Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada

Abstract

Background: North America is experiencing an opioid overdose epidemic, fuelled by the proliferation of fentanyl, related analogues, and fentanyl-adulterated opioids. British Columbia, Canada has similarly experienced a rapid increase in the proportion of opioid overdose deaths associated with fentanyl. This study builds off of research characterizing fentanyl exposure to further explore the presentation of fentanyl use and related overdoses among people who use drugs. Methods: From December 2016 to April 2017, rapid ethnographic fieldwork was conducted in Vancouver, Canada to examine the implementation of low-threshold overdose prevention sites, where people use drugs under the supervision of staff and peers trained to respond to overdose. Data collection included 185 hours of ethnographic observation and in-depth interviews with 72 people who inject drugs, 44 of whom reported experiencing an overdose in the year prior to the interviews. Results: While most participants had experienced previous opioid-related overdose, they characterized how fentanyl was markedly distinct in terms of: potency, and rapid onset. Ethnographic observations and participant narratives highlighted how fentanyl use and related overdoses had implications for frontline response, including: rapid onset, multiple concurrent overdoses, body and chest rigidity, and the need to administer larger doses of naloxone. Conclusions: Participant narratives, and observational data documented distinct symptoms for fentanyl-attributed overdoses compared to other opioid related overdose events, which had implications for response. Findings may serve to inform best practices in responding to fentanyl-related overdoses including; the provision of oxygen and effective doses of naloxone, and also considerations regarding overdose identification.

Understanding concurrent stimulant use among people on methadone: A qualitative study

“…pharmaceutical stimulants) that reduce the need to engage with the illicit drug market. This is of particular importance given that continued shifts within illicit drug markets are increasing bringing people (including those using stimulants) into contact with adulterants such as fentanyl and others . Further, within the context of these potential overdose‐related risks, ensuring access to harm reduction interventions (e.g.…”

“…In particular, it further demonstrates the need for increased attention to low‐threshold methadone treatment programs primarily oriented toward the management of opioid use rather than total drug abstinence, which is becoming more relevant as medications for opioid use disorder are scaled up in response to the overdose epidemic. Within this context, methadone treatment requirements, including the expectation that people remain abstinent from stimulants (as well as other drugs), that result in punitive measures like involuntary treatment discontinuation or penalties that increase the threshold of treatment are counterproductive and likely to increase overdose risk among people seeking alternatives amidst an increasingly toxic drug supply . Clinicians and pharmacists required to perform ongoing screening for all substance use will also need education in low‐threshold approaches and should be prepared to engage people in harm reduction strategies, such as supervised consumption sites and needle exchanges, while also offering treatment options for stimulant use.…”

Peer worker involvement in low-threshold supervised consumption facilities in the context of an overdose epidemic in Vancouver, Canada

“…That could cost a life. (Leslie, 56 year-old white woman) However, it is notable that peer workers successfully responded to all overdoses observed during our fieldwork despite challenges in identifying fentanyl-related overdoses (see Mayer et al, 2018) and no fatal overdoses have occurred at OPS (BC Coroners Service, 2018). Moreover, most interviewed OPS clients emphasized that peer workers were well trained in overdose response and responded effectively to overdoses occurring at OPS: Yeah, as soon as somebody [overdoses] -this person needs help -and they're on their feet, ready, and already beside the person, which I like.…”

“It’s Helped Me a Lot, Just Like to Stay Alive”: a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada

“…This change in the illicit drug market poses a twofold challenge as fentanyl is both extremely potent (estimated 50–100 times stronger than morphine) and its distribution within illicit opioid markets varies considerably [ 3 , 4 ]. People accessing drugs from the illicit market, therefore, seldom know the strength and purity of the drugs they are consuming, exposing people who use illicit drugs to considerable overdose risk [ 3 , 5 , 6 ]. This has resulted in a sharp increase in overdose mortality; more than 15,393 opioid-related overdose deaths have occurred in Canada since 2016, and over 94,000 in the United States (US) from 2017 to 2018 [ 1 , 7 ].…”