“There is a Place”: impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness

Abstract

BackgroundThe twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA).MethodsWe examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of “messy”, “ordered” and “social arenas” maps that provide insight into the social worlds of participants and the impact of MAPs.ResultsPrior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing.ConclusionsIn a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.

Investigating the need for alcohol harm reduction and managed alcohol programs for people experiencing homelessness and alcohol use disorders in Scotland

“…The current focus on drug‐related deaths in Scotland may put those who consume alcohol at greater risk of harm, as their needs are relatively invisible. Our study also shows similarities to those accessing MAPs in Canada who are typically male, with high rates of daily drinking and high levels of alcohol consumption and related harm [17,18,20,36]. This suggests the need for MAPs in Scotland, given the high levels of need and current lack of appropriate services.…”

“…Given this narrow focus within harm reduction, those who are at risk of alcohol‐related harms seem to be particularly vulnerable to being invisible within current service configurations. MAPs have been found to break the ‘vicious cycle’ of moving through multiple agencies, with people often not receiving the care they need [20]. In the current COVID‐19 pandemic, MAPs could provide safer management and supply of alcohol, in order to reduce the likelihood of withdrawal and infection of the virus [39].…”

“…Several studies in Canada have had positive results, with participants experiencing fewer withdrawal seizures; reduced alcohol‐related harms; improvements in relationships, quality of life, wellbeing and safety [15]; lower alcohol intake and use of less harmful types of alcohol [16]; ability to retain their housing throughout the study period [17]; and less harmful patterns of use [18], alongside evidence of cost–benefits [19]. MAPs have been described as ‘a safer physical environment’ [15; p.6], and as places for healing and reconnection [20]. Work in Canada has identified the key features of MAPs [6].…”

Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program

“…Managed alcohol programs and other alcohol-targeted interventions should be developed in homeless subjects with severe mental disorders (Pauly et al, 2019) as well as Mindfulness-Oriented Recovery Enhancement that has shown effectiveness in Co-Occurring Substance Dependence, Traumatic Stress, and Psychiatric Disorders (Garland et al, 2016).…”

What can primary care services do to help First Nations people with unhealthy alcohol use? A systematic review: Australia, New Zealand, USA and Canada

“…There is likely documentation of cultural and western treatments with First Nations peoples in that literature which has been missed. Additionally, approaches such as 'managed alcohol programs' were not within the scope of this review, but have been reported to offer some promise in improving health and wellbeing outcomes [106,107]. Community participation quality ratings may not be a true reflection on all studies' actual conduct as there may be more engagement than was recorded.…”