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Pauly B, Brown M, Chow C, Wettlaufer A, Graham B, Urbanoski K, Callaghan R, Rose C, Jordan M, Stockwell T, Thomas G, Sutherland C. "If I knew I could get that every hour instead of alcohol, I would take the cannabis": need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs. Harm Reduct J 2021; 18:65. [PMID: 34162375 PMCID: PMC8220712 DOI: 10.1186/s12954-021-00512-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool. Methods To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis. Results Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation. Conclusion Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.
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Affiliation(s)
- Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,School of Nursing, University of Victoria, Victoria, BC, Canada
| | - Meaghan Brown
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada. .,School of Nursing, University of Victoria, Victoria, BC, Canada.
| | - Clifton Chow
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,Vancouver Coastal Health, Victoria, BC, Canada
| | - Ashley Wettlaufer
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | | | - Brittany Graham
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,Vancouver Area Network of Drug Users (VANDU), Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Russell Callaghan
- Northern Medical Program, University of Northern British Columbia (UNBC), Prince George, BC, Canada.,School of Population and Public Health, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Cindy Rose
- Canadian Mental Health Association Sudbury/Manitoulin, Sudbury, Ontario, Canada
| | | | - Tim Stockwell
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.,Department of Psychology, University of Victoria, Victoria, BC, Canada
| | - Gerald Thomas
- Ministry of Health, Province of British Columbia, Victoria, BC, USA
| | - Christy Sutherland
- PHS Community Services Society, Vancouver, BC, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Stockwell T, Zhao J, Pauly B, Chow C, Vallance K, Wettlaufer A, Saunders JB, Chick J. Trajectories of Alcohol Use and Related Harms for Managed Alcohol Program Participants over 12 Months Compared with Local Controls: A Quasi-Experimental Study. Alcohol Alcohol 2021; 56:651-659. [PMID: 33418568 DOI: 10.1093/alcalc/agaa134] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 11/14/2022] Open
Abstract
AIM Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence. METHODS A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants. RESULTS Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6--12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants' liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms. CONCLUSION MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.
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Affiliation(s)
- T Stockwell
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada.,Department of Psychology, University of Victoria, Victoria, British Columbia, Canada
| | - J Zhao
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - B Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada.,School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - C Chow
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada.,Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - K Vallance
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - A Wettlaufer
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada.,Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, Ontario, Canada
| | - J B Saunders
- National Centre for Youth Substance Use Research, University of Queensland, Brisbane, Australia
| | - J Chick
- Castle Craig Hospital, UK.,School Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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Kouimtsidis C, Pauly B, Parkes T, Stockwell T, Baldacchino AM. COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper. Front Psychiatry 2021; 12:623649. [PMID: 33679480 PMCID: PMC7930817 DOI: 10.3389/fpsyt.2021.623649] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022] Open
Abstract
The COVID-19 pandemic is presenting significant challenges for health and social care systems globally. The implementation of unprecedented public health measures, alongside the augmentation of the treatment capacity for those severely affected by COVID-19, are compromising and limiting the delivery of essential care to people with severe substance use problems and, in some cases, widening extreme social inequities such as poverty and homelessness. This global pandemic is severely challenging current working practices. However, these challenges can provide a unique opportunity for a flexible and innovative learning approach, bringing certain interventions into the spotlight. Harm reduction responses are well-established evidenced approaches in the management of opioid dependence but not so well-known or implemented in relation to alcohol use disorders. In this position paper, we explore the potential for expanding harm reduction approaches during the COVID-19 crisis and beyond as part of substance use treatment services. We will examine alcohol use and related vulnerabilities during COVID-19, the impact of COVID-19 on substance use services, and the potential philosophical shift in orientation to harm reduction and outline a range of alcohol harm reduction approaches. We discuss relevant aspects of the Structured Preparation for Alcohol Detoxification (SPADe) treatment model, and Managed Alcohol Programs (MAPs), as part of a continuum of harm reduction and abstinence orientated treatment for alcohol use disorders. In conclusion, while COVID-19 has dramatically reduced and limited services, the pandemic has propelled the importance of alcohol harm reduction and created new opportunities for implementation of harm reduction philosophy and approaches, including programs that incorporate the provision of alcohol as medicine as part of the substance use treatment continuum.
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Affiliation(s)
- Christos Kouimtsidis
- Imperial College London and Surrey and Borders Partnership NHS Foundation Trust, London, United Kingdom
| | - Bernadette Pauly
- Canadian Institute for Substance Use Research, University of Victoria School of Nursing, Victoria, BC, Canada
| | - Tessa Parkes
- Faculty of Social Sciences, University of Stirling, Stirling, United Kingdom
| | - Tim Stockwell
- University of Victoria, Canadian Institute for Substance Use Research, Victoria, BC, Canada
| | - Alexander Mario Baldacchino
- Population and Behavioural Science Division, Medical School, St Andrews University, St Andrews, United Kingdom
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Pauly B, Brown M, Evans J, Gray E, Schiff R, Ivsins A, Krysowaty B, Vallance K, Stockwell T. "There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness. Harm Reduct J 2019; 16:70. [PMID: 31842903 PMCID: PMC6916004 DOI: 10.1186/s12954-019-0332-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/29/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA). METHODS We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs. RESULTS Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing. CONCLUSIONS In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.
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Affiliation(s)
- B. Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
- School of Nursing, University of Victoria, HSD Building A402A, Victoria, BC V8P 5C2 Canada
| | - M. Brown
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
- School of Nursing, University of Victoria, HSD Building A402A, Victoria, BC V8P 5C2 Canada
| | - J. Evans
- Department of Earth and Atmospheric Sciences, University of Alberta, 1-26 Earth Sciences Building, Edmonton, AB T6G 2E9 Canada
| | - E. Gray
- School of Social Work, MacEwan University, 9-505 Robbins Building, Box 1796, 10700-104 Avenue, Edmonton, AB T5J 2P2 Canada
| | - R. Schiff
- Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1 Canada
| | - A. Ivsins
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - B. Krysowaty
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - K. Vallance
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - T. Stockwell
- Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
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Fraser S. Articulating addiction in alcohol and other drug policy: A multiverse of habits. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 31:6-14. [DOI: 10.1016/j.drugpo.2015.10.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/29/2015] [Accepted: 10/30/2015] [Indexed: 11/26/2022]
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Treno AJ, Ponicki WR, Stockwell T, Macdonald S, Gruenewald PJ, Zhao J, Martin G, Greer A. Alcohol outlet densities and alcohol price: the British Columbia experiment in the partial privatization of alcohol sales off-premise. Alcohol Clin Exp Res 2013; 37:854-9. [PMID: 23316802 DOI: 10.1111/acer.12065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 09/22/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Alcohol beverage prices or taxes have been shown to be related to alcohol sales and use and related problems. What is not clear are the mechanisms underlying these relationships. METHODS This study examines the relationship between alcohol outlet density under conditions of the partial privatization of off-premise consumption in British Columbia (BC) occurring over the past decade. Two hypotheses are tested. First, reflecting basic supply-demand principles, greater geographic densities of alcohol outlets will be directly related to reductions in beverage prices in response to greater competition. Second, reflecting the effects of niche marketing and resulting market stratification, increased densities of private liquor stores will be especially related to reductions in beverage prices within this outlet category. Data were collected from: (i) a survey of BC private store prices and practices, (ii) alcohol outlet location information, and (iii) data on demographic characteristics. Multilevel models examine the relationships between prices at individual private liquor stores and the densities of government liquor stores, private liquor stores, bars, and restaurants, controlling for background demographics and geographic unit level effects. Spatial dependencies were also examined. RESULTS Increased densities of private liquor stores were associated with lower mean prices of beer and all alcohol aggregated across brands at the store level. There appeared to be no outlet level effect on discounting patterns, however, with the mean price differences apparently reflecting differences in the quality of brands carried rather than unequal prices for any given brand. CONCLUSIONS Increased densities of private off-sale alcohol outlets appear to result in lower prices charged at said establishments independently of other types of alcohol outlets suggesting that they represent an emerging marketing niche in the context of off-sale outlet privatization.
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Affiliation(s)
- Andrew J Treno
- Pacific Institute for Research and Evaluation, Berkeley, CA 94704, USA.
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Werb D, Nosyk B, Kerr T, Fischer B, Montaner J, Wood E. Estimating the economic value of British Columbia's domestic cannabis market: Implications for provincial cannabis policy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:436-41. [DOI: 10.1016/j.drugpo.2012.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 04/03/2012] [Accepted: 05/14/2012] [Indexed: 11/30/2022]
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Estimates of smoking-attributable mortality and hospitalization in BC, 2002-2007. Canadian Journal of Public Health 2012. [PMID: 22530538 DOI: 10.1007/bf03404219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this paper was to estimate the number and rate of deaths and hospitalizations attributable to smoking in British Columbia (BC) from 2002 to 2007. METHODS Using attributable fractions adjusted to BC smoking prevalence and mortality and hospital administrative data, estimates of smoking-attributable mortality (SAM) and smoking-attributable hospitalization (SAH) were calculated by year, disease category, sex, and geographic region. RESULTS Among active smoking adults 15 years of age and older, there were an estimated 4,851 deaths and 25,314 hospitalizations attributed to smoking in BC in 2007. SAM and SAH rates in 2007 were estimated as 119 and 633 per 100,000, respectively. Rates increased from 2002 to 2005 but have declined in subsequent years. Lung cancer and chronic obstructive pulmonary disease were responsible for the largest proportion of SAM and SAH, respectively. There were regional differences, with the Northern Health authority having the highest rate of SAM and SAH and Vancouver Coastal Health authority having the lowest. CONCLUSION Smoking still presents a substantial human and economic burden in BC. Estimates of annual SAM and SAH provide researchers with the ability to detect emerging trends, target intervention and cessation programs, and evaluate current smoking reduction programs. The methodology can be adapted to other provinces to allow for cross-province comparisons.
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Stockwell T, Zhao J, Macdonald S, Pakula B, Gruenewald P, Holder H. Changes in per capita alcohol sales during the partial privatization of British Columbia's retail alcohol monopoly 2003-2008: a multi-level local area analysis. Addiction 2009; 104:1827-36. [PMID: 19681801 DOI: 10.1111/j.1360-0443.2009.02658.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To investigate the independent effects on liquor sales of an increase in (a) the density of liquor outlets and (b) the proportion of liquor stores in private rather than government ownership in British Columbia between 2003/4 and 2007/8. DESIGN The British Columbia Liquor Distribution Branch provided data on litres of ethanol sold through different types of outlets in 89 local health areas of the province by beverage type. Multi-level regression models were used to examine the relationship between per capita alcohol sales and outlet densities for different types of liquor outlet after adjusting for potential confounding social, economic and demographic factors as well as spatial and temporal autocorrelation. SETTING Liquor outlets in 89 local health areas of British Columbia, Canada. FINDINGS The number of private stores per 10,000 residents was associated significantly and positively with per capita sales of ethanol in beer, coolers, spirits and wine, while the reverse held for government liquor stores. Significant positive effects were also identified for the number of bars and restaurants per head of population. The percentage of liquor stores in private versus government ownership was also associated significantly with per capita alcohol sales when controlling for density of liquor stores and of on-premise outlets (P < 0.01). CONCLUSION The trend towards privatisation of liquor outlets between 2003/04 and 2007/08 in British Columbia has contributed to increased per capita sales of alcohol and hence possibly also to increased alcohol-related harm.
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Affiliation(s)
- Tim Stockwell
- Centre for Addictions Research of British Columbia, University of Victoria, BCV8Y 2E4, Canada.
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