Toronto Public Health (TPH) is alerting the public after paramedics recently responded to six suspected opioid overdose-related deaths.
The health unit said that the number of people who died of a drug overdose between March 14 and 17 is triple the current average seen over a four-day period in the past 12 weeks. The deaths occured throughout the city, TPH said.
1/4: #DrugAlertTO: there has been an increase in suspected opioid overdose-related deaths attended by @torontomedics, incl. 6 suspected opioid overdose related deaths between Mar 14-17: https://t.co/v55NOtwjpq
— Toronto Public Health (@TOPublicHealth) March 18, 2024
And while it is not known at this point exactly what substances those who died consumed, public health's bulletin made mention of the recent identification of two high-potency synthetic painkillers in the city’s unregulated drug supply.
The "new" drugs found are nitazene opioids and were detected in drug samples collected by Toronto’s Drug Checking Service, a free and anonymous public health service that is offered at five harm reduction agencies in the downtown core.
The first substance, N-desethyl etonitazene, is considered to be up to 10 times stronger than fentanyl.
It was first identified on Feb. 23 at Parkdale Queen West Community Health Centre’s (PQWCHC) Queen West site. The sample analyzed, which was expected to be fentanyl, was a yellow/beige powder. Instead, it contained a combination of N-desethyl etonitazene and caffeine, the service said in a March 18 bulletin.
The second drug is called protonitazepyne and is believed to be more than 20 times stronger than fentanyl.
This substance, which is also known as N-pyrrolidino protonitazene or “pyro”, was first found on March 6 and then again on March 7, also in Toronto’s west end, but at PQWCHC’s Parkdale site. The samples contained a blue powder that was expected to be oxycodone (OxyContin), but actually contained protonitazepyne and etonitazepyne, another type of synthetic opioid.
Toronto's Check Checking Service's analysis site member at the Centre for Addiction and Mental Health (Clinical Laboratory and Diagnostic Services) identified these two new drugs by using a technique known as liquid chromatography-Orbitrap high resolution mass spectrometry. Another analysis site member at St. Michael’s Hospital (Department of Laboratory Medicine) has also identified them using gas chromatography-mass spectrometry. Both processes essentially separate and identify compounds found in a substance.
It is not known how much of these drugs were found in each sample as TDCS does not currently quantify N-desethyl etonitazene or protonitazepyne.
The city’s drug checking service noted that none of the samples they collected and analyzed were “reported as being associated with an overdose or other unpleasant or abnormal effects,” however it did not test the substances that were associated with the recent cluster of fatal overdoses, said Karen McDonald, the lead of Toronto's Drug Checking Service.
It should also be noted that because of the potency of these newly identified drugs, a higher amount of naloxone may be required to rouse persons who are experiencing an overdose, especially when the substance consumed with other central nervous system or respiratory depressants like benzodiazepine-related drugs or veterinary tranquilizers.
"Because these nitazene opioids are so strong, the chance of overdose are increased and also its likely that greater doses than normal of naloxone are going to be required to reverse the overdose," she said.
Further, the risk of overdosing on a nitazene opioid can also be higher for people accustomed to using less-potent types of opioids like oxycodone, Percocet, hydromorphone (Dilaudid), or hydrocodone compared to those who are used to consuming fentanyl as their opioid tolerance may be lower, TDCS said.
In a written statement, TPH said that it works in partnership with the city’s drug checking service to “directly support clients and to inform research and policy development, including the monitoring of data from a wide variety of sources,” however there’s much work to be done to get a handle on this crisis.
“Toronto continues be in the midst of a drug toxicity crisis, and Toronto Public Health continues to call for increased federal and provincial investments in prevention, harm reduction, and treatment supports. Overdoses and deaths due to the toxic drug supply are preventable,” a spokesperson said.
UNREGULATED DRUG SUPPLY CONSTANTLY EVOLVING
Meghan White has worked as an overdose prevention support worker at Parkdale Queen West Community Health Centre for about two and a half years.
She says that the “constantly evolving” unregulated drug supply is causing so many adverse reactions and is difficult for those who support people who use drugs.
“In my time here, I’ve witnessed, obviously, a lot of overdoses and just losing people in the community and there’s always something new and just when we think we have something under wraps or when we understand the substance a little bit better something changes, there’s a new drug be it an opioid, a new analog or some type of benzo or tranquilizer so it’s just been a whirlwind of trying to understand something that is constantly changing,” she told CTV News Toronto.
“There’s always something that is notable, something’s that’s new that’s causing overdoses.”
White said that anyone who is not used to consuming opioids and takes the two newly-identified substances would surely experience an overdose.
She said that responding to people overdosing day in and day out is hard enough, although it’s something she and her colleagues have been able to manage, but the struggle is that they can see evidence of more ways that they can help people, but those options aren’t being provided or they don’t have great enough capacity to provide those services.
“I think it’s also hard because there’s no 24-hour sites so when we close our doors and we go home for the night we know that people are going to be using these unregulated drugs that nobody really understands fully and who knows what can happen,” she said.
“It’s always kind of that fear of not if, but when are we going to find out that someone in our community has passed away again.”
White said the sadness of that reality gives her and her colleagues the motivation to continue advocating for more supports for people who use drugs and solutions to this crisis, like safer supply programs.
Nitazene opioids were initially synthesized in the 1950s, but were never clinically approved for market. Most are stronger than fentanyl and are classified by Toronto's Drug Checking Service as “high-2 potency opioids.”
According to the service, they first started showing up in the unregulated drug supply in Europe, the United States, and then Canada – primarily in Ontario and Quebec – in 2019. In Toronto, nitazene opioids were identified for the first time in the unregulated fentanyl supply in February 2021.
In late 2023, TDSC identified another highly-potent drug that was found for the first time in the unregulated supply. Medetomidine/dexmedetomidine is a tranquilizer that can put users in a deep state of unconsciousness, especially when consumed in combination with high-potency opioids, benzodiazepine-related drugs, and another animal tranquilizer called xylazine. The effects of consuming medetomidine/dexmedetomidine cannot be reversed with naloxone as these drugs are not opioids.
MORE SUPPORT NEEDED TO ADDRESS DRUG CRISIS
Speaking with CP24 on Tuesday, Zoe Dodd, co-organizer of the Toronto Overdose Prevention Society said that the unregulated drug supply is constantly changing and best way to prevent overdose deaths is to implement and fund policies that “actually help people.”
“We have a government that has sat on millions of dollars that could be transferred to healthcare, that could help people who are struggling to get onto OAT (Opioid Agonist Treatment) or safer supply programs. And they can also fund supervised consumption services and actually resource them so that they can be open longer,” she said, adding “real investment” in the system is the answer.
Dodd went on to say that it is next to impossible to get into detox, especially programs that offers medical assistance, not to mention the lack of culturally responsive and appropriate supports overall.
Laws surrounding the legalization and criminalization of drugs must also be changed, she said, adding more supports also need to be put in place to help those who have lost loved ones to the drug crisis.
“So it's only going continue to get worse until we actually implement policies and expand services so that people don't die,” said Dodd.
McDonald of Toronto's Drug Checking Srvice agreed.
"The only way out of this is to either replace the supply or to transition people off of it completely," she told CTV News Toronto's Beth Macdonell.
"So either introduce a regulatory framework like we have done for cannabis and alcohol for all drugs, not just some, and/or we need to be scaling up safer supply programs that transition people off the unknown and unregulated street supply."
TIPS FOR THOSE WHO CONSUME UNREGULATED DRUGS
As always, people who use drugs are advised to carry and be trained to use naloxone, check their drugs - ideally before using, and use at a supervised consumption site or overdose prevention site or with someone else and take turns spotting each other.
Those who must use alone are urged to let someone know before they consume and to do a small test dose first.
People who use drugs are also encouraged to talk to the person they got them from, if the sample did not contain what was expected, or get their drugs from another source.
With files from CTV News Toronto's Beth Macdonell.
