The Deadly Gamble of Fentanyl: Understanding the Opioid Crisis in British Columbia

Feature by EHN Guest Writer

Written by Matthew Harvey, Ph.D. (ABD), writer and researcher.

On July 15 2016, there was a sudden spike in admittances for opioid overdose at the Surrey Memorial Hospital in Surrey, BC. Over the next four days, more than forty patients—three times the usual number—were treated in the hospital’s emergency room for overdose symptoms. Three were admitted to the intensive care unit, and one died.[i]

What distinguished these events, and merited their publication in a medical journal, was the nature of the overdoses. More than half the patients were men from the local homeless population who had smoked crack cocaine laced with a close relative of the highly concentrated synthetic opioid fentanyl. None of the men had known their drugs were contaminated, and none had intended to use fentanyl. Police later reported that all 22 of these patients had likely purchased crack that came from a single batch sold by a single dealer.

Just as alarming was the difficulty of saving the overdose victims. Although almost all of the admitted patients had been treated with the emergency overdose-drug naloxone, they had required more than nine times the dose that is standard for other opioid drugs such as oxycodone and heroin.

British Columbia’s fentanyl epidemic

The experience these patients underwent is emblematic of the public health emergency currently facing British Columbia.[ii] While the province has struggled with high rates of misuse of both prescription and illicit opioids since the early 2000s, over the last five years overdose deaths have increased exponentially, totaling more than 1,500 in 2018 alone.[iii]

The significant majority of those deaths—an estimated 73%—were caused by fentanyl and other similar substances (“analogues”) created to imitate its effects. Together, they are a group of synthetic opioids far deadlier than the drugs that drove earlier stages of the crisis.[iv] Taking only accidental overdoses into account (i.e. excluding deaths by suicide and those where manner of death was unclear) fully 88% of opioid overdose deaths in BC, in 2018, involved fentanyl or one of its analogues.[v] Fentanyl killed more than 1,340 British Columbians in that year alone, and overdoses have continued at a similar rate in the first three months of 2019.[vi] Only Ontario and Alberta have seen deaths on a similar scale, and the chief difference between these provinces and those reporting fewer overdose fatalities is the availability and prevalence of fentanyl relative to other opioids.[vii]

Most of those affected are men, and the majority are between the ages of 20 and 39, and vulnerable populations such as the homeless, First Nations Canadians, and Canadians living with mental health disorders are especially hard-hit.[viii] The public health risk is so severe that it has reduced average life expectancy for British Columbians over each of the last three years—something that has not happened since World War II.[ix]

The fentanyl epidemic was declared a public health emergency in April 2016,[x] and in September of last year BC Public Health Minister Judy Darcy described it as the worst public health crisis in decades.[xi] Her comments accompanied the Federal Government’s emergency allocation of $72 million to improve access to addiction treatment services in BC, and came just one month after the province filed lawsuits against more than 40 companies involved in the manufacture and distribution of opioids.[xii]

Even as the government continues to ramp up its efforts to combat the epidemic, research has been underway investigating its causes, and how it can best be addressed. That research has revealed how the drug’s intensity and quick onset have combined with its low cost and the practice of mixing it with other substances to drastically increase the risks of using illicit opioids.

Fentanyl as the “third wave” of the opioid crisis

Fentanyl would not be nearly so dangerous had it not emerged during an ongoing opioid epidemic. The misuse of prescription and illicit opioids is caused by a complex web of factors ranging from over-prescription by doctors to economic depression.[xiii] The opioid crisis began in the 1990s as other pain medications were abandoned over safety concerns even while reports of chronic pain increased, due to factors such as increasing rates of obesity and an aging population.[xiv] Pharmaceutical companies stepped in to fill the gap with powerful new pain medications whose addictive properties they concealed, even as they drove the drugs’ popularity with aggressive lobbying and physician kickback schemes.[xv] Prescriptions for opioids tripled in Canada during the 1990s, and only began to decline as the public became aware of their dangers at the end of the 2000s.[xvi]

Even as misuse of prescription opioids declined, however, use of heroin began to increase, driven both by some users’ need for stronger doses of opioids and by the introduction of new and more abundant sources of the drug.[xvii] The problem was especially acute in port cities like Vancouver, which was a major import center for heroin,[xviii] and risks were greatest for those living in poverty or with mental health disorders.[xix] Over the late 2000s and early 2010s, the group of people who used opioids became younger, skewed male, and showed increasing evidence of using multiple substances as once.[xx]

This same population is now increasingly using fentanyl, which has emerged as the “third wave” of the opioid epidemic in BC. Its availability has skyrocketed over the last several years: police seizures of fentanyl numbered just 6 in 2009, but had reached 1,997 by 2016.[xxi]

But fentanyl is not necessarily an enjoyable drug. Its surge in popularity has very little to do with the preferences of the people consuming it. It is driven, instead, by the drug’s wholesale cost—which can be as low as 5% of the cost of heroin—and its potency, which makes it easier to transport.[xxii] The consensus among law enforcement agencies in Canada and the United States is that the fentanyl available on the street is manufactured primarily in illegal laboratories in China.[xxiii] From there, it is then sent through the global post, where it almost always passes undetected thanks to its minimal weight and volume, its largely odorless nature, and a series of outdated laws that prevent Canadian law enforcement from searching many packages sent through the Canadian postal service.[xxiv] Because of the drug’s low price and accessibility, dealers in BC and elsewhere have increasingly been selling their opioid-addicted customers “heroin” powder that is either adulterated with fentanyl or has been substituted entirely,[xxv] as well as counterfeit versions of prescription opioid pills containing fentanyl rather than the oxycodone that buyers expect.[xxvi]

Drug users are not happy about the change. In interviews and surveys, most express a strong dislike for fentanyl’s effects, which include dizziness, tingling in their arms and legs, and severe disorientation rather than the drowsiness and comfort usually experienced with other opioids.[xxvii] Many users also regard fentanyl as far more dangerous than other opioids, and try to avoid it for that reason.[xxviii]

But most find their options limited. In BC, as in other especially hard-hit parts of North America, it has become extremely difficult to find opioids that are not adulterated with fentanyl.[xxix] Worse, very few users can tell the difference drugs that are “pure” and those that are laced with fentanyl, leaving them dependent on their dealers to provide safe products.[xxx] And because those dealers are under economic pressure to sell the cheaper and more accessible fentanyl rather than heroin and prescription medications, its use has continued to spread. It is important to recognize that the increasing presence of fentanyl is the primary driver of the current wave of overdose deaths: BC is above the national average in median income, unemployment, obesity, and other key risk factors for drug addiction, and has developed a standout response to the crisis.[xxxi] The difference is fentanyl and fentanyl analogues.

Causes of fatal overdose

Fentanyl is not just a cheaper opioid with a different high. Its increasing prevalence has triggered a public health crisis specifically because it is such a deadly drug.[xxxii] Fentanyl injections are twice as likely to be fatal as heroin injections, and eight times as likely as injections of any other opioid.[xxxiii] By 2016 fentanyl was detected in 62% of all overdose deaths in BC, up from just 4% in 2012. That number has continued to rise, passing 80% in early 2018.[xxxiv] There are three factors behind this incredible lethality.

First, many users simply struggle to determine the correct dose of the drug, because it is so concentrated that even a high dose can be difficult to measure exactly without professional training and equipment.[xxxv] In fact, potentially lethal doses of fentanyl are so small that they overlap with doses considered safe for the managed treatment of pain.[xxxvi] This situation can and does lead to accidental overdoses, even among experienced users of illicit opioids.[xxxvii]

Second, as mentioned above, fentanyl is very often mixed with other drugs prior to sale. As in the case of the fentanyl-laced crack cocaine that affected so many people in Surrey, this mixing causes many people to use fentanyl unintentionally, and without any control over the dose.[xxxviii] This problem is exacerbated by the fact that almost everyone who has taken fentanyl—deliberately or not—is also a user of other drugs, usually heroin, crystal meth and other methamphetamines, or crack cocaine.[xxxix] Fentanyl can interact negatively with these other drugs, leading to potentially fatal overdose when taking what might otherwise have been a non-life-threatening dose.[xl]

The third factor that contributes to fentanyl’s deadliness is the difficulty of treating overdoses. BC is a leader in addressing the opioid crisis, thanks to its funding for Overdose Prevention Centers where users can inject or smoke safely and with easy access to emergency medical equipment. These centers are extremely effective: of the 268 drug overdose deaths in BC during the first three months of 2019, almost all (88%) took place at home or in hotel rooms. Just 10% took place on the street, and none at all took place in Overdose Prevention Centers.[xli] Those taking fentanyl at home have a much higher chance of overdosing without anyone nearby who can call 911 or administer live-saving naloxone, meaning that their overdoses are far more likely to be fatal.[xlii]

And fentanyl overdoses demand an almost instantaneous medical response if the patient is to be saved. Where high doses of heroin typically take 20-30 minutes to become fatal, fentanyl overdoses kill in as little as two minutes.[xliii] Naloxone must be administered within this window, in doses 2-to-5-times greater than that required to treat heroin overdoses, even as the patient’s body becomes rigid and they lose consciousness.[xliv]

Vulnerable communities

Fentanyl itself is not the only factor in the current epidemic, however. Some communities—and some individuals—are far more vulnerable to fatal overdose than others, and while the causes of this vulnerability are not unique to BC, they are certainly present. For instance, while incarcerated, many individuals do not have access to the drugs that they normally use, which can cause them to lose their built-up tolerance for opioids without them being aware of the change. The next time they use, their “regular” dose can be fatal. This problem puts convicts at much greater risk of death from overdosing.[xlv]

Other populations share similar dangers. Comorbid medical conditions including obesity and mental health disorders drastically increase the risk of death from fentanyl overdose.[xlvi] And both the incidence and deadliness of overdoses are higher for marginalized groups. Members of First Nations communities are five times as likely to experience a fentanyl overdose as are other British Columbians, and are three times as likely to die from one.[xlvii] Homelessness, too, is a major risk factor.[xlviii] Almost 30% of overdose victims in Canada lack permanent housing,[xlix] and homelessness is associated with a significantly increased risk of opioid overdose[l] as well as a far greater risk of starting to use injection drugs.[li]

These forms of social marginalization are linked to overdose risk in the same way that poverty is: it makes life harder, more dangerous, and more difficult, closing off opportunities and undermining financial and material safety nets. All of this turns people towards the relief provided by drugs. Persistent and unhealthy opioid use has been called a “disease of hopelessness,” much like alcohol misuse and death by suicide.[lii] According to Sarah Bythe, the founder of Vancouver’s Overdose Prevention Society, the loss of hope is a key cause of many overdose deaths, especially among these at-risk groups.[liii] “The more bad experiences a person has in their life, the more hopeless they feel and the less likely they might be to care,” she said. “If you’re living in an alley and everything’s going wrong, your life continues to spiral in a way where there’s nothing positive.”

Looking ahead

Despite the extraordinary deadliness of fentanyl, the difficulty of separating it from other substances, and the high risk it poses to many living in BC, there are reasons for hope. Emergency funding and the opening of many new Overdose Prevention Centers seem to have helped, with overdose fatalities appearing to level off through the end of 2018 and the beginning of 2019.[liv] The province’s exemplary Take Home Naloxone program has distributed over a hundred thousand naloxone treatment kits,[lv] which are estimated to have reduced fentanyl overdose deaths in 2018 by 15-30%.[lvi] At the same time, programs for distributing easy-to-use fentanyl test strips seem to have made headway in helping people detect the presence of fentanyl in their drugs.[lvii] Preliminary evidence suggests that British Columbians who use opioids are willing to use the test kits to help them avoid fentanyl and monitor the purity of their drugs, and that the test results might motivate them to visit Overdose Prevention Centers and apply the strips consistently.[lviii]

These trends are encouraging. So long as the BC government continues to take the same proactive approach that it has taken thus far, and continues to prioritize harm reduction over simply reducing the volume of drug use, the fentanyl epidemic will gradually wane. And they could still take bolder action to combat the crisis, moving beyond harm reduction to full decriminalization of possessing illegal drugs. This move, which has been strongly advocated by BC’s Provincial Health Officer Dr. Bonnie Henry,[lix] would address some of fentanyl’s unique dangers by making users far more likely to seek help and support, make use of emergency and preventive services, and avoid the risks of at-home use when alone.[lx]

For now, if you or a loved one struggle with opioid use, you can take action by promoting local Overdose Prevention Centers, destigmatizing drug use, and helping to educate your community about take-home naloxone kits and fentanyl test strips.

We Can Help You

If you would like to learn more about the treatment programs provided by EHN Canada, or if you have any questions about addiction or mental health, please call us at one of the numbers below. Our phone lines are open 24/7—so you can call us anytime.

  • 1-800-387-6198 for Bellwood Health Services in Toronto, ON
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Further Reading

Health Canada provides the following additional resources:

About fentanyl

About Canada’s opioid crisis

References

[i] Klar, S. A., Brodkin, E., Gibson, E., Padhi, S., Predy, C., Green, C., & Lee, V. (2016). Furanyl-fentanyl overdose events caused by smoking contaminated crack cocaine—British Columbia, Canada, July 15–18, 2016. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice36(9), 200.

[ii] McKee, G., Amlani, A., & Buxton, J. (2015). Illicit fentanyl: An emerging threat to people who use drugs in BC. BC Medical Journal, 57(6), 235.

[iii] Special Advisory Committee on the Epidemic of Opioid Overdoses, Public Health Agency of Canada Ottowa. (2019). National report: Apparent opioid-related deaths in Canada (January 2016 to December 2018). Retrieved from https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html

[iv] Abdesselam, K., Dann, M., Alwiss, R., Laroche, J., & Priouzeau, S. (2018). At-a-glance-Opioid surveillance: monitoring and responding to the evolving crisis. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(9), 312.

Armenian, P., Vo, K. T., Barr-Walker, J., & Lynch, K. L. (2018). Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology134, 121-132.

Mayer, S., Boyd, J., Collins, A., Kennedy, M. C., Fairbairn, N., & McNeil, R. (2018). Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada. Drug and Alcohol Dependence, 193, 69-74.

Somerville, N. J., O’Donnell, J., Gladden, R. M., Zibbell, J. E., Green, T. C., Younkin, M., … & Kuramoto-Crawford, J. (2017). Characteristics of fentanyl overdose—Massachusetts, 2014–2016. Morbidity and Mortality Weekly Report, 66(14), 382-386.

[v] Public Health Agency of Canada. (2019, 10 April). Updated Numbers on Opioid-Related Overdose Deaths in Canada. Retrieved from https://www.canada.ca/en/public-health/news/2019/04/updated-numbers-on-opioid-related-overdose-deaths-in-canada.html

Special Advisory Committee on the Epidemic of Opioid Overdoses, Public Health Agency of Canada Ottowa. (2019). National report: Apparent opioid-related deaths in Canada (January 2016 to December 2018). Retrieved from https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html

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[vi] British Columbia Coroners Service. (2019a). Fentanyl-detected illicit drug overdose deaths in BC, January 1, 2009—March 31, 2019. Retrieved from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/fentanyl-detected-overdose.pdf

[vii] Belzak, L., & Halverson, J. (2018). Evidence synthesis-The opioid crisis in Canada: a national perspective. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(6), 224.

[viii] British Columbia Coroners Service. (2019a). Fentanyl-detected illicit drug overdose deaths in BC, January 1, 2009—March 31, 2019. Retrieved from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/fentanyl-detected-overdose.pdf

Canadian Institute for Health Communication. (2018). Latest data on the opioid crisis. Retrieved from https://www.cihi.ca/en/latest-data-on-the-opioid-crisis

[ix] Statistics Canada. (2019a). Changes in life expectancy by selected causes of death, 2017. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/190530/dq190530d-eng.htm

Xibiao, Y., Jenny, S., Bonnie, H., Mark, T., & William, K. P. R. (2018). At-a-glance-Impact of drug overdose-related deaths on life expectancy at birth in British Columbia. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(6), 248.

[x] BC Center for Disease Control. (2018a). Estimated impact of the provincial take-home naloxone program on preventing illegal drug-related deaths in B.C.. Retrieved from http://www.bccdc.ca/health-professionals/data-reports/overdose-response-reports

[xi] Canadian Broadcasting Corporation. (2018b, 6 September). “Health minister announces $71.7M in emergency funding for drug treatment in B.C.” Retrieved from https://www.cbc.ca/news/canada/british-columbia/substance-abuse-announcement-toronto-opioid-symposium-1.4812842

[xii] Britten, L. (2018, 29 August). “B.C. sues opioid makers for ‘negligence and corruption’ about addiction risks.” Canadian Broadcasting Corporation. Retrieved from https://www.cbc.ca/news/canada/british-columbia/bc-opioid-lawsuit-1.4803030

[xiii] King, N. B., Fraser, V., Boikos, C., Richardson, R., & Harper, S. (2014). Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. American Journal of Public Health, 104(8), e32-e42.

[xiv] Dasgupta, N., Beletsky, L., & Ciccarone, D. (2018). Opioid crisis: no easy fix to its social and economic determinants. American Journal of Public Health, 108(2), 182-186.

[xv] Ciccarone, D. (2019). The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. International Journal on Drug Policy, 70.

Fischer, B., Jones, W., & Rehm, J. (2014). Trends and changes in prescription opioid analgesic dispensing in Canada 2005–2012: an update with a focus on recent interventions. BMC Health Services Research, 14(1), 90.

[xvi] Abdesselam, K., Dann, M., Alwiss, R., Laroche, J., & Priouzeau, S. (2018). At-a-glance-Opioid surveillance: monitoring and responding to the evolving crisis. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(9), 312.

[xvii] Ciccarone, D. (2019). The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. International Journal on Drug Policy, 70.

[xviii] Fischer, B., Rehm, J., Patra, J., & Cruz, M. F. (2006). Changes in illicit opioid use across Canada. CMAJ, 175(11), 1385-1385.

[xix] Wood, E., Kerr, T., Spittal, P. M., Tyndall, M. W., O Shaughnessy, M. V., & Schechter, M. T. (2003). The health care and fiscal costs of the illicit drug use epidemic: The impact of conventional drug control strategies, and the potential of a comprehensive approach. British Columbia Medical Journal, 45(3), 128-134.

[xx] Buxton, J. A., Skutezky, T., Tu, A. W., Waheed, B., Wallace, A., & Mak, S. (2009). The context of illicit drug overdose deaths in British Columbia, 2006. Harm Reduction Journal, 6(1), 9.

Fischer, B., Patra, J., Cruz., M., Gittens, J., & Rehm, J. (2008). Comparing heroin users and prescription opioid users in a Canadian multi-site population of illicit opioid users. Drug and Alcohol Review, 27(6), 625-632.

[xxi] Baldwin, N., Gray, R., Goel, A., Wood, E., Buxton, J. A., & Rieb, L. M. (2018). Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: an observational analysis. Drug and Alcohol Dependence, 185, 322-327.

[xxii] Frank, R. G., & Pollack, H. A. (2017). Addressing the fentanyl threat to public health. New England Journal of Medicine, 376(7), 605-607.

[xxiii] The Canadian Press Staff. (2019, 31 May). “Canada needs to ‘hold China accountable’ for flow of fentanyl: Scheer.” Global News. Retrieved from https://globalnews.ca/news/5340524/andrew-scheer-fentanyl-china/

U.S. Immigration and Customs Enforcement, U.S. Department of Homeland Security. (2018.) Statement of Matthew C. Allen regarding “Stopping the Poison Pills: Combatting the Trafficking of Illegal Fentanyl from China,” United States Senate Caucus on International Narcotics Control. Retrieved from https://www.drugcaucus.senate.gov/sites/default/files/FINAL%20ICE%20Allen%20-%20China%20Fentanyl%20Testimony.pdf

[xxiv] Brownell, C. (2019, 7 March). “For fentanyl importers, Canada Post is the shipping method of choice.” MacLean’s. Retrieved from https://www.macleans.ca/news/canada/fentanyl-mail/

Von Spakovsky, H., & Smith, P. (2019). China is poisoning America with fentanyl. The Heritage Foundation. Retrieved from https://www.heritage.org/crime-and-justice/commentary/china-poisoning-america-fentanyl

[xxv] Mars, S. G., Ondocsin, J., & Ciccarone, D. (2018). Sold as heroin: perceptions and use of an evolving drug in Baltimore, MD. Journal of Psychoactive Drugs, 50(2), 167-176.

Marshall, B. D., Krieger, M. S., Yedinak, J. L., Ogera, P., Banerjee, P., Alexander-Scott, N. E., … & Green, T. C. (2017a). Epidemiology of fentanyl-involved drug overdose deaths: a geospatial retrospective study in Rhode Island, USA. International Journal of Drug Policy, 46, 130-135.

[xxvi] McKee, G., Amlani, A., & Buxton, J. (2015). Illicit fentanyl: An emerging threat to people who use drugs in BC. BC Medical Journal, 57(6), 235.

[xxvii] Carroll, J. J., Marshall, B. D., Rich, J. D., & Green, T. C. (2017). Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study. International Journal of Drug Policy, 46, 136-145.

Ciccarone, D., Ondocsin, J., & Mars, S. G. (2017). Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and-substituted ‘heroin’. International Journal of Drug Policy, 46, 146-155.

Macmadu, A., Carroll, J. J., Hadland, S. E., Green, T. C., & Marshall, B. D. (2017). Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically. Addictive Behaviors, 68, 35-38.

[xxviii] Carroll, J. J., Marshall, B. D., Rich, J. D., & Green, T. C. (2017). Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study. International Journal of Drug Policy, 46, 136-145.

Mayer, S., Boyd, J., Collins, A., Kennedy, M. C., Fairbairn, N., & McNeil, R. (2018). Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada. Drug and Alcohol Dependence, 193, 69-74.

[xxix] Ciccarone, D., Ondocsin, J., & Mars, S. G. (2017). Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and-substituted ‘heroin’. International Journal of Drug Policy, 46, 146-155.
Mars, S. G., Ondocsin, J., & Ciccarone, D. (2018). Sold as heroin: perceptions and use of an evolving drug in Baltimore, MD. Journal of Psychoactive Drugs, 50(2), 167-176.

[xxx] Amlani, A., McKee, G., Khamis, N., Raghukumar, G., Tsang, E., & Buxton, J. A. (2015). Why the FUSS (Fentanyl Urine Screen Study)? A cross-sectional survey to characterize an emerging threat to people who use drugs in British Columbia, Canada. Harm Reduction Journal, 12(1), 54.

Jones, A. A., Jang, K., Panenka, W. J., Barr, A. M., MacEwan, G. W., Thornton, A. E., & Honer, W. G. (2018). Rapid change in fentanyl prevalence in a community-based, high-risk sample. JAMA Psychiatry, 75(3), 298-300.

Mayer, S., Boyd, J., Collins, A., Kennedy, M. C., Fairbairn, N., & McNeil, R. (2018). Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada. Drug and Alcohol Dependence, 193, 69-74.

[xxxi] Navaneelan, T., & Janz, T. (2015). Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias. Statistics Canada Catalogue no. 82-624-X. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm

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[xxxii] Abdesselam, K., Dann, M., Alwiss, R., Laroche, J., & Priouzeau, S. (2018). At-a-glance-Opioid surveillance: monitoring and responding to the evolving crisis. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(9), 312.

[xxxiii] Latimer, J., Ling, S., Flaherty, I., Jauncey, M., & Salmon, A. M. (2016). Risk of fentanyl overdose among clients of the Sydney Medically Supervised Injecting Centre. International Journal of Drug Policy, 37, 111-114.

[xxxiv] Baldwin, N., Gray, R., Goel, A., Wood, E., Buxton, J. A., & Rieb, L. M. (2018). Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: an observational analysis. Drug and Alcohol Dependence, 185, 322-327.

British Columbia Coroners Service. (2019a). Fentanyl-detected illicit drug overdose deaths in BC, January 1, 2009—March 31, 2019. Retrieved from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/fentanyl-detected-overdose.pdf

[xxxv] Sutter, M. E., Gerona, R. R., Davis, M. T., Roche, B. M., Colby, D. K., Chenoweth, J. A., … & Albertson, T. E. (2017). Fatal fentanyl: one pill can kill. Academic Emergency Medicine, 24(1), 106-113.

[xxxvi] Martin, T. L., Woodall, K. L., & McLellan, B. A. (2006). Fentanyl-related deaths in Ontario, Canada: toxicological findings and circumstances of death in 112 cases (2002–2004). Journal of Analytical Toxicology, 30(8), 603-610.

[xxxvii] Fairbairn, N., Coffin, P. O., & Walley, A. Y. (2017). Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: challenges and innovations responding to a dynamic epidemic. International Journal of Drug Policy, 46, 172-179.

Frank, R. G., & Pollack, H. A. (2017). Addressing the fentanyl threat to public health. New England Journal of Medicine, 376(7), 605-607.

[xxxviii] Sutter, M. E., Gerona, R. R., Davis, M. T., Roche, B. M., Colby, D. K., Chenoweth, J. A., … & Albertson, T. E. (2017). Fatal fentanyl: one pill can kill. Academic Emergency Medicine, 24(1), 106-113.

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