Addictions
A conversation with Premier Smith’s outgoing chief of staff, architect of Alberta’s recovery-focused drug policies

Marshall Smith, Alberta’s Chief of Staff, sits in his office at the Alberta Legislature in Edmonton
Marshall Smith, on what he has learned as an addict and policy leader and what’s next for him
Alberta Premier Danielle Smith’s chief of staff, Marshall Smith, is leaving his post at the end of October.
Since taking office in 2022, he has been instrumental in shaping Alberta’s drug policies and developing the Alberta Model — a recovery-focused addiction treatment policy that has gained international recognition for enhancing access to mental health and addiction services.
Under his guidance, Alberta has prioritized building recovery communities over harm-reduction programs. Government data show a 53 per cent decrease in opioid-related overdose deaths in June 2024 from the prior year, which may suggest Smith’s initiatives are having an impact.
In a statement on social media, the Premier shared that Smith informed her of his decision to retire earlier this year, after dedicating 32 years to public service. His departure comes just ahead of the United Conservative Party’s leadership review on Nov. 2.
Smith met with reporter Alexandra Keeler on Sept. 10 to discuss his personal journey from addiction to recovery and how it has shaped Alberta’s drug policies. On Oct. 10, they spoke by phone to discuss his recent decision to step down and what lies ahead for him.
AK: What emotional and psychological impact did your addiction have on your sense of self?
MS: It makes you feel powerless. Addiction is an illness of isolation, despair, loneliness and powerlessness. One of the hallmarks of addiction is continuing to use a substance despite a complete lack of control over your using, and over the circumstances that you’re in.
AK: Do you think that sense of powerlessness impacts an individual’s ability to provide informed consent for involuntary treatment?
MS: I think that, over time, if addiction is left unchecked or untreated, or is allowed to progress to its very latter stages, you absolutely lose agency over your ability to make decisions.
I used to get the question a lot: ‘Is it a disease? Is it a choice?’ And I say it’s both. It’s actually a disease of choices, which is to say that it’s a disease or an illness that affects my brain’s ability to make good choices.
AK: Were you the driving force behind Alberta’s shift away from harm reduction towards a recovery-focused approach, or was there a broader change in attitudes within the community?
MS: Certainly I’m not solely responsible. I’m a member of a broad community of people in recovery who have been advocating for these policies for two decades. I think that I have a background [and] certain skills that have found me in positions like this, where I can be most effective helping my community advance these ideas and concepts and actually get them implemented into policy and action.
AK: Obviously your lived experience with addiction brings a valuable perspective to the table. But what data sources are the province using to inform its addiction and recovery policies?
MS: We have a very broad literature base that we use to inform a lot of our policy decisions … Alberta [also] has the most comprehensive data collection and data analytics system in North America, bar none.
A practical example of how that’s useful is … [if] the data shows us that a very high number of people who were in custody — whether that’s corrections or police custody — went on to fatally overdose in a period after their release, that tells us that we need to focus on correctional programs, and we need to focus on policing programs.
And we’ve done that. We have amazing new correctional treatment programs that are second to none. I don’t know of anybody in Canada that’s doing this — we’ve taken [jail units where inmates sleep and live] and turned them into treatment centres, and connected them with our new treatment centres outside of jails. We partnered with police, because police have probably the most amount of contact with people who are using substances, and we gave them the ability to help people get on to opioid-substitution medications.
We’re going to go even further. Minister [of Mental Health and Addiction Dan] Williams has just announced the creation of the Centre of Recovery Excellence (CoRE), which is a first of its kind in Canada. It’s a Crown corporation not beholden to pharmaceutical money, which is a big change for us, and we were very deliberate about that.
[CoRE] will give us the ability to pull in data from across systems in government and have that data analyzed … So we’re entering into a very exciting time in terms of data and analytics around this issue.
AK: Without CoRE fully operational yet, what made you confident the recovery-focused approach would succeed?
MS: I see hundreds of thousands of Canadians every day entering recovery and maintaining their recovery … What I see in the alternative is a lot of drug use, homelessness, despair, disease [and] crime.
We spend a lot of time talking about data and evidence and science, and all of those things are good and necessary … but it’s not the only component of the decision-making process. … The policies that we’re making and the pathways that we take also have to be informed by the values of the community that we serve. … For far too long in Canada, that hasn’t been a consideration.
I think that we are at a place in Canada where the country is saying to us it’s time to revisit the direction that we’ve been going. I think that they’re saying to us, as policymakers, that we gave this a chance. We had become convinced by experts and the media … to give [pro-drug, harm-reduction policies like safer supply] a try …
[A]fter 20 years of that, I think that Canadians are ready to throw in the towel and to say, ‘We’re done with this. We’ve given you enough time to prove out your thesis. It’s not worked, and now we’re looking for fresh ideas.’
So Alberta is here leading that conversation of fresh and different ideas, and we’re happy to have that role.
The remainder of this interview took place on Oct. 10.
AK: Premier Smith announced your retirement at the end of October. What prompted your decision to step down?
MS: My time in Alberta has been a lengthy and intense role of system transformation over two premiers and standing up government twice.
While there’s still a lot of work to be done here, we have a tremendous team in Alberta that is leading that work under Minister Williams. I just felt that it’s time for me to step out of the role and continue to serve in other capacities.
AK: Looking ahead, what aspects of the Alberta Model will you carry with you into your future endeavours?
MS: I would say all aspects of the model need to be expanded across Canada, for jurisdictions that are interested.
Where I can be of the most assistance to other governments is talking to them about how to effectively organize themselves to be successful in this area. I think that governments across the country are struggling to figure out how to do that.
AK: What new opportunities do you hope to pursue that you haven’t been able to explore during your time in this role? Will your focus continue to be in addiction and drug policy?
MS: The majority of my focus will be on addiction and drug policy, but I have other areas of interest.
I’m passionate about the work that we’re doing with Indigenous people … I’m also very passionate about emerging technology and how we’re going to use that to uncover some of the answers that we’re looking for on these models.
I’m looking forward to having a little bit more freedom and focus.
This interview has been edited and condensed for clarity.
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
Subscribe to Break The Needle. Our content is always free – but if you want to help us commission more high-quality journalism, consider getting a voluntary paid subscription.
2025 Federal Election
Study links B.C.’s drug policies to more overdoses, but researchers urge caution

By Alexandra Keeler
A study links B.C.’s safer supply and decriminalization to more opioid hospitalizations, but experts note its limitations
A new study says B.C.’s safer supply and decriminalization policies may have failed to reduce overdoses. Furthermore, the very policies designed to help drug users may have actually increased hospitalizations.
“Neither the safer opioid supply policy nor the decriminalization of drug possession appeared to mitigate the opioid crisis, and both were associated with an increase in opioid overdose hospitalizations,” the study says.
The study has sparked debate, with some pointing to it as proof that B.C.’s drug policies failed. Others have questioned the study’s methodology and conclusions.
“The question we want to know the answer to [but cannot] is how many opioid hospitalizations would have occurred had the policy not have been implemented,” said Michael Wallace, a biostatistician and associate professor at the University of Waterloo.
“We can never come up with truly definitive conclusions in cases such as this, no matter what data we have, short of being able to magically duplicate B.C.”
Jumping to conclusions
B.C.’s controversial safer supply policies provide drug users with prescription opioids as an alternative to toxic street drugs. Its decriminalization policy permitted drug users to possess otherwise illegal substances for personal use.
The peer-reviewed study was led by health economist Hai Nguyen and conducted by researchers from Memorial University in Newfoundland, the University of Manitoba and Weill Cornell Medicine, a medical school in New York City. It was published in the medical journal JAMA Health Forum on March 21.
The researchers used a statistical method to create a “synthetic” comparison group, since there is no ideal control group. The researchers then compared B.C. to other provinces to assess the impact of certain drug policies.
Examining data from 2016 to 2023, the study links B.C.’s safer supply policies to a 33 per cent rise in opioid hospitalizations.
The study says the province’s decriminalization policies further drove up hospitalizations by 58 per cent.
“Neither the safer supply policy nor the subsequent decriminalization of drug possession appeared to alleviate the opioid crisis,” the study concludes. “Instead, both were associated with an increase in opioid overdose hospitalizations.”
The B.C. government rolled back decriminalization in April 2024 in response to widespread concerns over public drug use. This February, the province also officially acknowledged that diversion of safer supply drugs does occur.
The study did not conclusively determine whether the increase in hospital visits was due to diverted safer supply opioids, the toxic illicit supply, or other factors.
“There was insufficient evidence to conclusively attribute an increase in opioid overdose deaths to these policy changes,” the study says.
Nguyen’s team had published an earlier, 2024 study in JAMA Internal Medicine that also linked safer supply to increased hospitalizations. However, it failed to control for key confounders such as employment rates and naloxone access. Their 2025 study better accounts for these variables using the synthetic comparison group method.
The study’s authors did not respond to Canadian Affairs’ requests for comment.
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Correlation vs. causation
Chris Perlman, a health data and addiction expert at the University of Waterloo, says more studies are needed.
He believes the findings are weak, as they show correlation but not causation.
“The study provides a small signal that the rates of hospitalization have changed, but I wouldn’t conclude that it can be solely attributed to the safer supply and decrim[inalization] policy decisions,” said Perlman.
He also noted the rise in hospitalizations doesn’t necessarily mean more overdoses. Rather, more people may be reaching hospitals in time for treatment.
“Given that the [overdose] rate may have gone down, I wonder if we’re simply seeing an effect where more persons survive an overdose and actually receive treatment in hospital where they would have died in the pre-policy time period,” he said.
The Nguyen study acknowledges this possibility.
“The observed increase in opioid hospitalizations, without a corresponding increase in opioid deaths, may reflect greater willingness to seek medical assistance because decriminalization could reduce the stigma associated with drug use,” it says.
“However, it is also possible that reduced stigma and removal of criminal penalties facilitated the diversion of safer opioids, contributing to increased hospitalizations.”
Karen Urbanoski, an associate professor in the Public Health and Social Policy department at the University of Victoria, is more critical.
“The [study’s] findings do not warrant the conclusion that these policies are causally associated with increased hospitalization or overdose,” said Urbanoski, who also holds the Canada Research Chair in Substance Use, Addictions and Health Services.
Her team published a study in November 2023 that measured safer supply’s impact on mortality and acute care visits. It found safer supply opioids did reduce overdose deaths.
Critics, however, raised concerns that her study misrepresented its underlying data and showed no statistically significant reduction in deaths after accounting for confounding factors.
The Nguyen study differs from Urbanoski’s. While Urbanoski’s team focused on individual-level outcomes, the Nguyen study analyzed broader, population-level effects, including diversion.
Wallace, the biostatistician, agrees more individual-level data could strengthen analysis, but does not believe it undermines the study’s conclusions. Wallace thinks the researchers did their best with the available data they had.
“We do not have a ‘copy’ of B.C. where the policies weren’t implemented to compare with,” said Wallace.
B.C.’s overdose rate of 775 per 100,000 is well above the national average of 533.
Elenore Sturko, a Conservative MLA for Surrey-Cloverdale, has been a vocal critic of B.C.’s decriminalization and safer supply policies.
“If the government doesn’t want to believe this study, well then I invite them to do a similar study,” she told reporters on March 27.
“Show us the evidence that they have failed to show us since 2020,” she added, referring to the year B.C. implemented safer supply.
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
Our content is always free – but if you want to help us commission more high-quality journalism,
consider getting a voluntary paid subscription.
Addictions
Addiction experts demand witnessed dosing guidelines after pharmacy scam exposed

By Alexandra Keeler
The move follows explosive revelations that more than 60 B.C. pharmacies were allegedly participating in a scheme to overbill the government under its safer supply program. The scheme involved pharmacies incentivizing clients to fill prescriptions they did not require by offering them cash or rewards. Some of those clients then sold the drugs on the black market.
An addiction medicine advocacy group is urging B.C. to promptly issue new guidelines for witnessed dosing of drugs dispensed under the province’s controversial safer supply program.
In a March 24 letter to B.C.’s health minister, Addiction Medicine Canada criticized the BC Centre on Substance Use for dragging its feet on delivering the guidelines and downplaying the harms of prescription opioids.
The centre, a government-funded research hub, was tasked by the B.C. government with developing the guidelines after B.C. pledged in February to return to witnessed dosing. The government’s promise followed revelations that many B.C. pharmacies were exploiting rules permitting patients to take safer supply opioids home with them, leading to abuse of the program.
“I think this is just a delay,” said Dr. Jenny Melamed, a Surrey-based family physician and addiction specialist who signed the Addiction Medicine Canada letter. But she urged the centre to act promptly to release new guidelines.
“We’re doing harm and we cannot just leave people where they are.”
Addiction Medicine Canada’s letter also includes recommendations for moving clients off addictive opioids altogether.
“We should go back to evidence-based medicine, where we have medications that work for people in addiction,” said Melamed.
‘Best for patients’
On Feb. 19, the B.C. government said it would return to a witnessed dosing model. This model — which had been in place prior to the pandemic — will require safer supply participants to take prescribed opioids under the supervision of health-care professionals.
The move follows explosive revelations that more than 60 B.C. pharmacies were allegedly participating in a scheme to overbill the government under its safer supply program. The scheme involved pharmacies incentivizing clients to fill prescriptions they did not require by offering them cash or rewards. Some of those clients then sold the drugs on the black market.
In its Feb. 19 announcement, the province said new participants in the safer supply program would immediately be subject to the witnessed dosing requirement. For existing clients of the program, new guidelines would be forthcoming.
“The Ministry will work with the BC Centre on Substance Use to rapidly develop clinical guidelines to support prescribers that also takes into account what’s best for patients and their safety,” Kendra Wong, a spokesperson for B.C.’s health ministry, told Canadian Affairs in an emailed statement on Feb. 27.
More than a month later, addiction specialists are still waiting.
According to Addiction Medicine Canada’s letter, the BC Centre on Substance Use posed “fundamental questions” to the B.C. government, potentially causing the delay.
“We’re stuck in a place where the government publicly has said it’s told BCCSU to make guidance, and BCCSU has said it’s waiting for government to tell them what to do,” Melamed told Canadian Affairs.
This lag has frustrated addiction specialists, who argue the lack of clear guidance is impeding the transition to witnessed dosing and jeopardizing patient care. They warn that permitting take-home drugs leads to more diversion onto the streets, putting individuals at greater risk.
“Diversion of prescribed alternatives expands the number of people using opioids, and dying from hydromorphone and fentanyl use,” reads the letter, which was also co-signed by Dr. Robert Cooper and Dr. Michael Lester. The doctors are founding board members of Addiction Medicine Canada, a nonprofit that advises on addiction medicine and advocates for research-based treatment options.
“We have had people come in [to our clinic] and say they’ve accessed hydromorphone on the street and now they would like us to continue [prescribing] it,” Melamed told Canadian Affairs.
A spokesperson for the BC Centre on Substance Use declined to comment, referring Canadian Affairs to the Ministry of Health. The ministry was unable to provide comment by the publication deadline.
Big challenges
Under the witnessed dosing model, doctors, nurses and pharmacists will oversee consumption of opioids such as hydromorphone, methadone and morphine in clinics or pharmacies.
The shift back to witnessed dosing will place significant demands on pharmacists and patients. In April 2024, an estimated 4,400 people participated in B.C.’s safer supply program.
Chris Chiew, vice president of pharmacy and health-care innovation at the pharmacy chain London Drugs, told Canadian Affairs that the chain’s pharmacists will supervise consumption in semi-private booths.
Nathan Wong, a B.C.-based pharmacist who left the profession in 2024, fears witnessed dosing will overwhelm already overburdened pharmacists, creating new barriers to care.
“One of the biggest challenges of the retail pharmacy model is that there is a tension between making commercial profit, and being able to spend the necessary time with the patient to do a good and thorough job,” he said.
“Pharmacists often feel rushed to check prescriptions, and may not have the time to perform detailed patient counselling.”
Others say the return to witnessed dosing could create serious challenges for individuals who do not live close to health-care providers.
Shelley Singer, a resident of Cowichan Bay, B.C., on Vancouver Island, says it was difficult to make multiple, daily visits to a pharmacy each day when her daughter was placed on witnessed dosing years ago.
“It was ridiculous,” said Singer, whose local pharmacy is a 15-minute drive from her home. As a retiree, she was able to drive her daughter to the pharmacy twice a day for her doses. But she worries about patients who do not have that kind of support.
“I don’t believe witnessed supply is the way to go,” said Singer, who credits safer supply with saving her daughter’s life.
Melamed notes that not all safer supply medications require witnessed dosing.
“Methadone is under witness dosing because you start low and go slow, and then it’s based on a contingency management program,” she said. “When the urine shows evidence of no other drug, when the person is stable, [they can] take it at home.”
She also noted that Suboxone, a daily medication that prevents opioid highs, reduces cravings and alleviates withdrawal, does not require strict supervision.
Kendra Wong, of the B.C. health ministry, told Canadian Affairs that long-acting medications such as methadone and buprenorphine could be reintroduced to help reduce the strain on health-care professionals and patients.
“There are medications available through the [safer supply] program that have to be taken less often than others — some as far apart as every two to three days,” said Wong.
“Clinicians may choose to transition patients to those medications so that they have to come in less regularly.”
Such an approach would align with Addiction Medicine Canada’s recommendations to the ministry.
The group says it supports supervised dosing of hydromorphone as a short-term solution to prevent diversion. But Melamed said the long-term goal of any addiction treatment program should be to reduce users’ reliance on opioids.
The group recommends combining safer supply hydromorphone with opioid agonist therapies. These therapies use controlled medications to reduce withdrawal symptoms, cravings and some of the risks associated with addiction.
They also recommend limiting unsupervised hydromorphone to a maximum of five 8 mg tablets a day — down from the 30 tablets currently permitted with take-home supplies. And they recommend that doses be tapered over time.
“This protocol is being used with success by clinicians in B.C. and elsewhere,” the letter says.
“Please ensure that the administrative delay of the implementation of your new policy is not used to continue to harm the public.”
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
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