Killing Season was written by Peter Canning and published in 2021 by Johns Hopkins University Press. Peter is a paramedic in Hartford, Connecticut, USA with 25 years of experience under him. When he began his career, he saw people who had overdosed on drugs as only victims of their own character flaws; ‘he took care of them (in the back of the ambulance) but didn't care for them’. This book documents Peter's journey as a frontline paramedic in a city besieged with opioid overdoses, with overdose numbers and deaths rising daily.
In the book, as we ride along with Peter in the ambulance, he introduces us to several characters with opioid dependence. Peter describes how the 911 calls come in and we become very familiar with locations in the book that are frequent hot spots for drug use in the city of Hartford. As overdose numbers are increasing, and Peter is seeing some of the same familiar faces overdosing, he starts looking at the epidemic with a different mindset. Instead of dismissing drug users as ‘junkies’, he asks them about their history and how they ended up in the back of the ambulance after being resuscitated by paramedics and fire crews. In this book, we see the human behind the overdose, the somebody's somebody.
In the majority of cases, the people Peter meets started out on pain medication from their doctor for an injury. A steel worker with a back injury, a car crash victim, a war veteran. Patients were often prescribed strong opioid pain relief from their doctor. In many cases, doctors were given bonus packages from drug companies for writing scripts for strong opioid pain medication. Very quickly, people became dependent. This situation continued until scripts ran out and many patients were unable to obtain medication. If people who have an opioid addiction are unable to access more, they go into withdrawal. Symptoms include severe pain, sweating, vomiting, insomnia and anxiety. To stave off these symptoms and prevent themselves from becoming ‘dope sick’, many people turn to the streets.
Throughout this book, we follow the journeys of people that Peter meets on 911 overdose calls. No two stories are the same and, in many cases, we meet their families. Some have been completely cut off from their families, many have left abusive homes and relationships, some have had their parental rights terminated, and a small few are loved and supported by their families through their addiction.
During his time as a paramedic, Peter has educated himself on the science of addiction and how harm reduction strategies have been shown to be far more effective than the ‘war on drugs’ stance that was implemented in the 1970s. Peter has fought hard to reduce the stigmatisation and marginalisation that drug users face on a daily basis.
In chapter 18, entited ‘Age’, we are introduced to some new characters. The first is a 62-year-old woman with arthritic knees who has overdosed in a public toilet. When she could no longer afford to see her doctor for pain relief, the maintenance man in her apartment block offered to sell her Percocet (oxycodone and paracetamol), and then eventually heroin, which she snorted. The morning Peter met her, she had overdosed on what Peter suspected to be heroin cut with the much more potent, synthetic opioid fentanyl. This chapter shows that opioid use and dependence isn't just affecting (and killing) young people. He makes it clear that opioid addiction occurs in all age groups. Peter believes that opioid-related overdoses and deaths are significantly underestimated—particularly in the older populations.
One of the main focuses of this extremely well researched book is around harm reduction methods such as education, needle exchange, supervised injection and drug testing. These are far more effective at supporting people into treatment and long-term recovery than the message of ‘just say no to drugs’.
Chapter 23 discusses safe injection sites. Safe injection facilities (SIF) are where people who use opioids are able to inject (and snort/smoke) in a clean and safe environment and under the care of medical professionals.
In this chapter, Peter presents, Insite. This is a government-run safe injection site in Vancouver, Canada which opened in 2003. Here, people can access non-judgemental support and be supervised while using drugs. They can also exchange used needles for sterile ones, as well as access alcohol wipes, sterile water, clean cookers and new tourniquets. Peter described a study published in The Lancet in 2016 that presented overdose data before and after the opening of the Insite facility. In the 2 years after the opening, overdose rates across Vancouver had fallen by 35% and, in the time the facility has been in operation, there have been over 6440 overdoses and not one death. In a novel approach, directly above Insite, is Onsite. A 12-bed medical detox facility where people who feel ready to begin recovery can access inpatient support.
I found this chapter fascinating as Peter presents a number of studies, including a cost-benefit analysis published in the Harm Reduction Journal. This study looked at the estabnlishment of am SIF in Baltimore, Maryland, USA, where an investment into a safe injection facility costing $1.8 million, would save over $7.8 million in costs associated with opioid use and overdose. Six different areas of benefit were analysed:
Unfortunately, public perception of safe injection sites is not a popular one. However, safe injection sites have been shown to reduce drug-related litter (thus reducing accidental exposure to children), and helping prevent overdose and death in public places. It was disappointing to see in July 2021 that planning permission for Ireland's first supervised injection facility was deemed invalid (MacNamee, 2021).
In the book, Peter discusses and encourages people to be able to freely access their own supply of naloxone and be educated in how and when to use it. Some will argue that giving drug users naloxone will only encourage more overdoses; however, as Peter rightly counter-argues, ‘dead drug users don't recover’.
This book has helped me change my own thoughts on drug use and has helped me to better understand the science of addiction. Addiction is a disease just like any other and people deserve compassion and care. In serendipitous timing, while reading this book, I attended a 999 call at Limerick Drug and Alcohol Services, a drug and alcohol outreach centre that I never knew existed. I've been given an opportunity to shadow the social inclusion team of doctors, nurses, healthcare assistants and administrative staff to see the work they do and learn more about addiction services offered. This facility is run by the Health Service Executive (HSE). I am very much looking forward to learning about outreach programmes such as Take Home Naloxone and other support and rehabilitative services (HSE, 2021)
I highly recommend this book to anyone wanting to improve their understanding of addiction and drug use and how best to support people we meet with an addiction. This book has encouraged me to explore paramedic involvement in harm reduction as part of my BSc in Paramedic Studies at the University of Limerick and how paramedics can be a driving force for change in how the epidemic of addiction can be better managed.