Like most people who might be called heroes, Mark Baratta shies away from the label. A lean and purposeful man, Baratta has saved 17 people, each on separate occasions. He chalks it up, with a shrug of his shoulders, to keeping his head in the presence of death.
“I’ve always been that sort of person who doesn’t panic,” he says.
Under normal circumstances, you can imagine Baratta being honoured at a civic ceremony. Instead, Toronto police want him jailed.
The rub for Baratta is that he’s saving lives on the front lines of the opioid epidemic, an area where public health clashes with the criminal code, and with policies that infuriate outreach workers as half-measures.
The day of the interview, Baratta sat on a flat rock in the garden of the Parkdale Community Health Centre, the sun warming his back. His presence was appreciated, judging by the people who stopped to say hello and gladly hand over cigarettes.
He’s one of three “peer ambassadors” reaching out to drug users in a pilot project recently launched by the centre. It’s a shoestring operation, with Baratta barely getting $45 a week. But with lives lost daily to the “opioid crisis,” as Canadian health ministers have jointly declared it, the centre needed Baratta’s experience as a self-described “off and on user for 24 years.”
A new study by leading medical researchers found that in 2015, 734 people in Ontario died of opioid-related causes, 80 per cent of which were accidental, according to data from the Office of the Chief Coroner. Preliminary figures indicate that 135 of the deaths occurred in Toronto — an increase from 44 in 2004.
By all accounts, thousands more in Ontario are overdosing and being saved each year. Experts expect a higher death toll when more recent data is collected.
Overdose rates in British Columbia, where the epidemic is most severe, continue to rise despite a public health emergency declared a year ago. When an epidemic isn’t caught early enough, “it needs to run itself out,” says Benedikt Fischer, a senior scientist at the Centre for Addiction and Mental Health.
In late March, Toronto’s Board of Health adopted a drug overdose action plan that includes sites to inject drugs safely, and greater support services for people treated with methadone and Suboxone, opioid substitutes that prevent dangerous withdrawal symptoms. Harm reduction workers generally applaud the plan while calling for greater and more stable funding for their programs.
Baratta never overdosed, although he once “went on the nod” while on heroin and woke up to a pillow set ablaze by his cigarette. Now 43 and on methadone — a treatment used by 50,000 Ontarians in 2014 — he remembers his overdose rescues with eerie precision.
“I’ve brought back 18 people, technically 17, because one of them was the same person twice,” he says. “Eleven of those I know if I wasn’t there, they would be gone. The other seven, someone else was in the room and might have helped them.
“Of those 18, nine or 10 are all in the last two years, including one who was twice in four months,” he adds. “It is, sadly, becoming a little routine, and that’s what bothers me. It bothers me that it doesn’t bother me more.”
In the early years, his rescues were physical and intense: “screaming, keeping them on their feet, dumping ice on them and slapping them and being actually quite violent, and forcing them to stay conscious.”
More recently, they involved naloxone, an antidote to dangerous doses of opioids, a class of painkillers that includes fentanyl, morphine, oxycodone and heroin. Naloxone is so effective at bringing people back from comas that Toronto’s Board of Health wants the provincial government to make it available far more widely.
The last time Baratta saved someone with naloxone was April 3, three days before this interview. Normally, one injection of the antidote is enough, sometimes reversing the opioid’s effect so completely the user experiences withdrawal, a tortuous combination of vomiting, diarrhea, stomach cramps, high anxiety and cravings. The last person Baratta rescued needed three shots.
“He was on his knees with his forehead on the floor. He started to raise himself up slowly and we said, ‘Hey, you were as good as dead a couple of minutes ago,’” Baratta recalls. “And I couldn’t believe it because after three doses of naloxone, he’s still high.”
He posted a warning about that batch of heroin at Parkdale’s harm reduction program, in a room where users can pick up clean needles.
Baratta and other outreach workers are convinced that illicit street drugs laced with fentanyl, an opioid that can be 100 times more potent than morphine, is a major reason the death toll has skyrocketed.
Fentanyl has become the drug most commonly involved in opioid-related deaths in Ontario, but data on the impact of illicit drugs is non-existent. In B.C., more than 900 people died from an overdose of illicit drugs in 2016, an almost 80-per-cent increase from 2015. Fentanyl was responsible for much of the increase.
Fentanyl is cheap and easy to produce illegally. That has made it the adulterant of choice during the past two years, showing up in street batches of cocaine, oxycodone, ecstasy and heroin.
“People don’t die on fentanyl when they know they’re doing fentanyl,” Baratta says. “The problem is when they’re told something is heroin and it has fentanyl in it. So they do their normal heroin dose and they die.”
The danger is increased by a growing number of inexperienced dealers entering the illegal market and assuming heroin with an extra kick will keep customers coming back for more. “Except they don’t because they die,” Baratta says.
Baratta steers users to treatment programs if they express the desire. But the realities of his world are sledgehammer hard, and he’s not there to judge.
“When a person is an addict,” he says, “they don’t want you to do them the favour of helping them abstain. They want you to do them the favour of helping them get dope so they can get well, because they’re in hell while they’re in withdrawal.”
In January, he got a call from someone claiming to be an acquaintance in desperate need of a hit. Baratta says he turned to a friend he thought might have a safe supply of heroin, and delivered it himself when his friend wouldn’t. He walked right into a police sting.
He is charged with trafficking heroin and with possession of property obtained by crime. The property obtained, according to court documents, is the $250 police used to buy the heroin.
“It’s an absolute travesty,” says Natalie Kallio, head of the harm reduction program running Baratta’s pilot project, referring to his charge.
“They went through all that effort to catch someone who was trying to help a friend who was sick,” she says of police. “It’s crazy. They want to take off the streets someone who is saving lives every day.”
Baratta’s lawyer, Ari Goldkind, asks: “Was he entrapped into doing something he otherwise would never have done, or was he set up?”
Goldkind says he’s not calling on police to turn their backs on heroin dealers, but he expects the Crown attorney to consider Baratta’s community work before proceeding with the case.
Kallio blames Prohibition-era morality around drug use for what she describes as timid political reaction to the opioid epidemic. She supports the decriminalization of all drugs for personal use, a call echoed by many workers in Toronto’s harm reduction programs, which in 2016 issued 2.1 million needles and other sterile injection supplies to clients that made 139,000 visits.
“People are using drugs; they always have and always will. When you’re scared of being thrown in jail for what you need to do, everything becomes less safe,” Kallio says, referring to the dangers of illicit drug markets.
Toronto Public Health, which reports to the Board of Health and is mandated with improving the health of Toronto residents, touted the advantages of decriminalization in a 52-page report that outlines Toronto’s Overdose Action Plan, which the board adopted in late March.
The report notes that in 2001, Portugal legalized the possession of up to 10 days’ worth of all drugs for personal use while increasing investment in health services. Police focus on grabbing big drug traffickers and refer people with personal amounts allowed by the law to a commission that gauges interest in treatment. Studies have since noted significant decreases in the number of people who inject drugs, in overdoses and in HIV infections.
“The harms associated with the criminalization of drugs are well documented, and include high rates of incarceration for nonviolent drug offences,” the Public Health report says.
“The lack of support and compassion for people is perhaps the greatest harm of our current approach to drugs,” it adds. “People face profound stigma and discrimination, from society as a whole and from family and friends. This stigma is entrenched in our culture. There is no other group of people who are treated so poorly because of a health issue.
“Further, until such time as our drug laws are changed, more must be done for people who come into conflict with the law because of their substance use. People need support not punishment.”
And yet, Toronto Public Health stopped short of calling for decriminalization as part of its overdose plan.
“There is a lot of stigma still out there and I don’t think as a society we’re ready to move towards that yet,” says Dr. Rita Shahin, an associate medical officer of health at the municipal agency.
Toronto Public Health’s plan relies mostly on action from the federal and provincial governments. The city now provides $1.4 million a year for harm reduction programs and city council will be asked for a $374,000 increase only if the province refuses to hand over that amount.
The federal government has yet to approve key aspects of the plan, including the opening of three sites where users can inject illegal drugs in the presence of medical staff ready to intervene in case of overdose, the testing of street drugs before use, and giving drug users access to prescription heroin. The only place in Canada where users can get prescription heroin is at a site in Vancouver.
“Prescription heroin should be available everywhere,” says Craig Stephen, with the Toronto Harm Reduction Alliance. “We know people are dying from contaminants or unknown quantities (of fentanyl), so why not make available an alternative that is safe?”
For its part, the provincial ministry of health has said it is willing to fund the three safe injection sites, but has yet to announce how much of the $3.5 million requested it will provide.
“The response is slow and the need is urgent,” says Sarah Greig, who heads a harm reduction program in Etobicoke. “My guys are dying on the streets or in their apartments and people don’t care.”
She notes that harm reduction programs operate on shoestring budgets that are usually pieced together with short-term grants from different governments to prevent HIV or hepatitis C.
“Every frontline harm reduction worker I know is facing burnout,” she says. “People aren’t paid well, there is a lack of resources, and a lot of people, including peer workers, don’t know if they’ll have a job one year to the next.”
The previous Conservative government, under prime minister Stephen Harper, spent years trying to shut down a supervised injection site in Vancouver. Harper also passed the Respect for Communities Act, requiring 26 criteria to be met, including consultations with police and local community groups, before any other site could open.
Last December, the Liberal government introduced C-37, a bill that makes it easier to open drug injection sites. In February, it approved three sites in Montreal. C-37 also makes it harder to import bootleg fentanyl into Canada, partly by allowing customs agents to open couriered or mailed packages of less than 30 grams.
Michael McCormack, president of the Toronto Police Association, has called injection sites “a Band-Aid solution,” and warned of increased crime in neighbourhoods that host them, including “break and enter, shoplifting, theft from auto, fraud, prostitution, panhandling (and) selling of stolen property.”
The Centre for Addiction and Mental Health has long argued that people dependent on drugs should not be criminalized for possessing drugs for personal use. “That should be considered and be dealt with, first and foremost, as a health issue,” says Benedikt Fischer, senior scientist at CAMH’s Institute for Mental Health Policy Research.
Fischer also backs safe injection sites and access to prescription heroin as part of a comprehensive public health response to the opioid crisis. But while those policies would help users of street heroin, he says they won’t help the larger number of opioid addicts who never buy street drugs.
“The main problem is prescription opioids. For many, many years, the medical system overprescribed them,” says Fischer, who calls for more refined, long-term programs to treat dependency.
In 2007, the makers of OxyContin, Purdue Pharma, pleaded guilty to criminal charges of “misbranding” the painkiller as less addictive and less subject to abuse than other opioids. It agreed to pay a $600 million fine.
Particularly at risk are people who suffer what are commonly called the “social determinants of health,” including poverty, homelessness and unemployment. The emotional and physical pain this group numbs with opioids runs deep.
The new overdose study, by researchers at the Ontario Institute for Clinical Evaluative Sciences, St. Michael’s Hospital and the Ontario Drug Policy Research Network, found that 51 per cent of Ontario residents who died of opioid overdoses in 2015 lived in low-income neighbourhoods. Twenty-six per cent lived in high-income ones.
The study, funded by Ontario’s health ministry, also noted a spike in heroin-related deaths and called for more research to determine whether policies restricting access to prescription opioids had the unintended consequence of steering people to the dangerous illicit market.
In 2012, the health ministry acted to reduce opioid dependency by removing OxyContin from the Ontario Drug Benefit program, and did the same in 2016 with fentanyl patches of 75 and 100 micrograms. Harm reduction workers say the delisting had the unintended consequence of pushing low-income people dependent on those opioids, and without private insurance plans, to turn to street supplies.
Along with the death toll, another 600 people ended up in Toronto hospital emergency departments due to opioid poisoning in 2015. It’s about the same number that visited in the first nine months of 2016. At St. Michael’s Hospital, five to 10 overdose victims arrive each week, says Glen Bandiera, chief of emergency medicine.
Hundreds more are overdosing in Toronto each year without ever being taken to hospital, according to harm reduction workers.
Mark Baratta notes that drug users are reluctant to call 911 when someone they’re with overdoses, fearing police will show up and lay charges. He knows of overdose victims dragged out of apartments and onto the street before 911 was anonymously called. Toronto’s overdose plan calls for swift passage of the federal Good Samaritan Drug Overdose Act, a private member’s bill that would prevent people who call 911 from being charged with drug possession.
What’s clear is that the number of people suffering multiple overdoses is shockingly high. They’re easily found, for instance, during drop-in hours at Sarah Greig’s harm reduction program in Etobicoke. One of them asked the Star to use only his middle name, Robert, although his friends know him best as Juice.
He overdosed eight times in the past year.
“My psychiatrist says, ‘You won’t make it to your 55th birthday,” says Robert, who has a few months to go before that milestone. “I don’t know; I get stupid. I just want to get high and forget my troubles.”
Robert is tall, with long brown hair and a clean-shaven face that looks stern and confident. He’s not proud of being hooked on fentanyl, but he won’t easily give up his dignity, either.
“I’m tired of the judging and the crap like that, because I’m not a bad guy,” he says.
He’s been with the same woman for decades. They have a son and two grandchildren. He used drugs on and off for years, and worked at a tile-making factory until losing his job in 2013, the year he started on fentanyl. He and his wife spent the next three years homeless.
He was prescribed fentanyl for a bad knee and quickly developed a dependency. His prescription is for 10 fentanyl patches a month. The first day he met the Star he was high on both crystal methamphetamine, a stimulant, and fentanyl, a depressant. He was a controlled bundle of energy.
Robert lifted his left sleeve and revealed half of a 50-microgram fentanyl patch glued to his arm, the prescribed way a full patch should be used. The other half got the street treatment: he had placed it in a spoon, released the opioid by “cooking it” and then injected it, the route to a more powerful and immediate high.
He then lifted his right sleeve to reveal a string of needle marks running along the exterior of his forearm, from his wrist to his elbow.
Recently, Robert’s doctor found crystal meth in his urine and had him sign a contract swearing off the stimulant, or risk losing his fentanyl prescription. So Robert now buys clean urine from street contacts, at $25 a cup.
Also causing him difficulties is the medical policy around fentanyl patches: to renew his prescription of 10 he has to return 10 used patches. If he shares three with friends, or they get stolen, he’ll only get seven when he renews. To make up the difference he buys off the street, either fentanyl or heroin.
That’s how he overdosed the last time on heroin, and it took two naloxone shots to revive him.
“I’m tired of doing this,” he says. “I don’t know what’s keeping me going. My family is like, Robert, what are you doing? My cousins are like, Robert, you’re a loser. I’ve heard it all, and they’re right. What have I done? I haven’t done s—. You try to regroup, you hear your grandson’s voice …”
“We need a little more compassion, a little more sensitivity, and not so much judging. I’m not going to be a poster boy, but walk a mile in my shoes, man.”
The power of naloxone
For people who overdose on opioids, naloxone is a lifesaver.
“It can basically bring somebody from a coma back to being normal in about three minutes,” says Dr. Glen Bandiera, chief of emergency medicine at St. Michael’s Hospital.
Until recently, the kit consisted of two ampoules of naloxone sucked up with a syringe and injected. New kits are filled with easier-to-use nasal spray.
For years, it was only available in Ontario by prescription or, in Toronto, through a Public Health branch called The Works, which distributed 4,000 kits since 2011.
Demand was far greater than the restricted supply so Raffi Balian, a well-known harm reduction worker who recently died of an overdose, helped set up a kind of underground railroad a decade ago that brought thousands of naloxone kits to Toronto from the United States, where the antidote was more widely available.
One Chicago supplier, who spoke on the condition he not be identified, estimates that he alone supplied Toronto with about 8,000 naloxone kits in a decade.
“We were getting booze from you guys during Prohibition, so it’s kind of funny that in this situation it’s the reverse,” the supplier says.
Harm reduction workers credit the underground supply of naloxone, and the outreach of peer workers, with keeping Toronto’s body count well below Vancouver’s, where 215 people were killed by illicit drug overdoses in 2016.
In July 2016, Ontario’s ministry of health removed the need for a prescription to get naloxone and made it available free at pharmacies to opioid users, their family members and friends. Since then, 17,500 naloxone kits have been distributed this way in Ontario, including 3,000 in Toronto. Some pharmacies insist on registering OHIP cards before providing naloxone, a practice that users say keeps them away.
Toronto Public Health’s overdose plan calls on the provincial government to allow harm reduction programs and other community agencies to distribute naloxone kits to their clients. The ministry of health, which provides $8.5 million a year for harm reduction programs, has so far not responded to the recommendation.
Natalie Kallio, a Parkdale harm reduction worker, argues the reluctance is based on a twisted belief that more naloxone would encourage riskier drug behaviour. “It’s ludicrous,” she says. “No one wants to overdose. It’s like saying people who are allergic to peanuts will eat peanuts just because EpiPen exists.”