By Robert Cribb Staff Reporter, Mashal Butt, and Declan Keogh
Toronto’s street drug supply is being increasingly contaminated with a new category of “ultra-potent” opioids as overdose deaths soar.
The presence of these synthetic opioids — some far more powerful than fentanyl — has quadrupled in tests of street drugs in the city, from less than one per cent before the COVID-19 pandemic to four per cent, a Toronto Star and Investigative Journalism Bureau (IJB) investigation has found.
“It’s hugely meaningful,” said Dr. Daniel Beriault, who tests the contents of Toronto street drugs at St. Michael’s Hospital and heads the biochemistry division at Unity Health Toronto. “It’s life and death.”
Among the new breed of powerful synthetic opioids that began appearing in Toronto’s street drug supply is etonitazepyne — thought to be 10 to 20 times as strong as fentanyl. It began showing up in drug checking tests two weeks ago.
Between May and June, etonitazene (also considered 10 to 20 times as strong as fentanyl), etodesnitazene and metonitazene (both considered to have similar potency to fentanyl) emerged. Four months earlier, a similar synthetic opioid called isotonitazene (five times as potent as fentanyl) appeared for the first time.
The opioids were identified by the Centre on Drug Policy Evaluation (CDPE), a Toronto-based research agency that collects and tests small samples of street drugs collected from users and dealers. The ultra-potent opioids were primarily found in samples that were thought to be straight fentanyl.
Karen McDonald (left) and Dr. Cristiana Stefan. McDonald leads Toronto’s Drug Checking Service and Stefan is a clinical biochemist and toxicologist and laboratory director at the Centre for Addiction and Mental Health. Photo credit: Steve Russell / Toronto Star
The new findings were shared exclusively with the Star and IJB.
An analysis of newly obtained data on opioid overdoses across the country — including numbers from provincial coroners, street drug tests in Ontario and B.C., and a previously unpublished national drug user survey — reveals a national crisis spiking into uncharted territory during the pandemic.
Toronto saw an 81 per cent jump in opioid-related deaths between 2019 and late 2020.
Border closures and drug supply chain disruptions are blamed by researchers for creating a cocktail of new drugs and compounds.
“Any time you disrupt drug trafficking routes, unexpected things will happen,” said Daniel Werb, the executive director of the CDPE and a research scientist at St. Michael’s Hospital. “That’s why you see increasingly potent opioids on the market because the higher the potency, the more efficient the package is, the easier it is to traffic.”
And COVID-19 restrictions — including personal isolation and physical distancing, which reduced access to supervised injection sites — provide a double blow by reducing the oversight drug users traditionally rely on from friends and front-line workers.
“We’ve got a really, really dangerous drug supply,” Werb said. “And the public health response to COVID-19 is in some ways uncannily at odds with the public health strategy for reducing overdoses. The one thing you’re not supposed to do when using drugs is use alone. Those two pieces of advice are directly at odds.”
Since the new synthetics appeared, they have been detected in Toronto’s street drug checks weekly.
One sample from downtown Toronto that was associated with a drug overdose, tested on May 17, showed etonitazene and isotonitazene as the two most prominent drugs detected.
“It’s super alarming to us when we see these shifts in the supply,” said Karen McDonald, who leads Toronto’s Drug Checking Service at St. Michael’s Hospital.
“More potent drugs are circulating so you have to assume that overdoses are going to increase.”
The newly appearing opioids were all synthesized as prospective pain relievers in the 1950s but were never approved or used for medical purposes. Drug researchers don’t know exactly how or why they’re seeping into the drug supply now.
A laboratory technician at Toronto’s Centre for Addiction and Mental Health uses mass spectrometry equipment to analyze street drugs. Toronto’s street drug checking regime collects tiny samples provided by users or dealers seeking to learn the contents of their supply. Photo credit: Steve Russel / Toronto Star
The powerful drugs have been scarcely studied. So little is known that the World Health Organization’s expert committee on drug dependence cited Reddit posts in an official report last October to try to describe the addictive potential of isotonitazene.
“The actual toxicological effects of many of these novel psychoactive substances is not known,” said Dr. Cristiana Stefan, a clinical biochemist and toxicologist and laboratory director at the Centre for Addiction and Mental Health (CAMH).
She describes the introduction of these drugs into the illicit drug supply as an “unfortunate experiment,” in which many drug users are unwittingly taking part in an unregulated clinical trial.
“You feel helpless. You cannot stop this process.”
Toronto’s street drug checking regime collects tiny samples provided by users or dealers seeking to learn the contents of their supply. Those small donations are picked up every weekday by bike couriers with special Health Canada approval to transport the drugs from five supervised consumption sites across the city to testing labs at St. Michael’s Hospital and CAMH.
The street drug checks have produced another troubling finding: carfentanil — a known, ultra-potent opioid 100 times stronger than fentanyl — is re-emerging in Toronto’s drug supply. After it appeared in 2016 and peaked in 2019, Health Canada’s drug analysis data for Ontario show it disappeared from test results last year.
Carfentanil appeared in Toronto street drug samples more times between March and May 2021 than at any other time since drug checking began in 2019, CDPE results show.
Beriault recalls his reaction to first detecting carfentanil in his lab earlier this year as an “oh s— moment.”
“I heard about it … through the grapevine, through other chemists, but when I actually saw it in a drug sample, I was absolutely blown away.”
“If it’s just your first time or if you’ve only done (drugs) a few times recreationally and you hit the bad odds and the sample has carfentanil … there’s a good chance that you’re going to pass away or at least overdose,” he said. “It’s definitely contributing to the opioid crisis.”
Researchers suspect the new breed of ultra-potent synthetic opioids has reached well beyond the city.
Across Ontario, last year marked the deadliest year on record since the coroner began collecting overdose-specific data, with 2,132 dying of an overdose in 2020 — up 41 per cent from the year before.
Timmins, North Bay, Sudbury and Thunder Bay are among the top five for deaths per 100,000. In almost every case, the death rates jumped dramatically between 2018 and late last year, averaging a 172 per cent increase across the top five cities.
“I’ve seen more suffering right now than ever before,” said Joel Boivin, a registered nurse who works with the Sudbury Action Centre for Youth. “I’ve also seen the dramatic shift in drug supply (toxicity).”
Last year, Sudbury’s overdose mortality rate was 50.9 per 100,000, up 167 per cent from 2018.
Boivin, who’s worked in harm reduction for more than a decade, said he has been diagnosed with post-traumatic stress disorder due to the devastation he’s witnessed in his community. He stopped counting the number of people he’s personally known who died of an overdose.
“Nobody volunteers to witness hundreds and hundreds of deaths.”
Tamara Grant, 51, runs a supervised injection site out of her west-end apartment. She’s reversed over 60 overdoses since the pandemic began. No one has died under her watch, she said. Photo credit: Declan Keogh / IJB
The man sitting in front of Tamara Grant last fall had just injected fentanyl. She remembers thinking that something was off — the drug he was injecting was clear liquid instead of the usual purple-blue.
And it was rapidly shutting down the part of his brain that regulates breathing.
Within a minute his breathing stopped.
“He had slipped away,” Grant recalled. “There were no signs of any kind of movement, any kind of breathing or anything … that would show somebody being alive.”
The 51-year-old Toronto harm reduction worker quickly administered the life-saving drug naloxone to bring him back from overdose. But it was having no effect.
“Each time I did a shot and I waited and there was no reaction, the more I kept thinking that I had lost this person.”
For four long minutes, the man could not breathe on his own. Grant performed rescue breathing to keep him alive, desperately waiting for the naloxone to take effect.
It took two naloxone doses for the man’s breathing to return to normal. He regained consciousness.
After using drugs much of her life, Grant now runs a satellite supervised injection site from her home in Toronto’s west end. Several times a week, she welcomes drug users into her apartment — or visits them at their homes — so they can inject under watchful supervision.
Grant has never been busier. She estimates she’s reversed more than 60 overdoses since the beginning of the pandemic — roughly three times as many as the year before.
One of the reasons, she said, is the increasing presence of benzodiazepines in Toronto’s street drug supply.
Benzodiazepines, sedatives used to treat sleep or anxiety issues, are one of the most commonly prescribed medications in Canada. But when unexpectedly mixed with opioids, the effects can be fatal.
She said the man she saved last fall had taken drugs containing benzodiazepines.
And that cocktail of ingredients made his revival from overdose — even with life-saving naloxone — more challenging.
Toronto street drug checks have detected 13 benzodiazepine-related drugs in fentanyl samples, including etizolam, Xanax and Valium.
Benzodiazepine-related drugs have been found in 65 per cent of fentanyl samples reviewed in Toronto by CDPE since the start of the pandemic, compared with 37 per cent pre-pandemic.
A June 18 Toronto street drug sample connected to an overdose contained etizolam and fentanyl along with the newly emerged synthetic opioid metonitazene (considered as potent as fentanyl).
Coroner data and results from street drug checks in British Columbia show similar trends.
Benzodiazepines were detected in 60 per cent of the province’s 160 overdose deaths in May 2021, up from 15 per cent in July 2020.
“The changes with the benzodiazepines entering into the drug supply, in addition to fentanyl and fentanyl analogues and just the unpredictability of the drug supply … we just haven’t seen that and we’re just dealing with this new shock,” said Jennifer Matthews, who runs the British Columbia Centre on Substance Use drug checking services.
A drug sample as it arrives at one of Toronto’s street drug testing labs. These labs have found the city’s street drug supply is being increasingly contaminated with a new category of “ultra potent” opioids. Photo credit: Steve Russell / Toronto Star
In a survey of more than 1,000 people who use drugs in Toronto, Montreal and Vancouver, a consortium of Canadian drug policy and health researchers found greater isolation for drug users, widespread inability to access life-saving services like supervised injection sites and an increasingly toxic illicit drug supply throughout the pandemic.
In Toronto, respondents reported a 27 per cent increase in injecting drugs alone, and just over half of respondents said they were unable to access supervised injection sites due to reduced hours, reduced capacity and physical distancing requirements.
Vancouver survey respondents — nearly half of whom are Indigenous — reported a 39 per cent increase in inability to access supervised injection sites.
More than 250 First Nations people died of an overdose in B.C. last year, a 119 per cent increase from 2019.
“The pandemic and the opioid crisis have collided in the worst way possible and have resulted in a devastating amount of deaths,” said Dr. Nel Wieman, acting deputy chief medical officer at B.C.’s First Nations Health Authority.
In Montreal, nearly 40 per cent of survey respondents reported an increase in deadly fentanyl during the pandemic.
Cactus Montréal, a community organization that works with marginalized groups in the city, saw one overdose a week before the pandemic, said executive director Jean-François Mary.
During the pandemic, the numbers rose to as many as five overdoses a day.
“It’s like accompanying people on death row and they are innocent,” Mary said. “The only crime they committed was trying to feel better by using drugs.”
Grant estimates she’s known more than 200 people who have, over the years, died of an overdose. She considered a dozen close friends.
Many of them would be alive today if there were greater access to harm reduction services like supervised consumption sites, she said.
No one has ever died under her watch.
“I think it’s because I’m stubborn,” she said. “I don’t care if it’s somebody I’ve never met before … That’s a person, that’s someone’s family … someone’s friend. And I don’t want them dying in my hands.”
This article is also available on the Toronto Star website.