Cheque day: When the opioid crisis crashes down on Ottawa's ByWard Market

One week last winter changed everything.

On the last day of February, a woman in her mid-40s was found dead of a drug overdose in her bed at Shepherds of Good Hope, a homeless shelter at the corner of Murray Street and King Edward Avenue.

Three days later, a woman in her 20s, a beloved member of the shelter community, was discovered showing no vital signs during an hourly bed check. She was given naloxone, CPR and rushed to hospital, but to no avail.

Until then, drug deaths at the shelter had been extremely rare. Two in a week had never happened before in the three decades that staff there have ministered to the city’s homeless in the ByWard Market.

Many workers were distraught. Frontline staff develop strong bonds to the damaged and vulnerable people who come to Shepherds as an island of safety in chaotic lives.

“That was really jarring for us,” said Caroline Cox, senior manager of transitional shelter services at Shepherds. “That really didn’t happen before. And then it happened twice in one week.”

Cox and her co-workers knew the deaths were not a tragic coincidence, but pointed toward a fundamental change in the city’s drug supply: the arrival of fentanyl. Staff feared that such overdose deaths would soon become the new normal.

“I can’t do this every week,” an assistant manager warned Cox.

A sense of urgency gripped the shelter. Leaders at Shepherds and Ottawa Inner City Health, an organization that uses the shelter to deliver health care to the homeless, met to discuss ways to meet the fentanyl issue head on.

They were well aware of the devastation wrought by the crisis on the streets of Vancouver, Calgary and Edmonton. It was now clear that Ottawa would not escape the scourge of fentanyl — a cheap and powerful synthetic opioid that can kill any user.

The response of Shepherds and Inner City has dramatically changed the way they care for the city’s homeless. The organizations have introduced a raft of initiatives, including bed checks every 15 minutes, peer support workers, a medicinal opioid program and widespread naloxone distribution.

While supervised injection sites, including the ByWard Market’s controversial pop-up tent, have sparked public debate, the steadfast work in and around the shelter has gone on with little notice. “We’re just trying to keep up and keep people alive,” says Anne Marie Hopkins, an Inner City Health supervisor. “Our community is being slammed.”

Fentanyl has also changed the way many drug users look after themselves: They’re more likely to use together and in public now. If you’re overdosing, isolation can be a death sentence.

All of it means that the ByWard Market is now the scene of a nightly life-and-death drama — the likes of which this city has never known. 

Friday night in the ByWard Market finds 44-year-old Jason Paul LeBlanc giving an impromptu, sidewalk demonstration: How to save someone who’s overdosed.

LeBlanc — everyone calls him J.P. — is a peer outreach worker, one of 12 hired by Inner City Health during the past five months as part of its crisis-management strategy. Outreach workers patrol the streets of the market four nights a week, handing out clean needles, new crack pipes, test strips (to check drugs for the presence of fentanyl) and naloxone — the wonder drug, marketed as Narcan, that can reverse the effects of an otherwise fatal opioid overdose.

LeBlanc shows a small group of users how to take a knuckle and rub it hard on a victim’s breastbone, and how to deliver a shot of Narcan nasal spray if there’s no response.

“If someone’s ODing, they won’t be able to talk to you; they won’t be able to respond to you,” he explains.

Adrian Johnson, 45, a veteran of Ottawa’s downtown streets, lies flat on the sidewalk so that LeBlanc can better demonstrate how to deliver the Narcan. “The fentanyl is here now; it’s in everything,” says Johnson, who describes himself as someone suffering addiction and mental health issues. “Things are changing in a severe way.”

LeBlanc shows the assembled how to insert the Narcan nozzle into the victim’s nose and squeeze the device’s plunger. He tells them to wait three to five minutes for a response and, if there is none, to administer the drug a second time.

For LeBlanc, the nightly outreach work is therapy of sorts.

“I was on the street for 15 years,” he explains. “I was one of their (the shelter’s) biggest clients, and now that I’ve changed my life around, I get satisfaction out of trying to change other people’s lives.”

LeBlanc’s life has been deeply scarred by addiction.

He grew up in Cobourg. He played guitar, drums and tuba in his high school band. He would often babysit his younger siblings while his father and stepmother played bingo — and he was paid for his services, in beer. LeBlanc thought it was a great system, particularly since his friends were allowed to drink at his house.

“Little did I know,” he says, “but it was sending me right down a path of destruction. I became a complete mess.”

LeBlanc’s addictions blossomed. He lost a good-paying job clearing tree branches from hydro lines — “They tend to frown on people working around 27,000 volts who are strung out on heroin,” he says — and went into the grow-op business with some friends.

But the success of that enterprise only fuelled his addictions. He moved to Ottawa and hit rock bottom in 2011 when his girlfriend suffered fatal complications from endocarditis, a side effect of intravenous drug use. (Dirty needles can send bacteria to damaged areas of the heart.) His girlfriend had two damaged valves replaced, but even in recovery, she couldn’t put the brakes on her injection drug use.

“I couldn’t stop her,” LeBlanc says.

In the wake of his girlfriend’s death, LeBlanc overcame his own heroin addiction with the assistance of counsellors at the Sandy Hill Community Health Centre. They helped him find stable housing, and he learned to replace heroin with exercise — running — and medicinal marijuana.

As he took control of his own life, LeBlanc began to volunteer with organizations dedicated to advocating for drug decriminalization and harm reduction.

In June, he won a job as a peer support outreach worker with Inner City Health.

The idea behind the program is to employ people who already have a level of trust with drug users to educate and protect them. The outreach workers all have experienced homelessness and addiction — and can speak to users as fellow travellers on a hard road.

“I want to let people know it doesn’t have to be this way,” LeBlanc says.

Zack’s coat is three sizes too big. He takes it off and folds it carefully on top of his possessions, stuffed into three plastic bags, at Shepherds. His hands are dirty and track marks tattoo his forearms.

Still, at 26, dressed in a white T-shirt and baggy gym shorts, it’s easy to imagine that he once held a basketball scholarship to a U.S. college. He lost that opportunity, he says, after developing a heroin addiction with a girlfriend in Utah.

Toronto-born, he came to Ottawa to enter a drug-treatment program, but ended up on the street. Now, he sleeps most night at Shepherds.

Zack remains addicted to heroin, and uses the drug alongside what he describes as “weed, alcohol, cocaine, crack cocaine … a little bit of speed here and there, you know …”

On this Friday, he has just returned from using at the pop-up supervised injection site in nearby Raphael Brunet Park. Injecting at the site is one of the measures he’s taking to protect himself — and others — from fentanyl. In fact, among his possessions are seven naloxone kits: He carries the overdose antidote everywhere.

Zack says he has rescued 21 overdose victims in the past month by injecting naloxone. Most of them were people he was using with; one or two were strangers he happened to discover. They all survived.

“I’ve got a perfect record so far,” he says.

Naloxone can be injected into the fatty tissue of an overdose victim or delivered through a nasal spray. Medical and social workers now carry it in kits hanging from their belts. Nurses from Inner City Health are dispatched at speed with extra doses when an overdose victim is reported nearby. Sometimes they’re forced to climb over fences or explore deep into alleys to find them. 

Quick access to naloxone is the difference between life and death.

Last month, a drug user in a nearby housing unit died because those with him were unable to find anyone with the antidote in time. And one of Zack’s best friends, a dealer, died last month from touching drugs laced with carfentanil, one of the most powerful opioids ever developed. It’s used in veterinary medicine to anaesthetize large animals.

Finding an overdose victim, Zack says, can be “creepy and sad at the same time.”

“They turn greyish blue and life slowly drains out of them. All of a sudden, you see them just pretty much go to sleep. Their arms tighten up. Maybe their legs are shaking a bit. Their breathing could stop. It is scary. You have to react really quickly.”

“Code Abby.” 

That’s the phrase that signals a drug user has overdosed and isn’t breathing. Staff at Shepherds are all equipped with walkie-talkies, and Code Abby sends the shelter’s nurses into high gear, running with oxygen and naloxone.

Since two client deaths early this year, the shelter’s rescue workers have succeeded every time they’ve been sent into action. There have been some close calls.

Because of the power of fentanyl, one dose of naloxone — even two — are sometimes not enough to reverse its effects: It can take four or five doses.  

A client named Abby was one of the first at Shepherds to receive so many naloxone doses; her name has since become eponymous with overdose emergencies.

Shelter staff have had no choice but to become efficient at dealing with overdoses because there are so many: As many as 60 a month in and around Shepherds. (These statistics are not counted by Ottawa Public Health, which publishes the number of overdose victims taken to hospital each month.)

Anne Marie Hopkins says fentanyl has now invaded the city’s broader drug supply.

Fentanyl has been found, she says, in drugs such as speed and crack cocaine, which are not opioids. “There’s fentanyl in absolutely everything,” she says, “so people who are normally not at risk of overdosing on it are suddenly at risk.”

During the summer, the shelter experienced six overdoses in 40 minutes: Nurses were sprinting blocks away with naloxone. “They’re incredible at dealing with it and they’re heroic,” Hopkins says.

They’re people such as Daniel Davidson, a soft-spoken giant with a nose ring who mans the front door at Shepherds five evenings a week.

In recent months, he says he’s assisted 20 overdose victims and injected naloxone three times: “I have saved more than one person’s life. It feels good. But it’s heavy: It is a lot to think about sometimes.”

On the streets of the ByWard Market, J.P. LeBlanc is a naloxone evangelist: He preaches its benefits to users gathered in parking lots and slumped against sheltered walls.

“I want to get as many naloxone kits out as possible,” he says. “My goal is to educate people about overdoses and naloxone.”

Naloxone was developed in the early 1960s at a New York lab using a synthetic derivative of morphine.

The drug has miraculous properties: It blocks the brain’s opioid receptors and displaces opioids that are already there, allowing an overdose victim to quickly breathe again. (An opioid overdose depresses the central nervous and respiratory systems.) Naloxone is not addictive and doesn’t react badly with any other drug so administering it rarely causes harm.

Outreach workers in the ByWard Market have given out 250 naloxone kits during the past five months.

Still, LeBlanc encourages users to consume their drugs close to Shepherds: He wants them to be within easy striking distance of the shelter’s nursing staff.

“You can’t shoot up alone anymore,” he warns.

In the basement of Shepherds — a former Catholic boys’ school — is a narrow hallway with bedrooms on either side. The rooms all have bunk beds, which can together accommodate as many as 84 men.

On this night, LeBlanc and a fellow peer support worker make their way down the hallway, flashlight in hand.

They open one bedroom door and turn the flashlight onto each man’s chest to make sure he’s still breathing. Satisfied, they move on to the next room.

The routine is repeated every 15 minutes all night. The outreach workers also check washrooms and dark corners of the building for overdose victims.

Brain cells begin to die after about four minutes without oxygen. It means that someone who suffers a fentanyl overdose has to be discovered and given naloxone within that short window of time.

“That’s fentanyl: It’s terrifying,” Hopkins says.

In August 2016, the shelter recorded three drug overdoses. This August, it responded to 45 drug overdoses inside the building or nearby.

“It’s just what happens here now,” says Hopkins, an Ottawa-born social worker who has been with Inner City Health for the past eight years. “You have to always know who’s coming in at high risk. It’s a lot more work. There’s so much more stress. It’s heavily emotional. It’s chaotic.

“When a lot of people come it at once, keeping everyone safe is hard.”

Cheque Day falls on the last weekday of every month, when government support programs issue their payments. In the ByWard Market, the day is widely known as Mardi Gras.

The infusion of cash sends drug users on a buying spree and, every month, shelter staff brace for the fallout with extra staff and hyper vigilance. The commitment of shelter staff has likely saved dozens of lives.

But Ottawa Inner City Health executive director Wendy Muckle worries that their luck cannot hold: “We have had some terribly close calls. It is really just a matter of time. We have to have a better solution.”

New programs are already in the works. Inner City Health is applying for an exemption from the federal government that would allow regular clients to inject illegal drugs on the premises, supervised by nursing staff.

It’s also applying to set up a supervised injection site in a trailer now behind Shepherds so that other users can take drugs safely. It can be ready within 24 hours of government approval, Muckle says. 

Inner City Health has also launched a managed opioid program in which users are given prescription opioids provided they give up their street drugs.

The program — similar to Inner City’s internationally recognized managed-alcohol program — solves some critical issues: It reduces or eliminates overdoses, and it frees users from constantly trying to find money to buy drugs.

Still, it has been a tough sell to the city’s injection drug users, who are reluctant to give up old habits for the structure of a managed program.

For Alfred Newton, though, there was no other choice.

The soft-spoken 39-year-old signed up in September after overdosing on heroin five times in one week: He overdosed on the street and, one time, in the kitchen at Shepherds. Without the managed program, he says, “I would be in a casket.”

Newton receives two doses of synthetic heroin three times a day — one dose taken orally, and one injected. He injects alone in a room, supervised by a nurse watching on a webcam.

Newton believes the program is already helping him: “My diet has already changed,” he says. “Everything has changed.” He’s now hoping to find a place to live that supports addicts and to move on “instead of being trapped.”

In the meantime, those on the front lines wait anxiously for what comes next in the ever-changing opioid crisis.

Ottawa police recently confirmed that the synthetic opioid carfentanil — a drug 100 times more potent that fentanyl — has been found in seized heroin caches in the city. Shelter officials knew it was here. For one thing, Hopkins says, carefentanil overdose victims tend to present differently: they often arch backwards and stiffen during overdoses. It can take up to 10 doses of naloxone to revive them, she says.

Hopkins worries the dangerous new drug will only make a bad situation worse in the ByWard Market.

Inner City Health used to concentrate on stabilizing the lives of their clients: finding them better housing and improving their health. They still do that work, Hopkins says, but increasingly their focus is on more immediate questions.

“How are we going to keep people alive today? How are we going to keep people alive over the next four hours? What is happening at this moment outside? What drugs are outside right now? Where are people using? Do they have naloxone?

“People’s lives are on the line right now. I have been around this community for almost 10 years and I have never seen anything like this.”

By Andrew Duffy and Elizabeth Payne
Source: Ottawa Citizen