Is this the future of Canada’s fight against opioids? Why the ‘Alberta model’ has some alarmed

It sounded like Alberta Premier Danielle Smith was delivering good news. 
Standing at a podium that read “Alberta Recovery Model,” she rhymed off a number of encouraging trends when it came to drug-related deaths in her province. Alcohol, down. Methamphetamines, down. Cocaine, down — to name a few. Death rates had declined dramatically for each of them, according to the premier.
“Over time, far fewer Albertans have lost their lives to addiction in our province, and many drugs have their lowest mortality rate on record,” she told the press conference in early April.
It sounded like her government’s effort to address addiction by prioritizing treatment over harm reduction was paying off.
There was, however, an omission in Smith’s list. She didn’t mention fentanyl, the highly potent synthetic opioid that has upended North America’s illicit drug supply, causing deaths to soar, including in Alberta.
Last year, fentanyl and other non-pharmaceutical opioids contributed to the deaths of nearly 90 per cent of the 2,059 Albertans who died from drug or alcohol poisoning, far more than any other substance.
“While opioid addiction continues to be a significant area of focus for our government, it is important to remember that addiction is much more than opioids,” Smith said. “The vast majority of people struggling with addiction are not using opioids.”
That’s true, but opioids are by the far the deadliest.
This spring marked the fifth year of Alberta’s ruling United Conservative Party’s ambitious yet so far unproven attempt to combat addiction by investing hundreds of millions of dollars in residential rehab and other treatment resources while curtailing — and sometimes condemning — certain harm-reduction strategies promoted by public health experts.
It’s a marquee piece of the Smith government’s platform, one inherited from former premier Jason Kenney. 
The “recovery-oriented” Alberta model, as it’s come to be known, appears premised on the notion that rising rates of addiction are driving the unprecedented death toll. The solution, according to Alberta: increase and streamline addiction services while eliminating barriers to them. To skeptics of safer supply and other harm reduction strategies, this is the answer.
But there’s a hitch. It’s not clear if addiction is climbing. In fact, federal research indicates rates of addiction across Canada have dipped in recent years, apart from marijuana use.
What has undeniably changed is the nature of the illicit drug supply.
Since the emergence of fentanyl roughly a decade ago, street drugs have become tainted by an unpredictable and toxic cocktail of ingredients, from fillers such as caffeine and sucrose to obscure sedatives that don’t respond to overdose-reversing medication.
“If we’re not going to address the fact that the drug supply is so toxic, so volatile, then we’re only going to be making a dent,” says Gillian Kolla, an assistant professor of public health at Memorial University.
What’s particularly troublesome to Kolla and other critics of Alberta’s plan is how it reinforces a common but false dichotomy between harm reduction, such as prescribed safer supply, and traditional treatment.
It’s made to seem, they say, as if one approach can only thrive at the expense of the other. But as nearly all the experts interviewed by the Star insist, both strategies, while imperfect, are desperately needed.
Yet, with harm reduction a near-constant lightning rod for critics and controversy, the Alberta model is gaining traction.
Conservative Leader Pierre Poilievre, who, according to polls, is poised to become Canada’s next prime minister, frequently pillories harm reduction, recently labelling decriminalization as a path to “misery and despair.” Rather than saving lives, he claims, without evidence, that safer supply only fuels the crisis. He recently promised to scale back supervised consumption sites under a Conservative government, dubbing the facilities, which have reversed tens of thousands of overdoses in Canada, “drug dens.” Instead, the Tory leader has firmly thrown his support behind Alberta’s “promising” model.
Here in Ontario, Premier Doug Ford requested the federal government pause approval of new safer supply programs in May. That came after his government froze approval of supervised consumption sites last fall, pending a review after a woman was fatally shot near one facility in Toronto. When asked by the Star if Ontario plans to replicate the Alberta model, the province refused to say. However, Ontario recently joined Alberta and Saskatchewan in announcing plans to “collaborate on building systems of care that focus on recovery.”
Even the province that pioneered harm reduction in Canada is pulling back. Calls from British Columbia’s recently retired chief coroner, as well as its top doctor, to significantly expand safer supply, including through a non-prescription model, have been flatly rejected. Meanwhile, the province has neutered its decriminalization project. (The federal government recently rejected Toronto’s own request for decriminalization.)
Much ink has been spilled over the topic, but the embrace of harm reduction in recent years has been relatively limited in scope.
In B.C., those enrolled in safer supply programs represent less than three per cent of British Columbians who use illicit drugs. And despite being caricatured as forgoing traditional treatment, B.C. actually funds over 60 per cent more treatment beds than Alberta, based on recent figures. However, it still saw a record number of fatal drug poisonings last year.
In short, the politics surrounding harm reduction have always dwarfed its policy footprint.
And right now, it seems to be shrinking further — even as some drug user advocates say harm reduction doesn’t go nearly far enough.
That’s left some questioning whether Canadian drug policy will soon be following Edmonton’s lead.
All in on recovery
To stop a deadly crisis, it seems reasonable to assume you must understand what’s killing people.
“We’re talking about an addiction crisis,” Dan Williams, Alberta’s minister of mental health and addictions, declared in an April interview with CBC.
The staggering number of deaths and frequent reports of drug use in some Canadian cities would seem to back this up.
However, all but one of the experts interviewed by the Star say he’s not quite right.
“The opioid crisis is clearly a drug-poisoning crisis,” explains David Hodgins, a psychology professor from the University of Calgary.
There exist differing opinions on what sparked the epidemic, which began out west around 2013. Some point to the rise of OxyContin and other painkillers in the 1990s and 2000s. But others blame years of drug prohibition, in addition to the way governments, doctors and Big Pharma cracked down on Oxy use, including through mass de-prescribing and product changes that ultimately led some users to the black market.
What resulted was the emergence of fentanyl, a decades-old painkiller used by cancer patients that’s up to 100 times stronger than morphine. Fentanyl’s cheapness helps explain its staying power, as well as the virtual disappearance of heroin. Within a few years, the market was flooded. “It was like drowning without ever being in water,” says Karen Ward, a longtime harm-reduction advocate from Vancouver’s Downtown Eastside. 
Since 2016, more than 40,000 Canadians have died from opioids — a new, devastating normal.
“The reality is that some individuals are addicted, and we need to be addressing that issue in addition,” Hodgins continues. “But it’s also really crucial that we’re recognizing and addressing the problems with the drug supply.”
That’s where critics say Alberta hasn’t done nearly enough.
Premier Smith’s chief of staff, Marshall Smith, a charismatic recovering user who previously worked in the treatment industry, is widely considered the architect of the Alberta model. At its core, it encourages people to cease their substance use and attempt recovery, a broad term for the process by which a person overcomes addiction. In comparison to harm reduction, elements of which Minister Williams has dubbed “harm production,” Alberta frames the recovery-focused path as “the responsible and compassionate thing to do.” This emphasis on abstinence, although far more focused, resembles the way governments approached substance use before fentanyl changed everything.
Alberta has eliminated the $40-a-day fee at publicly funded treatment facilities, added about 745 addiction treatment or detox beds to the public system and expanded drug treatment courts to offer non-violent offenders “judicially supervised treatment and recovery.” Police officers can now help those they just arrested seek treatment in jail. 
Across the province, the government’s building 11 long-term residential treatment centres known as recovery communities, including partnering with five Indigenous communities devastated by opioid deaths. So far, two have opened since Alberta began announcing plans to build these facilities in 2020.
“I think Alberta is doing a lot of things right,” says Vincent Lam, a Toronto-based author and addiction medicine doctor. He highlights efforts to reduce barriers to public treatment, a persistent issue across Canada, as well as the move to centralize the delivery of addiction services under ministry control. In particular, Lam commends Smith’s government for articulating a “shared mission” revolving around recovery and bringing people “back into participation in the community.”
Other experts see the situation differently.
Dr. Esther Tailfeathers, an Indigenous physician and former provincial public health official from southern Alberta, has tried for years to combat the fentanyl-fueled epidemic in her own community, where people die waiting for treatment at a staggering rate. Four years after being announced, little progress has been made on the recovery community slated to serve the Kainai First Nation. “There’s nothing. It’s an open field,” she tells the Star. 
“If they want to send them to treatment, where is the treatment? Because it’s unavailable, it’s basically selling people a Cadillac that’s not there.”
In an email in March, Hunter Baril, a spokesperson for the minister of mental health and addiction, said the facility is no longer a government-led project and has been changed to a “capital grant process.” In other words, the province is still putting up the money, but the First Nation is now tasked with building the facility. Although first promised to open in 2021, Baril said construction is expected to be done in 2025. He also highlighted millions of dollars the province is already putting towards detox, pre-treatment and related services on the Blood Tribe reserve.
It’s difficult to determine just how many Albertans have been helped by this turn to recovery or how many are currently waitlisted for treatment. The government has not released such data despite repeated calls to show its focus on recovery is succeeding. When the Star asked Alberta for evidence, the government pointed to an increase in treatment capacity and the drops in non-opioid fatalities.
“We recognize that the opioid addiction crisis continues to impact Alberta and other provinces, which is why we are taking an approach based on recovery,” said Baril.
Controversially, Alberta is also planning to introduce legislation that would enable family members, police officers and doctors to refer adults and youth to treatment against their will. Smith’s government has dubbed the concept “compassionate intervention.”
Critics, including Lam, say forcing people into treatment without consent is not only ineffective but violates a person’s right to refuse medical care. “It is an entirely misplaced priority to think that forcing people to receive treatment will be the key to solving our problems,” Lam says.
Even when a person wants to stop using drugs, it’s hard to sustain abstinence, particularly among those dependent on opioids. But access to supervised consumption sites and safer supply can improve a person’s chances of recovery by helping to stabilize their lives and keep them alive, according to several experts. Fundamentally, though, what works for one person might not help another, necessitating a range of treatment options.
“The most common pathway to recovery is really people who are doing it without any formal help,” says Hodgins, who still supports Alberta’s push to expand access to treatment.
Meanwhile, people who are trying drugs for the first time or use them infrequently aren’t addicted so they wouldn’t be likely candidates for treatment. But because of the reality of the drug supply, they’re still at risk of dying. 
Ben Perrin, a criminal law professor at UBC, was once a staunch defender of the war on drugs. After serving as a criminal justice adviser to Prime Minister Stephen Harper, he left government as fentanyl was beginning to saturate the black market. It forced a reckoning.
“Essentially, everything I thought I knew about drug policy turned out to be wrong,” says Perrin, the author of 2020 book “Overdose: Heartbreak and Hope in Canada’s Opioid Crisis.”
He says now he believes there are four main pillars needed to confront what he calls an unregulated drug crisis: supervised consumption sites, safer supply, decriminalization and rapid access to evidence-based treatment.
Perrin says no government in Canada, provincial or federal, is getting it right. And in the case of Alberta, he only sees an interest in treatment. “It’s giving them only one way to stay alive, and it’s for them to stop using.”
It’s true Alberta has embraced some less controversial forms of harm reduction. The distribution of life-saving naloxone has increased in recent years. And far more Albertans now receive free medications known as opioid agonist therapies (OAT), such as methadone, that reduce withdrawal symptoms and cravings, including in prison.
Still, harm reduction strategies that Perrin and other experts stress are crucial have been neglected or eliminated entirely. Since the UCP came to power in 2019, evidence supporting supervised consumption sites has grown. However, these services have been scaled back, including through the closure of what was once Canada’s busiest supervised consumption site.
Lam calls wariness toward these facilities a mistake.
The Smith government has also effectively banned safer supply, which provides people most at risk of overdosing prescribed alternatives to tainted drugs bought on the street. In addition, Alberta has severely restricted access to an injectable form of OAT similar to safer supply that many had credited with saving their lives.
According to the Alberta government, fewer than 100 people now receive a regulated opioid called hydromorphone, the most common form of safer supply. However, unlike those programs — which typically allow patients to take their prescriptions home, saving them from making several visits each day — patients in Alberta must consume the medication under supervision at a handful of clinics around the province and only with the expectation they will soon transition to less potent opioids, such as methadone, even if they haven’t had success with them previously. 
Lam believes Alberta has struck the right balance. Moreover, he thinks the evidence behind safer supply isn’t very convincing and that any benefits would be marginal.
Lam’s one of many skeptics in the addiction medicine community who fear safer supply is fuelling new addictions. By not requiring patients to consume their prescription on site, some may sell or trade pills on the black market in order to secure the far more potent albeit deadly fentanyl. Critics worry naive youth could get their hands on the diverted safer supply and later move onto fentanyl.
Indeed, diversion does happen. But despite anecdotal reports and a marked rise in the seizure of drugs used in safer supply programs, the extent of the problem is not quite clear.
The B.C. government and provincial RCMP have both said there’s no evidence of widespread diversion. However, police in London recently raised alarm bells after seeing a massive local increase in trafficked hydromorphone, much of which the force says it has traced back to safer supply. (The city’s largest safer supply program is cooperating with police to crack down on this behaviour.)
What are the repercussions of such diversion? That’s also difficult to say. Currently, drug poisoning data indicate that safer supply isn’t directly exacerbating drug-related deaths. Last year, hydromorphone and other pharmaceutical opioids were only present in roughly two per cent of Albertans who died from drug poisoning. 
While safer supply is still being studied, research published this year in the British Medical Journal suggests giving people already dependent on opioids a regulated, take-home supply of drugs significantly reduces the likelihood of death. Other recent research shows notable decreases in emergency room visits, hospitalizations and health care costs among participants.
Although Alberta plans to establish a Crown corporation tasked with studying “evidence-based best practices,” Minister Williams in Alberta has already ruled out considering safer supply.
“The evidence base has come a long way, and it doesn’t seem like the political rhetoric has kept up,” says Kolla, who emphasized how new safer supply is.
Still, multiple experts in favour of safer supply agree diversion shouldn’t be ignored, including Kolla. She and other researchers are already studying ways to address it. But she doesn’t have faith any careful research will convince critics.
“We are in a moral panic,” says Kolla, who recently co-published an essay on this topic in the International Journal of Drug Policy. Similar backlash happened before when methadone, which she describes as a predecessor of safer supply, was rolled out in the 1960s.
“There’s just something about drug use … that makes it very, very difficult for us to have really nuanced policy discussions,” she says. Instead, many favour sensationalism, in her view, choosing ideology over evidence.
But that doesn’t change the fact that people will continue to use drugs.
“They’re dealing with pain, they’re dealing with trauma,” she continues. “These drugs make people feel good. So unless we actually deal with that reality, we’re not going to get anywhere.”
With files from Alex Boyd
This article was edited from a previous version that mistakenly referred to Gillian Kolla as an associate professor of public health at Memorial University.