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

'Everywhere I call, there's nothing available': Understanding the alcohol treatment landscape and needs among unstably housed people who use alcohol in Rhode Island

INTRODUCTION

Alcohol is a leading cause of morbidity and mortality in the United States and people who are unstably housed are disproportionately impacted by adverse alcohol-related health outcomes. Addressing the needs of unstably housed people with high-intensity alcohol use (i.e., heavy episodic use or binge drinking), including those whose goal is not abstinence, is critical to reducing harms among this population. This study explores the alcohol-related treatment and support needs among unstably housed people who use alcohol.

METHODS

Data collection included participant observation and semi-structured interviews (n = 25) with unstably housed people with high-intensity alcohol use. Data were analysed thematically, with attention to structural vulnerability and social-structural forces at shaping perceptions of and experiences with alcohol treatment.

RESULTS

Participants underscored how housing instability was critical in precipitating and maintaining heavy alcohol use, with alcohol often used to manage the stress and anxiety related to housing instability. While participants regularly engaged with alcohol treatment programs, program design and barriers to access undermined the effectiveness of these services for participants. Participants described the need for a range of program and service options across a continuum of care to be implemented to support participants in meeting their diverse needs and identified goals regarding alcohol use.

DISCUSSION AND CONCLUSIONS

Alcohol treatment and supports need to be modified so that they include a range of harm reduction and abstinence-based models to better meet people's diverse needs. Furthermore, treatment must be paired with permanent and affordable housing to address underlying drivers of alcohol-related harm for unstably housed people.

Translating the lived experience of illicit drinkers into program guidance for cannabis substitution: Experiences from the Canadian Managed Alcohol Program Study

A small but growing body of research has suggested the potential for cannabis substitution to support Managed Alcohol Program (MAP) service users to reduce acute and chronic alcohol-related harms. In 2022, researchers from the Canadian Managed Alcohol Program Study (CMAPS) noted a dearth of accessible, alcohol-specific educational resources to support service users and program staff to implement cannabis substitution pilots at several MAP sites in Canada. In this essay, we draw on over 10-years of collaboration between CMAPS, and organizations of people with lived experience (the Eastside Illicit Drinkers Group for Education (EIDGE) and SOLID Victoria) to describe our experiences co-creating cannabis education resources where none existed to support MAP sites interested in beginning to provide cannabis to participants. The research team relied on the unique lived experiences and informal cannabis-related harm reduction strategies described by EIDGE and SOLID members to create cannabis education resources that were accurate and relevant to MAP sites. EIDGE was familiar with creating peer-oriented educational resources and convened meetings and focus groups to engage peers. CMAPS research team members created standard cannabis unit equivalencies to support program delivery, and clinical advisors ensured that the stated risks and benefits of cannabis substitution, as well as tapering guidance for withdrawal management, were safe and feasible. The collaboration ultimately produced tailored client-facing and provider-facing resources. Our experience demonstrates that the lived expertise of drinkers can play an integral role in creating alcohol harm reduction informational materials, specifically those related to cannabis substitution, when combined with data from rigorous, community-based programs of research like CMAPS. We close by listing additional considerations for cannabis substitution program design for MAP settings emerging from this process of collaboration between illicit drinkers, service providers, clinicians, and researchers for consideration by other programs.

Vancouver's Alcohol Knowledge Exchange: lessons learned from creating a peer-involved alcohol harm reduction strategy in Vancouver's Downtown Eastside

Despite high rates of harm attributable to alcohol use itself and the associated marginalization of illicit drinkers in Vancouver's Downtown Eastside (DTES), alcohol-specific harm reduction services there are under-resourced and highly disconnected from one another. In response to these conditions and high rates of death amongst its membership, the Eastside Illicit Drinkers Group for Education, an affiliate group of the Vancouver Area Network of Drug Users, convened a regular meeting of stakeholders, termed a "community of practice" in 2019 to bring together peers who used beverage and non-beverage alcohol, shelter and harm reduction service providers, public health professionals, clinicians, and policymakers to improve system-level capacity to reduce alcohol-related harm. The discussions that followed from these meetings were transformed into the Vancouver Alcohol Strategy (VAS), a comprehensive, harm reduction-oriented policy framework for alcohol harm reduction in the DTES. This article highlights our experiences producing community-led alcohol policy through the VAS with specific attention to the ways in which people who use alcohol themselves were centred throughout the policy development process. We also provide summary overviews of each of the VAS document's 6 thematic areas for action, highlighting a sampling of the 47 total unique recommendations. Historically, people who use non-beverage alcohol and whose use of alcohol in public spaces is criminalized due to housing precarity and visible poverty have been excluded from the development of population-level alcohol policies that can harm this specific population. The process of policy development undertaken by the VAS has attempted to resist this top-down approach to public health policy development related to alcohol control by intentionally creating space for people with lived experience to guide our recommendations. We conclude by suggesting that a grassroots enthusiasm for harm reduction focused policy development exists in Vancouver's DTES, and requires resources from governmental public health institutions to meaningfully prevent and reduce alcohol-related and policy-induced harms.

Substance use disorders and COVID-19: reflections on international research and practice changes during the "poly-crisis"

Since March 2020, the COVID-19 pandemic has had a disproportionately high toll on vulnerable populations, coinciding with increased prevalence of alcohol-and drug-related deaths and pre-existing societal issues such as rising income inequality and homelessness. This poly-crisis has posed unique challenges to service delivery for people with substance use disorders, and innovative approaches have emerged. In this Perspectives paper we reflect on the poly-crisis and the changes to research and practice for those experiencing substance use disorders, following work undertaken as part of the InterGLAM project (part of the 2022. Lisbon Addictions conference). The authors, who were part of an InterGLAM working group, identified a range of creative and novel responses by gathering information from conference attendees about COVID-19-related changes to substance use disorder treatment in their countries. In this paper we describe these responses across a range of countries, focusing on changes to telehealth, provision of medications for opioid use disorder and alcohol harm reduction, as well as changes to how research was conducted. Implications include better equity in access to technology and secure data systems; increased prescribed safer supply in countries where this currently does not exist; flexible provision of medication for opioid use disorder; scale up of alcohol harm reduction for people with alcohol use disorders; greater involvement of people with lived/living experience in research; and additional support for research in low- and middle-income countries. The COVID-19 pandemic has changed the addictions field and there are lessons for ongoing and emerging crises.

Grayken lessons: between a rock and a hard place? A 37-year-old man with acute liver injury while enrolled in a managed alcohol program for severe alcohol use disorder

Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.

Clarifying rural-urban disparities in alcohol-related emergency department visits and hospitalizations in Ontario, Canada: A spatial analysis

PURPOSE

Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits and hospitalizations in Ontario to better understand this rural-urban disparity.

METHODS

This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models.

FINDINGS

Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate [aRR]: 1.67, 95% credible interval [CI]: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97).

CONCLUSIONS

There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.

The Potential for Managed Alcohol Programmes in Scotland during the COVID-19 Pandemic: A Qualitative Exploration of Key Areas for Implementation Using the Consolidated Framework for Implementation Research

People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.

Scoping review of managed alcohol programs

BACKGROUND

Internationally, strategies focusing on reducing alcohol-related harms in homeless populations with severe alcohol use disorder (AUD) continue to gain acceptance, especially when conventional modalities focused on alcohol abstinence have been unsuccessful. One such strategy is the managed alcohol program (MAP), an alcohol harm reduction program managing consumption by providing eligible individuals with regular doses of alcohol as a part of a structured program, and often providing resources such as housing and other social services. Evidence to the role of MAPs for individuals with AUD, including how MAPs are developed and implemented, is growing. Yet there has been limited collective review of literature findings.

METHODS

We conducted a scoping review to answer, "What is being evaluated in studies of MAPs? What factors are associated with a successful MAP, from the perspective of client outcomes? What are the factors perceived as making them a good fit for clients and for communities?" We first conducted a systematic search in PubMed, Embase, PsycINFO, CINAHL, Sociological Abstracts, Social Services Abstracts, and Google Scholar. Next, we searched the gray literature (through focused Google and Ecosia searches) and references of included articles to identify additional studies. We also contacted experts to ensure relevant studies were not missed. All articles were independently screened and extracted.

RESULTS

We included 32 studies with four categories of findings related to: (1) client outcomes resulting from MAP participation, (2) client experience within a MAP; (3) feasibility and fit considerations in MAP development within a community; and (4) recommendations for implementation and evaluation. There were 38 established MAPs found, of which 9 were featured in the literature. The majority were located in Canada; additional research works out of Australia, Poland, the USA, and the UK evaluate potential feasibility and fit of a MAP.

CONCLUSIONS

The growing literature showcases several outcomes of interest, with increasing efforts aimed at systematic measures by which to determine the effectiveness and potential risks of MAP. Based on a harm reduction approach, MAPs offer a promising, targeted intervention for individuals with severe AUD and experiencing homelessness. Research designs that allow for longitudinal follow-up and evaluation of health- and housing-sensitive outcomes are recommended.

"A place to be safe, feel at home and get better": including the experiential knowledge of potential users in the design of the first wet service in Montreal, Canada

Background

The harmful use of alcohol is one of the leading health risk factors for people’s health worldwide, but some populations, like people who experience homelessness, are more vulnerable to its detrimental effects. In the past decades, harm reduction interventions that target these complex issues has been developed. For example, wet services include a wide range of arrangements (wet shelters, drop-in centers, transitory housing, etc.) that allow indoor alcohol use and Managed Alcohol Programs provide regulated doses of alcohol in addition to accommodation and services. Although the positive impacts of these interventions have been reported, little is known about how to integrate the knowledge of people experiencing homelessness and alcohol dependence into the design of such programs. The aim of this study is to present the findings of such an attempt in a first wet service in Montreal, Canada.

Methods

Community based participatory research approach and qualitative methods—including semi-structured interviews and focus groups—were used to collect the knowledge of potential users (n = 34) of the wet service. The data collected was thematically analyzed.

Results

Participants reported experiencing harsh living conditions, poverty, stigmatization and police harassment, which increased their alcohol use. The intersection between participants’ alcohol dependence and homelessness with the high barriers to access public services translated into their exclusion from several of such services. Participants envisioned Montreal’s wet service as a safe space to drink, a place that would provide multiple services, a home, and a site of recovery.

Conclusions

Integrating the knowledge of potential users into the design of harm reduction interventions is essential to develop better and more adapted services to meet complex needs. We propose that it could fosters users’ engagement and contribute to their sense of empower, which is crucial for a group that is typically discriminated against and suffers from marginalization.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD - especially drug use disorders - as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.

Managed alcohol: one community's innovative response to risk management during COVID-19

BACKGROUND

Harm reduction programs often lack community-based support and can be controversial, despite data demonstrating effectiveness. This article describes one small Alaskan community's development of a harm reduction managed alcohol program (MAP) in the context of a city-run quarantine site for individuals experiencing homelessness. The MAP was developed to support quarantining by COVID-19-exposed or COVID-positive individuals who also experienced chronic homelessness, a severe alcohol use disorder, and heightened health risks related to potentially unsupported alcohol withdrawal.

METHOD

Five interviews with key informants involved in planning or implementation of the MAP were conducted using rapid qualitative analysis and narrative analysis techniques.

OUTCOME

This study documents the planning and implementation of an innovative application of a managed alcohol harm reduction intervention in the context of the COVID-19 pandemic. In this instance, a MAP was used specifically to limit hospital admissions for alcohol withdrawal during a surge of cases in the community, as well as to mitigate spread of the virus. Key informants report no residents enrolled in the MAP program as a part of quarantine required hospitalization for withdrawal or for COVID symptoms, and no shelter resident left the quarantine site while still contagious with COVID-19. Additionally, the level of community support for the program was much higher than originally expected by organizers.

CONCLUSIONS

This program highlighted an example of how a community recognized the complexity and potential risk to individuals experiencing structural vulnerability related to homelessness and a severe AUD, and the community at large, and was able to create an alternative path to minimize those risks using a harm reduction strategy.

Exploring the Potential of Implementing Managed Alcohol Programmes to Reduce Risk of COVID-19 Infection and Transmission, and Wider Harms, for People Experiencing Alcohol Dependency and Homelessness in Scotland

People who experience homelessness and alcohol dependency are more vulnerable than the general population to risks/harms relating to COVID-19. This mixed methods study explored stakeholder perspectives concerning the impact of COVID-19 and the potential utility of introducing managed alcohol programmes (MAPs) in Scotland as part of a wider health/social care response for this group. Data sources included: 12 case record reviews; 40 semi-structured qualitative interviews; and meeting notes from a practitioner-researcher group exploring implementation of MAPs within a third sector/not-for-profit organisation. A series of paintings were curated as a novel part of the research process to support knowledge translation. The case note review highlighted the complexity of health problems experienced, in addition to alcohol dependency, including polysubstance use, challenges related to alcohol access/use during lockdown, and complying with stay-at-home rules. Qualitative analysis generated five subthemes under the theme of ‘MAPs as a response to COVID-19′: changes to alcohol supply/use including polysubstance use; COVID-19-related changes to substance use/homelessness services; negative changes to services for people with alcohol problems; the potential for MAPs in the context of COVID-19; and fears and concerns about providing MAPs as a COVID-19 response. We conclude that MAPs have the potential to reduce a range of harms for this group, including COVID-19-related harms.

Harm reduction for smokers living with HIV

Tobacco use is now a leading cause of death in people living with HIV in the USA. Increasing cessation rates in this group is a public health priority, yet the results of clinical trials aimed at optimising tobacco treatment strategies have been largely disappointing. Combinations of behavioural and pharmacological cessation therapies in people living with HIV have yielded increases in short-term quit rates, but few have shown long-term efficacy. Even with aggressive therapy combining intensive behavioural treatment with pharmacological agents, most smokers living with HIV continue to smoke. The generalised approach to tobacco treatment that prevails in guidelines and in clinical practices might do a disservice to these individuals, who represent a sizable segment of the population of people living with HIV. Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.

Socioeconomic factors and substances involved in poisoning-related emergency department visits in British Columbia, Canada

INTRODUCTION

Canada's opioid crisis has taken thousands of lives, increasing awareness of poisoning-related injuries as an important public health issue. However, in British Columbia (BC), where overdose mortality rates are the highest in Canada, studies have not yet identified which demographic populations most often visit emergency departments (ED) due to all poisonings, nor which substances are most commonly involved. The aim of this study was to explore these gaps, after developing a methodology for calculating ED visit rates in BC.

METHODS

Poisoning-related ED visit rates during fiscal years 2012/13 to 2016/17, inclusive, were calculated by sex, age group, poisoning substance and socioeconomic status, using a novel methodology developed in this study. ED data were sourced from the National Ambulatory Care Reporting System and population data from Statistics Canada's 2016 (or 2011) census profiles.

RESULTS

During the study period, there were an estimated 81 463 poisoning-related ED visits (351.2 per 100 000 population). Infants, toddlers, youth and those aged 20-64 years had elevated risks of poisoning-related ED visits. Rates were highest among those in neighbourhoods with the greatest material (607.8 per 100 000 population) or social (484.2 per 100 000 population) deprivation. Over time, narcotics and psychodysleptics became increasingly common poisoning agents, while alcohol remained problematic.

CONCLUSION

A methodology for estimating ED visit rates in BC was developed and applied to determine poisoning-related ED visit rates among various demographic groups within BC. British Columbians most vulnerable to poisoning have been identified, emphasizing the need for efforts to limit drug overdoses and excessive alcohol intoxication to reduce rates of these preventable injuries.

COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper

The COVID-19 pandemic is presenting significant challenges for health and social care systems globally. The implementation of unprecedented public health measures, alongside the augmentation of the treatment capacity for those severely affected by COVID-19, are compromising and limiting the delivery of essential care to people with severe substance use problems and, in some cases, widening extreme social inequities such as poverty and homelessness. This global pandemic is severely challenging current working practices. However, these challenges can provide a unique opportunity for a flexible and innovative learning approach, bringing certain interventions into the spotlight. Harm reduction responses are well-established evidenced approaches in the management of opioid dependence but not so well-known or implemented in relation to alcohol use disorders. In this position paper, we explore the potential for expanding harm reduction approaches during the COVID-19 crisis and beyond as part of substance use treatment services. We will examine alcohol use and related vulnerabilities during COVID-19, the impact of COVID-19 on substance use services, and the potential philosophical shift in orientation to harm reduction and outline a range of alcohol harm reduction approaches. We discuss relevant aspects of the Structured Preparation for Alcohol Detoxification (SPADe) treatment model, and Managed Alcohol Programs (MAPs), as part of a continuum of harm reduction and abstinence orientated treatment for alcohol use disorders. In conclusion, while COVID-19 has dramatically reduced and limited services, the pandemic has propelled the importance of alcohol harm reduction and created new opportunities for implementation of harm reduction philosophy and approaches, including programs that incorporate the provision of alcohol as medicine as part of the substance use treatment continuum.

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

INTRODUCTION AND AIMS

Managed alcohol programs (MAP) are a harm reduction approach for those experiencing alcohol use disorders (AUD) and homelessness. These programs were developed in Canada and have had positive results; very few exist in the UK and Ireland. The aim of this study was to scope the feasibility and acceptability of implementing MAPs in Scotland.

DESIGN AND METHODS

Using mixed-methods, we conducted two linked phases of work. Quantitative data were collected from the case records of 33 people accessing eight third sector services in Scotland and analysed in SPSS using descriptive and inferential statistics. Qualitative data were collected in Scotland via semi-structured interviews with 29 individuals in a range of roles, including strategic informants (n = 12), service staff (n = 8) and potential beneficiaries (n = 9). Data were analysed using Framework Analysis in NVivo.

RESULTS

The case record review revealed high levels of alcohol use, related health and social harms, illicit drug use, withdrawal symptoms, and mental and physical health problems. Most participants highlighted a lack of alcohol harm reduction services and the potential of MAPs to address this gap for this group.

DISCUSSION AND CONCLUSIONS

Our findings highlight the potential for MAPs in Scotland to prevent harms for those experiencing homelessness and AUDs, due to high levels of need. Future research should examine the implementation of MAPs in Scotland in a range of service contexts to understand their effectiveness in addressing harms and promoting wellbeing for those experiencing AUDs and homelessness.

Exploring the experience of inpatients with severe alcohol use disorder on a managed alcohol program (MAP) at St. Paul's Hospital

Background

Managed alcohol programs are a harm reduction approach for people with severe alcohol use disorder that provide alcohol in a structured setting. We examined the patient experience of receiving alcohol after the implementation of a hospital-based managed alcohol program.

Methods

Using an interpretative descriptive methodology, we conducted interviews with five patients. The criteria for enrollment included continuation of community managed alcohol program or provision of alcohol for stabilization in hospital and ability to provide consent.

Results

Five themes emerged in the analysis: (1) Reasons for alcohol use highlighting factors leading to alcohol consumption; (2) I’m very appreciative indicating participant’s perception of hospital-based managed alcohol program; (3) From just vibrating to calm and It’s kinda like a pacifier for me recognizing the impact of hospital-based managed alcohol program on managing withdrawal and on psychological health; (4) I have no need to go anywhere at all demonstrating engagement in healthcare; and (5) Might be nice to have a selection for other people indicating the need for a broader selection of alcohol.

Conclusions

This study helped to explore the effectiveness of a hospital-based managed alcohol program as experienced by the patients. Overall, participants had a positive experience on hospital-based managed alcohol program. Their perceptions can be used to inform implementation of managed alcohol programs in other hospital settings.

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

BACKGROUND

The 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).

METHODS

We 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.

RESULTS

Prior 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.

CONCLUSIONS

In 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.