Small Conversations for a Better World Podcast
Small Conversations for a Better World Podcast
The Last High / Dr. Daniel Kalla
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Dr. Daniel Kalla talks to us about why he wrote his 11th novel, The Last High, a Globe and Mail Best Spring Read choice. He gives us an intriguing look into the devastation this epidemic has caused in his chosen field of emergency medicine, the impacts of the pandemic and where change is desperately needed.
BIO: Born, raised, and still residing in Vancouver, Daniel spends his days (and sometimes nights) working as an Emergency Department Physician at St. Paul’s Hospital for the past twenty years. He has been the Emergency Department Head since 2013. He is clinical associate professor at the University of British Columbia.
Daniel is also the author of eleven published novels, which have been translated into twelve languages. He has had two novels options for film, and his Shanghai trilogy has is being developed for a TV series. In his eleventh novel, The Last High, Daniel uses his real-life experience as a physician in a downtown hospital to tackle the causes and impacts of the opioid crisis in an realistic gritty thriller that he wrote, in part, as a cautionary tale.
Daniel received his B.Sc. in mathematics and his MD from the University of British Columbia, where he is now an clinical associate professor and the department head of a major urban ER. He the proud father of two girls and a poorly behaved but lovable mutt, Milo.
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Gillian and Dan discuss this graph. ://health-infobase.canada.ca/substance-related-harms/opioids/graphs?index=340)
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Health is wealth, and this is where we're going to talk about it. The Small Conversations for a Better World Podcast with hosts Jillian McCormick and Susanna Steers. This podcast represents the opinions of the hosts and or their guests to the show. The content is for informational purposes only and should not be taken as medical advice nor establish a legal standard of care. Hello, everyone, and welcome to the Small Conversations for a Better World podcast. I'm Susanna Steers.
SPEAKER_04And I'm Gillian McCormick.
SPEAKER_01Just when we thought that things might be starting to turn around with regard to the COVID-19 pandemic, it is suddenly apparent that another deadly health crisis is continuing to pick up steam here in Vancouver, and that's the opioid crisis. Today we're going to talk about this crisis as it appears in Vancouver, BC. We know that fentanyl and other opioids have reached in and touched many people's lives. And we want to acknowledge that this is a huge topic and that one hour is not going to do it justice. So this is just one tiny toe dipped into this seething ocean that is opioid addiction, otherwise known as opioid use disorder. To help us in our journey to understand what has happened in this crisis and what is happening now, is a very special guest with a frontline knowledge of the common, dangerous, and tragic consequences of opioid use. And he has a cautionary tale to tell. Joining us today is Vancouver native Dr. Daniel Kalla. Dr. Kalla has worked in emergency medicine for the past 20 years and since 2013 has been emergency department head at St. Paul's Hospital. For those who may not know, St. Paul's is Vancouver's downtown hospital and is positioned at the veritable epicenter of our opioid crisis. Daniel also happens to be the best-selling author of 11 novels translated into 12 languages, three of which are being developed into TV series. His latest release, The Last High, is about, you guessed it, a super potent fentanyl wreaking havoc on the streets of Vancouver. It's a page turner. Exciting and at the very same time, very, very chilling. Dr. Kalla, welcome to the podcast.
SPEAKER_03So
Daniel Kalla: Doctor/Author
SPEAKER_03you're Vancouver born, raised, educated. Now you have your own family, including kids and dog, I understand. You're the head of an ER, and you're a novel writer with almost a dozen titles. That's a pretty unique combination of accomplishments. Can you tell us about how that all evolved?
SPEAKER_00Well, it's it's from uh, you know, in large part from years of having untreated ADHD has led me in uh in many directions in my life. Um, but uh no, I don't even know how it's involved, to be honest with you, Jillian. I just I always knew I wanted to write, you know, I I always wanted to be a doctor. It was in my it's very much in my blood and my genetics. I'm a third generation doctor, so I started down that route, but I always kept writing in in mind. And when I when my first daughter was born 22 plus years ago, um I fulfilled a pledge to myself to take a night course and I dragged a couple friends with me and I started writing, and I haven't stopped since. And luckily, being in emergency medicine, it's uh it's a career that often lends uh because of the shift work, because of the hours, um, the opportunity to pursue other interests. And mine has always been writing.
SPEAKER_03And so can you tell us what your approach to writing is? Like, do you write a novel all at once or do you putter along in small steps?
SPEAKER_00I I didn't think you'd stump me on the first couple questions, but my approach, my my approach is not terribly um regimented or organized. You know, I I mean I do have that's that's not entirely accurate. I um I it starts with the idea, you know, which can take me months or years to come up with. Um and then, you know, I I work from I will create an outline, uh, but it's a very loose, relatively short outline for a novel idea. And then uh I never go back to the outline once I start writing a novel. And I I tend to write in fiery bursts, you know. Once once uh I get momentum, once the characters take shape in my mind, I tend to write very quickly. Um it's just I just the way I create, the way I write is it's so, but it's always that first um step of finding the story, the theme, the characters I want to write about that often.
SPEAKER_04Uh is there always an element of medical science in there?
SPEAKER_00Yeah, I mean, medicine is my gimmick. You know, I I always knew that with writing that that it would, you know, that I wanted to take readers behind, you know, behind the curtain, as it were, to show them my world and and what I know best about. But it's let me explore all kinds of huge themes, you know, from medical ethics to obviously pandemics and super bugs and now the opioid crisis and even a historical trilogy about you know a doctor surviving and saying hi, World War II. So it's not always that it's the most central component of my story, but generally uh there are doctors and nurses and other uh health workers who tend to be in my uh novels because it's the world I know best. But I often use that as a springboard to tackle big themes and topics that I want to tackle.
SPEAKER_03I understand that by the time a book is published and readable by the public, it's probably been two years since you actually wrote it. Is that right in terms of the publishing process?
SPEAKER_00Yeah, that's about right. I well, for the last high, for example, it was probably depends what you see mean by write it, because you write the first draft and then you go back and forth, you know, through drafts for months and months and months. So to put it in perspective, I finished the first draft or the last high in maybe September of 2018. I finished the final draft maybe in June of 2019, and it's being published in May of 2020. So it's okay, you know, 18 months lag time. So yeah. Yeah, absolutely. I I I don't I have never written a more personally or professionally, anyway. I mean, fortunately the opioid crisis hasn't touched me much personally, but professionally it's decimated my career and my work and my workplace. And I I don't remember being as affected by anything medically as as the opioid crisis. So it was very much in the forefront of my mind. I really wanted to write, as you described it in the intro, the best way to describe it, a cautionary tale. I wanted people to know what a massive issue it was. And it really was peaking in 2018. You know, then a lot of harm reduction measures, a lot of effort, you know, in Vancouver, provincially, nationally, went to fighting the opioid crisis. So it did, it had improved somewhat. I mean, it was still devastating uh compared to even five, six years ago. But now with COVID, as you know, in the last month in May, we had the highest death toll ever in Vancouver from opioids. So um it's certainly not like the problem settled or gone away in any way, shape, or form. But I really want I have grown daughters, and and you know, and uh uh for me I was writing a tale particularly for for people in their teens and their twenties and to understand um the allure, the dangers, and uh the threat of opioids.
SPEAKER_03So you you just used the word that it decimated your workplace. Can you describe that? Why that word?
SPEAKER_00Because it, I mean, it it's it's unbelievable how many of our sort of regular clientele, you know, in St. Paul's Emergency, a lot of the downtown east side residents and and people with opioid disorder who lived in the area would frequent us because you know they didn't always have a lot of other options. And you know, they most of them have family doctors and clinics that support them, but they they live a lot of time, you know, their daytime is often nocturnal because of their lifestyle. So uh when they needed help, they often turned to us. And we got to know, I mean, for 20 years working down there, I got to know a lot of the people on a first name basis, and and they just started disappearing. You know, it was unbelievable. Regular clients who we'd seen, you know, 10, 15 years just weren't showing up anymore. And then you started to hear about the death tolls, you know, climbing, you know, over a thousand people in a year, and you know, many, if not most of them in Vancouver, many from the downtown east side. And and so it was just it had a you know, it had a substantial impact on the clientele that we saw regularly. Continues to.
SPEAKER_03It continues to, yeah. It sounds like last month was pretty indicative of that. So within the novel, you allude to a few things that I was surprised by and I wanted to ask about. I promise I'm not gonna give away plot secrets, um, but I do want to pick apart a few things. Does that sound okay to you?
SPEAKER_00No, it sounds great. I I think you can give away plot secrets, you know. Uh as well, but as you know, I I think it's an interesting, you know, I I like to think it's a you know, it's a it's a relatively compelling who-done it to the end, but but it's no secret to say it's very much not an ensemble cast of villains because the opioid trade is run by an ensemble cast of people here. And I wanted multiple representation from you know, from the victims on the street all the way up to the gang lords who you know who who import the the product. And so I don't think there's much you can give away by asking.
SPEAKER_03All right. I'll dive in here. And well, and to that note, um, I thought it that was a fantastic part of the novel was how well you depicted that it's everywhere, and it involves so many levels and layers of people. Okay, so my
Transplant Lists, Poisons and Users
SPEAKER_03first thing to knock off the list is the transplant list. It's shorter than it's ever been. Is that true?
SPEAKER_00Yeah, very much so. Um it's one of the only positive byproducts of the tragedy that's existed. They they changed the rules. It used to be people who um were um intravenous drug users and had hepatitis C and such were not candidates. So I don't know, five, ten years ago they changed the rules about transplant. So that affected the recipient or uh or organ donor list to begin with. But then when the opioid crisis became as bad as it did, because a lot of these people, you know, the first thing in an opioid overdose when someone stops breathing and they effectively suffocate in room here if nobody's around to give them the antidote or mouth-to-mouth resuscitation. I mean, it's dead simple to reverse, but if they're alone and they die, the first organ to die is the brain after four to six minutes. Sometimes, because these people are often young and healthy, the heart is resuscitatable. So if somebody finds them after 10 minutes and the heart gets resuscitated, but they're effectively brain dead. And so those people make the best uh organ donors because of because the the rest of their organs have survived and their brains haven't. So it's very, it's you know, it's it's it's it's tragic. I mean, at least, and as I allude to in the novel, at least for some families and stuff, it gives a sense of of purpose to the to the devastating loss of their loved ones.
SPEAKER_03I I I I'm just sitting here with my mouth agape. It is um a weird macabre silver lining, as you speak.
SPEAKER_00Yeah, yeah.
SPEAKER_03And then poison control plays a big part in your plot. Um and we wondered if that's really a part of the process of discerning whether a death has been due to opiates. Is that is that true? And is that where the toxicology report comes from? I don't know.
SPEAKER_00No, and and uh I but I didn't mean to imply that. The the the heroine, as you know, uh who is herself uh an ex-addict, uh, is is a toxicologist as well as an emergency doctor. So and some emergency doctor, I work with two toxicologists in my emergency department. People have sub-specialty training in toxicology, and they often work as the consultants and experts for poison control on the side. So she used her connections through poison control to find out if there were other reports and to get a sense of, I mean, yeah, they the poison control, they all they always know about the poisons on the street and the epidemiology and stuff. So, in that sense, it's true. But the link to poison control was because she also worked for them, so she used her inside track. So, as an average of merch doc, I sometimes consult poison control when I get strange poisonings and stuff. But for opioid overdoses, I wouldn't do that routinely.
SPEAKER_03But but that weird poison is a particular concept when it comes to the opioid. And I've I've heard it said that there's a poison supply of drugs on the street. The users have a poison supply. Um and then it that concept seems to highlight a couple of different facts. Like one, that the amount of of perhaps fentanyl or opioid being taken to create an overdose is therefore acting as a poison in the body. Would it not be?
SPEAKER_00Well, for sure. I mean, uh opioid's one of the most uh potent poisons in some senses, depending on how you define a poison. In terms of overdose deaths, it's the most potent poison we have on the streets right now. It's more potent than serin or cyanide because nobody's dying, nobody's dying of that in the city. So but you know, I think it's a really important distinction that we talk about opioids. Um, for instance, fentanyl was one of the safest medicines we had in the hospital. We use it all the time for pain control, often certain in surgical and short-term procedures. We use it because we control the dose, we know exactly what we're giving. Um, all opioids do the exact same thing effectively. I mean, there's some subtle differences, but they all cause the same degree of of can cause the same degree of analgesia or pain control, and they can cause the same amount of euphoria and and various other side effects. But it's all dependent on the dosage. And the problem is that fentanyl is fentanyl is a very highly potent opioids. So when when it replaced heroin, which it largely has on the street, there's practically no heroin, it's almost all fentanyl, it is a hundred times more potent than heroin. And users were taking huge hits, you know, of it. So we used to see, we you know, 15 years ago, we saw a significant number of people die of heroin overdose. But imagine if now the product they're getting is a hundred times as potent. And on top of it, as I lead to in this book, there are these opioid or sorry, fentanyl analogs, which are ultra potent, carfentanyl being the most well-known of them, and that's an elephant tranquilizer, it's a hundred times as potent as fentanyl. So it's 10,000 times as potent as heroin. So you can imagine how easy it would be to overdose and die on those drugs. And that's the problem. And you know, and the other thing I allude to in the book is the absolute lack of quality control in these terrible street labs that are, you know, where these cooks are cooking up the fentanyl that they're selling. You'd never know how potent a product you're getting from one to the next. And so that's an incredibly deadly combination.
SPEAKER_02That was a great um image that just clears up a lot of questions about a lot of things.
SPEAKER_01When I was reading your book, I really appreciated the images of the different kinds of people who might use opioids. Um, you know, in Vancouver, we often focus specifically on, oh, it's all down in the downtown east side, and those people are not like me. Um and even if that's if even if that were true, the end of the day, those people were all someone's kids too. They're all people and have their own lives and and you know, had had time before they were, before they succumbed to uh their opioid addictions. Um I guess they're in that circumstance, their current circumstances can often be directly linked to their opioid use disorder in the way that it's a disease process that has altered their physiology and their thoughts and behaviors. Um but opioid deaths from fentanyl have been happening to other people, you know, white collar users from lawyers to parents to doctors and regular folks for whatever reason have become addicted to opioids. Um, would you say that that's a fair statement?
SPEAKER_00Uh yeah, but I'd like to answer that in two parts. To the global nature of opioids, first of all, absolutely. There's deaths from people, you know, as the start of the book is five teenagers dying from opioid overdose without ever realizing they're taking opioids. That happens all the time, the inadvertent users. Then there's a whole degree of other drug users like cocaine, you know, coke addicts and uh, and even some crystal meth addicts and or uh or you know, users, even casual users who are getting contaminated product, who get fentanyl in their product and die from that. Then there's people who try it once the first time, and those people are very vulnerable because they don't have the sort of season tolerance in their system. So there's a whole spectrum of people. And you know, you scratch the surface, you talk to your friends in Vancouver, chances are they'll know somebody with one or two degree separation who's lost somebody to this fentanyl crisis. It's it's that pervasive, it's terrible that way. So uh there's that component. But the second component, well, the group you raised first, you know, the harder core opioid use disorder, the downtown east side of patients, the them that we'll never be part of. A, you said it beautifully, they are loved by, you know, they're often buried by parents. They have they're they're mourned and missed by friends and families. Uh, they're definitely people too, I think they have a genetic disease that, you know, addiction is an inheritable, genetically inheritable illness. We it's it's not necessarily some lifestyle choice or some you know, you know, poor uh judgment on their part that they end up in this the shape they do. But even if you accept that there's some lifestyle choice on their part, the alcoholics, uh cocaine addicts, gambling addicts, they can live for 10, 20 years, be functional or not functional, destroy some lives, but they rarely die of their disease. Uh and then there's a chance at some point they'll hit rock bottom, they'll get help, they'll be rehabilitated, and then they'll go on with you know constructive lives. With these opioid use users, I mean, 10% of them are dying or were dying a year. It's they're they're playing Russian roulette every time they use. So if you can keep them alive and well enough during their addiction until the point where they're ready and contemplative is the word they use to consider treatment, to consider uh stopping, uh, you know, you you there's lots of potentially productive years of life after addiction. So that's why I think it's so devastating for um the uh opioid users in particular.
SPEAKER_01Yeah, it's a scary, scary drug, a scary group of drugs. Um so, listeners, the last high is fiction. It's very readable, page-turning, exciting fiction that you should read this summer. And because we are extremely lucky, and uh Daniel is quite generous, he has agreed to read a section of his novel for us.
SPEAKER_00I think probably the easiest is just to start with the prologue of the novel because it gives a sense of the what I see as one of the biggest issues of Botopia is how it how everyone is potentially vulnerable. So I'll start with the prologue.
SPEAKER_01Great.
Daniel Reads Prologue
SPEAKER_00Great prologue. The host music courses through Alexa. The hypnotic beat and melting layers of sound feel as if they come from within, as if her heart is the amplifier, and the warmth is so enveloping, like being lowered into the most perfect bubble bath. The bliss is almost unbearable. Alexa can't lift her head off her chest, but she can move her eyes with. Quick sweep of the room, she sees all her friends who matter most to her Rachel, Nick, Joshua, Grayson, and Taylor. The only ones who matter at all, really. Taylor, her very best friend, is slouched at a weird angle on the couch beside her. Taylor had promised to ensure Alexa got some alone time with Josh at the party, even though she had a crush on them too. Typical Taylor, always putting her friends first. Taylor's eyes are still open, but the pupils are tiny as pinholes. And her complexion, it's grayish blue while her lips have turned almost purple. So strange, but so beautiful. Alexa shifts her gaze to the left and sees Josh and Gray sprawled out on the other couch, propped up by their abutting shoulders. Josh's eyes are as glassy as Taylor's while Grays are shut all together. They're both so still. And Josh's exposed arms are modeled deep dark blue. Alexa wishes she could just tell him how much she loves him. Tonight was supposed to be the night. Alexa looks down at her own hands. Her fingers feel foreign to her, and the color of her nails match that of Lew of Taylor's lips. She knows it's not right, but it's so wild. The floating warmth intensifies. Alexa feels as though she's falling off the couch even though she's not moving. She's never drunk anything more than a beer or two in her sixteen years. How could one cup of Nick's punch make her so woozy? Somewhere in the back of her brain she can hear her mother's panicked voice, a distant scream, telling her to breathe. But her mum's nowhere near the party. Alexa finds it all kind of funny. She wants to laugh. She wants to tell her Taylor how exquisitely wrong it all is, but she can't move her lips. Besides, dreams are stealing over her now, and she can't hold on any longer.
SPEAKER_03Okay, so I have a 16-year-old and an 18-year-old. And I read that passage, and then I was hooked, horrified, like that feeling in your stomach of like this is the thing that we fear. And uh and definitely hooked to read the rest of the novel. Um it's so chilling, it's such a scary thing. And I mean, we just can't say to our kids enough like, don't try things, don't try things, don't try anything. It could have fanol in it, don't try things.
SPEAKER_05Yeah.
SPEAKER_03Anyway, uh it's gonna be required reading in my house. Yes. Um, and so listeners, uh, if you have teenagers, it's totally an appropriate novel for a teenager to read. And I want those images portrayed in your novel on the backs of my kids' eyelids forever. So you mentioned earlier that that was part of what you had in mind when you wrote your novel was speaking in a sense to your own children.
SPEAKER_00Yeah, very much so. Thank you for that. I mean, those kind words. And that was it. I know it's sometimes a bit difficult, definitely, it was difficult to write, a difficult scene to write, to some difficult storylines with the kids to follow, but I thought it was so necessary, right? And you know, I I I like to compare, I don't know if you guys are old enough to remember that series in the 80s or 90s that was on TV called Scared Straight, where they would take these juvenile offender kids and bring them, yeah, and they'd bring them into the hardest core like Rikers or these worst prisons, and they'd leave meet these murderers and lifers, and and these guys would just scream at them and tell them what was going to happen when they're out when they come into adult jail and how they were violated, and how and the idea was just to scare, you know, to scare them straight. And for me, this is the novelistic equivalent of scared straight. I wanted it's so easy, it's so easy just to say, oh, I'll try this. So what could go wrong? You know, every every you know, teenagers and 20s, you're more experimental, you're more, you know, you feel indestructible, and and and you know, and I wanted people to know these are the exact I wanted kids, I wanted young adults, no, those are those are the people who die from this, along with the you know, the harder core opioid use disorders. So it was a really important message for me to to get to people, to readers.
SPEAKER_01I'm thinking at this point it might be a good idea to get into a little nuts and bolts and give a little background for people. Um, for example, what actually is an opioid? You hear it all the time. What
Opioid 101
SPEAKER_01is it?
SPEAKER_00Well, opioids are a class of drugs that, you know, originally they they all chemically relate back to opium, you know, the poppy which comes from poppies, and it's a naturally occurring chemical that led to opium, which led to morphine, and and they're all chemically, as I said, they're very similar drugs in terms of how they they act. Um, it's just a matter of how potent they are. I mean, I could get into bigger differences, but but effectively, you know, they've been known for 150, 200 years to be very effective painkillers. They uh affect uh the receptors in the spinal cord and that uh diminish your response to pain. But at the same time, they also affect the brain. Um, they have dopamine-producing uh products in terms of uh neuroreceptors and neurochemicals, and they give that sense of euphoria. And they also, you know, why that what makes them so deadly is they affect the breathing center in the brainstem. We all breathe unconsciously, right? We have a drive to breathe while we sleep, while we're awake, we don't have to think about it. But opioids in big enough dosage, they suppress that center. Uh, you know, sometimes we see people who are very drowsy and awake, but they're not breathing. You have to remind them to breathe. We can watch on our oxygen monitors, our oxygen saturation monitors, we can watch their oxygen levels drop. We just say, breathe, you know. So uh so but and we also have a very good antidote to opium called naloxone or narcan. Those are the kits people carry, and you know, I'm sure most of the listeners have heard of them or familiar with them. And and and those are just uh it's just a a form of chemical that binds to the opioid receptor sites in the brain um much more intensely than uh than the opioid itself. So it blocks the effect of the opioid from doing that and and it dislodges any any opioids that are already connected to the receptors. So that's why it reverses things. So, you know, in a way it's a very benign drug because otherwise it causes very little damage or do anything. It's just that when you stop somebody breathing, it's just like you know, lowering a sleeping person into a bathtub or a drunk person underwater in a bathtub. You know, if something's not done, they will die very quickly.
SPEAKER_03My point of access to this conversation is that as a physio, I have a professional role to play in helping people with different kinds of pain to find ways to manage their recovery from surgeries or from injuries so to prevent chronic pain from happening at all, and to help people who do suffer from chronic pain to find ways to manage that pain that aren't pharmaceutical necessarily. But a huge part of that is couched as to help prevent people from needing long-term use of opiums.
SPEAKER_00You know, we've really come to realize in the last 20 years our whole approach to pain, and especially opioids in chronic pain, has been so misguided, you know, partly driven arguably criminally by the pharmaceutical industry, but also misguided from the medical point of view, in terms of how liberal we've been, how long we've kept people on, when there's much better modalities like physiotherapy, like lots of other things. We we've, you know, in medicine in general, philosophically, we've started to rethink pain. And the idea is that you know nobody should be in agony, but not all pain needs to be treated. It's an important sensory response, it's there for a purpose for your body to be aware of something. And you know, and and and we went so off the rails in the late 90s, and you know, and then you've heard a lot about Purdue Pharma and OxyContin and their you know their crimp their criminal uh campaign to to push that drug on so many people. It was much worse in the States where they created millions and millions of addicts by using it, but it happened in Canada too. And so, yeah, so the the pharmaceutical industry and the medical industry medical profession has been culpable in the abuse of opioid addicts. There's a stat that says nine out of ten um opioid dependent people, people with opioid use disorder started off on some form of prescription opioids. So um we've you know there's a lot of guilt to be spread um for the crisis.
SPEAKER_03Absolutely. And my personal story is that in 2019 I I had to have a bilateral dysquectomy and laminectomy or laminotomy. And and so um following protocol, I was prescribed an opiate. And I I'd probably taken like a mild opiate, you know, your T4s, I think, might have one at earlier times in my life, but but it was nothing like this thing. And uh boy, when you pick up your meds from the pharmacy, they now come with this very dire warning about how even if you use this medication the way it's prescribed, you can become addicted. And I I'm not lying, it scared the shit out of me to be on this medication. It was really scary. I I've said to people, and people literally said to me, if you have a reason for the pain, you can't get addicted. But I felt that that wasn't true. And what I found personally is that I had to be aware of when the need switched from being truly about calming physical pain so that I could move or sleep, and actually became, I'm considering taking a dose of that medication because I have emotional pain. Yeah, I didn't have a craving for it the way that a heroin or a fentanyl addict would describe having, um, but I could appreciate the precipice that I stood on. And if I wasn't as self-aware, or maybe I didn't have all the supports that I have, it would have been a pretty easy slippery slope. Um, which was just a powerful um experience that I I don't think I completely understood before that moment.
SPEAKER_00Yeah, that's I mean that's pretty honest of you to and and uh forthcoming of you to share that because it's true. I've had so many. I I've not really had much experience with opioids personally. I I think I've tonel three is the maximum I've taken, but I've heard stories from friends who said, wow, you know, I was in a lot of pain, but wow, this felt good. I could see how easy it is, you know, and everybody, there's different degrees of susceptibility and vulnerability. They say some people become addicted to opioids after a single use, right? And it is such a fine line of when pain stops. Because pain, you know, pain's not a red light, green light thing. It it ebbs and waxes and wanes. And you know, it's so easy just to, you know, it's so easy for doctors just to keep somebody on opioids for just a little longer than necessary, so easy for the patients to just use it. And it and it and it it's so uh subtle and uh so quickly you can cross the line into addiction without even realizing it. You know, and there's some characters, as you know, in the book that are described that way.
SPEAKER_03Yeah, beautifully described that way, very clear examples. So I found some stats that I found were interesting on the Canada.ca reports on opium-related harms in Canada. And so, for those who are interested in this, the link to this site and these stats will be included in our show notes. And I you don't have to see the graph to understand this, but I'll just describe it. That it said in 2016 our crude rate of death was just over 20 per 100,000 population in BC. And the crude rate in Canada is about 10 per 100,000. So in 2016, we were already double. And then by 2018, we peaked at just over 31 per 100,000 population rates of death. And by 2019, we had come right back down to our original 20 over 100,000. Can you speak to the reasons for first why so high in BC in the first place?
SPEAKER_00Yeah, uh Vancouver, uh I think BC in in general, the climate is a huge factor in the uh in some of the high rates we have of opioid use disorder because a lot of opioid users end up as homeless. And uh you know, BC Climate supports a year-round homelessness. You can't be homeless in Montreal in January and such. So there's a lot of users are drawn out to BC that way, and it's just easier to live that lifestyle here. So that's part of it. We're a port city, we're a cosmopolitan city. There's always been a pretty booming drug culture in Vancouver and in BC. So I think all those factors, and we're a multicultural city, and uh, so I think all those factors um uh have contributed to making to go to so Vancouver's always had a bigger drug problem per capita than relative to to uh to other um cities and and areas in Canada. And in fact, you know, I think the postal code that that that the downtown east side occupies is the poorest postal code in the country and uh you know with the highest rate of addiction and highest rate of of homelessness of anywhere else in the country. So so I think there is there's that. In terms of, you know, they declared a public health emergency in 2016, and 20 per 100,000 is nothing to be proud of. I mean, it's a devastatingly high uh number of fatalities. Um, and so when, you know, I think the fentanyl death rate even by 2016 was up five or six, or the opioid death rate was up five or six hundred percent over what it had been five or ten years below before. So it's not like coming down to 2016 levels is not acceptable. It's still a huge death rate. But at that time they did declare a public health emergency. And I'll give the government and my region and my hospital a lot of credit. They did a ton of work in harm reduction strategies. You know, we already had some of the safe injection sites, but there was more of that. Uh, there was more um, you know, at St. Paul's the addiction services, which are world-leading, um, were increased uh incredibly with with rapid access um at 27 days a week to uh addiction medical specialists with community supports, with opioid outreach teams that went into the community. Um, you know, and there was a lot of then the also this, you know, one of the keys of harm reductions of treating um opioid people with opioid use disorders is providing a safer alternative. It's still a form of opioids, but one that are less likely to cause intense highs and certainly less likely to cause overdoses. Methadone is the one that's been around forever that most people know. But there's a new one called Suboxone, which is a partial uh agonist, partial antagonist, which is a fancy way of saying it it it it's a it it doesn't really cause the the intense highs, but it's incredibly good at blocking out other drugs. So while you're on it, it's almost impossible to overdose on because it binds so strongly to the receptors in the brain that that the fentanyl and heroin and all the other drugs of abuse can't really compete with it when somebody's taking it. So there's tons of evidence that a good Suboxone program, um, getting you only need to get seven or eight. Yeah, I I can't remember what the number is, but it's a very small number of users to get them on Suboxone to save one life over a year. It's it's it could cut down the mortality rate in many regions by 50% in one year. So so all of these measures, this sort of multifaceted, um multidisciplinary approach uh was was brought to bear, and uh it was making a difference, as we said, not not enough of a difference. We still had a huge fentanyl problem even before COVID, but now through COVID, we're seeing a worsening of the fentanyl issue again.
SPEAKER_01So, what's happening right now to the number of overdose deaths as a result of COVID is is is that changing radically right now?
COVID Opioid Deaths Increase
SPEAKER_00Yeah, COVID's had a terrible impact on on harm reduction. Uh, first of all, you know, understandably, it's so much attention and effort and resources being directed to COVID, so other programs from uh you know from uh surgery non-urgent surgeries to opioid addiction is uh has suffered at the expense of that. Um, second of all, um the drug supplies become more unstable because it's harder to get. Most of the fentanyl comes from China and from Mexico, and it's it's some drugs still getting in, but there's less drug available. So, you know, the traffickers and dealers are doing what always they do. They make do with what they have, so they're using more of drugs like carfentanyl if they have it, and they're making an even a terrible product even worse and more dangerous, if that's believable, with you know, with not the cons not as consistent um uh uh supply of drugs. So and the third thing that's really ironically sad and is that when everybody, when the stay-at-home measures were coming in and social distancing was being so reinforced, a lot of users were choosing not to associate with other uh users and not go to the safe injection site for fear of getting COVID, and we're using more often loan, which is you know thousands of times deadlier than their risk of dying of COVID. But it's still, you know, understandably they were getting that message. So all of those factors uh combine to make this to make the death rate spike of opioid overdoses.
SPEAKER_01Okay, what what does a day, a typical shift at at St. Paul's emergency room, look like when there's no pandemic to navigate?
SPEAKER_00You know, first of all, anybody who works in an emergency will tell you there is no typical shift. It can be dead, it can be dead quiet, it can be mayhem, it you know, you don't know what you're gonna see. That's one of the joys of emergency medicine. Even after 25 years of doing it, you never quite know what to expect. There are more predictable things. So if it's a Friday night in St. Paul's, you know you're gonna see a lot of drunk kids from the bar have overdosed on alcohol or alcohol poisoning. You're gonna see some overdoses. I mean, seven days a week we see the opioid overdoses at night that, you know, um, and and you know, you'll see more injuries, more fights at that time, maybe more stabbings. Uh in the daytime, you'll see more typical medical problems like chest pains and gallbladder attacks. And and so it's just, you know, it it the only thing that makes it slightly predictable is the day of the week and the time of the day, but even still, you never know what you're gonna get.
SPEAKER_01Does the full moon have an effect? You keep hearing that story too.
SPEAKER_00I I don't think so. I I mean I shouldn't say I uh who knows. It depends if you I everybody that's not my superstition. I have my own superstitions, but uh the full moon and full moon is not one of them.
SPEAKER_01Not one of them. Well, I'm curious, you know, we see the images uh over the television screen screens of of what's happened in New York City in the ERs there and urgent care centers and you know, lines out on the street and people everywhere. What has it been like in your emergency room um over the course of this COVID-19 pandemic?
SPEAKER_00I mean, it's you know, in in March, in late February in March, when we were starting to get reports of Italy and all those places, and we already had some COVID cases in BC. We we were geared up, you know, we literally just scrambled. I'm really proud of how our emergency responded and how our staff responded. We divided into you know high risk, high-risk and low-risk COVID zones. We got PPE organized. We we we literally restructured and re-engineered our emergency department for the onslaught that we were expecting. And you know, we waited with fear and uh, you know, uneasy anticipation, and it never really materialized. I mean, BC has been so relatively uh spared compared to almost any other region of its size from COVID. We've, you know, as of today, I think it's I can't remember, a couple thousand cases. Uh there were up until last week, there were less people who died overall from COVID, is who overdo died of overdose deaths last month from May. So uh, you know, and by the time April and May came, the our emergency was just very slow. We were seeing a lot of people who were scared of COVID or who wanted to be tested, but very few of them were positives. I mean, we've been seeing very, very few positive COVID cases, and it just people were staying away from the emergency to the point where we were getting quite scared that people with heart attacks and strokes and all kinds of other medical. Emergencies were just too afraid to come to the hospital, and that's actually been proven to be the case. But now the volumes are tending towards the pre-COVID level, we're probably 85-90% what we were before COVID. So it's normalizing.
SPEAKER_04Right. We're getting a little braver and coming out more because we're doing really well here regarding COVID in the U.S.
SPEAKER_00Phenomenally well. But that no, yeah, exactly. As we're learning, as we're learning from our poor neighbors, that can change in a heartbeat.
unknownYes.
SPEAKER_03So it's it's been suggested quietly by some and rather loudly and emphatically by others that if the opiate crisis were being dealt with with as much effort and compassion as the pandemic has been, we would see some vastly different results regarding the opiate crisis. What are your thoughts on how the crisis has been managed or approached thus far? And where might you like to see it go?
SPEAKER_00Yeah, I think I don't disagree with that statement at all. I'm I'm I'm of the school of thought that we've we've we never have done enough. Um I think in the last couple of years there's certainly been a lot more effort put in. But I think you know, you still, as we were talking about much earlier in the interview, there's the still a lot of people who have that kind of bias. Oh, that's them. It's those people who have the problem, not that it's us and that it's endemic in our community. Um I I we I I personally am of the belief that we should decriminalize uh opioids, that we should control it like we control marijuana, we should have an entirely safe supply. Um, I think we'd be able to prevent thousands of deaths that way. We the the war on drugs has never worked. It's an abject failure. We need to stop the foreign supply of fentanyl coming into our borders and stuff, and then we need to get the incredible criminal elements that are just making it so dangerous, the dealers and traffickers and and gangs that control the drug trade. We need to control that. But the users need to be treated as the victims of this, you know, and need to help. We need better rehab, we need better options of alternate safe opioid agonist or or replacement drug in the while they're transitioning. And I think yeah, we treat this like a like a disease, and we don't stigmatize the sufferers. And I think then maybe we we we make progress. And I don't think, I don't think in any municipality, any country that's taken that approach, there's any proof that that encourages drug use or you know enables drug use. I don't believe that's the case at all. I think it saves lives and I think it it helps people climb out of the uh chasm that they fall into once they become opioid dependent.
SPEAKER_03Oh, it's a case of I'll say the word political will or the will of the people rather than that it doesn't isn't effective to do the things you suggested.
SPEAKER_00It takes political will, it takes political courage, uh, and it takes some education of the general public to understand uh what they're doing and why they're it's not like you're decriminalizing the drug because you you're getting in the business of promoting it. It's it's as an it's a deterrent, you know.
SPEAKER_03I would agree that the education of the general public piece is an enormous piece. Um I stumbled across actually a different podcast while I was trying to research another podcast that Sue and I were um researching for, and it just happened to be about opiates and more down in the United States. But over the course of listening to this entire podcast, which is really well created, I learned so much about the opiate crisis that I didn't understand at all previously. Like I just had no idea. Uh so I think the education piece is going to be a key part of um the whole strategy for sure. We wanted to know if there is a toll taken by the front line of this crisis, your colleagues and your team at St. Paul's, for example, in witnessing the addicts day in and day out.
SPEAKER_00Yeah, that's a good question. And it's hard sometimes not to get jaded because you know, addicts come in all shapes and sizes, and you know, they often can be belligerent and immature and childish. You know, they're often, particularly to our poor nursing staff, who are just incredible at St. Paul's because they they suffer abuse, you know, they can be very demanding. Uh again, I'm generalizing, but I'm just uh I only mean some of them, but it can be, you know, and they can be unfortunately so many of them to support their habits have been forced into petty crimes, so they they can steal from us. They, you know, they're often don't have enough food, and they they so it's it's a it can be a very challenging population to look after, uh, because you don't you see them at their worst, not their best, right? And and so uh sometimes it's easy to forget that um you know they're they're people they're suffering, they're not proud of the state they're in and their condition they're in. And so sometimes, you know, you unintentionally, especially when you worked a bunch of shifts and being ground down by a lot of you know repetitive conversations about why you're not gonna give them more opioids and and stuff. You can paint paint a lot of them with the same brush, but but that's not fair. But uh I also I think you know the flip side of the coin is that as I said, I get to know some of these people and hear their stories and see their families sometimes and see, and it can be anybody. There's nobody's immune to this, right? And as I said, nobody chooses to end up as a street person, you know, who just whose life is just about going from fix to fix. It's you talk to them. They're they're a lot of them are most of them are miserable and it's not their choice, but they feel trapped and in imprisoned in this lifestyle. So all those factors, um, yeah, so at times you can get frustrated and and burnt out from it, and other times you can be inspired and hopeful for you know for for the future for for them.
SPEAKER_01So I read a piece that you wrote recently for the Toronto Star, where you reflected on how the COVID pandemic really brought home to you how we need to get back to what's really important in our lives. And I'm just wondering, can you tell us a little more about what you wrote and and how you're feeling about that?
SPEAKER_00Uh yeah, so maybe my piece was a bit overly optimistic, but uh I was trying to point out that despite all the doom and gloom, all the the death and health suffering that people are experiencing, all the economic impact, that there can be uh you know a silver lining of the pandemic of what we're going through. I was pointing out that the planets had a chance to take a breather, that the air quality is better, that that uh the CO2 emissions are down, that and that I I I would like to extend that belief to the human race that we've been given, you know, by being sort of imprisoned in our home own homes with the stay-at-home order and stuff, that we've been given an opportunity to evaluate what all the things we took for granted before and all the things that that that we didn't even realize we had and were appreciating before. I mean, for me, just simple things like you know, socializing with friends or you know, going to play a game of tennis and and and going to a park that was open, all of that, you know, I and I I so many of my friends and colleagues have expressed the same. They're not complaining. I I see a kind of stoicism and bravery and even a bit of renewed altruism in people is this collectively. We have the sense we're all in it together. And I think there's real historical precedent after the Black Death came the enlightenment of the Renaissance, and after the Spanish flu came the you know enlightenment and economic boom of the roaring twenties. So I think this is an opportunity for us to separate the trivial and material from what really matters in our lives. And at least I'm hoping. It's such a terrible thing. I'm just hoping something good will come out of it.
SPEAKER_01Yeah, yeah, that we'll learn something, move forward into something good out of all of the whatever this has brought us.
SPEAKER_04Your article made me hopeful when I read that piece about how the Renaissance was born of the Black Plague. Like, oh, I'd like to be part of a Renaissance. That sounds like a good thing.
SPEAKER_00But I didn't what I didn't mention is there was about a hundred years in between. The seeds of the Renaissance, the the foundations could have never happened without some changes from the black thing.
SPEAKER_01Well, I think we're due for a renaissance, though. When you look around the world, it's time. We have to be doing some things differently.
SPEAKER_00So you know, a lot of people have this theory of infectious diseases that it is mother's nature's way of striking back and um you know correcting the course, right? That that these diseases because we've overburdened the planet and uh you know the the and in a way and and not in a wipe half the population way out, but in a way to to make us stop and think about what we're doing. And I know too many people have died, obviously, but if if you know we make a difference about global warming, if racial disparities improve, if if if if there's more kindness and a slightly better world emerges out of it, then maybe it's worth going through a pandemic.
SPEAKER_04Daniel, we ask everyone who comes to our podcast our very favorite question, which is according
What is health?
SPEAKER_04to you, what is health?
SPEAKER_00I think health to me uh is wellness, you know, physical wellness being free of pain and disability, and and mental wellness being free of you know angst and and and and depression. I mean, obviously range of emotions is normal, but but having an escape and having an opportunity to appreciate and enjoy life, I think to me that is how I see health and being healthy.
SPEAKER_04And if I can pursue further, what is health for a person with a substance use disorder?
SPEAKER_00I mean, I I don't know. I I've never had one, so I'd only have to speculate. But I think health in their case would be hope, you know. I mean the same things. They want to be free of uh of fear, you know, about hunger and fear and pain and and the things that the hope for you know working towards if they're not already clean and at least working towards sobriety and and reclaiming a life that uh has been pretty impaired by their substance dependence.
SPEAKER_04I like that. Dr. Kella, thank you.
SPEAKER_03Thank you so much for your excellence as a writer and your bold statement in form of novel about this devastating crisis that continues to unfold, and your service to those with urgent health needs in the downtown core of Vancouver.
SPEAKER_00Well, thank you. I really enjoyed it. It was an enlightening conversation for me too. So I really enjoyed our chat. Thank you for having me on.
SPEAKER_04I'm so pleased. Uh, we're really grateful you could come. It must have been, must be an extremely busy time for you to share your story with us. So we will be talking about the last high and pandemic all summer, and we'll be looking out for your next novel in the years to come.
SPEAKER_01That's all for today's small conversation. We hope you will all head out right now and buy Daniel Kennela's book, The Last High, from an independent local bookstore. His website is DanielKenella.com. He can be found on Facebook at Daniel Kennela Author and on Twitter at Daniel Kennela. We'll provide links to all those places in the show notes. And we'll be here next time. And we'll have the coffee on.
SPEAKER_03If you liked what you heard, we'd encourage you to head on over to iTunes and leave us a five-star review. Better yet, subscribe and leave a review. And it really helps to make it easier for others to find out to help promote the dismal conversation.