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Alcohol use disorders (AUDs) are not equitably spread across the population, with some groups, such as people who are experiencing homelessness, being more vulnerable to AUDs due to social inequalities, stigma, and complex social and structural processes. Managed alcohol programs (MAPs) are a harm reduction approach first developed in Canada for those experiencing AUDs and homelessness with positive results. This study aimed to describe the factors that should be considered when implementing MAPs in Scotland. 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). Vignettes were used to support data collection. Data were analysed using Framework in NVivo. Participants highlighted six considerations to inform the implementation of MAPs in Scotland: the importance of individualized care; provision of alcohol; holistic care and a focus on well-being; types of settings and service models; staffing; and autonomy and rules. Future research should focus on piloting MAPs in a range of service contexts, using different models of care and settings, to develop an enhanced understanding of their effectiveness in addressing harms and promoting well-being for those experiencing AUDs and homelessness. [ABSTRACT FROM AUTHOR]

Introduction Managed Alcohol Programs (MAPs) are designed to improve health and housing outcomes for unstably housed people with an alcohol use disorder (AUD). The present study assesses the association of MAP participation with healthcare and mortality outcomes. Methods A retrospective cohort study assessed health outcomes for 205 MAP participants and 128 controls recruited from five Canadian cities in 2006–2017. Survival and negative binomial regression models were used to calculate hazard ratios (HR) of death and emergency room (ER) visits and hospital bed days (HBDs). Covariates included age, sex, AUD severity and housing stability score. Results In fully adjusted models, compared with times outside MAPs, participants had significantly reduced risk of mortality (HR = 0.37, P  = 0.0001) and ER attendance (HR = 0.74, P  = 0.0002), and fewer HBDs yearly (10.40 vs 20.08, P  = 0.0184). Over the 12 years, people enrolled in a MAP at some point had significantly fewer HBDs per year than controls after MAP enrolment (12.78 vs 20.08, P  = 0.0001) but not significantly different rates of death or ER presentation. MAP participants had significantly more alcohol-related but significantly fewer nonalcohol-related ER presentations than controls. Conclusion Attendance at a MAP was associated with reduced risk of mortality or morbidity and less hospital utilization for individuals with unstable housing and severe AUDs. MAPs are a promising approach to reduce mortality risk and time spent in hospital for people with an AUD and experiencing homelessness. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Managed alcohol programs (MAPs) have been implemented in Canada to reduce harms of severe alcohol use disorder and homelessness. Programs traditionally provide participants with regulated doses of alcohol as part of residential housing or shelter services. This study describes the experience of members of a non-residential, peer-initiated and peer-run MAP in Vancouver, BC, Canada. Semi-structured qualitative interviews were conducted with 14 members of the Community Managed Alcohol Program (CMAP) using questionnaires from the larger Canadian Managed Alcohol Program Study. Participants were recruited through word of mouth; interviews were audio-taped and transcribed. Data were coded inductively and analyzed using the constant comparative method. The CMAP was a community response to ongoing harms and increasing deaths related to the consumption of non-beverage alcohol (NBA). Participants reported that daily doses of self-managed alcohol and other supports provided by the program enabled them to change harmful drinking patterns, reduce NBA consumption, engage in program activities and feel a greater sense of well-being. Implementation of a non-residential, peer-initiated and peer-run MAP had an overall positive impact on participants' lives. Reported benefits included shifting away from NBA use, self-managing levels of alcohol consumption and developing stronger community engagement. Further investigation of this model of MAP is warranted. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness. [ABSTRACT FROM AUTHOR]

This project examined the effectiveness of a transitional program in breaking the cycle of homelessness. Within a community-based research approach, the authors conducted a case study to describe the program and participants within a context in which housing is largely unavailable and unaffordable. Although most participants successfully transitioned to housing few transitioned from homelessness to economic self-sufficiency in market housing and participants remained in poverty. Evaluations of housing programs can "blame the victim" or "blame the program" when measures of success are not achieved. Interventions to address homelessness require attention to the system-level forces that create and sustain poverty and inequities. [ABSTRACT FROM AUTHOR]

Background: Managed alcohol programs (MAPs) are a harm reduction strategy for people with severe alcohol dependence and unstable housing. MAPs provide controlled access to alcohol usually alongside accommodation, meals, and other supports. Patterns of alcohol consumption and related harms among MAP participants and controls from a homeless shelter in Thunder Bay, Ontario, were investigated in 2013. Methods: Structured interviews were conducted with 18 MAP and 20 control participants assessed as alcohol dependent with most using non-beverage alcohol (NBA). Qualitative interviews were conducted with seven participants and four MAP staff concerning perceptions and experiences of the program. Program alcohol consumption records were obtained for MAP participants, and records of police contacts and use of health services were obtained for participants and controls. Some participants' liver function test (LFT) results were available for before and after MAP entry. Results: Compared with periods off the MAP, MAP participants had 41 % fewer police contacts, 33 % fewer police contacts leading to custody time (x2 = 43.84, P < 0.001), 87 % fewer detox admissions (t = −1.68, P = 0.06), and 32 % fewer hospital admissions (t = −2.08, P = 0.03). MAP and control participants shared similar characteristics, indicating the groups were broadly comparable. There were reductions in nearly all available LFT scores after MAP entry. Compared with controls, MAP participants had 43 % fewer police contacts, significantly fewer police contacts (−38 %) that resulted in custody time (x2 = 66.10, P < 0.001), 70 % fewer detox admissions (t = −2.19, P = 0.02), and 47 % fewer emergency room presentations. NBA use was significantly less frequent for MAP participants versus controls (t = −2.34, P < 0.05). Marked but non-significant reductions were observed in the number of participants self-reporting alcohol-related harms in the domains of home life, legal issues, and withdrawal seizures. Qualitative interviews with staff and MAP participants provided additional insight into reductions of non-beverage alcohol use and reductions of police and health-care contacts. It was unclear if overall volume of alcohol consumption was reduced as a result of MAP participation. Conclusions: The quantitative and qualitative findings of this pilot study suggest that MAP participation was associated with a number of positive outcomes including fewer hospital admissions, detox episodes, and police contacts leading to custody, reduced NBA consumption, and decreases in some alcohol-related harms. These encouraging trends are being investigated in a larger national study. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to provide rationale, methodological guidance and clarity in the use of case study designs and theory driven approaches to evaluation of interventions to end homelessness.Design/methodology/approach – Using an evaluation of a transitional shelter program aiming to support permanent exits from homelessness as an example, the authors show how case study designs and theory driven evaluation is well suited to the study of the effectiveness of homelessness interventions within the broader socio-political and economic context in which they are being implemented. Findings – Taking account of the context as part of program evaluation and research on homelessness interventions moves away from blaming programs and individuals for systemic failures to better understanding of how the context influences successes and failures. Case study designs are particularly useful for studying implementation and the context which influences program outcomes. Theory driven evaluations and the use of realist evaluation as an approach can provide a broader understanding of how homelessness interventions work particularly for whom and under what conditions. These methodological and theoretical approaches provide a consistent strategy for evaluating programs aimed at ending homelessness. Originality/value – There is a need for greater capacity in the homelessness sector to apply approaches to evaluation that take into account the broader socio-political and economic context in which programs are being implemented. Through the use of a case example, the authors provide guidance for application of case study design and theory driven approaches as a strategy for approaches programs aimed at ending homelessness. [ABSTRACT FROM AUTHOR]

Homelessness is a serious and growing issue. Evaluations of systemic-level changes are needed to determine progress in reducing or ending homelessness. The report card methodology is one means of systems-level assessment. Rather than solely establishing an enumeration, homelessness report cards can capture pertinent information about structural determinants of homelessness. This information can inform the development of evidence-based strategies aimed at ending (rather than managing) homelessness. To aid in the development of homelessness report card creation, a systems-level Homelessness Outcome Reporting Normative Framework (the HORN Framework) was developed. This article provides an overview of the framework and its application. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsFindingsConclusionManaged Alcohol Programs (MAPs) are a harm reduction strategy for people experiencing homelessness and alcohol dependence. Despite a growing evidence base, resistance to MAPs is apparent due to limited knowledge of alcohol harm reduction and the cultural preference for abstinence-based approaches. To address this, service managers working in a not-for-profit organization in Scotland designed and delivered a program of alcohol-specific staff training as part of a larger study exploring the potential implementation of MAPs during the COVID-19 pandemic.Semi-structured interviews were conducted with 15 service managers and staff regarding their experiences of the training provided. Data were analyzed using Framework Analysis, and Lewin’s model of organizational change was applied to the findings to gain deeper theoretical insight into data relating to staff knowledge, training, and organizational change.Participants described increased knowledge about alcohol harm reduction and MAPs, as well as increased opportunities for conversations around cultural change. Findings highlight individual- and organizational-level change is required when implementing novel harm reduction interventions like MAPs.The findings have implications for the future implementation of MAPs in homelessness settings. Training can promote staff buy-in, facilitate the involvement of staff within the planning process, and change organizational culture. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the response of homeless alcohol drinkers to less affordable alcoholic beverages.