er nightmare: users overdosing on toxic drug supply can turn violent, putting doctors, patients at risk
6 minute read
thrashing, agitated patients put doctors, nurses and other patients in danger in emergency rooms.
dan janisse
/
postmedia
an increasingly toxic drug supply is having a knock-on effect on canada’s already overloaded emergency rooms, forcing doctors to balance reversing overdoses while avoiding users going into such severe withdrawal they endanger others.
illicit street drugs have become so contaminated with other chemicals — including animal tranquilizers — it can take 10 times the usual dose of naloxone, the potentially lifesaving overdose antidote, to restore a person’s breathing sufficiently enough to keep them from dying.
“it speaks to the increased toxicity of what’s circulating on the street right now,” said calgary emergency physician dr. eddy lang.
but high doses of naloxone given to regular opioid users also significantly risk precipitating “acute agitated withdrawal,” warns a brief report published online ahead of print by the canadian journal of emergency medicine.
people can wake up screaming, thrashing, confused and trying to strike staff.
“severe naloxone-induced opioid withdrawal with agitation should be managed as a high-risk agitated delirium, prioritizing patient and staff safety through standardized emergency department protocols, including verbal de-escalation attempt, trained security involvement and judicious use of physical and chemical restraints when necessary,” the authors wrote.
the quick, concise “just the facts” summary on balancing opioid reversal and withdrawal comes as cities across the country are reporting stark upticks in opioid-related overdoses, adding to the strain on paramedic and emergency staff and potentially worsening violence in ers already operating in what leaders recently described as a chronic disaster state.
“there’s no question: when we use naloxone to reverse patients, they can become very agitated and violent,” said lang, a professor of emergency medicine at the university of calgary.
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“they’re generally incoherent. it’s rare that they’re like that in the usual state. it’s just that in the withdrawal state, they’re thrashing, they’re throwing punches, they’re yelling and it can be very scary for the team, and it can be very disruptive,” including for other patients.
“that’s the nature of emergency care,” lang said. “you can have a case like this happening a metre, or a couple of metres away from a 95-year-old who has broken their hip. they’re in pain, they’re scared and now to have this nightmare scenario playing out just a few meters away.
“that can’t be good for anyone’s recovery.”
while opioid-related deaths have been trending downward since the height of the covid pandemic, toxic drug alerts have been issued in recent months in cities from fredericton to victoria. toronto paramedic services received 411 non-fatal suspected opioid overdose calls in february, compared to 171 calls in february 2025; the 387 calls in march were higher than the monthly average for all of 2025. an “increasingly toxic and unpredictable” drug supply recently prompted an alert from the windsor-essex health unit and an urgent meeting of dozens of community partners. saskatchewan’s health ministry issued an alert for regina following 140 overdose-related calls in the first three weeks of april, many involving cardiac arrest. in january, the bc centre for disease control issued a province-wide drug alert over an increase in non-fatal poisonings.
tests of street drug samples are turning up fentanyl containing medetomidine and xylazine, tranquilizers and sedatives from the world of veterinary medicine that, in humans, decrease blood pressure and heart rate and slow breathing. others contain valium or other “benzos” (benzodiazepines). some analyses show a mixture of fentanyl, medetomidine and benzos in the same sample.
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naloxone only works for opioids. it doesn’t treat or reverse the effects of other contaminants.
overdoses have become more complex, lang and other emergency physicians said. the toxicity of the contaminants can lead to significant changes in heart rhythms or heart rates, prolonged sedation and brain injuries. they also hang around in the bloodstream longer.
paramedics are finding people in deeper states of coma. “unfortunately, sometimes the amount of oxygen deprivation that occurs during these prolonged ingestions is fatal,” lang said.
unlike 30 years ago, when most cardiac arrest patients were people in their 60s and 70s who’d collapsed with chest pain, “many are now younger people whose hearts stopped because of opioid ingestion,” he said.
the intensity of the care necessarily means more resources — more equipment, more staff, more medications, more space in emergency departments that are already overcrowded and out of beds, with people often lying on floors.
“previously these patients wouldn’t require high levels of critical care and are now requiring admission to hospital or admission to icu for more intensive care for longer periods of time,” said dr. taryn lloyd, an emergency and addictions medicine doctor at toronto’s st. michael’s hospital.
“there’s no question: when we use naloxone to reverse patients, they can become very agitated and violent,” says dr. eddy lang.
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some people come in already agitated from naloxone and in withdrawal, sweating profusely, their heart beating too fast and in acute pain.
“it’s such a powerful addiction,” lang said. opioid users describe the high “as being so encompassing and so euphoric.
“they’re in this warm cloud of happiness that is just so addictive. they have to go back and back, even if it means they’re homeless, they’re involved in crime, they’ve alienated their families,” lang said.
“so, imagine, you’re in this state of warm cloudiness and suddenly you are abruptly and violently woken up by naloxone. any pain you may have been covering up with the opioid use is now heightened, and your whole body is aching.”
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the situation can move from someone barely breathing who can’t be roused “to now they’re thrashing, jumping up in bed and their arms flailing in a way that is really scary to see and can be very traumatizing to the staff,” lang said.
ers sometimes have separate areas used for mental health and addiction cases, rooms that are locked and secured, without windows or any items people can use to hurt themselves. but there’s a limit to those spaces “and only a few places in north america have taken the whole idea of keeping mental health and addiction patients separate from the general population,” lang said.
despite the concerns around opioid overdoses, lang said alcohol and crystal meth are likely bigger sources of violence than opioid overdose withdrawal. “when people get intoxicated with alcohol, it’s just a recipe for very bad decisions.”
the approach at st. michael’s is to prevent agitation from opioid withdrawal as much as possible. “five years ago, we would have gone with a different dosing strategy,” lloyd said. “now we go low and slow and take our time, anticipating that the patient may respond in a manner that’s unsafe.” like the emergency medicine journal article, they’re now spreading the word to other emergency providers.
the highest risk period for relapse and subsequent overdose is within the first 72 hours. of those discharged from an er alive, five to eight per cent will die within one year. but with too few addiction rehab or shelter beds, emergency doctors warn of a revolving door.
supervised drug consumption sites in alberta and ontario are being replaced by models based on addiction treatment and recovery. ottawa’s medical officer of health, dr. trevor arnason, last week warned the closure of the city’s two remaining consumption sites could lead to a quick rise in paramedic calls and er visits this summer, “based on what we have seen in other jurisdictions.”
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the evidence is mixed, however: a study by the canadian centre of recovery excellence (core), an alberta crown corporation, detected no statistically significant changes in er visits or suspected opioid-related calls to ems after a red deer safe consumption site closed in march 2025. more previous clients were started on methadone or other drugs to reduce cravings, and death rates were stable. however, the authors urged caution in interpreting the findings, given the rising prevalence of carfentanil, another potent animal tranquilizer, in the city’s street drug supply and the study’s limited (26 weeks) follow-up.
“no one wants to be an addict; nobody wants this life,” lang said. “but they’ve stumbled into this and now it’s like a ball and chain.” safe housing can be a catalyst for “transformational change,” he said.
“getting them into housing is the most effective way of breaking that bond between the addiction and the person.”
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