Dr Hannah Carver, Lecturer in Substance Use, Faculty of Social Sciences, University of Stirling
Hannah Carver explores how Managed Alcohol Programmes can play a role in supporting homeless people during the current coronavirus pandemic.
Watch the lecture online or read the transcript below.
Hello, my name is Hannah Carver and I’m a lecturer in substance use at the University of Stirling. My research focus is on drug and alcohol use, which have certainly been affected by the COVID-19 pandemic. This lecture was recorded on the 9th of June 2020, using the evidence available at this time.
In this lecture, I will discuss the need for alcohol harm reduction approaches for a group of people who are at particularly high risk of coronavirus, that is, people who are homeless. We will look at a particular intervention called managed alcohol programmes, which aim to support people who are homeless with alcohol use disorders. I won’t be covering homelessness in much detail in this lecture.
Across the world around 2.3 billion people drink alcohol, which is just under half of the population. Some of the highest rates of alcohol use are in Europe, with Scotland having the highest rates of alcohol use in the UK. Alcohol use disorders or alcohol dependence affects 237 million adult men and 46 million adult women worldwide. The harmful use of alcohol results in approximately 3 million deaths every year globally, which is just over 5 percent of all deaths.
In Scotland, rates of alcohol use and alcohol related harm are high, with more than 1100 deaths attributable to alcohol recorded in 2017. Alcohol use in Scotland is estimated to cost more than £3.6 billion each year, with high costs to health, social care and criminal justice services. Alcohol use disorders are not equitably spread across the population, with particular groups of people such as people who are homeless being at much higher risk of alcohol use and related harm.
In Scotland, homelessness affects a significant number of people with higher rates of substance use and mental health problems than those who are not homeless. Alcohol use disorders and homelessness are closely connected to complex social and structural processes and policies that create extreme social inequalities, poverty and adverse life events.
Alcohol use can be the reason for people becoming homeless, a response to trauma, poverty and difficult life circumstances and also as a way of coping with being homeless. Those experiencing homelessness are much more likely to experience significant harms associated with alcohol use, including acute harms like alcohol poisoning and seizures, chronic health conditions like liver disease and cancer, as well as premature death, poor mental health, assaults and injury and almost inevitable social exclusion. For people who are homeless, access to mental and physical health care services can be challenging. For many people who experience homelessness and alcohol use disorders, treatment options are limited and abstinence-based programmes, where alcohol use is stopped completely, are hard to comply with because of unrealistic or undesirable goals. Many people will struggle to access appropriate treatment services and there is limited evidence regarding the types of treatments that work for people who are homeless.
So, the aim of harm reduction is to reduce harms and to meet people where they are at rather than forcing or expecting people to stop drinking completely. Many treatments for alcohol use disorders do expect abstinence, which is often not desired or achievable for many people, but especially for those who are homeless. Harm reduction strategies help people to reduce the harms associated with their alcohol use, for example, by teaching strategies such as eating before drinking, limiting the number of drinks you have, drinking lower alcohol drinks and drinking with friends. There are also broader strategies to reduce injury, violence and public disorder, for example, through the use of plastic rather than glass bottles. But, compared to drug use, there are far fewer options and a weaker evidence base for alcohol harm reduction.
So, we know that for people who are homeless with alcohol use disorders, access to abstinence based treatment is generally challenging and for some, it can be completely unwanted or unrealistic. Some people do not have the desire, motivation or practical support to stop drinking and detoxification can be unethical and impractical, if people are expected to go back to living on the streets afterwards. So in order to keep people safe, alcohol harm reduction approaches are essential.
People who are homeless are being particularly affected by the coronavirus pandemic. They are much more likely to be at risk due to co-morbidities, for example, with higher rates of respiratory conditions. Self-isolation is impossible if you’re living on the streets or in temporary accommodation and those with alcohol use disorders are at even greater risk as they need to continue drinking to prevent withdrawal, which can lead to some serious health conditions and even death. Lockdown and self-isolation are very challenging if you need to go out and get hold of alcohol. In a recent BMJ article by Finlay and Gilmore, it is argued that those with alcohol use disorders are particularly in need of support during the COVID-19 pandemic. While support organisations are moving online, there are some people who are unable to access such support. This is particularly true of people who are homeless. The authors state that ‘While we cannot claim to be a nation recovering from COVID-19 if we do not adequately support the most vulnerable among us”.
Across the world, guidance has been issued by a range of organisations regarding how to support people with alcohol use disorders during the pandemic. One of the most important things is to ensure supplies of alcohol to people are maintained in order to prevent withdrawals. If people who are homeless are being housed, for example, in hotels, then they need to have continued access to alcohol in a way that doesn’t put them at risk of infection or withdrawals to keep them safe from both alcohol harms and coronavirus related harms.
Managed Alcohol Programmes
One evidence based alcohol harm reduction approach for people who are homeless is Managed Alcohol Programmes. Managed Alcohol Programmes, provide a structured and non-judgemental approach to alcohol harm reduction that does more than just educating people about safer drinking strategies. They are programmes where alcohol is provided in measured regular doses throughout the day as a harm reduction intervention.
Managed Alcohol Programmes were created in Canada in the late 1990s to deal with a crisis situation where three men froze to death on the streets of Toronto. Since then, a further 23 managed alcohol programmes across 13 Canadian cities have been established, providing vital support to vulnerable people. During the Covid-19 pandemic, at least 10 more programs have been established across Canada. There are also Managed Alcohol Programmes in Ireland and other countries are looking to implement them, including Australia and Scotland. These programmes are for people who are experiencing homelessness and alcohol use disorders, who find it hard to engage with higher threshold addiction services. They vary in terms of how they operate so they can be delivered in residential or drop-in settings, but most will involve the practice of providing beverage alcohol on a regular schedule throughout the day as part of a range of supports including regular meals, access to health care and social and cultural programming, as well as assistance with life skills.
In all instances, harm reduction is the guiding principle behind these programmes. Several studies in Canada have had positive results, with participants experiencing fewer withdrawal seizures; reduced alcohol related harms; improvements in relationships, quality of life, well-being and safety; lower alcohol intake and use of less harmful types of alcohol; the ability to retain their housing throughout the study period, and less harmful patterns of use; alongside evidence of cost benefits. Overall, these studies have shown that managed alcohol programmes can reduce alcohol related harms, including withdrawal seizures, improve relationships, quality of life, well-being and safety, reduce alcohol intake, help people to retain their housing and enable them to feel safer and have opportunities for healing and connection.
Alcohol harm reduction is complex and ethically challenging, not least because alcohol poses significant risks to health and safety that are dose-dependent, so the risks increase as the alcohol levels increase. As alcohol consumption continues when someone joins a Managed Alcohol Programme, there is a need to recognise that while evidence is positive, the impact of long term heavy drinking needs to be investigated.
In 2019, we conducted a mixed methods study to explore whether managed alcohol programmes could be implemented in Scotland. This study was led by Dr Tessa Parkes. The study involved looking at the case records of 33 people who would meet the eligibility criteria for a managed alcohol programme, as well as conducting interviews with 29 strategic stakeholders, homeless services staff and service users. From the case record review, we found high levels of physical and mental health problems, alcohol withdrawal symptoms and drug use. Our study shows similarities to those accessing Managed Alcohol Programmes in Canada. So, people are typically male with high rates of daily drinking and high levels of alcohol consumption. This suggests a need for this intervention in Scotland. In the interviews, participants were really clear that alcohol harm reduction services are needed in Scotland for this group of people who are at high risk of harms due to their alcohol use and housing problems.
Participants felt that these programmes would be valuable for those who had exhausted other treatment options and were in need of alternative approaches. And high rates of both alcohol and drug use among this group of people was viewed as a particular current concern in Scotland that needed to be considered when developing services. We are now conducting a six month project led by Dr Tessa Parkes, which is funded by the Chief Scientist Office to evaluate Managed Alcohol Programmes in third sector homelessness services in Scotland. We will evaluate the programmes that are being set up in a range of services across Scotland using mixed methods, so we will extract quantitative data on people’s alcohol use and other related issues, and conduct qualitative interviews with a range of staff and service users. The aim of the study is to fully understand whether managed alcohol programmes can prevent infection or reduce the spread of COVID-19 for people who are homeless and experiencing alcohol use disorders.
For people who are experiencing homelessness and alcohol use disorders, harm reduction approaches are essential. Managed Alcohol Programmes are an evidence based approach for this group, which from the findings of our study, should be implemented in Scotland. They are particularly necessary during the COVID-19 pandemic in order to reduce the even greater risks for people who are homeless. Research in Canada has shown positive effects of MAPs over the short and long term, and we’ve identified a high level of need among people accessing homelessness services in Scotland. And our new study will help to increase the evidence base and determine how best to implement Managed Alcohol Programmes in Scotland. If you’d like more information about managed alcohol programmes, please have a look at our research briefing and our article in The Conversation.