Managed alcohol programs: out from under the radar

The practice of providing alcohol to people with severe alcohol dependence is a complex and sometimes controversial approach to harm-reduction, and it’s one that many communities in Canada have tried—some very publicly and some quietly under the radar. These programs, which give alcohol in measured, regular doses throughout the day, usually along with housing and other supports, are known as Managed Alcohol Programs, or MAPs.

For the first time, a peer-reviewed journal has compiled the largest collection of peer-reviewed articles on MAPs, that seeks to bring this radical harm-reduction strategy out into the open and shed light on how, in their different forms, they contribute to the health and well-being of participants.

This special issue of Drug and Alcohol Review features four papers by researchers at the University of Victoria’s Canadian Institute for Substance Use Research (CISUR, formerly CARBC) from the Canadian Managed Alcohol Program Study (CMAPS), which looks at data from approximately 380 individual MAP participants and controls across the country—the largest study ever conducted.

The issue’s co-editors, CMAPS principal investigators Bernie Pauly and Tim Stockwell of UVic, say this represents the most significant publication of findings related to MAPs to date and is a significant step forward in developing knowledge to inform best policies and practices around MAPs.

“It’s intended to stimulate debate and focus future research on strategies to improve outcomes for this vulnerable and often under-serviced population,” Stockwell and Pauly write in the editorial accompanying the research findings.

The work highlights the diversity of MAPs across Canada. Pauly’s paper looks at 13 MAPs and found that they all had a common goal of preserving dignity and reducing harms of drinking while increasing access to housing, health services, and cultural connections. However, they varied widely in how they were implemented, who was eligible to participate, whether permanent housing was provided and if a gendered lens or Indigenous worldviews informed program development and delivery.

“MAPs provide housing, home and hope, but we must ensure permanent housing is available for participants ongoing.” says Pauly. “The initial results are promising in reducing acute and social harms as well as economic costs. But more research is needed on long term chronic harms. We also need to take a closer look at how we can better provide culturally appropriate care to Indigenous people and more relevant services for women.”

The paper led by CISUR director Tim Stockwell looks at alcohol-related harms and housing stability among established MAP participants compared to new participants and controls. The clients also had more success with housing stability in a MAP than before they were enrolled. Another study, led by CISUR research affiliate Clifton Chow, looked at how four MAPs recorded and managed drinking outside of the program. Two proved to have effective measures to reduce outside drinking, with clients reporting low levels of drinking outside of the program to both program staff and the independent research team. However, participants at the other two MAPs told researchers they were drinking twice as much alcohol as they were administered. 

“Alcohol is one of the most dangerous psychoactive substances with many physical and mental health comorbidities, so it is imperative that all MAPs find a way to reduce drinking outside of the program and help minimize alcohol-related harms to clients,” says Stockwell, who was one of the study’s co-authors.

A paper led by CISUR/Psychology honours student Rebekah Erickson bridged the work of CMAPS with CISUR’s research on minimum unit pricing for alcohol. A common criticism of this alcohol pricing policy is that it will hurt problem drinkers by forcing them to turn to negative coping strategies such as stealing or drinking non-beverage alcohol. Erickson’s paper looks at the potential negative unintended consequences of alcohol being unaffordable to people with alcohol dependence and housing instability and found that even the heaviest drinkers will reduce their drinking when alcohol prices rise 

“Our research supports the idea that even the heaviest drinkers will reduce their drinking when alcohol prices rise,” says Erickson.

MAP participants were even more likely to use less harmful coping strategies. While using illicit drugs to cope was common, the most widely used drug was cannabis.

“Given that cannabis is regarded to be less harmful than alcohol, we may want to rethink whether or not we consider it a hazardous coping mechanism—and perhaps even explore the idea of cannabis substitution as a harm-reduction strategy for people with alcohol dependence,” says Stockwell.

CISUR’s research on MAPs—widely regarded as a made-in-Canada harm-reduction approach—is gaining recognition both locally and globally. CISUR is currently working with community partners to explore the need for MAPs in Victoria and other communities, and Pauly will be travelling to Scotland in March to speak about the CMAPS project as part of her role as an Honourary Professor at the University of Stirling.

Funding is provided by the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, Vancouver Coastal Health and the Centre for Addiction and Mental Health.

To learn more about CMAPS, visit cmaps.ca.