Managed Alcohol Programin the Rural Community

Daniela MagureanSOWK 693

Research as a Foundation for Leadership

Purpose of Inquiry“Homelessness affects a significant number of Canadians of all ages and is

associated with a high burden of illness, yet the health care system may not adequately meet the needs of homeless people” (Hwang, 2001 p.232).

“Individuals challenged by severe alcohol dependence who are chronically homeless, unstably housed or chronically street involved, have not been able to benefit from more traditional alcohol interventions” (Muckle et al., 2012, p.4)

“Heavy and binge drinking are problems that continue to increase in rural areas nationwide. Because of the difficulties inherent in accessing and administering substance abuse treatment in rural areas, special attention should be given to tailoring alcohol abuse interventions to the needs of rural residents” (Jackson et al., 206, p.122)

Managed Alcohol Programmes (MAPs)

A harm reduction strategy used to minimise the personal harm and

adverse societal effects that alcohol dependence can lead to by providing an alternative to zero-tolerance approaches that incorporate drinking goals (abstinence or moderation) that are compatible with the needs of the individual, and promoting access to services by offering low-threshold alternatives.

Enables clients to gain access to services despite continued alcohol consumption and works to help the patient understand the risks involved in their behaviour and make decisions about their own treatment goals” (Muckle et al, 2012, p. 3)

Research questionCan Managed Alcohol Programmes (MAPs) support homeless chronic alcoholic population living in the rural community to decrease in their beverage and non-beverage alcohol consumption and lower their service use of intakes to emergency department and police encounters ?

Research Hypothesis

With a participation in the MAP for 5-24 months (mean of 16 months) will the individuals:

Decrease in the non-beverage alcohol consumption?Decrease in the average of alcohol consumed per day?Would police encounters and emergency department

visits decrease?Will the individuals’ well-being, nutrition and hygiene

improve?

Why it is important to do this review?

“MAP is a novel intervention and has, to the best of our knowledge, never been assessed in a systematic way by itself or against any conventional intervention” (Muckle et al., 2012 p. 3).

“Homeless populations are disproportionately affected by the social, economic and health burden that alcohol dependence impresses”(Muckle et al., 2012 p. 3).

Trends in heavy drinking were sharper in rural counties (3.8% to 5.4% compared with 4.9% to 6.0% in metro counties). Metropolitan and rural counties overall saw similar increases in binge drinking, however, the greatest increase occurred in remote micropolitan counties (12.7% to 15.7%)” (Jackson et al., 2006, p. 122).

Aims of ResearchTo establish whether the MAPs were contributing to: improvements in health and well-being of

participants reductions in their use of emergency, hospital and

police servicesless hazardous patterns of alcohol including reduced

use of non-beverage alcohol. informing for the development of future program and

policy recommendations. (Pauly et al., 2013, p.4)

Homeless People and Chronic Alcoholism

“Alcoholism affects 53%-73% of homeless adults with a high frequency of heavy alcoholism (i.e., > 20 drinks/day

Non-beverage alcohol is commonly used by the homeless due to its low cost and availability

Homeless people have higher rates of chronic illnesses, longer hospital stays with higher costs and increased mortality compared with those who have home addresses

Police encounters are recurrent for public drunkenness. In one study, 70% of alcoholic men had a history of imprisonment” (Podymow et al., 2006, p.45).

Harms from Alcohol“Harms from alcohol can be broadly classified as acute, chronic, and

social “(Rehm et al., 2009; Stockwell et al., 2010).

“Prolonged, heavy alcohol use increases the risk of numerous physical diseases while episodes of intoxication increase risk of self-inflicted and accidental injuries” (Pauly et al., 2013 p.4).

“In this population such problems are especially prevalent and, as well, may be compounded by the use of non-beverage sources: alcohol such as rubbing alcohol, mouthwash, hair spray or alcohol-based hand sanitizers” (Pauly et al., 2013 p.4).

Research ObjectivesTo improve health and well-being of participants

To reduce the usage of emergency, hospital and police services.

To resort to less hazardous patterns of alcohol use

To inform the development of program in rural area

Implications for researchAdditional evaluation studies are needed as there are

not too many studies available on MAPs and their efficacy

Self-reported data – biased?Socially desirable responsesSmall samples can not be generalizedNo randomized samplesSome studies do not have control groupsStudies found are small pilot projects

Implication for practice“There is insufficient evidence to advise for or against

the implementation of MAPs as a method for regulating alcohol consumption or reducing antisocial behaviour, or both among vulnerable individuals at high risk of alcohol abuse compared to brief intervention, moderate drinking, no intervention or any 12-step variant” (Muckle et al., 2012, p.10).

There is no evidence for rural areas/settings/community of MAPs being implemented.

MethodStreet Angel Shelter will provide on-going 20 beds

Participants are referred by shelter staff, police or community workers and are chronically homeless with severe alcoholism showing evidence of harm to self and community

Study subjects are housed at the shelter in an area designed for MAP and provided with beds and meals

The program employed two client care workers, one nurse and one social worker to help clients with activities of daily living, help with social benefits applications and supervise and support with medication management and medical appointments

(Podymow et al., 2006, p. 46)

MethodParticipants are given up to a maximum of 5 ounces (140ml) of wine or 3

ounces (90ml) of sherry hourly, on demand from 07:00 a.m.- 10:00 .m., 7 days per week

Medical care is provided 24 hours per day by nurses and 2 physicians. Daily nurse support and weekly physician visits

Medical records are kept on a secured online system developed by Cranbrook Health Unit

Participants were enrolled into MAP and included for analysis with approval from East Kootenay Regional Hospital research ethics board and Cranbrook Police services

(Podymow et al., 2006, p. 46).

Sampling strategySeventeen adults, 18 years and older with an average age of 51

years: 15 men and 2 women, homeless for at least 2 years Majority were single white-males, with alcoholic parents, started

drinking in their teens and were not educated beyond high schoolAll participants have tried detox and abstention, but were not able

to maintain sobriety and half of individuals had at least one chronic or psychiatric illness

Adults challenged with chronic alcoholism with a mean duration of alcoholism of 35 years and are consuming beverage and non-beverage alcohol on a daily basis

Adults have high emergency department visits and police encounters

(Podymow et al., 2006, p. 46)

RecruitmentCranbrook RCMP, East Kootenay Regional Hospital

Emergency Department, Street Angel Homeless Shelter indicated that they support 17 homeless individuals consuming non-beverage alcohol on a weekly or more often daily basis. East Kootenay Addiction Services Society is supporting these individuals with addiction and mental health support .

First responders and specialized support services provide the individuals with information on Managed Alcohol Program and its benefits.

Research designA small-scale mixed method study research design:

quantitative and qualitative:

Quantitative: Medical/ Police Records, Surveys, Structured interviews , Alcohol Use Disorders Inventory Test (AUDIT), Liver Function Tests, Alcohol Administration Data.

Qualitative: Open-ended qualitative Interviews and Diener’s Satisfaction with Life Scale.

(Podymow et al., 2006, p.46-48)(Pauly et al., 2013, p. 15-18)

Data CollectionData for all 17 subjects was included in analysisAn informed consent and confidentiality statement was

read to each participantConsent to obtain hospital and police records was signedNo one left the program before 5 months or was excluded

from the studyThe project was analyzed as a before and after study designCharts from the hospital were reviewed before program

entry and while subjects were in the program (Podymow et al., 2006, p.46)

Data CollectionThe charts noted before and after hospital visits for emergency

department, hospital admission, length of stay and blood test markers for alcohol use

Police records were accessed and the encounters were recorded for each participant for same period with the hospital records.

Participants were included in structured interviews about their drinking patterns: daily beverage and non-beverage alcohol intake before program entry compared with in-program consumption.

Life satisfaction was measured by means of Diener’s Satisfaction With Life (DSWL) Scale - the clients care workers were interviewed for their observations of the participants’ drinking patterns, hygiene, sleep, nutrition and medication compliance.

(Podymow et al., 2006, p.46)

ResultsFor all participants the amount of alcohol per day

decreased Great majority of participants retained their housingClient care workers noted improved hygiene and

nutrition for all participants during the programBlood markers compared from before and after MAP

were non significantUse of ambulance services, ED visits and police

encounters seen a decrease.

Ethical ConsiderationsInformed Consent to be re-signed 6 months from baseline to

ensure consent is still given by participant

“Self-rated physical health declined for most residents. Liver functioning deteriorated for some participants during the 6-month study period. Alcohol consumption increased for some residents after 6 months of starting the program, possibly due to public drinking being more prevalent in the warmer summer months” (Stockwell et al., 2013, p.1)

Culturally-sensitive programming for homeless chronic alcoholic Aboriginal peoples

Conclusion

“MAPs provided a safe and stable environment for this profoundly vulnerable population with an increase in personal safety where the individuals have greater feelings of self-worth and well-being. Moreover, it resulted in substantial economic savings for the local community” (Pauly et al., 2013, p.43).

Dissemination/Action Plan

Further to the evaluation of MAP the results will be shared with the City of Cranbrook, Cranbrook RCMP, East Kootenay Regional Hospital and also, forwarded to the Centre for Addictions of British Columbia

The MAP implemented for the first time in a rural community will provide a starting point for the implementation of similar programs in other rural communities

ReferencesHwang, S. W. (2001). Homelessness and health. Canadian Medical Association Journal, 164(2), 229-233.

Jackson, J. E., Doescher, M. P., & Hart, L. G. (2006). Problem drinking: rural and urban trends in America, 1995/1997 to 2003. Preventive medicine, 43(2), 122-124.

Muckle, W., Muckle, J., Welch, V., & Tugwell, P. (2012). Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse. status and date: New, published in, (12).

MuckleW, Oyewumi L, Robinson V, Tugwell P, ter Kuile, A. Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.:CD0006747.

Podymow, T., Turnbull, J., Coyle, D., Yetisir, E., & Wells, G. (2006). Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. Canadian Medical Association.Journal, 174(1), 45-49. Retrieved from http://ezproxy.lib.ucalgary.ca/login?url=http://search.proquest.com/docview/204838708?accountid=9838.

ReferencesSingle, E. (1997). The concept of harm reduction and its application to alcohol: The 6th Dorothy Black lecture. Drugs: Education, Prevention, and Policy, 4(1), 7-22.

South West LHIN. (2011). Managed Alcohol: Housing, Health & Hospital Diversion. Exploring a Managed Alcohol Model for the City of London.

Stockwell, B. P. T., Chow, C., Gray, E., Krysowaty, B., Vallance K, Zhao, J. & Perkin, K. (2013). Towards alcohol harm reduction: Preliminary results from an evaluation of a Canadian managed alcohol program. Victoria, BC: Centre for Addictions Research of British Columbia.

Tjepkema, M. (2004). Alcohol and illicit drug dependence. Health Reports, 15, 9-19.

Witkiewitz, K., & Marlatt, A.G. (2006). Overview of harm reduction treatments for alcohol problems. International Journal of Drug Policy, 17(4), 285-294.

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