Recently, Managed Alcohol Programs (MAPs have emerged as an alcohol harm reduction model for those living with severe alcohol use disorder (AUD) and experiencing homelessness. There is still a lack of clarity about the role of these programs in relation to Housing First (HF) discourse. The authors examine the role of MAPs within a policy environment that has become dominated by a focus on HF approaches to addressing homelessness. This examination includes a focus on Canadian policy contexts where MAPs originated and are still predominately located. The purpose of this paper is to trace the development of MAPs as a novel response to homelessness among people experiencing severe AUD and to describe the place of MAPs within a HF context.
This conceptual paper outlines the development of discourses related to persons experiencing severe AUD and homelessness, with a focus on HF and MAPs as responses to these challenges. The authors compare the key characteristics of MAPs with “core principles” and values as outlined in various definitions of HF.
MAPs incorporate many of the core values or principles of HF as outlined in some definitions, although not all. MAPs (and other housing/treatment models) provide critical housing and support services for populations who might not fit well with or who might not prefer HF models.
The “silver bullet” discourse surrounding HF (and harm reduction) can obscure the importance of programs (such as MAPs) that do not fully align with all HF principles and program models. This is despite the fact that MAPs (and other models) provide critical housing and support services for populations who might fall between the cracks of HF models. There is the potential for MAPs to help fill a gap in the application of harm reduction in HF programs. The authors also suggest a need to move beyond HF discourse, to embrace complexity and move toward examining what mixture of different housing and harm reduction supports are needed to provide a complete or comprehensive array of services and supports for people who use substances and are experiencing homelessness.
Schiff, R., Pauly, B., Hall, S., Vallance, K., Ivsins, A., Brown, M., Gray, E., Krysowaty, B. and Evans, J. (2019), "Managed alcohol programs in the context of Housing First", Housing, Care and Support, Vol. 22 No. 4, pp. 207-215. https://doi.org/10.1108/HCS-02-2019-0006Download as .RIS
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Although not all homeless people suffer from substance use problems, particularly alcohol use disorders (SUDs/AUDs), those who do live with these issues have unique support needs in order to sustain housing stability. Research over the past several decades has focused on how to address concurrent challenges related to AUD treatment/recovery and housing instability (Waegemakers Schiff and Schiff, 2014). This includes almost two decades of discourse on “Treatment First” and “Housing First” approaches (Waegemakers Schiff and Schiff, 2014). Recently, Managed Alcohol Programs (MAPs) have emerged in Canada, and in other countries, as an alcohol harm reduction model for those living with severe AUD and homelessness or housing instability. Early research demonstrates the effectiveness of MAPs in several domains (reduction in alcohol-related harms; reduced consumption, increased safety; reduced emergency service use, reduced costs) and significant levels of satisfaction for clients (Hammond et al., 2016; Pauly et al., 2016; Stockwell et al., 2018; Vallance et al., 2016). However, there is still a lack of clarity about the role of these programs in housing policy arenas that have become increasingly dominated by Housing First (HF) discourse. The purpose of this commentary is threefold: to examine the implementation of harm reduction in housing for homeless individuals; to trace the development of MAPs as an important response to homelessness among people experiencing severe AUD; and to describe their role within the context of HF. We focus particularly on the Canadian context where the majority of MAPs are located. We also incorporate reflection on Canadian, US and European contexts where HF has become a dominant force in housing and homelessness policy.
Alcohol dependence, harms and homelessness
According to the World Health Organization (WHO) (2015), over 5 percent of illness and injuries can be attributed to alcohol-related causes. Alcohol dependence is associated with harms that can be described as acute, chronic and social. In terms of acute harms, physical injuries may be sustained for alcohol-related reasons, which place an individual at an increased risk of acute injury owing to alcohol use (Canadian Substance Use Costs and Harms Scientific Working Group, 2018). Physical harms also include acute alcohol poisoning, injury, withdrawal and seizures (Stockwell, Williams and Pauly, 2012; Stockwell, Butt, Beirness, Gliksman and Paradis, 2012; Rehm et al., 2009). In terms of chronic harms, AUDs contribute to an estimated 3.8 percent of global deaths due to chronic diseases such as cirrhosis of the liver, as well as morbidity from alcohol-attributable pancreatitis, cancers and cardiovascular disease (Rehm et al., 2009).
Alcohol use is also associated with a significant number of social harms, including physical and sexual violence, criminal behavior, family breakdown and financial problems (Stockwell, Williams and Pauly, 2012; Stockwell, Butt, Beirness, Gliksman and Paradis, 2012). When people with substance use disorders also lack stable housing, they are exposed to additional health risks related to homelessness, thereby facing a double burden of potential harm and health risk. The health impacts arising from alcohol dependence among people experiencing homelessness are exacerbated by a lack of access to direct and indirect social and health supports (Pauly et al., 2013). These challenges are further compounded by the criminalization of street-based consumption of non-beverage alcohol (NBA), such as mouthwash (Crabtree et al., 2018).
In a five-year population study on the demographic and clinical use patterns of all individuals visiting an Emergency Department (ED), Mandelberg et al. (2000) compared frequent users of the ED to all other ED visits. Among the frequent ED users, 38 percent reported being homeless and 79 percent were seen for alcohol dependence. Mandelberg et al. (2000) identified that frequent use of the ED was a reflection of urban social inequities of poverty, homelessness, alcohol use and illness, essentially emphasizing the associated acute, chronic and social harms related to alcohol use.
Mortality is also significantly increased among individuals experiencing homelessness, with causes of increased mortality correlated with substance misuse, disease, suicide and unintentional injuries (Fazel et al., 2014). Alcohol use among homeless individuals contributes to a standardized mortality ratio two to five times greater than the age-standardized general population (Fazel et al., 2014). Homelessness also contributes to the persistence of alcohol dependence and harms, in that it is more difficult to treat and manage alcohol dependence when combined with homelessness in comparison with the general population (Fazel et al., 2014).
“Treatment First” and the emergence of “Housing First” for people with substance use disorders
People experiencing substance use problems and homelessness have long faced barriers to obtaining housing. For much of the twentieth century, supportive housing providers followed an abstinence-based model making it more difficult for those who continue to use substances to be eligible for housing: “A dominating approach to homelessness has been the so-called treatment first: the homeless person should prove abstinence from substances in order to qualify for independent living” (Dyb, 2016, p. 77). Such models also expect that individuals progress through different stages of transitional housing by demonstrating increased readiness for independent housing through compliance with mental health and substance use treatment and contingent on abstinence. These approaches have been variably discussed in the literature as “treatment first/treatment before housing”, “continuum of care” (CoC) and “housing ready” approaches. However, owing to the challenges of treating and managing substance use dependence when combined with homelessness, these abstinence-based housing models were often ineffective for supporting recovery and eventually achieving housing stability among people with severe AUD and homelessness (Culhane and Metraux, 2008; Schiff et al., 2010).
In the 1990s, the newly created New York based Pathways to Housing program (PTH) used the term “housing first” as an explicit alternative to treatment first/housing ready/CoC approaches. PTH incorporated a harm reduction philosophy, prioritizing consumer choice, direct placement into permanent housing and no requirements for sobriety or treatment compliance (Tsemberis et al., 2004). Early research on the PTH model revealed significant success, when compared with CoC and treatment first models, with success often defined as achieving longitudinal housing stability for homeless people with concurrent mental health and substance use disorders (Gulcur et al., 2003; Tsemberis et al., 2004). With the success demonstrated by the PTH program, agencies and governments across North America, Europe, Australia and elsewhere became increasingly interested in adopting the concept of HF (although not necessarily the PTH model) as a preferred approach to housing homeless individuals. As Baker and Evans (2016) argue, the recent rapid uptake of HF into diverse international policy arenas may have been at least partially attributable to the malleability of the concept and the ability of diverse groups to advance their interests and policy agendas.
With the widespread interest in HF as a solution to homelessness, there emerged a plethora of different program models as well as debate about what actually defines a HF program or approach. For example, whether scattered site housing (a prerequisite of the PTH model) was necessary or if communal settings could also fit within definitions of HF. As Waegemakers Schiff and Schiff (2014) discuss, what has emerged is both a philosophy of HF, defined by key principles or values and specific program models such as the PTH and the Canadian At Home/Chez Soi (AHCS) (Goering et al., 2011) models. Pleace and Bretherton (2017) provide a useful taxonomy of the different types of HF models that have emerged over the past two decades, including the PTH model, “Communal Housing First” and “Housing First Light”.
Overall, there is significant evidence to support the efficacy of HF (as opposed to treatment first models) for the population that it was intended for those with co-occurring serious mental illness and substance use disorders (Baxter et al., 2019; Goering et al., 2011). However, there are many limitations of the current understanding of HF implementation and efficacy, including questions related to program fidelity and efficacy when the PTH and AHCS protocols are applied to other populations such as those with severe AUD (Kertesz et al., 2009; Woodhall-Melnik and Dunn, 2016).
Program fidelity, and disparity in terms of the ways in which HF is implemented, has led to questions about program relevance and efficacy for diverse populations (Baxter et al., 2019; Woodhall-Melnik and Dunn, 2016), especially in those who use substances or have substance use problems when abstinence is not obtainable (Grazioli et al., 2015; Johnsen and Teixeira, 2012). This is especially important in implementation of harm reduction in HF models. The significance of the distinction between philosophy and program model for people experiencing substance use issues is that while many programs may embrace a HF philosophy, including harm reduction, there is lack of clarity and great variability in the extent to which principles of harm reduction are actually implemented in programs. Although harm reduction is a principle of many HF programs, program descriptions are not always explicit about the ways in which harm reduction is being implemented. In fact, it is often unclear if harm reduction is being implemented as a philosophy, program model and/or a set of interventions (Pauly, 2008). In some cases, harm reduction philosophy is in name only or limited to distribution of supplies for safer use constituting partial implementation of harm reduction for illicit drugs with providers turning a blind eye to harmful use (Pauly et al., 2017; Wallace et al., 2018).
In terms of program attrition, most HF studies indicate between 70 and 80 percent success rates in housing retention, such that another 20–30 percent of those admitted to HF programs return to homelessness or are lost to follow-up. There are examples of HF that tolerate onsite drinking but do not provide or manage alcohol such as that described by Collins et al. (2012). In a nonrandomized controlled trial conducted in Seattle, Collins et al. (2012) found that 75 percent who were initially homeless with severe AUD remained housed two years later, with reduced ED visits and reduced jail time. They also found that alcohol use was not a predictor of return to homelessness. These authors found that:
[…] participants receiving a project-based [Housing First] HF intervention reduced their alcohol use and experience of alcohol related problems over a two-year follow-up as a function of length of exposure to [Housing First] HF.
(Collins et al., 2012, p. 938)
The findings however provide few details on how harm reduction was implemented, nor an assessment of which measures were associated with these outcomes. Such studies are few and far between, and most literature on HF lacks description of the evidence related to attrition from HF programs and the characteristics of those who are lost to follow-up or return to homelessness. Other literature notes that there is limited implementation of alcohol harm reduction measures and this constrains the ability for many HF models to respond to the needs of some individuals experiencing severe AUD (Kertesz et al., 2009; Woodhall-Melnik and Dunn, 2016). Based on the data available through the PTH research, AHCS study in Canada and other studies of HF retention rates, this population makes up a portion of that 20–30 percent of people who are not successful in traditional HF program models. Although the rates of HF success are undeniably significant and demonstrate the efficacy of this approach for ending homelessness for many individuals, there may be some for whom tolerance of substance use is not enough to reduce harms or ensure maintenance of housing. MAPs may fill a gap in housing and support service provision for this population.
The emergence of alcohol harm reduction and MAPs
Alcohol harm reduction strategies for those experiencing severe AUD and homelessness are gaining traction. Exploration of moderate drinking as a potential harm-reduction treatment approach was the subject of research beginning over 30 years ago with the introduction of a pilot program for males with alcohol dependence (Marlatt and Witkiewitz, 2002). This led to debate related to defining treatment for alcohol dependence. Sobell and Sobell (1973) indicated that moderate drinking could be an appropriate component of treatment for those with severe and chronic alcohol use. It was also found that reduced drinking vs abstaining from alcohol was a path to recovery for those who were not in any treatment programs (Marlatt and Witkiewitz, 2002; Sobell et al., 2001). Later, a WHO bulletin (Sayers, 2001) suggested viewing alcohol use on a continuum and to have this seen as “within the broader goal of preventing and reducing alcohol related problems at the population level […] with the goal of reduction of alcohol related morbidity and mortality” (p. 66).
In Canada, the rationale for one of the earliest MAPs arose from the freezing deaths of three homeless men in Toronto, Ontario, with recommendations to provide 24/7 shelter to men with severe AUD (Pauly et al., 2018). MAPs are an alcohol harm reduction and homelessness intervention that operate out of homeless shelters, low-barrier residential settings and, in some cases, even day programs. MAPs:
[…] are a harm reduction strategy that incorporates the provision of regulated doses of alcohol alongside accommodation and other supports to address the twin harms of severe alcohol dependence and homelessness.
(Pauly et al., 2016, p. 2)
MAPs administer alcohol to clients in structured, scheduled doses, with staff members on site 24/7, providing support for clients while also monitoring levels of intoxication and respecting clients’ independence (Pauly et al., 2016). Individual MAPs may vary in policies and processes of implementation, such as admission criteria, protocols for alcohol administration and rules related to consuming alcohol outside of the program, but all share the common practice of regularly scheduled administered alcohol while offering connections to psychosocial and health supports as well as programming intended to promote engagement in activities of daily living, social belonging and community integration (Pauly et al., 2016; Stockwell et al., 2018). Ultimately, MAPs aim to:
[…] decrease or prevent alcohol related harms by reducing heavy episodic drinking, use of non-beverage alcohol, public intoxication, drinking in unsafe settings and high costs associated with police and emergency services while increasing access to primary care and other health and social services.
(Pauly et al., 2018, p. S137)
MAP participants are “typically individuals with severe alcohol dependence and long histories of homelessness, public intoxication and regular consumption of non-palatable alcohol” (Hammond et al., 2016, p. 1). Pauly et al. (2018) provide a description of the key elements of 13 MAPs in Canada including review of the followings: program goals and eligibility, alcohol dispensing procedures, funding models, accommodation, primary care supports and sociocultural supports. Most of the MAPs offer some sort of accommodation, which may take various forms including shelter-based, transitional, or permanent supportive housing. This is often accompanied by food service as well as several other on- and offsite health and social supports. Common eligibility criteria for accessing MAPs include the followings: severe AUD (often with heavy episodic and NBA drinking); chronic homelessness; high levels of emergency health, social and justice system service use; and multiple attempts at abstinence-based treatment interventions (Pauly et al., 2018).
The number of MAPs has increased significantly in recent years, with over 20 MAPs currently in place in upwards of ten cities across Canada (Pauly et al., 2018). The Canadian Managed Alcohol Program Study (CMAPS) is a national project examining how people’s lives change when they enter an MAP. The CMAPS evaluation is being conducted by the Canadian Institute for Substance Use Research, led by Pauly and Stockwell, and focuses on implementation and outcomes of MAPs by looking at changes in clients’ substance use, substance use-related harms, housing status, health and quality of life as a function of being in an MAP (University of Victoria Communications, 2018).
Early evidence from the CMAPS evaluation indicates effectiveness in terms of reduced police contacts, fewer hospital admissions and a reduction in NBA consumption when compared with a control group who met the criteria for a MAP, but who were not currently enrolled in a MAP (Vallance et al., 2016). MAP participants also report feeling safer and experience a sense of connection to family and home in MAP than in other settings available to them such as hospitals, shelters and jails (Pauly et al., 2016). In a comparison of 175 MAP participants in five cities and 189 controls, Stockwell et al. (2018) found that “long term MAP residents (>2 months) drank significantly more days (+5.5) but 7.1 standard drinks fewer per drinking day than did controls over the last 30 days” (p. 159). In this same analysis, long-term MAP residents reported significantly fewer acute alcohol-related harms in the domains of health, safety, social, legal and withdrawal symptoms. In other analysis, Erickson et al. (2018) reported that MAP participants were more likely to report positive strategies for coping when alcohol was not available such as re-budgeting, waiting for money or going without. As individuals entering MAP often have long histories of homelessness and have not been previously or recently stably housed (Pauly et al., 2016), MAPs may be filling important gaps by facilitating housing stabilization for those who would not be successful in independent housing or in the traditional HF program models listed earlier.
Managed alcohol programs in the context of “Housing First”
Increasingly, HF has been framed as an approach to housing instead of a specific program model. Various international and Canadian sources have outlined “key principles” and “core values” of HF as an overall approach; these are considered to be principles and values that would inform the development of specific program models. We touch on four descriptions of these core values and describe their relationship to elements of MAPs (Lancione et al., 2018; Polvere et al., 2014; Waegemakers Schiff and Schiff, 2014; Woodhall-Melnik and Dunn, 2016). Table I provides comparison specifically with the “key principles” and “core values” of HF as defined by the Canadian Housing First Toolkit (CHFT) (Polvere et al., 2014).
Woodhall-Melnik and Dunn (2016) suggest that the core values of HF approaches internationally are “(1) no requirement for consumers to demonstrate housing readiness, (2) the provision of individualized supports, and (3) the incorporation of the principle of self-determination” (p. 290). MAPs certainly demonstrate comparable “core values” given the alcohol management and embodiment of harm reduction philosophy and incorporation of individualized supports. MAPs operate within a foundational premise or underpinning philosophy of HF (as described by Waegemakers Schiff and Schiff, 2014): the assertion that housing is a human right, should not be predicated on sobriety or treatment compliance, and that basic needs must be met before an individual can address other concerns.
Lancione et al. (2018) take a slightly different approach to describing these key principles in a European context. They suggest that four “key principles” of HF can be taken and applied through different program models:
Housing first of all.
Housing and support to be kept separate.
The operation is based on a harm reduction philosophy.
The operation is based on individual freedom of choice on whether to use supports (Lancione et al., 2018, p. 2). Although the first and third of these principles apply to MAPs, the other two do not: MAPs usually integrate housing and some health and psychosocial services on site; MAPs require alcohol management, however, there is no requirement to accept other supports.
The CHFT outlines a set of “core principles” for HF programs (as outlined in Table I). These principles include “harm reduction”, which aligns with MAPs. However, there is a lack of detail here (and in the literature more generally) on the actual implementation of harm reduction interventions to prevent harms for HF participants. There is also lack of clarity on how HF programs should implement harm reduction philosophy and practices. To some extent, the implementation of HF has failed to incorporate important elements of and recent developments in harm reduction philosophy and approach. As MAPs offer clarity on how harm reduction can be integrated, there is the potential for MAPs to help fill this gap in the implementation of harm reduction in HF programs specifically for those with severe AUDs and homelessness.
In terms of the remaining CHFT principles, MAPs also incorporate many of the elements outlined. Table I provides an illustration of the ways in which MAPs do and do not align with the “core principles” of HF as described in the CHFT.
MAPs incorporate many of the HF “core principles” as outlined in the CHFT, although not all. Most significantly, MAPs do not completely separate housing and support services; access to some health and psychosocial service are onsite as well as in the community. Other differences include provision of shelter-based, transitional and supported housing in MAPs as opposed to independent housing in many HF programs and differences in the approach to community integration. Despite differences compared with the CHFT, MAPs do align with all of the core values or principles as outlined by others such as Woodhall-Melnik and Dunn (2016) and Waegemakers Schiff and Schiff (2014). This inconsistency points to an overall concern about the current literature on HF: the idea of HF, as either a specific program model or overall approach, is still somewhat vague and the literature lacks consensus on the key elements that define it. This lack of a clear definition points to additional concerns about the current discourse surrounding HF approaches and program models. As several authors have pointed out (Katz et al., 2017; Pleace and Bretherton, 2013; Pleace, 2018) the dialogue that has developed around HF, and which has had a strong influence on policy environments, presents the danger of seeking singular solutions (or piecemeal and fragmented solutions) to complex issues such as homelessness and/or substance use disorders. The early evidence on MAPs indicates that they provide housing and supports that increase stability for a unique segment of the unstably housed population that does not appear to succeed in HF programs. The “silver bullet” discourse surrounding HF can obscure the importance of programs (such as MAPs) that do not fully fit with all HF principles and program models across contexts. This is despite the fact that MAPs and other models might be preferred and provide critical housing and support services for populations who might fall between the cracks of traditional HF models and lack of or limited implementation of harm reduction; see for example Kertesz et al. (2009) and Schiff and Waegemakers Schiff (2010) on the needs and preferences of those with severe AUD, involved with the criminal justice system or transitioning out of institutional settings. With this in mind, it is critical that research, policy and program development move beyond a focus on HF as a singular solution and embrace the need for “integrated homelessness strategies” (Pleace, 2018). There is a need to embrace diversity with recognition that many different program models are needed to address heterogenous client needs and preferences. This includes a move toward examining what mixture of different program theories, models and delivery approaches can provide a complete or more comprehensive array of housing and support services. Embracing complexity can help to inform the development of inclusive housing policies and plans that can meet the needs of diverse populations across diverse geographies.
Alignment of MAPs with key principles and core values of Housing First as defined in the CHFT
|Core principles of HF as defined in the Canadian Housing First Toolkit||Managed alcohol programs alignment with core principles|
|Immediate access to housing with no housing readiness requirements||Immediate access to supported housing; no requirement for sobriety or housing readiness|
|Consumer choice and self-determination, which is enabled through the provision of a rent supplement||Communal housing environments; participants maintain self-determination in decision making about treatment and substance use|
|Individualized, client-driven and recovery-oriented supports||Harm reduction orientation; health and social supports are individualized and client driven|
|Separation of housing and services||Housing and services may or may not be separate from the MAP|
|Harm reduction||MAPs are based on an alcohol harm reduction approach|
|Community integration||MAPs support clients in moving toward community integration on an individualized and client determined basis|
The idea that housing stability is necessary for successful treatment or management of substance use is predicated on the conceptual arguments put forward in Maslow’s Hierarchy of Needs (Maslow and Lewis, 1987); i.e., that housing (and other physiological needs) must be met before more complex needs and challenges can be addressed.
The term Housing First was coined in 1988 by a Los Angeles, CA based program “Beyond Shelter”, which focused on rapid rehousing but still utilized a CoC approach.
Whereas most current MAPs provide some form of housing/accommodation, there are some MAPs that operate exclusively as day programs and independent of housing environments.
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About the authors
Rebecca Schiff is based at the Department of Health Sciences, Lakehead University, Thunder Bay, Canada.
Bernie Pauly is based at the University of Victoria, Victoria, Canada.
Shana Hall is based at the University of Victoria, Victoria, Canada.
Kate Vallance is based at the Centre for Addictions Research of BC, University of Victoria, Victoria, Canada.
Andrew Ivsinsc is based at the Centre for Addictions Research of BC, University of Victoria, Victoria, Canada.
Meaghan Brown is based at the Centre for Addictions Research of BC, University of Victoria, Victoria, Canada.
Erin Gray is based at the MacEwan University, Edmonton, Canada.
Bonnie Krysowaty is based at the Department of Health Sciences, Lakehead University, Thunder Bay, Canada.
Joshua Evans is based at the University of Alberta, Edmonton, Canada.