Q&A, Part 2: 'Our fatal overdose numbers have gone down dramatically off the peak.'
Alberta is pursuing a very different path toward treatment of drug addiction. In this interview, a top provincial official explains why, and what kind of help Ottawa can offer.
This is the second part of a two-part interview with Marshall Smith, chief of staff to Alberta premier Danielle Smith, and himself a recovering drug addict. Please find part one of this interview here. What follows has been edited for length and clarity.
Jen Gerson: Is safe supply off the table in Alberta or is that something that the province may consider offering in certain circumstances?
Marshall Smith: No, safe supply is off the table … We have regulated the provision of full agonist opioids to people who have a substance use disorder.
JG: We do provide methadone, for example.
MS: That’s different. That’s different. We have a schedule of opioids, the bad ones, and we have said that no person in Alberta may provide, prescribe or dispense any of these scheduled opioids to a person that they know is addicted to them.
That is in contrast to British Columbia where their express goal is literally to hand it out. Their goal in British Columbia is to replace the illicit drug supply with a pharmaceutical drug supply. They want these things flooded onto the streets. They will say [that’s not the case]. I have documentation that proves otherwise.
We take a much more measured, data-driven and evidence-based approach to this.
The term “safe supply” is not a medical term. It’s a marketing term. Like clean coal. It doesn’t appear anywhere in medical evidence. It’s a term that was created in a boardroom with drug-user groups and communications professionals to market policy. If you strip away the marketing term of “safe supply” you’re left with what it actually is. And what it actually is, is the wide-scale distribution of opioids to the population.
Now, Alberta recognizes that there is very likely a population of addicts who have been heroin addicts for 20-30 years or they’re very seriously addicted. We don’t expect them to just recover. That’s not reasonable. And that they may require the provision of hydromorph or a list of these drugs that they may require that for a period of time before they’re able to transition. What we’ve done is we have adopted the Swiss model in Alberta and we have clinics that we call Narcotics Transition Services. So, not safe supply. Narcotics Transition Services.
And not anybody can do this. If you’re a doctor in a strip mall and you believe that you have a patient in front of you for which nothing is working, you have to refer them to the specialty clinic just like any other area of medicine. This is a highly specialized area of medicine. It requires a specialty doctor and a specialty clinic.
JG: Is it an inpatient clinic?
MS: No, it’s an outpatient clinic. We’ve created eight of these clinics in Alberta called Narcotics Transition Services. When you get there they assess you, they provide wraparound supports. They will give you the hydromorph, but it’s a witnessed dose. You have to take the dose in front of someone, so there’s no opportunity to divert the drugs into the community. And then they actually work with the patient to bring them along. They monitor them. They come in every day to do that.
JG: In an environment where you have your illicit opioid supply being routinely adulterated by fentanyl or other types of toxins or potentially lethal adulterants, is there not there an argument for a pharmaceutical alternative that is not going to poison people?
MS: What we’ve done in Alberta is we’ve examined actual evidence. The international evidence which we weigh a lot heavier here in our model than locally British Columbia-driven evidence.
And so what the strong evidence tells us from years of harms relating to the oxycontin crisis is when you allow ambulatory prescriptions of opioids to flow freely into the community, that extreme harms come to the population. I am not necessarily concerned that a heroin addict takes a tab of morphine. That is not the public-health concern with safe supply.
The concern with safe supply — and the problem with the literature that’s being generated by the people who are running the safe supply programs — is that none of the things that they’re measuring examine harms beyond the harms done to the addict that they’re studying.
The big problem with safe supply is the diversion of these drugs into the broader population. For example, if you live in a home where one person in that home has an opioid prescription, everybody in that house is five times more likely to develop a substance use disorder. We know without a shadow of a doubt that the more opioids you put into a population, the more harm comes of it. Full stop.
We also know that addicts who are going to collect safe supply drugs more often than not leave the clinic and sell the drugs or divert them for other purposes.
And the reason for that is that in an addict’s perspective fentanyl is not poison. Fentanyl is the good stuff. They ask for fentanyl. They want fentanyl.
What they’ve done is they’ve created a market commodity. Give addicts bottles of morphine and they take to the street and they sell it and either get cash and buy fentanyl, or they take the bottles of morphine to the dealer and they trade them for fentanyl.
In my day when I was on the street a tab of morphine cost about $20 for one tablet. Today on the streets of Vancouver you can pick up a tab of morphine for $1. That’s how much of it is on the street. That’s how much flooding of the market they’ve done.
By the way, that dollar that they sell the pill for is less than it costs the government to dispense it. The government is paying a premium to dole this stuff out into the street. They’ve put so much on the street that the cost of it has gone below what it cost them to dispense it: The dealers collect it up in duffel bags and just take it to a different jurisdiction and sell it and make 20X their profit.
They’ll take these pills to places like university campuses, high school campuses, et cetera.
JG: So, essentially what we have here is a natural experiment playing out in Alberta and B.C., roughly the same size provinces, different demographic realities, different socioeconomic realties, but it’s an interesting natural experiment and obviously the proof is in the pudding. Can you talk a little bit about the success, from your perspective, that you’ve seen as a result of Alberta’s approach. I’m talking about mortality rates, overdose rates, those sorts of things.
MS: I think that it’s early days. We’re three-and-a-half years into an eight-year strategy so we’re halfway through and we’re just now getting around to our urban strategies. We’ve been doing a lot of work in our midsize communities building treatment centres and whatnot. We are also opening 11 brand new recovery communities which are large, long-term treatment facilities. They’re about the size of a football field. We’re opening the first one in Red Deer.
The treatment spaces that we have in Alberta are fully funded and accessible. In Alberta if you want to go to treatment all you have to do is swipe your care card. There’s no paying out of pocket. You see a lot of this in B.C. and Ontario where families are confronted with wracking up $30,000 bills to send their loved one to treatment. That’s not acceptable to us. That’s not what a health-care system should look like.
JG: How many beds are there just off the top?
MS: We have about 1,300 beds and with the 11 recovery communities that we’re building we’ll be doubling that. Really this isn’t rocket science. The people who are out there on the streets who are very sick they need health care, they need treatment, they need to get into recovery. And when there are no treatment beds available for them to go into, that backs up the system in detox and when there are no detox beds that backs up into the shelter system. And then if they don’t want to go to shelter or there’s no shelter capacity available they wind up tenting on the streets.
JG: I just want to get a straightforward answer on this one and that is what have we seen in terms of overdose and fatality rates in Alberta compared to B.C.?
MS: Our fatal overdose numbers have gone down dramatically off the peak, at the height of our fatalities which occurred sort of mid-pandemic last November.
JG: Is there any comparable data coming out of B.C?
MS: Well, B.C. releases their data monthly so if I go to new tab and I go to B.C., opioid deaths, October 2022 … They had 179 deaths compared to our 92.
Now nobody here for a moment is saying good job. There are still 92 people that died in August which is still way too high. The point of what I’m putting on the table is that Alberta’s numbers are going down. B.C.’s are continuing to go up despite the fact that it’s the same drug supply, it’s the same sort of circumstances.
B.C. and Alberta have experienced COVID. We’ve come out of it in the same way. The things that are different is when we’ve been very busy over the last three years while the rest of the world was doing pandemic, mental health and addiction and our government have been busy retooling our addiction care system. As people come back now that the pandemic is waning, they are coming back to a very different system of care than the one that they left when they walked themselves out.
JG: The person who is skeptical of your approach and is an advocate of B.C.’s approach might say these aren’t apples to apples comparisons. By adopting different philosophical approaches, what you’re doing is ensuring that the most chronic addicts are going to be incentivized to go to British Columbia. A, because the weather is milder, so if you’re going to be sleeping rough, you’re going to have an easier time of it. And, B, because if you have a safe supply jurisdiction right next to a non-safe supply jurisdiction, people are going to go to B.C. So, of course the numbers are going to be higher in B.C., of course you’re going to see more overdose deaths, of course you’re going to see more tent cities in B.C. because you’ve created a situation where the Alberta addicts who become chronic or who otherwise would have struggled into this system are just getting sucked into the next one.
MS: I would say that there’s no evidence of that, and I would say that if you think that I would welcome you to join me on a walk through Edmonton’s downtown and I will show you that we have a population of addicts there that are every bit as severe as British Columbia.
Look, there’s always going to be a conversation about the fact that Victoria has better weather than Edmonton. And I am frequently perplexed as somebody who has lived on the streets, I’m frequently perplexed by how somebody can tent in minus-35 weather, but there they are right out my window. I don’t know how to respond to that other than to say that I would challenge anybody to put evidence in front of me that that’s what’s happening because I’m not sure that that is provable.
JG: It would be interesting to me if B.C. could track how many of their addicts are local versus coming from the rest of Canada, and whether or not that’s changed over time.
MS: B.C. can’t even track how many treatment beds they have. It is so chaotic out there the things that they’re able to track, good luck.
JG: Bringing this conversation back full circle I initially got interested in this conversation as a result of Pierre Poilievre’s video. Obviously, as I mentioned Pierre Poilievre’s approach and video got heavily criticized. What would you like to see a federal government, Conservative or Liberal, what would you like to see a federal government be doing differently in its approach to mental health and addiction.
MS: Sure. I guess at a 30,000-foot level I would say that we would like the federal government to respect the direction that a province wanted to go in and work with those provinces to further that. Now, that doesn’t necessarily bode well for my fellows in British Columbia, but it sure would be nice to have the federal government respect the fact that Albertans want to go in a different direction than British Columbia, and be supportive of that.
JG: That means that if Pierre Poilievre becomes prime minister that would entail a Conservative government respecting B.C.’s safe supply.
MS: Look, part of the problem is that the only money that the federal government is handing out right now is money for safe supply programs. In the absence of any other options provinces are grabbing for the money that is there and getting on that bandwagon. We have not. I can tell you that as chief of staff to the minister for mental health and addiction and now chief of staff to the premier, being in these offices for the last three-and-a-half years since 2019, I have not ever received a single phone call from Health Canada. Not once has the federal minister’s office ever reached out for a conversation. Now, we’ve met with her once when she came to town. It was very brief. But as a regular workaday thing my phone has never rung from them to ask how they could be of assistance.
JG: It seems like you’ve had more conversations with contemporaries in the United States than you’ve had with Health Canada.
MS: And other provinces. We talk on a very regular basis with Manitoba and Saskatchewan and Michael Tibollo in Ontario. He’s lovely. We have conversations amongst our colleagues and when we do that, when we get together and talk about these issues everybody is shaking their head going this is crazy. What is going on. And a lot of other provinces are looking at Alberta and wanting to follow those things. You should phone Manitoba and ask them about the degree to which they’re pursuing the Alberta model.
JG: What specific support could the federal government provide?
MS: Look, I think the type of support they could provide is capital. One-time capital money to help us build treatment centres. Certainly you want to have the provincial government provide the operating money. That’s a health delivery, that’s our responsibility. But instead of providing grants to activist organizations they should be providing grant money to provinces to help build the infrastructure that we need for our care system in the province.
That would go a long way. We need beds. We’ve got decay happening in our urban cities. This is not just Vancouver or in the case of British Columbia this is going on in Kelowna and Kamloops and Prince George and Victoria. It’s spreading all over the place. It’s happening in Edmonton and Calgary. It’s happening in Winnipeg. It’s happening in Saskatoon and this is ripping right across the country.
We have people in LRT and transit stations across the country who are afraid to ride transit, who won’t send their kids on the public system because of the dangers of people who are addicted to meth or who are in psychosis attacking them or things like that. So, we’re in trouble and we have to get very, very serious about building a system for the future if we are to have a hope of having communities that are livable. My fear is that what is coming from British Columbia or others is just more of the same and it does not seem to be working.
I mean 20 years ago they were doing this, starting this process. Here we are 20 years later and everything is markedly worse. What they’re doing just simply isn’t working and so I think we would be negligent not to pause and say whatever else is true about individual things that are going on, as a system this isn’t getting us the results that we’re looking for and we’ve got to start charting a new course. And that’s what we’re doing in Alberta.
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