Caught in a crisis

As a cold September rain poured down in Kenora, a van stopped to pick up a young man who residents in this northwestern Ontario town typically shun.

"People cross the street when they see me," Jory Smith said. "It feels horrible."

This was no ordinary van. It was a mobile health unit, run by a small team of street nurses, and it was designed to give some dignity back to drug users like Smith.

The 31-year-old has been addicted to opioids for years, but said they've become "harder to find" in this region since authorities started cracking down on opioid prescriptions. So he's turned to crystal meth, a dramatically different kind of drug that has become readily available here.

Despite its reputation as a tourist haven — with its cottages on Lake of the Woods and renowned fishing and boating — Kenora is a town gripped by addiction.

Like many others in this community of 15,000, Jory Smith is addicted to opioids and crystal meth, and every day is a quest to find a way to alleviate the debilitating withdrawal symptoms and cravings that make him "dopesick."

"I become this irritable, rude, like, just paranoid, delusional person."

And like many other addicts, Smith is prepared to do whatever it takes to find and pay for the drug that makes life bearable. That includes "fencing" (acting as a go-between for stolen goods) or finding drugs for other addicts (for a price, of course).

Using and dealing have made Smith a pariah in this small community, even though he grew up here. But the Northwestern Health Unit van is a safe space, free of judgment.

Nurses Becky Shorrock and Jen Carlson, along with family doctor Jonny Grek, recognize addiction as a health issue. The team believes that in addition to dispensing clean needles, wound care and HIV testing, their mobile unit is meant to build trust with addicts who don't feel welcome in doctors' offices, hospitals or social service agencies.

Shorrock said a big part of the team's job is fostering "an environment where [people with addictions] can come and feel like normal people."

Climbing into the van, Smith cheerfully accepted a sandwich and shelter from the rain. He and Shorrock began to joke with one another.

It's a respite from an often tough existence. In the last year, Smith was hit in the head with an axe during a fight (it took 17 stitches to sew up the wound). He has also been mourning the death of his girlfriend, who suffered from health problems indirectly related to drug use. He almost died himself recently from an overdose.

Opioids such as heroin, oxycodone and fentanyl depress the nervous system and have a sedative effect. Methamphetamines, on the other hand, are stimulants and have the opposite effect, making people euphoric and feeling like they have endless energy.

As a result, meth can keep users awake for days at a time as well as suppress their appetite, putting them at risk of malnourishment or dehydration. Crystal meth can also raise blood pressure, induce an irregular heartbeat and cause agitation, involuntary body movements (sometimes known as "flailing" or "tweaking"), hallucinations and paranoia. It can also create the sensation of "meth bugs," where users feel things crawling under their skin and claw at themselves, creating a risk of infection. Many users get meth psychosis.

Smith has experienced both hallucinations and psychosis, which is why he tries to get enough rest. "If I don't sleep every night, then it's like Dr. Jekyll and Mr. Hyde. I become this irritable, rude, like, just paranoid, delusional person."

People take crystal meth by either smoking or injecting it. Smith does the latter, which he notes is "ironic." While growing up in Kenora and the nearby Rat Portage First Nation, Smith remembers being "scared of needles."

"I never planned this [life] for myself. It's not something I wanted to do."

That said, he was exposed to drugs at a young age. "The first person to shoot me up was … someone who I looked up to as a younger person," Smith said. "If he was to tell me not to use, then I probably wouldn't have used."

In addition, Smith's father sold weed out of an apartment in Kenora known as "the Office," which he later turned over to his son. Smith sold other drugs, including meth and opioids, out of that unit before the building was shut down.

"Crystal meth is everywhere. It’s affecting all walks of life in our community."

Smith would much rather have a legitimate job, but when he tries to apply for one, his reputation comes back to haunt him. "Either I won't get called back [or] if I do, and then they … realize I am who I am, then they'll cancel [the interview] or they'll say they overbooked or whatever."

So Smith's life has become a seemingly unbreakable cycle, in which he commits crimes to feed his addiction, goes to jail, comes out sober and then relapses, starting all over again. Without a trace of resentment or self-pity, he acknowledged that jail has been the only place where he's been drug-free for long stretches.

"As much as, like, nobody wants to go to jail, [it's] really the only place where I can grow as a person," Smith said.

Fellow Kenora resident Will Lacy knows the devastation of crystal meth intimately. The 47-year-old said he ran a million-dollar business before addiction tore his life apart. "It took me down harder and faster than any other drug I've used," Lacy said. "Within months, I was unable to keep a place to live in."

Lacy has been in and out of recovery for 25 years. While he continues to struggle with opioids, he's now an outreach liaison between the Northwestern Health Unit and other drug users in Kenora. "Crystal meth is everywhere," Lacy said. "It's affecting all walks of life in our community."

Kenora is a microcosm of a larger problem. A few years ago, it took shocking death tolls for most Canadians to realize that opioids like fentanyl (and the more potent carfentanil) had created a public health emergency. While federal, provincial and territorial governments have been preoccupied with stemming opioid addiction, crystal meth use has been rising, particularly in western and central Canada.

Health care workers and law enforcement officials warn that meth's powerful hold on users, in tandem with its disruptive, hard-to-treat symptoms, may be leading Canada into a devastating drug emergency on top of the existing opioid crisis.

II.

Crystal meth has been around for decades. It's a synthetic drug that's easy (though dangerous) to make. Ingredients have included ephedrine, pseudoephedrine and red phosphorus, but the U.S. Drug Enforcement Agency said the composition has changed as dealers substitute other chemicals based on what's available.

Like cocaine, meth makes a user high by releasing the neurotransmitter dopamine into the brain. But with meth, the effects are more pronounced, last longer and keep users awake for extended periods of time.

Meth is also very cheap. According to the Ontario Provincial Police (OPP), the going street rate for meth in northwestern Ontario is $10 to $30 a "point" (one-tenth of a gram). Dealers operate on the principle of supply and demand, so police say communities plagued by addiction — like Kenora — are an attractive market in which to sell a cheap drug.

The fact that the town is located within a few hundred kilometres of both Winnipeg and the Fort Frances-International Falls, Minn., border is also key.

"We'd been warned for years by our counterparts in the United States that [crystal meth] is coming," said Insp. Jeff Duggan, head of Kenora's OPP detachment. "The attitude at the time was, 'Nah, it'll never come here — it's a small town.'"

Duggan said in 2016, crystal meth hit with full force. Crime rates — primarily thefts of items Duggan believes people were selling to feed their addiction — increased dramatically. The OPP said it has seen meth activity rise in several communities elsewhere in the province.

Thunder Bay, to the east, is a much larger city than Kenora (with a population of about 110,000) and suffers a high rate of opioid addiction, with the highest per capita rate of fatal overdoses in Ontario. Cocaine remains the stimulant drug of choice in Thunder Bay, and police statistics don't yet reflect a significant meth presence. But drug users there say it has arrived.

"It's just starting to come here," a 32-year-old woman who uses crack cocaine told CBC while roaming the streets of Thunder Bay one morning this fall. She said she had just seen people using meth in the motel behind her. (CBC is protecting her identity because she fears she'll be harmed by other drug users for speaking to the media.)

Det. Staff Sgt. Marc Despres, based in Thunder Bay as part of the OPP's Organized Crime Enforcement Bureau, doesn't doubt that meth dealers have the city in their sights.

"I believe it's just a matter of time before we see methamphetamine become an issue in Thunder Bay," Despres said in an email to CBC. "I've observed this trend with crack cocaine and opiates. Both of these substances were an issue in smaller northwestern Ontario communities well before they took hold in Thunder Bay."

While working as an emergency physician at the Winnipeg Health Sciences Centre, Dr. Carolyn Snider saw crystal meth become the "predominant substance" among patients around 2017.

She said there were times when "everybody, basically, that was coming in was just having these out-of-control, awful psychoses," Snider said. "And other times, it would be … more the uncontrollable movements."

"You'd turn to the cops that were often in there and you'd say, 'There's a bad batch out there,' and they'd say, 'Absolutely.'"

Snider said it was an "incredibly frustrating" period, because as front-line staff were struggling to manage five or six patients actively suffering from meth psychosis at any given time, "all we heard about nationally was the opiate crisis" — and that's where federal funding was going.

Snider is now the medical director of the emergency department at Toronto's St. Michael's Hospital. There, she sees that opioids are still very much a problem — she said she gave more naloxone to reverse overdoses in her first week at St. Mike's than for the entire previous year in Winnipeg.

But she has also seen several cases of meth hallucinations and psychosis, and believes that as the drug moves eastward, it won't be long until Toronto hospitals see the same levels as Winnipeg.

"Even if it isn't being recognized in certain cities or towns across Canada, it's a big problem, and it's probably coming."

It's critical, Snider said, for health-care providers to be ready. "With the paranoia, with the hallucinations, with being extremely escalated, there is sometimes a safety risk. And it's not just to us as staff, but it's to other patients and often to the patient themselves," she said.

One of the first things health care workers need to do in those circumstances is de-escalate the situation, Snider said, starting with speaking calmly and assuring paranoid patients that they're safe.

But that's often not enough. She said paramedics and doctors have also started using olanzapine, an antipsychotic drug, to try to provide immediate relief for patients suffering distressing symptoms from meth use.

"[Olanzapine] sort of gels their brain a bit," Snider said. "Their brain is firing all over the place, and if we can help just bring it together a little bit so that we can start working and talking through it, that's helpful."

If that doesn't work, and safety is a concern, patients sometimes have to be sedated further, or even physically restrained.

After the patient has settled down, there's little more that health care workers can do.

Snider said it's upsetting to watch patients leave the emergency department knowing that their meth-induced mood swings, paranoia and hallucinations can last for days — not to mention the "cravings that come afterwards."

"All of that sets somebody up to use again very quickly," Snider said.

"The understanding of how to treat somebody who is interested in stopping methamphetamines is very, very minimal," she said. "It's a whole other area of substance use and addiction that is so hard."

III.

According to data from both Canada and the U.S., more people using meth are at risk of dying from overdoses than ever before. Just as dealers have cut opioids like heroin with potentially deadly fentanyl or carfentanil, they have also mixed them into other types of drugs.

Dr. Dirk Huyer, Ontario's chief coroner, said that the number of overdose deaths in which both crystal meth and an opioid were detected "dramatically" increased in the province between 2015 and 2018, from 24 cases to 245. It's not known whether the individual in each case took both drugs knowingly, which raises the concern that people could be taking meth contaminated with fentanyl or carfentanil.

Deaths due to "meth toxicity" have also increased, though not as much — from 38 cases in 2015 to 54 in 2018, Huyer said. In those cases, a meth-induced irregular heartbeat could be a possible cause of death.

Part of the problem in treating meth addiction, medical experts say, is that unlike opioid replacement therapy — which uses suboxone or methadone to relieve withdrawal symptoms — meth has no pharmaceutical solution to reduce cravings.

Other treatments that have shown some effectiveness in treating meth addiction, such as cognitive behavioural therapy, are "unavailable through most parts of the country," said Dr. Keith Ahamad, an addictions specialist at St. Paul's Hospital in Vancouver and a clinician-scientist at the B.C. Centre on Substance Use. Ahamad said the rise of meth use on the back of the opioid emergency signals that what Canada is really facing is not a meth or opioid crisis, but an addiction crisis.

Unless policymakers and communities deal with the factors that put people at risk of harmful drug use — including poor housing, poverty, unemployment, social isolation and a history of trauma — "we're going to continue chasing our tail here," he said.

Ahamad said the state of housing in Canada is a "major factor" in drug use, and people who are homeless, living in shelters or crowded, unsafe spaces seek out crystal meth in particular.

"To protect themselves and their belongings, they need to stay awake. And in order to stay awake, they use crystal methamphetamine daily," he said. "In doing that, they put themselves at risk of developing addiction and the consequences of ongoing crystal methamphetamine use."

Ahamad said "people will use drugs that are readily available." He believes policymakers "need to take a step back and recognize that people are using substances, including alcohol, crystal methamphetamine and opioids, at much higher rates than they used to, and we need to look at the reasons why."

IV.

Last year, the rise in meth use finally got the attention of the federal government. After consultations with health care workers, addictions specialists, police, Indigenous organizations, public health organizations and harm reduction workers, the House of Commons Standing Committee on Health released 23 recommendations in June 2019.

They ranged from public education about the harms of meth to improving access to addictions care to developing "evidence-based treatment guidelines for problematic methamphetamine use and addiction," as well as treatment for people suffering from meth psychosis.

The recommendations also suggested additional federal funding to expand supervised consumption sites and drug-checking services to help keep users safe. They also suggested that Health Canada and the Public Health Agency of Canada establish a pilot project looking at ways to provide "an uncontaminated supply of pharmaceutical grade methamphetamines, drawing on similar approaches currently available for opiate users."

(In a dissenting report, Conservative Party members of the parliamentary committee disagreed with providing a pharmaceutical-grade drug supply and expansion of supervised consumption sites, arguing that "taxpayers do not want to pay to keep addicts safely addicted to drugs.")

More than six months since they were published, it's not clear which, if any, of the recommendations will be implemented, or when. The Liberal government has not indicated what actions it will take.

"Someone on crystal meth can take up a lot of space."

In an email to CBC, a Health Canada spokesperson said the department is "closely reviewing the final report and recommendations of the House of Commons Standing Committee on Health to determine potential next steps that could be taken in collaboration with provinces, territories and other partners to better address methamphetamine use in Canada."

Health Canada pointed out it "has made a number of investments to address problematic substance use, many of which help to address problematic methamphetamine use," and noted the federal government had allocated $150 million in one-time emergency funding to provinces and territories as part of its opioid crisis response. Health Canada said Saskatchewan and Manitoba have committed to dedicating some portion of their funding to addressing methamphetamine use.

The recommendations have given Dr. Carolyn Snider hope. "It was good to see the government acknowledge … the need to approach this, because it was almost like it was just being ignored and yet I saw so many people devastated by it."

But it's still largely talk at the federal government level. Some organizations have decided they can't wait.

In recent years, staff at St. Stephen's Community House in Toronto started noticing that increased meth use was leading to an "exacerbation of underlying mental health concerns" among its clients.

At the same time, clients using crystal meth were being barred from services they desperately needed, said Janet Stevenson, a manager in the urban health and homelessness services department at St. Stephen's.

"Because of experiences of … extreme paranoia, psychosis, there can be aggression," she said. "And so that leads them to not having a connection with anybody and then that just leads to continual deterioration."

St. Stephen's started pilot projects targeted at meth users, including a drop-in group called AMP (short for amphetamine). Every two weeks, people who use meth come, have an informal dinner and realize they don't need to feel self-conscious about their meth-related behaviours.

The environment is tailored to people who are over-stimulated through meth use. The lighting is soft and calming and there's minimal furniture. There's also lots of space for people to spread out and re-sort their belongings — a compulsive trait that's common among meth users.

"Someone on crystal meth can take up a lot of space," said Richard Kikot, a former meth addict who was a coordinator of the AMP program (he has since left to start another job).

People who use meth tend to be fidgety and find it soothing to take things apart and put them back together. That's led to a companion program where participants learn to fix bikes.

What's most important, said Filippo Vescio, another peer worker with the program, is that users "feel a part of something."

Meth users are often socially isolated, and may forget basic elements of self-care, including eating, drinking water and sleeping. Peers like Vescio provide an informal way for them to find out about addiction treatment, safer drug use and other supports.

Vescio, who is 41, was addicted to meth himself, and did time for theft, drug possession and trafficking. In prison, he worked through a recovery program. But once he got out, he had to break a 20-year routine of spending his days looking for drugs.

Now sober for more than a year, Vescio's new routine includes helping other people suffering from addiction — both through the drop-in meth program and doing outreach in the streets.

St. Stephen's has applied for funding to expand the peer support program to serve 100 participants, and hire more peer support workers, like Vescio, to give meth users an opportunity for employment. They're awaiting a response from the federal government.

The organization has also developed learning modules — posted on YouTube — to educate health care and service providers across the country about crystal meth and techniques for working with users, such as de-escalation.

As part of his own recovery process, Vescio changed his nickname from "Monkey" — the name people gave him on the streets — to "Five." He said he chose the new moniker (the first two letters of his first and last names) to reclaim his identity.

"I guess I'm going to try and learn more about myself, and become who I'm supposed to be instead of who I was, and who the drugs made me, right?"

Like Vescio, Jory Smith knows that to change his life, he has to go through rehab — and then find something to replace his all-consuming drug-seeking routine in Kenora. He mused that it could eventually include helping others struggling with addiction.

"I want to live a life of … having something to remember or look back on and think that, you know, that's not a waste of a life."