Fighting fire with fire: Managed Alcohol Programs need to be widely implemented

It’s 6:15 a.m. after another -33 C January night in Ottawa. I drive myself to work while listening to this week’s radio hit song about how beer is the answer to all my life’s sorrows.

I arrive and park my car, but before I get out of the parking lot I need to walk over and check on the man and woman under their cardboard box, huddled away in desperation, to ensure they are still breathing – luckily, today things are all OK.

I get into my office inside the run-down emergency shelter, with its newly acquired broken window from one of last night’s mental health episodes, complete a shift change with a colleague who is finishing a long overnight shift and it is now 7:15 a.m.  

I complete my first round and say good morning to the Managed Alcohol Program’s clients as they line up out front of my office for their first drink. For the first pour, I must serve an extra-large portion of wine – since they can’t drink while they are sleeping, their bodies are at serious risk of withdrawing. Some chug it down in one gulp while others hold it tight, analyzing and nourishing it like reuniting with a long-lost friend.

They will be back in 60 minutes for another drink and we will repeat this for the rest of the day until it is time for bed. After every shift, I leave wondering how many of the clients will make it one more day.

Alcohol has a grip on these people’s lives that will not let go.

We should not be surprised. Society endorses drinking as socially acceptable and in environments where it is more permissive, use rates increase. In Canada, alcohol is part of many of our social gatherings, is often a central theme at all holidays and celebrations and is regularly displayed in the media as a normal and even expected lubricant of socializing.

Alcohol is the most consumed drug by Canadians. It accounts for upwards of 77,000 hospitalizations per year – compare that to only 75,000 for heart attacks – and costs for treating alcohol-related issues in Canada sit at approximately $14,600,000,000 annually.

Generally, it is believed that abstinence as exemplified by programs and belief systems such as Alcoholics Anonymous (AA) is the only way to deal with alcohol dependence. AA and similar 12-step programs do have a level of effectiveness but they do not work for everyone. Especially when paired with homelessness, alcohol abuse can become difficult to treat, more harmful and more expensive as people with alcohol use disorder turn to non-beverage alcohol such as mouthwash or antifreeze, become violent and require regular intervention from emergency services.

A solution that needs wider implementation is fighting fire with fire – the Managed Alcohol Programs (MAPs) mentioned above. In MAPs, individuals are provided with safe alcohol choices (wine or sherry instead of hairspray or mouthwash) as well as shelter, food and access to other health and social services.

MAPs have been adopted across Canada since 1997 yet despite evidence that the program works, it serves less than 1,000 people nationally.

By no means do we suggest this is the preferred course of action. Alcohol is harmful. But if a cancer patient’s initial treatment plan is not successful, do we ask that patient to just try harder or do we seek alternatives? Why then do we continue to apply an all-or-nothing, abstinence-based approach to treating alcoholism?

Abstinence is not always in the best interest of a patient’s health. We know that alcohol withdrawal can have life-threatening side effects. Despite the shortcomings and optics of under-funded emergency shelter programming, MAPs can be an integral part of the solution and are demonstrably necessary.

When in MAPs, despite drinking more frequently throughout the day, participants’ overall consumption actually decreases. Although there are continued health risks associated with long-term drinking, decreasing the total amount consumed positively affects the long-term health of those with an alcohol dependency. Keeping a consistent level of safe alcohol in the body can keep the harmful effects of withdrawal at bay and keep people out of emergency rooms when they cycle through excess and withdrawal.

Another benefit of MAPs is that people with alcohol use disorder interact regularly with supportive staff. In this setting, other underlying issues such as mental health disorders and physical health comorbidities can be properly identified and treated.

Further, MAP participants show improvement in all aspects of their quality of life. They improve social connections with friends and family, are in better financial positions, participate in employment and/or education and improve their housing situations. MAPs create an opportunity for people to live a dignified life and enable them to become self-sufficient.

When MAP was first and quietly introduced in Ottawa to avoid controversy, calls from the community to emergency services over public disorder dropped dramatically – one officer recounts that over the course of one year, there were 362 fewer calls to the police about one specific person.

But even if we do not fully appreciate the fact that this is just the right thing to do, we surely cannot overlook the economic upside. Estimates show that for every dollar invested in MAPs, $1.20 is saved through reduced spending on health, social and legal services.  

If we do not act now, we will incur even greater consequences – both in public health and financial – as the secondary implications of this pandemic will long outlast the virus itself. Survivors of community-wide disasters – similar in nature to our current plight – experience increased alcohol use, a pattern that is already occurring.

It is no longer a question of whether MAPs work. Evidence-based research and reason prove they do. And if the COVID-19 pandemic has taught us one thing, it is that we need to follow evidence-based research and reason.