Managed alcohol programs: Is it time for a more radical approach to reduce harms for people experiencing homelessness and alcohol use disorders?

Welcome to this special section of the Drug and Alcohol Review presenting new research and commentary on a complex and at times controversial area of substance use policy: the provision of alcohol as a harm reduction measure, commonly known as Managed Alcohol Programs (MAP). MAPs are for people experiencing homelessness and severe alcohol-related problems. It is widely thought that the practice of managing the supply of alcohol by providing regular doses to individuals as part of a formal program is an almost uniquely Canadian phenomenon. There are examples in other countries of programs that tolerate drinking or provide alcohol in exchange for work keeping public space tidy 1, 2. In this section, we specifically focus on programs in which beverage alcohol is provided in measured, regular doses throughout the day, usually in a residential setting, as a harm-reduction strategy. Pauly et al. 3 describe the wide ranging practices and policies found across 14 Canadian MAPs, highlighting critical implementation issues. We suspect there are many other programs operating quietly in order to avoid public criticism and the risk of being shut down. By way of illustration, we were asked 2 years ago to help with a scan of existing services for people who are homeless and experiencing severe alcohol dependence in a city with a view to estimating the need for a MAP. However, the scan uncovered four MAPs already operating in that city. Pauly et al. report on the variation in programs along six key dimensions: program goals and eligibility; alcohol dispensing and administration; funding models and money management; accommodation; primary care services; and cultural and social dimensions. Muckle et al. 4 briefly describe the evolution of perhaps the best known Canadian MAP, run by the Shepherds of Good Hope in Ottawa. While all MAPs focus on filling a gap in services for people who are otherwise unstably housed, they variously operate as a cooperative for making and sharing alcohol, as a day program, as a shelter or as a source of permanent accommodation. The provision of alcohol varies considerably in relation to timing and quantity of ‘dosing’, for example, from an hourly standard drink to a daily ration. Program rules and policies vary with more or less emphasis on third party management of alcohol consumption. Two papers in this section focus on the complexities of managing the consumption of alcohol by people with severe dependence in a hospital setting. Hill et al. 5 illustrate some challenges for inpatient treatment of serious comorbid illnesses with a case study. Brookes et al. 6 conducted a scoping review of alcohol administration in hospitals as well as the development and implementation of community-based MAPs. From this review, they provide relevant and timely insights for implementation of MAP protocols within a hospital setting to ensure better care in hospital, completion of hospital care and transition to community care. In Vancouver, the Eastside Illicit Drinkers Group for Education, comprising of people who consume non-beverage alcohol, has long advocated for better services for their community. In this special section, the Eastside Illicit Drinkers Group for Education provides perspectives on the importance of harm reduction for their members and the need for additional support such as MAPs 7. Their contribution is an eloquent testimony to the structural sources of stigma that are embedded in health and social systems that impede development of services for an often-overlooked population. They highlight the importance and need for community-based MAPs that are tailored to the needs of people experiencing marginalisation and isolation. Before 2016, there was, to our knowledge, only a single peer-reviewed publication describing outcomes for MAPs 8. Four of the papers in this section are early outputs from the Canadian Managed Alcohol Programs Study, a Canada-wide study that seeks to bring these programs out into the open and shed light on the extent to which, in their different forms, they contribute to the health and well-being of participants. Stockwell et al. 9 present some basic comparisons on self-reported patterns of use and related harms among 175 clients attending six different MAPs in comparison with 189 individuals eligible for but not enrolled in a MAP. These results are encouraging even though selection biases favouring the MAP clients cannot be ruled out. However, Chow et al. 10 find that clients of some MAPs are consuming considerable amounts of alcohol outside of their program and to an extent that the program staff are likely unaware. They also suggest that the extent of outside drinking—or at least willingness to be open about this to the independent research team—was related to how program policies on outside drinking were implemented. Erickson et al. 11 explore how both MAP clients and controls report coping when they cannot access sufficient alcohol. Most commonly, strategies deemed ‘positive’ or potentially harm reducing are reported, for example, seeking treatment or going without alcohol. While some ‘negative’ strategies such as resorting to non-beverage alcohol or stealing alcohol were reported, the MAP clients were significantly less likely to engage in these strategies than were controls. These findings are discussed in relation to concerns that broader public health strategies, such as minimum alcohol pricing 12, may have unintended negative consequences for vulnerable individuals with alcohol dependence. We are aware of efforts to initiate MAPs in other countries, including Ireland and Australia. Ezard et al. 13 present the results of a study designed to test the feasibility of initiating a MAP in an Australian city. Using survey methodology, Ezard et al. examined the acceptability of different MAP models for people experiencing severe alcohol dependence and homelessness among potential services users. They found a high degree of acceptability and undertook predictions of cost effectiveness of implementing such models, suggesting that such programs would be cost effective. These are very early days for research on MAPs, and the offerings in this section provide numerous insights but undoubtedly raise as many questions as they answer. We wish to highlight three concerns repeatedly raised by reviewers and commentators in relation to current research on MAP. First, how is it possible to separate out the benefits of providing accommodation, food or other basic necessities for health as part of a MAP for individuals who are, otherwise at best, unstably housed from the benefits of managing their alcohol? We note evidence that clients of residential MAPs (the majority) mostly stay, often for many years. It seems likely that having access to a secure and ‘managed’ supply of beverage alcohol may be the key to this housing success and better outcomes. In his commentary, Gaetz 14 provides reflections on MAPs as part of a pragmatic overall response to homelessness. He highlights how homeless program rules and policies are typically skewed towards abstinence rather than harm reduction. We would like to point out that in the Canadian Managed Alcohol Programs Study, the majority of participants were homeless and unable to secure housing prior to MAP, often rotating through shelters, streets, jails and hospitals 15. We have previously reported evidence 16 that, in marked contrast, there is a very low turnover of residents on MAPs. A second concern is the relationship between program development and implementation and the specific outcomes of programs. We contend that program implementation matters and that, in particular, variations in program settings and the implementation of policies around alcohol management are implicated in the extent to which programs achieve goals of harm reduction. The findings of Chow et al. 10 and our pilot studies 16 provide some empirical support that specifics of MAP implementation may be critically important for the types of outcomes achieved. The third common concern reflects the success of many of these programs helping their clients maintain stable accommodation after years of living in and out of jails, shelters, camping and parks, hospital beds and emergency rooms. Room 17 highlights the critical point that alcohol is a toxic, carcinogenic intoxicant and one of the leading causes of preventable death, injury and illness, globally. How can or do we justify providing large amounts of such a dangerous substance to already vulnerable populations? There is growing evidence that MAPs may be successful in reducing acute alcohol-related harms such as violence-related injuries, alcoholic poisoning and freezing on a cold winter night 16. But what about ongoing and increased risks of serious alcohol-related diseases as a result of uninterrupted consumption (e.g. liver cirrhosis, cancers of the digestive system)? Are these inevitable, or what strategies can be developed to also minimise risks of chronic alcohol-related harms for this population? In Table 1 we provide a provisional summary of the intended benefits of MAPs in relation to different categories of alcohol-related harm and proposed strategies to mitigate unintended negative consequences. This summarises some of our learnings and impressions to date from our interactions with the clients, staff and managers of these programs in Canada. It is intended to stimulate debate and focus future research on strategies to improve outcomes for this most vulnerable and often under-serviced population.

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