Nine ambulances, lights and sirens blaring, raced north on Hastings Street toward St. Paul’s, Vancouver’s downtown hospital, in a three-hour stretch one afternoon last month. “Every time you hear a siren, you know someone’s gone down,” said Ronda Mountain, a 35-year resident of Vancouver’s Downtown Eastside.

This neighbourhood is the epicentre of Canada’s devastating opioid crisis. “Narcan kit behind counter,” read chalkboard signs outside local businesses, advertising the life-saving medication used to block the effects of opioids in cases of overdoses. “We are naloxone certified,” said another. Paper signs like these are taped to apartment doors. Some residents carry pocket-sized, black Narcan (a brand name for naloxone) kits clipped to their backpacks, visible thanks to the bright red cross emblazoned across the front. Last month, bus drivers were trained to inject the medication.

In 1993, Vancouver’s heroin crisis galvanized the city, and forever changed drug policy in the country, ushering in harm reduction— a new approach to addiction—and eventually, federal approval for supervised injection sites. During that crisis, one person per day was dying from an overdose in B.C. Last month, the average hit four deaths per day in the province, up more than 70 per cent from this time last year. Fentanyl (far more powerful than heroin) was blamed in more than 60 per cent of cases. With city morgues filled to capacity, authorities have been forced to lease space from funeral homes to store the bodies that keep piling up.

“We can’t even grieve,” said Laura Shaever, who has lost multiple friends to fentanyl. “It’s just death, death, death—day in, day out.”

A 50-year-old labourer named Starr (who asked that only his first name be used) is one of an army of locals who have been patrolling the neighbourhood, carrying Narcan kits, ready to assist overdose victims. Every night, he heads into the dark as soon as he finishes work. He’s a recovering cocaine addict; he stopped cold turkey one night 20 years ago after his best friend died in his arms from an overdose. That memory keeps him out there, helping those he can. So far, Starr has revived 34 people using naloxone, he says. But he’s lost two.

The death of a “little girl, no more than 20,” haunts him, he said, his eyes filling with tears. He found her squatting on an Eastside sidewalk one night this fall, battered by cold rains that fell in sheets. It so upset him that he briefly quit his patrols. But after 10 nights at home, Starr decided he had to go out again. His first night back on the beat he saved three people from overdosing.

When a person goes into overdose, their body can “forget” to keep breathing, said a thirtysomething community nurse dressed in green jeans and combat boots; “that’s why it’s so important to give them breaths,” she said. She was running a standing-room-only Narcan training session in the lobby at VANDU, the Vancouver Area Network of Drug Users, one afternoon. Forty people followed her instructions, practising filling a syringe and injecting it into an orange.

Steve Herbrik, a silver-haired retiree from Port Coquitlam, a suburb east of Vancouver, had driven into the city for the training. Growing up, his dad, an alcoholic, had managed the Safari, a Hastings Street cafe. Herbrik, a former mail carrier, remembers him being carted from their home on a stretcher one night, after drinking too much. “Help me, Steve,” was the last thing he said. “I see my dad’s face in all these people,” Herbrik said.

A single shot of naloxone used to be enough to revive an overdose victim. Then came carfentanyl, fentanyl’s more lethal sister medication. It can take as many as 10 shots to revive someone who has injected carfentanyl, the nurse said. They have stopped advising compressions because of it: “With carfentanyl, the body goes so rigid that we kept breaking ribs trying to do compressions,” said Starr.

To the north, a pop-up, safe injection site has opened up in a white tent in the alley behind Pigeon Park Savings. It is the initiative of Sarah Blyth, former commissioner of the Vancouver Park Board, and Ann Livingston, who founded the Downtown Eastside Street Market, which operates on the property. “We weren’t going to stand by and watch people die in the alley,” Livingston, a veteran Downtown Eastside activist, explained with a shrug. She’s had to fight off the police department to keep the tent—a sale item at Canadian Tire—running. Inside, three men and a woman, all of them white, clean-cut, and in their twenties and thirties, were injecting themselves with drugs.

In the street beyond the tent, a buzz was building. Cheque day, or “Welfare Wednesday,” was just two days away. In the hours ahead, dealers would begin fronting drugs, says Jesse, a baby-faced 22-year-old from Montreal who is addicted to heroin. He’s overdosed twice since arriving in Vancouver a few weeks ago, most recently on carfentanyl. In all, he’s lost 12 acquaintances to fentanyl; two were his closest friends. They died in front of him. He believes he’s going to die this way, too.