Open sided tents could be used for safe smoking sites next to safe injection sites as more people smoke illicit drugs than inject them these days.

(ROB MUNRO / iNFOnews.ca)

Throughout BC's overdose crisis, the picture we form in our minds of who is dying has changed.

It is not, and never was confined to a more visible homeless population — the majority use drugs alone at home. And in at least the last few years, the way they use drugs has also changed.

There has been a dramatic shift by opioid users to smoking rather than injecting their drugs.

“Smoking continues to be the predominant mode of consumption in suspected unregulated drug deaths, with nearly seven out of every 10 investigations indicating that the decedent smoked their substances,” says a June 2023 BC Coroners report.

That’s up from 29% in 2016.

In fact, smoking has been the predominant mode of consumption in the Coroners death investigations since 2017.

It does caution, however, that not all overdose deaths can be classified as one or the other since they need to find evidence of smoking or injecting. If, for example, someone dies in hospital, there may be no indication as to how they took the drug.

Often there will be both smoking and injecting equipment present at an overdose site, Alexis Crabtree, a public health physician with the BC Centre for Disease Control’s Substance Use and Harm Reduction unit, pointed out to iNFOnews.ca.

The centre does regular surveys of people using harm reduction sites. Two years ago there were questions about why people choose to smoke or inject their drugs.

“It doesn’t seem like there’s one reason we can point to," Crabtree said. “We know that people who use drugs protect their health in a variety of different ways. Some choose smoking to reduce their risk of blood borne infections like HIV and Hepatitis C.”

Some people may also be prone to infection at the injection site so choose to smoke instead.

“Some people transition to smoking when they have vein damage and can no longer inject,” Crabtree said. “Fentanyl is shorter acting than heroin so it’s injected more frequently and that might predispose to vein damage and people transition to smoking sooner.”

That may be a valid reason for switching but only a small part of the change since the trend to smoking rather than injecting is more prevalent among younger people and females.

There’s one other, very disturbing, reason people give for smoking rather than injecting.

“The thing we worry about is this idea that it decreases overdose risk specifically,” Crabtree said. “Smoking is a high risk for drug poisoning, just like injection is, because the street drugs that are available are so highly potent and so unpredictable.”

Those drugs can be so strong that even a small amount, taken as a “test,” can poison the user, whether injecting or smoking.

And, while there are some chemical difference to the drug if it is smoked or injected, “for the purposes of overdose risk, the differences are outweighed by the similarities,” Crabtree said.

The advice is the same for people using opioids, no matter what their method of consumption.

“If anyone is smoking drugs our strong message to them is to carry naloxone and use with another person present and stagger their use or use an overdose protection service, if available in their community,” Crabtree said.

That’s good advice but the reality is that people who smoke their drugs are more likely to do it alone than those who inject.

The vast majority (84%) of overdose deaths are indoors, with 55% being in private homes. Usually the users are alone and they can’t administer naloxone to themselves when they overdose.

For those who use overdose prevention sites, those mostly don’t allow smoking areas even though, technically, it’s not actually smoking.

Users heat the drug in a pipe or on foil and inhale the vapour, rather than burning it and inhaling smoke. It’s a process formally called pyrolysis.

READ MORE: Kelowna on track for new illicit drug supply death record

The Fraser Health Authority, in the Lower Mainland, launched an awareness campaign last fall stressing that “smoking toxic substances carries the same risk of overdose as injecting them.”

At that time, the province had 42 overdose prevention sites but only 13 offered inhalation services, Sheila Malcolmson, Minister of Mental Health and Addictions, said at the time in a news release about the campaign.

“Interior Health is fully committed to continue implementing and adjusting services, given the ongoing devastating impacts of the poisoned drug crisis,” Interior Health said in an email to iNFOnews.ca last week. “This includes Interior Health completing construction on an indoor inhalation overdose prevention site in Kelowna and actively planning to open further overdose prevention services in our region.”

It doesn’t say if those new services will include smoking sites but does say that many BC Housing facilities do have outdoor inhalation sites.

From Crabtree’s perspective, more can and should be done.

“The current needs of people who use drugs include a need to have places to inhale substances in a way that they can be witnessed in their use and responded to if a poisoning occurs,” Crabtree said. “We need to have access to that around the province in order to prevent drug poisoning deaths.”

The BC Centre for Disease Control has guidelines for outdoor inhalation sites, usually a tent with open sides to allow the vapour to dissipate.

Indoor guidelines offer ventilation recommendations so staff in those areas are kept safe.

“It absolutely can be offered safely to people and needs to be because, so many people are smoking and it creates a barrier to them using overdose prevention services,” Crabtree said.

Overdose prevention sites are not for everyone and are only one part of the solution to the opioid crisis, she noted.

“Ultimately there’s the immediate response to this immediate emergency that we’re in,” Crabtree said. “Then there’s the long term work of building a society that gives people what they’re looking for – creating a society where people feel a sense of connection and belonging.”

There are currently nine overdose prevention sites in the Interior Health region including one each in Kamloops, Vernon, Kelowna and Penticton. Go here for locations.

Crabtree also pointed to a number of apps that users can download that may help in an overdose situation.

Connect by Lifeguard provides a direct link to emergency services when an overdose occurs along with Naloxone and CPR guidance, drug alerts and direct access to local mental health and addiction support services.

Brave App connects people with community members when they are vulnerable to an overdose. Users set up an overdose plan detailing how, when, and who is sent to for help

The National Overdose Response Service, at 1-888-688-6677 is a free hotline that providing confidential, non-judgmental support for people using drugs.

These are available at the App Store or on Google Play and there is no police involvement with the services, Crabtree said.

To contact a reporter for this story, email Rob Munro or call 250-808-0143 or email the editor. You can also submit photos, videos or news tips to the newsroom and be entered to win a monthly prize draw.

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