"It's All Better Now"

Inside the miniature railway house there is a woman sitting at her kitchen table. There is only one chair. She’s elderly. I will call her Ann.

Ann’s body is twisted from an accident that occurred when she was a teenager involving a logging truck. Opioids came into her life then.

“Pain like you wouldn’t know is possible,” she said, speaking of the experience of life with a broken back - pain that was attenuated only with a prescription of morphine.

When the doctors cut Ann’s script, she went to the street to find relief. First it was heroin; now it’s fentanyl, or “down,” as it’s referred to by many who use it.

Ann’s use of down is double edged.

She knows the risks, and she’s afraid of having a fatal overdose on it, but fentanyl’s potency knocks the pain out like nothing else can, she explains. This is the reason why it is used in hospital to treat acute pain after surgery. What many people don’t realize is that heroin is practically impossible to find these days. Fentanyl has almost completely replaced it. It’s easier to make, easier to transport, it’s cheap, and beyond potent - about 50 times more potent than heroin.

The line between death and pain relief is a fine one.

Finding the right dose can be like playing Russian roulette, especially since the potency varies according to the batch, how much it has been stepped on (i.e. cut with other chemicals), and the way it’s used (injected, smoked, or swallowed in pill form). For someone like me with no tolerance built up to opioids, a dose of fentanyl in the 2 milligram range could be fatal. A person with a high tolerance will do more than that in a day for the relief they seek, but again, it depends on the batch and the dealer who cut it.

Adding carfentanil to the mix is more dangerous.

Originally used to tranquilize large mammals such as Elephants, it is an extremely potent synthetic opioid analgesic- about 100 times stronger than fentanyl. When it makes its way down into the local street drug supply every month or so overdoses become more prevalent. Even people with a high tolerance for fentanyl are nervous of carfentanil, but if that is all that is available they will use it.

The pain that Ann deals with hunches her over; she walks with a stoop; the dream of upright posture left her many years ago.

“It’s hard to imagine at one time I was a gymnast,” she says, with irony, but I can imagine it, picturing what her life was like before the accident.

She asks me if I can stay for a few minutes while she does her shot. A particularly potent batch of down containing carfentanil has been circulating locally, with a rash of overdoses associated with it.

There are no regulations when it comes to the production of street drugs; no guarantees; no quality control. This is one of the reasons why a “safe supply” of lab produced, doctor prescribed opioids for people struggling with addiction can be life saving.

Contrary to what many people assume about fentanyl users, even though Ann intentionally uses down, she does not want to die. It is only her pain that she is trying to ameliorate. This is important to understand about people who use fentanyl.

I agree to stay while she injects, acting as a one person overdose prevention site.

I’m not here to interfere, but to simply be present in case things go sideways. If Ann goes down, I will phone 911, administer naloxone, and perform rescue breaths. We argue about the 911 bit. She worries that the flashing lights of the ambulance will attract attention and too many questions. Ann doesn’t want anyone to know she uses-especially her neighbours. Nonetheless, I tell her 911 is non-negotiable.

All the supplies are laid on the table - the 1ml syringe, a sterile water ampule, alcohol wipes, the lighter, cooker, and a cotton filter. She doesn’t use a tourniquet.

Ann prepares the fix then draws the brownish liquid into the syringe through the filter…she’s been doing it this way for decades. The process is methodical and automatic.

I watch only until the syringe is hovering above the vein in her hand before turning my eyes away. Seeing the needle penetrate the flesh has become too much for me. There is something that impacts me deeply - the energetics of it. I used to watch and even helped instruct people in the step by step process of safer injection techniques, but over time pictures of needles piercing veins have crept into my dream-time, giving me nightmares that I can live without.

When Ann sighs I know the drug is in and turn back toward her. There is a tiny point of blood on her hand where the needle went in. Her eye lids get heavy, looking a little blissed out and glassey, but not closing completely. Ann’s breathing slows down, but remains regular - no gurgling sound. She isn’t turning blue, she isn’t nodding off. Considering she has just injected fentanyl, these are all “good” signs that she isn’t going into overdose. After a few minutes of quiet time, Ann turns to me, looks me in the eye, and with a slightly nodding head, says,

“Yes…it’s all better now.”