Could Quebec’s successful battle against the opioid epidemic be turning?

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The harm prevention worker Jean-François Mary carries a black zip-up case about the size of an old phone receiver wherever he goes in Montreal.

Inside are four vials of naloxone, which helps counteract opioid overdoses. He and his colleagues have had to jab the antidote into more users than they can count this year – far more than ever before.

Until recently, Quebec existed in a charmed circle all its own amid the raging opioid epidemic. In 2018, it ranked second from the bottom among Canadian provinces and U.S. states in terms of opioid fatalities, with 207 deaths.

But the province’s advantage is beginning to slip away. In 2020, it recorded 547 drug overdose deaths, a 32-per-cent increase over the year before.

“We have more than one death a day in Quebec right now and nobody cares,” says Mr. Mary, executive director of CACTUS Montréal, a non-profit that operates a supervised injection site in Montreal’s downtown.

The cost of a crisis

The rise in opioid poisoning in Quebec is in line with a countrywide explosion during the pandemic. But the recent spike is an especially worrying trend for la belle province, which had largely remained insulated from the crisis. A chorus of activists and academics are now calling on the provincial government to act quickly, before Quebec goes the way of the rest of the country, where a toxic drug supply has killed nearly 20,000 people since 2016.

“We were an exception in North America,” he says. “But May showed us we weren’t a real exception. … It could happen to us, too.”

How Quebec managed to protect itself from such an expansive public health crisis reflects several quirks of the province’s distinct society, including its political orientation, medical culture and criminal distribution networks.

André-Anne Parent, a professor in the school of social work at the University of Montreal, credited the provincial government’s relatively generous and consistent funding of community organizations, including those that help drug users. Quebec funds these groups in part through a program known by its French acronym, PSOC, with stable money tied to their mission, rather than one-off grants for particular projects as in some other provinces, allowing them to operate more effectively, he argues.

“That’s a structural difference in Quebec,” Dr. Parent says. “It’s a factor for sure.”

Although he disputes the generosity of his government funding, Mr. Mary allows that on-the-ground intervention by groups like CACTUS, founded in 1989 as North America’s first needle-exchange program, saves many lives. He and his colleagues have managed to train a large number of community support workers in CPR and overdose prevention, he says; they stand out in downtown Montreal thanks to the yellow containers they carry for collecting used syringes.

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Quebec community health groups say they also learned valuable lessons from coping with a particularly punishing HIV/AIDS epidemic, including the importance of trying experimental treatments and the primacy of harm reduction.

“We’re not going to ask people to stop using drugs because it’s not realistic, just like it’s not realistic to ask people to stop having sexual encounters,” says Chantal Montmorency, co-ordinator-general of the Association québécoise pour la promotion de la santé des personnes utilisatrices de drogues (AQPSUD).

The provincial ministry of health and social services also touted Quebec’s relatively early adoption of free naloxone kits in pharmacies. When the program rolled out in 2017, it was ahead of several Western provinces, including Saskatchewan and B.C.

Nothing seems to have protected Quebec as well, however, as the peculiarities of its legal and illegal drug markets. Quebec has by far the lowest rate of opioid prescription in the country, for example. Its pharmacists dispensed just 3.6 defined daily doses of the six most popular opioids per resident in 2016, according to a study by the Canadian Institute for Health Information – less than half of Alberta’s rate and far below the national average of 6.1.

Better training for health professionals and the absence of private pain management clinics of a kind that are common in Ontario have kept a lid on the spread of that class of drugs, Quebec’s health ministry said in a written statement.

The province’s linguistic bubble might have also spared the province from some of the aggressive pharmaceutical marketing that pushed many doctors to overprescribe opioids in the rest of North America, says Mr. Mary of CACTUS. In a continent with 350 million anglophones and fewer than 10 million francophones, learning to push certain drugs in Quebec wasn’t worth it for Big Pharma. (Dr. Robyn Tamblyn, professor of medicine and epidemiology at McGill University, says the idea that doctors trained in francophone medical schools would be less exposed to opioid marketing than those in the English-speaking world “is a reasonable possibility but has not been tested.”)

The province’s illicit drug dealers have also contributed, almost inadvertently, to keeping dangerous opioids off the streets. Black-market versions of the painkiller fentanyl have been a leading cause of overdoses across Canada in recent years, but they are far less prevalent in Quebec. About 5 per cent of the province’s accidental overdoses were found to have been caused by fentanyl in 2017, according to a recent study of coroners’ reports by Dr. Parent and colleagues. (That year in B.C., about 80 per cent of overdose deaths involved fentanyl or its analogues.)

The tastes of Quebec drug users have also kept them protected to some extent. The province has traditionally preferred cocaine to opiates, says Ms. Montmorency; until a few years ago, about 80 per cent of Montreal’s injection drug users took cocaine rather than heroin or other depressants, estimates Mr. Mary. “Montreal has been a coke city forever,” he says.

That preference may also reflect the business imperatives of major drug cartels. The Quebec market was slow to absorb crystal meth, as well, observes Jean-Sébastien Fallu, a professor at the University of Montreal’s school of pyschoeducation focusing on substance abuse – perhaps because the Hells Angels, who were known to dominate the sale of cocaine, did not traffic in the newer drug.

The protective wall around Quebec’s drug supply has started to crack, however. “Downers,” like hydromorphone, began to spread through the province around the time of the 2008 financial crisis, says Mr. Mary, as people sought relief during a time of stress. The appeal of selling super-powerful opioids such as fentanyl eventually became irresistible – Mr. Mary estimates dealers can make the same profit from importing a kilo of fentanyl as they can from a tonne of heroin. Even the Hells Angels sell opioids now, he says.

“We’ve been saying it for a decade now: it’s coming. The money appeal was there,” Mr. Mary says. “But public health was waiting for the numbers to go up to act. We could have been prepared.”

The numbers are indeed going up, slowly but distinctly. The Quebec government reported 62 deaths linked to fentanyl or its analogues last year – still a small fraction of the province’s death toll from overdoses, but almost 20 more than the previous year. The drug is now “everywhere,” Ms. Montmorency says.

The rise of fentanyl is one reason overdose deaths have shot up during the pandemic. Another is the province’s strict lockdown, which has worsened conditions for drug users, advocates argue. More people have been dying since the government imposed a curfew in January, because it further pushes users to consume alone, Ms. Montmorency says. “We’re losing members of our families, our friends, our colleagues.”

At the supervised drug-use site operated by CACTUS, the number of overdoses has increased at least fivefold in the past year, Mr. Mary says, from about one a week to more than one a day. By using antidotes and mouth-to-mouth resuscitation – performed during the pandemic through an elaborate viral filter – the facility has avoided any deaths, but the rise in drug potency is clearly having an effect. A staff member recently set an in-house record by using nine vials of naloxone to revive one user.

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Fentanyl’s new prevalence in Montreal was confirmed in late April when police seized $1.4-million worth of the drug, the largest such bust in the province’s history – a sting that did nothing to stop the opioid’s flow through the city, Mr. Mary says. The seizure has only pushed users to find less familiar suppliers; one woman he knows recently overdosed on her new supply because she didn’t know how strong it was.

“The police strategy right now is making the situation worse,” he says.

What Quebec needs is a safe, legal supply of drugs, Mr. Mary argues. He would be willing to provide medical-grade heroin out of his clinic, but until that becomes politically feasible – and the Crosstown Clinic in Vancouver is still one of the few places in the world to offer that treatment – there are other ways of screening out dangerous concentrations of fentanyl.

CACTUS is awaiting federal approval for a waiver that would allow the organization to test the composition of street drugs without running afoul of trafficking laws. In the meantime, and more controversially, Mr. Mary believes authorities should collaborate with black-market dealers to temper the deadly strength of their product.

“Street drug dealers are not the enemy in the overdose crisis,” Mr. Mary says. “We need to work with them. Send that message up to the top: ‘Your batch is too strong.’ ” (This tactic would be a first in Canada, he believes.)

In the midst of this growing crisis, Quebec’s opioid overdose prevention strategy for 2018 to 2020 recently expired. The document – which included guidance on training for pain treatment and the expansion of access to naloxone, among other programs – didn’t go far enough anyway, Dr. Fallu says. Despite calls from Montreal public health for the decriminalization of hard drugs, for example, the province has refused to take up the issue. The relatively conservative government of François Legault takes an “ideological and anti-scientific approach” to drug policy, argues Dr. Fallu, including imposing higher age limits on cannabis use. The Premier’s reluctance to act more aggressively to stop the surge of overdose deaths is a “scandal,” the professor says. “It’s crazy. It’s depressing. It’s enraging. It’s frustrating.”

(The provincial ministry of health points out that while its overdose strategy has technically expired, the government has set aside $15-million to continue the measures it contained, including funding for supervised drug-use sites.)

Standing outside of the CACTUS office, Mr. Mary reflects on the people whose lives depend on Quebec winning the next stage of the fight against overdoses. In the window hangs black-and-white photos of local drug users – some hugging or smiling or looking defiantly at the camera.

“Luckily none of them are dead,” he says. “Only the living. That’s rare.”

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