On a frigid February night in Edmonton, I’m downtown with 4B Harm Reduction. The street outreach conducted by this non-profit society is time-tested—scour the city’s forgotten corners for people who need support. On any given shift, they might respond to drug poisonings, frostbite, heatstroke, hunger, fatigue-induced psychosis or the many barriers to accessing shelter. Mostly 4B aims to keep hope alive despite society’s structural neglect.
Tonight we’ve gathered in an underground LRT station passageway. Beside us, a long stretch of yellow fencing separates us from a lone electrical outlet, a rare treasure in public spaces. The outlet was recently deemed too popular among the city’s unhoused citizens—hence the fence.
Through slurred speech, Brandon Shaw fawns over my toque, which reads “Hoot ’n’ Blow” beside an owl logo. I offer it as a trade for his, but he declines. Someone later explains Shaw was afraid he’d picked up lice in the shelters. He was protecting me.
Brandon is the namesake of the organization (“For B”), which was launched by his mother, Angie Staines. He’s 28 years old and still alive after 12 years unhoused—but only just. In the summer of 2022, Staines and her team found Brandon blue-lipped, deep in a fentanyl poisoning. They revived him with naloxone and oxygen. But in the ensuing months he was set on fire during a drug deal gone wrong, then suffered a kidney infection, then withered through the dysentery that hospitalized over 100 of his unhoused neighbours.
Half of Alberta’s treatment beds are in explicitly faith-based facilities, with an overwhelming focus on total abstinence.
Like everyone down here, Shaw’s life could have taken any number of trajectories. Twelve years earlier he had been a multitalented and athletic kid running full speed into behavioural challenges. “I left home for the first time out of fear and shame of the pain and harm I was causing my family,” he says. “I knew something was up with me; I just didn’t know what.” He quickly gave up on youth shelters. “I didn’t last long, because of my drug use and mental health,” he says (many shelters have strict abstinence policies). “And nobody asked me what I want or what I need.” So, managing bipolar disorder and ADHD with street drugs, the runaway teenager took up residence in a tent.
Years later Shaw would wait months on a medical detox list, only to be refused support for his potentially seizure-inducing benzodiazepine withdrawal. Given that his earlier attempts at detox from benzodiazepine-laced fentanyl “felt like having a stroke,” he was desperate for a better option.
Like so many other people 4B was out to support that night, Shaw is up against systems seemingly built to fail. Successive provincial governments have ignored survivors like him while holding fast to outdated conceptions of drug use and addiction.
In 2014 Dr. Esther Tailfeathers sounded the alarm about a sudden escalation of opioid poisonings in her native Kainai Nation (Blood Tribe or Blood Reserve), bordering Lethbridge, where she practises family medicine and advocates for harm reduction. “I had no idea we wouldn’t get on top of this, we wouldn’t have a good strategy—[that by 2024] we’d still be chasing the tail of the problem,” she says. At the time, she remembers, “We thought we were an anomaly, that it wasn’t happening anywhere else to this degree.”
Kainai was at the vanguard of the cataclysmic shift in Canada’s criminalized opioid supply, from use of regulated pharmaceuticals and “old-school heroin” to potent synthetics such as fentanyl that are made without opium poppy. Recognizing the trauma of people who use drugs, their families and frontline responders, Tailfeathers’s daughter Elle-Máijá documented the period. In 2021 she released the film Kímmapiiyipitssini: The Meaning of Empathy.
Recently the doctor and her daughter “started counting the number of people in the film that have died. It was over half of them.”
Alberta has lately seen a seven-year drop in Indigenous life expectancy. In 2015 life expectancy for a First Nations man in Alberta was 67; today it’s 60. For First Nations women, it’s dropped from 73 to 66. This decline has been attributed in large part to our province’s narrow scope of drug policies, centred on abstinence. To Tailfeathers it seems like a conscious reframing of John A. Macdonald’s “clearing the plains” starvation politics. “Macdonald and all these other leaders thought they knew what was best for Indigenous people,” she says. “In 150 years there’s been no change… Making decisions about us, without us, is still colonial.”
During the NDP term in government (2015–2019), AHS incrementally piloted and adopted interventions falling under a “harm reduction” umbrella, such as naloxone distribution, supervised consumption sites and prescribed injectable hydromorphone. But these measures were too little, too late. While the tide of regulated opioids retreated—in an overcorrection to what some experts saw as loose prescribing practices—annual toxicity deaths in Alberta rose from around 100 in 2012 to 805 in 2018. In 2023 Alberta was on track to exceed 2,000 opioid-related deaths for the first time. (The data is not yet finalized.)
Elaine Hyshka, Canada Research Chair in Health Systems Innovation at the University of Alberta, still agonizes over the opportunities missed in the early days of the crisis. “The exponential increase in deaths was directly related to a change in the illegal drug supply. Before, people were primarily using prescription opioids. Those became less available, and the illegal market moved to fill that void.” With dangerous drugs flooding in, and deaths rising fast, drug policy experts called for immediate harm-reduction measures to save lives.
In the years since 2019, however, harm reduction has been turned into a political wedge, and “addiction,” an amorphous term increasingly avoided by drug-policy experts, has been reinforced as the nexus of public interventions. But we’re taking aim at the wrong target, says Hyshka. As Brandon Shaw’s story illustrates, this isn’t an addiction crisis, it’s a mass poisoning.
Successive provincial governments have ignored survivors like Brandon while holding fast to outdated conceptions of drug use and addiction.
When Jason Kenney’s United Conservative Party took power in 2019, it began cutting harm-reduction services. By 2023, grassroots overdose prevention sites had been criminalized, the number of supervised consumption booths in Alberta had been reduced by 35 per cent, and every patient in Alberta accessing a prescribed supply of hydromorphone (a synthetic opioid) was forced to accept a regimen of “witnessed oral dosing” in central facilities. To harm-reduction advocates, these restrictions became synonymous with the government’s recovery-oriented (or abstinence-oriented) focus.
Brandon Shaw experienced first-hand the staggering increase in poisonings during the transition to synthetic opioids. “I moved to BC [in 2013] when you could still buy actual heroin. …I had a somewhat normal life, working day labour, living in a ‘wet house’ [sober-living facility with loose rules]. Then fentanyl came along and everything changed.”
“At first, we just thought we were getting strong-ass dope… then we noticed all our friends were dying. My routine was on its head. Before, I would use four times a day. Then fentanyl came out and I was using sporadically, at weird times of day.” Shaw describes fentanyl’s lack of “legs,” its shortened effects compared to heroin or other opioids. After losing many friends to poisoning, he recognized the threat to his survival and returned to Edmonton in 2015.
As in BC, the ground in Alberta had fundamentally shifted. But a public health response equal to the crisis was nowhere in sight in this province. With few options to choose from, Shaw returned to residential treatment for his third time—for his first, as a teen, he had been involuntarily committed through the Protection of Children Abusing Drugs (PChAD) Act. He would eventually tally a total of seven attempts in the system.
Through these stays in “rehab,” Shaw learned some basic living skills. But these didn’t help him overcome his biggest barrier: securing stable housing. What he needed, according to Alberta’s drug-treatment system, was to be drug-free. “When you’re using drugs, that alone really screws you for a lot of options—there’s very little low-barrier housing. A lot of these places are 12-step-oriented.”
The 12-step method, developed in the 1930s for people dependent on alcohol, is rooted in Christian values to support people through abstinence. Countless people credit 12-step’s community support for their eventual success in maintaining abstinence. But the method has its limits and drawbacks. Critics refer to the community shaming that reveals itself, as one example, when people admit to resumption of drug use (or, to use the more stigma-laced term, when they “relapse”). Speaking of her own experience in a 12-step program, New York Times journalist Maia Szalavitz put it bluntly: “Such clearly religious practices would not be accepted as medical or psychological treatment for any other condition.”
An internal AHS document reveals that 12-step-based strategies are central in publicly funded facilities harbouring three-quarters of Alberta’s treatment beds. Around half of Alberta’s treatment beds are in explicitly faith-based facilities. Between religious undertones and an overwhelming focus on total abstinence from drugs, rehab can exclude people seeking other approaches to recovery, including ones that don’t aggravate their existing shame.
But one life-altering experience in treatment stands out for Shaw. “I’ve experienced all kinds of trauma through the last 12 years,” he says, summarizing lifetimes of harm in one breath. During an extended stint at Our House Addiction Recovery Centre in Edmonton, Shaw says, he underwent six months of trauma therapy with a professionally certified counsellor. That length of time “was the only way I was able to get vulnerable… I had to trust him more than anyone I’ve ever trusted.”
Trauma therapy, however, is expensive, intensive and outside the scope of most treatment facilities in Alberta. It takes weeks or months to conduct pre-screening and ensure that a participant is in position for routine follow-up and therapeutic work outside of regular sessions. In effect, trauma therapy requires someone to be sheltered, supported by a close network and ready to face their demons. Shaw wanted “treatment that would fit [him] individually, not just a one-shoe-fits-all, for every single person coming in.” Instead, the option offered by most rehab facilities he visited in Alberta seemed to create “a revolving door. It doesn’t work.”
After decades of advocacy by mental health professionals, Alberta not long ago was set to expand its therapeutic options. But in 2021, a day before the ribbon was to be cut on the College of Counselling Therapy of Alberta, the provincial government announced the college was “no longer a priority.” It cancelled the launch, preventing the professionalization of oversight and regulation of mental health and addiction therapy. Instead, the Kenney government doubled down on treatment facilities that are cheaper and unaccountable.
The lack of accountability at Alberta’s existing treatment services troubles Tailfeathers. “Without evaluation, we have no idea what works and what doesn’t,” she says. “[A program] might look good, but are we actually evaluating whether it’s successful or not? Is there an overall decrease in mortality, an increase in people returning to the workforce, children staying in their households with their parents?” Our government is “shooting from the hip, putting all their eggs in one basket.”
Despite regularly publishing data on drug-related EMS-dispatch and drug-related mortality, the government of Alberta hasn’t shown how treatment impacts the odds of survival—if it even knows. Hyshka suggests the starting point to assess success would be to see if people who attended treatment “had any EMS activations or attended a hospital for substance use disorder for six months and one year following discharge.” In Alberta’s centralized medical system, this should be easy.
Alberta’s Ministry of Mental Health and Addiction did not reply to any of my questions. Reporting requirements to the government were, however, disclosed to me by a director and a manager at two private but publicly funded residential treatment facilities and a staff member at an AHS detox facility. (They requested anonymity to protect their provincial funding.)
The responses from the three facilities provide a rare insight into the government’s selective data management. By collecting client participation data such as number of people initiating and completing treatment, number on wait lists, and participant demographics, the government attends to the needs of the treatment industry.
Conversely, the government appears to actively ignore client outcomes, including how many people maintain abstinence or even survive in the months following their participation in a treatment program. And while the government tracks the number of people discharged early from treatment and the reasons for early discharge, this information is not publicly disclosed. As a result, the industry is protected from evaluation and scrutiny while clients continue to be ushered through the system. And the fact that one facility admitted to a “triage process” while another did not suggests the possibility of “pay-to-play”—priority access for people with the right network and a willingness to make donations.
The collecting of data on people using services and what helps them complete programs can create an impression that the programs are supporting recovery goals. But this hinges on how we define recovery and success. The lack of follow-up with patients, says Hyshka, “means the system isn’t accountable to [the public] or to patients. If you’re a politician and you’re not measuring success, you can’t be held accountable for your policy decisions.” And as Shaw points out, a “revolving door” system in which clients leave treatment only to re-enlist months later—at thousands of dollars per stay—represents a tremendous business opportunity.
It turns out that, in the distinct but overlapping worlds of addiction and drug poisoning, definitions of “recovery” and “success” are not universal.
The Alberta government claims that “acute interventions,” a veiled reference to harm-reduction services, have “come at the expense of supporting the long-term wellness and recovery of individuals, families and communities.” The implication is that helping people stay alive while using drugs comes at a cost to the individuals and their communities by delaying their transition to “recovery.” The government defines recovery as “a process of sustained action toward physical, social and spiritual healing and wellness while consistently pursuing a substance-free life.” This contrasts with harm-reduction-oriented definitions, many of which centre a person’s own goals related to drug use alongside informed consent on supports.
The goals, actions and performance metrics built into recovery-oriented (abstinence) systems of care are detailed in the 2023–26 business plan for Mental Health and Addiction. The ministry’s budget is $300-million for 2023–24, of which at least 80 per cent is allocated to addiction and mental health recovery programming and capital costs. In a rare instance, the plan specifies a secondary objective of reducing “opioid-related overdoses in the province, with a focus on Indigenous Albertans who are disproportionately affected.” The initiatives listed are limited to residential and day treatment, a helpline and an expansion of the Virtual Opioid Dependency Program (VODP)—hardly a complete recipe for managing a toxic drug supply.
The VODP was originally designed to provide access for people in rural settings to treatment and opioid agonist medications (such as methadone and Suboxone); it was recently adopted for use in prisons. However, a 2022 study funded by AHS and co-authored by Nathaniel Day, the medical director of VODP, showed considerable participant dropout. Those who could be studied, the authors admitted, “were individuals who remained in treatment and were agreeable to completing assessments, [so] they may have also had more positive outcomes.”
The best treatment for opioid use disorder is medication. “Rehab” for opioid use has little supporting evidence.
Alberta’s recovery-oriented system is operating as a flimsy raft in a storm of toxic drugs, unaffordable housing and structural neglect. Thousands of Albertans, unable to hang on, are annually lost at sea. Others, with resources, luck and a willingness to define recovery as abstinence, are eventually carried to dry land. How many Albertans are saved, and for how long, our government either doesn’t know or won’t say.
In their emphasis on mortality, advocates for harm-reduction options misinterpret the ideology underpinning Alberta government’s approach to the poisoning crisis. Long term, the government’s apparent hope is that its recovery-oriented system will give rise to drug-free communities. In the short term, however, the “pursuit of a substance-free life” is being prioritized over minimizing death and illness caused by an unregulated supply.
The way treatment programs are instructed to monitor participant mortality rates helps illustrate this ideology. An executive director at a facility (residential treatment facility #1 in the table) told me that they only learn about the deaths of recent participants through alumni, 12-step meetings, mentorship programs or when someone voluntarily reports a death to the facility. If a participant’s death is reported within two months of the person’s exit from a program, it is relayed to the Alberta government. That completes reporting.
In the run-up to the 2023 provincial election, UCP candidates frequently celebrated their system’s supposed ability to reduce deaths. But during the same period, drug toxicity deaths rose steeply, topping 195 in April 2023—Alberta’s worst month on record. The government has since pivoted to a “Recovery Capital Index” to measure the success of treatment. This approach defines recovery capital as “the combination of personal, social, community and other supports that a person can draw upon to begin and sustain their recovery from addiction,” including housing, employment and family connection among the eight factors in the framework.
An individual’s index is measured at several timepoints during treatment using the My Recovery Plan app. Created by BC-based Last Door Recovery Society, the app was licensed to the Alberta government through sole-source contracts totalling nearly $1.8-million.
David Hodgins, a professor of psychology at the University of Calgary, describes recovery capital as an “increasingly recognized construct describing dimensions of recovery beyond reduction of problematic substance use.” He points out that no research yet exists on whether the app improves outcomes, though this is typical for mental health apps. Hodgins is also careful to emphasize that recovery capital “has nothing to do with reducing drug poisoning deaths, beyond the idea that more people being successfully treated is a good thing. It may help people maintain abstinence by pointing out areas of strength and areas of need.”
The director at residential treatment facility #1, mentioned previously, was enthusiastic about Alberta’s new framework, saying, “I see the successes every day… Recovery capital is measured in simple points: when they come in, at the 30-day mark, when they exit… we see huge increases at those points and huge decreases in the barriers to recovery.”
Recovery Capital Index scores, if they improve—and assuming they can be trusted and are released transparently—may eventually help justify the Alberta government’s focus on rehab. But, says Hyshka, “if the number one goal is to reduce the death rate, funding treatment beds is not going to do that.”
She emphasizes that the gold-standard treatment for opioid use disorder is medication, while residential treatment has little supporting evidence thus far. In any case, she reminds us, “a large percentage of people who use opioids or other substances are not going to meet the criteria for substance use disorder [or for being admitted to treatment], but they’re still at risk of dying—especially if they’re accessing drugs from the illegal market.”
The Mental Health and Addiction ministry’s $300-million budget in 2023–24 is a roughly 40 per cent year-over-year increase. This is laudable spending against historical underfunding on mental health and substance use supports. But the same budget announcement designated just $14.5-million for supervised consumption sites, a 30 per cent drop that was obscured in subsequent budget releases. Underscoring this quiet manoeuvring, the UCP’s fall 2023 annual general meeting passed a resolution calling for the wholesale defunding of supervised consumption services. And the Alberta government continues to build out its plans for its notorious Compassionate Intervention Act. This legislation is expected to empower police, families and healthcare providers to obtain court orders that compel people deemed a danger to themselves or others to undergo addiction treatment.
“Tough love” might seem compassionate to some. But Hyshka says the evidence shows that people are at “much higher risk of death from poisoning” following a period of forced abstinence. She also worries that “we already have trouble encouraging people to talk openly about their [drug] use and speak out and reach for help when they need it.” Fearful of being subjected to involuntary treatment by those they trust, “people will stop reaching out for help.”
Despite plans to construct 11 “therapeutic communities,” at least four of them in First Nations communities, including Enoch Cree, Kainai, Siksika and Tsuut’ina first nations, the government is signalling further privatization in the ownership structures. Not only will the success rates of treatment remain unknown to the public and to patients, it’s unclear how public money is being spent. Tailfeathers is troubled by this lack of transparency: “It’s like building all the brick residential schools… we’ve got these things built, but nobody knows what happens inside.”
The government’s first such contracts, in Red Deer and Lethbridge, were awarded to Edgewood Health Network and Fresh Start Recovery. Edgewood is a private company backed by undisclosed investors, while Fresh Start is a non-profit. Both corporations are perennial Lead Sponsors of the Recovery Capital Conference, a public centrepiece of the UCP government’s recovery-oriented system of care.
The conference also happens to be organized by Last Door Recovery Society, the organization that licenses My Recovery Plan to the Alberta government. After a former staff member was charged with multiple sexual assaults in 2023, Last Door came under fire for alleged attempts by senior staff to prevent survivors and community members from coming forward. As individuals and treatment facilities load recovery capital scores into My Recovery Plan to shore up the government’s appearance of system monitoring, Last Door will grow its financial capital. Reducing deaths will remain a secondary concern.
To Tailfeathers, addressing deaths must be a top priority. The trauma of unending crisis and loss is “wearing down people at the frontlines,” while the government’s strategy is “way off the mark in terms of… healing people who are seeking the drugs.”
“If politicians are not measuring success, they can’t be held accountable for their policy decisions.”
It’s a sunny fall day seven months after my first meeting with Brandon Shaw, and my phone call with him is interrupted by someone dropping boxes of naloxone at his apartment. He’s been housed since spring, after detoxing at home with Staines’s support and getting access to a safe supply of hydromorphone. When he picks up the phone again he tells me, “Things are going amazing. I’m at a place in my life where I have more now than I ever have—emotional supports, people I work with in advocacy—all these people now that have come into my life… Without my mom, I can’t guarantee you I’d be here today.”
When he was unhoused, he says, he was stripped of his voice and “tired of people crossing the street to get away.” With the support of 4B Harm Reduction, Shaw has launched a public education project—The Curbside Philosophy—to restore power to his community. As a society, he says, we spend so much time talking about unhoused people—Shaw wants us to speak with them. His project makes short videos situating real people inside the politics.
Not everyone from Shaw’s past has been able to transition to a life like his. “What keeps me up at night are the people I had to leave behind,” he says. His voice breaks as he describes the displacement of people who used to meet every day at the recently relocated Boyle Street Community Services, a ripple effect of the gentrification that is driving unhoused Edmontonians and their services out of the core.
Shaw knows his luck—in having Angie Staines as his mother, in surviving his interludes between the “revolving doors” of treatment, in finding a purpose with 4B Harm Reduction, in the grassroots community that supported him while he faced exclusion by the system. “I don’t want my whole recovery to be founded on… the fear of 12-step—having to tell everybody what a screwup you are. …When I screwed up, my community was behind me. People were just happy to see I wasn’t driven by fear and shame.”
Euan Thomson co-launched EACH+EVERY, which supports evidence-based, humane solutions to unregulated drug toxicity.
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