Harm Reduction and Abstinence Treatment for Alcohol Use Disorder

Substance use and addictions are on a spectrum that has a depth of impact which fluctuates with each individual. Each person is located on this continuum of use; creating varying levels of addiction, needs, and goals. Leading to a context of different demands and requirement for intervention, as the type of intervention differs between people. In many client-centred treatment ideals the individual who is seeking treatment is the person to determine the level and type of treatment they participate in. As we will see this is true for Harm Reduction (HR) models and relates to abstinence. The momentum towards HR, and the use of HR theoretical ideas presents us with client-centred ideals, that a person should be able to access care and supports no matter their level of substance use. In HR models it is up to the person to determine how much they wish to decrease the use of a substance. In abstinence-based treatments, the goal is always no use of substances at all. This paper will be looking at HR and abstinence-based programming around alcohol use.

HR and abstinence-based treatments are commonly thought of as opposing ideas or in opposition to each other (Kellogg, 2003; Lee, Engstrom, & Petersen, 2011). However, HR and abstinence are not exclusive to each other. Both practices can work together to support individuals ‘where they are’ and aim to help someone in achieving their own personal recovery goals.

A frequent misconception of harm reduction is that it supports, or encourages, illicit substance use and does not consider the role of abstinence in addiction treatment. However, harm reduction approaches do not presume a specific outcome, which means that abstinence-based interventions can also fall within the spectrum of harm reduction goals. Essentially, harm reduction supports the idea that those with addiction or substance use issues should be treated with dignity and respect and have a wide selection of treatment options in order to make an informed decision about their individual needs and what would be the most effective for them, while also reducing the harms (CMHA, 2018).

This paper will discuss HR and abstinence-based treatment programs for alcohol, with individuals who are homeless and how both types of treatments can benefit and/or detract from recovery. A short case study will be provided at the end of this paper in order to highlight the specific impacts and values each type of treatment can have for one person’s recovery.

Harm Reduction

HR is a client-centred, evidence-based, public health approach that pursues a reduction in the social and health harms connected to addiction, substance use, and other high-risk behaviours (CMHA, 2018; Lee, Engstrom, & Petersen, 2011). HR does this without automatically demanding individuals who use substances to abstain from the use of substances and places the priority on decreasing the possible adverse effects of the substance or behaviour (CMHA, 2018; Lee, Engstrom, & Petersen, 2011; Podymow et al., 2006; Riley et al., 1999). An important aspect of an HR approach is that it offers individuals “who use substances a choice of how they will minimize harms through non-judgemental and non-coercive strategies in order to enhance skills and knowledge to live safer and healthier lives” (CMHA, 2018). HR models can include abstinence; however, HR supports are considered low-barrier because abstinence is not needed to use the service and other impediments to access services have been removed as well (Lee, Engstrom, & Petersen, 2011). 

As part of the HR movement Housing First (HF) programs have gained in popularity and have become the evidence-based practice preferred within the homelessness sector (Homeless Hub, 2018). HF programs provide permanent, independent housing without a person needing to be sober, abstinent, and engaged in treatment (Adair, et al. 2017; Stefancic & Tsemberis, 2007). This is taking an HR approach to housing as they are low barrier housing programs. HF removes major obstacles to obtaining and maintain housing for people who are chronically homeless and usually living with mental illnesses (Stefancic & Tsemberis, 2007) and the goal of HF is not to just house people but to also promote consumer choices, recovery, and community integration (Stefancic & Tsemberis, 2007). This is what we see with HR and substance use.

The HF model is focused on housing the ‘hardest to house’ populations, those who are not seen to be ‘housing ready’ by Treatment First (TF) programs, which require an individual to be “housing ready” by going to treatment or being abstinent of any substances. Those who are struggling with high levels of alcohol dependency and are homeless often face barriers to gaining accommodations at shelters, transitional housing programs and permanent housing because of their alcohol use (Vallance et. al, 2016).  It is very challenging for people who are not seen as ‘housing ready’ to exit homelessness and those who fit the criteria are then often evicted because of relapse, breaking program rules, or they leave because they want to be independent and self-determined. This population are usually the chronic or episodically homeless, who despite being only 8% of the clients who use the shelter system for long periods of time, “use almost half of available shelter capacity” (Kneebone & Jadidzadeh, 2017, p. 1). It is with this population that the rest of this paper will focus on in relation to HR and abstinence-based programs and how they both can be used during a person’s recovery.

Alcohol Misuse and Homelessness

 Severe alcohol use and alcohol dependency is linked with negative and significant health and social cost; sometimes also linked with homelessness and precarious housing or instability (Lehman & Cordray, 1993; Muckle et al., 2012; Vallance et. al, 2016). The Canadian Institute for Health Information (2017) found that in 2015-2016, about 56, 600 Canadians were hospitalized because of a health risk caused by alcohol (Canadian Institute for Health Information, 2017). This report also found that “low income was associated with a lower prevalence of heavy drinking yet significantly higher rates for hospitalizations entirely caused by alcohol” (Canadian Institute for Health Information, 2017, p. 18). Those who are experiencing precarious housing are found to have higher rates of alcohol misuse and have mortality rates that are six times higher from alcohol-related causes than the general population (Crabtree et al., 2018; Palepu et al., 2013; Hwang et al., 2009). This is attributed to social determinants of health and how they link with low income, high-stress levels, few social supports, a lack of resources, poor diet, unsafe drinking settings, beverage choice, and the regularity of binge drinking (Canadian Institute for Health Information, 2017). Because of this “socially marginalized drinkers” use health services at higher rates (Crabtree et al., 2018).

 Alcohol has been shown to increase a person’s risks for many physical health issues as well as an increased risk for accidental or self-inflicted injury and experiences of violence (Vallance et. al, 2016). Non-beverage alcohol (mouthwash, hand-sanitizer with alcohol, rubbing alcohol, etc.) may be consumed in the place of beverage alcohol because they are lower in cost and more readily available; these sources of alcohol further add to the health risks for a person (Crabtree et al., 2018; Vallance et. al, 2016).  

 In order to address the negative health impacts and precarious housing, Managed Alcohol Programs (MAP) take the HF models to a next stage with a HR approach by providing beverage alcohol to program participants staying in the shelter, in an attempt to stabilize drinking patterns and decrease the consumption of non-beverage alcohol (Pauly et al., 2016; Podymow et al., 2006; Stockwell et al., 2018; Vallance et. al, 2016). These programs hope to not only lower the harm to the person but also decrease hospital visits and engagement with police and/or the justice system (Podymow et al., 2006; Stockwell et al., 2018; Vallance et. al, 2016).

  Podymow et al. (2006) show in their study on a MAP in Ottawa that for those who participated, police encounters decreased by 51% and emergency department visits decreased by 36%. The alcohol markers in the blood tests of the participants remained consistent through the research (Podymow et al., 2006). While participants and case managers stated that there were improvements in the participants’ hygiene, nutrition, and health; especially when related to medical appointments attended and medication compliance (Podymow et al., 2006).  This research, however, did not assess alcohol intake outside of the MAP premises, therefore, it is unknown to what impact, if any, MAP had on the overall alcohol consumption for the individuals but the indicators show there was a positive benefit to the overall health of the participants.

 Another MAP study, which was completed in Thunder Bay by Pauly et al. (2016) and Vallance et. al. (2016). In their research, Pauly et al. (2016) found that the MAP program helped participants retain their housing as well as presented an increase in positive experiences around safety and overall quality of life. Once stabilized in the MAP, it was found that the participants regain a sense of self, home, and family (Pauly et al., 2016). All of which are important aspects of one’s recovery from an addiction. With aspects of HR such as respect, trust, and non-judgemental care, with alcohol management, this allowed for the potential of recovery and indicates that HR is an important part of the recovery discourse (Pauly et al., 2016). 

 For the same database as above, Vallance et. al. (2016) report that the MAP participants consumed non-beverage alcohol on fewer days and had few detoxification episodes than the controls. As well as fewer police contacts and hospital admissions than before the MAP. However, questions still remain around if the quantity of alcohol overall was reduced for participants and further research must be completed (Vallance et. al., 2016).

Stockwell et al. (2018) have shown through their comparison of six managed alcohol programs in Canada that MAP can reduce the harms associated with alcohol. In this study, the long-term MAP residents drank more often than the controls (regular access to alcohol) but they drank fewer standard drinks per drinking day than the controls did; included in this were drinks outside of the program and non-beverage sources of alcohol (Stockwell et al., 2018). The long-term MAP residence also drank less non-beverage alcohols and was less likely to report experiences of social, health, safety, and legal problems in the past 30 days (Stockwell et al., 2018). 

Abstinence. There are many different types of treatment programs and housing options that involve a person being abstinent from drugs and alcohol in order to gain access to supports. There are abstinent-contingent housing programs where testing for alcohol and drugs in a person’s system occurs (Rash et al., 2016). If a person tests positive while living in one of these programs, they are removed from their housing immediately (Rash et al., 2016). These programs are a type of behavioural intervention contingency management (CM) program (Rash et al., 2016). Other types of housing and treatment that are alcohol and drug-free are: sober living homes, half-way houses, recovery homes and centres, and after-care housing (Rash et al., 2016; Polcin, Korcha, Bond, & Galloway, 2010a, 2010b; Wittman, Polcin, & Sheridan, 2017). Within these programs, the frequency and level of drug testing change between programs; as does when, and if, someone would lose their housing due to positive drug and alcohol testing (Rash et al., 2016). For example, sober living homes (SLH) are different than residential treatment and halfway houses because they do not offer formal treatment (Edwards, 2018; Polcin & Henderson, 2008) and the level of structure in each SLH would vary depending on the peers within the house.

SLHs have gained in popularity as part of a continuum of services and care for those wishing to be abstinent or in recovery from alcohol addiction; treatment programs will work with SLH to provide housing for those who have completed residential treatment or are taking part in outpatient treatment programs (Wittman, Polcin, & Sheridan, 2017). Lack of housing and a safe place to live has and is been a large issue for those coming out of treatment program or who are in recovery and little attention is often paid to finding suitable housing for the clients (Wittman, Polcin, & Sheridan, 2017). Often “without an alcohol- and drug-free living environment persons receiving treatment services have been vulnerable to relapse and homelessness (Wittman, Polcin, & Sheridan, 2017 p. 160).

Wittman and Polcin’s (2014) research on SLHs found that they were modelled on the “12 step” principles of Alcoholics Anonymous (AA) and were grassroots, peer-based services for those with drug and alcohol disorders. The philosophies of AA promote the inclusion of everyone at all level of alcohol consumption, however, “the 12-step and disease-based approaches generally prioritize abstinence as the goal, and often as a condition, of treatment” (Lee, Engstrom, & Petersen, 2011, p. 1152)which is what we can see in the SLHs housing models. 

Polcin et al.’s (2010b) research on SLHs observed that substantial improvements in employment, substance use, mental health symptoms, and arrests during an 18-month period for 245 people. Polcin et al.’s (2010a) research with 55 people living in SLHs, 35 % of whom were recently homeless, had similar results as the above-mentioned study.

Harm Reduction and Abstinence. As stated above both HR and abstinence-based programs can work together and do not have to be seen in opposition to each other. Both models have strengths, weakness and both work in different ways at different times for individuals. MAPs can aid a far-reaching group of people who are deep in their alcohol use disorders and need HR principles in order to help keep them safe, in order to, lessen the harm they are experiencing. However, once in a later stage of their recovery, it may be difficult for those who have reached abstinence, or have greatly reduced their intake of alcohol, to continue to live in an environment where alcohol is readily available and other individuals are partaking in regular alcohol consumption. There is a sacrifice in the “power of the social environment and the influence of peer support that can enhance the functioning of residents” (Wittman, Polcin, & Sheridan, 2017, p. 160) within MAPs and HF programs.

When an individual has been able to decrease their intake of alcohol, or is abstinent, is when SLHs can be very helpful. Peer support, and the social influences in an SLH, can help to provide support and an environment of recovery with few triggers for the individual. As “sobriety permeates the home environment through daily living among peers” (Wittman, Polcin, & Sheridan, 2017 p. 160). However, if a person does have a “slip”, or begins to engage in alcohol consumption again, they can lose their housing and support system. Becoming once again homeless and in greater harm of injury, violence, hospitalization, engagement with the police and justice system, as well as have a higher risk of death. 

Gradualism. Gradualism is an approach that works towards building a bridge between HR and abstinence-based treatments, with the idea of creating a therapeutic continuum that works with the strengths and reduces the shortfalls of both HR and abstinence approaches (Kellogg, 2003). This approach does, however, have abstinence as the end goal and is perhaps better understood as an “abstinence-eventually” model (Kellogg, 2003). As the driving principle is that “the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans” (Kellogg, 2003). This model, as presented by Kellogg (2003), is contradictory concerning the true understandings of HR, which is to be client-centred. An HR treatment model looks to truly allow the client to determine their recovery goals, not pushing them in either direction of what is “best” for them.

Case study. Allan is a 57-year-old man who grew up in low socioeconomic status in rural Ontario. He grew up in an abusive home with his mother, father, and younger brother. Allan came to Toronto at the age of 18 to work. Allan started drinking at the age of 10 with his friends, they also experimented with other drugs such as cannabis, psilocybin mushroom, and LSD, but Allan usually only drank alcohol. By the time Allan was 35 he was drinking heavily every day and had been missing work due to his alcohol consumption. At age 39, Allan was fired from his job. He tried to find stable work but was unable to find something permeant. Allan did, however, get hired for odd jobs through friends and was able to sustain himself for a while with cash jobs. After drinking heavily one-night, Allan slipped outside and hurt his back and broke his ankle. During this time, Allan was unable to work, he lost many of his social connections, and spent most of his time drinking alone in his house. When he was 45, Allan lost his house and went bankrupt. He tried staying with friends and family, however, it always ended up negatively with his friends and family being frustrated with Allan’s drinking. Allan started to bounce between shelters and sleeping on the streets. He did this until he was 54 at which time he was granted a spot in a MAP program. Once in the MAP, Allan was able to stabilize and receive proper and consistent healthcare for the issues he has been having over the past 15 years. Because of MAP, Allan has been able to decrease his involvement with the police, as he has stopped sleeping and consuming alcohol in public, as well as, he is no longer stealing alcohol and rubbing alcohol from stores or getting into fights with shelter residents or people on the streets. Allan has slowly decreased his alcohol intake by working closely with the staff at MAP to determine his goals and how he can reduce his intake safely. All of this together has provided Allan with a sense of control over his life; something he has not felt in a long time. Once Allan was at this point, he was ready to get out of the MAP shelter and live in a more stable location. He was referred to a transitional housing program that was based in HR for older men with substance misuse and addictions issues. After living here for a year Allan’s alcohol use increased as he was around people drinking all of the time and found it difficult to not join them and to not be triggered by the atmosphere. Once he started to notice this, Allan reconnected with his workers at MAP and regained some of the mental stability he had done in that program. He decided he would go into a treatment program. After waiting for 6 months Allan was placed in a 3-month treatment program for alcohol use disorder. He struggled with becoming abstinent in the time leading up to the program, as was required of him and after two tires he was able to go to the treatment program. It was at this treatment program he achieved his goal of long-term abstinence and remained sober for the full 3-months. At the end of the 3-months, Allan moved into an SLH and has continued to work on staying sober.

Conclusion. It is in the case study of Allan, and the discussion above, that we can see how HR treatment programs and abstinence-based programming can work together to aid in one’s recovery. Both HR and abstinence models can offer individuals different recovery supports at different times in their recovery. For different people, with alternative goals than Allan, abstinence could be their main goal right away, when leaving a detox program, or treatment centre and they may have the resources and support to achieve this goal. As for Allan, his process needed more time, support, and space to heal, both physically and mentally, before he was ready to be rid of the “crutch” or coping mechanism of his alcohol use disorder. 

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