Managed alcohol programs: care without abstinence

A man arrives at the emergency department once again in the same year. He lives on the street, drinks every day, and when there is no alcohol, he drinks mouthwash or cleaning alcohol. He has been through several detoxifications and went back to drinking soon after each one. The team knows how to treat withdrawal, but no one knows what to do after discharge. The scene is fictional and was written for teaching.

This text is about managed alcohol programs, known in English as managed alcohol programs: services that offer regular doses of alcoholic beverages, along with housing and care, to people with severe alcohol dependence and without stable housing. The goal is to look at what studies show about these programs, who they were designed for and what changed in the lives of participants. If you play the case of the day on NEXO, you will recognize the type of reasoning: understanding the patient's context before choosing the approach.

Key points

• The programs offer alcohol at regular times, along with housing, food, and care.
• The target population is people with severe alcohol dependence and without stable housing.
• Studies found fewer contacts with the police, fewer hospitalizations, and less use of non-potable alcohol.
• Participants described more safety, more stable housing, and better quality of life.
• The model was also used in hospitals and shelters during the COVID-19 pandemic.
• The evidence base is still small and concentrated in Canada.

What a managed alcohol program is

Managed alcohol programs offer controlled access to alcohol, usually along with housing, meals, and other supports, to people with severe alcohol dependence and unstable housing (Vallance et al., 2016). The idea is to stabilize the drinking pattern and replace the use of non-potable alcohol, such as cleaning alcohol and mouthwash, with alcoholic beverages from a safe source (Pauly et al., 2019).

A scoping review described the program as a harm reduction strategy that provides regular doses of alcohol to eligible people, within an organized structure, often with other support resources (Smith-Bernardin et al., 2022). The programs have existed since the late 1990s, especially in Canada (Smith-Bernardin et al., 2022).

Most of the studied programs are in Canada, but the scoping review also found research in Australia, Poland, the United States, and the United Kingdom (Smith-Bernardin et al., 2022). At the time of the review, there were 38 established programs, in permanent housing, shelters, non-residential day services, and mobile services (Smith-Bernardin et al., 2022). This variety makes it difficult to compare results from one place with another, and each service adapts the model to the local reality.

In practice, operation usually follows a routine. Alcohol is offered regularly, along with accommodation and health and social supports, to stabilize the drinking pattern (Pauly et al., 2019). The details of quantity and interval depend on each protocol and on the team's assessment, and for this reason this text avoids citing dose numbers.

Alcohol harm reduction seeks to reduce the harms of drinking without necessarily requiring the person to drink less or stop drinking (Kouimtsidis et al., 2021). This point is what surprises most those who learned to treat dependence only through abstinence. It connects with what we discussed in harm reduction and clinical reasoning beyond all or nothing: the immediate goal is to reduce harm, not to reach an ideal that the person cannot yet achieve. The same logic supports other services in the field, such as those described in drug checking: what sample analysis reveals and in supervised consumption rooms: what the evidence says.

Who these programs were designed for

Severe alcohol dependence and homelessness often go together. Among homeless men in economically developed countries, the prevalence of severe alcohol use disorder was estimated at nearly 40 in 100 (Kouimtsidis et al., 2021). An international review found 10 studies on men in this situation, with little data on women (Kouimtsidis et al., 2021).

The scoping review defined severe disorder by the presence of six or more symptoms described in the DSM-5 diagnostic manual (Smith-Bernardin et al., 2022). For anyone thinking about choosing the ICD-10 code, the reasoning resembles finding the right ICD-10 code: severity and pattern of use are part of the diagnosis, not just the presence of consumption.

People who reach these programs often have a long history of comings and goings. In five programs in five Canadian cities, participants described a world of circulation among health, justice, housing and shelters, in which abstinence was often required to receive help (Pauly et al., 2019). Residents reported a life of survival on the street marked by criminalization, unmet health needs, stigma and unsafe places to drink (Pauly et al., 2019).

The problem of non-beverage alcohol

Non-beverage alcohol, such as rubbing alcohol, cooking wine, mouthwash and hand sanitizer, brings risks to the person and to others when consumed in large amounts and mixed with other substances (Westenberg et al., 2021). More than 30 in 100 countries surveyed by the World Health Organization have policies on this type of alcohol, called surrogate alcohol (Smith-Bernardin et al., 2022).

In Edmonton, Canada, 150 homeless people answered a questionnaire, and 36 of them, 24 in 100, reported consuming non-beverage alcohol in the previous six months (Westenberg et al., 2021). Most participants were male (71.3 in 100) and identified as Indigenous (74.0 in 100) (Westenberg et al., 2021). Those who consumed non-beverage alcohol were older and had more psychological distress than those who did not (Westenberg et al., 2021).

Barriers to care also appeared. Among participants with unmet harm reduction needs, 60.9 in 100 cited structural barriers, such as availability and location; for hospital care needs, it was 58.3 in 100 (Westenberg et al., 2021).

For the clinician, this finding has a practical side. A person who arrives intoxicated may have drunk something very different from an ordinary beverage, and the history needs to go beyond asking "how much do you drink". This care in the history taking connects with interpreting signs, symptoms and history with attention to context.

The same study showed that barriers change depending on the type of help. For skills training (58.5 in 100) and counseling (53.6 in 100), the reported barriers were mostly motivational (Westenberg et al., 2021). This suggests that offering a service is only part of the way, and that how the person is welcomed weighs as much as the existence of the service. A program that accepts the person as they are, drinking, can reduce some of these barriers by creating a bond before proposing other goals.

The conversation about non-beverage alcohol also helps explain the reasoning behind the model. When the person is going to drink anyway, offering a beverage of known composition, at a predictable time and in a safe place, exchanges a high and unpredictable risk for a smaller, monitored risk (Smith-Bernardin et al., 2022). The logic is similar to that of other harm reduction strategies, such as drug checking and supervised consumption rooms.

What the studies show about outcomes

The scoping review included 32 studies and concluded that the programs can reduce alcohol-related harms and improve outcomes in people with severe dependence, with early evidence of lower total consumption, more housing retention and better quality of life (Smith-Bernardin et al., 2022). The authors note that long-term evaluation and implementation still need more study (Smith-Bernardin et al., 2022).

A review of reviews on interventions for people who are homeless or precariously housed included three reviews on managed alcohol programs (Magwood et al., 2020). According to that review, the programs reduced or stabilized alcohol consumption (Magwood et al., 2020).

In Thunder Bay, Canada, a pilot study compared 18 participants in a program with 20 shelter controls, most of them using non-beverage alcohol (Vallance et al., 2016). Compared with periods outside the program, participants had 41 per 100 fewer police contacts and 32 per 100 fewer hospital admissions (Vallance et al., 2016). Compared with controls, participants had 43 per 100 fewer police contacts, 70 per 100 fewer detox admissions and 47 per 100 fewer emergency department visits (Vallance et al., 2016).

The same study found less frequent use of non-beverage alcohol among program participants and a reduction in almost all available liver function tests after entry (Vallance et al., 2016). The authors warn that the small sample size limited some statistical comparisons (Vallance et al., 2016).

Participants also spoke about their experience. In a pilot study with 38 people, all self-identified as Indigenous, program participants were more likely to keep their housing and reported more safety and better quality of life than on the street, in prison, in shelters or in hospitals (Pauly et al., 2016). They described the program as a safe place, and the authors interpreted the service as a safer microenvironment, with potential for healing and recovery (Pauly et al., 2016).

The five-city study heard 53 participants, 4 former participants and 50 team members (Pauly et al., 2019). The article title, "There is a place", sums up what participants said: after entering the program, they had a fixed place, team support and a routine that allowed them to take care of their health (Pauly et al., 2019). The authors describe the program as a new space, with safer locations and a safe supply of alcohol, and with opportunities to reconnect with family and friends (Pauly et al., 2019).

This account matters because the outcome of interest goes beyond the number of drinks. For someone who has spent years on the street, having a room, a meal and someone who asks how the day went already changes the risk of violence, hypothermia and early death. The scoping review lists among the chronic harms of heavy consumption liver disease, cancer, vascular events and gastrointestinal diseases, and among the social harms violence and difficulty keeping housing (Smith-Bernardin et al., 2022).

The limits of the evidence need to be stated clearly. Most studies are small, observational and conducted in a few services, and the scoping review calls for long-term evaluations and implementation studies (Smith-Bernardin et al., 2022). The Thunder Bay study compared a small group of people, and the reduction in detox admissions relative to periods outside the program was close to the limit of statistical significance (Vallance et al., 2016). Reading these numbers with caution is part of the same reasoning we use to interpret the quality of the evidence for any intervention.

The table summarizes the main findings.

Study	Design	Main finding	Source
Scoping review	32 studies	Early evidence of lower consumption, more housing and better quality of life	(Smith-Bernardin et al., 2022)
Review of reviews	Three reviews on the programs	Reduced or stabilized consumption	(Magwood et al., 2020)
Thunder Bay	18 participants and 20 controls	Fewer police contacts and fewer emergency department visits	(Vallance et al., 2016)
Pilot in Ontario	38 participants	More housing stability and more safety	(Pauly et al., 2016)
Five Canadian cities	Case study with 53 participants	Exit from the cycle of street, shelter, hospital and prison	(Pauly et al., 2019)

Managed alcohol in the hospital and during the pandemic

The model left the shelters and entered other places. In a managed alcohol program inside a hospital, five patients were interviewed, and five themes emerged: reasons for drinking, gratitude for the program, control of withdrawal and calming effect, plus engagement in care and the wish for more drink options (Parappilly et al., 2020). The authors describe the hospital program as an option for patients with severe dependence who refuse or have not responded to conventional treatment and whose drinking interferes with medical care (Parappilly et al., 2020).

A group of internists, psychiatrists and addiction specialists listed harm reduction practices to consider in hospitals, and cited the benefits of programs that offer safe, controlled alcohol during admission (Sharma et al., 2017). The same authors note that many of these recommendations may be seen as controversial and call for dialogue with hospital teams (Sharma et al., 2017).

The COVID-19 pandemic sped up use of the model. In Halifax, Canada, a health team offered medications and alcohol to 77 residents of isolation hotels for people without housing (Brothers et al., 2022). Over 1059 person-days, there were zero overdoses, and 6 residents (8 in 100) left isolation before the end of the period, of whom 4 returned (Brothers et al., 2022).

The themes of the hospital study help to understand the experience from the inside. One theme was named "from just shaking to calm", and another dealt with engagement in care (Parappilly et al., 2020). Overall, the participants had a positive experience with the hospital program (Parappilly et al., 2020).

The residents of the Halifax hotels had a mean age of 42 years, and 24 in 100 were women (Brothers et al., 2022). Of the total, 62 residents (81 in 100) received medications, alcohol or cigarettes during isolation (Brothers et al., 2022). The authors concluded that the program had high rates of completion of the 14 days of isolation and few adverse events (Brothers et al., 2022).

In Lisbon, the pandemic response included emergency shelters for people without housing, and more than 600 people went through them between March and August 2020 (Fuertes et al., 2021). In this context, Portugal's national drug agency announced the intention to open a managed alcohol program (Fuertes et al., 2021).

A position paper by authors from the United Kingdom and Canada noted that limited access to alcohol during restrictions led to abrupt interruptions in drinking and a temporary rise in hospital visits for withdrawal (Kouimtsidis et al., 2021). The authors argue for managed alcohol programs and structured preparation for detoxification as parts of a single continuum of care, from harm reduction to treatment aimed at abstinence (Kouimtsidis et al., 2021).

What changes for the clinician

The managed alcohol program calls for a change of perspective. Instead of treating each detoxification as a fresh start, it recognizes that some people will keep drinking, and organizes care around that.

Some practical points emerge from the studies:

• Ask about non-beverage alcohol, because it is common among people without housing (Westenberg et al., 2021).
• Remember that requiring abstinence can push people away from housing and care (Pauly et al., 2019).
• Consider abrupt abstinence a risk when access to alcohol changes suddenly (Kouimtsidis et al., 2021).
• Know that managed alcohol has already worked inside hospitals and shelters (Parappilly et al., 2020).
• Read the results with caution, since the studies are small (Vallance et al., 2016).

The programs are also exploring other strategies. In six Canadian programs, 12 of 19 participants (63 out of every 100) were already replacing alcohol with cannabis, mainly for craving and withdrawal (Pauly et al., 2021). Most of them, 16 of 19 (84.2 out of every 100), said they were willing to take part in a formal substitution program (Pauly et al., 2021).

This approach fits with what we discussed about clinical decision-making: the course of action depends on what is possible for that person. It also recalls the importance of prognostic reasoning, because the trajectory of people living on the street with severe dependence changes when care is no longer conditioned on abstinence.

For teams that work together, the model depends on nurses, social workers, housing workers and physicians, as in interprofessional clinical reasoning. Discussing cases of patients who return repeatedly to the emergency department in morbidity and mortality sessions can show where the system failed, and not only where the patient failed.

The experience of students and residents with these patients is often marked by frustration. The person comes back, the team feels the work was wasted, and stigma grows. Knowing about managed alcohol programs offers another way of seeing the same patient: someone with a severe, chronic illness, who needs continuous care and a safe place, and who can have real gains even without stopping drinking (Pauly et al., 2016). This reading fits with case-based learning, in which the patient's context enters the reasoning from the first clue.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by looking for the code in ICD-10.

The limits on using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the Researcher page explains how to get in touch. Professionals who write or review cases find information on the Curator and Creators pages, and institutions can learn about the proposal on the partnerships page. Training with differential diagnosis and clues and dealing with diagnostic uncertainty complete this practice.

Frequently asked questions

What is a managed alcohol program?

It is a service that offers alcohol in regular doses, usually together with housing, meals and support, to people with severe alcohol dependence and unstable housing (Vallance et al., 2016).

Do the programs increase alcohol consumption?

A review of reviews concluded that the programs reduced or stabilized consumption (Magwood et al., 2020), and a scoping review found early evidence of lower total consumption (Smith-Bernardin et al., 2022).

Why offer alcohol instead of requiring abstinence?

Participants described a cycle between the street, shelter, hospital and prison in which abstinence was usually a condition for receiving help (Pauly et al., 2019), and the program offers an alternative for those who were left out of that care.

Do the programs reduce the use of non-beverage alcohol?

In Thunder Bay, the use of non-beverage alcohol was less frequent among program participants than among controls (Vallance et al., 2016).

Do these programs work in the hospital?

Patients in a hospital program described a positive experience, with better withdrawal control and more engagement in care (Parappilly et al., 2020).

Take-home messages

• Managed alcohol programs offer regular alcohol, housing and care to people with severe dependence and no housing.
• Non-beverage alcohol is common in this group and brings its own risks.
• The studies show fewer contacts with the police, fewer hospital admissions and more housing stability.
• The model was used in hospitals and shelters during the COVID-19 pandemic.
• The evidence is still limited and comes mostly from Canada.
• For the clinician, the question shifts from "how to make it stop" to "how to reduce harm now".

Want to practice your reasoning with progressive clues? Play today's case.

References

1. Brothers TD, Leaman M, Bonn M, et al. Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug Alcohol Depend. 2022. PMID 35461084.
2. Fuertes R, Belo E, Merendeiro C, et al. Lisbon's COVID 19 response: harm reduction interventions for people who use alcohol and other drugs in emergency shelters. Harm Reduct J. 2021. PMID 33494726.
3. Kouimtsidis C, Pauly B, Parkes T, et al. COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper. Front Psychiatry. 2021. PMID 33679480.
4. Magwood O, Salvalaggio G, Beder M, et al. The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS One. 2020. PMID 31945092.
5. Parappilly BP, Garrod E, Longoz R, et al. Exploring the experience of inpatients with severe alcohol use disorder on a managed alcohol program (MAP) at St. Paul's Hospital. Harm Reduct J. 2020. PMID 32398062.
6. Pauly B, Brown M, Chow C, et al. "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. Harm Reduct J. 2021. PMID 34162375.
7. Pauly B, Brown M, Evans J, et al. "There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness. Harm Reduct J. 2019. PMID 31842903.
8. Pauly BB, Gray E, Perkin K, et al. Finding safety: a pilot study of managed alcohol program participants' perceptions of housing and quality of life. Harm Reduct J. 2016. PMID 27156564.
9. Sharma M, Lamba W, Cauderella A, et al. Harm reduction in hospitals. Harm Reduct J. 2017. PMID 28583121.
10. Smith-Bernardin SM, Suen LW, Barr-Walker J, et al. Scoping review of managed alcohol programs. Harm Reduct J. 2022. PMID 35879719.
11. Vallance K, Stockwell T, Pauly B, et al. Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study. Harm Reduct J. 2016. PMID 27156792.
12. Westenberg JN, Kamel MM, Addorisio S, et al. Non-beverage alcohol consumption among individuals experiencing chronic homelessness in Edmonton, Canada: a cross-sectional study. Harm Reduct J. 2021. PMID 34657618.