Overdose

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NATIONAL BESTSELLER

An astonishing and powerful look at the ongoing opioid crisis

North America is in the middle of a health emergency. Life expectancies are declining. Someone is dying every two hours in Canada from illicit drug overdose. Fentanyl has become a looming presence—an opioid more powerful, pervasive, and deadly than any previous street drug.

The victims are many—and often not whom we might expect. They include the poor and forgotten but also our neighbours: professionals, students, and parents. Despite the thousands of deaths, these victims have remained largely invisible.

But not anymore. Benjamin Perrin, a law and policy expert, shines a light in this darkest of corners—and his findings challenge many assumptions about the crisis. Why do people use drugs despite the risk of overdosing? Can we crack down on the fentanyl supply? Do supervised consumption sites and providing “safe drugs” enable the problem? Which treatments work? Would decriminalizing all drugs help or do further harm?

In this urgent and humane look at a devastating epidemic, Perrin draws on behind-the-scenes interviews with those on the frontlines, including undercover police officers, intelligence analysts, border agents, prosecutors, healthcare professionals, Indigenous organizations, activists, and people who use drugs. Not only does he unveil the many complexities of this situation, but he also offers a new way forward—one that may save thousands of lives.NATIONAL BESTSELLER

A Loan Stars Pick
One of CBC‘s “40 great books to read this season”

Praise for Overdose:

“[An] important book, the best yet on the crisis. . . . Attitudes about drug use and drug users are changing. More people are coming to see what Perrin calls a clear moral wrong: ‘The injustice of unmercifully judging and punishing people who are using drugs in an attempt to get relief from the pain in their lives.’ [Overdose] should help hasten that welcome change.”
—The Globe and Mail

“Overdose is a necessary and searching investigation into a devastating epidemic that should never have happened. Benjamin Perrin painstakingly shows that it need not continue if we, as a society, heed the evidence.”
—Gabor Maté M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
 
“In Overdose, we walk the streets with the author and meet law enforcement officers, healthcare providers, former users, and activists. Along the way, we overcome any prejudice we may have toward the opioid crisis and its victims. Using empirical research, Perrin guides us through the ramifications of the complex problem of the opioid crisis and looks at ways forward. A real eye-opener.”
—The Hon. Marie Deschamps, former Justice, Supreme Court of Canada
 
“A brilliantly argued chronicle of the opioid crisis, Overdose is beautifully written and impeccably researched. Equally moving, informative, and persuasive, it makes a crucial contribution to the national debate on how we deal with illicit drugs in our society—a clarion call to end the failed war on drugs and instead adopt a compassionate evidence-based approach that emphasizes ‘safe supply’, and decriminalization for illicit drug users.” 
—Prof. Joel Bakan, author of The Corporation
 
“We are in a national health emergency, but government will not say so. These are not ‘overdose’ deaths as much as they are poisonings. The current approach is failing. For anyone who wants to understand this crisis, who can, like Perrin, keep an open mind, I urge you to read Overdose.” 
—Elizabeth May, O.C., M.P., former Leader, Green Party of Canada
 
“Overdose is an eye-opening examination of why it is important to dump old stereotypes about substance use. Perrin masterfully describes how his past beliefs about how to deal with the problems—which were grounded in criminalization and punishment—have drastically changed. This is a crisis that demands our attention. And this excellent, highly readable, and thoroughly researched book is a great place to start.” 
—Prof. Timothy Caulfield, Canada Research Chair in Health Law & Policy and author of The Cure for Everything! and Relax, Dammit!

“If you are a skeptic, as Perrin once was, of progressive public policy to address the opioid crisis, then this matter-of-fact, evidence-based account is a must read. As Canadians, we must address this crisis with care, compassion, understanding, and concrete action. We all have a role to play.” 
—Puglaas, The Hon. Jody Wilson-Raybould, P.C., Q.C., M.P., former Minister of Justice and Attorney General of Canada

“A powerful indictment of Canada’s current policies toward illegal drugs. Perrin’s book is an excellent popular primer on the issues associated with drugs in Canada and more intensely in B.C. Perrin is surely right.”
—Dr. Stephen T. Easton, Professor of Economics, Simon Fraser University & Senior Research Fellow, The Fraser Institute

“Overdose is incisive, compelling and powerful. It is as clear and clinical an indictment of the failed policy of drug prohibition as I’ve seen. This book shows that evidence and compassion can be reconciled in this critical public issue. More importantly, it proves that they must be.”
—Don Davies, MP & Health Critic (NDP)

“[Overdose] takes a hard look at Canada’s opioid crisis and those it has affected, with a national call to action as well as concrete ideas on how to improve the situation.”
—Drug & Alcohol Testing Association of Canada

“Benjamin Perrin challenges popular assumptions about opioid users—in particular, those addicted to Fentanyl—offering a humane approach to solving this devastating health crisis.”
—Quill & Quire

“Bold, informed . . . Overdose [is] a book for every politician in Canada. . . . every municipality faces the disastrous public health challenge of opioids, and no councillor or mayor or city manager should be without this book.”
—The Tyee

“[An] accessible investigation of Canada’s drug crisis . . . written from an unexpected vantage point. Overdose serves as a good introduction to the issues and one in which people less familiar with the crisis will find progressive arguments presented in a straightforward and compelling manner.”
—The Straight

“Overdose does not rely on jargon and is not just endless rows of statistics. Instead it offers a very human approach through straightforward conversations with all types of people. Top notch health officials like Dr. Bonnie Henry, to frontline healthcare workers, social workers, First Nations, poverty rights advocates, addicts and loved ones of addicts are all brought into the fold in this book.”
—The Vancouver Sun

“Perrin . . . speaks to multitudes of experts from all sides of the issue, addicts, police officers, drug addiction counsellors, judges, lawyers, frontline workers, Indigenous organizations, activists, border agents, and intelligence analysts. Perrin is able to weave together an exceptionally insightful book that helps illuminate the complexity of the issues involved and comes to concrete conclusions about the best way to fight and win this crisis.”
—Drug & Alcohol Testing Association of Canada
BENJAMIN PERRIN is a professor at the University of British Columbia, Peter A. Allard School of Law. He served as a law clerk at the Supreme Court of Canada, and was the lead justice and public safety advisor to Prime Minister Stephen Harper from 2012-13. Professor Perrin is the author of two previous books: Invisible Chains: Canada’s Underground World of Human Trafficking, which was a national bestseller and named one of the top books of the year by The Globe and Mail, and Victim Law: The Law of Victims of Crime in Canada. He lives in Vancouver, BC.
 
https://benjaminperrin.ca/— 1 —
What Is the Opioid Crisis?
 
“I don’t think anybody really saw this coming.”—Dr. Mark Tyndall, Executive Director, BC Centre for Disease Control
 
A sleepy suburb on the outskirts of Greater Vancouver was about to get a wake-up call—in more ways than one. At 1:30 a.m., the stillness of a balmy late-summer night in Delta was shattered by the blaring siren and f lashing lights of an ambulance racing to a family home.
 
“The paramedic walked up to a house in Delta because a friend of somebody called 911 saying this guy’s passed out; he’s not breathing,” said Linda Lupini, who heads BC Emergency Health Services. “Before they got into the house there were two kids who’d overdosed on the front stairs. So they thought they were at the address—the kids are overdosed; that’s the call.”
 
The paramedics began working frantically to help resuscitate them. The tell-tale signs of a drug overdose include unresponsiveness, blue lips, and difficulty breathing—or not breathing at all. The outcome can be fatal.
 
“Are you coming upstairs?!” someone screamed from inside the house.
 
“What do you mean?” replied a confused paramedic.
 
“The kid we called for is upstairs.”
 
There were three simultaneous drug overdoses at the house that night—and that was just the beginning. Within 26 minutes the 911 switchboard lit up like a Christmas tree. Drug overdose calls kept coming in. Paramedics would revive someone only to learn from them that someone else had taken drugs at the same party and could be at risk.
 
“Then we were working with dispatch, trying to find all these kids,” said Lupini.
 
In total, 11 young people who were at the party overdosed the night of September 1, 2016, after taking what they thought was a small amount of cocaine. What they didn’t know was that it had been laced with fentanyl—a potent opioid drug. One went into full cardiac arrest.
 
“We had parents doing CPR on the front lawn on their kids,” said Lupini. “We had 11 teenagers literally not breathing. They were all resuscitated, but barely. A few came close to not making it. It was so traumatic for the front-line staff. We just didn’t have the resources to respond to something like that.
 
“The problem for an ambulance service is that the increase in calls are your highest acuity—Code 3,” she continued. “They’re gonna die in minutes.”
 
Between January 2016 and June 2019, a record-shattering 13,913 people across Canada died f rom opioid-related drug overdoses. In 2018, when the annual death count hit 4588, a life was lost every two hours. According to Dr. Theresa Tam, Canada’s chief public health officer, opioid-related overdoses have become the leading cause of death for 30- to 39-year-olds. And although every part of the country has been affected by the opioid crisis, British Columbia, Alberta, Ontario, Saskatchewan, and Manitoba have been the hardest hit.
 
On April 14, 2016, British Columbia declared the opioid crisis a public health emergency after illicit drug overdose deaths began sky-rocketing. Historically, about 200 to 300 people a year had lost their lives this way, but by 2015 the number of overdose deaths had risen to 530. Worst was yet to come. By 2018 that number had almost tripled, reaching 1542. It hit me just how serious the situation was when the BC Coroners Service announced that illicit drugs were claiming more lives than murder, suicide, and car accidents combined. By 2019, the number of overdose deaths in the province finally started to decline as thousands had already died and the response to the crisis ramped out, even as the number of 911 overdose calls continued to grow to almost 25,000.
 
“For the longest while we said it’s a crisis,” said Jennifer Breakspear, executive director of the Portland Hotel Society (PHS) Community Services Society, which provides supportive housing for over 2000 people in Vancouver and Victoria as well as various programs and services. PHS also operates Insite, North America’s first supervised injection site. Breakspear was hired to head up PHS in January 2017. And although she’d had experience in leading a non-profit focused on reproductive health, she described the transition to PHS as a real “crash course.”
 
As I sat on a couch in Breakspear’s office on East Hastings Street, fire truck and ambulance sirens kept interrupting her—a constant reminder that Vancouver’s Downtown Eastside is ground zero in this crisis. “The soundtrack of my workday,” she remarked as another emergency vehicle raced by. Without a doubt, several of them that hour would have been heading to overdoses in the immediate area.
 
When the public health emergency was declared in 2016, Breakspear told me, everyone thought it was the height of the crisis. Since then, though, “the numbers have continued to worsen. I don’t want to say it’s become the normal—the new norm. That sounds so offensive,” she said. “This is still a situation in which people are dying every day, and I don’t know how you could ever wrap your head around calling it ‘normal.’”
 
That harsh realization is especially disturbing for the loved ones of those who’ve died during this overdose crisis. “The thought that it’s the new normal is just crushing,” said Leslie McBain, co-founder of Moms Stop the Harm, a national advocacy group of families that have lost loved ones to drug overdoses, including her own son. “Fentanyl is still out there; it’s still killing people. People have no alternative.”
 
“Crisis” is the word that everyone I spoke to used to describe this state of affairs, including police officers, medical experts, and groups of people who use drugs alike. And BC is like the canary in a coal mine; the problem has spread across the rest of the country, too. The only place you’d see more body bags would be in an actual war. But even that’s not an entirely accurate comparison: 159 courageous Canadians died during the conflict in Afghanistan, and 516 died during the Korean War. Combined, those losses are significantly lower than the number of Canadians who died f rom fatal overdoses in 2018 alone.
 
Given the massive fatalities during the opioid crisis, Vancouver’s morgue has been filled to capacity and the BC Coroners Service has been forced to develop extraordinary plans to store bodies while the coroner investigates. “We are in urgent need of temporary body storage owing to the public health emergency,” wrote Aaron Burns with the BC Ministry of Justice in a December 19, 2016, email plea to funeral home directors in the BC Lower Mainland. (The email was released under the Freedom of Information and Protection of Privacy Act.) “Bodies are kept at hospital morgues or funeral homes while the coroner conducts the investigation,” Burns continued. “It would only be situations where those places are overwhelmed by volume that storage would pose a problem for us. That being said, we’ve come close to that point in the recent past and looked into refrigerated shipping containers as a contingency.”
 
The impact of the opioid crisis is widespread. For people who use drugs, it means never knowing whether they’ll be next. It means being blamed. It means being treated like criminals and lowlifes. This crisis continues to catastrophically affect families, friends, and loved ones of those who have died or are using substances and are at risk. And it’s had a devastating impact on those working hard to save lives, including “peers”—people with lived experience using drugs—and professional first responders like paramedics, firefighters, and police officers.
 
Carolyn Sinclair is the manager of the BC Provincial Overdose Mobile Response Team, which provides crisis support to professional first responders. I first met Sinclair several years ago in her previous role as head of Police Victim Services of BC. She knows about supporting people in traumatic situations and she knows law enforcement. That, combined with her positive outlook and cheerful attitude, made her the perfect person for this new job. Her team was set up when it became clear that the relentless trauma of the opioid crisis was hitting first responders hard.
 
“In April 2018 we had 27 completed suicides by first responders,” said Sinclair. It was a startling figure, one that she believes is directly linked to the opioid crisis. I asked her to tell me about some of these individuals so that I could get a better idea of how this public health emergency was affecting them. In one instance, she said, “the fire-fighters arrived at the house and found a mom down. The first person in was a young firefighter. They didn’t realize that there was a little four-year-old girl that had also gotten into Mom’s drugs and that she’d crawled behind a chair. They didn’t know she was there until later. The little girl is still in an induced coma, and there are some fire-fighters that are visiting her every day. The first firefighter to that scene committed suicide.”
 
The opioid epidemic has spread across the continent like wildfire. In the United States, more than 500,000 people died f rom drug overdoses between 2000 and 2015. And those figures have been accelerating, as they’ve been in Canada, owing to a dramatic increase in synthetic opioid–related deaths. In 2017, an estimated 70,237 people died f rom illicit drug overdoses in the U.S. That’s more than the total number of American troops, 58,220, who died between 1961 and 1975 during the entire Vietnam War.
 
In response, on October 26, 2017, the United States declared the opioid crisis a national public health emergency. Canada has yet to take that step. But despite the U.S. declaration, even the most rudimentary medical interventions that have been proven to save lives (such as “take-home” naloxone—the antidote to an opioid overdose—and supervised consumption sites) have faced roadblocks. President Donald Trump has instead insisted on building a wall on the US–Mexico border to deal with the problem—an idea that experts agree would do nothing to address it.
 
What’s responsible for causing this carnage?
 
The opioid crisis has many complex and interrelated causes. But the immediate starting point is a drug I’d never heard of until it started popping up in news reports about overdose deaths: fentanyl.
 
“The main driver of the crisis that we’re in is the contaminated drug supply, and we have little to no control over it,” said Chris Buchner, director of communicable diseases and harm reduction at Fraser Health, which covers the sprawling suburbs outside of Vancouver and has the unfortunate distinction of having the highest number of illicit drug overdose deaths of any health authority in the province.
 
“It’s horrendous. I hate people calling it ‘overdose,’ because people are being poisoned. ‘Overdose’ means they used too much. They’re using what they normally would,” said Shelda Kastor with the Western Aboriginal Harm Reduction Society. Indeed, Kastor’s explanation is backed up by data f rom the coroner’s office.
 
In 2012, fentanyl was found in just 4% of post-mortem toxicology investigations of illicit drug overdose deaths in BC—a negligible amount that no one really paid much attention to. Since then, illicit drug overdose deaths where fentanyl has been detected (on its own or combined with other drugs, such as cocaine, methamphetamine, and heroin) jumped to 15% in 2013, 25% in 2014, 29% in 2015, 67% in 2016, 82% in 2017, and a staggering 87% in 2018. Multiple drug use, including alcohol, is frequently identified in these cases, with fentanyl as a common denominator.
 
When you look at the annual number of illicit drug overdose deaths over the last decade—taking out those where fentanyl was detected—you see a relatively stable rate. In 2007 and 2017 alike, there were roughly 200 illicit drug overdose deaths in BC that did not involve fentanyl. Illicit fentanyl is clearly the immediate cause of the dramatic rise in overdose deaths. But, as I would find out, there was plenty of blame to be shared for this crisis.US

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