In the landscape of ill icit drug harm reduction andalcohol policy, there are few options for thoseimpacted by the harms of high risk or ill icit drinking(unsafe settings, unsafe sources such as non-beverage alcohol and unsafe patterns ofconsumption) and/or severe alcohol dependence.These harms are not new but are being escalatedduring the response to COVID-19, creating a surge ofunmet need and propelling interests in thedevelopment of Managed Alcohol Programs (MAPs)across Canada and elsewhere. In this bulletin, we provide some beginning guidanceand suggestions for organizations looking to initiateor scale up a MAP. There is substantial and growingevidence that MAPs are a unique intervention toreduce harms related to high risk drinking, severealcohol dependence, homelessness and poverty (1-4). Please see www.cmaps.ca for more detailedinformation on the Canadian Managed AlcoholProgram Study (CMAPS). This guidance is based onsix common elements of MAPs (5), CMAPS researchon implementation and outcomes as well asextensive experience and wisdom of the CMAPScommunity of practice. This bulletin focuses onfrequently asked questions received by the CMAPSteam.

Scale up of ManagedAlcohol Programs

REFERENCES

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C A N A D I A N I N S T I T U T E F O R S U B S T A N C E U S E R E S E A R C H B U L L E T I N # 2 0 J U N E 2 0 2 0

S t o c k w e l l , T . e t . a l ( 2 0 1 8 ) . D o e s m a n a g i n g t h ec o n s u m p t i o n o f p e o p l e w i t h s e v e r e a l c o h o ld e p e n d e n c e r e d u c e h a r m ? A c o m p a r i s o n o fp a r t i c i p a n t s i n s i x C a n a d i a n m a n a g e d a l c o h o lp r o g r a m s w i t h l o c a l l y r e c r u i t e d c o n t r o l s . D r u gA l c o h o l R e v . , 3 7 : S 1 5 9 - S 1 6 6 .d o i : 1 0 . 1 1 1 1 / d a r . 1 2 6 1 8V a l l a n c e , K . , e t a l . ( 2 0 1 6 ) . D o m a n a g e d a l c o h o lp r o g r a m s c h a n g e p a t t e r n s o f a l c o h o l c o n s u m p t i o na n d r e d u c e r e l a t e d h a r m ? A p i l o t s t u d y . H a r mR e d u c t J 1 3 , 1 3 ( 2 0 1 6 ) .h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 5 4 - 0 1 6 - 0 1 0 3 - 4P a u l y , B . e t a l . ( 2 0 1 6 ) . F i n d i n g s a f e t y : a p i l o t s t u d yo f m a n a g e d a l c o h o l p r o g r a m p a r t i c i p a n t s ’p e r c e p t i o n s o f h o u s i n g a n d q u a l i t y o f l i f e . H a r mR e d u c t J 1 3 , 1 5 . h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 5 4 -0 1 6 - 0 1 0 2 - 5P a u l y , B . e t a l . ( 2 0 1 9 ) “ T h e r e i s a P l a c e ” : i m p a c t so f m a n a g e d a l c o h o l p r o g r a m s f o r p e o p l ee x p e r i e n c i n g s e v e r e a l c o h o l d e p e n d e n c e a n dh o m e l e s s n e s s . H a r m R e d u c t J 1 6 , 7 0 .h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 5 4 - 0 1 9 - 0 3 3 2 - 4P a u l y , B . , e t a l . ( 2 0 1 8 ) , C o m m u n i t y m a n a g e da l c o h o l p r o g r a m s i n C a n a d a : O v e r v i e w o f k e yd i m e n s i o n s a n d i m p l e m e n t a t i o n . D r u g a n d A l c o h o lR e v i e w , 3 7 ( S u p p l e m e n t 1 ) : p . S 1 3 2 - 1 3 9 .

1 .

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5 .

P a u l y , B . , G r a h a m , B , V a l l a n c e , K . , B r o w n ,M . , & S t o c k w e l l , T . ( 2 0 2 0 ) . S c a l e u p o fM a n a g e d A l c o h o l P r o g r a m s . C I S U R B u l l e t i n# 2 0 , V i c t o r i a , B C : U n i v e r s i t y o f V i c t o r i a .

What are the program goals?MAPs are harm reduction programs intended toreduce harms of high-risk drinking or severealcohol use disorder often coupled with ongoingexperiences of homelessness or poverty. Programgoals should be first and foremost to reduce theharms of substance use. Harms of high riskdrinking and severe alcohol use disorder includerisks in the external environment related toviolence and assault as well as harms related tounsafe sources of alcohol such as non-beveragealcohol, unsafe patterns of drinking, orcomplicated withdrawal. There are many different MAPs, includingcommunity day programs, residential modelslocated in shelters, transitional and permanenthousing and hospital-based programs. Outside ofhospital-based models, the majority of communityMAPs are operated by local non-profit societiesthrough multiple sources of funding. Dependingon the location of the MAP and the health ofclients, there are varying degrees of professionalhealthcare involvement. The most common isprovision of primary care by physicians andnurses either on site or through communityoutreach.

What is the program eligibility? General eligibility criteria for a MAP include that theperson has a longstanding and ongoing pattern ofhigh-risk drinking and is at high risk foralcohol-related harms. These harms may be relatedto homelessness, risk of homelessness and/or ill icitor “survival drinking.” Eligible individuals will alsonot have succeeded in abstinence-orientedtreatments for alcohol use disorders despitemultiple attempts and remain unable or unwilling tostop drinking. Eligibility can be based on assessment of harmsassociated with alcohol use (e.g. drinking in publicspaces that increase risk of violence and assault,frequent interactions with police and emergencyservices, amount and type of consumptionincluding binge drinking and non-beverage alcohol,as well as the impacts resulting from relatedstigma). Specific criteria are established by eachprogram to determine who they aim to serve. Forexample, specific clientele or settings (e.g. in long-term care, male-only, Indigenous-led, peer-led). Todate, there are no programs that cater exclusivelyto women or those who identify as LGBTQ.

PROGRAM GOALS &

ELIGIBILITY

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Who will provide the alcohol? At what intervalwill alcohol be provided and of what type?Much of this can be determined throughdevelopment of an individual managed alcoholplan (iMAP) tailored to each client. An iMAP canbe developed by individuals for themselves, incollaboration with a peer support or other harmreduction worker or with a clinician. Alcoholdelivery and provision should be accompanied bywellness checks. Primary care providers may beconsulted regarding general alcohol managementas needed especially in relation to interactionswith medications and healthcare needs. The iMAP should be adapted to the individualclient’s current needs, health status and drinkingpatterns.See EIDGE/CISUR for Safer Drinking Tipsand other resources at www.cmaps.ca. Part ofbuilding the iMAP is to identify the frequency andtype of alcohol based on an assessment of harmsand benefits. Administration of alcohol may varyfrom 1-2 to up to 12 times per day. Daily quantityshould not exceed levels of usual alcoholconsumption prior to MAP entry. Frequency ofadministration should be based on clients ability toself-manage. The focus should always be onenhancing the capacity of individual clients to buildtheir capacity to safely self-manage their alcoholconsumption. Screening for intoxication,withdrawal and other health risks at the time ofalcohol delivery or administration is important topromote overall safety and wellness. If needed, theiMAP may be adjusted. Such screening can bedone by appropriately trained individuals includingharm reduction workers, & housing staff. TheCMAPS project has collated assessment andscreening resources from many established MAPsthat are available by joining the CMAPSCommunity of Practice at www.cmaps.ca.

How can the alcohol be funded?Alcohol may be funded by a combinationof client contributions and programsubsidies. Funding the costs of alcohol isone of the most challenging aspects ofsetting up and running a MAP.There arelimited avenues for purchasing alcoholoutside of retail vendors. U Brew orbrewing onsite can reduce costs andenhance participate involvement.

How should alcohol be stored?Storage of alcohol is an importantconsideration and locked storage is criticalfor client safety. Options include onsitestorage in a staff-monitored area inhousing or day programs, similar to anymedication storage or money managementsystems.Staff and clients should both signoff on paperwork to establish the clientreceived their alcohol, whether a dose isadministered onsite or for takeawayconsumption. This can be helpful tomanage situations when questions ariseas to whether or not the client hasreceived alcohol.

Where can alcohol bepurchased from?Alcohol may be purchased1) from retail vendors; 2)through arrangements withlocal breweries anddistillers at reduced/wholesale pricing and/or bydonation. Additional optionsto reduce cost of sourcingalcohol are 3) using aUBREW or UVin companyor 4) brewing the alcohol onsite.

ALCOHOL PROCUREMENT

& FUNDINGALCOHOL DELIVERY &

ADMINISTRATION

P A G E 3

How will food and accommodation beprovided?MAP programs often provide basic socialdeterminants of health such as food andhousing. Meals may be offered severaltimes a day. Program participants areoften involved in meal planning andpreparation. Food is important to overallhealth. Often individuals with high levelsof alcohol consumption have nutritionalneeds that are unmet in part due todrinking but also due to income andother factors such as lack of spaces forcooking. Housing is a critical piece forpreventing alcohol related harms. MAPScan be an important aspect of HousingFirst Programs. Being in a MAP hasbeen found to increase housing stability.Permanent housing options are preferredso that individuals are able to stayregardless of their tenure on MAP.

SOCIAL & CULTURALCONNECTIONS

What kind of social and culturalconnections will be available?Substance use is often a response totrauma and other difficult lifecircumstances. Drinking is a socialactivity and social connections areimportant to mental health and well-being. An important aspect of managedalcohol programming is the ability toaccess appropriate social and culturalsupports that enhance client wellbeing.Such supports and activities should bedesigned by and for individuals in theprogram with lived experience. Onceindividuals are stabilized they oftenreconnect with self, family and others.

Should we plan for program evaluation? Whatshould we consider in planning for evaluation? What about research?Program evaluation is an important aspect ofplanning and scaling up any MAP. There are manyresources available to support program evaluation for thepurposes of program improvement. Program evaluationprovides important information about how a particularMAP is working and what might be done to improve it.Some potential areas for program evaluation include:describing the characteristics of people in the program,severity of use, changes in alcohol-related harms overtime or changes in patterns of consumption. Client intake,assessment, iMAPs, and daily alcohol consumptionrecords can be reviewed and collated as per eachorganization’s procedures and protocols. Programevaluation is not necessarily the same as researchalthough there is some overlap. Research generallyinvolves contributing to a broader body of knowledgeusing rigorous research designs, more in-depth datacollection and analysis and is often done through thirdparties or collaborations between programs and academicresearchers such as the CMAPS project.

How should primary care be involved? When shouldclinicians be consulted? What clinical monitoringshould be done?It is important that clients have access to primary care(e.g. nurse, nurse practitioner, or physician) on a regularbasis to address ongoing primary care needs. Individualsentering into a MAP may be disconnected from primarycare but have extensive primary care needs and in somecases may have complex health issues. Registerednurses are well suited to support assessment anddevelopment of iMAP in consultation with physicians onspecific medical issues. Nurse practitioners and/orphysicians are important for timely diagnosis and toprovide medical management and routine clinicalmonitoring such as blood and liver function tests.

FOOD &

ACCOMMODATIONPRIMARY CARE &

CLINICAL MONITORING

PROGRAM EVALUATION

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