The soap bottle just missed his head.

Standing in the doorway of a cluttered Halifax apartment, Derek, a primary care paramedic, watched it smash against the wall.

Derek was there because the woman who threw it had called 911 again — she did so nearly every day. She said she had chest pain. But when she saw the green patch on his uniform, she erupted. Green meant he could not give her what she wanted: fentanyl.

She screamed at him to call “the red tags” — advanced care paramedics authorized to administer opioids. With none available, Derek declared the scene unsafe and left. Later that night, she called again. This time, a red-patched unit was available. She got her dose.

Derek says he was not angry at the woman, but at the system that left her trapped in addiction — and him powerless to help.

First responders across Canada say it is not overdoses that leave them feeling burned out — it is the endless cycle of calls they cannot meaningfully resolve. Understaffed, overburdened and dispatched into crises they are not equipped to fix, many feel morally and emotionally drained.

“We’re sending our first responders to try and manage what should otherwise be dealt with at structural and systemic levels,” said Nicholas Carleton, a University of Regina researcher who studies the mental health of public safety personnel.

Canadian Affairs agreed to use pseudonyms for the two frontline workers referenced in this story. Canadian Affairs also spoke with nine other first responders who agreed to speak only on background. All of these sources cited concerns about workplace retaliation for speaking out.

Moral injury

Canada’s opioid crisis is pushing frontline workers such as paramedics to the brink.

A 2024 study of 350 Quebec paramedics shows one in three have seriously considered suicide. Globally, ambulance workers have among the highest suicide rates of public service personnel.

Between 2017 and 2024, Canadian paramedics responded to nearly 240,000 suspected opioid overdoses. More than 50,000 of those were fatal.

Yet many paramedics say overdose calls are not the hardest part of the job.

“When they do come up, they’re pretty easy calls,” said Derek. Naloxone, a drug that reverses overdoses, is readily available. “I can actually fix the problem,” he said. “[It’s a] bit of instant gratification, honestly.”

What drains him are the calls they cannot fix: mental health crises, child neglect and abuse, homelessness.

“The ER has a [cardiac catheterization] lab that can do surgery in minutes to fix a heart attack. But there’s nowhere I can bring the mental health patients.

“So they call. And they call. And they call.”

Thomas, a primary care paramedic in Eastern Ontario, echoes that frustration.

“The ER isn’t a good place to treat addiction,” he said. “They need intensive, long-term psychological inpatient treatment and a healthy environment and support system — first responders cannot offer that.”

That powerlessness erodes trust. Paramedics say patients with addictions often become aggressive, or stop seeking help altogether.

“We have a terrible relationship with the people in our community struggling with addiction,” Thomas said. “They know they will sit in an ER bed for a few hours while being in withdrawals and then be discharged with a waitlist or no follow-up.”

Carleton, of the University of Regina, says that reviving people repeatedly without improvement decreases morale.

“You’re resuscitating someone time and time again,” said Carleton, who is also director of the Psychological Trauma and Stress Systems Lab, a federal unit dedicated to mental health research for public safety personnel. “That can lead to compassion fatigue … and moral injury.”

Katy Kamkar, a clinical psychologist focused on first responder mental health, says moral injury arises when workers are trapped in ethically impossible situations — saving a life while knowing that person will be back in the same state tomorrow.

“Burnout is … emotional exhaustion, depersonalization, and reduced personal accomplishment,” she said in an emailed statement. “High call volumes, lack of support or follow-up care for patients, and/or bureaucratic constraints … can increase the risk of reduced empathy, absenteeism and increased turnover.”

Kamkar says moral injury affects all branches of public safety, not just paramedics. Firefighters, who are often the first to arrive on the scene, face trauma from overdose deaths. Police report distress enforcing laws that criminalize suffering.

Understaffed and overburdened

Staffing shortages are another major stressor.

“First responders were amazing during the pandemic, but it also caused a lot of fatigue, and a lot of people left our business because of stress and violence,” said Marc-André Périard, vice president of the Paramedic Chiefs of Canada.

Nearly half of emergency medical services workers experience daily “Code Blacks,” where there are no ambulances available. Vacancy rates are climbing across emergency services. The federal government predicts paramedic shortages will persist over the coming decade, alongside moderate shortages of police and firefighters.

Unsafe work conditions are another concern. Responders enter chaotic scenes where bystanders — often fellow drug users — mistake them for police. Paramedics can face hostility from patients they just saved, says Périard.

“People are upset that they’ve been taken out of their high [when Naloxone is administered] and not realizing how close to dying they were,” he said.

Thomas says safety is undermined by vague, inconsistently enforced policies. And efforts to collect meaningful data can be hampered by a work culture that punishes reporting workplace dangers.

“If you report violence, it can come back to haunt you in performance reviews” he said.

Some hesitate to wait for police before entering volatile scenes, fearing delayed response times.

“[What] would help mitigate violence is to have management support their staff directly in … waiting for police before arriving at the scene, support paramedics in leaving an unsafe scene … and for police and the Crown to pursue cases of violence against health-care workers,” Thomas said.

“Right now, the onus is on us … [but once you enter], leaving a scene is considered patient abandonment,” he said.

Upstream solutions

Carleton says paramedics’ ability to refer patients to addiction and mental health referral networks varies widely based on their location. These networks rely on inconsistent local staffing, creating a patchwork system where people easily fall through the cracks.

“[Any] referral system butts up really quickly against the challenges our health-care system is facing,” he said. “Those infrastructures simply don’t exist at the size and scale that we need.”

Périard agrees. “There’s a lot of investment in safe injection sites, but not as much [resources] put into help[ing] these people deal with their addictions,” he said.

Until that changes, the cycle will continue.

On May 8, Alberta renewed a $1.5 million grant to support first responders’ mental health. Carleton welcomes the funding, but says it risks being futile without also addressing understaffing, excessive workloads and unsafe conditions.

“I applaud Alberta’s investment. But there need to be guardrails and protections in place, because some programs should be quickly dismissed as ineffective — but they aren’t always,” he said.

Carleton’s research found that fewer than 10 mental health programs marketed to Canadian governments — out of 300 in total — are backed up by evidence showing their effectiveness.

In his view, the answer is not complicated — but enormous.

“We’ve got to get way further upstream,” he said.

“We’re rapidly approaching more and more crisis-level challenges… with fewer and fewer [first responders], and we’re asking them to do more and more.”

This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.