Alexandra Pontbriand fumbled through the first aid pouch as the man’s body shut down.
Her hands shook but she pressed on, securing the vial of naloxone that would get his lungs working again. When she tried to break it open, the glass tube shattered between her fingers. Blood ran down her hands.
Across the room, the man’s pulse barely registered. A fentanyl overdose hits the body like a flash flood: pupils shrink, muscles go limp, lips turn blue and lungs stop sending oxygen to the blood.
Without something to stimulate his breathing again, he could have died in the safe injection site, sitting just a few feet from Pontbriand. Her fingers lacerated by sharp glass, she wasn’t able to dose him with the life-saving drug naloxone.
But she didn’t panic.
Pontbriand called for a colleague to help save the man. By the time they got the syringe ready, a nurse had already started administering oxygen. He came back to life.
That was the first time either of them had to prep a dose of naloxone. Looking back today — just three years later — it almost seems like a quaint memory.
“We had no way of knowing how bad it would get,” said Pontbriand, a community worker at Spectre de Rue, one of Montreal’s only safe injection sites. “Back then, overdoses were still pretty rare. It was a monthly occurrence. Now it happens every day. And that’s just the ones we see here.
“Out there, on the streets, people are dying. One day the pandemic will end but not for us. COVID will go away and life will go back to normal. But the overdose pandemic isn’t going anywhere. And once that dawns on you, you feel powerless to stop it.
“Some days it feels like you’re fighting against death itself. You can’t win that fight.”
At the most primal level, the workers at Spectre de Rue’s safe injection site have one job: to keep their users from dying of an overdose. They do remarkable work. In the four years since the site opened, not a single person has died there.
That’s the good news.
Here’s the hard part. Last year medical staff had to perform 405 interventions on site — a 50 per cent increase over the previous year. Hundreds of times, people like Pontbriand had to intervene as people’s bodies shut down. Hundreds of times, they brought them back from the brink.
Outside the walls of the safe injection site, people are dying in huge numbers.
There were 571 overdose deaths in Quebec last year. That’s a 30 per cent jump from 2019. Some of those people attended Spectre de Rue during the day but died while consuming drugs at home or on the street.
To work in this field is to live with a sort of endless grief. The person who waves goodbye as they step out the door one afternoon could end up at the morgue the following morning.
And while there are scientifically proven ways to get the crisis under control, Quebec’s government has been unresponsive.
Despite massive death tolls, no increase in funding for safe injection sites appeared in the budget tabled by the provincial government in March.
Meanwhile, the health ministry allowed funding to expire on its strategy to fight overdoses.
Saving drug users isn’t a priority for the Coalition Avenir Québec government.
Nevertheless, the people at Spectre de Rue persist in the fight against death.
‘Impossible to replace that high’
“There is no heroin anymore.”
Julie Laflamme-Desgroseilliers sips coffee from a mug the size of a cereal bowl. It’s after 5 p.m., probably not the best time for a fistful of caffeine, but I get the feeling this is the only quiet moment she’s had all day.
“Once fentanyl arrives on the market, it’s impossible to replace that high,” she continues. “It’s an incredibly strong drug but human beings, we’re adaptable. So our bodies build a resistance to it and then you can’t just go back to heroin or dilaudid. It won’t work anymore.
“Fentanyl is here to stay, unfortunately.”
We sit across from each other in the basement of Spectre de Rue’s Ontario St. headquarters. Before it expanded its services to include a safe injection site in 2017, Spectre ran a needle exchange program out of the building for 20 years.
This place was here when the neighbourhood was just a patchwork of dive bars and low-rent housing a few blocks east of Berri metro — the epicentre of Montreal’s open-air heroin trade.
Now the building sits across from an artisanal cheese shop and a bakery that sells organic pastries. You might think the site clashes with the neighbourhood’s gentrifying aesthetic but it’s a pretty nondescript storefront, complete with neon lighting and a dozen houseplants in various stages of decay.
“They don’t let me near the plants,” Laflamme-Desgroseilliers says. “All I have to do is look at them and they die.”
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With nine years under her belt, Laflamme-Desgroseilliers has been working at Spectre de Rue for what feels like an eternity.
She was the one who helped Pontbriand prepare her first dose of naloxone to save the dying man three years ago. Now she’s certified to teach people how to administer it.
“We used to make kits with two doses in them,” she says, zipping open a black pouch. “Now each bag has six. One or two hits used to be enough to bring someone back. Those were simpler times.”
There are two ways to give someone naloxone. It comes as a nasal spray or in a glass vial you load into a syringe and jab into someone’s arm or leg. Doses are administered every three minutes until a person’s vital signs are under control.
Laflamme-Desgroseilliers says that, over time, you learn to lean on your “lizard brain” and go through the motions. She says some people describe going into an out-of-body experience, where it feels like they’re watching themselves administer the drug.
“This right here, you can jab it through someone’s jeans if you’re in a bind,” says Pontbriand, wielding a syringe wrapped in cellophane. “It’s a pretty amazing little kit.”
Not that long ago, naloxone was a virtually unknown commodity in Quebec. It was available at day centres in Montreal and maybe a few other major cities across the province. Back then, the fentanyl crisis was limited to the rest of North America. In fact, some pharmacies refused to carry naloxone for fear of the clientele it would attract.
That all changed when the borders closed at the outset of the pandemic last year. With drug smuggling routes thrown into disarray, reliable sources of heroin dried up and dealers had to get creative — mixing drugs and cutting crack, cocaine and opioids with synthetic downers like fentanyl.
“The pandemic was our point of no return,” says Pontbriand. “We didn’t see a jump in overdoses because more people suddenly started using drugs. It's fentanyl.”
In April, Montreal police seized an estimated $1.4 million worth of fentanyl from a network of dealers who operated downtown and in the South Shore suburbs. It was the largest fentanyl bust in Quebec history but two police sources who spoke to me say that record probably won’t stand for very long.
The cops also seized $20,000 in cash and a stockpile of crack, cocaine, heroin, amphetamines and Xanax, suggesting those narcotics were being cut with the powerful drug.
Some policy changes are working. It’s now the law that anyone who needs naloxone can walk into any pharmacy in Quebec, ask for it and get the life-saving drug free of charge. The pharmacist, in turn, must order it within 48 hours.
Every police car patrolling the streets of Montreal has a naloxone kit. They can be found in clinics, at the hospital and every month new outreach workers are trained to administer the drug.
Of course, naloxone only works if someone is there to inject it into the person as they overdose. Despite a surge in overdoses at all four of Montreal’s safe injection sites last year, no one died because there was always staff on hand ready to intervene.
Spectre de Rue alone had 9,207 visits last year. CACTUS Montreal’s services were used 20,818 times, and l’Anonyme had 14,802 visits. That’s over 40,000 times people went to use the safe injection sites, and not one of them died.
“We’re just the tip of the iceberg,” says Pontbriand. “A handful of safe injection rooms in a city of 2 million. There’s a lot that happens out there in the shadows.”
All the losses they have suffered
There is one certainty of life on the front lines: everybody breaks.
“No matter how resilient you are, no matter how tough you think you might be, you’ll reach your limit,” says Laflamme-Desgroseilliers. “The crisis caught up with me last summer. I was driving back from a training exercise in Quebec City when I got a call that one of our users had died.
“It broke me. I burst into tears right there in the car. At the time, we were losing one or two people a week in the neighbourhood. Death had almost become a normal thing. We’d all lost people we knew, we’d all seen people walk out the door and never come back.
“But the crazy thing is I didn’t even know this person. Couldn’t put a face to the name. It wasn’t the death of this one person anymore. It was just the principle of one more person lost to the crisis. So now, when someone dies I cry just as much as I would if I knew them.
“Because now I know it won’t end. Now I know it won’t end and so many people out there don’t give a shit. It’s unsettling. That death changed something in me forever.”
For Pontbriand, it was the loss of someone she’d come to know.
“When I heard that Philippe had died, the first thing I thought was ‘overdose’,” she said. “But I was wrong. He’d been murdered. That was a tipping point for me. For some reason, that forced me to start preparing for a crisis that wouldn’t end. It forced me to harden myself against all the death that was about to come.”
Philippe was an artist, someone with a tender heart in an environment where people project a hard exterior just to get by.
“He’d asked me once, ‘I know you can’t hug me, but if you see that I’m having a tough time, could you put your hand on my shoulder?’” said Laflamme-Desgroseilliers, who also knew him. “That kind of vulnerability is rare on the streets.”
“I can’t really talk about my memories with Phil because so many of them were in the safe injection room and that’s deeply personal,” said Pontbriand. “I’ve been working in this field for 10 years and I never attended someone’s funeral. Going to Philippe’s memorial service helped me grieve a lot of the other losses we’d suffered.
“His family reached out, they visited our site and spent some time with us to, I suppose, get some sort of closure. They were wonderful just as he is. They donated a substantial amount in his name and if there’s anything that we can cling to in these hard times, that’s it right there.”
Pontbriand and Philippe’s sister message each other now and again. She says it helps keep his memory alive.
Quebec drags its feet
Increasingly, experts say the only sure-fire way to stop overdoses is by having a clean supply of drugs.
Black-market narcotics don’t come with dosing guidelines or organic certification. The closest people can get right now is having their drugs tested for impurities.
Six months ago, a network of community groups sent the provincial government a request to set up a drug-checking system in Montreal and the North Shore suburbs. Quebec can work with Canada to exempt these sites from the Controlled Drugs and Substances Act.
Both governments simply have to inspect the site and sign off on the exemption. But one of the project’s organizers says Quebec has dragged its feet every step of the way.
“People are dosing themselves with unknown quantities of fentanyl and it’s killing them,” said Jean-François Mary, who runs CACTUS Montreal. “We have the equipment, the funding and the expertise to do something about it. We can detect fentanyl levels before a person uses the drug and that kind of information can save lives.
“The federal government has been very fast and supportive. I can’t say the same about the provincial.”
The CAQ was against Spectre de Rue’s safe injection site before it ever got off the ground. Back when he was an opposition MNA in 2017, the CAQ’s Jean-François Roberge backed a group of parents who tried to get an injunction against the site.
“My party is in favour of a safe injection site but not just anywhere,” Roberge told Radio-Canada at the time.
“Especially in a neighbourhood with so many families.”
It didn’t matter that Spectre already ran a needle exchange program that takes upwards of 60,000 syringes off the streets every year, or that the harm reduction model is designed to save people’s lives and provide them the opportunity to eventually get sober.
Back then, it was just good politics for Roberge to stand with families and against drug users.
Fast forward four years and Roberge is now a cabinet minister in a government for whom overdose deaths weren’t important enough to get a budget line in the midst of a historic opioid crisis.
Mary says it’s looking like the drug-checking sites will get off the ground by the end of May.
In the meantime, people who show up to Spectre de Rue follow a protocol to share as much information as they can about the drugs they plan on using. When they walk through the site’s doors, they provide a pseudonym, tell staff what drugs they think they’ll inject and then head to the waiting room.
All of the information is entered into a database that helps track tainted batches of drugs. If the drugs could be tested, that could help sound the alarm before the casualties pile up as they did last summer. Between June and September, 219 people across the province died of an opioid-related overdose, according to public health records.
For Pontbriand and her team, the best they can do for now is to create a loving, non-judgemental environment for the people who use their site.
The waiting room at Spectre de Rue is lined with chalkboard paint, where users and staff can etch colourful drawings on the walls. Pre-pandemic, it was a pretty cool place to hang out.
Across another set of doors, a cardboard sign that reads “DJ NURSE” hangs above the nursing station next to the safe injection room.
“All they have to do is ask the nurse and she’ll put on some music for them,” says Laflamme-Desgroseilliers. “Before the pandemic, they could sit in the other room and watch movies as they came down. It’s a great place.”
One day, it’s possible Laflamme-Desgroseilliers will do more teaching and less intervention work, but she says it’s been a life-changing experience.
“I don’t know if I could do anything else,” she says. “There’s this guy here who I’ve seen for years. We barely spoke because he’s not much of a talker. Lately we’ve started actually having conversations.
“One time he told me, ‘Julie, if I get sober, it’ll be with you. No one else.’
“That’s why we do this. This keeps people alive and as long as they’re alive, there’s hope that things can be better.”