On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement.

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness.

Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting.

BACKGROUND: While supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region. METHODS: Between June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively. RESULTS: Among 200 PWID (median age, IQR: 35, 28-43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08-8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06-5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02-6.58). CONCLUSIONS: Our findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.

Community managed alcohol programs in Canada: Overview of key dimensions and implementation.

INTRODUCTION AND AIMS: People with severe alcohol dependence and unstable housing are vulnerable to multiple harms related to drinking and homelessness. Managed Alcohol Programs (MAP) aim to reduce harms of severe alcohol use without expecting cessation of use. There is promising evidence that MAPs reduce acute and social harms associated with alcohol dependence. The aim of this paper is to describe MAPs in Canada including key dimensions and implementation issues. DESIGN AND METHODS: Thirteen Canadian MAPs were identified through the Canadian Managed Alcohol Program Study. Nine key informant interviews were conducted and analysed alongside program documents and reports to create individual case reports. Inductive content analysis and cross case comparisons were employed to identify six key dimensions of MAPs. RESULTS: Community based MAPs have a common goal of preserving dignity and reducing harms of drinking while increasing access to housing, health and social services. MAPs are offered as both residential and day programs with differences in six key dimensions including program goals and eligibility, food and accomodation, alcohol dispensing and administration, funding and money management, primary care services and clinical monitoring, and social and cultural connections. DISCUSSION AND CONCLUSIONS: MAPs consist of four pillars with the alcohol intervention provided alongside housing interventions, primary care services, social and cultural interventions. Availability of permanent housing and re-establishing social and cultural connections are central to recovery and healing goals of MAPs. Additional research regarding Indigenous and gendered approaches to program development as well as outcomes related to chronic harms and differences in alcohol management are needed.

Does managing the consumption of people with severe alcohol dependence reduce harm? A comparison of participants in six Canadian managed alcohol programs with locally recruited controls.

INTRODUCTION AND AIMS: Managed alcohol programs (MAP) are intended for people with severe alcohol-related problems and unstable housing. We investigated whether MAP participation was associated with changes in drinking patterns and related harms. DESIGN AND METHODS: One hundred and seventy-five MAP participants from five Canadian cities (Hamilton, Ottawa, Toronto, Thunder Bay and Vancouver) and 189 same-city controls were assessed for alcohol consumption, health, safety and harm outcomes. Length of stay in a MAP was investigated as a predictor of drinking patterns, non-beverage alcohol consumption and related harms. Statistical controls were included for housing stability, age, gender, ethnic background and city of residence. Negative binomial regression and logistic regression models were used. RESULTS: Recently admitted MAP participants (≤2 months) and controls were both high consumers of alcohol, predominantly male, of similar ethnic background, similarly represented across the five cities and equally alcohol dependent (mean Severity of Alcohol Dependence Questionnaire = 29.7 and 31.4). After controlling for ethnicity, age, sex, city and housing stability, long-term MAP residents (>2 months) drank significantly more days (+5.5) but 7.1 standard drinks fewer per drinking day than did controls over the last 30 days. Long-term MAP residents reported significantly fewer alcohol-related harms in the domains of health, safety, social, legal and withdrawal. DISCUSSION AND CONCLUSIONS: Participation in a MAP was associated with more frequent drinking at lower quantities per day. Participation was associated with reduced alcohol-related harms over the past 30 days. Future analyses will examine outcomes longitudinally through follow-up interviews, police and health care records.

Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study.

BACKGROUND: Managed alcohol programs (MAPs) are a harm reduction strategy for people with severe alcohol dependence and unstable housing. MAPs provide controlled access to alcohol usually alongside accommodation, meals, and other supports. Patterns of alcohol consumption and related harms among MAP participants and controls from a homeless shelter in Thunder Bay, Ontario, were investigated in 2013. METHODS: Structured interviews were conducted with 18 MAP and 20 control participants assessed as alcohol dependent with most using non-beverage alcohol (NBA). Qualitative interviews were conducted with seven participants and four MAP staff concerning perceptions and experiences of the program. Program alcohol consumption records were obtained for MAP participants, and records of police contacts and use of health services were obtained for participants and controls. Some participants' liver function test (LFT) results were available for before and after MAP entry. RESULTS: Compared with periods off the MAP, MAP participants had 41 % fewer police contacts, 33 % fewer police contacts leading to custody time (x (2) = 43.84, P < 0.001), 87 % fewer detox admissions (t = -1.68, P = 0.06), and 32 % fewer hospital admissions (t = -2.08, P = 0.03). MAP and control participants shared similar characteristics, indicating the groups were broadly comparable. There were reductions in nearly all available LFT scores after MAP entry. Compared with controls, MAP participants had 43 % fewer police contacts, significantly fewer police contacts (-38 %) that resulted in custody time (x (2) = 66.10, P < 0.001), 70 % fewer detox admissions (t = -2.19, P = 0.02), and 47 % fewer emergency room presentations. NBA use was significantly less frequent for MAP participants versus controls (t = -2.34, P < 0.05). Marked but non-significant reductions were observed in the number of participants self-reporting alcohol-related harms in the domains of home life, legal issues, and withdrawal seizures. Qualitative interviews with staff and MAP participants provided additional insight into reductions of non-beverage alcohol use and reductions of police and health-care contacts. It was unclear if overall volume of alcohol consumption was reduced as a result of MAP participation. CONCLUSIONS: The quantitative and qualitative findings of this pilot study suggest that MAP participation was associated with a number of positive outcomes including fewer hospital admissions, detox episodes, and police contacts leading to custody, reduced NBA consumption, and decreases in some alcohol-related harms. These encouraging trends are being investigated in a larger national study.

Finding safety: a pilot study of managed alcohol program participants' perceptions of housing and quality of life.

BACKGROUND: There is a higher prevalence of alcohol use and severe alcohol dependence among homeless populations. The combination of alcohol use and lack of housing contributes to increased vulnerability to the harms of substance use including stigma, injury, illness, and death. Managed alcohol programs (MAPs) administer prescribed doses of alcohol at regular intervals to people with severe and chronic alcohol dependence and homelessness. As a pilot for a larger national study of MAPs, we conducted an in-depth evaluation of one program in Ontario, Canada. In this paper, we report on housing and quality of life outcomes and experiences of the MAP participants and staff. METHODS: We conducted a pilot study using mixed methods. The sample consisted of 38 people enrolled in or eligible for entry into a MAP who completed a structured quantitative survey that included measures related to their housing and quality of life. All of the participants self-identified as Indigenous. In addition, we conducted 11 in-depth qualitative interviews with seven MAP residents and four program staff and analyzed the interviews using constant comparative analysis. The qualitative analysis was informed by Rhodes' risk environment framework. RESULTS: When compared to controls, MAP participants were more likely to retain their housing and experienced increased safety and improved quality of life compared to life on the streets, in jails, shelters, or hospitals. They described the MAP as a safe place characterized by caring, respect, trust and a nonjudgmental approach with a sense of family and home as well as opportunities to reconnect with family members. CONCLUSIONS: The MAP was, as described by participants, a safer environment and a home with feelings of family and a sense of community that countered stigma, loss, and dislocation with potential for healing and recovery. The MAP environment characterized by caring, respect, trust, a sense of home, "feeling like family", and the opportunities for family and cultural reconnections is consistent with First Nations principles for healing and recovery and principles of harm reduction.