COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper

Meanings of hope constructed by users of mental health services during the COVID-19 pandemic

OBJECTIVE

To analyze the production of meanings of hope in the discourses of specialized mental health services users in an inland city of Minas Gerais in the context of the COVID-19 pandemic.

METHOD

Qualitative study based on the theoretical-methodological framework of French Discourse Analysis and the theoretical construct of hope. Semi-structured interviews were conducted from August 2022 to May 2023.

RESULTS

The discursive block entitled "The meanings of Hope constructed in the COVID-19 Pandemic" addresses the meanings constructed about hope that are permeated by the effects arising from discursive memories. The discursive excerpts enunciate signs of religious/spirituality discourse; solidarity discourse; disease model; and resilience discourse.

CONCLUSION

Pre-constructed discourses elsewhere on spirituality/religiosity, solidarity, disease model and resilience permeate the production of meanings of hope in the discourses of mental health services users. It is important to enable nurses to grasp the constructed meanings of hope and to recognize them as a therapeutic resource that constitutes care.

City-level drug policies in Portugal: the COVID-19 pandemic as an analyzer of harm reduction responsiveness in Porto and Lisbon

BACKGROUND

The COVID-19 pandemic health crisis and its potential implications for people who use drugs (PWUD) created permissive conditions toward social innovation and experimentation. Still, it also exposed gaps in harm reduction approaches. Harm reduction responsiveness was informed by the priorities defined at the local level, so it was not applied uniformly in different regions. This paper intends to contribute to the analysis of harm reduction responsiveness during the COVID-19 outbreak by comparing the adaptations and implementation of harm reduction and municipal services to support street-involved (SI) PWUD in two Portuguese cities- Porto and Lisbon. This study aims to shed light on the city-level implementation of drug policies in Portugal.

METHODS

This study is based on a comparative qualitative analysis based on the experiences of PWUD and Harm Reduction (HR) professionals regarding the implementation of harm reduction responses during the COVID-19 pandemic in Porto and Lisbon. The study is based on interviews with SI PWUD (n = 22, 12 in Porto and 10 in Lisbon) and online focus groups with harm reduction professionals (N = 12, 6 in Porto and 6 in Lisbon).

RESULTS

Harm reduction teams in Porto and Lisbon implemented contingency plans and proactive adaptations to respond to the pandemic-related emerging needs. However, the study revealed contrasting experiences in the city-level support to harm reduction and responsiveness to the impacts of COVID-19 among SI PWUD in Porto and Lisbon. There were relevant differences in the support they received from the City Council and the city-level responses implemented to support SI PWUD. While the approach in Porto was described as restrictive and zero-tolerance towards drug use, Lisbon´s strategy was harm reduction-focused and inclusive. The study participants revealed better results in Lisbon regarding the harm reduction responsiveness to the pandemic health crisis and the accessibility and adherence of SI PWUD to services.

CONCLUSION

The pandemic constraints and adaptations must be contextualized in the ongoing city-level debates regarding drug policies and harm reduction in Portugal. Moreover, city-level drug policies and local support are crucial to map the opportunities and challenges of implementing the Portuguese Drug Decriminalization Model in different contexts.

Exploring and describing alcohol harm reduction interventions: a scoping review of literature from the past decade in the western world

CONTEXT

Regular alcohol use is a predominant risk factor for disease, injury, and social harm. While robust evidence is advocating for implementing interventions to reduce the harms of illegal substance use, less literature is dedicated to identifying and understanding interventions aiming at reducing the various harms associated with alcohol.

OBJECTIVES

This review describes how alcohol harm reduction (AHR) interventions are currently conducted and analyzes the facilitators and barriers identified by the studies on their efficacy.

METHOD

This scoping review with evidence appraisal included articles published between 2011 and 2022, addressing one or more AHR interventions for population of at least 18 years (including alcohol user who have an addiction but also alcohol user with harmful drinking), conducted in North industrialized countries (Europe, Nort America, Australia).

RESULTS

Among the 61 articles selected, we identified several forms of support (face-to-face or remote, support in residential settings, structural interventions, and interventions created upon spontaneous initiatives), and strategies of intervention were also analyzed (the ones based upon learning and skill development, the ones based upon psychological support, the ones focusing upon socio-economic conditions, strategies focusing on the coordination and adaptation of the care system, and those strategies based on peer support). The facilitators linked to fundamental characteristics of the interventions were the promotion of empowerment and autonomy of beneficiaries, setting objectives tailored to individual needs, professionals harmonizing their values, evidence-based interventions taking into account cultural contexts, and comprehensive and holistic support. Practical facilitators from the intervention process consist of increasing the number of sessions, involvement, and formation of members of staff, disposing of the necessary resources, and using technological tools.

DISCUSSION

The sheer variety of AHR interventions demonstrates that this is a fertile field in terms of intervention design and innovation. This work illustrates the importance of designing effective, adapted harm reduction interventions, prioritizing interventions that make support more accessible to more people. This also prompts us to consider the potential benefits of invoking proportionate universalism in the design of AHR interventions in order to operationalize alcohol harm reduction philosophy. accessible to more people.

A qualitative exploration of the relevance of training provision in planning for implementation of managed alcohol programs within a third sector setting

Background

Managed Alcohol Programs (MAPs) are a harm reduction strategy for people experiencing homelessness and alcohol dependence. Despite a growing evidence base, resistance to MAPs is apparent due to limited knowledge of alcohol harm reduction and the cultural preference for abstinence-based approaches. To address this, service managers working in a not-for-profit organization in Scotland designed and delivered a program of alcohol-specific staff training as part of a larger study exploring the potential implementation of MAPs during the COVID-19 pandemic.

Methods

Semi-structured interviews were conducted with 15 service managers and staff regarding their experiences of the training provided. Data were analyzed using Framework Analysis, and Lewin's model of organizational change was applied to the findings to gain deeper theoretical insight into data relating to staff knowledge, training, and organizational change.

Findings

Participants described increased knowledge about alcohol harm reduction and MAPs, as well as increased opportunities for conversations around cultural change. Findings highlight individual- and organizational-level change is required when implementing novel harm reduction interventions like MAPs.

Conclusion

The findings have implications for the future implementation of MAPs in homelessness settings. Training can promote staff buy-in, facilitate the involvement of staff within the planning process, and change organizational culture.

Alcohol-related brain damage: an umbrella (term) for the approaching post-COVID monsoon

Individuals with alcohol-related brain damage (ARBD) represent a population whose healthcare needs often go unmet. This is the result of a lack of not only an awareness surrounding the condition by healthcare professionals, but also healthcare service inclusion and delivery, more broadly. The Coronavirus 2019 (COVID-19) pandemic and the associated lockdowns dramatically affected the accessibility and availability of addiction services globally, while also driving changes in alcohol consumption among the most vulnerable. In the absence of change, this culmination of increased high-risk drinking behaviour, lack of awareness by healthcare professionals and severely limited service delivery for individuals living with ARBD post COVID-19, represents a perfect storm that is rapidly approaching our health and care services world-wide. Collectively, this will reduce positive health outcomes in an already at-risk group.

Substance use disorders and COVID-19: reflections on international research and practice changes during the "poly-crisis"

Since March 2020, the COVID-19 pandemic has had a disproportionately high toll on vulnerable populations, coinciding with increased prevalence of alcohol-and drug-related deaths and pre-existing societal issues such as rising income inequality and homelessness. This poly-crisis has posed unique challenges to service delivery for people with substance use disorders, and innovative approaches have emerged. In this Perspectives paper we reflect on the poly-crisis and the changes to research and practice for those experiencing substance use disorders, following work undertaken as part of the InterGLAM project (part of the 2022. Lisbon Addictions conference). The authors, who were part of an InterGLAM working group, identified a range of creative and novel responses by gathering information from conference attendees about COVID-19-related changes to substance use disorder treatment in their countries. In this paper we describe these responses across a range of countries, focusing on changes to telehealth, provision of medications for opioid use disorder and alcohol harm reduction, as well as changes to how research was conducted. Implications include better equity in access to technology and secure data systems; increased prescribed safer supply in countries where this currently does not exist; flexible provision of medication for opioid use disorder; scale up of alcohol harm reduction for people with alcohol use disorders; greater involvement of people with lived/living experience in research; and additional support for research in low- and middle-income countries. The COVID-19 pandemic has changed the addictions field and there are lessons for ongoing and emerging crises.

Harm Reduction Strategies for Severe Alcohol Use Disorder in the Context of Homelessness: A Rapid Review

Severe alcohol use disorder (AUD) in the context of housing instability remains one of the most complex health and social issues. Homelessness is related to increased vulnerability to stigma, marginalization and harmful ways of alcohol consumption, including non-beverage alcohol use (NBA). As a result, severe intoxication, alcohol poisoning, injury and death are common occurrences. Although harm minimization strategies have been readily proposed and examined in the context of drug use, applying the same principles to severe AUD remains controversial within the research and treatment community. This article summarizes the emerging research on managed alcohol programs to increase awareness about alcohol-related strategies that address severe AUD and provide other wrap-around supports such as housing, health and social services to mitigate various harms, including COVID-19.

Problemas ligados ao álcool em centros de emergência (PLACE)-People experiencing homelessness with alcohol-related problems in Lisbon's emergency shelters during the COVID-19 pandemic: a description and analysis of a harm reduction intervention

Introduction

Alcohol-related problems disproportionally affect people experiencing homelessness. As the first wave of the COVID-2019 pandemic spread in 2020, a number of emergency shelters were opened in Lisbon. Increased difficulties in obtaining alcohol could have led to an increased incidence of alcohol withdrawal. Therefore, a low-threshold harm reduction intervention was introduced to these emergency shelters. This consisted of a fixed medication treatment, made available immediately for those with specific conditions, without the need for a medical evaluation or abstinence from alcohol, together with an offer of subsequent access to specialized addiction centers. The Problemas Ligados ao Álcool em Centros de Emergência (PLACE) study (alcohol-related problems in emergency shelters) is a retrospective mixed-methods observational study. It describes the demographic, health, and social characteristics of shelter users participating in the program and aims to evaluate the intervention as well as the experience of the patients, professionals, and decision-makers involved.

Results

A total of 69 people using shelters self-reported alcohol-related problems. Among them, 36.2% of the people accepted a pharmacological intervention, and 23.2% selected an addiction appointment. The take-up of the intervention was associated with better housing outcomes. A description of an individual's trajectory after leaving the shelter is provided.

Discussion

This study suggests that non-abstinence-focused interventions can be useful and well-tolerated in treating addiction in this population.

The Potential for Managed Alcohol Programmes in Scotland during the COVID-19 Pandemic: A Qualitative Exploration of Key Areas for Implementation Using the Consolidated Framework for Implementation Research

People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.

Harm reduction and abstinence-based models for treatment of substance use disorders during the COVID-19 pandemic: a global perspective

The COVID-19 pandemic has significantly affected treatment services for people with substance use disorders (SUDs). Based on the perspectives of service providers from eight countries, we discuss the impact of the pandemic on SUD treatment services. Although many countries quickly adapted in provision of harm reduction services by changes in policy and service delivery, some went into a forced abstinence-based strategy. Similarly, disruption of abstinence-based approaches such as therapeutic communities has been reported. Global awareness is crucial for responsible management of SUDs during the pandemic, and the development of international health policy guidelines is an urgent need in this area.

A multicentric survey among patients with substance use disorders during the COVID-19 lockdown in India

BACKGROUND

The unprecedented first wave of the COVID-19 pandemic severely impacted mental health services globally. However, the negative impact of such disruptions on people with substance use disorders (SUD) seeking treatment remains unclear. We aim to explore the behaviors adopted by these individuals to overcome the service disruptions.

MATERIALS AND METHODS

We explored the changes related to substance use behavior (quit attempts, withdrawal experienced, treatment-seeking, and risky behaviors), and behavioral changes in response to COVID-19 lockdown. A cross-sectional survey was conducted among 404 people with SUD seeking treatment from seven centers across India. They were assessed by a specially designed structured questionnaire during the first wave (June-September) of the pandemic.

RESULTS

An overwhelming majority experienced withdrawal symptoms, with close to half making quit attempts and seeking treatment during the lockdown. Three-fourth of the sample reported difficulty in accessing treatment services and medications. Patients with opioid use were significantly more likely to think about quitting (χ² = 20.408, P = 0.000), make attempts (χ² = 12.436, P = 0.000), seek treatment (χ ² = 7.536, P = 0.006), and self-medicate for withdrawal symptoms (χ² = 5.885, P = 0.015). In turn, those with alcohol use were more likely to use telepsychiatry services (χ² = 35.143, P = 0.000) and experience stigma by family members (χ² = 29.951, P = 0.000) and neighbors (χ² = 17.725, P = 0.000). Among COVID-19 safety precautions, majority practised wearing masks and social distancing but not others.

CONCLUSION

COVID-19 lockdown led a significant proportion of substance users, especially opioid users, to make quit attempts and seek help. However, these could not be sustained due to difficulty in accessing treatment services. Further, significant proportion failed to adhere to COVID-19 safety precautions.

Exploring the Potential of Implementing Managed Alcohol Programmes to Reduce Risk of COVID-19 Infection and Transmission, and Wider Harms, for People Experiencing Alcohol Dependency and Homelessness in Scotland

People who experience homelessness and alcohol dependency are more vulnerable than the general population to risks/harms relating to COVID-19. This mixed methods study explored stakeholder perspectives concerning the impact of COVID-19 and the potential utility of introducing managed alcohol programmes (MAPs) in Scotland as part of a wider health/social care response for this group. Data sources included: 12 case record reviews; 40 semi-structured qualitative interviews; and meeting notes from a practitioner-researcher group exploring implementation of MAPs within a third sector/not-for-profit organisation. A series of paintings were curated as a novel part of the research process to support knowledge translation. The case note review highlighted the complexity of health problems experienced, in addition to alcohol dependency, including polysubstance use, challenges related to alcohol access/use during lockdown, and complying with stay-at-home rules. Qualitative analysis generated five subthemes under the theme of ‘MAPs as a response to COVID-19′: changes to alcohol supply/use including polysubstance use; COVID-19-related changes to substance use/homelessness services; negative changes to services for people with alcohol problems; the potential for MAPs in the context of COVID-19; and fears and concerns about providing MAPs as a COVID-19 response. We conclude that MAPs have the potential to reduce a range of harms for this group, including COVID-19-related harms.