Alcohol & drugs

Overdose: what to do

Canada's street drug supply is toxic. Fentanyl and other very strong opioids are found in drugs sold as heroin, oxy, "down", and often in drugs sold as something else entirely: pills, cocaine, meth. Sedatives such as benzodiazepines and veterinary tranquillizers are increasingly mixed in too. Anyone who uses any street drug can overdose, including people who have used for years.

Signs of an opioid overdose

• Can't be woken up, or won't respond to their name or a hard knuckle rub on the breastbone.
• Slow, shallow or no breathing. Snoring or gurgling sounds.
• Blue or grey lips and fingertips.
• Tiny "pinpoint" pupils.
• Cold, clammy skin. Limp body.

What to do

1. Shout their name and rub their breastbone hard with your knuckles. If they don't respond:
2. Call 911. Say "someone is not breathing" or "someone is unresponsive". Put the phone on speaker so the dispatcher can guide you.
3. Give naloxone (Narcan). Nasal spray: tilt the head back and spray into one nostril. Injectable: inject into a large muscle like the thigh or upper arm, through clothes is fine.
4. Breathe for them. Tilt the head back, lift the chin, pinch the nose, and give one breath every 5 seconds. Opioid overdose kills by stopping breathing, so rescue breaths are the most important thing you can do. If you can't or won't give breaths, do chest compressions.
5. If there's no improvement after 2–3 minutes, give another dose of naloxone. Keep breathing for them.
6. Stay with them. Naloxone wears off in 30–90 minutes and the opioids may last longer, so they can stop breathing again. If you must leave them, put them in the recovery position: on their side, top knee bent forward, head tilted back, so they don't choke.

Get a free naloxone kit

Free take-home naloxone kits are available at most pharmacies across Canada (no prescription, usually no health card needed), and at harm reduction sites, many shelters, drop-ins, outreach teams and some public health offices. Most places will also show you how to use it in about five minutes. Carry one, even if you don't use. The life you save is usually someone else's.

You are protected when you call 911

Canada's Good Samaritan Drug Overdose Act protects the person overdosing and anyone who stays or calls for help from being charged with simple possession of drugs, and from being charged for breaking conditions related to simple possession (such as bail, probation or parole conditions). It does not protect against other charges like trafficking, or outstanding warrants, but for most people at the scene of an overdose, calling 911 will not get you in trouble. Please call.

Stimulant overdose (cocaine, crack, meth)

Signs include very high body temperature, chest pain, racing heart, seizures, severe confusion, paranoia or agitation, or collapse. Call 911. Move them somewhere cool, keep them away from anything they could hurt themselves on, and don't hold them down during a seizure. Because stimulants are often contaminated with fentanyl, give naloxone if they become unresponsive or stop breathing.

Alcohol poisoning

Signs include being unable to wake them, vomiting while passed out, slow or irregular breathing, seizures, and pale or blue skin. Call 911. Put them in the recovery position so they don't choke on vomit. Never leave them to "sleep it off" on their back.

Harm reduction: using more safely

You don't have to be ready to quit to deserve care. Harm reduction means meeting you where you are and helping you stay alive and healthy while you use. It's not "enabling". It's how people stay alive long enough to make changes, and it's recommended by doctors and public health across Canada.

The most important rules

• Don't use alone. Most overdose deaths happen when nobody is there to help. Use with someone you trust, take turns, and make sure one person is always alert.
• If you must use alone, call the National Overdose Response Service (NORS): 1-888-688-6677. It's free, confidential, and available 24/7 anywhere in Canada. A peer stays on the phone with you while you use. If you stop responding, they send help to your location. They are not the police, and you don't have to give your name.
• Use at a supervised consumption or overdose prevention site if there is one near you. Staff will respond if you overdose, and nobody has died of an overdose at these sites. Ask 211 or a harm reduction program where the nearest one is.
• Start low, go slow. Try a small amount first, especially from a new dealer or new batch, or after any break.
• Carry naloxone and make sure the people around you know where it is.
• Get your drugs checked. Many cities have free drug-checking services that tell you what's actually in your drugs. Fentanyl and benzo test strips are also often free at harm reduction programs.
• Avoid mixing opioids with alcohol, benzos or other downers. Combining depressants is one of the most common ways people die.

Safer supplies

Harm reduction programs, many pharmacies and some public health offices give out free new needles, syringes, cookers, filters, sterile water, alcohol swabs, tourniquets, glass stems and mouthpieces, foil, straws and condoms, and a safe container to return used needles. Using new equipment every time prevents HIV, hepatitis C, abscesses and serious infections.

• Never share needles, syringes, cookers, water, filters, pipes or straws.
• Smoking or snorting is less risky than injecting for overdose and infection. If you inject, consider switching to smoking some of the time.
• Rotate injection sites, and watch for redness, heat, swelling or pus. Get infections treated early at a clinic, drop-in nurse or hospital. Untreated abscesses can become life-threatening.
• Get tested for HIV and hepatitis C. Hep C is now curable with pills. Treatment is covered by public health plans and takes about 8–12 weeks.

Safer drinking

If you drink heavily, you can lower your risk without stopping all at once:

• Stick to beverage alcohol. Never drink hand sanitizer, mouthwash, rubbing alcohol or anything not meant to be drunk. Many contain methanol or other chemicals that cause blindness, organ failure and death.
• Eat when you drink, and drink water in between.
• Ask a doctor about thiamine (vitamin B1). Heavy drinking drains it and a lack of it can cause permanent brain damage. It's cheap and often free at clinics.
• Ask about managed alcohol programs. Some Canadian cities have programs that give people with severe alcohol use disorder a regular, measured amount of alcohol along with housing, food and health care. They reduce emergency visits, police contact and dangerous drinking.

Alcohol: cutting down or stopping safely

Alcohol use disorder is a medical condition, not a moral failure. Many people who are homeless started drinking to cope with pain, trauma, loss or mental illness. Many kept drinking because stopping made them sick. Recovery is possible, and it doesn't have to start with going cold turkey on a sidewalk.

Signs you may be in withdrawal

• Shaking hands ("the shakes"), sweating, fast heartbeat, nausea, vomiting.
• Anxiety, agitation, not being able to sleep.
• Seeing, hearing or feeling things that aren't there.
• Confusion, or not knowing where you are.
• Seizures. Call 911.

Withdrawal usually starts 6–24 hours after your last drink and is most dangerous in the 2–4 days after that.

Ways to get help with drinking

If you relapse

Relapse is part of recovery for most people with alcoholism. It doesn't erase what you've done. Many people need several tries before something sticks. Get back in touch with whoever was helping you, and be honest with them. They've seen it before. If you relapse after a period of not drinking, remember that your body may react to alcohol more strongly than it used to.

Drugs: treatment and recovery

Addiction is a health condition. You deserve the same respect and care as someone with diabetes or heart disease. There are more options now than ever, and many don't require you to stop using completely before you start.

Opioids (fentanyl, heroin, oxy, "down")

Opioid agonist treatment (OAT) is the most effective treatment for opioid addiction there is. It cuts the risk of dying roughly in half. OAT gives you a safe, long-acting medication that stops withdrawal and cravings, so you can stop chasing and start stabilizing your life. Options include:

• Buprenorphine (Suboxone and others), a daily film or tablet, or a monthly injection. Safer in overdose.
• Methadone, a daily liquid. Works well for people with heavy fentanyl use.
• Slow-release oral morphine (Kadian), a daily capsule, used in some provinces.
• Injectable OAT (hydromorphone or diacetylmorphine), for people for whom other options haven't worked, in some cities.

You can often start OAT the same day at a rapid access addiction clinic, some community health centres, some hospital emergency departments and some outreach programs. Some pharmacies will deliver your dose to a shelter or witness it daily. In most provinces, OAT is covered for people on income assistance or with low income.

Stimulants (crack, cocaine, meth)

There's no approved medication yet that "fixes" stimulant addiction, but a lot helps:

• Contingency management, programs that give small rewards for meeting goals. It's one of the best-proven approaches for stimulants, offered in some cities.
• Counselling and group programs, including day and evening programs.
• Sleep, food and safety first. Stimulant "crashes" are brutal, and a detox bed or shelter bed can get you through them.
• Treating what's underneath, such as ADHD, depression, psychosis, trauma or chronic pain, often makes a big difference.

Meth and cocaine can cause paranoia and psychosis, especially with no sleep. If you're seeing or hearing things, or you feel unsafe, go to a hospital or call 988. It usually improves with sleep, food and time away from the drug.

Benzodiazepines ("benzos", "downers")

The path through treatment

1. Talk to someone. A doctor, nurse, outreach worker, drop-in worker, or 211. Say "I want help with my drug use." That's all you need to say.
2. Stabilize. This might mean OAT, detox, or just getting into a shelter with support.
3. Treatment. Day programs, live-in programs, counselling, or ongoing care with a doctor. Many treatment centres have waitlists. Ask to be put on the list and ask what you can do while you wait.
4. After-care and housing. The first weeks after treatment are high-risk. Ask for supportive or recovery housing, and a plan for what happens when you leave. Recovery lasts much better when you have somewhere stable to live.

Peer support

• Narcotics Anonymous: na.org, with free meetings across Canada.
• Cocaine Anonymous: ca.org.
• SMART Recovery: smartrecovery.org, non-religious and science-based.
• Peer-run drug user unions and harm reduction programs in many cities. They're run by people who use or used drugs and are often the easiest place to start.