Since the beginning of the COVID-19 crisis, Portuguese officials have worked to ensure supports are in place for unhoused people at risk of experiencing alcohol withdrawal symptoms. But one promising alcohol harm reduction program has yet to get off the ground due to economic barriers.
In April 2020, the Portuguese National Drugs Agency (SICAD) issued guidance on low-threshold pharmacological treatment for unhoused people with alcohol use disorders at shelter reception centers. The agency also finally approved the harm reduction-based Managed Alcohol Program (MAP) designed in 2013 by Lisbon-based Community Intervention Association (CRESCER).
“The MAP is a low-threshold, non-abstinence and community-based response that combines housing with an on-site clinical team that does the management of alcohol supply by providing regular doses to individuals as a harm-reduction strategy,” said psychologist and CRESCER coordinator Cristiana Merendeiro.
The MAP provides a no-cost, safe supply of alcohol at scheduled intervals to support individuals interested in managing or reducing their drinking. One of the first programs in the world, Seaton House, was formed in Toronto in 1997 after three unhoused men physically dependent on alcohol froze to death the previous year, according to the researchers from the Centre for Addictions Research of British Columbia.
Lisbon harm reductionists are eager to roll out the new resource, but are facing issues common among harm reduction organizations in gentrifying cities. “Currently, property speculation is a reality in Lisbon’s private rental market with touristic sector competition and housing prices scale-up,” said Merendeiro.
That makes it uniquely difficult to obtain a space that meets the MAP’s needs. According to Merendeiro, those needs include “30 individual rooms, kitchen and canteen, nursing ward, offices and interior and exterior common spaces,” all centrally located and convenient to public transportation, to “enable people to take part in the community, with daily-life interactions with neighbors and easy access to services.”
Merendeiro believes that “a strong political will could eliminate these barriers. In January, the Lisbon City Assembly representatives called for its implementation. “CRESCER has already had the opportunity to meet future public and private partners who saw this project very favorably,” Medendiero added, “and kindly offered their help finding a place to materialize it.”
Filter engaged Merendeiro in a Q&A to explain the details of the much-anticipated program. The interview has been lightly edited for length and clarity.
Filter: What inspired the design of the Managed Alcohol Program (MAP)?
Merendeiro: CRESCER is an NGO with 20 years of experience working with vulnerable groups in outreach settings, providing harm reduction and other social and health services for approximately 2,000 people per year. CRESCER has outreach teams operating daily in the main urban areas of Lisbon with high levels of drug use, including heavy alcohol consumption.
The main barrier identified by these outreach teams is the absence of responses that meet the needs of people who are homeless and have problematic alcohol use, specifically housing and support to managed alcohol consumption. Temporary housing responses do not allow on-site alcohol consumption and, most of the time, do not accept people when they are intoxicated. Treatment responses also have an abstinence-only approach. These aspects create insurmountable barriers for this population, who remain chronically homeless and extremely vulnerable, dealing with a substantial deterioration of their health due to the escalation of alcohol consumption.
It took seven years for the MAP to be approved by SICAD. How has CRESCER’s approach to it changed since then?
In the beginning, the MAP was developed with a perspective of being a long-term solution for heavy alcohol users who kept experiencing homelessness. Throughout the years, CRESCER has accumulated experience with its Housing First program. This experience brought a different perspective about the MAP as a transitional and health-focused response that should help people manage their consumption, improve quality of life and, in time, connect them with long-term housing responses.
Each person has a therapeutic plan, which includes alcoholic drinks supply in measured, regular doses throughout the day, managed by clinical staff.
What will a typical day in the MAP look like?
People who participate in will have access to housing (individual rooms) and on-site services. Each person has a therapeutic plan, which includes alcoholic drinks supply in measured, regular doses throughout the day, managed by clinical staff. This is an inpatient care response however people are free to use community services during the day.
The MAP will provide on-site services like medical, psychiatric and nursing care; psychological and social support; social and health referrals; access to infectious diseases screening and vaccination/treatment; personal (hygiene, domestic chores, budgeting) and social skills development, as well as leisure activities. It also promotes the use of off-site services, like health and social community services, as well as cultural, training and employment programs.
This program offers a secure place to rest and improve sleep patterns, access to good hygiene conditions, better nutrition and hydration, and close health monitoring—which helps people manage their consumption. Practical strategies to help people change their drinking patterns are also trained: Drink only in the MAP’s safe environment; use drinks with lower alcohol content; pre-define the drinking frequency and units of alcohol per day; eat before and while drinking; alternate alcoholic with non-alcoholic drinks; set a time to drink during the day (such as starting after breakfast and stopping after dinner); and plan alcohol-free periods.
The program also helps reduce violent contacts and injuries, emergency calls due to intoxication and problems with police (which are frequent when people are on the street) and prevent life-threatening situations that arise because of alcohol withdrawal.
Will the MAP impose expectations on participants’ drinking?
The reduction of alcohol use is not a requirement for participation in CRESCER’s MAP. However, our
experience taught us that most people with problematic alcohol use in a homeless situation want help to manage their consumption, but do not find this opportunity in the available abstinence-only responses.
The foundation of the harm reduction approach is to meet people “where they are at” and start the support process from that point. In the MAP approach, each person signs an agreement with a clinical staff where their alcohol management goals are detailed. Practical strategies focused on changing drinking patterns are also trained, simultaneously with the improvement of sleeping, eating and hygiene patterns. These strategies, associated with the staff’s commitment to develop respectful and warm relationships with the beneficiaries, facilitate the reduction of alcohol use. So does the presence of peer specialists, who offer trust and create hope in the possibility of recovery in ways that other staff cannot do.
It is easier for a person to manage consumption in a protected context where basic needs are assured.
Our experience with a Housing First program, which has been running since 2013 and has integrated more than 100 people, has showed us that housing provides the ground to manage consumption. This program provides immediate access to housing combined with off-site support and community-based services—with no preconditions related to sobriety or engagement with psychiatric treatment—to people experiencing long-term homelessness and using drugs. It is easier for a person to manage consumption in a protected context where basic needs are assured. We should not ignore that substance consumption and its numbing effect can be a coping mechanism to deal with the traumatic experience of homelessness.
How has the COVID-19 crisis made the MAP even more necessary? What opportunities has the crisis presented?
With COVID-19 pandemic the problem of people experiencing homelessness with severe alcohol
consumption has taken a greater dimension. The number of people in this situation, who cannot protect themselves from infection, has scaled up. With confinement measures and fewer people on the streets, access to money has turned to be more difficult, putting this population at greater risk of alcohol withdrawal (which could be a life-threatening situation).
Up until now, long-term responses to this population had not been implemented. This program, which was already very needed before the pandemic, would be a first step towards the implementation of a new and integrated national harm reduction strategy to face alcohol-related problems in Portugal.
How can harm reductionists around the world support your work and the movement for more alcohol harm reduction options?
In 2001, Portuguese decriminalization law set the field for the implementation of important community-based responses for people who used drugs. This network of services does not include a low-threshold response for people who use alcohol, yet it is a recognized necessity by harm reduction community. Advocating for this response is a responsibility of all harm reductionists who work with people who are dealing with heavy alcohol consumption while living through extremely vulnerable situations.
Photograph of CRESCER workers conducting outreach, courtesy of CRESCER
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