The thing I learned from writing a 100,000-word book (that was the 2013 book, not the latest) is that you never come close to using all your material. The Alberta government is working on substantially increasing the amount of patient-level data, and aggregating all of that together, to get the kind of statistics some people are calling for here. I left that out because (a) it's in the future; I have no idea how effective it'll be (b) Already from here, that kind of effort looks like a Pandora's box of privacy concerns, so I'll wait until that fight happens before writing about it.
But I was cross with one reader who commented on another post about the lack of data in Alberta because, to me, this looked like a highly selective case of curiosity. I mean, holy jumpers, where's the reliable public information we can use to measure the success of any program in any field at any level of government in Canada? Are our ports in the right place? Is our rail system well deployed? How's it going with the 2 billion trees, and what's the name of the person who decided to throw in a few hundred million trees from a source that was previously excluded?
I had a prof who once said, if you want to destroy somebody's argument, check their footnotes. I've used that advice a hundred times. But if you're going to insist on data in one province for one policy area, you're going to need to show me where you've demanded it elsewhere.
The intellectual clash between Mr. Smith and Dr. Larson is interesting. I sense that Dr. Larson feels disrespected and her ideas on appropriate care are getting trashed by what she sees as an interloper from the political branch of health care that doesn’t know much.
Fair enough, but these tensions are healthy, in my opinion. Dr. Larson has to understand that a publicly funded healthcare system is going to have political priorities that take into account what public expectations are. In many jurisdictions, the public is not happy with the status quo and this is going to test the mettle of healthcare providers who are trying hard to keep people alive but not appreciated for their efforts.
It seems to me that the tension between Smith and Larson is NOT healthy, since Smith has power and influence and Larson doesn’t. It also seems to me that Smith’s credentials in this effort are over appreciated by the right wing government that admires his “boot strapped” background, but have a tendency to dismiss “experts” like Larson who have studied and worked in this field for decades.
My view on our healthcare system is that there is far too much resistance to change, and while the bulk of that resistance is from unionized workers and administrators the general public is also reluctant to try new approaches even though we know that changes are needed.
Dr. Larson and her cohorts need to feel that they have a voice when change is needed and perhaps the Alberta government should do more listening? But in the end, the “we have always done it this way” mentality that runs through our public healthcare system needs some booster cables. Mr. Smith is holding the cables and has the support of the government to use them.
The question running through my mind as I read Dr. Larson's diatribe against Mr. Smith's "new way" was curiosity as to what her thoughts are on the methods used in the province next door, who have followed the path she is vocally espousing.
Is she seriously arguing - as an expert - that Alberta would have been "better off" to go down the same road as BC?
The roads Alberta and BC are on are really not that different as Paul Wells pointed out in a previous article. The major difference is a fantasy created by the uninformed YouTube rants by Pierre Poilievre, which Wells actually called irresponsible. The data available from the two provinces do not reveal any differences that would support either province claiming being ahead of the other.
Mr. Wells - I still think that it is impermissible to call you by your first name; respect and all - I commend your reporting and I accuse you of making me think - a painful process. Well, accuse is a strong word but you do make me think.
I live in Alberta and I am aware that the model that is underway / happening / whatever you wish to call it here appears to be very different than elsewhere in much of Canada. I have to admit that I have a bias against the "harm reduction" approach (what a misnomer when you supply poison) but I also have to admit that addiction does seem to be incredibly hard to treat and overcome.
I am glad that Alberta is trying to treat addiction and to try to assist addicts to get off their habits but I worry that it seems that there are quite a number of folks who sincerely try to overcome addiction but fail. What happens then?
Ultimately, my point is that this is a far, far more complex issue than I could ever coherently describe, let alone prescribe a cure.
My hat is off to the folks who work in this area and my hat is off to you for your fine reporting and analysis.
Paul, solid reporting and wise advise in your conclusion. It's a complex mess, a societal problem with no simple solutions. Gabor Mate in The Myth of Normal: Trauma, Illness and Healing In A Toxic Culture gets at the complex societal mess quite well.
As someone who’s been very much affected by this problem I have two comments I’d like add: one is that regarding new users, there is growing evidence of a strong genetic link. Anyone like me who’s seen substance abuse with parents, aunts, uncles, brothers, sisters and children knows what I’m talking about. Secondly, addicts need a strong desire to quit. You can’t « force » recovery, I’m convinced of this, even after prolonged, drug-free incarceration. I wish there were more incentives to quit. People won’t hire you if you’re an ex-addict with a criminal record! So many young men slide back into getting high because even with a loving and supportive family, they don’t see a future for themselves and feel ashamed of their past.
Thank you for providing me with a greater understanding for this complex issue.
Maybe the addicts cant always stop, and perhaps we can stop being so judge mental.
Most of us avoid the addicts and fear for our children. Only natural I thank you for providing insights that has helped me with more empathy.
A few weeks ago, behind a Toronto Shoppers Drugmart, I saw one addict doing his best to help another. A brief glimpse broke my heart ay their despair.
On my way out from the drug store, they were trying to move along, this time I put my fear aside and asked if they needed anything… YES, they needed WATER!
I purchased water and protein bars for them. Their thanks touched my heart.
Thank you again for taking time to dive into this complex issue. I learned a lot and feel much better informed, cheers to both Dr. Larson and Mr. Smith.
I can only snap my head back and forth when experts argue, and should reserve judgement.
The politicians should really confine themselves to asking for the budget needed to improve some program, from the most-consensus experts, and voting on allocating that.
Instead, the political level likes to pick the budget, and compel the levels below to invent justifications for that being enough. The Alberta conservatives' record on that one is spotted with the memory of Stephen Duckett, I'll leave that story to wikipedia. I hope these interviewees fare better.
One might hope for a part IV, where we learn what the system is for people who are not marginal. That was always a chunk of the addict population, but more so now with opioids, because so many were hooked by their doctors for pain. 31% of the dead were employed; only half were poor. The interviewees are very focused on the slum-dwellers.
But in BC, construction unions are asking for naxalone to be in supply at construction sites - because of that employed 30%, a third are construction workers. 20% of all opioid deaths come from the construction industry, half just lost their jobs first.
A fair bit of the article is devoted to the proof that many of their patients are not like you and I, damaged. That sounds like there's a whole separate branch of the problem, then, from the half that's from working people that are housed and solvent.
Starting from Alberta's numbers and making some inferences:
. 8755 opioid clients in 2023 (up from 7884 in 2022, despite 1528 opioid poisoning deaths that year)
. 1867 opioid poisoning deaths in 2023
. 55% of deaths were users of illegal drugs who had 'received services' within 30 days of their deaths. This seems a reasonable proxy for the people we see on the street. Assume all remaining deaths were users who were not clients (Roy Brander says 31% of the dead were employed and 'half' of the dead were not poor, which supports the inference that 45% of the dead were not clients of the system)
If there are 8755 drug user clients, using street drugs once a day who make up 55% of deaths, that means the street users have an 11.7% chance of opioid poisoning death each year from each use having a one-in-2926 chance of killing them.
That leaves 45% of deaths, 840 people, who were not drug user clients. If they were using the same drugs, but only once a month rather than daily, that means there are a bit over 200,000 invisible users in Alberta.
So, for every person you see on the street, there are roughly twenty five that you don't recognize. That is 4.6% of Alberta's population. Almost one in twenty people.
31% of the dead were employed, only half were poor? 20% of the dead were construction workers? This is important data that can give better clues to solutions. Where do you get data like that?
...that's to a bunch of reports, and they've used some weird database-display tool that doesn't let you select and copy text. But on that first link, also notice that 48% of drug deaths occurred in "private residence", i.e. home of a non-homeless person.
There's a specific stat for "cheque day". It's significant but not that dramatic: from 6.1 deaths/day to 7.6: a 25% increase over non-cheque days.
The construction industry stats are in news stories:
The BC data is consistent with the Alberta data. 71% male in both provinces. 48% of deaths in home for BC compares to 45% of deaths in Alberta being people who weren't already active clients of the system.
With all the money that is being spent while the problem gets worse, it's crazy that there isn't more and better data.
My own googling has found stuff that has been seriously disappointing given the scope and seriousness of the issue.
If you aren't trying really hard to figure out what is actually going on, what hope is there of finding solutions?
Nice. As someone who is 4+ in the ACE category, I appreciate your look at that. So many of the people I've met who are struggling don't have the supports they need to get through trauma. I had the luxury of a graduate degree and $10,000 of therapy to get stabilized. My privilege is rare and for the 12% of us, it is a lot of work to stay healthy. I wished that were discussed more often when it comes to addictions, especially with women.
Dr Larson let's her slip show a bit when she heads straight for the accusation that the current Govt is on a " for profit" trajectory. While there may be many good arguments for providing private supplied care in our Medicare system, private pay will always be a non starter in this country.
As an observer who hasn't used drugs and has no experience in the difficulties faced by both sides of the drug treatment industry ( for lack of a better word), it is disappointing to see it turn into an " us" vs " them" discussion when ,from an outsiders point of view, both are trying to end the scourge of drug addiction.
Paul, I felt your reporting on this was hurried and breathless. That's not to say that what you've written isn't valuable. I read every word and appreciate that you took time from your regularly scheduled political reporting work to shine a light on this heartbreaking issue and bring your considerable perspective to bear on it. The 'but' is that it felt rushed and lacking substance. Perhaps depth is the more appropriate word here. Premier Kenney's work to immediately dismantle harm reduction needed to be approached. Your belated entry of Dr. Larson's email is an acknowledgement of that. I felt the same critique rising within me as I read your volume on Trudeau recently. And, everyone needs an editor! (U of A grad.. sorry)
This was an important series. I hope you will stay with the story, though. Come back to it somehow and continue to add depth through follow up pieces as you speak with more people. The problem - and the people who are caught in it, both the addicts and those working to help them - deserve it. We will continue to support you.
Thank you for a necessary and thought provoking series on a wrenching problem. Many smart, dedicated people are working to try to solve it and governments are clearly prepared to dedicate significant resources to solutions.
What disturbed me most was the feeling that there is not yet any kind of coherent, clear, data driven approach to understanding and solving the problem. This has to be the first priority.
From what I read, any solution needs three pillars:
1. Reduce the flow of new users
2. Keep existing users alive as long as possible
3. Help existing users recover into non-users
The medical system and harm reduction people are totally dedicated to keeping the users alive as long as possible. However, the Alberta data shows that a user has about a 20% chance of death in a given year. The users are known to the system and receive extensive services, but the Russian roulette of opioid poisoning means they still die. Harm reduction buys time, but unless there is recovery, death is the outcome of regularly playing Russian roulette.
Similarly, Marshall Smith is leaning heavily into recovery. Recovery is the only way to get out alive from the game of Russian roulette. Recovery has to be part of a solution.
Everyone is part of the continuum of getting to a solution but instead there seems to be arguing and recrimination.
What I didn't read any of in this series was about efforts to reduce the flow of new users. Despite the horrific numbers of user deaths, the Alberta data shows the dead are more than being replaced by new users. Better than keeping a user alive as long as possible, better than helping a user recover, is avoiding someone becoming a user in the first place. How can we do that?
Governments are clearly willing to dedicate resources but absent a coherent plan the resources aren't going to get to solutions.
Why I repeated the question about "metrics" in comments to both previous parts. If you have no measure of your success, you aren't doing medical science. I think that's at the heart of Dr. Larson's criticisms, as well.
Exactly! There isn't yet a coherent vision of what the problem is and the approach to solve it. Thanks to this column, I poked through the Alberta data. There is lots of data. What is missing is using the data as evidence to make and test hypothesis about what is going on, what potential solutions might be and what data needs to be gathered to support confirming or refuting the hypothesis.
My twenty minutes of looking at the Alberta data had several things jump out at me:
- about 20% of users die every year. This is pretty consistent (16-26%).
- new users come in at about 150% of the level of users who die (!!!)
> this is clearly a problem. Why is nobody talking about the flow of new users?
- users who die are known to the system and get multiple services
This then causes one to wonder at other data, easily gathered, but seemingly missing. It has been years, why isn't it being gathered? The cost of the data has to be far less than the resources currently dedicated to the problem.
For instance, the data shows users who die. What about users who recover? There is no data and Marshall Smith is just starting to swing big on recovery. Based on the paper he wrote for BC, just over 50% of users recover. Assuming this is true and the best attainable number, then it means that even if the harm reduction and recovery people succeed, half of new users will die playing Russian roulette with fentanyl and the other half will recover.
If so, reducing the flow of new users is a huge missing piece in the system. Opiod dispensing in Alberta has been stable since 2020 and about 20% less than 2016-19, yet the flow of new users is higher than 2016-19. Where are the new users coming from? Are there ways to reduce the flow of new users? What is the data that would help illustrate that? How do we get it?
Thanks! Not-studying drugs, and not-studying drug policy effectiveness, has been an important feature of the War on Drugs from inception.
It's a big part of that "budget first, then prove the budget was correct" approach.
Nobody was ever permitted to acquire cannabis in a lab to study toxicity and addictiveness, because, I believe, they knew it would find none - after the Schaeffer commission under Nixon, and the LeDain Commission here, had their scientific conclusions simply ignored and shrugged off.
So, it's important to note what they are "not-studying". Or "studiously avoiding", you could say.
There is starting to be some research indicating that houselessness is a contributing factor to addiction, rather than the opposite. I don’t have the papers handy right now, but I was stunned, and did a decent amount of fact-checking at the time. It seemed to hold up.
There’s also some indication that if you are sleeping outside, especially in the winter, using opioids improves your survival. The medical reasons are beyond my knowledge, but I think it’s related to heart rate and body temperature.
Great Story, a little unnerving, a little heartbreaking, Definetly tragic.
This story points out the challenges caused by this epidemic that Alberta is facing, and by extension the rest of Canada.
I am beginning to wonder if there is a solution to this problem.
When you look at the history of drug use and addiction in Canada , it seems that we have progressed from Marijuana, Hash, LSD, Mescaline, Heroine, Uppers and Downers ,Cocaine,Extasy, Crack, Methamphetamine, and now a much more dangerous class of drugs, Fentanyl, Nitazene, Carfentinil.
It seems that we are facing a multi headed monster, a Hydra, where we try to cut the heads off only to have them create another two.
Is the answer building a super prison like the government of El Salvador built?
For El Salvador's worst gangs and criminals.
A Canadian version for Drug Gangs and Dealers? Minimum sentence twenty years to life?
One thing seems to be certain, unless we find a solution to this problem it will remain a cancer on Canadian society.
Seeing a couple of people here argue that we need to crack down on drug dealers - I just wanted to bring the perspective that there's not always a binary distinction to be made between addicts and dealers. Many dealers are addicts. I'd bet most live with the kind of trauma addicts live with, as described by Felitti and Anda.
I don't want to sound like too much of a bleeding-heart here. I don't even necessarily disagree that one path would be to crack down on dealers. I don't know enough to opine on that intelligently. But I do want to push back on the notion of "drug dealers" as a separate class of people who are *perpetuating* this problem rather than being, at least in part, *caught up in* some of what Paul describes.
"In fact the biggest thing that keeps people from getting well is often the entire sum of their lives until now, compounded by the influence of drugs that are more potent than anything earlier generations had to deal with."
That sums up the situation. Unfortunately, we cannot change history, we can only learn and help those suffering from trauma to move forward. Advocates for harms-reduction and those supporting recovery-oriented care appear to be in subtle conflict. These groups need to put their biases aside and work together. Living in a substance-induced state is not living.
In the meantime, the evil doers are the drug dealers. They are pushing our most vulnerable to finding temporary relief in their addictive drugs. We need to revive our War on Drugs with a concerted national effort to remove the source.
(Hard to figure what to do with tired tropes rolled out by Larson. There’s a steady supply hanging around climate change policy - where the inertia is at least once removed from the struggles we all see in our communities every day.)
Thank you for the series - undertaken in the middle of a book launch shows an impressive commitment to getting the story the attention it needs.
I’m curious about the possible introduction of psychedelics in the spectrum of care - as a means to address the underlying trauma linked to addiction. Anything on the horizon?
I’ve been following the new interest in psychedelics too. I’m tentatively optimistic for that. I don’t believe at this point that any of the current strategies will work, as glad as I am for the tremendous efforts.
The reference to the ACE study is of paramount importance. Much else pales beside that and goes to the heart of the 1st Nation component of the larger problem. Given the reactive treatment oriented nature of medicine the science of prevention is virtually stillborn and so it is difficult to respond scientifically to the implications of the ACE study. One thing seems clear though, prevention will need to begin very early in life. Trauma treatment needs to begin with infants and toddlers, whatever the intervention turns out to be.
After the second instalment of this piece, these lyrics have been rambling through my head, as they have off and on for the last 30+ years.
“First they taught us to depend on their nation-states to mend our tired minds, our broken bones, our bleeding limbs. But now they’ve sold off all the splints and contracted out the tourniquets and if we jump through hoops then we might just survive.” - Chris Hannah, probably.
Thanks for covering this complex issue in a thoughtful way Mr Wells.
The thing I learned from writing a 100,000-word book (that was the 2013 book, not the latest) is that you never come close to using all your material. The Alberta government is working on substantially increasing the amount of patient-level data, and aggregating all of that together, to get the kind of statistics some people are calling for here. I left that out because (a) it's in the future; I have no idea how effective it'll be (b) Already from here, that kind of effort looks like a Pandora's box of privacy concerns, so I'll wait until that fight happens before writing about it.
But I was cross with one reader who commented on another post about the lack of data in Alberta because, to me, this looked like a highly selective case of curiosity. I mean, holy jumpers, where's the reliable public information we can use to measure the success of any program in any field at any level of government in Canada? Are our ports in the right place? Is our rail system well deployed? How's it going with the 2 billion trees, and what's the name of the person who decided to throw in a few hundred million trees from a source that was previously excluded?
I had a prof who once said, if you want to destroy somebody's argument, check their footnotes. I've used that advice a hundred times. But if you're going to insist on data in one province for one policy area, you're going to need to show me where you've demanded it elsewhere.
The intellectual clash between Mr. Smith and Dr. Larson is interesting. I sense that Dr. Larson feels disrespected and her ideas on appropriate care are getting trashed by what she sees as an interloper from the political branch of health care that doesn’t know much.
Fair enough, but these tensions are healthy, in my opinion. Dr. Larson has to understand that a publicly funded healthcare system is going to have political priorities that take into account what public expectations are. In many jurisdictions, the public is not happy with the status quo and this is going to test the mettle of healthcare providers who are trying hard to keep people alive but not appreciated for their efforts.
It seems to me that the tension between Smith and Larson is NOT healthy, since Smith has power and influence and Larson doesn’t. It also seems to me that Smith’s credentials in this effort are over appreciated by the right wing government that admires his “boot strapped” background, but have a tendency to dismiss “experts” like Larson who have studied and worked in this field for decades.
Fair. Also: You might just be surprised at which other governments don't like experts who tell them what they don't want to hear.
Thoughtful comments, thanks.
My view on our healthcare system is that there is far too much resistance to change, and while the bulk of that resistance is from unionized workers and administrators the general public is also reluctant to try new approaches even though we know that changes are needed.
Dr. Larson and her cohorts need to feel that they have a voice when change is needed and perhaps the Alberta government should do more listening? But in the end, the “we have always done it this way” mentality that runs through our public healthcare system needs some booster cables. Mr. Smith is holding the cables and has the support of the government to use them.
Great series on a very important topic, BTW.
The question running through my mind as I read Dr. Larson's diatribe against Mr. Smith's "new way" was curiosity as to what her thoughts are on the methods used in the province next door, who have followed the path she is vocally espousing.
Is she seriously arguing - as an expert - that Alberta would have been "better off" to go down the same road as BC?
The roads Alberta and BC are on are really not that different as Paul Wells pointed out in a previous article. The major difference is a fantasy created by the uninformed YouTube rants by Pierre Poilievre, which Wells actually called irresponsible. The data available from the two provinces do not reveal any differences that would support either province claiming being ahead of the other.
Mr. Wells - I still think that it is impermissible to call you by your first name; respect and all - I commend your reporting and I accuse you of making me think - a painful process. Well, accuse is a strong word but you do make me think.
I live in Alberta and I am aware that the model that is underway / happening / whatever you wish to call it here appears to be very different than elsewhere in much of Canada. I have to admit that I have a bias against the "harm reduction" approach (what a misnomer when you supply poison) but I also have to admit that addiction does seem to be incredibly hard to treat and overcome.
I am glad that Alberta is trying to treat addiction and to try to assist addicts to get off their habits but I worry that it seems that there are quite a number of folks who sincerely try to overcome addiction but fail. What happens then?
Ultimately, my point is that this is a far, far more complex issue than I could ever coherently describe, let alone prescribe a cure.
My hat is off to the folks who work in this area and my hat is off to you for your fine reporting and analysis.
Paul, solid reporting and wise advise in your conclusion. It's a complex mess, a societal problem with no simple solutions. Gabor Mate in The Myth of Normal: Trauma, Illness and Healing In A Toxic Culture gets at the complex societal mess quite well.
As someone who’s been very much affected by this problem I have two comments I’d like add: one is that regarding new users, there is growing evidence of a strong genetic link. Anyone like me who’s seen substance abuse with parents, aunts, uncles, brothers, sisters and children knows what I’m talking about. Secondly, addicts need a strong desire to quit. You can’t « force » recovery, I’m convinced of this, even after prolonged, drug-free incarceration. I wish there were more incentives to quit. People won’t hire you if you’re an ex-addict with a criminal record! So many young men slide back into getting high because even with a loving and supportive family, they don’t see a future for themselves and feel ashamed of their past.
Thank you for providing me with a greater understanding for this complex issue.
Maybe the addicts cant always stop, and perhaps we can stop being so judge mental.
Most of us avoid the addicts and fear for our children. Only natural I thank you for providing insights that has helped me with more empathy.
A few weeks ago, behind a Toronto Shoppers Drugmart, I saw one addict doing his best to help another. A brief glimpse broke my heart ay their despair.
On my way out from the drug store, they were trying to move along, this time I put my fear aside and asked if they needed anything… YES, they needed WATER!
I purchased water and protein bars for them. Their thanks touched my heart.
Thank you again for taking time to dive into this complex issue. I learned a lot and feel much better informed, cheers to both Dr. Larson and Mr. Smith.
Heading out to get Gabor Mate’s book.
I can only snap my head back and forth when experts argue, and should reserve judgement.
The politicians should really confine themselves to asking for the budget needed to improve some program, from the most-consensus experts, and voting on allocating that.
Instead, the political level likes to pick the budget, and compel the levels below to invent justifications for that being enough. The Alberta conservatives' record on that one is spotted with the memory of Stephen Duckett, I'll leave that story to wikipedia. I hope these interviewees fare better.
One might hope for a part IV, where we learn what the system is for people who are not marginal. That was always a chunk of the addict population, but more so now with opioids, because so many were hooked by their doctors for pain. 31% of the dead were employed; only half were poor. The interviewees are very focused on the slum-dwellers.
But in BC, construction unions are asking for naxalone to be in supply at construction sites - because of that employed 30%, a third are construction workers. 20% of all opioid deaths come from the construction industry, half just lost their jobs first.
A fair bit of the article is devoted to the proof that many of their patients are not like you and I, damaged. That sounds like there's a whole separate branch of the problem, then, from the half that's from working people that are housed and solvent.
Starting from Alberta's numbers and making some inferences:
. 8755 opioid clients in 2023 (up from 7884 in 2022, despite 1528 opioid poisoning deaths that year)
. 1867 opioid poisoning deaths in 2023
. 55% of deaths were users of illegal drugs who had 'received services' within 30 days of their deaths. This seems a reasonable proxy for the people we see on the street. Assume all remaining deaths were users who were not clients (Roy Brander says 31% of the dead were employed and 'half' of the dead were not poor, which supports the inference that 45% of the dead were not clients of the system)
If there are 8755 drug user clients, using street drugs once a day who make up 55% of deaths, that means the street users have an 11.7% chance of opioid poisoning death each year from each use having a one-in-2926 chance of killing them.
That leaves 45% of deaths, 840 people, who were not drug user clients. If they were using the same drugs, but only once a month rather than daily, that means there are a bit over 200,000 invisible users in Alberta.
So, for every person you see on the street, there are roughly twenty five that you don't recognize. That is 4.6% of Alberta's population. Almost one in twenty people.
31% of the dead were employed, only half were poor? 20% of the dead were construction workers? This is important data that can give better clues to solutions. Where do you get data like that?
Five minutes with google:
https://www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports
...that's to a bunch of reports, and they've used some weird database-display tool that doesn't let you select and copy text. But on that first link, also notice that 48% of drug deaths occurred in "private residence", i.e. home of a non-homeless person.
There's a specific stat for "cheque day". It's significant but not that dramatic: from 6.1 deaths/day to 7.6: a 25% increase over non-cheque days.
The construction industry stats are in news stories:
https://www.cbc.ca/news/canada/british-columbia/high-percentage-of-opioid-overdose-victims-worked-in-construction-industry-says-statscan-report-1.4908050
The employment stuff was in StatsCan, but dates back to 2016:
https://www150.statcan.gc.ca/n1/pub/82-003-x/2021002/article/00003-eng.htm
...whereas that first link, the BC report, is fresh, June 2024.
The BC data is consistent with the Alberta data. 71% male in both provinces. 48% of deaths in home for BC compares to 45% of deaths in Alberta being people who weren't already active clients of the system.
With all the money that is being spent while the problem gets worse, it's crazy that there isn't more and better data.
My own googling has found stuff that has been seriously disappointing given the scope and seriousness of the issue.
If you aren't trying really hard to figure out what is actually going on, what hope is there of finding solutions?
Nice. As someone who is 4+ in the ACE category, I appreciate your look at that. So many of the people I've met who are struggling don't have the supports they need to get through trauma. I had the luxury of a graduate degree and $10,000 of therapy to get stabilized. My privilege is rare and for the 12% of us, it is a lot of work to stay healthy. I wished that were discussed more often when it comes to addictions, especially with women.
Dr Larson let's her slip show a bit when she heads straight for the accusation that the current Govt is on a " for profit" trajectory. While there may be many good arguments for providing private supplied care in our Medicare system, private pay will always be a non starter in this country.
As an observer who hasn't used drugs and has no experience in the difficulties faced by both sides of the drug treatment industry ( for lack of a better word), it is disappointing to see it turn into an " us" vs " them" discussion when ,from an outsiders point of view, both are trying to end the scourge of drug addiction.
Paul, I felt your reporting on this was hurried and breathless. That's not to say that what you've written isn't valuable. I read every word and appreciate that you took time from your regularly scheduled political reporting work to shine a light on this heartbreaking issue and bring your considerable perspective to bear on it. The 'but' is that it felt rushed and lacking substance. Perhaps depth is the more appropriate word here. Premier Kenney's work to immediately dismantle harm reduction needed to be approached. Your belated entry of Dr. Larson's email is an acknowledgement of that. I felt the same critique rising within me as I read your volume on Trudeau recently. And, everyone needs an editor! (U of A grad.. sorry)
This was an important series. I hope you will stay with the story, though. Come back to it somehow and continue to add depth through follow up pieces as you speak with more people. The problem - and the people who are caught in it, both the addicts and those working to help them - deserve it. We will continue to support you.
Thank you for a necessary and thought provoking series on a wrenching problem. Many smart, dedicated people are working to try to solve it and governments are clearly prepared to dedicate significant resources to solutions.
What disturbed me most was the feeling that there is not yet any kind of coherent, clear, data driven approach to understanding and solving the problem. This has to be the first priority.
From what I read, any solution needs three pillars:
1. Reduce the flow of new users
2. Keep existing users alive as long as possible
3. Help existing users recover into non-users
The medical system and harm reduction people are totally dedicated to keeping the users alive as long as possible. However, the Alberta data shows that a user has about a 20% chance of death in a given year. The users are known to the system and receive extensive services, but the Russian roulette of opioid poisoning means they still die. Harm reduction buys time, but unless there is recovery, death is the outcome of regularly playing Russian roulette.
Similarly, Marshall Smith is leaning heavily into recovery. Recovery is the only way to get out alive from the game of Russian roulette. Recovery has to be part of a solution.
Everyone is part of the continuum of getting to a solution but instead there seems to be arguing and recrimination.
What I didn't read any of in this series was about efforts to reduce the flow of new users. Despite the horrific numbers of user deaths, the Alberta data shows the dead are more than being replaced by new users. Better than keeping a user alive as long as possible, better than helping a user recover, is avoiding someone becoming a user in the first place. How can we do that?
Governments are clearly willing to dedicate resources but absent a coherent plan the resources aren't going to get to solutions.
"If you can't measure it, you can't manage it".
Why I repeated the question about "metrics" in comments to both previous parts. If you have no measure of your success, you aren't doing medical science. I think that's at the heart of Dr. Larson's criticisms, as well.
Exactly! There isn't yet a coherent vision of what the problem is and the approach to solve it. Thanks to this column, I poked through the Alberta data. There is lots of data. What is missing is using the data as evidence to make and test hypothesis about what is going on, what potential solutions might be and what data needs to be gathered to support confirming or refuting the hypothesis.
My twenty minutes of looking at the Alberta data had several things jump out at me:
- about 20% of users die every year. This is pretty consistent (16-26%).
- new users come in at about 150% of the level of users who die (!!!)
> this is clearly a problem. Why is nobody talking about the flow of new users?
- users who die are known to the system and get multiple services
This then causes one to wonder at other data, easily gathered, but seemingly missing. It has been years, why isn't it being gathered? The cost of the data has to be far less than the resources currently dedicated to the problem.
For instance, the data shows users who die. What about users who recover? There is no data and Marshall Smith is just starting to swing big on recovery. Based on the paper he wrote for BC, just over 50% of users recover. Assuming this is true and the best attainable number, then it means that even if the harm reduction and recovery people succeed, half of new users will die playing Russian roulette with fentanyl and the other half will recover.
If so, reducing the flow of new users is a huge missing piece in the system. Opiod dispensing in Alberta has been stable since 2020 and about 20% less than 2016-19, yet the flow of new users is higher than 2016-19. Where are the new users coming from? Are there ways to reduce the flow of new users? What is the data that would help illustrate that? How do we get it?
This is a long way of agreeing with your comment.
Thanks! Not-studying drugs, and not-studying drug policy effectiveness, has been an important feature of the War on Drugs from inception.
It's a big part of that "budget first, then prove the budget was correct" approach.
Nobody was ever permitted to acquire cannabis in a lab to study toxicity and addictiveness, because, I believe, they knew it would find none - after the Schaeffer commission under Nixon, and the LeDain Commission here, had their scientific conclusions simply ignored and shrugged off.
So, it's important to note what they are "not-studying". Or "studiously avoiding", you could say.
In response to your new users question:
There is starting to be some research indicating that houselessness is a contributing factor to addiction, rather than the opposite. I don’t have the papers handy right now, but I was stunned, and did a decent amount of fact-checking at the time. It seemed to hold up.
There’s also some indication that if you are sleeping outside, especially in the winter, using opioids improves your survival. The medical reasons are beyond my knowledge, but I think it’s related to heart rate and body temperature.
That is most interesting. Thank you!
There is a pretty direct connection between the cost of housing and homelessness.
Even the strongest among us would find living on the streets hard to sustain for more than a few days.
A big part of Marshall Smith's recovery approach is that those on the recovery path are given housing in a recovery centre.
So it makes sense that there is a connection between homelessness and opiod poisoning deaths.
If so, a deliberate policy of building enough housing so that there is enough for everyone would have do a lot more than just solve homelessness.
Great Writing
Great Story, a little unnerving, a little heartbreaking, Definetly tragic.
This story points out the challenges caused by this epidemic that Alberta is facing, and by extension the rest of Canada.
I am beginning to wonder if there is a solution to this problem.
When you look at the history of drug use and addiction in Canada , it seems that we have progressed from Marijuana, Hash, LSD, Mescaline, Heroine, Uppers and Downers ,Cocaine,Extasy, Crack, Methamphetamine, and now a much more dangerous class of drugs, Fentanyl, Nitazene, Carfentinil.
It seems that we are facing a multi headed monster, a Hydra, where we try to cut the heads off only to have them create another two.
Is the answer building a super prison like the government of El Salvador built?
For El Salvador's worst gangs and criminals.
A Canadian version for Drug Gangs and Dealers? Minimum sentence twenty years to life?
One thing seems to be certain, unless we find a solution to this problem it will remain a cancer on Canadian society.
Seeing a couple of people here argue that we need to crack down on drug dealers - I just wanted to bring the perspective that there's not always a binary distinction to be made between addicts and dealers. Many dealers are addicts. I'd bet most live with the kind of trauma addicts live with, as described by Felitti and Anda.
I don't want to sound like too much of a bleeding-heart here. I don't even necessarily disagree that one path would be to crack down on dealers. I don't know enough to opine on that intelligently. But I do want to push back on the notion of "drug dealers" as a separate class of people who are *perpetuating* this problem rather than being, at least in part, *caught up in* some of what Paul describes.
"In fact the biggest thing that keeps people from getting well is often the entire sum of their lives until now, compounded by the influence of drugs that are more potent than anything earlier generations had to deal with."
That sums up the situation. Unfortunately, we cannot change history, we can only learn and help those suffering from trauma to move forward. Advocates for harms-reduction and those supporting recovery-oriented care appear to be in subtle conflict. These groups need to put their biases aside and work together. Living in a substance-induced state is not living.
In the meantime, the evil doers are the drug dealers. They are pushing our most vulnerable to finding temporary relief in their addictive drugs. We need to revive our War on Drugs with a concerted national effort to remove the source.
We've been losing the War on Drugs for 50+ years, and your strategy is to just double down on it?
Sadly, statistics do not bear out your thinking because use is up, while charges are down.
(Hard to figure what to do with tired tropes rolled out by Larson. There’s a steady supply hanging around climate change policy - where the inertia is at least once removed from the struggles we all see in our communities every day.)
Thank you for the series - undertaken in the middle of a book launch shows an impressive commitment to getting the story the attention it needs.
I’m curious about the possible introduction of psychedelics in the spectrum of care - as a means to address the underlying trauma linked to addiction. Anything on the horizon?
(Here’s a pod I found to be quite helpful in getting a baseline of knowledge. https://podcasts.apple.com/ca/podcast/hell-high-water-with-john-heilemann/id1529346075?i=1000533332278 )
Again, thank you for the effort.
I’ve been following the new interest in psychedelics too. I’m tentatively optimistic for that. I don’t believe at this point that any of the current strategies will work, as glad as I am for the tremendous efforts.
The reference to the ACE study is of paramount importance. Much else pales beside that and goes to the heart of the 1st Nation component of the larger problem. Given the reactive treatment oriented nature of medicine the science of prevention is virtually stillborn and so it is difficult to respond scientifically to the implications of the ACE study. One thing seems clear though, prevention will need to begin very early in life. Trauma treatment needs to begin with infants and toddlers, whatever the intervention turns out to be.
After the second instalment of this piece, these lyrics have been rambling through my head, as they have off and on for the last 30+ years.
“First they taught us to depend on their nation-states to mend our tired minds, our broken bones, our bleeding limbs. But now they’ve sold off all the splints and contracted out the tourniquets and if we jump through hoops then we might just survive.” - Chris Hannah, probably.
Thanks for covering this complex issue in a thoughtful way Mr Wells.