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

Association between religiosity/spirituality and substance use among homeless individuals

BACKGROUND

Alcohol and illicit drug use are prevalent among homeless people. Religiosity and spirituality (RS) have been widely associated with lower consumption of substances. However, evidence of this relationship among homeless people is still scarce.

AIMS

To evaluate the associations between RS and alcohol and illicit drug consumption among homeless people in a large Brazilian urban center.

METHOD

This cross-sectional study was carried out in São Paulo city, Brazil. Aspects such as spirituality (FACIT-Sp12), religiosity (DUREL), spiritual-religious coping (Brief-RCOPE), and self-report questions concerning the current substance use (alcohol and illicit substances) were evaluated. Adjusted logistic regression models were used to assess the impact of RS beliefs on alcohol and illicit drug consumption.

RESULTS

A total of 456 homeless people were included, of an average age of 44.5 (SD = 12.6) years. More than half of the participants consumed alcohol (55.7%) weekly and 34.2% used illicit drugs weekly. Adjusted logistic regression models identified that aspects of RS were associated with lower likelihood factors for alcohol and illicit drug use; conversely, negative spiritual religious coping (SRC) strategies were associated with a higher likelihood to use both.

CONCLUSION

The prevalence of alcohol and illicit drug use among participants was high. RS and positive SRC were important protective factors for lower consumption of these substances. Conversely, negative SRC strategies were associated with risk factors.

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.

The impact of alcohol minimum unit pricing on people with experience of homelessness: Qualitative study

BACKGROUND

Alcohol Minimum Unit Pricing (MUP) was introduced in Scotland in May 2018. Existing evidence suggests MUP can reduce alcohol consumption in the general population, but there is little research about its impact on vulnerable groups. This qualitative study explored experiences of MUP among people with experience of homelessness.

METHODS

We conducted qualitative semi-structured interviews with a purposive sample of 46 people with current or recent experience of homelessness who were current drinkers when MUP was introduced. Participants (30 men and 16 women) were aged 21 to 73 years. Interviews focused on views and experiences of MUP. Data were analysed using thematic analysis.

RESULTS

People with experience of homelessness were aware of MUP but it was accorded low priority in their hierarchy of concerns. Reported impacts varied. Some participants reduced their drinking, or moved away from drinking strong white cider, in line with policy intentions. Others were unaffected because the cost of their preferred drink (usually wine, vodka or beer) did not change substantially. A minority reported increased involvement in begging. Wider personal, relational and social factors also played an important role in responses to MUP.

CONCLUSION

This is the first qualitative study to provide a detailed exploration of the impact of MUP among people with experience of homelessness. Our findings suggest that MUP worked as intended for some people with experience of homelessness, while a minority reported negative consequences. Our findings are of international significance to policymakers, emphasising the need to consider the impact of population level health policies on marginalised groups and the wider contextual factors that affect responses to policies within these groups. It is important to invest further in secure housing and appropriate support services and to implement and evaluate harm reduction initiatives such as managed alcohol programmes.

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.

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.

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.

Electroencephalographic neurofeedback as a tool for reducing harm and risk associated with alcohol use disorder: A critical review

ISSUES

Alcohol use disorder (AUD) causes the highest harms around the world. Many people use alcohol to reduce stress and anxiety, considered as risk factors for AUD. Chronic alcohol use leads to changes in the reward system and the high level of stress may exacerbate neuroendocrine responses. Electroencephalographic (EEG) neurofeedback shows reduction of stress, anxiety and alcohol abuse and it could be an important tool for reducing harm and risk associated with AUD. The aim of this paper is to review the studies that investigated the effects of EEG neurofeedback in subjects with AUD and it proposes to discuss this intervention as a tool for reducing harm and risk in AUD.

APPROACH

Medline, PsycINFO and LILACS databases were searched and appropriated terms were used. Inclusion criterion was adopted. The year of publication was not limited because of the scarce number of studies. Eighty-two papers returned and eight were included. A critical review was conducted.

KEY FINDINGS

Most of the papers analysed used the alpha/theta protocol to reduce the 'hyperexcitation' of the nervous system. This protocol provides relaxation, decreases anxiety or stress, prevents alcohol relapse, maintains abstinence and increases the feeling of well-being.

IMPLICATIONS

EEG neurofeedback has important effects on AUD and anxiety or stress. Studies reinforce the use of EEG neurofeedback as an alternative tool for reducing harm and risk in AUD.

CONCLUSION

EEG neurofeedback is an intervention to treat AUD, specifically, to reduce harm and risk. However, more randomised studies are necessary to consolidate the effectiveness of the technique.

"If I knew I could get that every hour instead of alcohol, I would take the cannabis": need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs

Background

While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool.

Methods

To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis.

Results

Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation.

Conclusion

Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

"You know, we can change the services to suit the circumstances of what is happening in the world": a rapid case study of the COVID-19 response across city centre homelessness and health services in Edinburgh, Scotland

BACKGROUND

The COVID-19 pandemic has necessitated unprecedented changes in the way that health, social, and housing services are delivered to individuals experiencing homelessness and problem substance use. Protecting those at high risk of infection/transmission, whilst addressing the multiple health and social needs of this group, is of utmost importance. This study aimed to document the impact of the COVID-19 pandemic on individuals who were experiencing homelessness in one city centre in Scotland, and how services adapted in response.

METHODS

Semi-structured interviews were conducted with individuals with lived/living experience of homelessness (n = 10), staff within onethird sector service (n = 5), and external professionals (n = 5), during April-August 2020, using a rapid case study design. These were audio-recorded, fully transcribed, and analysed using Framework. Analysis was informed by inclusion health and equity-orientated approaches to meeting the needs of people with multiple and complex needs, and emerging literature on providing harm reduction in the context of COVID-19.

RESULTS

Those with lived/living experience of homelessness and problem substance use faced a range of additional challenges during the pandemic. Mental health and use of substances were affected, influenced by social isolation and access to services. A range of supports were provided which flexed over the lockdown period, including housing, health and social care, substance use treatment, and harm reduction. As well as documenting the additional risks encountered, findings describe COVID-19 as a 'path-breaking' event that created opportunities to get evidence into action, increase partnership working and communication, to proactively address risks.

CONCLUSIONS

This rapid case study has described the significant impact of the COVID-19 pandemic on a group of people experiencing homelessness and problem substance use within one city centre in Scotland and provides a unique lens on service/professional responses. It concludes with lessons that can inform the international and ongoing response to this pandemic. It is vital to recognise the vision and leadership that has adapted organisational responses in order to reduce harms. We must learn from such successes that were motivated both by compassion and care for those vulnerable to harms and the desire to provide high-quality, evidence-based, harm reduction services.

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.