $15 a day for a long time. The cost when compared to getting a pill is only a couple dollars more, so.

Karmik is more focused on festival and nightlife culture. But at the same time, we are really integrated into public health [in Vancouver]. We don't condemn or condone substance use… A lot of people come to Karmik already having made choices about what they're going to be doing with their night or their lives, and we're here to help support them along that way.

It comes down to accessibility. Having access to the services that are going to be able to make people safer in all communities—not just cities, not just specific, localized areas. For example, have the opportunity to be able to test substances… A great step is looking at how we can implement harm reduction philosophies and policies. How do they fit in?

A lot of the issues arise in rural communities where we might not have the same disposition toward harm reduction philosophies as people in urban settings… When we talk about making resources accessible, it's not just pragmatic—we also need the ideology accessible and supported by certain members of the community so any of these policies can move forward and materialize into more pragmatic pieces.

The stigma associated with heroin is so strong. And now that fentanyl is being cut into almost any recreational drug, it is deconstructing that stigma: Where is it coming from? Why are certain drugs more stigmatized than others? Why do some users feel appropriate concerning use of services and others don't? A lot of programs right now aren't tackling that stigma, and that's a big part of it.

We need to protect our children against drug prohibition, and not drug legalization (because that's way too vague of a term). We need to end prohibition around a lot of different substances so we can increase the validity of substances that are being widely used or are available… We need to increase the ability for these substances to be regulated, checked, and monitored. If we had regulatory bodies that were able to look into those pieces and put them into practice, this "Russian roulette" that we see with people taking different pills or substances could be avoided… We also need to look at how our society and political ideologies deal with people who use substances, deal with trafficking charges, and criminology aspects altogether. The criminalization of substances and drug dealers has not supported anybody except for the mass global market and banking, so when we look at those policies, incarceration does not increase anyone's ability for rehabilitation unless those supportive services are there after.

Public health emergencies [need to be declared] wherever there's an extraordinary burden of illness and death caused by opiates, which I think is everywhere [in Canada]. That would allow the chief medical health officers to allocate special resources and overcome any legal and other obstructions to mitigate risk because of health. We don't have that authority all the time… For example, if there's a public health emergency, in some jurisdictions that public health officer would have the authority to suspend legislation that inhibits their development to safe injection [sites].

The other thing would be coordinated public health surveillance. We don't have standardized tests reporting; we don't have a coordinated system where we know what drugs users are using; what labs are finding on toxicology; what numbers of people are presenting to emergency departments for overdose and withdrawal. That should all be part of a coordinated national public health surveillance system, which we don't have. It's present in the United States.

We're having a lot of conferences, and there's a [federal] summit [coming up]… Everybody's hearts and minds and prayers are going out to the individuals and families affected by this. It seems like the key messages are getting pretty banal. Why have we not seen this? I don't know… I can only hope that some of these things are happening behind the scenes and are ready to be deployed, but I have my doubts. I think that the third, of course, is naloxone is critical. It should distributed widely. It shouldn't just be distributed at pharmacies but nightclubs, stores, and gas stations. It should be distributed in injection and nasal spray form, and it should be free.

Parties are about the music and not about the drugs, but drugs happen. Club owners not only should be responsible from our public health and public safety point of view, but also good business. They should partner with public health authorities to provide those services for people who attend their establishments.

if you think about the problem as helping people with substance use disorders, helping people who are on opioids but don't yet have a substance use disorder, and helping people who have pain and aren't yet on opioids. Those are some of the three big segments.

For people who have an addiction and want help, they should get ready access to drugs that will alleviate the withdrawal symptoms, but they should also have ready access to the support that can help them down the road.

That last group of people, the people who are at risk, I think a lot of things could be done. Obviously, the biggest danger to those people arises from the fact that they don't know what they're taking. Somebody who buys and sells on the street doesn't realize he's got fentanyl or carfentanil in a drug. There are people who are increasingly seeking out fentanyl specifically though.

There may be some people who are entrenched users, people who just don't want to quit. Maybe they should have access to pharmaceutical-grade heroin… On one extreme end, it is complete change in the laws and taking sort of a Portugal model. Safe consumption sites too. People just, with rare exceptions, don't generally die in those places.

People go to the dentist or have bad knees or whatever, I think this is a very tough situation. Over the last 20 years, we've developed this genuine familiarity with opioids, and we've lost the fear that we really should have or the respect that we should have for the drugs… Now to see these drugs deployed like crazy in hospitals and in [doctor's] offices, and yet, it's just no big deal. That is a testament to the tremendous marketing efforts of Purdue and other companies in the 1990s and the pain experts who helped convey this bullshit message that these drugs are safe and effective for long-term pain. So for people who aren't on opioids, for people who aren't yet on opioids, what can we do? We could prescribe them much less freely.

We should maybe make the initial prescription three days or maybe seven days in some jurisdictions… Maybe dentists should not be allowed to give 60 Percocet tablets to somebody who has just had some dental work. That's insane. We know that the more drugs a person is given the first month of therapy, the more prescriptions and the more tablets, the more likely they are to be using drugs a year later. If the evidence for the use of opioids was good, I would feel less strongly about this. The evidence is horrible. It is coming back to these groups of patients who aren't on opioids. But we should be using anti-inflammatory drugs more often and using opioids much less often, certainly, not starting people on fentanyl. That just doesn't make any sense. I think it's malpractice to do that, actually.

My feeling is that [fentanyl] is being sold through more traditional [crime channels]. I have seen dealers, including those from Canada, being active online. But I wouldn't say they are the majority of those selling fentanyl in Canada. There are actually many benefits that come from online drug markets. Rather than shut them down, maybe it would be better to have these sales occur online rather than offline. It's much easier to track drug trades. So if you want to know how big fentanyl is, it's much easier to look at what people post and to get an idea of how many customers are in Canada. Online gives us more data to work with.

Second of all, people are going to post comments about drugs they've bought. If there's a bad batch of fentanyl—whether it be too pure or not pure enough—people are going to say, "I bought this batch from this person. It was really strong; be careful." That is better help for drug users. There's also likely to be less risk of violence when you're buying online because people don't meet in person; it goes through the mail.

If the government wanted to attack cryptomarkets, the dark web, and online drug dealers, what we've seen is they're mostly targeting platforms… That doesn't really help. They shut down Silk Road, then three weeks later we had Silk Road 2, which was pixel for pixel identical. What they need to do more is look for the people who make these drugs. That is a lot of work, but the best way to go about it is to do good old police investigations… The latest numbers we have is that the drug trade online all over the world is in the hundreds of millions of dollars. The drug trade offline… the estimates range from hundreds of billions to trillions of dollars.

[With mail], the big problem is that drug dealers are very aware of the techniques being used by Canada Post or USPS to inspect packages. They know exactly how to box them… The main challenge, then, becomes the cost. Let's say Canada Post is to inspect ten percent of packages. That's going to take time—your package is going to be stuck for an extra day or two. You're not going to be happy because your package is late, and that is going to put pressure on these mail services… There would be public outcry.

I don't think there is any one approach that will fix this given the complexity of the issue… Some research-focused options I think we should be considering are first, better surveillance—at a national level—as it relates to prescribing opioids, as well as overdoses and deaths. That is really needed because, until now, we've relied on data from very specific jurisdictions. Those measures are not consistently defined, and we have huge gaps in our knowledge as to what's happening across the country. If we had that system in place… It would actually then allow us to drill down to the local level to see how those issues do vary by city or county. That would then let us target specific interventions to communities and populations that are at most risk. We only have limited resources, and we need to know how to best spend those resources.

Certainly something that has been discussed in Canada is better rapid identification within emergency departments of overdoses as they occur and some of the circumstances of those overdoses: What were the drugs involved? What did the person think they took? People might think they took ecstasy or cocaine when they actually took fentanyl or carfentanil… That can be really informative for the public [to know] as well as police services, prescribers, and others. That would require a large amount of organization and improved communication between the hospitals, policy makers, and some kind of centralized group that would be tasked with maintaining that data and reporting on it. Right now we don't have that in Canada…. I really think that's something that should be pushed forward at a national level.

We have to have a strategy that's balanced. It can't be all enforcement-driven. What we're proposing [in Calgary] is that we focus on three main objectives. Obviously restricting access and the supply of illicit drugs, and how do we do that? We're working with the federal government, provincial government to make legislative changes and regulatory changes. Things like the bill process, the precursors, things of that nature. Obviously we have to work collaboratively with Canadian Border Services Agency (CBSA) because really, they're on the frontlines. The less fentanyl coming into the country, the better off we will be. Because, right now, they're only getting a fraction of what's coming in.

The second key objective is: How do we reduce the demand for illegal drugs and prescription drugs? There's a lot of people in our country dealing with trauma who are turning to prescription drugs or illicit opioids to self-medicate. Working with the medical community, we need to reduce the amount of prescriptions for opioids, or have people that are on opioids monitored, not just given a prescription and a refill and that's it.

The last thing is, there are a lot of indicators that we have problems. One is the number of deaths, the number of overdoses where people survive. But, I feel, especially in Calgary, our crime rates have gone through the roof. If you're taking 50 tablets of fentanyl a day, that's a thousand dollar a day drug habit. That's a lot of crime you have to commit to support that. So we really need to work with programs that can link harm reduction to crime reduction. We need to stop people being victimized in our community, but the people who are breaking into houses and stealing cars are really victims themselves. They're doing that to feed their addiction.

Any prevention and intervention programs… They all have to be evidence-based. In my opinion, the police shouldn't be dictating what harm reduction models or programs we have in the community. That needs to come from medical professionals. Law enforcement has to listen to that… Public opinion really needs to change, and we need to deal with the addiction because if we don't deal with the addiction, we're not dealing with the crime.

When someone's in the emergency room, it's the wrong time to talk about prevention, but it is the time for a crisis response… We've treated this like individual moral failing, rather than looking in the mirror and calling it a failure of the very systems designed to protect the health and safety of Canadians.

In terms of response, it absolutely must be urgent, proportional, and collaborative. The urgency is well-known to local communities across Canada, and has been for years. In Ontario, it's one opioid-related death every 13 hours… Proportional speaks to providing the same amount of resources and attention to other important but less common forms of deaths and injury: anaphylaxis, road safety, influenza, SARS. With collaboration, it's that "Nothing about us without us" phrase… People who are using drugs should be included in policy and programming, design and delivery. That phrase should go beyond that to include non-profits and community groups—those people who've been dealing with these problems for a number of years… If we're looking for status quo solutions, invite the status quo to the policy and planning tables.

You want to see interventions around prevention—not "just say no" campaigns, but programs that will delay or prevent the onset of substance use… This speaks to the broader determinants of health, for which we do not need more research and reports. We need to actually do something. We don't need another workshop on the opioid crisis; we know what works… There's some uncomfortable truths for those government agencies that have been sitting idle for 16 years on this file, but we need them to step up now more than ever.

The issues of stereotypes, stigmatization, and outright discrimination [of those who use drugs] are rife throughout Canadian society. The folks who are policy makers, they're humans like the rest of us. We see stereotypes and discrimination on a systemic level in multiple sectors… The media has an essential role to play [in fighting the stigmatization of drug use]; it's where most of the public and policy makers get their information. If the language is deplorable, discriminatory, and focused on individual moral failure, that's the message that Canadians hear.

Interviews have been edited for length and clarity.

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