“We pay a lot of attention to the deaths associated with the toxicity of fentanyl, but what we’re not looking at is all the people who survive overdoses.”
It is sometimes called the “hidden” epidemic.
The precise number of drug users who have suffered overdose-related brain damage in Canada is not known.
But the effects of that epidemic are readily apparent on the downtown streets of cities like Ottawa, where social disorder has grown steadily worse, and the job of caring for people who use drugs has grown ever more challenging.
“We’ve been talking in our circles about hypoxic brain injury for a couple of years now because we’ve seen how many overdoses are happening,” said Rob Boyd, chief executive officer of Ottawa Inner City Health, a non-profit agency that has delivered health care to the city’s homeless since 2001.
“Hypoxic brain injury affects people’s ability to plan, their impulse control, their ability to follow through on things, and it affects their recovery prospects in general.”
University of Victoria neuropsychology professor Mauricio Garcia-Barrera is one of the few researchers who has studied the phenomenon in Canada. He said hypoxic brain injuries can lead to a “vicious cycle” for drug users, making it more difficult for them to manage their daily lives while deepening their stress levels, mental health conditions and addiction problems.
“We pay a lot of attention to the deaths associated with the toxicity of fentanyl, but what we’re not looking at is all the people who survive overdoses,” Garcia-Barrera said in an interview. “Many, many more people survive those events, and a significant number of them are going to be presenting with symptoms of brain injury.”
Research in the United States has established there are about 15 non-fatal drug overdoses for every one that kills a drug user.
If the same ratio holds true in Canada, it means there have been more than 650,000 non-fatal overdoses in the country since 2016.
Every non-fatal drug overdose has the potential to inflict brain damage. Synthetic opioids like fentanyl target the brain stem, which controls breathing, and an overdose can depress breathing to the point that neurons are starved of oxygen. Unless normal breathing is restored through the timely delivery of Naloxone, a medication that rapidly reverses the effects of opioids, an overdose victim begins to suffer brain damage within minutes.
For the past eight years, those on the front lines of the toxic drug crisis in Canada have raced to keep people alive through emergency measures such as supervised injection sites, safe supply programs and the distribution of Naloxone kits.
In Ottawa, more than 500 people have died from opioid-related overdoses during the past three years; thousands more have survived their overdoses. Staff at the city’s busiest supervised injection site, The Trailer on Murray Street, last year reversed 1,784 overdoses. Staff at Somerset West’s supervised consumption site successfully reversed 487 overdoses.
Boyd warned that Premier Doug Ford’s plan to eliminate 10 supervised consumption sites in the province, including Somerset West’s, will lead to a greater incidence of brain damage. More people, he said, will be consuming drugs in isolated places, where Naloxone may not be readily available.
“When we’re there and we can administer Naloxone to people immediately, we’re protecting the brain,” he said. “That’s what overdose intervention is all about because each and every minute is important.”
According to Prof. Garcia-Barrera, those who suffer hypoxic brain injuries can experience trouble with attention, memory, motor co-ordination, emotional regulation, decision-making and problem-solving.
Self-awareness can also be affected, he said, making drug users less likely to view their addiction as a problem to be addressed. For those who do seek help, issues with memory and executive function can make drug rehab extraordinarily difficult.
“They tell us they feel very easily overwhelmed,” he said.
No one in Ottawa has tried to measure the prevalence of hypoxic brain injury among this city’s drug users.
Several academic studies have tried to assess the scope of the problem in Canada, but identifying overdose-related brain injuries is an inexact science.
A July 2023 B.C. study examined health information from 824,000 people randomly selected from a provincial database. Researchers identified 5,357 people who had experienced one or more overdoses between 2015 and 2019, and discovered that one per cent of them had also been diagnosed with encephalopathy, the brain damage that can result from a non-fatal overdose.
The study concluded that people who suffered drug overdoses were 15 times more likely to have encephalopathy than someone who had never had an overdose.
In March 2021, the Public Health Agency of Canada also published a study that attempted to quantify the problem.
Federal researchers analyzed hospital administrative data from the Canadian Institute for Health Information between April 1, 2019 and March 31, 2020. It showed that, across Canada (excluding Quebec), there were 4,433 opioid overdose-related hospitalizations. The researchers found 4.2 per cent of overdose victims admitted to hospital also received a diagnosis for an anoxic brain injury.
Fentanyl or one of its analogues were involved in half of those cases.
The federal study concluded: “Anoxic brain injury is often an under-recognized consequence of opioid-related poisonings, and for those who survive, the lasting effects can include significant changes to physical, cognitive, and behavioural functioning which may warrant additional supports.”
Rob Boyd believes the academic research underestimates the problem since many overdose victims do not go to hospital, while hospitalized overdose victims are not always assessed for brain damage.
What’s more, he said, the prevalence of brain damage is elevated among the homeless population even before accounting for the impact of drug overdoses: “Unfortunately I can’t really put a number on it, but there’s a high prevalence of brain injury to begin with because of the high number of assaults they’ve experienced as adults or as children.”
Somerset Ward Coun. Ariel Troster said the brain injury epidemic is contributing to the erratic behaviour of people who use drugs in Ottawa. Many of the leaders within the drug-using community – people who once warned others against injecting near families or schools – have died from overdoses or suffered significant brain injuries, she said.
“We’re noticing people are really spaced out: they don’t seem to have a sense of appropriate time and place,” Troster said. “It’s leading to people pulling out their works and ingesting drugs at a bus stop, in front of schools, very publicly – and that’s become very distressing to the community.”
There’s no doubt, Boyd said, that the brain injury epidemic is making the management and care of the city’s most vulnerable people that much more challenging.
“There’s a growing percentage of people who are never going to able to fall under the Housing First model: they’re going to need 24/7, wraparound supports,” he said. “We talk about being people’s external brains because they need constant queuing and prompting for basic daily living skills… We now have to question capacity a lot more than we’ve had to in the past.”
The Housing First philosophy holds that alcoholics and drug users should be given the stability of a home rather than moved in stages through shelters, treatment programs and group homes. But hypoxic brain damage means more people will be unable to live independently, Boyd said, and will require supportive housing or long-term care.
In British Columbia, Premier David Eby has vowed to open rehab facilities to provide “involuntary care” to brain-injured people with severe addictions who are also mentally ill. Eby said the program would be carried out under the authority of the Mental Health Act.
“It is costly for people struggling with these conditions,” he told reporters. “They are not safe, and increasingly, I’m concerned that the way that they are interacting in our communities is making everybody less safe.”
During the past eight years, the brain injury epidemic has been largely overshadowed by the more sprawling and deadly opioid epidemic.
Across Canada, drug overdoses have claimed the lives of more than 44,000 people since 2016. Federal data shows the vast majority of those deaths (80 per cent) have been connected to fentanyl and its analogues – powerful synthetic opioids that can be fatal even in small doses.
Fentanyl acts on the central nervous system – medically, it’s used to relieve severe pain – but street versions of the drug are unpredictable and can be contaminated with toxic chemical compounds. It means overdoses are common.
In high doses, fentanyl can interfere with brain receptors that govern the drive to breathe, leading to slow, shallow breathing that deprives the brain of oxygen. Brain damage can occur within a few minutes of the hypoxia that results from such ineffective breathing.
Michelle McDonald, executive director of the advocacy group Brain Injury Canada, said her organization is seeing more people with overdose-related brain injuries looking for help. “It’s not being discussed, the challenges experienced by those who survive overdoses,” she said.
McDonald said few programs are designed for drug users with acquired brain injuries (ABIs). Existing ABI programs are already underfunded, she said, and cannot offer the support and mentorship that drug users need.
“They have trouble with information processing and memory so 12-step programs generally don’t work,” McDonald said.
Boyd said the same issues make drug treatment and harm reduction programs more difficult to deliver to those with hypoxic brain injuries. Methadone programs, for instance, require participants to start on a low dose and return every day to a clinic for doses that gradually increase. (Methadone is a long-acting opioid used to treat more damaging opioid addictions.)
“That means they have to come back the next day and the next day and the next day,” Boyd explained. “It’s really difficult to do with a brain injury: It impacts your ability to plan and follow through on plans.”
Prof. Garcia-Barrera said frontline responders should screen overdose victims for hypoxic brain injuries since an early diagnosis improves the chances of recovery.
“To some extent they are treatable,” he said. “There are regions of the brain that, unfortunately, they cannot fully recover, but there’s a lot of compensation that can happen through the brain’s plasticity: You can recover cognitive functions that have been affected, you can retrain the brain.”
Coun. Troster said that while it’s difficult to understand how to tackle all of the problems that flow from the brain injury epidemic, she knows safe consumption sites are part of the answer.
“I’m extremely concerned about the long-term brain damage of the drug-using population,” she said. “I’m very worried there are dark days ahead once this policy takes effect.”
Andrew Duffy is a National Newspaper Award-winning reporter and long-form feature writer based in Ottawa. To support his work, including exclusive content for subscribers only, sign up here: ottawacitizen.com/subscribe
Illustrations by Sofia Misenheimer
