In the summer of 2012, a forensic toxicologist from the B.C. Coroner's Service examined a blood sample to help determine the cause of death in a case that pointed to a drug overdose. He was asked to look for lethal levels of OxyContin, but he made a surprising find: The culprit was fentanyl, which at that time was not known as a street drug in Canada.
Walter Martz, the toxicologist, recognized the potential for a dangerous shift. He flagged the case, and triggered events that led to the declaration of British Columbia's first public health emergency earlier this month.
"He said if fentanyl is starting to replace OxyContin, this could be dangerous," recalled chief coroner Lisa Lapointe. Dr. Martz's hunch was correct, and we know this because his response brought about changes in the way the powerful opioid is detected and tracked.
Dr. Martz has moved to Zurich to head up another forensic toxicology lab, but, since his 2012 discovery, the coroner's office has charted a steady increase in drug overdose deaths in B.C. – and fentanyl is claiming a growing share. The synthetic painkiller now contributes to about one third of those fatalities.
Perry Kendall is B.C.'s provincial health officer, a job he held in 2009, when the H1N1 pandemic prompted the World Health Organization to declare a public health emergency of international concern. In British Columbia, H1N1 was responsible for 57 deaths and put more than 1,000 people in hospital.
In a recent interview, Dr. Kendall said he had considered declaring a public health emergency at that time, but did not feel it was warranted. "We had a declaration ready in case H1N1 got out of hand. And it didn't."
But the rising toll of deaths by drug overdose, he believes, is getting out of hand.
In the 1990s, British Columbia experienced a different drug crisis. Fuelled by cheap heroin on the street, drug deaths peaked in 1998 before harm-reduction interventions began bringing down the toll.
Now the numbers are rising again: Last year, 465 people died in B.C. from illicit drug overdoses. The numbers for 2016 are already looking worse, and Dr. Kendall warns that if the trend holds, the province will lose as many as 800 people to overdoses this year.
It does not take much fentanyl – which was developed as a prescription painkiller and is 100 times more powerful than morphine – to be fatal, and before Dr. Martz's find, the Coroner's Service was using tests that detected it only at high levels. More sensitive tests were adopted, and deaths related to fentanyl are now tracked.
The problem is not exclusively fentanyl, but the drug has heightened alarm among health and law enforcement agencies, which, along with representatives of drug users, are monitoring the trend through the B.C. Drug Overdose and Alert Partnership (DOAP).
Members of DOAP were worried about fentanyl particularly because the illicit form was turning up in other street drugs, such as heroin, and many users were unaware they were taking it. But one particular incident turned that concern to alarm.
Jane Buxton, a member of DOAP and the harm-reduction lead for the B.C. Centre for Disease Control, said the moment came during the Thanksgiving long weekend in 2014, when Insite, Vancouver's safe-injection facility, recorded 31 overdoses in two days. Police issued a warning to local users about a batch of bad heroin. Tests later revealed it was not heroin – the victims had unknowingly ingested a cocktail of fentanyl and caffeine.
The DOAP team recommended changes, including wider distribution of naloxone, a treatment that can reverse an opioid overdose. That and other measures have saved lives, but have not been enough to turn the tide.
"It's important to get better and more timely data to figure out where we need to do interventions," Dr. Buxton explained. What the coroner's statistics do not do is track clusters of overdoses when they occur, so that service agencies can target warnings to at-risk users before it is too late.
"The deaths are the tragic tip of the iceberg," Dr. Buxton said. "The people we need to reach out to are the people who are at risk of an overdose."
In early April, Dr. Kendall met with public health officers from the regional health authorities for a regular conference in Victoria. Armed with the recommendations from DOAP, the health officers took the opportunity to lean on Dr. Kendall to do what he had not done during the H1N1 pandemic – declare a public emergency so he could take further measures.
Over two days of meetings, the health officers lobbied Dr. Kendall to invoke those emergency powers, which would give him the authority to gather real-time data on overdoses so timely and accurate warnings could be issued to users when bad drugs hit the streets.
"I thought the data they had was adequate to realize this was big concern, but my colleagues all said no, absolutely we need more data to enable us to enhance our responses," Dr. Kendall said.
He spent the weekend thinking about the recommendation. It would be the first time these powers had ever been used in B.C.
Provincial Health Minister Terry Lake was mulling the problem over as well. Dr. Kendall is frequently on the conference calls for the minister's morning briefing, and the issue of fentanyl – and the rise of overdose deaths – was not new, but the trend line was discouraging. On Monday, April 11, both men had arrived at the same conclusion: Something more had to be done.
"On the weekend, The Globe and Mail ran a story of the pathway of fentanyl into the country," Mr. Lake recalled. The article was part of a Globe investigation that found that Ontario, like the other provinces and Ottawa, is not taking adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain. Illicit fentanyl, largely a product of organized crime, has its roots in abuse of prescription painkillers.
"I spent a lot of time on the weekend thinking about it," Mr. Lake said. "And then on Monday morning, I said to Dr. Kendall: 'Is there anything more we can be doing?'"
The chief health officer explained his plan to invoke emergency powers. Mr. Lake agreed. "I said: 'Whatever we can do, we should do, because this is truly an epidemic that needs to be addressed,'" the Health Minister said.
Mr. Lake said in an interview that he sees these overdose deaths as a public health concern, not a criminal matter.
"If this was Ebola or any other communicable disease, we would be saying, 'Whoa, we have to do something.' I think it was a growing realization that it wasn't getting better and lives and families are being destroyed despite all we are doing – and we are doing a lot. We wanted to make sure we are doing as much as we possibly could."