The lineups start before 8 in the morning outside the drug stores of Thunder Bay – recovering opioid users form queues to obtain their daily dose of methadone, the drug that alleviates the wretched symptoms of withdrawal.
Across Canada, the opioid epidemic killed an estimated 4,000 people last year. Since 2014, fentanyl is the drug that has been implicated in a majority of the deaths. But Thunder Bay is different.
There is fentanyl here, too – and heroin and crack cocaine and crystal meth. But the drug most frequently found in the bodies of people who died after overdosing in this city is the same one prescribed to wean people off their addictions.
The leading opioid present in the bodies of overdose victims in Thunder Bay is methadone.
“With methadone, you can’t jump back and forth, you have to stay on the same amount of dosage,” said Ron Kanutski, a former drug user who comes from the Lake Helen Reserve and is now an addiction counsellor. “So, if you are taking methadone, and then you are taking fentanyl, and then you go back to your methadone dosage, that’s it. Pow. Lights out.”
The statistics on methadone in Thunder Bay are sobering.
There were 1,827 people taking legally prescribed methadone in Thunder Bay and the surrounding district in 2018, a number that was down slightly from five years earlier when there were 1,995. But, over the same period, the number of users of Suboxone – a newer and less-addictive synthetic opioid that is a methadone alternative − climbed from 461 to 2,077.
That means the number of people in this region receiving opioid therapy increased by more than 56 per cent over those years.
It could be that more people in this region are feeling comfortable about coming forward and getting treatment, said Cynthia Olsen, the head of the Thunder Bay Drug Strategy, a program created by the city in 2009. Or it could mean, she said, that more people are becoming addicted to opioids.
“We know, across Canada, opioid use has not slowed down,” Ms. Olsen said. “And neither have the deaths."
Thunder Bay’s drug strategy involves 60 community groups that are working to prevent, treat and reduce the harms of substance abuse. It targets a wide range of drugs, including alcohol, prescription pharmaceuticals, marijuana and illegal opioids. The most recent report of its opioid-response task force points out that Thunder Bay has the highest number of people on methadone in Ontario and that it is the drug most often detected in the city’s overdose deaths.
Opioids such as heroin, fentanyl, oxycodone, codeine, hydromorphone and morphine are a class of drug that activate the body’s opioid receptors to inhibit pain or induce euphoria. They are prescribed legally for pain relief, and are consumed illegally for recreational purposes.
But they can also be deadly. An overdose of opioids − including methadone − slows breathing, sometimes to a stop.
Opioids are also addictive. Withdrawal brings on chills, widespread pain and body aches, nausea, insomnia, diarrhea, nervousness and sweating. If a drug user decides it’s time to quit, a doctor may prescribe methadone or Suboxone to alleviate those symptoms without bringing on a high, which allows the person to live a more stable life.
When methadone became widely available as a treatment option in Ontario in 1996, it was intended to be taken for a year or two as a way of gradually ending an addiction, Mr. Kanutski said. But some people in Thunder Bay, he added, have been on it for decades.
Although that is true everywhere in Ontario, Thunder Bay is home to a disproportionate number of methadone users.
According to the Ontario Drug Policy Research Network, 2.2 per cent of the residents in the area served by the Thunder Bay District Health Unit, which slices across the centre of Northwestern Ontario from Lake Superior to Hudson Bay, were taking opioids to treat their addictions in 2018. That was 5½ times the provincial rate, and more than 10 times the rate in Toronto.
In 2018, there were 250 doctors who prescribed opioids, including methadone, in the Thunder Bay region. Toronto, with 25 times the population, had just more than 900.
In 2014, as Alvin Fiddler, the Grand Chief of the Nishnawbe Aski Nation, accepted an award from the Thunder Bay Medical Society, he took doctors to task for opening a seventh methadone clinic in Thunder Bay but failing to provide adequate health services on reserves. His censure made little impact.
Prescribing methadone can be a lucrative proposition.
A number of Ontario’s highest-billing physicians are methadone providers. They charge, not only for prescribing the drug and for addiction counselling, but also for the frequent urine tests that are required by their patients, who must turn up weekly to stay in the program.
Methadone, meanwhile, is a crutch, not a cure.
“It keeps people dependent,” said Mr. Kanutski, who was never addicted to opioids but says he used “probably just about everything else” before he became sober 29 years ago.
“You will never hear about a methadone healing centre,” he said. “It’s called a maintenance program because it’s paid to keep you where you are at.”
On the streets, opioid users call it the “liquid handcuff” because, once they are in an opioid program, their life becomes regimented around their next dose. Every day, those who have not earned the right to walk away with more than a single dose must make a trip to the pharmacy.
Even the most trusted users, who are allowed to “carry” a week’s supply, must take one dose in seven orally under the supervision of a pharmacist or doctor before they can go home with another six that have been mixed with fruit juice so they cannot be injected into someone’s arm.
But still, it is diverted for sale on the streets.
In 2015-16, the most recent year for which numbers are available, methadone was present in the bodies of half of the 14 people who succumbed to a drug overdose in the Thunder Bay region.
Ms. Olsen cautions that the presence of methadone in the body of someone who had died of a drug overdose does not mean that methadone was the killer. There may have been other opioids in the person’s system that contributed to, or even caused, the death.
Nor does it mean that the person who died was receiving methadone prescribed by a doctor, Ms. Olsen said. There is a healthy black market in methadone in Thunder Bay.
A pharmacist who worked for several years at a Shoppers Drug Mart in the city and now works for the provincial government recalls the various ways that patients would try to keep some of their dosage for resale.
Some would try to hide it in their cheeks, said the pharmacist, who was granted anonymity because he does not have permission from his current employer to speak on the record. That is why all users must say a few words at the drug store counter after they have downed their daily dose.
There are also many stories, he said, of people vomiting up the methadone so they could sell it illegally. Drug users will buy bile infused with methadone.
Methadone can take several days to stabilize in the body, the pharmacist said. So some people may try to buy extra amounts from a friend or a dealer when they do not get immediate relief from their withdrawal symptoms.
And the strict regimen of the methadone program may also deter people from taking part, he said.
Police Chief Sylvie Hauth said methadone is among the drugs traded by the criminal gangs that have moved into Northwestern Ontario.
“They see how lucrative it is,” Chief Hauth said. “We can’t arrest them fast enough. We have times when we have put three in custody and six will be behind them saying ‘I will take my chances, it’s worth it.' ”
Many people in Thunder Bay are making money off methadone, Mr. Kanutski said.
Some of them are doctors, some are pharmacists and some are illegal drug dealers. And the desperation of the users who are not being weaned off of opioids is keeping them in business, he said. “People have to know there is a way out" of methadone treatment.