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

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

BACKGROUND

People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.

METHODS

A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.

FINDINGS

The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.

CONCLUSION

This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

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.

A Hospital-based Managed Alcohol Program in a Canadian Setting

OBJECTIVES

A managed alcohol program (MAP) is a harm reduction strategy that provides regularly, witnessed alcohol to individuals with a severe alcohol use disorder. Although community MAPs have positive outcomes, applicability to hospital settings is unknown. This study describes a hospital-based MAP, characterizes its participants, and evaluates outcomes.

METHODS

A retrospective chart review of MAP participants was conducted at an academic hospital in Vancouver, Canada, between July 2016 and October 2017. Data included demographics, alcohol/substance use, alcohol withdrawal risk, and MAP indication. Outcomes after MAP initiation included the change in mean daily alcohol consumption and liver enzymes.

RESULTS

Seventeen patients participated in 26 hospital admissions: 76% male, mean age of 54 years, daily consumption prehospitalization of a mean 14 alcohol standard drinks, 59% reported previous nonbeverage alcohol consumption, and 41% participated in a community MAP. Most participants were high risk for severe, complicated alcohol withdrawal and presented in moderate withdrawal. Continuation of community MAP was the most common indication for hospital-based MAP initiation (38%), followed by a history of leaving hospital against medical advice (35%) and hospital illicit alcohol use (15%). Hospital-based MAP resulted in a mean of 5 fewer alcohol standard drinks daily compared with preadmission ( P = 0.002; 95% confidence interval, 2-8) and improvement in liver enzymes, with few adverse events.

CONCLUSIONS

Participation in a hospital-based MAP may be an effective safe approach to reduce harms for some individuals with severe alcohol use disorder. Further study is needed to understand who benefits most from hospital-MAP and potential benefits/harms following hospital discharge.

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.