Managed Alcohol Programs Offer Harm Reduction to Unhoused People

December 6, 2022

It’s a bitterly cold day in Montreal. The snow is falling in thick, cartoonish flakes, relentless winds have dropped the temperatures far below freezing, and the sidewalk is slick with ice. But inside PAQ3 it’s warm, and people are laughing. And it feels like a home.

PAQ3 is the simple name for Project Autochones du Québec’s most recent project, its Managed Alcohol Program (MAP), which provides alcohol as well as housing and services to people with “severe alcohol addiction.” PAQ is an Indigenous-led organization that supports First Nations, Inuit and Métis people facing housing insecurity in Montreal. The organization uses a “culturally adapted approach based on empowerment and harm reduction.”

PAQ’s MAP house originally opened as a pilot project in 2021, and can accommodate eight residents at a time. Each person has their own lockable bedroom, with access to a communal kitchen and community games room. Participants can choose to be connected with primary care services, and the program has a focus on connecting or reconnecting participants with their Indigenous cultures. Nobody in the house is beholden to overly restrictive rules, only mutual respect and a commitment to the program.

“The MAP is very cutting-edge, they’re very much at the forefront of harm reduction,” Kayla, an intervention worker at the house, told Filter. She formerly used banned drugs, and said that—together with a diploma in addictions, counseling and community—prepared her for her role. “It’s been really cool to be able to experience this, to be able to stretch the counseling muscle, but as well to validate the harm reduction instead of having an abstinence-based sort of thing.”

There’s never an imposed goal to reach abstinence or decrease one’s drinking.

Abstinence-based models of recovery are common everywhere, but particularly in shelter settings. People under the influence of drugs such as alcohol will often be turned away from shelters or services, unless it’s a “wet” shelter. Even if a shelter allows intoxication, it doesn’t always allow consumption on-site, which is where the PAQ3 MAP house differs.

Residents there generally receive one beer an hour, though the amount depends on what they’ve agreed with intervention workers. There’s never an imposed goal to reach abstinence or decrease one’s drinking—instead, the goal is to keep people safe and give residents more control over their own alcohol consumption.

“I’ve witnessed numerous times people have been kicked outta shelters or whatnot,” Pierre Parent, a healthcare navigator with the Indigenous Street Workers Project in Montreal, told Filter. “I know the dire consequences that may occur—that did occur.”

Parent, an Indigenous man from James Bay Cree Territory, has experienced his own addictions and comparable interventions, and has seen many of his peers benefit from MAPs. He noted that this harm reduction approach gives people more autonomy than an abstinence-only policy.

“It’s not realistic, it’s just not realistic [to expect abstinence],” he said. “These are the realities, and we need to believe in a harm reduction approach above all else.”

Parent added that projects like PAQ3 are essential to keeping people alive, helping them to navigate their alcohol use more safely. For people who drink large quantities daily, sudden withdrawal can be extremely dangerous, even fatal. Most MAP participants have been drinking heavily “for years and years and years,” he said. “So this needs to be supervised medically, clinically, properly.”

Residents are permitted to stay at PAQ3 indefinitely. When a space opens up, it’s often filled by people referred from other PAQ sites.

“You’re not meeting people where they’re at if you’re just banning them from using substances.”

“The whole concept of harm reduction means that you have to understand and meet people where they’re at,” Kayla said, highlighting unfair demands made of unhoused people in order for them to “deserve” shelter. “You’re not meeting people where they’re at if you’re just banning them from using substances.”

MAPs across the country have helped people who use alcohol while unhoused; preliminary studies have shown evidence that MAPs “reduce acute and social harms associated with alcohol dependence.” Canada has been a world leader in piloting MAPs, which are now springing up in other countries.

Mary Walsh is a harm reduction researcher at St John’s Women’s Centre, which runs a MAP for women, non-binary and two-spirit folks in Newfoundland. She has seen particular value in asking people about what their goals are for their alcohol use, rather than imposing any expectations.

“We partner with our local health authority’s harm reduction nursing team, and they meet with the health care providers, the case managers and the participants to create a care plan,” Walsh told Filter. “That outlines what folks’ goals are around their alcohol consumption, and what their prescription is going to be for the amount of alcohol they receive through us, as well as what other wraparound supports we can provide to them.”

Walsh noted that there are plenty of goals other than abstinence that participants choose to focus on for their safety and wellbeing.

“We’ve seen people looking to have more choice in the sex work that they do … if they don’t have to worry about getting their alcohol.”

“We found, especially because we’re serving a gendered population, that the goals have been very gendered,” she said. “We’ve seen people looking to have more choice in the sex work that they do, so folks have more choice around what clients they’ll take, or when they can say yes or no to clients if they don’t have to worry about getting their alcohol.”

While PAQ3 works on a residential basis, other MAPs vary. St John’s Women’s Centre doesn’t have access to congregate living settings, so operates on an outreach-based model. Currently, it can work with up to 15 participants.

“We’ve been bringing people alcohol where they live, so sometimes that might look like a shelter, sometimes they have their own independent living, and then depending on the person, they might come pick up the alcohol from our offices and take it back with them,” Walsh said. The program, she emphasized, operates with a high degree of trust and respect, because that’s what its participants deserve.

For Guy Felicella, a harm reduction and recovery advocate who works for the BC Centre on Substance Use, harm reduction was life-saving during his years on the street.

“Being homeless is relentless,” he told Filter. “It’s probably the most mentally and physically punishing condition I’ve ever dealt with or recovered from in my life.”

“You know how they prove that they deserve housing? They’re a human being. That’s the requirement.”

Felicella spent 30 years experiencing homelessness, addiction or jail in Vancouver. During that period he was revived from overdose six times, and faced five bone infections. Shelter housing was never guaranteed. But even if it had been, it wouldn’t have been enough.

“Shelters create an illusion that people are being housed, but they’re not,” he said. “People always say, ‘They’ve got to prove that they deserve housing.’ You know how they prove that they deserve housing? They’re a human being. That’s the requirement.”

Felicella related that he was turned away from shelters in Vancouver multiple times—including during the winter in conditions highly dangerous to people sleeping outside—because he had been using drugs.

On one particular night, “I was turned away from a cold weather shelter because I was high,” he said. “I went and propped open the door to an apartment building and slept in the laundry room. I was woken by two police.” He was then charged with trespassing, before being released back out into the cold.

“I was just saying to myself, man, I just can’t catch a break,” he recalled. “So, you know, the requirement of somebody coming in to get shelter should be that they need shelter, not that you have to be sober to access it.”

“In my hometown, I’ve seen people OD because of the fact that they can’t get help and they feel like they’re stuck,” said Kayla, who is originally from Winnipeg. “People were constantly feeling angry and frustrated, to the point where they just took that anger out on themselves, which was even more detrimental.”

“Flat out, you’d be saving lives. Flat out.”

Both Walsh and Kayla report a high rate of success in that participants in their respective MAPs have gained more stability in their lives. This means more capacity to connect with health care workers, including visiting the dentist and getting consultations for potentially neglected medical issues. Walsh also noted that the programs provide relative financial stability and more food security, as people can spend money they would’ve spent on alcohol on groceries instead.

I asked Kayla what would happen if shelters and services that have abstinence requirements instead allowed consumption on site.

“Flat out, you’d be saving lives,” she immediately replied. “Flat out. You’re saving communities, and you’re saving lives for sure, and you’re undoing harm that has been done by those abstinence-based programs.”

“No place is perfect, and you can’t please all the people all of the time,” Parent said of MAPs. “But during my struggles, I could see myself having to come here. The whole basis for me is harm reduction and trauma-based responses, and you have a safe space here.”

 


 

Photograph by Santeri Viinamäki via Wikimedia Commons/Creative Commons 4.0

Eve Cable

Eve is a journalist based in Montreal, Quebec covering community news and harm reduction. She is a reporter at the Eastern Door, and her work can be found in The Rover, Xtra, THIS magazine and more.

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