Marshall Smith joins Charles Fain Lehman to discuss Alberta, Canada’s innovative, recovery-focused approach to the drug addiction crisis.
Audio Transcript
Charles Fain Lehman: Welcome to 10 Blocks. I am Charles Fain Lehman, a fellow at the Manhattan Institute and a contributing editor of City Journal.
Last year, over a hundred thousand Americans died by drug overdose, driven by the spread of deadly new synthetic drugs. That hundred thousand death figure represents more than 30 out of every hundred thousand Americans, an unprecedented crisis. What listeners may not know is that America's not the only nation struggling with drug overdose death. To our north in Canada, there is a similar and rapidly growing problem. In 2022, nearly 20 in every hundred thousand Canadians died by drug overdose, thanks, similarly, to the spread of potent synthetic drugs like fentanyl and methamphetamine. My guest today is one of the men trying to tackle that crisis. Marshall Smith is the outgoing chief of staff to Alberta Premier Danielle Smith, no relation. In that role, he architected a pioneering strategy for addressing addiction and drug overdose death. The Alberta Model, as it's being called, has attracted attention around the world among nations struggling with addiction. Marshall, welcome to 10 Blocks.
Marshall Smith: It's good to see you, Charles. Thanks so much for having me.
Charles Fain Lehman: Absolutely. Before we talk a little bit about your work, I want to frame the conversation by asking you to tell me a little bit how you got into dealing with addiction, substance use recovery, the whole space.
Marshall Smith: Sure. Well, look, I'm a person in long-term recovery from addiction of 18 years. And before I was chief of staff to the Premier of Alberta, I had a fairly lengthy career in government. I started my career as a correctional officer out of high school. I grew up in Los Angeles, moved back to Canada, became a correctional officer, and had a great career in law enforcement until I was in my mid-twenties. I had my first political role under then Premier Gordon Campbell in 2001 in British Columbia.
I was alcoholic all through my teens. I was a pretty accomplished drinker, as they say. And one night around 2002, tried cocaine for the first time, and that led me on a very dark spiral, which saw me give up my suit and tie and office at the legislative buildings and vanish into the streets of Vancouver's notorious Downtown Eastside where I lived as a homeless drug addict for about four and a half years. I was given a choice to clean up and go to treatment, or face jail, by the police. I chose treatment and I've never looked back. And today, 18 years later, I find myself in the role of chief of staff to the Premier of Alberta. And that certainly was not an easy journey back from living in alleyways and eating out of garbage cans to where I am today and most recently. So that's a bit of my personal journey.
Charles Fain Lehman: And how did you find yourself working on substance use and addiction in Alberta? And I wonder actually, as part of that, as I alluded to earlier, I think a lot of your American listeners may not parse that Canada is dealing with many of the same problems as the United States. So can you talk a little bit about the drug problem that Canada and Western Canada in particular are currently dealing with?
Marshall Smith: So I would say about 15 years ago, calling on my experience, in government running institutions, as an addict on the streets and navigating that system, I've sort of recommitted to myself to fixing the system, and I architected a strategy which was then called Strategies to Strengthen Recovery in British Columbia, which the government of British Columbia was not interested in. And today, that strategy is now known as the Alberta Model. Alberta and Canada definitely is struggling very much like jurisdictions throughout the United States. We have a very serious overdose crisis in some jurisdictions in Canada, like British Columbia to our west. Six British Columbians a day are dying of fatal overdose. And Alberta had a very serious problem as well. So political leaders and policy leaders were struggling and are struggling to find a way to navigate this. And that's what brings me to this role.
Charles Fain Lehman: And I wonder if you could talk a little bit about the different strategies in British Columbia and Alberta, and we'll get into the Alberta Model a little bit, but part of what's interesting is you're coming from British Columbia into Alberta. The British Columbia model is very different from I think what Alberta has pursued, what a lot of U.S. jurisdictions have pursued, but increasingly looks like what at least some places in the U.S. are trying. So can you tell me about what they were trying, to some extent are still trying in B.C.
Marshall Smith: Right. So the harm reduction model or the British Columbia model is very much anchored in a social libertarian view, that people who have substance use disorders or addiction are victims of a poisoned world and that they really are victims of that. They're victims of racism, they're victims of colonialism, they're victims of capitalism and oppression, and that they use drugs to soothe the ills that the world has put upon them and that they have been traumatized. And while certainly trauma is something a lot of people experience and I don't want to diminish that, the reality is is that we know through medical evidence that addiction is a chronic neurobiological brain disease, right? It's a medical problem and it's a problem for which there is highly successful treatment and that recovery should be expected.
And so, I would say about 15 years ago, British Columbia took off on this experiment really, where they believed that if we could just supervise people while they used, or we could make them comfortable, or we could give them substitute drugs, or we could do all of those things, that people would sort of naturally choose on their own time, in their own space, to use responsibly, etc. Of course, all of those things negate everything that we know about the nature of addiction, which is that it's a progressive illness and that people lose the ability to control the amount that they use.
So British Columbia has been engaged in this for quite a long time, and they have gotten progressively more ridiculous about the policies that they are putting forward. Most recently, the latest thing that they're doing is this policy called Safe Supply, where the government is actively widely distributing high-potency opioids to as many people as they can with as few restrictions as they can, what could go wrong? And we're seeing really, really tragic results as a result of that. In contrast, Alberta on the other side of the Rockies, is taking a very different view. We're taking the view that addiction is a chronic healthcare problem. It can be treated and recovery should be expected of the people who are entering that. We should expect that. And that government's role is to provide programs and services that help people get off drugs, get their life back in order and return to the community as a positive, engaged citizen. And we're having great success in doing that.
Charles Fain Lehman: Yeah. Part of why I find the Alberta recovery model interesting is that it sort of breaks out of the two dominant paradigms where on the one hand you have the BC model, which in many senses has been under the Trudeau government nationalized for safer supply. BC drug possession was largely decriminalized. They've sort of rolled it back, but that's still kind of the policy. BC has a supervised consumption site. So that's one model. And then another model, particularly here in the States, is this sort of aggressive law enforcement forward approach that says we need to treat drug use and drug possession predominantly as an issue for the courts and criminal justice system. And so what's interesting to me about the Alberta Model is that it's not really trying to do either of those. It's trying to do a third thing. I wonder if you could, can you talk through what that third thing looks like, what the components of the policy are and the components of the approach?
Marshall Smith: Well, let me just say in general, we love people who are in addiction. We want to take a very compassionate approach to what they're going through. That doesn't mean that we're pushovers. It doesn't mean that we aren't going to set good boundaries. It doesn't mean that we're going to give them the drugs to use. In fact, just the opposite. We don't believe that those are compassionate things to do. We don't believe that that's the way you treat people that you love. We don't believe that that's the way you treat people that are your neighbors, your family members, your sisters, your brothers, your co-workers. We believe that sometimes friends and loved ones have to have difficult conversations with each other.
And so at a policy level, we say that as a community, we're going to set boundaries and clear expectations for ourselves. We are going to make the investments into dramatic system transformation. We're going to make treatment widely available and free of charge. We're going to make opioid substitutions like Suboxone and Sublocade available on demand with no charge and no wait list. We're going to get into schools. We're going to do early intervention and prevention. We're going to get into our correctional centers and we're going to refurbish many of those units to have treatment centers inside of jails. We're going to enlist the support of our police to give them tools so that when they engage people on the streets who are in addiction, they have more than just handcuffs to help this out. We are going to take medications like Sublocade, which is the injectable version that lasts for 30 days, we're going to make that free. It's a thousand dollars per injection.
We're going to invest in our indigenous populations, our First Nations here in Alberta, by helping them to build massive treatment complexes on their nations so that we can come alongside them and reconcile those issues that are plaguing their communities. And the backbone of our system is and will always be voluntary. We want people to be able to go of their own will, if they have any left, into one of our facilities.
However, one of the next components that's coming for our system is for a small percentage of the population and the one which policymakers and elected officials are struggling so greatly, is for that portion of the population who has lost the capacity to make good healthcare decisions, in many cases, they've lost even bodily autonomy, out on the streets they're living in tents, under overpasses, they're injecting fentanyl into their neck, they're selling their bodies. I mean, it's really outrageous. And of course, we're finding them dead in tents or burned alive or all kinds of really heinous stuff. We believe that that is not compassionate, that that is outrageous that we would sit back as a community and fold our hands and say something that we hear all the time that, "They have to want help before it can be available." Or, "They have to hit rock bottom," as if somebody in that circumstance doesn't understand what rock bottom already looks like.
So when we say as a community that we're going to sit back and wait for the only people in this equation who don't have the ability to make good healthcare choices to all of a sudden start making them for themselves, that we're going to wait until that happens, thousands more people are going to die. We simply can't wait for that anymore. And so we are introducing next spring the Compassionate Intervention Act, which is a non-criminal healthcare intervention process that borrows from the best practices of Portugal and Massachusetts and other jurisdictions around the world that we've scoured. We've worked with academics, we've worked with a lot of thought leaders and legal scholars to come up with a great system where families, loved ones, child protection officers, doctors, police officers can make an application if somebody has lost or is a danger to themself or others, they can be apprehended and brought into detox. They can be assessed and then they go before a panel that is a healthcare panel and they can ordered into treatment if they've lost that capacity.
That is, albeit, a small population, but it's a very challenging population. And until governments and jurisdictions summon the courage to make these political decisions, to put the money up, to actually fund an adequate system of care, cities across Canada and across the United States are going to continue to see ballooning levels of homelessness, tent encampments, violence, and chaos.
Charles Fain Lehman: One of the features I want to talk just about for a second is the long-term residential care component. Some critics of the Alberta Model and of recovery in general say, "Well, recovery really doesn't work. Once you're hooked, you're really hooked for a long time. Recovery is a very halting start-stop process." And they often point to studies that correctly show high relapse rates following short-term treatment. And you've said a lot of what's going on, there's people just aren't getting enough resources. A, how do you think about the efficacy of recovery and then, B, what is the role of long-term care in the Alberta Model, and how does that play in?
Marshall Smith: Well, that's the spirit. I hear from naysayers all the time this sort of grouchy, "Recovery doesn't work for everyone," and, "Dead addicts don't recover," and kind of all of this. And I just say, "Well, that's the spirit," right? No, we have an obligation to be cheerleaders, to be advocates, to tell people they can do it, that no matter how far down this road they've gone, that recovery is possible and that it's attractive and that you should get on board. That's what I want to see out of a system. I reject the naysayers. Of course, we can always build better systems, and I agree that for the population that we're talking about that is sort of plaguing our outdoor spaces and our civic spaces and the addicted population that is visible, a new model must be built. And so in Alberta, we understand at a very deep level that somebody who has been living on the streets for years, has been using opiates for years, that is deeply entrenched in and out of jail, that a 25-day treatment program is simply not going to be adequate.
The problem isn't treatment. The problem is is that we have failed over decades to build an adequate treatment system to properly match the type of care that people need. You don't get to take somebody out of a garbage can in an alleyway who has been there for years in and out of jail, put them in a 25-day treatment program, and then blame treatment for being ineffective. That is outrageous. In fact, the blame lives with all of us, right? We are the ones as a community who has not demanded that better systems of care for these people be created. So what we're doing in Alberta to respond to that is we're building 11 very large, high capacity, long-term treatment centers. They're called recovery communities.
And you can go to these recovery communities. You just swipe your care card. It doesn't require that you pay anything. It's funded by the taxpayer of Alberta. It's individualized care up to one year. So it's a blending of housing, treatment, and recovery supports all under one roof. And there are phases that are more intensive than others. Not everybody stays that long. Some people require a shorter stay, some people require a longer stay. And so that is the new model that we're building here in order to address that.
And I should also just say, Charles, there's nothing new about that. There have been long-term treatment programs going on around the world since time immemorial. If you go to Italy or any of the Bronze Age countries, et cetera, they pioneered multi-year programs a long time ago. They're very successful models. But for some reason, in North America, mainly because of insurance providers or pharma or the fact that government, we were moralizing about this and government didn't want to step up and fund this adequately, we've been stuck with this highly medicalized 25-day, 60-day program that has been largely ineffective for a low recovery capital, high acuity patient.
Charles Fain Lehman: I want to talk just a little bit about outcomes and then transferability before we wrap up, so let me talk a little bit about how you're thinking about success here, because it seems like there's some preliminary data that say OD deaths are starting to come down in Alberta. Those might end up getting revised up. But there's a real question about whether and to what extent the program is fully implemented. How are you thinking about measuring success? What does success in the numbers look like and where should people interested in this experiment be looking in order to learn about whether it's succeeding or failing?
Marshall Smith: Sure. I love that question. And you're right, there's a lot to unpack and there's a lot to look at it there. I would add to that, that there are critics out there, I try not to listen to them too much, but we're four years into a 10-year implementation strategy. It took the folks in British Columbia about 20 years to destroy that province with their policies. So I would ask for just a little bit of patience while we fully implement our strategy here. And the reality is we've just created the Canadian Centre for Recovery Excellence, which is a Crown corporation. Its job is to measure and assess the efficacy of the programs and the model. That's coming online now. You quite rightly point out that the fatal overdose numbers are dropping. As a matter of fact, one of the best stats that I like to drive the point home is between May of 2023 and May of 2024, globally all substances, we saw about a 50% reduction in overdose fatalities.
In fact, the best stat that I've seen is in Calgary, as a matter of fact. Looking at May of last year and May of this year, in May of '23, there were 70 fatalities, 70 fatalities in Calgary, and in May of this year there were 17. So I can't help but be guardedly optimistic that we're headed in the right direction. And it's not just a matter of the opioid supply because we are seeing a reduction in all substances broadly. We're seeing a reduction in fatals related to alcohol, cannabis, cocaine, methamphetamine, benzodiazepines, and opioids. Opioids get all the attention because of fentanyl. But the reality is is that there are a lot of other substances that harm people out there, and our model is built for all of them, not just opioids. And so we're encouraged to see that these reductions are across the board.
Charles Fain Lehman: And lastly, you're obviously not a US-based policymaker. There are things that you can do in Canada that you can't do in the United States and vice versa. There are different policy constraints. That said, I think Alberta is interesting as it's a relatively small jurisdiction, 5 million people, that's a reasonably sized American state. And I think part of why its approach is interesting to American policymakers is that you have a similar federal model where the provinces are taking the lead in much the same way that for better or worse, substance use care is going to happen predominantly on the state level in the United States. So that's all sort of wind up to say, if I'm a state-level policymaker listening to this, what lessons do you think I can learn from Alberta? What should I be looking for?
Marshall Smith: Yeah, this is great. I mean, we could do a whole podcast just on this piece. I would say, look, I've got a lot of friends in the United States. I'm down there frequently consulting with different states. There's a lot of activity going on in California, in Washington. So I would say this, while there are some stark differences, Canada has a socialized medicine, America is more of an insurance-based process, I'm not entirely sure though that what we're doing in Canada can't be done there. I think the reality is is that it comes down to political courage. Counties in the United States, particularly the large ones, have a tremendous amount of power. States have a tremendous amount of power. They could, anytime they want, choose to fund treatment that is not insurance-based. That's fully within their jurisdiction. So if the problem becomes too severe, they are going to have to step in and they're going to have to fund state-operated treatment facilities or contract those out to not-for-profit operators, et cetera.
But I think that it's a cop-out to say that, "Well, we have a different system." It is that way because they're choosing to hide behind the shrubbery of that. But the reality is is you need to have the political courage, you need to make the commitment. For the taxpayers of states in the U.S., man, I've talked to a lot of Americans in jurisdictions, like take San Francisco for example. They would gladly pay a little more taxes if it meant having places that were appropriately run for a lot of the people in the Tenderloin to go off to long-term treatment and clear those streets off. The challenge that you're running into in the United States is you're going the way of Vancouver where the population down there is seeing a huge amount of money being poured into things that they know intuitively are making things worse, and it's certainly visibly not getting better.
And so we have this saying in recovery that you can't fix a problem with the same mind that created it in the first place. You're listening to the wrong people and state leaders and jurisdictions down there want to be listening to people who have been in addiction with lived experience, but who are now in recovery of a significant length of time, who can look back on their time and advise with a clear mind what was needed and what was necessary. If you ask people, this is, again, the tale of two provinces, British Columbia is largely advised by people who are actively using drugs. The drug addict unions of the Downtown Eastside are at the policy table, and they carry outsized influence on drug policy.
And if you ask an addict who is using drugs and who is high what they want and what they need, they will always tell you the same thing. They want free drugs, they want the police to go away, and they want a hotel room to use in. That is what they want. And because they are the ones advising in British Columbia, that is what you're seeing come out in terms of policy. If you ask addicts in recovery what they need and what they want, they will tell you something that looks a lot more like Alberta. So to political leaders down there, get the right people around you, be advised by the right people. Make the courageous commitments. Set yourself up. I do a lot of talking to political leaders about governance, how to organize yourself in government to be effective, how to organize yourself to make decisions. Who is in charge? Who is going to be accountable for making these changes? What powers do they have in order to make the changes and make sure that you're set up properly before you embark on a major system change like we have.
Charles Fain Lehman: Well, I think that's a good place to leave it. Marshall, thanks so much for joining us on 10 Blocks.
You can find City Journal on X, @CityJournal, and on Instagram, @cityjournal_mi. If you like what you've heard on today's podcast, please give us a nice rating on iTunes. Marshall, great to talk with you as always, and thank you for the illuminating discussion.
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