Author: Samira Prasad

From The Globe and Mail article

There are many reasons why hospital emergency departments have been under unprecedented strain lately, but new research shows that the shift by family doctors to virtual care since the start of the pandemic is not one of them, according to the president of the Ontario Medical Association.

In a study by the Ontario Medical Association, published in the CMAJ (Canadian Medical Association Journal) on Monday, researchers found primary care physicians’ transition to virtual care was not associated with increased emergency department visits by their patients.

“There are other reasons why emergency departments are overwhelmed. It’s not because doctors have pivoted to a hybrid model and are now seeing their patients virtually as well,” OMA president Rose Zacharias said.

The study adds to growing research on the impact of virtual care, which has taken off in Canada since doctors were driven to restrict in-office visits early in the pandemic to reduce COVID-19 transmission. Many doctors began offering appointments by phone or video call.

Meanwhile, in the past year, emergency departments have struggled to keep up with demand, Dr. Zacharias said. But this has been the result of multiple factors, including burnout among health care professionals, a backlog in care, and patients showing up in greater numbers and sicker after a period of public-health restrictions, she said.

As well, there is a shortage of doctors and nurses in Ontario, with more than one million people in the province lacking a family doctor in the first place, she said, explaining the latest findings show patients who did have family doctors were not turning to emergency departments because of a decline in the availability of in-person care.

---

While the researchers did not study the reasons for this, lead author Lauren Lapointe-Shaw suggested a couple of potential explanations. Patients tend to use virtual walk-in clinics for new, acute problems, many of which require a physical exam of some kind, such as abdominal pain, she said. She suspects in many cases, patients may be redirected to an emergency department for that physical exam, since virtual walk-in clinics do not have a bricks-and-mortar facility where patients can be assessed in person.

Another potential reason may involve the relationship and trust between patient and doctor, said Dr. Lapointe-Shaw, who is a general internist physician at Toronto’s University Health Network and assistant professor at the University of Toronto. Patients may have less confidence in doctors they meet for the first time virtually and who do not examine them physically, and so are more likely to visit an emergency department for a second opinion, she said.

Her co-author Tara Kiran, a family doctor at St. Michael’s Hospital and Fidani Chair of Improvement and Innovation at the University of Toronto, emphasized the need to integrate virtual-care options into family care in a way that strengthens continued relationships between health care professionals and patients. That includes the increased use of asynchronous messaging, such as e-mails via a secure platform, which is highly desired by patients but not currently widely used, she said.

It’s important to avoid using virtual care in a way that fragments the continuity of patients’ care, Dr. Kiran said.

“A strong relationship between one physician and a patient has been shown time and again to have better outcomes for patients, even lower costs for the system,” she said.

From the Toronto Star article

Machines that dispense HIV self-testing kits, clean needles and other harm reduction supplies have been installed in Atlantic Canada with plans for 100 in the next three years across the country, which continues to grapple with HIV cases and an opioid crisis.

Sean Rourke, scientist with MAP Centre for Urban Health Solutions, said the project started when he was working to get the first self-testing kit for HIV approved and available in Canada. Health Canada approved the test in November 2020 and Rourke said the next step was making it available to those who need it. MAP Centre is affiliated with Toronto’s St. Michael’s Hospital.

Rourke said 10 per cent of people in Canada with HIV don’t know it. “That’s about 7,000 people. Those people aren’t benefiting from treatment.”

To help distribute the tests, the I’m Ready program was launched, which allows people to download an app on their phone to get the test delivered to their home or ready for pickup at locations across the country. Rourke said the program is working but it’s not reaching everyone, including those without a phone or stable housing.

That’s when the idea to launch Our Healthbox machines in communities that need it came to life. It’s a smart machine with a digital screen that works like a vending machine with free HIV and COVID-19 self-testing kits as well as clean needles, Naloxone, crack kits with safe smoking paraphernalia, condoms and other things Rourke says we take for granted like feminine hygiene products, socks and mitts. Our Healthbox will also notify clients if there is a bad drug supply.

The federally funded Our Healthbox program will also feature educational videos accessible on the machine including on how to administer Naloxone for overdoses. The people monitoring the machines have the flexibility to put other items in it, too.

Our Healthbox will launch Monday in four communities in New Brunswick. One will be going to a front-line harm reduction service in Moncton called ENSEMBLE; another will be set up in the vestibule of a United Church in Sackville, the third will be stationed at a Guardian Pharmacy in Richibucto; and the fourth will be delivered to Woodstock First Nation.

Rourke, along with researchers at St. Mike’s, plans to set up as many as 50 machines in Canada this year, and 50 more over the next three years.

From TVO Today

HAMILTON—On December 23, a winter storm hit Hamilton and much of southern Ontario. Hundreds of people in Steeltown lost power, and schools, businesses, and public spaces closed. The medical officer of health issued a cold-weather alert, which happens when temperatures are (or are expected to drop) below -15 C, or -20 C with wind chill.

Such alerts are more than just a warning — they trigger the opening of drop-in warming centres. But on this night the extreme weather meant that city facilities such as libraries and recreation centres were closed.

By night time on Christmas Eve the storm had passed and the temperature was warming above the threshold, so Hamilton’s medical officer of health called off the alert — meaning some vulnerable Hamiltonians no longer had a warm place to stay. That evening, the Hub, a drop-in resource centre downtown for people who are unhoused or sleeping rough, had been open for its usual hours from 5 p.m. to 9 p.m. Although the Hub doesn’t have beds, people can show up for a warm meal, use the internet, and charge their phones. Under its contract with the city, the cancellation of the cold alert meant additional operating hours would not be funded without first receiving special approval.

Word that the Hub would close caused an uproar online. Twitter users wrote that the lack of warming centres was “unacceptable” and “unconscionable” and Ward 2 councillor Cameron Kroetsch wrote that the situation constituted a “policy failure,” which “shouldn’t have happened in the first place.”

In some Ontario cities, cold-weather responses such as warming centres and outreach are tied to cold alerts, and thresholds vary by district. But research suggests common thresholds aren’t based on science and risk leaving people out in the cold.

Because of the snowstorm on December 23, “a lot of people didn’t get to the traditional daytime warming centres,” says Hub director Jen Bonner. Libraries had closed in the afternoon, and coffee shops closed early for Christmas Eve. “Although that wind chill was under the threshold, it was still really cold.”

Hamilton’s cold-alert threshold is “ridiculous,” Bonner says. “We can’t be leaving people outside for extended period of time waiting for it to get to -15 C.”

Bonner says private donors stepped up, allowing the centre to stay open that night and for an additional three days. She says it costs roughly $3,000 per night to operate.

City leaders offered to cover costs, Bonner says, and days later, Mayor Andrea Horwath announced that Hamilton had contracted the Hub to operate nightly until March 3, irrespective of the weather. (Donors were offered their money back, or for it to funnel into alternative Hub services.)

“It was deemed that there was a bit of a gap with respect to our response,” says Michelle Baird, Hamilton’s director of housing services. She says the city has learned that people need more service even when the temperature is above the cold-alert threshold. “We are looking at moving more to a winter response, if you will, as opposed to simply a cold alert,” Baird says.

Hamilton is not alone. This week in Toronto, the board of health urged similar action, saying the city should ensure people can access warm spaces at all times until mid-April.

According to experts in health and homelessness, a winter response may be more successful at preventing cold-related injuries and deaths. Research by Stephen Hwang, internist and director of MAP Centre for Urban Health Solutions at St. Michael’s Hospital, found that unhoused people are at risk from the cold well before the temperature drops to -15 C. In reviewing Toronto coroner’s records and emergency-department charts from downtown hospitals (covering 2004-2015), Hwang and his team found that 72 per cent of hypothermia cases in people experiencing homelessness occurred in temperatures warmer than -15 C. Researchers also found that unhoused people accounted for 25 per cent of Toronto’s hypothermic injuries in that period and 20 per cent of deaths.

“I think that the current threshold of -15 C that’s often used is not really based on clear evidence in terms of health effects. I suspect that it’s largely driven by resource concerns,” Hwang says. “It would make more sense to maintain warming centres and resources for people who are unhoused whenever the temperature is colder than zero degrees or, alternatively, throughout the winter months, regardless of the temperature.”

Lire cet article en français

From CP24

Toronto’s Board of Health is urging the city to keep its warming centres open 24/7 for the remainder of the winter season.

The board of health voted overwhelmingly in favour of the motion Monday afternoon during its monthly meeting.

The motion, jointly presented by councillors Ausma Malik, Ajejandra Bravo and Gord Perks, also asks city council to declare a public health crisis based on the “systemic failure of all three levels of government to provide adequate 24-hour, drop-in and respite spaces.”

In a statement released following the meeting, a spokesperson for John Tory said that the mayor “supports a pragmatic approach based on the best advice from our city staff” when it comes to helping Toronto’s most vulnerable.

The spokesperson, however, noted that last year roughly half of the times that warming centres were opened it was done in the absence of an Extreme Cold Weather Alert, which is the automatic trigger for the opening of the centres.

---

Deputants urge city to act

A dozen deputants, many of whom shared difficult first-hand stories about how the cold has harmed those they love and care about, spoke during Monday’s meeting.

Dr. Jacqueline Vincent, a psychiatry resident at St. Michael’s Hospital, asked why it acceptable to continuously holding discussions about basic human rights like people not freezing to death on the streets instead of doing something about it.

“Please do what you can to help make help patients keep their fingers and toes and feet intact. Please do what you can to prevent me from seeing more patients like the one I did just a couple of weeks go whose feet were so badly frostbitten they could not walk for days,” she said.

“Please help my patients keep themselves and their belongings warm and dry during cold winter says.”

Dr. Stephen Hwang, an internal medicine physician at St. Mike’s and the director of Unity Health’s MAP Centre for Urban Health Solutions, expressed how he’s become “increasingly concerned” about the health and wellbeing of unhoused people in Toronto this winter.

Hwang, who along with colleagues published a research paper on the effects of hypothermia on people experiencing homelessness in Toronto, said he often faces the “impossible dilemma” of discharging his patients to the street and the cold “after having laboured so hard and so long to help them recover from a serious illness.”

Le conseil de santé demande instamment à la Ville de maintenir les centres d’accueil ouverts en tout temps pendant le reste de l’hiver.

Tiré de CP24

Le conseil de santé de Toronto demande instamment à la Ville de maintenir ses centres d’accueil ouverts 24 heures sur 24, 7 jours sur 7, pour le reste de la saison hivernale.

Le conseil de santé a voté massivement en faveur de la motion, lundi après-midi, lors de sa réunion mensuelle.

La motion, présentée conjointement par les conseillers Ausma Malik, Ajejandra Bravo et Gord Perks, demande également au conseil municipal de déclarer une crise de santé publique en raison de « l’échec systémique des trois ordres de gouvernement à fournir des espaces adéquats de répit 24 heures ».

Dans une déclaration publiée à la suite de la réunion, un porte-parole de John Tory a déclaré que le maire « soutient une approche pragmatique basée sur les meilleurs conseils de notre personnel municipal » lorsqu’il s’agit d’aider les personnes les plus vulnérables de Toronto.

Le porte-parole a toutefois souligné que l’année dernière, près de la moitié des occasions où les centres d’accueil ont été ouverts l’ont été en l’absence d’une alerte de froid extrême, qui est le déclencheur automatique de l’ouverture de ces centres.

---

Des intervenants exhortent la Ville à agir

Une douzaine d’intervenants, dont plusieurs ont partagé des histoires personnelles éprouvantes sur la façon dont le froid a affecté ceux qu’ils aiment et dont ils se soucient, ont pris la parole au cours de la réunion de lundi.

La Dre Jacqueline Vincent, résidente en psychiatrie à l’hôpital St. Michael, a demandé pourquoi il était acceptable de tenir continuellement des discussions sur les droits fondamentaux de la personne, comme le fait que les gens ne meurent pas de froid dans la rue, au lieu de prendre des mesures pour remédier à la situation.

« S’il vous plaît, faites ce que vous pouvez pour aider les patients à garder leurs doigts, leurs orteils et leurs pieds en bonne santé. S’il vous plaît, faites ce que vous pouvez pour que je ne voie plus de patients comme celui que j’ai vu il y a quelques semaines et dont les pieds étaient tellement gelés qu’il a été incapable de marcher pendant plusieurs jours », a-t-elle déclaré.

« S’il vous plaît, aidez mes patients à se garder, eux et leurs biens, au chaud et au sec pendant les froids de l’hiver. »

Le Dr Stephen Hwang, médecin en médecine interne à St. Michael’s et directeur du Centre MAP pour des solutions de santé urbaine d’Unity Health, a exprimé comment il est devenu « de plus en plus préoccupé » cet hiver par la santé et le bien-être des personnes sans logis à Toronto.

Le Dr Hwang, qui a publié avec ses collègues un document de recherche sur les effets de l’hypothermie sur les personnes sans domicile fixe à Toronto, a déclaré qu’il était souvent confronté au « dilemme impossible » de renvoyer ses patients dans la rue et le froid « après avoir travaillé si dur et si longtemps pour les aider à se remettre d’une maladie grave ».

From the St. Michael’s Foundation

Dr. Dan Werb is an epidemiologist, a policy analyst and the winner of the prestigious Hilary Weston Writers’ Trust Prize for Nonfiction for his latest book, The Invisible Siege: The Rise of Coronaviruses and the Search for a Cure. We talked to Dr. Werb, who is also the executive director of the Centre on Drug Policy Evaluation at St. Michael’s MAP Centre for Urban Health Solutions.

What was it like winning the Writers’ Trust Prize for The Invisible Siege and, before that, being shortlisted for a 2019 Governor General’s Award for The City of Omens: A Search for the Missing Women of the Borderlands?

Winning the Writers’ Trust Prize was a complete and utter shock; I was absolutely convinced that there were other, more worthy books. Being nominated for the Governor General’s Award was such an honour, but very unexpected, too, because the book had an American publisher, and I didn’t know whether anyone in Canada was really paying attention to it.

How challenging was it writing about COVID-19 while in the throes of the pandemic, when there was such a lack of global vaccine distribution?

I’m an epidemiologist, not a virologist, so I must admit that when the pandemic happened, I didn’t know what a coronavirus was other than it was related to the 2002 SARS virus. I approached the book as a way to put boundaries on my own anxiety and dread. But I knew the stakes of getting the story of COVID-19 right.

On the one hand, I was writing a piece of entertainment. On the other, I was offering a real account of what happened, and conveying the illness and loss we all experienced. Meanwhile, I was frustrated by the number of people succumbing to the virus simply because market forces precluded vaccines from being distributed to under-resourced countries.

The best ways to stop people from getting infected and dying are blanketing the world with vaccines and making sure populations, everywhere, are immunized.

Yet, there’s an air of hope to The Invisible Siege.  

I set myself the task of telling readers about the science, which didn’t suddenly emerge the day the virus appeared. I focused on the early days of coronavirus research, decades ago, and its long trajectory leading to this pandemic—how we were able to create protections and blunt the force of whatever coronavirus showed up next. That’s what fills me with such hope: our capacity to deal with future virulent threats.

How can we prepare for future public health crises through what you describe as the “epidemic triangle”?

There are basically three pieces to prevention: biomedical, structural and community resilience.

The first is addressing viruses as families rather than as individual strains, and focusing on broad-based vaccines and treatments instead of individual ones.

Structural prevention, which may be the hardest, is recognizing and reversing the damage that deforestation and displacement of wild animals has brought—the ‘spillover events’ causing epidemic pathogens.

And community resilience is about acting quickly and locally to curb the outbreak of the virus. That means imposing effective public health measures and isolating people who are sick.

You also do a lot of work around public health interventions for the marginalized drug-using population at MAP Centre for Urban Health Solutions. You talk about coming up with “non-judgmental solutions” for those who use drugs and whose lives can be cut short by accidental overdose.

We’re in the midst of an overdose mortality epidemic, which has claimed about as many lives as COVID-19 over the past seven years. But unlike the case of the virus, the numbers are going up, not down, and the victims of this epidemic are overwhelmingly young people. So, there’s a real urgency to find many different ways to address this problem, such as reassessing how to control drugs and drug use, moving progressive drug policies forward and advancing life-saving interventions. If you’re a donor, you can make a massive difference in this space because there’s so much to do.

From the Globe and Mail article

In the emergency department at the Royal Alexandra Hospital in Edmonton, Dr. Louis Hugo Francescutti recently treated a patient who was homeless and was there for the 360th time.

“I’ve had others that are in the 500 range,” he said in a recent phone interview from the hospital. “I’m at work right now – I came in at 6 o’clock, and the first six patients I saw were experiencing homelessness.”

With homelessness at crisis levels in cities across the country, emergency-room doctors and nurses have become a frequent point of contact for people without shelter, who face elevated risks of injury, illness and death and often have nowhere else to turn.

The medical toll of homelessness has become so acute that hospitals are now required by the Canadian Institute for Health Information (CIHI) to track whenever a lack of shelter is mentioned in a patient’s chart.

But doctors and nurses are not obligated to ask patients about their housing status, so this information is not always making it onto those charts in the first place – meaning the picture is incomplete.

And without data, the toll of the crisis remains difficult to measure and address – and opportunities for intervention are being missed.

Under the World Health Organization’s International Classification of Diseases (ICD), which is used to track global health statistics, homelessness is coded as Z59.0.

---

One of the biggest opportunities for improvements in the Z59.0 data collection is in emergency departments – the part of the health care system that homeless patients most frequently access

The nature of emergency care – focused and brief interactions – means that housing status is less likely to get logged in those cases.

“When you admit someone to hospital, you do take a fairly complete history and describe where they live and who’s living with them,” said Dr. Stephen Hwang, a general internistand director of the MAP Centre for Urban Health Solutions at St. Michael’s Hospital in Torontoand one of the world’s leading researchers on homelessness, housing and health. “But you don’t do that in the emergency department, necessarily.”

CIHI plans to publish its first report on Z59.0 data this year, with a goal of raising awareness of the code for both physicians and researchers across the country, to get them thinking about the value of asking the question, both clinically and statistically.

From CBC

Kayla DeMong considers it a sign of success if her clients keep showing up.

DeMong is the executive director of Prairie Harm Reduction. The organization provides supports to people who use drugs, including Saskatchewan’s only supervised consumption site in Saskatoon’s Pleasant Hill neighbourhood. 

As a rule, the group doesn’t require abstinence in order to access its services, which sets them apart from some other addiction services.

“When we force people or manipulate them to seek abstinence as a part of engaging in support services, we’re just creating a cycle for them of disappointment and a lot of difficulty ahead,” said DeMong.

Advocates say that harm reduction aims to meet people where they’re at. That can mean supporting someone to continue using drugs in a supervised way amid rising overdose-related deaths. 

Some support programs, like housing and employment services, require clients to completely give up drug use before accessing them.

Not only can that create barriers to getting care and assistance, DeMong says, it also perpetuates the idea that someone lacks value because they use drugs.

“In the long run, it [abstinence] limits their ability to engage in services and create community and build relationships with positive support,” she said.

Prairie Harm Reduction’s supervised injection site provides spaces for people to use different kinds of drugs in a safer setting, and a community centre that offers access to other support services. 

Harm reduction common in medicine

There are few areas in health care that require absolute abstinence or compliance to receive care. 

“Harm reduction is something we do in medicine all the time, because if we only are going to treat good patients, we don’t treat anybody,” said Eugenia Oviedo-Joekes, a University of British Columbia scientist and Canada Research Chair in person-centred addiction care.

She says that when it comes to other chronic illnesses, such as diabetes or heart disease, patients aren’t turned away if they refuse to give up sugar or visit the gym.

“It seems that in addiction, suddenly we have this high bar for people: If you don’t stop using drugs, I’m not going to treat you,” said Oviedo-Joekes.

Focusing solely on a person’s drug addiction can also ignore conditions that may be exacerbating drug use, like past and present trauma, housing and financial insecurity, and physical and mental health issues. 

Not requiring abstinence in order to access services “means that people can walk in somewhere and, right away, someone’s there to talk to them,” said Zoë Dodd, community scholar at the MAP Centre for Urban Health Solutions at Unity Health in Toronto.

“[Harm reduction] makes space for building relationships with people and actually getting to know them, which is, I think, the biggest part of harm reduction,” Dodd said.

From Global News

A rise in the circulation of highly potent fentanyl that is increasingly being mixed with other drugs is making Canada’s street drug supply so toxic and unpredictable, tools to prevent overdoses such as naloxone are not always fully effective, experts say.

The situation has become so volatile, front-line doctors and workers say they are left to guess at what mixture of substances a person in crisis may have been exposed to, which is why they say Canada needs to move faster on measures like safe supply and drug regulation to stop the sharp rise in opioid-related deaths in Canada.

---

Tara Gomes, a scientist at Unity Health Toronto and director of the Ontario Drug Policy Research Network, says the increasing unpredictability in the drug supply in Canada poses challenges for community-based programs that help people who use drugs, as they are not set up to handle the longer-term care that may be required to aid someone overdosing from opioids mixed with benzos.

“They’re able to administer naloxone, and the person might be OK … but they are not able to be roused and people within those programs have to help monitor that person might have to stay open later or make sure there are people around because this person might need a couple of hours before they’re fully aroused and can leave the program,” Gomes said.

From the Toronto Star

People who used a virtual-only medical service — a kind of virtual walk-in clinic — during the pandemic were more likely to later go to an emergency room than patients who did appointments with their own family doctor online, a study by Toronto researchers has shown.

The study published Thursday in the Journal of Medical Internet Research explores the different outcomes between two kinds of virtual medical care during the pandemic — that given by walk-in-style clinics and that given by family doctors.

Conducted by the University Health Network, ICES, Women’s College Hospital and Unity Health Toronto, the study found that the patients who saw a physician who was not their family doctor through a virtual-only medical service were twice as likely to visit an emergency department within 30 days.

The visits “can add to an already overwhelming strain” on emergency departments caused by staff shortages and the prevalence of viruses, says lead author Dr. Lauren Lapointe-Shaw, a general internist at Toronto General Hospital and an assistant professor at U of T.

“To add any potential demand related to these virtual appointments is suboptimal.”

Emergency departments in Ontario have been experiencing record-high wait times and some rural emergency departments have closed temporarily because of a lack of staff.

The study showed that patients who had a virtual-only walk-in appointment often had a virtual follow up and then ended up in emergency, in contrast to patients who had a virtual appointment with their family doctor and then could have an in-person follow up, possibly avoiding a hospital visit because they were able to have a physical exam.

From the CBC News article

An evolving mix of opioid cocktails and changing consumption habits mean governments must now respond more aggressively to the overdose crisis, experts say.

More than 32,000 Canadians have died of toxic drug overdoses since 2016, according to data released by Health Canada last month.

Over 3,500 people died of overdoses in the first half of 2022 (data is available only up to June). That’s almost 20 people per day, and more than half the number of people who died of overdoses during the first year of the pandemic.

The federal government has spent hundreds of millions of dollars to combat the crisis by funding community-led projects such as safe consumption sites and safe supply programs and improving access to naloxone, medication that can reverse the effects of an opioid overdose.

Fentanyl remains a driving factor in overdose deaths; Health Canada says that 76 per cent of all overdose deaths involve that opioid. But an increasing number of overdose deaths involve more than one substance.

Health Canada said just under half of the 3,556 overdose deaths that occurred in the first half of last year involved a stimulant such as cocaine or methamphetamine. At the same time, health services are increasingly warning of illicit opioids being contaminated with depressants such as benzodiazepine or “benzos.”

Tara Gomes of the Ontario Drug Policy Research Network said the two trends are likely linked.

“What we’re seeing more and more is benzodiazepines in the opioid supply. So they’re actually mixed in with the fentanyl,” she said.

That means the people who use these drugs aren’t necessarily aware that they’re taking benzo along with the opioid, she said.

But Gomes said some are intentionally using stimulants in an effort to counteract the sedative effects of an opioid and benzo cocktail.

“Oftentimes what they’re looking to do is counteract those effects, try and moderate the effects of the opioid so that they don’t get too sedated,” she said.

Benzodiazepines are dangerous when paired with an opioid like fentanyl because the added sedation increases the risk of an overdose, says Health Canada.

And the lifesaving medication naloxone does not work on benzos.

“It makes it more challenging for already burdened overdose prevention services,” Cheyenne Johnson, executive director of the British Columbia Centre on Substance Use, told CBC News.

Johnson also said a mix of opioids and benzos can also complicate substance use treatment by intensifying withdrawal symptoms. Such symptoms can include extreme anxiety, sweats and dangerous seizures.

“It makes it very complicated in terms of managing their cravings and withdrawals when there’s multiple types of potentially unknown substances like benzodiazepines” she said.

Fentanyl and benzodiazepines on their own can be used in clinical settings, but Johnson said substances never meant for human consumption are appearing in the illicit drug supply.

Xylazines, an animal sedative, and nitazenes — a synthetic opioid that is estimated to be several times more potent than fentanyl — are two such drugs, Johnson said.

“The sky is the limit on what is coming next,” she said.

Karen McDonald, head of Toronto’s Drug Checking Service, echoed Johnson’s point, saying that the illicit drug supply “is increasingly more contaminated, more toxic and less predictable.”

“[It’s a] recipe for disaster,” she said.

McDonald’s organization tests samples from the illicit drug supply to warn people who use drugs about what is being mixed in. But while the technology her organization uses is quite sophisticated, she said the illicit supply changes so fast that it feels like they’re “constantly playing catch-up.”