Building on the “Alberta Model”: How to Strengthen Alberta’s Response to the Opioid Crisis

The opioid crisis and broader issues with addiction and substance abuse have touched every province over the past several years. The problem has been acute in Alberta and British Columbia. The so-called “Alberta recovery model” has sought to prioritize addiction recovery over the harm reduction model that has prevailed in BC and elsewhere. Progress on reducing drug-related deaths has been rather mixed. Even proponents of the Alberta recovery model, warn that the full implementation of a recovery-oriented model will take ongoing public investment and time.

July 2, 2024

Introduction

The opioid crisis and broader issues with addiction and substance abuse have touched every province over the past several years. Data from the Government of Canada shows that there were 42,494 apparent toxicity deaths nationwide reported between January 2016 and September 2023.

The problem has been acute in Alberta and British Columbia. Research by the Stanford Network on Addiction Policy (SNAP) estimates that though the two provinces account for a quarter of the national population, they have been home to just under half of drug-related deaths over the past several years.

The policy responses in Alberta and BC have diverged since about 2018. The so-called “Alberta recovery model” has sought to prioritize addiction recovery over the harm reduction model that has prevailed in BC and elsewhere.

The Alberta government’s approach, which has involved major public investments in recovery centres and even legislation to establish a new provincial Crown corporation called the Canadian Centre for Recovery Excellence, is not without its critics. Progress on reducing drug-related deaths has been rather mixed.

Even proponents of the Alberta recovery model, like Julian Somers, a health sciences professor at Simon Fraser University, warn that the full implementation of a recovery-oriented model will take ongoing public investment and time. This type of policy transformation involves not only reconfiguring treatment facilities but also reshaping how different branches of the government collaborate and interact.

Paul Sobey, chief medical officer at the ROSC Solutions Group, similarly highlights the need for substantial investments in infrastructure to support the Alberta recovery model. While progress has been made with the establishment of therapeutic living communities, the current infrastructure falls short of meeting the growing demand for recovery services.

These are only some of the impediments to making greater progress on addiction recovery in the Province of Alberta. The purpose of this Alberta 360 policy brief is to synthesis recent research and commentary on the Alberta recovery model and identify incremental policy recommendations to strengthen its implementation and improve its outcomes.

The policy brief has been produced based on interviews with leading practitioners and scholars, including Somers, Sobey, and others. The goal is to arm Alberta policymakers with a set of policy recommendations to build on the Alberta recovery model.

We recognize that some critics believe that the basic assumptions of the model are wrong and that it ought to incorporate the principles of harm reduction, including an expanded role for safe injection sites, safe supply, and similar policy interventions. We do not account for those arguments here. Our goal is to draw on expert commentary and perspectives to set out policy recommendations to improve the Alberta recovery model’s outcome on its own terms.

What’s in the Alberta Model?

The Alberta recovery model (or sometimes “Alberta Model”) for addressing addictions is a comprehensive approach that emphasizes access to treatment, and a supportive community environment to assist individuals recovering with substance use.

It was conceived as a platform commitment by the United Conservative Party in Alberta’s 2019 election. In particular, the party promised to appoint a dedicated minister to the addiction file and develop a strategy focused on recovery.

The Alberta Model took shape following the campaign. It was first launched later that year with a focus on the expansion of recovery centres as well as support for local organizations committed to a recovery-oriented model. The Alberta government contrasted its approach with the harm reduction model being pursued in other provinces.

In basic terms, the Alberta model operates on the principle that addiction is a complex and multifaceted issue, requiring a broad spectrum of responses that include not only medical and therapeutic interventions but also societal and policy-level actions. It advocates for the integration of services across the healthcare system, social services, and community-based organizations to ensure that individuals have access to a continuum of care that is responsive to their specific needs.

The Alberta Model incorporates several key components:

Prevention and Education: Programs aimed at reducing the start of substance use through community education, school programs, and outreach efforts.
Early Intervention: Training healthcare providers and community members to identify early signs of addiction and connect individuals with the appropriate resources to prevent escalation.
Treatment Options: A variety of treatment services tailored to individual needs, including medically supervised detoxification, residential treatment, outpatient counseling, and medication-assisted treatment.
Recovery Support: Long-term support for individuals in post-treatment, including access to recovery housing, employment services, and community-based support groups. Recovery coaches and peer support specialists play a significant role in maintaining sobriety and helping individuals rebuild their lives.
Drug Treatment Courts: An innovative aspect of the Alberta Model, these courts offer an evidence-based, non-adversarial approach to address drug-driven criminal behavior. Participants receive intensive drug treatment, judicial supervision, frequent drug testing, and support services aimed at reducing recidivism and promoting recovery.

Provincial policymaking on the file has been supported by a mental health and addictions advisory council composed of doctors and community activists which was established in late 2019. It released a major report in 2022 that set out a series of recommendations that it describes as “a shift in philosophy” and a “system transformation” that roots provincial policy in the goal of recovery.

A major development in such a transformation is the creation of the recently-announced Canadian Centre for Recovery Excellence. A new provincial Crown corporation, the centre will work with university researchers to carry out analysis of different recovery interventions and models to inform provincial policymaking. Its enabling legislation was tabled in the Alberta legislature in early April 2024 and it is expected to be fully established this summer.

The provincial government has also established a new organization called Recovery Alberta, which will take over the duties of handling mental health and addictions from the Alberta Health Service (AHS). It was announced in April that Recovery Alberta will have an annual budget of $1.13 billion.

The Alberta Model Remains Incomplete

Yet notwithstanding some of the progress with respect to the Alberta Model, there remains areas of improvement. For example, Julian Somers, a leading addiction scholar at Simon Fraser University, highlights the substantial effort required to shift from a decades-old status quo to a system that fully supports recovery.

“One of the challenges with reforming government from the status quo of the last few decades in North America to something that is recovery-oriented,” says Somers.

A significant aspect of the transformation and reforming of how addiction is treated involves the reconfiguration of how various branches of the provincial government cooperate and interact, likened by Somers to “retooling a factory.”

He warns that such a fundamental shift, especially one without precedent, necessitates a long-term commitment to revamp facilities, modify the roles and responsibilities of different actors, and develop suitable curriculums for those in recovery programs. He advises that a government that is committed to such a policy transformation needs to prioritize its attention and fiscal resources.

Adam Zivo, a Munk School alumni and founder of the Center for Responsible Drug Policy, a public policy think-tank focused on addiction issues, echoes the sentiment that adopting the Alberta model is a time-intensive process, drawing parallels to Portugal’s significant investment in treatment capacity before embarking on decriminalization experiments. He emphasizes that unlike the misconceived notion of unrestricted drug use, the Portuguese model fosters a non-criminal accountability system that encourages treatment over penalization.

Alberta has had a drug treatment court in effect since 2005 that offers people a chance to avoid prison for drug use-related offenses by going into treatment. However, Zivo warns that sending people for treatment is not effective without a sufficient system in place.

“There’s no point in having drug courts that divert people to treatment if there isn’t the treatment capacity to absorb them” says Zivo.

Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University, views the Alberta Model as a long-term vision, estimating at least a decade for its full realization. He observes that while foundational elements have been laid, with recovery communities already operational and more planned, the intricacies of legal frameworks and handling involuntary addicts are areas of active discussion.

“They’re still working out, there’s a lot of time talking about the legal frameworks, and what do we do with people who don’t necessarily want to be in care,” Humphreys points out.

While the Alberta Model has ambitious goals, a key takeaway with these experts is that policymakers must balance short-term demands with longer-term plans. The recovery model requires long-run investments that will need to withstand possible legal challenges and electoral changes.

The Need for More Recovery Centres

Paul Sobey acknowledges the ongoing nature of the initiative, noting that only a handful of therapeutic living communities have been established, with more comprehensive services in the pipeline. As of 2024, the Alberta government lists just two such facilities as being open, with nine more still being planned.

“It’s still a work in progress,” Sobey says.

Several cities in Alberta have begun to convert empty office buildings into housing in a bid to repopulate city centres and boost the housing supply. The Alberta government should collaborate with municipal governments to convert at least one former office building in both Calgary and Edmonton into a recovery community.

By inserting recovery communities into the city centres in existing buildings, the Alberta government could not only save money, but increase its coordination with municipal governments by sharing more responsibilities. This would free up resources at the provincial level and further integrate the Alberta Model into municipal programs and services.

Many addicts do reside in Alberta’s two largest cities. There are currently no recovery communities planned for Edmonton, and only one is in development in Calgary, which still has a 25 or 30 percent office vacancy rate.

If both cities are sitting on empty real estate, it should be converted into urban recovery communities. Addicts may feel more comfortable going into treatment if it will take place in a familiar setting.

Since 2019, Vancouver has built 1,500 staffed social and supportive homes for at-risk residents. Tenants are provided with skills and employment training, meals, and access to health supports

While there is a risk of people relapsing while in recovery due to the prevalence of illegal narcotics in the larger cities, Vancouver’s experiment with assisted housing may be a model to integrate into Alberta’s recovery model. New conditions should certainly be applied, such as prohibiting drugs on-site and making bag checks mandatory to make sure they are not being smuggled in.

If the environment of an office tower is not appropriate for a recovery centre, it can still serve as temporary shelter for people seeking addiction treatment. If Calgary and Edmonton lack enough recovery centres, these buildings can serve as a point of first contact before addicted persons can be sent to built-up recovery centres.

Conceptualizing Success in a Recovery-Oriented Model

Despite initially positive signs from the dropping numbers of monthly drug-related fatalities in Alberta in 2022, the numbers have risen again.

In December 2021, there were approximately 47.7 deaths per 100,000 people in the province. That statistic dropped to 37.8 deaths per 100,000 people the following year, before rising to 37.3 percent in 2023.

At a glance, that may seem to be overall progress from 2021 to 2023, but the period from March until October 2023 saw increased fatalities relative to 2021.

Critics of the Alberta Model have seized on this as proof that it is not working, but experts note that fatalities are not the only metric to determine its success.

Julian Somers underscores this point, highlighting the time it may take for measurable changes to manifest.

“It may be years before that results in any kind of measurable change in outcomes,” says Somers. ”You’d expect to see outcomes in reduced probability of reoffending before you would expect to see measurable reductions at the population level in mortality.”

In contrast to the growing concern over mortality rates, Zivo draws attention to a broader perspective, noting that Alberta’s mortality rates, while increasing, remain comparatively lower than those of British Columbia.

This observation by Zivo suggests that a singular focus on mortality rates may overshadow other pertinent factors in assessing the effectiveness of addiction policies.

Humphreys echoes this sentiment, asserting that while deaths are undoubtedly tragic, they should not be viewed as the sole determinant of policy success. He says there are limitations of such a narrow focus, stating that it sidelines critical statistics, like the number of individuals in recovery and those still struggling with addiction.

“Deaths are obviously terrible, but they are not the only indicator of policy… Part of the recovery model is rejecting the idea that that is the sole indicator,” says Humphreys.

Other metrics that might inform how policymakers think about success include the number of individuals in recovery or treatment, how many people are not using drugs and in-recovery, as well as dropping numbers of addicted persons. While a reduction in fatalities is obviously a goal, there is far more to it.

Even on this front though the Alberta Model is showing promising signs of its early success. Alberta recorded the lowest monthly number of fatal drug poisonings in August 2022, at 26.6 deaths per 100,000 people. Since then the numbers did increase, but as of the last update, it had fallen back to 27.9 fatalities per 100,000 people in February 2024, before rising to 30 per 100,000 in March 2024.

The Opioid Dependency Program (ODP) provides narcotic substitutes like methadone or suboxone initiation to addicted persons and helps them to access additional services. Between 2018 to 2023, the number of monthly of ODP clients has doubled from under 1,500 to about 3,000. Additionally, the number of people using narcotic replacements like suboxone has steadily increased since 2018, from 4,047 to 8,262 per 100,000 people.

Can Alberta Redefine Safe Supply?

Safe supply, as it exists in British Columbia, is often held up as the alternative to the Alberta Model, which is perceived as ruling out any form of government-provided narcotics. The reality is more nuanced.

Alberta does, in fact, offer consumption of narcotic-replacements which can be instrumental in an addict’s first steps to recovery. These include buprenorphine/naloxone, methadone or injectable extended-release buprenorphine that stave off opioid cravings.

“I think narcotic transition services epitomize what safe supply should be,” says Zivo.

However, Zivo acknowledges the distinctiveness of Alberta’s approach to safe supply, emphasizing its focus on improving individuals’ well-being rather than perpetuating addiction. While similar in purpose, he notes the substantial differences between the Alberta model and conventional safe supply initiatives, cautioning against conflating the two.

Sobey says typical harm reduction strategies, of which safe-supply of actual narcotics, fail to facilitate progress towards cessation.

“Harm reduction is where you meet people where they’re at, and then you use various interventions to move people along the continuum towards stopping drug usage,” says Sobey. “What happens when I meet a person where they’re at and they don’t move?” It’s called harm production, and I think that’s a narrative that needs to be expressed a lot more commonly.”

Sobey further critiques the current narrative surrounding safe supply initiatives, highlighting the onus on policymakers and practitioners to demonstrate their effectiveness in reducing harms and preventing diversion. He questions the efficacy of existing policies, particularly in jurisdictions like British Columbia with alarmingly high overdose death rates.

Keith Humphreys also refutes claims that Alberta lacks harm reduction services, pointing to the presence of supervised consumption sites within the province.

“That is bullshit. There are supervised consumption sites,” says Humphreys. “The difference, though, is that it’s all done in the service of getting people into recovery. And that is a fundamental difference.

Humphreys draws parallels between past drug epidemics, such as the oxycontin era, and the current challenges posed by substances like fentanyl. He warns against complacency in assuming that legal regulation alone will address the underlying issues contributing to addiction and overdose deaths.

Communication to the Public is Crucial

Improving communication about processes of the Alberta Model should be a key objective, both externally and internally.

Humphreys refers to the failures of past efforts to combat drug epidemics as facts that the public should be informed of.

“I think it’s really important to say to the public that in the history of the world, we’ve never turned around an epidemic by waiting for people to get really sick and throwing resources at them,” says Humphreys.

Sobey raises critical questions about the clarity and definition of the “recovery system of care” within the Alberta Model.

“What is that? Nobody knows what it is, nobody’s defined it yet,” says Sobey.

Sobey elaborates on the concept of recovery capital as key to defining and communicating what the Alberta government is aiming to achieve.

“Recovery capital is basically when an individual, a group or a community comes to the table to establish or take a shot at recovery, and it’s what you got in your backpack,” says Sobey, “It requires a village to heal an individual, that’s where that comes from.”

Sobey says the term “recovery-oriented system” connotes bureaucracy and heavy-handed government intervention. He favours the term “inclusive recovery”, which he credits to David Best, a professor of addiction recovery at Leeds Trinity University in Leeds, England.

“Inclusive recovery communities’ denote that the community is where the reservoir of recovery capital exists and it flows from the community to the individual,” says Sobey.

As for defining its concepts more clearly to the province’s residents, the Alberta government should launch a comprehensive public awareness campaign. It spent $22 million on promoting Alberta’s oil and gas industry as part of its “Energy War Room” strategy previously and should do the same with the Alberta Model.

Beyond simply promoting its strategy, billboards advertising the Alberta Model could reach more people who need it, especially with regards to the locations of the recovery centres. If the addictions crisis is in fact a crisis, it should be treated as one at all levels, including in the public eye, and promoted in a similar fashion to the safety measures during the COVID-19 pandemic.

Conclusion

The Alberta Model, with its ambitious aim of transforming addiction treatment into a recovery-oriented system, is still a new approach in the midst of the province’s ongoing battle against addiction.

Its comprehensive strategy, focusing on accessibility to treatment and fostering supportive community environments, displays an ambition to create a robust framework designed to address the complex and multifaceted nature of substance use disorders.

The model highlights the importance of integrating services across healthcare, social services, and community organizations, ensuring a continuum of care responsive to individual needs. However, the Alberta Model is still in its nascent stages, grappling with challenges that range from infrastructure development to public communication and the nuanced debate around safe supply initiatives.

The $1.13 billion being spent to establish recovery Alberta is a significant increase in the previously measured money budgeted for the province’s addictions strategy. in 2022 for example, $60 million was added for recovery-oriented care in addition to annual $1.7 billion allocated to the Ministry of Mental Health and Addictions.

The need for substantial investment in infrastructure and the transformative effort required for government branches to collaborate effectively are crucial.

Where the Alberta Model runs into problems is the lack of clear communication from the provincial government about the program, such as spreading awareness about exactly what a “recovery-oriented system of care” entails, as well as shifting the narrative away from fatalities being the sole metric of success. There are opportunities to expand infrastructure for the program, such as utilizing empty commercial spaces in the centres of Calgary and Edmonton.

The challenges highlighted, including the need for more infrastructure, better metrics for success beyond mortality rates, and clear communication, are areas for ongoing focus and improvement.

To summarize, the Alberta Model has the potential to become a transformative example of dealing with addictions, but it must take advantage of opportunities to build more infrastructure around it. Those crafting the model must also make their efforts far more public and inform Albertans about exactly what they are doing to prevent polarizing misconceptions about the province’s addiction policy.

The Alberta Model remains incomplete. There are some key areas for improvement before it can make long-run improvements to the province’s drug and opioid crisis.

Key recommendations include:

Enhance Infrastructure and Accessibility: Invest in the development and expansion of treatment facilities, utilizing available spaces in urban centers like Calgary and Edmonton to increase the accessibility and capacity of addiction treatment services.
Improve Communication and Public Awareness: Implement a robust communication strategy to clearly explain the objectives and components of the recovery-oriented system of care. This should include educating the public on the various metrics of success beyond mortality rates and ensuring transparency about the initiatives being undertaken.
Foster Collaborative Efforts: Strengthen collaboration across healthcare, social services, and community organizations to ensure a seamless continuum of care. This collaborative approach should address the comprehensive needs of individuals with substance use disorders, fostering a supportive environment conducive to recovery.

Geoff Russ is a policy manager and columnist based in Vancouver.

For more information about Ontario 360 and its objectives contact:
Sean Speer
Project Co-Director
sean.speer@utoronto.ca

Drew Fagan
Project Co-Director
drew.fagan@utoronto.ca

on360.ca