Coroner's inquest jury makes 21 recommendations to reduce fatal drug overdoses

Jurors at a coroner's inquest into the fatal overdose of a 20-year-old man in British Columbia have recommended the province improves treatment options for people struggling with addiction, including access to pharmaceutical-grade heroin.

Brandon Jansen was at treatment centre for an addiction to fentanyl when he died in March, a month before the province declared a public health emergency into opioid-related deaths.

He was among 914 people in British Columbia who died from a drug overdose in 2016.

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The B.C. Coroners Service said before the inquest that the process would be an avenue to explore some of the issues arising from the deaths.

Among its 21 recommendations, the five-person jury said standards of practice should be developed for treating people living with opioid addictions, and outcome measures and standards for treatment centres should be improved.

It also said access should be expanded to the opioid-replacement therapy suboxone, and to pharmaceutical-grade heroin and hydromorphone for chronic opioid users.

Jansen had entered the private Sunshine Coast Health Centre for his 11th attempt at treatment.

The jury found Jansen died from "a mixed opioid drug overdose" and classified his death as accidental.

More opioid-replacement treatments needed at centres

The centre's chief executive Melanie Jordan said in November that the young man died partly due to the fact that the antidote naloxone and the therapeutic drug suboxone were not available.

An investigation by Vancouver Coastal Health released that month said the centre in Powell River was in compliance with provincial regulations.

The health authority said in a report that the RCMP found evidence suggesting Jansen likely got the drugs that contributed to his death from another patient who obtained them while on a day pass.

It said police also found "another illegal substance" in Jansen's room hidden in a container labelled as supplements, which were believed to have been brought to the centre by a family member.

Michelle Jansen said she visited her son the day before he died and did not bring him any supplements or medication.

She said that at the time of his death, the centre did not carry naloxone because it could not get the appropriate authorization from provincial health regulators to administer the drug.

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Jansen said that based on the report, staff might have saved her son's life had a higher authority insisted that treatment centre in B.C. be armed with naloxone during an opioid crisis.

The centre's chief medical officer was also waiting for approval to prescribe suboxone, which stops cravings and can prevent opioid overdoses.

Jordan has said the centre was granted authorization to prescribe suboxone last July, days after the College of Physicians and Surgeons of B.C. lifted restrictions that previously limited who could administer the drug.

The jury recommended treatment centres provide access to opoiod-replacement interventions.

Increased regulation?

Of the 21 recommendations, five involve further regulations around treatment facilities, including additional beds for teenagers, and developing educational requirements for people working in centres. 

Currently the vast majority of treatment centres in the province are private, and they vary drastically in cost and quality.

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"I don't think there are stringent controls are in place," said Jansen, who said she would have liked to have seen the report go further.

"I would have liked to have seen really rigid processes and policies and procedures being recommended. Perhaps the inquest wasn't the forum for that. I certainly will lobby for that, and push for that."

NDP MLA Selina Robinson, a former youth drug and alcohol counsellor, said that the recommendations seemed "quite reasonable" at first glance, but also focused in on the need for regulation of treatment centres. 

"There's never been an education requirement for operating a treatment centre or recovery house in this province," she said.

"It's really been a free for all, pretty much anyone can hang a shingle, and say they offer services. We're dealing with a vulnerable population ... We require regulation on a whole bunch of other treatments in this province, but certainly not here." 

The Ministry of Health said they were unavailable for comment Wednesday evening. 

With files from Brenna Rose and Justin McElroy