By Danilo Falzon, Dr Hannah Carver and Professor Tessa Parkes, Salvation Army Centre for Addiction Services and Research, University of Stirling

Managed Alcohol Programmes (MAPs) are a harm reduction intervention for those experiencing homelessness and alcohol use disorders (AUDs) which provide regular and measured doses of alcohol to service users throughout the day, alongside a range of health and social supports. In this post, Danilo Falzon, Dr Hannah Carver and Professor Tessa Parkes share their mixed-methods research exploring the potential for MAPs to reduce the risks faced by those experiencing homelessness and AUDs in Scotland during the COVID-19 pandemic. Commissioned paintings by Linda McGowan and Stu Duffy from the Unexpected Gallery in Glasgow are provided, which showcase the themes and findings of this research.

People experiencing homelessness and alcohol use disorders (AUDs) face significant risks around their physical and mental health. While evidence on rates of AUD amongst people experiencing homelessness varies, there is some evidence to suggest that over half may experience alcohol dependency, and that those experiencing homelessness are more susceptible to significant harms related to their alcohol use due to a number of intersecting factors. During the COVID-19 pandemic, particularly during the initial lockdown, the challenges facing this group were exacerbated. Such individuals were at higher risk of serious disease or death from the virus. Additionally, during the initial lockdown, there were significant concerns about the ability of such individuals to isolate due to the need to source alcohol, and restrictions on consuming alcohol in many settings such as hostels. Additionally, limited footfall through cities and a move away from the use of cash led to reductions in income from begging which created significant challenges in securing funds to purchase alcohol. This had potentially serious ramifications, increasing individuals’ risk of experiencing withdrawal and seizures.

What did our research involve?

Building on our previous research conducted in 2019 regarding the need and potential for MAPs in Scotland and implementation considerations, and in light of the challenges described above, our mixed-methods study sought to assess the potential for Managed Alcohol Programmes (MAPs) to reduce the risks faced by those experiencing homelessness and AUDs in Scotland during the COVID-19 pandemic. MAPs are a harm reduction intervention for those experiencing homelessness and AUDs which provide regular and measured doses of alcohol to service users throughout the day. They aim to improve health and social outcomes by providing a range of supports around housing, health, education and wellbeing. Currently, most MAPs operate in Canada, although there are examples elsewhere, for example in Ireland, the US, and one recently opening in Scotland run by the Simon Community. The evidence base around MAPs is promising, pointing to a number of benefits for service users including: reduced alcohol related harms; less harmful patterns of use; reduced contact with police and emergency health services; and the rebuilding of relationships, healing and identification of meaningful goals around alcohol consumption.

In the context of the COVID-19 pandemic, MAPs may be able to reduce the risk of transmission to service users by reducing their need to source alcohol. To explore this potential in a Scottish context, we interviewed 40 participants: service managers, frontline staff, and prospective MAP service users from four Salvation Army settings; as well as a range of external stakeholders. We also analysed the case records of 12 service users who met the MAP inclusion criteria in order to examine their alcohol use and related harm, physical and mental health, and COVID-19 related factors. In addition to these data, we commissioned two artists, Linda McGowan and Stu Duffy from An Unexpected Gallery in Glasgow, to create paintings to represent the themes and findings of the research. The artwork produced was able to capture and illustrate a number of important themes such as: the emotional challenges faced by lived experience participants during the pandemic; the assertive outreach work carried out by services during the lockdown; and the perceived benefits of MAPs in terms of connection, healing and wider wellbeing.

What did we find?

Our research findings highlighted the complexity of physical and mental health problems, levels of alcohol dependency and polysubstance use, and the challenges of accessing alcohol during the lockdown. Our qualitative data provided a mixed picture in how the pandemic impacted both people’s access to alcohol and their levels of alcohol/drug use in general. Some participants discussed disruptions to accessing alcohol due to lockdown restrictions. This reduction in alcohol availability was described as having both positive and negative aspects and varied by individual. For some, the lockdown had presented an opportunity to reduce alcohol consumption. For others, the reduced availability of alcohol was seen as having increased the use of drugs in addition to alcohol.

Our research captured the way in which services adapted to support clients in a rapidly shifting environment. In spite of extremely challenging circumstances, services were able to adapt quickly and flexibly to provide tailored support. A key change was the relaxation of previously strict abstinence rules for services in order to prevent service users from experiencing withdrawal and reducing their need to break lockdown rules. This was described as a massive cultural shift for services which had previously maintained an abstinence-based approach towards alcohol. However, in spite of these positive service adaptions, a number of challenges and negative changes to service provision were discussed. Lived experience participants often described the lockdown as a time of fear, isolation and anxiety, and as a time which exacerbated already significant challenges to their physical and mental wellbeing. The lockdown also illuminated the limitations in relation to the availability and suitability of alcohol services. Lived experience participants described gaps in services, for example, waiting extended periods of time for support, and being advised not to detox during the lockdown due to a lack of available support. In Scotland, the focus has traditionally been on abstinence-only approaches to alcohol treatment, such as detoxification. The pandemic served to highlight the inadequacy of this approach for many people with complex, intersecting challenges and the need for harm reduction provision.

Participants discussed the ways in which MAPs could potentially help to reduce risk of COVID-19 transmission. Although the rate of infection amongst this group has not been as severe as initially feared, participants described how MAPs could help reduce risk by enabling people to stay in their accommodation. The challenges faced by those experiencing homelessness and alcohol dependency in following lockdown restrictions was evidenced by our case review data, which showed that the majority of participants broke lockdown rules in order to source and consume alcohol. It was also noted by participants that MAPs have the potential to provide more than just alcohol: they can provide a space for meaningful relationships and interactions which might help replace some of the social benefits lost through the closure of communal spaces. In spite of the opportunities and benefits of MAPs, a number of challenges and concerns were discussed, including: funding; changing service and staff attitudes; ensuring community buy-in; and staff fears around their responsibilities and roles, including potentially having to purchase alcohol for clients.

What do the findings mean?

Our research was conducted at a time of significant changes to the established rhythms of daily life - disruptions which presented significant challenges to us all. Those experiencing homelessness, alcohol dependency, and poor physical and mental health felt these disruptions more acutely than most and were placed at significantly heightened risk from the virus. Our research was able to capture some of the challenges faced by this group by highlighting how the implementation of MAPs in Scotland might help to reduce the risk of transmission, by alleviating the need to break lockdown rules and providing safe spaces during a challenging period. The relaxation of rules around alcohol consumption within the studied services highlighted the potential benefits of greater emphasis on alcohol harm reduction – an approach better suited to the needs of a group for whom abstinence-only approaches may not be desired, appropriate or effective. Although participants highlighted the short-term benefits of MAPs in potentially reducing the risk of COVID-19 transmission, there was a perception that MAPs could and should be a longer-term solution to significant gaps in treatment and support for those with alcohol dependency. Some participants warned against a return to an abstinence-only service landscape in the post-pandemic future. We concluded that MAPs should therefore be a vital part of service provision in Scotland for those experiencing homelessness and AUDs.

SHAAP Blogposts are published with the permission of the authors. The views expressed are solely the authors' own and do not necessarily represent the views of Scottish Health Action on Alcohol Problems (SHAAP).