A deadly rush
A prescription drug containing Fentanyl -- intended to ease pain in the suffering -- has also made its way onto London streets and into the veins of the city's drug addicts. Coupled with a rise in superbug infections, dozens of desperate addicts have lost their lives in only two years.
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Peter Hookimawillillene leans forward on the edge of a chair, glaring at the floor, body ready to bolt out of here if he hears another stupid question.
The only reason he's talking to a reporter at all is because moments earlier a woman suggested he not say a thing.
Moments earlier, he was slumped in another chair, oblivious to the chaos in the main lobby at Streetscape, crowded with men and women trying to escape the cold Saturday morning.
Peter, Peter, there is someone here to talk to you, a Streetscape outreach worker tells him.
"Don't talk to anyone, Peter. You can't talk right now," a woman shouts.
Peter swears at her.
"I'll do what I want," he says, and he lumbers up and shambles to a back room where he takes his tenuous hold on a chair and on civility.
"What do you want to talk about?" he grumbles.
Your friend. The one who overdosed.
"Denise. My lover."
How did you meet.
"Just drinking. North Bay."
What was she like?
"OK. Ojibway woman. 36."
How did you get to London.
What did you do here?
"It's just the rush. That's all you are looking for is a rush. It's all you can feel. That's what I am looking for, a rush."
What was her last name?
"Why do you want to know?"
Perhaps to call her parents, learn more about her.
"You want to dig up the past, that's bullshit. She was an addict. I'm an addict."
What do you remember most about her?
He turns from the floor to shoot a glare.
"Most of all, nothing."
Did you find her?
"I didn't find her. She found herself," he says.
Soon, Hookimawillillene springs up, angry at the questions, and leaves. Only once in a 10-minute interview does he open up, about finding her.
"The only thing that bothers me . . . she did it without me there."
Not that Hookimawillillene could have done much.
Three months ago, Denise injected an opioid called fentanyl into her veins and died quickly of an overdose.
Denise is only one of dozens and dozens of street people in London who have died, often instantly, in the past two years.
"This is reaching epidemic proportions," says Henry Eastabrook, an outreach worker with the London InterCommunity Health Centre. "All these deaths, it's been awful. I can count 36 people I know who died in the past year and a half."
Fentanyl, the ingredient in a prescription painkiller finding its way onto London streets, is blamed for many of the deaths.
So, too, is the spread of the superbug MRSA (methicillin-resistant Staphylococcus aureus).
Complicating street life in the city now is the rumoured upsurge in heroin, the continuing grip of oxycodone and a rise in injection drug use.
"Fentanyl is a crisis, but there is a bigger crisis in that people are dying from injection drug use and poverty," Eastabrook says.
The heightened dangers to an already vulnerable population has outreach workers looking for a radical solution -- allowing addicts to carry a drug that will stop any overdose in its tracks.
That solution will require more than money; it will require a sea change in how the rest of London views people who use illicit drugs.
"If we could . . . look at people who are injecting substance as neighbours with a problem rather than as criminals, as social pariahs, as enemies, as threats, then I think we could much more easily develop programs that alleviate a lot of the social ills associated with substance abuse," Eastabrook says.
Fentanyl is a powerful synthetic opioid, or narcotic. In the mid-1990s, Janssen Pharmaceutica developed the Duragesic patch, which releases fentanyl over 72 hours through the skin.
Across the border in Detroit and other U.S. cities, illicit fentanyl is showing up in granular form, made in drug labs in Mexico, and often sold in a mixture as heroin or cocaine.
It's not clear if that form of the drug has reached London.
The patch is dangerous enough, even when used properly. Health Canada and the U.S. Federal Drug Administration (FDA) have issued warnings that fentanyl patches can cause serious and life-threatening breathing problems.
Yet it's clear from a 2007 FDA warning that despite the dangers, doctors were overprescribing the patch.
Physicians "have inappropriately prescribed the fentanyl patch to patients for acute pain following surgery, for headaches, occasional or mild pain, and other indications for which a fentanyl patch should not be prescribed," the FDA warned.
In January 2009, Health Canada reiterated its warning to physicians that the drug should be prescribed only to patients who have already built up a tolerance to painkillers and who need round-the-clock pain relief for a long period of time.
Diverted to the street, the patches are chewed or broken down so the gel can be injected, snorted or smoked.
"It seems to be more available out there now," says Michael McGregor, a London Cares outreach worker for the Unity Project.
"People who have prescriptions can divert it pretty easily.
"Even a used patch -- there is more than enough Fentanyl to overdose, that's how strong it is," McGregor adds.
When a 72-hour dose hits the bloodstream all at once, a user can go into respiratory arrest.
"The problem is there is no way to regulate the hit that you get. You end up with 72 hours of drugs in one hit," Eastabrook says. "The people go into respiratory arrest so quickly, they don't live long enough to get to the hospital."
On the wall of his crammed office, McGregor keeps a list of the dead he knows, totalling 26 so far in just over a year.
"From late summer to late fall, we were hearing about a death every week and a half," he says.
Some were from overdoses; some were from infections.
Hand in hand with the increased use of fentanyl and other injected drugs has come an increase in infections caused by the bacteria MRSA, says Sue Tobin, a nurse practitioner with the health centre.
"It is a big problem. Because most people are injecting, they are getting infected. I have known 10 people who died of this for sure."
Addicts face a range of health problems, because of the drugs and the lifestyles they lead. But MRSA presents an entirely new threat. Patients with the infections caused by MRSA need treatment through an IV, Tobin says, but addicts won't stay in hospitals long because they don't want to go through withdrawal.
Hospitals can release other patients with PICC lines, small tubes that run from the surface of the arm to close to the heart for injecting medicine. But addicts can't be released with PICC lines, for the obvious reason they'll use the line to inject illicit drugs straight to the heart, Tobin says.
As a result, addicts are left to fend off MRSA on their own.
"Because they are not able to get medical care, they are spreading the infection to other people."
MRSA infection begins with small red bumps on the skin that can turn into deep, pus-filled boils. MRSA can eventually produce a flesh-eating infection and endocarditis, a potentially fatal inflammation in the heart.
"I know so many people who are deathly ill with it," Tobin says. "Grossly deformed arms and legs, cut-away tissue, it is just awful. We starting seeing it two years ago. All of a sudden, we were saying, where did this come from?"
Tobin and other street workers wonder if a shortage of oxycodone is exacerbating the problem.
As doctors come under more heat for overprescribing the painkillers that contain the chemical, the supply may be decreasing and the price rising.
That's forcing addicts to share their drugs, spreading the infections through needles dipped into the communal pools of melted painkiller.
Few will admit they have an illness until it's obvious, lest their friends refuse to share.
But the doctors managing area methadone clinics say if anything, there seems to be more oxycodone addiction than ever.
"It seems doctors are shying away from oxy, but whether it means there is less out there, I am skeptical," says Dr. John Craven, associate director of Clinic 528, a London methadone treatment centre where painkiller addicts can ease off their drugs by taking methadone.
About two years ago, the clinic had 850 patients. Now it has 1,100.
"We have over 100 people on the waiting list. The clinic is bursting at the seams," Craven says.
In St. Thomas, Clinic 217 has signed up 190 patients in its first 11 months of operation.
"We are seeing younger patients, even under 18 and a few 16, people from all walks of life," says director Dr. Brooke Noftle.
The London clinic is starting to see people with addictions to fentanyl and an increase in people addicted to the painkiller Dilauda, Craven adds.
In part because of the growing numbers of addicts, Canada's medical regulators are developing new guidelines for doctors prescribing all painkillers.
"I don't think they have been significantly changed in 10 years," says Kathyrn Clarke, spokesperson for the Ontario College of Physicians and Surgeons.
National guidelines should be completed by spring, she says.
While London addiction workers welcome anything that slows the diversion of painkillers to the streets, they hope to develop a much more radical solution to the plague of overdoses.
In several major U.S. cities, harm reduction agencies hand out anti-overdose kits to addicts.
Those kits include vials of nalaxone, a drug that can stop the fatal depression of the central nervous and respiratory systems caused by overdoses.
"So if you are out with a peer and that person is going into arrest, you can inject someone and revive them long enough to get the ambulance there and get to the hospital. It has saved countless lives," Eastabrook says.
He and other health officials in London have started to explore getting nalaxone, under the trade name Narcan, into London.
"It is just an idea we are brainstorming," McGregor says. "It is really preliminary."
The cost alone appears prohibitive. A $1.50 dose in Chicago would cost $30 in Canada, McGregor says.
Even if the costs drop over time, street workers in London could face a larger barrier: the public's attitude toward addicts.
Harm reduction is a pillar of the citywide effort -- called London Cares -- to battle homeless and addiction with outreach workers providing clean needles to addicts.
But one city outreach agency ran afoul of London Cares for allowing users to shoot up in its bathroom, rather than on the street.
Anything as radical as a safe injection site would be years away, if ever, given the federal government is going to the Supreme Court of Canada to shut down a site in Vancouver.
"The lens that people are viewed through . . . is very often critical and judgmental," Eastabrook says. "Because there is no real understanding of the issues that lead people to using substances there is little public will to support these programs."
Even so, the latest scourges to hit street people are only making those who help addicts more determined to change the attitude of others, Eastabrook says.
"When you see people who are intelligent, talented, who are full of hope, die . . . the memory of those folks won't go away. For most of us who do this, it fires our work up."
Randy Richmond is a Free Press reporter.
By RANDY RICHMOND, THE LONDON FREE PRESS
Last Updated: 13th February 2010, 1:44am
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