This article describes the effect of providing supportive shelter for a subset of chronically homeless people with alcoholism and providing them with institutionally administered alcohol as a harm-reduction measure. The 17 participants enrolled in MAP drank heavily and had long drinking histories. They were regular users of nonbeverage alcohols such as mouthwash, had significant medical and psychiatric comorbidities, and were frequent users of emergency, hospital and police services. Within MAP they received housing, health care and treatment of their alcoholism with doses of alcohol that were modest in comparison with their previous levels of consumption.
Police encounters decreased by 51% and ED visits by 36%, which, given the associated “unit encounter” costs ($93 and $270, respectively), offset a portion of the costs of MAP. Police encounters and ED visits were seen to increase for 2 subjects (), but both had been in jail or living in another province during the 2 years before MAP enrolment and their reports were not captured in the Ottawa system. Blood-test markers of alcohol use remained stable, and participants and client care workers reported improvements in health, nutrition and hygiene. Compliance with prescribed medications and attendance at medical appointments was excellent compared with what might be predicted for alcoholic individuals living without homes. Three participants died of causes and at ages that have previously been described among homeless people;15,16,18
they died of intracerebral hemorrhage, cardiac arrest and acute alcoholic hepatitis, respectively. It must be noted that MAP is intended as a program with no stop date per admitted individual; participants would be expected to die of causes that are consequences of life-long addiction.
This study had limitations. Although it may have been preferable to compare 2 such groups in a randomized controlled trial, logistical, population and financial constraints made such methodology unfeasible. Potential biases identified with the one-group pretest–post-test study design include biases of history, maturation, testing and instrumentation, as well as statistical regression to the mean. However, there has been no change in ED, police or social policies to account for the decreased use of ED and police services. Maturation or biologic changes in the participants over time would tend to bias against MAP, with expected declines in health. Pre-and post-program hospital and police encounters would not be subjected to testing bias, since external databases were used. Observations were repeated over time with no instrument decay or regression to the mean. Clinical regression, in which participants might enter MAP when addictive consequences were at their worst and therefore appear to improve, is another possible source of bias; but the addiction in this group was of a severe and long-standing nature, and severity at program entry was likely representative of overall severity.
Continuity of care among homeless people has been found to be exceptionally difficult. Shelter operators already having demonstrated cultural competence in caring for the homeless were integrated into a shelter-based medical model of care to address previously unmet needs. This served to treat vulnerable individuals in a timely manner and coordinate their care, which allowed timely discharge from hospital. Police in frequent contact with people repeatedly inebriated in public have the opportunity to refer potential program participants to MAP and address a need within a system otherwise obliged to repeatedly process minor offences and bring people in for overnight detox in a police cell. Program development is ongoing for preventive care against infections such as tuberculosis and hepatitis and for administration of HIV tests and immunizations. For people whose drinking pattern has stabilized in MAP, psychiatric evaluations and follow-up have been successful.31
Finally, the option to detoxify from alcohol is always presented; once stabilized in the program, a few participants have successfully been medically detoxified and received housing, a formidable accomplishment considering the severity of an on-average 35-year addiction in which subjects drank daily to unconsciousness. This appears attributable to tempering alcohol consumption in a safe environment, which makes alterations of behaviour, including detoxification, possible.
In one large study,32,33
mentally ill homeless people in supportive housing had decreased shelter use, incarcerations, admissions to hospital and lengths of hospital stay. In another study,24
only 20% of people with case__managed alcoholism were able to maintain housing. Although housing is immensely beneficial for health, it is difficult to maintain without appropriate skills. Part of the success of MAP has likely been due to the supportive housing provided, but housing alone would not have prevented alcohol-seeking, consumption and the harm therefrom.
MAP is an innovative program based on a harm-reduction model that, when evaluated in a small group, appeared to be effective in decreasing alcohol consumption and the use of crisis services. Those responsible for the well-being of homeless people should consider the implementation and prospective evaluation of programs that integrate health services within shelters using a harm-reduction strategy.
@ See related article page 50