My latest in Watershed magazine: when fentanyl takes over

Kissed by Jesus.

When you ask addicts, or those who are regulars on the sidewalk outside the Bridge Street United Church in Belleville – or anywhere – what using fentanyl is like, the first time they did it, that’s what some will say: it’s like the heavens parting, and some deity reaching down to embrace them.

For the first time in their lives, they’ll say – lives which have been too often sad and lonely and dark – they felt wanted and loved.

Some writers used to say heroin was like returning to the womb, except fentanyl is 100 times better, users say. The warmth starts in their toes and fingers, and creeps towards their heads and hearts.

All your troubles go away, they say. Nothing else intrudes on the bliss that results from fentanyl. They fall in love with it.

The first time, they say, nothing else compares. There is no joy as complete as the joy bestowed on them by fentanyl, that first time. Until that first feeling fades.

And then, the pain begins. The darkness returns. The depression seizes them.

After the vampire that is fentanyl sinks its fangs into them, nothing else is ever the same. It owns them. It controls them.

Fentanyl takes over.

**

Dr. Meldon Kahan is dispassionately describing what fentanyl does to the human brain.

“We all have, in our brains, a reward system,” says Kahan, who is a Professor in the Department of Family Medicine at the University of Toronto, and Medical Director of the Substance Use Service at Women’s College Hospital. “It’s in the middle of our brain. And when we do something that’s important for survival – like eating or sex or what have you – there’s a dopamine spike in our reward pathway in the brain. That’s what gives us a sense of pleasure.”

He pauses.

“That is all related to the memory part of our brain, too. So, we vividly remember the next day how it felt. And, that memory center, it’s related to the executive function part of our brain – which is what tells us to go out and do it again and again. Drug use acts on that reward center in our brain, too. And the dopamine spike users experience is often more powerful than what they get from activities like eating or sex. In essence, the drug hijacks the reward center of our brain, and it becomes more important than normal survival activities.”

Heroin and other opiates literally do that; they hijack a person’s brain. But how to they compare to fentanyl?

“Fentanyl,” Khan says, exhaling. “Well. It is an extraordinary drug. The other opiates are like puppy dogs compared to fentanyl. I’ve seen patients where their entire existence is focussed on getting it, because they cannot tolerate withdrawal from it.They are tormented every single day by powerful cravings.” He pauses again. “And, sure, they have free will. But addiction is a mental disorder. Their decision-making is completely compromised. Whatever they are going to do in their life is completely compromised by the drug.”

“And the drugs we have to counter it? They’re not enough.”

**

Fentanyl is an opioid, which essentially relieve pain. It is a synthetic opioid, too, which means that it was made by people, not nature.

Fentanyl – its formal name is N-phenyl-N-[1-(2-phenylethyl)-4- piperidinyl]propanamide – has been around for a long time. It was invented in the Belgian laboratory of Dr. Paul Janssen in 1959 or so. Janssen was in the pharmaceutical business, and he had been looking for a drug that would be as potent as it was fast-acting – and make him a fast buck.

Morphine and the like were available back then, but Janssen wanted something stronger than that. He and his colleagues played around with the molecules in morphine and meperidine for a while, until they decided to synthesize a derivative, one that would break through the blood-brain barrier much faster. In 1960, they did. They created fentanyl.

It was as much as 200 times more potent than morphine. It was more than 50 times more powerful than heroin. It was, and would for a long time remain, the most potent opiate in the world. Like other opiates, it could cause “fatigue, sedation, nausea, vomiting, dizziness, respiratory depression, and unconsciousness/anesthesia,” the American Pain Society wrote a decade ago. Too much of it could kill. But unlike the others, its effects – especially if taken orally or nasally, which is how most addicts now use it – could be felt in just seconds.

Oh, and this: it was wildly, massively addictive. Wrote the Pain Society, in what would be one of the biggest all-time understatements: “Patients need to be carefully monitored for signs of opioid overdose.”

**

They should be. About 22 people die every day from opioid overdoses in Canada; most of them are men in their thirties, and 82 per cent of the time, it’s fentanyl that kills them. B.C., Alberta and Ontario have it the worst.

On one cold and unforgiving February night in Belleville, Ontario, nobody was “carefully monitoring” Brian Orford and his friends at the Bridge Street United Church. Mostly, locals were doing what doing what they always do: staying away. Crossing the street to avoid the sad-looking people at the basement entrance to the church. Or, avoiding the area entirely.

On the two days in question, in the first week of February, the Belleville police issued a statement that is the sort of thing you see in war-torn corners of the world. But not so much in Belleville, Ontario, the Friendly City. For Belleville, as far as anyone could remember, this was a first:

“The Belleville Police Service is advising the public to exercise caution and avoid unnecessary travel to the downtown core area following reports of a significant number of overdoses on Tuesday afternoon,” the statement read. “[There is a] need for increased vigilance and awareness in the affected areas.”

It was a state of emergency, the authorities would say, which is what you declare when you’ve got “a danger of major proportions,” one that could cause “serious harm” to people. So, just about every ambulance and paramedic and police officer in the 613 area code hurried to the corner of Bridge and Church streets, sirens and tires cutting through the night.

Two dozen of Brian Orford’s friends had overdosed on fentanyl mixed with something else. Close to half of them were at death’s door, with doctors and nurses frantically working to save their lives.

The news flashed across the country like a rocket, because something like that had never really happened before in Small Town Canada. Belleville, the Friendly City, became the scary city. On TV, news anchors solemnly described it as unprecedented, because it was. Things would get worse before they got better, too: on the Thursday, the very next day, with overdoses continuing to happen on and along Bridge Street, Belleville declared the actual state of emergency. Life on the sidewalk at the Bridge Street United Church – never good – had gotten measurably worse.

Brian Orford is 44 years old, but he looks much older than that. His eyes are profoundly sad, sadder than an unused crib in a dumpster. His hands are swollen and red from drug use, and they clutch at the corners of his donated parka. He’s been on the streets, without a home, for almost a decade.

Orford, who grew up in and around Belleville, is well-known at the church. Like the others – hundreds of them – he comes in the mornings for the continental breakfast, usually a bagel. On Sundays, they come for something that is closer to a full meal. They get fed at the Sally Ann, too, depending on donations.

When you stop and ask if he will talk to you, Brian Orford says sure, and leans against the church wall, as if to steady himself. He speaks in a voice that sounds weary and broken. He’s asked about his friends, the ones who overdosed and nearly died. Was it a bad batch of fentanyl?

“A lot of people here have switched to those other drugs,” Brian Orford says. “It’s pretty dangerous.”

The fentanyl is being cut with GHB, the date rape drug. Xylazine, too. That one is called “tranq dope,” and it started up in the States a few years ago. Tranq is even deadlier than fentanyl, because naloxone – or Narcan, which is used to save those who are overdosing – doesn’t work on it. If you use too much tranq, you can get necrosis – rotting of human tissue, flesh-eating wounds. Parts of you can literally fall off. They call it the zombie drug.

Brian Orford talks a bit more about his friends, in a quiet voice, and then he excuses himself to get something to eat in the basement of the church. He shuffles off, bent like a twig in a storm.

**

The overdoses at the Bridge Street United Church still happen, but not as bad as in February. Maybe it’s because the people there stick together. Compared to other towns and cities, they look after each other. They’re proud of that.

Tammy and Sherri do. Tammy sits on a bit of cardboard on the ground, Sherri beside her, on the lawn chair she favors. They’re both 51 years old. They’re best friends, they say. They don’t want to give their last names, because feel ashamed by what their lives have become. They don’t want to get their pictures taken, either, because some of their family don’t know where they are.

Which is on the street, for years. Both have been living on Belleville’s streets for a couple years, now. Tammy, who is Indigenous and tattooed and smart and plain-spoken, is from Belleville “and out Peterborough way.” Sherri, who is quieter and usually willing to let Tammy speak for both of them, is from a little town near Brantford. Sherri is housed now, in a rooming house. Tammy is hoping to be, but she’s scared about it: she’s not used to living under a roof. Sherri isn’t addicted to anything except coffee and cigarettes, she says. Tammy, meanwhile, doesn’t hesitate: she’s addicted to fentanyl.

They’re asked, first off, what they and everyone at Bridge Street really need. Safe supply? Programs? They both answer: housing. “We need more low-income housing for everybody,” Tammy says. “There’s not enough housing.” No one ever really kicks a drug habit, she says, unless they have a place to live. It gives them hope, more than just about anything else. “If you don’t have housing, that just adds to your drug problem,” says Tammy. “I just want a home. Then I can work on my addiction.”

One of Tammy’s sons comes up and sits down on the ground beside her. He’s a gangly, dark-haired boy, and he doesn’t say a single word during a discussion that lasts a long time. He’s an addict, too. Tammy has three other kids; Sherri has six. All of Sherri’s were taken away from her, for adoption. Tammy’s are on the street, like her.

The conversation turns to what social workers and politicians prefer, which is “hubs” where there is “safe supply.” Tammy immediately frowns and shakes her head. Sherri shakes her head, too. Some places offer people like her weaker-dose opioid pills to get them off fentanyl, Tammy says. But most of the addicts just sell the pills to get more fentanyl, she says. And then the people they sold pills to? They start looking for something more powerful – and then they turn to fentanyl.

“I was into fentanyl really, really bad,” Tammy says. “So I went to Kingston to get clean, about eight months ago. They dropped me off at the hub they have there. It’s just a place where they do drugs. It’s the epitome of friggin’ drug abuse, there.”

They’re asked about the night of all the overdoses, the night Belleville made the national news. “I ended up dying right here on the lawn,” Tammy recalls, pointing at the dirt. She had no vital signs, but she was eventually brought back. She continues: “I don’t remember what was in it. Maybe tranq.” She squints, remembering. “Narcan just brings you back to life. It doesn’t work on the tranq.”

She stops and looks at a scarecrow of a man wobbling down the sidewalk. “You okay, buddy?” she calls out to him. “You okay?” He nods and moves off. Tammy waves a thin arm in the direction of the other ghostly people navigating the sidewalk. She starts to say something, then stops.

Kids as young as 15 can now be found at the church, Tammy and Sherri say. Much older people, too, well into their seventies. People sometimes drive by the church in their big, shinybSUVs and scream at them, they say. These people drive up and down Bridge Street and tell them to die, over and over. “Some people are really mean,” Sherri says.

They’re both quiet for a while.

**

Lori Regenstrief is a doctor. Her expertise is addiction, and she’s blessed with the ability to speak passionately about it. She’s helped addicts in Vancouver’s Downtown Eastside, Inuvik, Sudbury, Manitoulin Island and inner city Toronto. These days, she’s in Hamilton. Reached while on the road, again up near the Arctic, Regenstrief listens carefully to what Tammy had to say about hubs and “safe supply.”

“It’s almost like palliative care,” she says, agreeing. “You are basically saying to people like Tammy, ‘Well, you don’t have to get better. You just stay where you are and we’ll give you these pills.’”

Tammy is right about so-called safe supply, she says. “Look, even with small amounts of fentanyl, people become very quickly addicted. It’s very, very addictive. It’s way more potent than heroin. And, you know, we never as a society offered heroin on a wide scale, did we? We never said: ‘Oh, high school kids should really have access to clean heroin,’ did we?

She pauses, and she sounds angry. “But that’s what we’re doing now.”

**

The discussion, which has gone on for a long time, is coming to an end. Tammy and Sherri are asked whether the outside world – the world beyond Bridge Street – understands them. Cares about them. Wants to know them.

Sherri shakes her head and says nothing. She looks down the road.

Tammy finally speaks. “They want us to be invisible,” she says.

“Gone.”