Introduction

In July 2020, 175 British Columbians died from drug overdose as the province marked the third straight month with over 170 overdose deaths.[1] Since the opioid overdose crisis was declared a public health emergency in 2016, nearly 6000 illicit drug overdose deaths have been reported in BC.

A male with the pseudonym John Doe was seen for forensic evaluation in August 2020 following a conviction for the distribution of fentanyl and crystal methamphetamine. During the assessment, he spoke about distributing drugs and how the illicit drug market had changed during the COVID-19 pandemic. Because he had already been convicted of this crime, he was not in jeopardy of incriminating himself by disclosing this information. He agreed to have his information presented as a case report because, in his words, “I want to provide information that hopefully can prevent overdoses and save someone’s life. I think it’ll be useful for the medical community.” Written informed consent was obtained. Of note, the term opioids is used in this article to refer to the street-level illicit opioids sold that can include any mix of carfentanil, fentanyl, and heroin.

Experiences in BC’s illicit drug trade

According to John Doe, the main opioid of choice in the BC drug supply is currently carfentanil from China. He reported that his distributors aim to mix one part of carfentanil to nine parts of heroin, sugar, and other substances. He has seen people make fentanyl twice by mixing carfentanil with other ingredients and then microwaving it. The mix is mashed down with a fork to form clumps. He says most of the opioids are made in drug houses, and most of the crystal meth is made in BC, but he does not know how it is made.

Prior to the COVID-19 pandemic, for street-level opioids John Doe bought an ounce of opioids for $1500 on a weekly basis. During the week he sold this amount for $2500 to $3000. He estimated that he netted $4800 to $6000 a month after losses from providing samples and “fronting” drugs (i.e., providing drugs to individuals who may not immediately have money to pay for them, with the intention that they use some of the drugs and sell the rest to repay the dealer). John Doe would often not be paid back for the drugs he fronted. For opioids, he sold 0.1 g (1 point) for $20, 0.4 g (a quarter) for $50, 1 g for $90, 1.75 g (a half ball) for $150, and 3.5 g (a ball) for $275. He also sold crystal meth at $10 for 0.1 g (a point), $30 for 0.4 g (a quarter), $60 for 1 g, $100 for 1.75 g (a half ball), and $175 for 3.75 g (a ball).

John Doe started street-level drug dealing in September 2019. He became involved in drug distribution because he found it financially rewarding and it provided flexibility to his schedule. His last legal employment was at a grocery store where he made $300 a week after taxes. By distributing drugs, he made $400 to $600 daily before the COVID-19 pandemic. On average he worked 6 hours a day, 7 days a week, sometimes making “$300 an hour, and other days [making] $20.”

John Doe described the downsides to this line of work. The main one was interacting with the police. He claimed the police confiscated his money, confiscated his drugs and destroyed them, and breached him and took him into custody. Another downside was dealing with overdoses: “Some people can’t take it because you are killing people. What you’re selling can kill someone.” Participating in the drug trade also meant being a victim of violence. In John Doe’s case, people who use drugs (PWUD) tried to stab him: the first time it was with a knife and the second time it was with a used needle.

When asked why he continued to sell drugs, he answered, “I know it’s bad, but the money is really good. Especially if I move up to higher ranks, you can make a lot of money off it.” John Doe hoped to move up the ranks.

Quality control

When asked what his products consisted of, John Doe replied, “I’m never really too sure what’s in my product.” When he purchased cannabis for his own use, it was always from a dispensary: “I don’t trust weed from anyone.”

John Doe maintained quality control in his own products, he explained, by giving samples to his clients. “They’re not going to deny free dope,” he said. After his clients used the samples, John Doe would ask them, “What does it taste like? How does it burn? Is it strong?” He then informed his supplier who would modify the batch with more or less carfentanil to make sure it met the standard for the street trade.

John Doe’s customers generally trusted what he provided them because, “From a business point of view, it’s best to have customers who trust you, so all the customers come to you. It does benefit the drug dealer. A lot of people sell fake [drugs]. If people try your stuff and it’s good, they’ll tell more people.” John Doe said he did not lie to his customers, so they would trust him. When asked about selling a bad batch of drugs and people overdosing, he said, “If it’s a bad batch, I’ll probably still sell it because I don’t want to waste it and lose profit. That’s just the truth and the reality.” He did say that people in the drug trade use drug-testing strips. “A lot do. A lot who buy a batch of pills do. Because in a way, [then] you’re not misinforming the consumer. A lot of people test their own, and if you lie to them they won’t be your customer in the future.” He also said that PWUD use drug-testing strips: “Some addicts use [them] for Xanax, molly (MDMA)Moli, benzos, Percocets, T3s, Adderall. The people who use fent, they want fentanyl in it.”

Why many PWUD seek out fentanyl

When asked why PWUD intentionally seek fentanyl, John Doe responded, “For a lot of users, once you use heroin for a long time the high isn’t as effective. You’re only using to not get sick. So if you’re using fentanyl, it’s stronger. The high gets better, and it lasts a little bit longer, but the withdrawals are even worse. But once you use fentanyl for a long period of time, you are just using to not get sick. That’s why when people see someone overdose, they want to go buy off that person’s dealer because they know they’ll get stronger stuff.” He added that heroin isn’t asked for often now: “Not really these days; it’s mostly just fentanyl.”

Interactions between mental health and substance use

John Doe explained what he observed about the relationship between addiction and mental health: “It’s a lot. I had conversations with my customers. One of them was in [postgraduate] school, and his mom passed away, and he got in a car accident and he started using hydromorphone and it went to fentanyl use. A lot of his issues were from mental health challenges. There was no guidance or counseling for him. A lot of my customers have mental health issues, but they are so into their addiction and they don’t get help. Some of them are born with mental health issues, but they never got the proper help for it, which contributed more to their addiction.”

John Doe named the biggest mental health issues his clients have: “Depression, a lot of them have PTSD, anxiety, a lot of them have trauma. A lot of them were sexually abused when they were younger.” He offered some suggestions for how mental health professionals can help them: “Maybe give them more options, like seeing a doctor or a psychiatrist, I guess. Some of their mental problems are very severe.”

When asked what he had seen regarding the relationship between drug use and psychosis, John Doe stated, “I see a lot of psychosis with crystal meth use. They call it ‘side talk.’ If they use meth for a long time, they’re paranoid all the time thinking someone’s after them. If someone has side talk, it usually occurs in intoxication after the drug has been used. I see them talking to themselves all day. For some people it’s very severe. They don’t care about their personal hygiene. They don’t care about their health or their wealth. I remember one guy that just named cars when he was using; he would use and just say car parts. He thought cops were after him. He was really paranoid. When people use meth, they get that psychosis. I don’t have to be a doctor to know it messes up their mind.”

On the relationship between psychosis and addiction, he stated, “It makes it really worse. It’s like they don’t really ask [for help]. It seems like they’re untreatable, like there’s no way they can get help.” When asked about the connection between mental health and addiction treatment, he added, “It would be hard to treat someone with just their addiction and not treat their mental health.” Commenting on the relationship between overdose and suicide, John Doe said, “Ten percent of people injecting fentanyl want to die. A lot of people get tired with the lifestyle; a lot of people get tired of finding their next fix.”

Impact of COVID-19

Since becoming involved with the illicit drug trade in September 2019, John Doe witnessed changes in the trade that began during the pandemic. The pandemic caused drug prices to go up because there was a reduced drug supply. “When they closed the borders, it was harder for people to get drugs,” he said, as the price of drugs appeared to follow a supply and demand curve (steady demand and decreased supply). For John Doe, the price of an ounce of opioids went up to $1700 from $1500, and an ounce of crystal methamphetamine went to $650 from $300. The price of small amounts of drugs also increased, with opioids going to $25 from $20 a point. He said that drugs were selling at full per-point prices rather than being discounted for buying larger amounts. In addition, people who sold drugs no longer provided free samples or fronted drugs.

When asked about the attitudes of PWUD toward COVID-19, John Doe stated that some were scared of COVID-19: “A lot of them had lung problems because they smoke heavy and had weakened immune systems. I see a lot of addicts get sick and they get sick and weak for weeks off the common cold.” He added, “A lot of them didn’t care. They were homeless, what could they do?” He noted some public health interventions: “A lot of people were handing out masks and hand sanitizer. There was way more free food handed out. There were more shelters. Some of it’s good and bad. If they knew where their next meal was coming from or they had a place to stay, they would spend more money on drugs.” As for physical distancing, he said, “A lot of [PWUD] were encouraged, but no one was really physically distancing, I guess some were, but not that many. . . . It wasn’t really considered in the drug community. People didn’t take it seriously.”

As for other public health measures practised by PWUD, such as self-isolating and hand washing, he said, “A lot of people were in shelters and they were only open for certain hours and they would have to go on the street. . . . They did [wash their hands]; someone put hand sanitizers on the street, but they were quickly destroyed after a week.”

In response to why COVID-19 deaths were not worse on the Downtown Eastside since the pandemic, John Doe said he did not know: “With their lifestyle they come into contact a lot. They share tinfoil, they share needles. I was really surprised it didn’t have the impact they thought it would.” He reported, however, that there were fewer people selling drugs between March and May of 2020 as many were afraid of getting COVID-19 from their customers. But a lot of people selling drugs “. . . didn’t care about the customers. They were just money for them. A lot of the dealers were scared of getting infected and they wore gloves, and masks. I even saw someone wear that plastic shield on their face.”

For his own means of protection, he wore gloves and a mask. “I would avoid contact, I would make it minimum. I wouldn’t place the drugs in their hand. I would place it on a garbage bin, or the curb on the side of a building. I would have minimum contact with the user.” He stated, “I was mostly worried about the distance because I didn’t want too many people coming near me. A lot of my friends would wash their money when they got home.” Generally, he said, among people who sold drugs, “We were physically distancing; we would just be chilling and talking. Drug dealers, yeah, when they had a chance, more than normal.”

Impact of the Canada Emergency Response Benefit

The Canada Emergency Response Benefit (CERB) provides financial support to Canadian workers who experienced reduced earnings due to the COVID-19 pandemic.[2] John Doe said, “The addicts got [CERB] too, and most of the addicts spent it on drugs.” He stated that after CERB, “I never made money like on the day CERB came out. The consumers were spending a lot of money. It was way easier for them to access drugs.” Before CERB, he was making $400 to $600 a day. The week after CERB came, he made $1000 a day. “There were some addicts who spent their whole cheque all on drugs. As soon as they got their cheque they spent it all on drugs. It was kind of shocking.”

John Doe believes that the people who left the drug trade in March to May of 2020 returned to their regular numbers by mid-May 2020 after hearing about the record profits from the diverted CERB. He estimated that by the end of June 2020, there were more people selling drugs than before COVID-19.

He also believes that CERB was the biggest contributor to the record overdoses in May and June: “After welfare day, the overdoses spike and then decrease and when welfare comes around again it spikes. CERB made it worse! People were getting CERB and their welfare. The overdoses spiked, then it stayed steady; it didn’t drop back down like normal. That’s how I saw things.”

When asked if he saw any benefits of CERB, he said, “[Before CERB], addicts would go to high-end stores like Nordstrom and Holt Renfrew. They would steal nice clothes, watches, or anything that was worth a lot of money—PS4s or cell phones. [They’d] ask drug dealers for dope for it.” He believes crime decreased with CERB because, “People were more financially stable.” As a result, people who used drugs no longer needed to steal as much to support their habit. He said, “For about a week, there was no fights, no stabbings.” Other benefits of CERB were that, “Addicts had a chance to take care of their hygiene; [they were] able to buy food and feed themselves. Some of them could stay in hotels and it opened up shelter spaces, so a lot of them weren’t sleeping on the streets.” Overall, he said, that for PWUD, CERB was a benefit because, “A lot of them were taking care of themselves. By week two, there was less people panhandling and begging for money.” From what he saw, CERB also helped with physical distancing; the cheques helped people buy tents so they could separate better than in shelters, where people may be more crammed together. “They closed Hyde Park and a lot of them went over to Strathcona, which was a bigger space.”

Impact of safe supply

In response to the dual public health emergencies of the overdose crisis and COVID-19, the province announced new clinical guidelines in March 2020 to provide pharmaceutical-grade drugs to PWUD with the aim of reducing their exposure to a toxic drug supply, risk of withdrawal, and exposure to COVID-19.[3] This safe supply of drugs included oral hydromorphone, long-acting morphine (M-Eslon), dextroamphetamine (Dexedrine), and methylphenidate (Ritalin).

From John Doe’s point of view, some of his profit was cut into by the safe supply of amphetamines. However, he was not worried about his finances as the majority of his profits came from opioids, not crystal methamphetamine. He felt that this was generalizable to most people who sell drugs; “I don’t think it cuts into our profits as drug dealers. Because a lot of addicts want that same high they usually get.” He did not believe safe supply is saving lives, explaining, “Once you’re addicted to fentanyl, it’s hard to get off.”

John Doe believes that some people who sell drugs dislike safe supply because they sell just enough opioids to prevent their customers from getting withdrawals, so PWUD need to keep going back to them. “Some people use it when they can’t get fentanyl so they don’t get sick,” he said. He believes that safe supply can help with withdrawals when fentanyl is not available for PWUD.

According to John Doe, the street price of 8-mg hydromorphone tablets before safe supply was $5 a tablet. After the initiation of safe supply, it went down to $2 a tablet. He believes that the hydromorphone prescribed in safe supply is not largely used by those who use fentanyl. When asked what he thinks happens to the hydromorphone prescribed in safe supply, he replied, “A lot of people sell it to get fentanyl.” When asked who the hydromorphone from safe supply is sold to, he stated, “[To] people [who] only use hydromorphone. They don’t use fentanyl.”

Prevention of overdose

John Doe believes the most effective interventions against overdose are safe injection sites and naloxone kits: “The safe injection sites do really work. Maybe more awareness [is needed]—a lot of addicts are already aware—but [for] families and stuff. And I guess Narcan, Narcan is really effective. They need to hand out more Narcan kits for free.”

Lessons for health care providers

John Doe provided in-depth insights into the BC illicit drug market. This report may have limitations in terms of generalizability as it is based on the subjective experiences of one individual and drug markets may vary across Canada. However, his firsthand account of the illicit drug trade does highlight some critical lessons for health care providers.

The intentional move to more potent opioids

John Doe’s account warns us that the production of street opioids is moving intentionally toward carfentanil and away from fentanyl, indicating that the drug supply is becoming even more toxic over time. He was able to articulate why overdose is not a deterrent from opioid use as PWUD have likely become tolerant of the current drug supply and are looking for ever-higher-potency opioids. In the free market of the illicit drug trade, PWUD are specifically asking for higher-potency opioids and suppliers are filling this demand.

The financial burden of drug use

If we assume most people who use opioids will use between 0.1 g and 1.75 g daily, the daily cost is $20 to $175 pre-COVID-19 and $25 to $427.50 during the pandemic. If we assume most people who use amphetamines will use between 0.1 g and 1 g daily, the daily cost is $10 to $60 pre-COVID-19 and $10 to $100 during the pandemic. This shows how quickly addiction can lead to financial ruin, as well as the level of crime (including theft and drug distribution) and participation in the sex trade that will be required to maintain a certain level of drug use.

Facilitating change in people who use and sell drugs

Although not the case with John Doe, many people who sell opioids and crystal methamphetamine also use these drugs. The drug trade can be lucrative, and John Doe’s account can help health care providers and law enforcement understand the opportunity costs to the people who sell drugs when they are asked to change what they do to make money.

Motivational interviewing is an evidence-based therapeutic approach to addiction treatment. During motivational interviewing, the therapist helps the patient develop discrepancy by clarifying their goals and values and revealing how their behavior is in conflict with them. If a motivational interviewing approach is taken toward people who sell drugs as well, the real-world downsides of negative police interactions, knowing that people are dying from the products sold, and the risk of violent encounters can be used to help them develop discrepancy between their current behaviors and their goals.

The risk of laced products

Another downside of the illicit drug trade is the prevalence of laced products. Even John Doe would not buy his cannabis from other illicit drug suppliers. Health care providers can encourage their patients who use cannabis to buy from reputable, legal sources as a harm reduction strategy. In addition, if patients who use drugs intend on using drugs without fentanyl, they should be encouraged to have their drugs tested, and drug-testing sites should be expanded.

The interplay between mental illness and addiction

John Doe witnessed the connection between mental health issues and addiction in his customers. Specifically, he saw the interplay between depression, anxiety, posttraumatic stress disorder, psychosis, and suicide with addiction. When present, these issues should be treated concurrently in line with best evidence.[4]

The need for withdrawal management

John Doe recounted the increased difficulty of procuring illicit drugs during the COVID-19 pandemic, which may result in PWUD experiencing increased withdrawal and craving symptoms. Physicians need to be aware of this and provide opioid agonist therapy along with supports, including psychosocial care and appropriate harm reduction practices, to support these vulnerable clients.

Unintended consequences

Since the COVID-19 pandemic began, there has been a spike in opioid overdoses. John Doe highlighted some of the unintended consequences of programs designed to help during the pandemic. With CERB, he saw a reduction in crime; an increase in shelter space; and better hygiene, nutrition, and physical distancing among PWUD. However, CERB also allowed PWUD greater access to drugs, leading to record profits for individuals like John Doe. The impact of the new safe supply clinical guidelines introduced in March 2020 is currently unknown. John Doe does state that some individuals who cannot obtain high-potency opioids such as fentanyl use the hydromorphone prescribed in safe supply to treat or prevent withdrawal. His account of PWUD diverting safe supply medications to obtain high-potency opioids like fentanyl is a concern that has been shared by physicians.[5] Any evaluation of the CERB program and safe prescribing guidelines should specifically measure the unintended consequences of allowing increased access to a toxic drug supply for PWUD. In addition, overdose rates specifically involving hydromorphone should be measured. This evaluation will allow health care providers to optimize these programs to provide the greatest benefit and minimize harm.

Competing interests

None declared.

This article has been peer reviewed.

Dr Mathew is the medical director for complex mental health and substance use services at BC Mental Health and Substance Use Services, Provincial Health Services Authority; a clinical associate professor in the Department of Psychiatry at UBC; and an addiction and forensic psychiatrist. Mr Wong is a graduate student in the Department of Psychiatry at UBC. Dr Krausz is the UBC-Providence leadership chair for addiction research, the director of addiction psychiatry, and a professor in the Department of Psychiatry at UBC.