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| Pixabay: Md Habibur |
But I'm finding the workarounds for Facebook's news article bans are getting blown up faster than new ones emerge, so posting this piece in full on my blog seems to be the only option for broader sharing. Here it is:
A school on fire. A multi-vehicle pileup on the Malahat. A high-impact earthquake. First responders call these kinds of major disasters “mass casualty incidents” – MCIs.That’s the perfect term for 900-block Pandora, says a local B.C. Ambulance Service paramedic speaking on condition of anonymity.
“Pandora is a slow-motion MCI,” he says. “We’re in a state of system failure, and it’s devastating to so many people. I don’t even see a light at the end of the tunnel, just a big black pit and people falling into it.”
Drugs get the headlines when it comes to the hot zones for homelessness. But it’s the constant crisis, repeat drug poisonings, and emergence of once-rare diseases and health conditions that alarm health care providers and first responders the most.
A bacterial dysentery once seen only in travellers returning from impoverished lands now routinely rips through the city’s homeless communities, where people have been left with no routine access to washrooms, clean water, or a place to wash their hands. It killed three people in the last year.
Syphilis is spiking for the first time ever among heterosexual females living homeless, coinciding with a global shortage of the primary drug for treating it. Tuberculosis is now being transmitted locally due to people living for long periods in confined, crowded spaces. Haemophilus influenzae type b (Hib) has emerged in the street community, a bacterial infection linked to meningitis that’s usually only seen in unvaccinated toddlers.
Festering leg wounds “like something out of World War I trench warfare” are common sights for first responders nowadays, notes the paramedic.
“Ten years ago, I can think of maybe 10 people who had lower leg wounds,” says Kellie Guarasci, clinical nurse lead at Victoria Cool Aid Society’s community health clinic, providing primary care to 7,000 registered patients.
“Since COVID and with the increasingly toxic drugs, they have become so common. The lack of housing is a part of that. People have no place to get warm and dry, and they may never have a time when they can lie down with their legs elevated and let their circulation function as it should.”
The poisonous illicit drug supply adds a deadly layer, killing users outright if they get the dosing wrong and leaving others with permanent brain injuries from the oxygen deprivation of a near-death experience. Emergency departments bulge with the struggle to manage the stream of extremely sick people from the street in the midst of the broader crisis in primary care access.
The state of people’s mental health is a whole other emergency that affects the housed and unhoused alike, but with particular impact for those living on the streets.
Psychosis brought on by methamphetamine and the highly toxic soup of animal tranquilizers and benzodiazepines in the illicit opioid stream feeds a new kind of mental health crisis, and worsens any existing mental illnesses.
Some of the people living on Pandora are on “extended leave” under the Mental Health Act. That means they’ve been certified as a risk to themselves or others, mostly for the purposes of being forced to take their psychiatric medications regularly. But beyond that, they’re left to live homeless.
And while it’s impossible to untangle addiction needs from mental health needs among people living homeless, none of the psychiatrists are cross-trained at the region’s lone psychiatric emergency department at Royal Jubilee Hospital, notes local addiction specialist Dr. Nathan Stefani.
The Psychiatric Emergency Service (PES) is “a dark place,” says the paramedic, who has spent many hours waiting with people in extreme states of mental health crisis only to see them released within minutes of being seen. “Taking someone from Pandora to PES is worse than doing nothing at all.”
(The people on Pandora agree. Asked whether in-patient psychiatric care is ever an option for him, one long-time resident on the block with bipolar disorder snorted and said, “You’ve got to be kidding. This is where they actually drop off the crazy ones.”)
Paramedics have a particularly bleak front-row seat to the social crisis, with jobs that leave them responding to the sickest of the sick without ever knowing if a person actually gets better. They see the same faces overdosing repeatedly – sometimes even in the same day.
But other health professionals on the front lines of the crisis paint a similarly dire picture of the state of health and mental health among people living homeless.
“We’re seeing osteomyelitis, infectious pneumonias, tuberculosis, COPD,” says Stefani, an emergency physician at both local hospitals. “People are developing infections in their blood that seeds infection in their spine, which is worsened by the prolonged posture of people ‘on the nod.’ So many people have bad feet.
“We’re seeing a lot of young women in serious disrepair - people who look decades older than their actual age. And now we’re seeing elderly people who have never been homeless, living in their cars, their RVs, on somebody’s couch. There is such despair that comes with not having a place to call your own.”
***
The roots of the health crisis for people in extreme poverty go back decades, and have been well-documented in countless reports, royal commissions, coroners’ findings, task force reports, studies and media stories over the years.
The gradual closure of Canada’s big psychiatric hospitals starting in the 1970s is often pointed to as the problem. But so many other shifts in policy, politics and the world in general complicate any attempt to find an easy scapegoat.
The closing of the institutions was supposed to be balanced off by an increase in community services that never materialized. Then came the federal government’s withdrawal from social housing in the 1990s, a critical factor in the rise of homelessness.
That was compounded by the gentrification of communities, which erased neighbourhoods where poor people once could afford to live. The rise of real estate as a form of investment has led to market rents so pricey that many of the 254,000 people on income assistance in B.C. can’t afford anywhere to live unless government is helping pay for it, particularly in Greater Victoria and Vancouver.
Housing precarity is a major determinant of health and can significantly worsen health outcomes, notes Char Futcher, a community social worker with the region’s Palliative Outreach Response Team.
“A wound for someone who experiences privilege within our systems isn’t terminal, but it can be for someone who experiences poverty and housing precarity,” says Futcher.
The public’s thoughts tend to go to street drugs when they think about drug use among people living homeless. But Stefani notes that “alcohol is still the drug that kills the most people.”
“How do you cope with living on the street? You find alcohol,” he says. “But even a couple months of binge-level drinking can lead to a gastric bleed.”
The fact that neither mental health nor addiction are included under the Canada Health Act has compounded the crisis. With no federal mandate establishing a minimum level of care, provinces are free to decide how much service they’ll provide. The rise of neo-liberal ideology around the world starting in the 1980s brought in governments focused on reducing spending in those areas even further.
The double stigma around mental health and substance use ensures that pushback about the cuts at election time is unlikely. Illicit drug use makes up just three to four per cent of all drug use in Canada, but carries so much disproportionate stigma that virtually all blame for substance-related health issues is projected onto the people themselves.
Alone among modern health issues, the provision of health care for people who use illicit drugs is largely subject to the whims of politicians and the police, who give and deny that care in unpredictable ways that often lead to even more harm, sickness and cost. Stopping the use of substances is widely considered to be the only goal.
“For any other health condition, the goal is to reduce your symptoms, improve your quality of life, and lengthen your life. There is no other condition where the goal is to stop having the condition,” says Dr. Reka Gustafson, Chief Medical Health Officer for Island Health.
“I would never be telling someone with diabetes that I won’t treat them until they quit having diabetes. But that’s what we are doing. It’s important that we don’t just say addiction is a medical condition, but treat it like it is.”
In B.C., residential treatment aimed at abstinence is perceived by many as the only approach. But even there, much of that work has been left to the private sector, where there’s little regulation, no transparency, no monitoring of outcomes, and a major cost barrier.
People unable to afford $30,000 or more for private treatment line up for fewer than 1,000 publicly funded beds for the entire province. Anyone dealing with the added complexities of homelessness generally ends up left out entirely, unable to figure their way in.
That’s compounded by the ongoing crisis in primary care. Nurses and doctors with the Cool Aid mobile outreach van say hardly a day goes by when someone who isn’t marginalized or vulnerable enough to meet the van’s mandate for care comes to the van asking for help with their own health-care need.
A shift in the makeup of the illicit drug supply has added immensely to the health crisis on the region’s most impoverished city blocks.
Heroin was once the most common opioid, and a very familiar one that health professionals knew how to deal with. But synthetic opioids flooded into the legal drug market in the 2000s as pharmaceutical companies like Purdue Pharma put money in doctors’ pockets in the US as rewards for getting more of their patients onto the pills. That soon spawned a major change in the illegal market as well.
Then came fentanyl and its analogs, first emerging in Canada in the illicit supply around 2012 and quickly becoming the dominant opioid. Its high potency sent overdose deaths soaring, but also introduced new and complicated health conditions from other chemicals being cut into the fentanyl to make its effects last longer.
That includes animal tranquilizers like xylazine, known to cause massive skin ulceration, and now medetomadine, which causes such heavy sedation that even the overdose-reversing drug naloxone can’t be counted on anymore.
The impact of that shift in the illicit supply has been profound, says Gustafson. But the decision to leave things that way has been a choice, she adds. It’s political will that stops access to regulated substances.
“We are not obliged to rely on the criminal market. We’ve chosen that,” says Gustafson. “We’ve chosen to allow the criminal market to drive the substances that people use in our community.”
The new drugs have complicated detox processes immensely. The multi-chemical opioid stream leaves people feeling brutally ill for much longer during withdrawal, which dampens even the most motivated user’s desire to leave their addiction behind.
People get so sick so fast after the drugs wear off nowadays that they typically can’t bear the long waits in the hospital emergency room unless they can figure a way to bring their street drugs with them - much to the consternation of hospital officials who don’t want to accommodate the use of illicit substances on hospital property.
One Pandora resident beaten unconscious last month while asleep says friends came to his rescue after he was taken to hospital, bringing him an ounce of street drugs that he hid in the crotch of his underwear. He was in the midst of a CT scan for a badly bruised kidney when it dawned on him that it was still there, for anyone reading those scans to see.
Health professionals working in detox struggle to find any prescription drug that might mitigate the misery from the ever-changing illicit supply.
“People are withdrawing from drugs that we can’t help them with,” says Dr. Ryan Mader, who works on the Cool Aid outreach van relied on by people living homeless and precariously housed. “There are things that people are withdrawing from that we don’t have medications for, and the withdrawal symptoms are overlayering with each other in ways we don’t understand yet. We need more tools in our toolbox.”
Mader notes that two-thirds of the opioid overdoses that the Cool Aid team sees are among people who don’t even use opioids.
“They’re stimulant users who accidentally got exposed to fentanyl. So that complicates things too. We need access to more means to manage people in withdrawal, but it’s different in every case.”
***
So that’s the bad news. But necessity is the mother of invention, and there is innovation and new care models developing as people at all levels of the crisis step into the challenge.
JT, homeless for 10 years, gets his chronic leg wounds treated every two days at the health clinic on Johnson. That helps him stay out of hospital, where he spent seven months last year due to his infected legs.
The Cool Aid health van stops at 10 locations where people live homeless and precariously housed. Peer2Peer Indigenous Society provides mobile wound care on Pandora and beyond from a converted ambulance.
At RJH, medical professionals saw the need to figure out how to support a person’s opioid dependency well enough that they would stick around to get their other health issues treated. They launched a pilot in 2023 pairing a dedicated nursing team with an addictions doctor.
The pilot became a program in 2024. And it’s working. The team has supported 700 people to date, and rates of “left before being seen” at the hospital have fallen from 30 per cent to two per cent.
What works about the program, known colloquially as the Substance Use Network, is that it deals with people’s real needs, say SUN nurses Anna Waters and Meghan Leahy. People get the prescriptions they need at a dosage that meets their level of tolerance, and bedside care from non-judgmental nurses familiar with substance dependency and homelessness.
“We’re consulted right at triage for someone with a history of substance use disorder, regardless of the health issue that is bringing them in,” says Waters. “It’s been amazing at getting people to stay at hospital. We see people finally able to make real change – patients who were completely entrenched and homeless, and here they are now, abstinent for a year.”
Leahy says the program is “changing the narrative” within the hospital, and lessening stigma.
“We’re treating something medical here. We’re facilitating patient care,” she says.
A key component of the work is the “order set” – essentially a check list developed by Stefani to help health professionals determine an appropriate level of medication based on an individual’s current tolerance level. It’s helping other doctors less familiar with addiction get over their fear of prescribing at levels many times above the norm for a population with astounding opioid tolerance.
The work also includes community networking and planning for discharge. The SUN nurses leap into all kinds of tasks, from calling about pet care for a person needing to stay in hospital to ensuring community outreach teams know when a person is in hospital, and when they’re released.
Trying to “smooth and streamline care for opioid users” is a vital need in health care, says Stefani. An estimated 100,000 people in B.C. have opioid use disorder.
“People are actually getting seen for their illnesses now,” he says. “They’re staying in hospital, getting their antibiotics, getting their dignity.”
For people experiencing a mental health crisis, finding an alternative to calling the police can literally be the difference between life and death. CB.C. did a deep dive in 2018 to examine circumstances in 460 cases of people killed by police in the previous 18 years, and found that 70 per cent of those killed were people with known mental health problems or substance use disorders.
B.C. now has peer-led crisis teams that the public can call for rapid response to a mental health crisis. The CRCL initiative - Crisis Response Community Led – is managed by the Canadian Mental Health Society in partnership with local non-profits. CRCL operates out of AVI Victoria in this region and responds to an average 320 calls a month, says CMHA CEO Jonny Morris.
Provincially, CRCL responds to 20,000 calls a year for rapid mental health support, with 98 per cent of those calls avoiding the need for police involvement, says Morris. That really matters given that “crisis is all too often the first occasion for care” when it comes to mental health.
Morris also appreciates the work of the provincially funded Community Counselling Program. While it isn’t specific to people living homeless, it supports outreach and in-house counselling services for adults with mental health or substance use issues at eight non-profits and First Nations in the Island Health region, and in 44 B.C. communities overall.
In other good news, two health scourges once common for people from the street community have largely been eradicated in the region.
Hepatitis C was once rampant in the street community. Since a permanent cure came along in 2014, Guarasci says Cool Aid has treated almost 1,000 people, and sees few cases nowadays.
Rates of HIV were as high as 30 per cent in the Canadian street population back in the late 1990s and 2000s, but Guarasci says it’s rare now to find it in the street community. HIV once spread rapidly through the sharing of needles among injection drug users, but the majority of substance users now smoke their drugs and a medication to prevent HIV has been available in Canada since 2016.
***
B.C. is now seven years into the 10-year plan laid out in Pathway to Hope, the John Horgan government’s strategy to map a new route away from crisis and toward prevention and quality care for people living with mental health challenges and addiction.
But the ministry that was to shepherd the plan was scrapped in 2024, and the minister in charge of it has long since left government. While Health Minister Josie Osborne is still mentioning the plan, there hasn’t been a progress report in three years.
The calls for involuntary care as a solution to visible mental illness and addiction on the streets have grown louder in the past year. But Morris notes that there were “real issues with mass institutionalization” back when that was the common way of dealing with things. Studies of forced addiction treatment have found no significant reduction in substance use, and high rates of overdose deaths after discharge.
“Institutionalizing removes people from sight, yes, but CMHA looks at it as a last resort. Can you truly say that everything else has been tried?” asks Morris. “We do have fundamental problems we need to grapple with. Brain injury is very much one of those. But mental illness is very treatable without coercion or force if services are made available.”
Rapid diagnosis is critical, he adds. “It’s the first point of clarity, the first chance to get closer to the right medication. Mental health can’t be treated in episodic ways.”
Getting mental health and addiction under the Canada Health Act is a great long-term dream, agrees Morris. But his more immediate concern is the expiry next spring of a 10-year, $5 billion bilateral agreement between the provinces and the federal government that currently funds $82 million worth of mental health and addiction services in B.C.
“That agreement drops off the face of the Earth in March 2027,” says Morris. “We’re in a campaign right now to make sure it’s renewed.”
Gustafson says a system of care for substance users is emerging piece by piece in Island Health and beyond, albeit still complicated by the stigma and resistance to treating substance use as a medical condition.
But where she finds the most hope is among BC municipal leaders, who she believes are grasping their role in helping to build resilient communities far more than other levels of government. Addressing the visible street crisis is one thing, but stopping the flow of broken people into homelessness is the critical piece.
“The social determinants of health are driving this issue. We’re not going to treat ourselves out of this,” says Gustafson. “Unless we stop the path to homelessness, we are never going to catch up.”
The urgent conversations ought to be focused on issues far from the street, she says – issues like genuinely universal $10/day childcare, the important role of public health nurses, support and connection for families.
“I attended the Union of BC Municipalities meeting last fall, and what I really heard was the change in the narrative at the municipal level,” says Gustafson. “Absolutely they’re going to need help from the province and the federal government, but the wisdom I heard there, it was clear that they understood that there isn’t a simple solution. This is complex.”
In the short term, Guarasci has her own small wish: Timely access to detox. Medical detox is the first step for anyone with an opioid or alcohol dependency seeking recovery, but it’s been 17 years since the health region opened those 21 beds at the Community Medical Detox at RJH, with no further expansion. Waits are now at least five to six weeks.
The crisis in health care for the street community spawns a whole other health crisis for the people charged with taking care of them, says another B.C. Ambulance paramedic whose own mental health has been profoundly affected by her work.
“You help a person through an overdose and that feels great, then you see them again and they’re worse, then you see them again and they’re doing well and you feel hopeful, then you see them again and they’re in cardiac arrest, and you can’t save them. After 10 years, that really gets to you,” she says. “I have to content myself with knowing that I did my best for that person in that moment.”
But while she’s well familiar with the moral injury and burnout that can result from working on the front lines, she hates to see her employer placing blame for paramedic burnout on the people dying in B.C.’s ongoing opioid crisis.
“People see this framing and they think, ‘Those addicts don’t deserve services.’ The public gets thinking that their grandma didn’t get an ambulance for her bad knee because an addict overdosed,” she says.
“We don’t think that way about diabetes, or heart attacks, or any other illness. It boils my blood. It wasn’t nice things happening in your life that led you to the street. These are the people who need our help the most.”
30
“Pandora is a slow-motion MCI,” he says. “We’re in a state of system failure, and it’s devastating to so many people. I don’t even see a light at the end of the tunnel, just a big black pit and people falling into it.”
Drugs get the headlines when it comes to the hot zones for homelessness. But it’s the constant crisis, repeat drug poisonings, and emergence of once-rare diseases and health conditions that alarm health care providers and first responders the most.
A bacterial dysentery once seen only in travellers returning from impoverished lands now routinely rips through the city’s homeless communities, where people have been left with no routine access to washrooms, clean water, or a place to wash their hands. It killed three people in the last year.
Syphilis is spiking for the first time ever among heterosexual females living homeless, coinciding with a global shortage of the primary drug for treating it. Tuberculosis is now being transmitted locally due to people living for long periods in confined, crowded spaces. Haemophilus influenzae type b (Hib) has emerged in the street community, a bacterial infection linked to meningitis that’s usually only seen in unvaccinated toddlers.
Festering leg wounds “like something out of World War I trench warfare” are common sights for first responders nowadays, notes the paramedic.
“Ten years ago, I can think of maybe 10 people who had lower leg wounds,” says Kellie Guarasci, clinical nurse lead at Victoria Cool Aid Society’s community health clinic, providing primary care to 7,000 registered patients.
“Since COVID and with the increasingly toxic drugs, they have become so common. The lack of housing is a part of that. People have no place to get warm and dry, and they may never have a time when they can lie down with their legs elevated and let their circulation function as it should.”
The poisonous illicit drug supply adds a deadly layer, killing users outright if they get the dosing wrong and leaving others with permanent brain injuries from the oxygen deprivation of a near-death experience. Emergency departments bulge with the struggle to manage the stream of extremely sick people from the street in the midst of the broader crisis in primary care access.
The state of people’s mental health is a whole other emergency that affects the housed and unhoused alike, but with particular impact for those living on the streets.
Psychosis brought on by methamphetamine and the highly toxic soup of animal tranquilizers and benzodiazepines in the illicit opioid stream feeds a new kind of mental health crisis, and worsens any existing mental illnesses.
Some of the people living on Pandora are on “extended leave” under the Mental Health Act. That means they’ve been certified as a risk to themselves or others, mostly for the purposes of being forced to take their psychiatric medications regularly. But beyond that, they’re left to live homeless.
And while it’s impossible to untangle addiction needs from mental health needs among people living homeless, none of the psychiatrists are cross-trained at the region’s lone psychiatric emergency department at Royal Jubilee Hospital, notes local addiction specialist Dr. Nathan Stefani.
The Psychiatric Emergency Service (PES) is “a dark place,” says the paramedic, who has spent many hours waiting with people in extreme states of mental health crisis only to see them released within minutes of being seen. “Taking someone from Pandora to PES is worse than doing nothing at all.”
(The people on Pandora agree. Asked whether in-patient psychiatric care is ever an option for him, one long-time resident on the block with bipolar disorder snorted and said, “You’ve got to be kidding. This is where they actually drop off the crazy ones.”)
Paramedics have a particularly bleak front-row seat to the social crisis, with jobs that leave them responding to the sickest of the sick without ever knowing if a person actually gets better. They see the same faces overdosing repeatedly – sometimes even in the same day.
But other health professionals on the front lines of the crisis paint a similarly dire picture of the state of health and mental health among people living homeless.
“We’re seeing osteomyelitis, infectious pneumonias, tuberculosis, COPD,” says Stefani, an emergency physician at both local hospitals. “People are developing infections in their blood that seeds infection in their spine, which is worsened by the prolonged posture of people ‘on the nod.’ So many people have bad feet.
“We’re seeing a lot of young women in serious disrepair - people who look decades older than their actual age. And now we’re seeing elderly people who have never been homeless, living in their cars, their RVs, on somebody’s couch. There is such despair that comes with not having a place to call your own.”
***
The roots of the health crisis for people in extreme poverty go back decades, and have been well-documented in countless reports, royal commissions, coroners’ findings, task force reports, studies and media stories over the years.
The gradual closure of Canada’s big psychiatric hospitals starting in the 1970s is often pointed to as the problem. But so many other shifts in policy, politics and the world in general complicate any attempt to find an easy scapegoat.
The closing of the institutions was supposed to be balanced off by an increase in community services that never materialized. Then came the federal government’s withdrawal from social housing in the 1990s, a critical factor in the rise of homelessness.
That was compounded by the gentrification of communities, which erased neighbourhoods where poor people once could afford to live. The rise of real estate as a form of investment has led to market rents so pricey that many of the 254,000 people on income assistance in B.C. can’t afford anywhere to live unless government is helping pay for it, particularly in Greater Victoria and Vancouver.
Housing precarity is a major determinant of health and can significantly worsen health outcomes, notes Char Futcher, a community social worker with the region’s Palliative Outreach Response Team.
“A wound for someone who experiences privilege within our systems isn’t terminal, but it can be for someone who experiences poverty and housing precarity,” says Futcher.
The public’s thoughts tend to go to street drugs when they think about drug use among people living homeless. But Stefani notes that “alcohol is still the drug that kills the most people.”
“How do you cope with living on the street? You find alcohol,” he says. “But even a couple months of binge-level drinking can lead to a gastric bleed.”
The fact that neither mental health nor addiction are included under the Canada Health Act has compounded the crisis. With no federal mandate establishing a minimum level of care, provinces are free to decide how much service they’ll provide. The rise of neo-liberal ideology around the world starting in the 1980s brought in governments focused on reducing spending in those areas even further.
The double stigma around mental health and substance use ensures that pushback about the cuts at election time is unlikely. Illicit drug use makes up just three to four per cent of all drug use in Canada, but carries so much disproportionate stigma that virtually all blame for substance-related health issues is projected onto the people themselves.
Alone among modern health issues, the provision of health care for people who use illicit drugs is largely subject to the whims of politicians and the police, who give and deny that care in unpredictable ways that often lead to even more harm, sickness and cost. Stopping the use of substances is widely considered to be the only goal.
“For any other health condition, the goal is to reduce your symptoms, improve your quality of life, and lengthen your life. There is no other condition where the goal is to stop having the condition,” says Dr. Reka Gustafson, Chief Medical Health Officer for Island Health.
“I would never be telling someone with diabetes that I won’t treat them until they quit having diabetes. But that’s what we are doing. It’s important that we don’t just say addiction is a medical condition, but treat it like it is.”
In B.C., residential treatment aimed at abstinence is perceived by many as the only approach. But even there, much of that work has been left to the private sector, where there’s little regulation, no transparency, no monitoring of outcomes, and a major cost barrier.
People unable to afford $30,000 or more for private treatment line up for fewer than 1,000 publicly funded beds for the entire province. Anyone dealing with the added complexities of homelessness generally ends up left out entirely, unable to figure their way in.
That’s compounded by the ongoing crisis in primary care. Nurses and doctors with the Cool Aid mobile outreach van say hardly a day goes by when someone who isn’t marginalized or vulnerable enough to meet the van’s mandate for care comes to the van asking for help with their own health-care need.
A shift in the makeup of the illicit drug supply has added immensely to the health crisis on the region’s most impoverished city blocks.
Heroin was once the most common opioid, and a very familiar one that health professionals knew how to deal with. But synthetic opioids flooded into the legal drug market in the 2000s as pharmaceutical companies like Purdue Pharma put money in doctors’ pockets in the US as rewards for getting more of their patients onto the pills. That soon spawned a major change in the illegal market as well.
Then came fentanyl and its analogs, first emerging in Canada in the illicit supply around 2012 and quickly becoming the dominant opioid. Its high potency sent overdose deaths soaring, but also introduced new and complicated health conditions from other chemicals being cut into the fentanyl to make its effects last longer.
That includes animal tranquilizers like xylazine, known to cause massive skin ulceration, and now medetomadine, which causes such heavy sedation that even the overdose-reversing drug naloxone can’t be counted on anymore.
The impact of that shift in the illicit supply has been profound, says Gustafson. But the decision to leave things that way has been a choice, she adds. It’s political will that stops access to regulated substances.
“We are not obliged to rely on the criminal market. We’ve chosen that,” says Gustafson. “We’ve chosen to allow the criminal market to drive the substances that people use in our community.”
The new drugs have complicated detox processes immensely. The multi-chemical opioid stream leaves people feeling brutally ill for much longer during withdrawal, which dampens even the most motivated user’s desire to leave their addiction behind.
People get so sick so fast after the drugs wear off nowadays that they typically can’t bear the long waits in the hospital emergency room unless they can figure a way to bring their street drugs with them - much to the consternation of hospital officials who don’t want to accommodate the use of illicit substances on hospital property.
One Pandora resident beaten unconscious last month while asleep says friends came to his rescue after he was taken to hospital, bringing him an ounce of street drugs that he hid in the crotch of his underwear. He was in the midst of a CT scan for a badly bruised kidney when it dawned on him that it was still there, for anyone reading those scans to see.
Health professionals working in detox struggle to find any prescription drug that might mitigate the misery from the ever-changing illicit supply.
“People are withdrawing from drugs that we can’t help them with,” says Dr. Ryan Mader, who works on the Cool Aid outreach van relied on by people living homeless and precariously housed. “There are things that people are withdrawing from that we don’t have medications for, and the withdrawal symptoms are overlayering with each other in ways we don’t understand yet. We need more tools in our toolbox.”
Mader notes that two-thirds of the opioid overdoses that the Cool Aid team sees are among people who don’t even use opioids.
“They’re stimulant users who accidentally got exposed to fentanyl. So that complicates things too. We need access to more means to manage people in withdrawal, but it’s different in every case.”
***
So that’s the bad news. But necessity is the mother of invention, and there is innovation and new care models developing as people at all levels of the crisis step into the challenge.
JT, homeless for 10 years, gets his chronic leg wounds treated every two days at the health clinic on Johnson. That helps him stay out of hospital, where he spent seven months last year due to his infected legs.
The Cool Aid health van stops at 10 locations where people live homeless and precariously housed. Peer2Peer Indigenous Society provides mobile wound care on Pandora and beyond from a converted ambulance.
At RJH, medical professionals saw the need to figure out how to support a person’s opioid dependency well enough that they would stick around to get their other health issues treated. They launched a pilot in 2023 pairing a dedicated nursing team with an addictions doctor.
The pilot became a program in 2024. And it’s working. The team has supported 700 people to date, and rates of “left before being seen” at the hospital have fallen from 30 per cent to two per cent.
What works about the program, known colloquially as the Substance Use Network, is that it deals with people’s real needs, say SUN nurses Anna Waters and Meghan Leahy. People get the prescriptions they need at a dosage that meets their level of tolerance, and bedside care from non-judgmental nurses familiar with substance dependency and homelessness.
“We’re consulted right at triage for someone with a history of substance use disorder, regardless of the health issue that is bringing them in,” says Waters. “It’s been amazing at getting people to stay at hospital. We see people finally able to make real change – patients who were completely entrenched and homeless, and here they are now, abstinent for a year.”
Leahy says the program is “changing the narrative” within the hospital, and lessening stigma.
“We’re treating something medical here. We’re facilitating patient care,” she says.
A key component of the work is the “order set” – essentially a check list developed by Stefani to help health professionals determine an appropriate level of medication based on an individual’s current tolerance level. It’s helping other doctors less familiar with addiction get over their fear of prescribing at levels many times above the norm for a population with astounding opioid tolerance.
The work also includes community networking and planning for discharge. The SUN nurses leap into all kinds of tasks, from calling about pet care for a person needing to stay in hospital to ensuring community outreach teams know when a person is in hospital, and when they’re released.
Trying to “smooth and streamline care for opioid users” is a vital need in health care, says Stefani. An estimated 100,000 people in B.C. have opioid use disorder.
“People are actually getting seen for their illnesses now,” he says. “They’re staying in hospital, getting their antibiotics, getting their dignity.”
For people experiencing a mental health crisis, finding an alternative to calling the police can literally be the difference between life and death. CB.C. did a deep dive in 2018 to examine circumstances in 460 cases of people killed by police in the previous 18 years, and found that 70 per cent of those killed were people with known mental health problems or substance use disorders.
B.C. now has peer-led crisis teams that the public can call for rapid response to a mental health crisis. The CRCL initiative - Crisis Response Community Led – is managed by the Canadian Mental Health Society in partnership with local non-profits. CRCL operates out of AVI Victoria in this region and responds to an average 320 calls a month, says CMHA CEO Jonny Morris.
Provincially, CRCL responds to 20,000 calls a year for rapid mental health support, with 98 per cent of those calls avoiding the need for police involvement, says Morris. That really matters given that “crisis is all too often the first occasion for care” when it comes to mental health.
Morris also appreciates the work of the provincially funded Community Counselling Program. While it isn’t specific to people living homeless, it supports outreach and in-house counselling services for adults with mental health or substance use issues at eight non-profits and First Nations in the Island Health region, and in 44 B.C. communities overall.
In other good news, two health scourges once common for people from the street community have largely been eradicated in the region.
Hepatitis C was once rampant in the street community. Since a permanent cure came along in 2014, Guarasci says Cool Aid has treated almost 1,000 people, and sees few cases nowadays.
Rates of HIV were as high as 30 per cent in the Canadian street population back in the late 1990s and 2000s, but Guarasci says it’s rare now to find it in the street community. HIV once spread rapidly through the sharing of needles among injection drug users, but the majority of substance users now smoke their drugs and a medication to prevent HIV has been available in Canada since 2016.
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B.C. is now seven years into the 10-year plan laid out in Pathway to Hope, the John Horgan government’s strategy to map a new route away from crisis and toward prevention and quality care for people living with mental health challenges and addiction.
But the ministry that was to shepherd the plan was scrapped in 2024, and the minister in charge of it has long since left government. While Health Minister Josie Osborne is still mentioning the plan, there hasn’t been a progress report in three years.
The calls for involuntary care as a solution to visible mental illness and addiction on the streets have grown louder in the past year. But Morris notes that there were “real issues with mass institutionalization” back when that was the common way of dealing with things. Studies of forced addiction treatment have found no significant reduction in substance use, and high rates of overdose deaths after discharge.
“Institutionalizing removes people from sight, yes, but CMHA looks at it as a last resort. Can you truly say that everything else has been tried?” asks Morris. “We do have fundamental problems we need to grapple with. Brain injury is very much one of those. But mental illness is very treatable without coercion or force if services are made available.”
Rapid diagnosis is critical, he adds. “It’s the first point of clarity, the first chance to get closer to the right medication. Mental health can’t be treated in episodic ways.”
Getting mental health and addiction under the Canada Health Act is a great long-term dream, agrees Morris. But his more immediate concern is the expiry next spring of a 10-year, $5 billion bilateral agreement between the provinces and the federal government that currently funds $82 million worth of mental health and addiction services in B.C.
“That agreement drops off the face of the Earth in March 2027,” says Morris. “We’re in a campaign right now to make sure it’s renewed.”
Gustafson says a system of care for substance users is emerging piece by piece in Island Health and beyond, albeit still complicated by the stigma and resistance to treating substance use as a medical condition.
But where she finds the most hope is among BC municipal leaders, who she believes are grasping their role in helping to build resilient communities far more than other levels of government. Addressing the visible street crisis is one thing, but stopping the flow of broken people into homelessness is the critical piece.
“The social determinants of health are driving this issue. We’re not going to treat ourselves out of this,” says Gustafson. “Unless we stop the path to homelessness, we are never going to catch up.”
The urgent conversations ought to be focused on issues far from the street, she says – issues like genuinely universal $10/day childcare, the important role of public health nurses, support and connection for families.
“I attended the Union of BC Municipalities meeting last fall, and what I really heard was the change in the narrative at the municipal level,” says Gustafson. “Absolutely they’re going to need help from the province and the federal government, but the wisdom I heard there, it was clear that they understood that there isn’t a simple solution. This is complex.”
In the short term, Guarasci has her own small wish: Timely access to detox. Medical detox is the first step for anyone with an opioid or alcohol dependency seeking recovery, but it’s been 17 years since the health region opened those 21 beds at the Community Medical Detox at RJH, with no further expansion. Waits are now at least five to six weeks.
The crisis in health care for the street community spawns a whole other health crisis for the people charged with taking care of them, says another B.C. Ambulance paramedic whose own mental health has been profoundly affected by her work.
“You help a person through an overdose and that feels great, then you see them again and they’re worse, then you see them again and they’re doing well and you feel hopeful, then you see them again and they’re in cardiac arrest, and you can’t save them. After 10 years, that really gets to you,” she says. “I have to content myself with knowing that I did my best for that person in that moment.”
But while she’s well familiar with the moral injury and burnout that can result from working on the front lines, she hates to see her employer placing blame for paramedic burnout on the people dying in B.C.’s ongoing opioid crisis.
“People see this framing and they think, ‘Those addicts don’t deserve services.’ The public gets thinking that their grandma didn’t get an ambulance for her bad knee because an addict overdosed,” she says.
“We don’t think that way about diabetes, or heart attacks, or any other illness. It boils my blood. It wasn’t nice things happening in your life that led you to the street. These are the people who need our help the most.”
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