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Spring 2009 | Vol 12 No 3

The last word

Message in a bottle: Wet shelters embody true harm reduction approach

By Tomislav Svoboda

In the winter of 1996, Eugene Upper, Kompani Mirsalah-Aldin and Irwin Hardy froze to death on three separate nights in the streets of Toronto. A coalition of poverty and housing activists led by street nurse Cathy Crowe and human rights lawyer Peter Rosenthal advocated for an inquest. A coroner's inquest determined that in addition to homelessness, uncontrolled heavy alcohol use and severe mental illness were implicated in the deaths. The jury recommended that a 24-hour in-shelter harm reduction program including in-shelter provision of alcohol be implemented in the shelter system. A 12-hour municipally run shelter was designated as the program site. Front-line staff led by Arthur Manuel developed the Annex Harm Reduction Program within this shelter, which included an in-shelter drinking program despite senior administration statements that such a program was neither necessary nor feasible.

The program aimed to provide shelter for homeless men who avoided shelters or who were repeatedly barred from other shelters due to difficult behaviours related to alcohol use, severe mental illness and other factors. From the front-line perspective, these were individuals who were not being helped by numerous hospitalizations, incarcerations, court appearances and police pickups. Annex staff adopted a harm reduction approach in the strict sense, supporting clients in their use of alcohol in a variety of ways, including serving alcohol as part of a managed alcohol program and storing alcohol for clients, building staff-client relationships and accepting difficult behaviours in a supportive shelter environment.

Two shelter-based programs in Canada have now adopted the Annex model. These managed alcohol programs in Ottawa and Hamilton, Ontario, serve alcohol up to 11 hourly drinks a day as an alternative to drinking beverage and non-beverage alcohol on the street. The drinking programs are part of more comprehensive programs that include multidisciplinary health care, social work, shelter, meals and other supports.

Despite being embraced by front-line advocates as providing ongoing benefits to clients, shelter-managed alcohol programs continue to be highly controversial and are subject to ongoing criticism by community leaders and commentators. During a recent Toronto City Council budget review, Annex staff were questioned about providing alcohol and cigarettes to clients. In 2004, city council had requested that staff report back on harm reduction alternatives to providing alcohol to shelter clients.

Although numerous studies have evaluated harm reduction as an approach to assist homeless opiate-dependent individuals, there has been little discussion in the medical or addiction literature about this approach for those pejoratively called "skid row alcoholics." The plight of the homeless sub-population these programs serve, although well known, is not well described in the scientific literature, making this population more vulnerable to misconceptions in public and professional debates. Front-line service providers recognize them as "frequent flyers"; they have been called "million-dollar men," reflecting their intense use of emergency rooms, ambulances, prisons and other services that do not address their underlying problems.

Various interrelated moral and empirical imperatives motivate the shelter-based managed-alcohol programs, including removing class-based application of law; not denying services because of alcohol use; reducing harms by removing clients from dangerous environments and providing services otherwise not available; and applying interventions appropriate to the stages of change. In our society, if you are poor and without a home it is illegal to drink; but if you have financial means and a home you can drink as much as you want. Without shelter-based managed-alcohol programs, a poor person without a home is subjected to a state of prohibition; drinking is forbidden in parks, shelters or hospitals. A person will be denied access to emergency shelter, hospital care and other social services if he or she wishes to drink while using these services.

Good data suggest that applying action- or maintenance-oriented approaches to those who are in pre-contemplation will fail; yet these misapplied approaches underlie policies that link shelter, hospital and financial assistance care to successful abstinence. The managed-alcohol shelter programs have been described as "safe drinking sites," leveraging empirical understanding from the heavily studied "safe injection sites" that are increasingly show-ing benefit over abstinence-based approaches.

With the expectation that the first three imperatives and argument by analogy would not be sufficient to dissuade unfair bias against these programs, studies were conducted to determine whether managed-alcohol programs provide greater benefit than the usual abstinence-based care. A preliminary study conducted by Joyce Burnstein at Toronto Public Health suggested that deaths among clients who stayed at Seaton House, Toronto's largest shelter for men where the Annex program resides, dropped after starting the program. Three peer-reviewed studies have shown benefits from managed-alcohol-type programs: Thornquist and colleagues in Academic Emergency Medicine in 2002; Podymow and colleagues in the Canadian Medical Association Journal in 2006; and a 2006 University of Toronto PhD dissertation on the Annex program all found large drops in emergency room visits, detox unit visits and police interactions and incarcerations and increased time spent in shelter out of harm's way for those enrolled in managed-alcohol programs.

Many questions remain unanswered, and managed drinking programs continue to be controversial. For now, in the minds of many front-line care providers and hardened alcohol-dependent individuals, these programs are a better alternative to a life filled with mouthwash, rubbing alcohol, street assaults and blackouts, ambulance pickups and incarcerations.

Dr. Tomislav Svoboda helped to develop the Annex program. He is a community medicine specialist and clinical director at Seaton House and an associate scientist at the Centre for Research on Inner City Health at St. Michael's Hospital in Toronto.

Editorials do not necessarily reflect the views of CAMH.