30 January 2016

When alcohol abstinence fails supervised serving may reduce harms. "MAP" or wet rooms.

Managed Alcohol Programs - (MAP). Slow progress of effective hostel protocol to save money, suffering and dignity of our most marginalised citizens. 
Dear Colleagues,
I have been writing these summaries for many years but there is little more dramatic I can think of than the findings of three published studies and numerous other reports of allowing alcohol to alcoholics in refuges under strict supervision with psychosocial supports.  I wrote enthusiastically about a Canadian study by Tiina Podymow in 2006 ( http://www.redfernclinic.com/c/2006/01/supplying-alcohol-to-alcoholics-may_9924.php4 ).  The other two are from 2009 and 2012, both from Seattle (see refs below). 
Essentially these interventions allow limited quantities of alcohol such as one standard drink per hour in previously ‘dry’ hostels. Thus there is a supervised supply from trained staff inside the establishments from opening at 5 or 6pm up to 10pm or later. 
The published findings of events before and after implementation of the ‘managed alcohol program’ show substantial and significant improvements.  Both medical and police interactions dropped while overall alcohol consumption also dropped.  The authors of some of the studies quantify the benefits using estimates of the costs of police and medical services, each showing very dramatic savings per individual. 
These subjects were all hostel residents who had had multiple attempts at abstinence, detoxification, meetings and medical interventions without success.  Hence for some of these high-end alcohol users “managed alcohol” may be a better goal than enforced abstinence in return for the bed for the night.  The may also be some parallels with the use of nicotine replacement therapies, opiate maintenance treatments and other harm reduction strategies.  Outright overnight bans on alcohol in these hostels may be a well meaning policy which has paradoxically increased harms to those it was intended to help. 
The very fact that the trials were able to be performed is impressive.  It is my belief that these publications are so persuasive that a randomised trial is warranted on a large scale, such are the potential benefits to the alcoholic drinkers, their families and society at large. 
The take-home message from the three reports is that when abstinence based interventions for chronic alcoholics are unsuccessful, further pursuit of abstinence, even temporarily may lead to unwanted consequences which are expensive, painful and time consuming.  And they are avoidable. 
One possibly reason for the findings might be that residents facing overnight lock-up may drink very heavily in the period immediately before entering the hostel.  Such binge drinking is known to be associated with complications from falls and injuries, chest infections, nerve/skin damage from pressure necrosis, liver disease, ulcers, etcetera. 
In 2011 Time Magazine was so impressed that they ran an enthusiastic article (The ‘Wet House’ Where Alcoholics Can Keep Drinking - link below).  This was based on an original story in the New York Times (link below). 
Next time you hear of someone’s operation being postponed due to lack of hospital bed, recovery services or operating theatre time, it is possible that the services are being used by a person in the position above suffering some urgent but preventable medical or surgical complication requiring your local hospital services.  This may also apply to casualty waiting times, blood transfusion services, ambulance, rehabilitation and more.  Likewise, when the police are tied up with local issues of this nature they could be attending to other important policing matters. 
Notes by Andrew Byrne .. http://methadone-research.blogspot.com/
Since writing this I have become aware that Prof Kate Dolan has done a lot of work in this area and has provided much needed summaries of the English and Canadian experience with detailed suggestions for Managed Alcohol Programs in Sydney (refs below). 
Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ 2006 174;1:45-49        http://www.cmaj.ca/content/174/1/45.full
Larimer ME, Malone DK … (et al.) Marlatt GA. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349-57      http://www.ncbi.nlm.nih.gov/pubmed/19336710
Collins SE, Malone DK, et al. WG, Marlatt GA, Larimer ME. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012 Mar;102(3):511-9        http://www.ncbi.nlm.nih.gov/pubmed/22390516
Happy Hour? ‘Wet Houses’ Allow Alcoholics to Drink, With Surprising Results. Time Magazine            http://healthland.time.com/2011/04/27/happy-hour-wet-houses-allow-alcoholics-to-drink-with-surprising-results/
The Wet House Where Alcoholics Can Keep Drinking            http://www.nytimes.com/2011/05/01/magazine/mag-01YouAreHere-t.html?_r=1
Feasibility of a Managed Alcohol Program for Sydney.
Introduction to Professor Kate Dolan’s work in this area:
British Columbia’s North-West remote areas.
Ottawas MAP

I acknowledge the traditional owners and custodians of this land on which I walk and work, the Gadigal people of the Eora nation, and pay my respects to elders both past and present.