When news broke that British Columbia had suffered its worst-ever month for illicit-drug overdose deaths in November, Toronto's mayor contacted his Vancouver counterpart to offer help, as he would have if the West Coast city had experienced a "natural disaster."
Vancouver Mayor Gregor Robertson told John Tory there was not much Toronto could do from afar, other than brace itself for the eastward spread of illicit fentanyl, the powerful painkiller driving B.C.'s crisis.
The correspondence so rattled Mr. Tory that he decided to throw his political weight behind a meeting of nearly 20 organizations – including police, paramedics, hospital officials, and harm reduction advocates – that is set to take place at Toronto City Hall on Monday and will guide the city's strategy on illicit-drug overdoses.
Bootleg fentanyl has not taken the toll on Canada's largest city that it has on other major centres, but on Toronto's streets, there are signs the problem is escalating.
Toronto police seized more than three kilograms of fentanyl last year, up 750 per cent from the approximately 350 grams of fentanyl the force confiscated the year before. The city's paramedics used the overdose antidote naloxone more often in 2016 than in the two years prior, and the local public-health unit says that, anecdotally, outreach workers are seeing more overdoses linked to illicit fentanyl than in the past.
Yet Toronto's preparations are well behind Vancouver's: There is no real-time surveillance of overdoses or overdose deaths, naloxone is not as widely available as it is on the West Coast and Toronto's plan for three supervised-injection sites is bogged down, awaiting approval from Ottawa and funding from Queen's Park.
Monday's meeting of the Toronto Early Warning and Alert Partnership, convened by the city's acting chief medical officer of health, is designed to bring together all the players who would help in an overdose epidemic, something Mr. Robertson and his staff urged Toronto to do as soon as possible.
"Even just to read [Mr. Robertson's] e-mails was horrific," Mr. Tory said. "He was describing to me that [first responders] were just traumatized by this repeated instance of people they were finding in all corners of Vancouver, hundreds of people, some of whom were able to be helped and some of whom were losing their lives."
Councillor Joe Cressy, chair of the Toronto Drug Strategy, said the city has already been preparing for bootleg fentanyl to cause more overdoses, but he said it needs more real-time information and financial support, especially from upper levels of government.
"The risk of fatal overdose has moved from the marginalized back alleys and on to the main streets and Bay Street," Mr. Cressy said. "The overdose crisis is about to hit home for many more people in the city of Toronto."
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 cut with other drugs and sold on the street or pressed into pills and sold as fake OxyContin.
Quantifying the reach of bootleg fentanyl in Toronto – and all of Ontario – is difficult right now.
The most recent opioid-overdose death figures from the Office of the Chief Coroner of Ontario are from the end of 2015. (B.C., which declared a public-health emergency in response to the overdose crisis last spring, releases monthly figures. The province had 128 overdose deaths in November alone.)
Still, the out-of-date statistics for Ontario show that 707 people died of opioid overdoses in 2015, some involving alcohol and multiple opioids, up from 514 in 2010. Fentanyl was to blame or partly to blame in 204 of the cases in 2015, more than any other single opioid.
In Toronto, there were 154 deaths caused by opioids or a combination of opioids and alcohol in 2015. Again, fentanyl was the most frequent culprit, according to the coroner's office.
Acting Inspector Steve Watts of the Toronto Police drug squad said the force not only seized significantly more fentanyl in 2016 than it did in years past, it also found the drug in new disguises.
In 2015, most of the fentanyl Toronto police confiscated was in prescription patches; by 2016, it was primarily discovered cut into cocaine, heroin and fake OxyContin pills, he said.
"There's been a significant increase between 2015 and 2016 in terms of fentanyl," Insp. Watts said. "It's just becoming more prevalent."
Toronto's paramedics, in the meantime, used the antidote naloxone to revive 161 overdose victims in 2016, up from 110 in 2015 and 109 in 2014. It's not known which opioids were behind those overdoses.
Last year was the first in which all paramedics were required to carry naloxone kits, which likely contributed to the increase in its use. Prior to 2016, only about 30 per cent of Toronto paramedics carried the antidote, said Kim McKinnon, a spokeswoman for Toronto Paramedic Services.
Monday's meeting aims to gather this kind of scattered information in one place, then use it to guide the city's response.
"We don't have a complete picture," said Susan Shepherd, manager of the Toronto Drug Strategy. "By bringing everyone together and sharing that information we'll be able to have a better picture of what is happening on the street level."
Mr. Tory, who has also asked the country's big-city mayors to address the issue at a meeting this month, said it was time for politicians to approach the overdose epidemic as they would a frightening new disease or spike in crime.
"I think it's time we started to treat this as the national crisis that it is," he said.