This story is part of A Killer High: A Globe examination into the rise of fentanyl in Canada.
A surge in overdose deaths in Ontario linked to illicit fentanyl is exposing gaps at every level of the health-care system, leaving front-line workers who are responsible for monitoring drug use ill-equipped to respond to the crisis.
Ontario has no surveillance systems tracking a community's drug-use patterns, including physicians who prescribe too many painkillers to their patients or opioids that get diverted to the street. There is also no timely information on the number of fatal opioid overdoses. And hospitals are not required to inform municipal medical-health officers about the number of patients they treat for drug overdoses.
Medical experts say the lack of a co-ordinated response to a spike in overdose deaths in many communities in Ontario is symptomatic of a broader problem: Illicit fentanyl, largely a product of organized crime, has its roots in Canada's epidemic of prescription painkiller abuse.
"I think you really have a very broken system," said Meldon Kahan, medical director of the Substance Use Service at Women's College Hospital in Toronto. "There's a pervasive sense that addiction is not the responsibility of the health-care system."
A Globe and Mail investigation found that neither Ottawa nor the provinces are taking adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain – in 2015 alone, doctors wrote enough prescriptions for one in every two Canadians. And addiction-treatment programs are few and far between – a legacy, in part, of the former Conservative government's tough-on-crime policies.
Fentanyl was developed as a prescription painkiller, but gained popularity as a street drug after OxyContin was removed from the market in Canada in 2012. OxyContin was popular not only with people who became addicted after their doctors prescribed the drug, but also with heroin users, because they could easily snort it like cocaine or inject it like heroin for a quick high.
Fentanyl is up to 100 times more toxic than morphine – the equivalent of two grains of salt can kill a healthy adult. The illicit version of fentanyl is manufactured in China and smuggled into Canada, where the white crystalline powder is diluted with powdered sugar, baby powder or antihistamines. It is also cut with other illicit drugs and sold on the street as heroin or pressed into tablets and sold as fake OxyContin.
In British Columbia and Alberta, the two hardest-hit provinces, fatal overdoses linked to fentanyl soared from 42 in 2012 to 418 in 2015. The Globe investigation also found that the scourge of fentanyl is rapidly moving east.
In the Niagara Region in Southern Ontario, five people have died of overdoses since January after taking heroin believed to be laced with fentanyl. In all of 2015, by comparison, there were only five fatal heroin overdoses in the region.
Toronto Public Health issued an alert last month saying, "a white powdered substance sold as heroin and/or 'china white' " is behind four fatal overdoses in two days reported online to the agency's harm-reduction workers. An illicit version of the prescription opioid fentanyl is known on the street as China White.
Waterloo Region, Peterborough and Kingston have also seen a spike in overdoses.
Federal Health Minister Jane Philpott said Health Canada is funding several projects aimed at developing safer opioid prescribing practices and a pan-Canadian approach to monitoring prescription drug abuse.
"We have sent the message out loud and clear that this is a priority for us," Dr. Philpott said.
The lack of a co-ordinated response in Ontario – the country's largest per capita user of prescription painkillers – stands in stark contrast to British Columbia, which medical experts say serves as a model for the rest of Canada. Officials from the provincial Health Ministry, the B.C. Centre for Disease Control and the province's five regional health authorities meet regularly to discuss prevention measures, treatment, harm reduction and enforcement.
Kieran Michael Moore, associate medical officer of health for KFL&A Public Health, an agency representing Kingston and neighbouring communities, wants Ontario to replicate the B.C. model. Such a system, he said, would allow public-health workers to gather intelligence from the field, including from hospitals, and target those areas most in need of treatment and harm-reduction measures.
"This is a battle," Dr. Moore said. "You need real-time information at your fingertips to be able to have good, reactive policy and effective intervention."
British Columbia is home to some of Canada's most progressive harm-reduction initiatives, including supervised injection sites, heroin-assisted treatment (for a limited group of patients) and a province-wide program that distributes an opioid-overdose-reversing drug to users, free of charge.
Philip Owen, a right-wing politician who served as Vancouver mayor from 1993 to 2002, became an unlikely supporter of supervised injection service after learning about it in the mid-1990s. Vancouver at the time was at the height of an HIV/AIDS epidemic and the status quo, he recognized, was not working. Heeding the calls of local activists, Mr. Owen travelled to Europe, met with other mayors and toured some of the consumption sites that were already open there.
"[City] staff were kind of split on it," Mr. Owen recalled in an interview. "Council was certainly split on it … I was somewhere in the middle. I wasn't sure if I was for or against it. I had to learn about it, and the more I learned, the more I realized that [supervised injection service] is part of recovery, and it's a health issue."
With support from both the provincial and federal governments at the time, Mr. Owen – along with Larry Campbell, who succeeded him as mayor in 2002 – helped open Insite in 2003. It's the first and only government-sanctioned supervised injection site in North America. Other cities, including Toronto, are planning on following Vancouver's lead.
Ontario Health Minister Eric Hoskins said through a spokesman that his ministry "continues to examine opportunities to strengthen addiction services and treatment, with a focus on prescription narcotic misuse and addiction."
Donna May wishes there was treatment available for her daughter after she became addicted to OxyContin and her doctor cut her off. Ms. May, who asked The Globe to refer to her daughter by her nickname, Jac, said she turned to the street, using heroin and working as a prostitute to feed her drug habit. She was in hospital for several weeks after contracting flesh-eating disease. "She had no tools to get clean."
On Aug. 21, 2012, Ms. May found her daughter in her bedroom in respiratory distress. "I heard the rattling sound and knew she was overdosing," Ms. May said. Jac died later that day. She was 34.