Giving alcohol to alcoholics: not as controversial as it seems

A Dutch program pays chronic alcoholics in beer for cleaning the streets and parks. A Canadian homeless shelter provides their alcohol clients with six ounces of white wine every 90 minutes. Giving alcohol to alcoholics, it seems counterproductive from a ‘just say no’ perspective, but I would like to argue that it makes sense on many levels.
The strongest case for giving alcohol to people with chronic alcohol dependence is based on the principle of ‘harm reduction’. Canadian ‘wet-shelter’ programs have emerged for two main reasons. The first is that many homeless shelters are abstinence based which means inveterate drinks would continue to sleep rough, even in freezing winter months, resulting in tragic deaths. The second reason is that chronic inebriates often consume non-beverage alcohol like hand sanitizer, mouth wash and aftershave thereby exacerbating already severe health problems. A recent study by the Centre for Addictions Research found that a “managed alcohol program” approach reduced emergency hospital visits and arrests among participants at the Kwae Kii Win Centre Managed Alcohol Centre by 40-80%. Significant changes among program participants included an improvement in accommodation renewed contact with their families, and better diet. Whilst participants still receive their alcohol throughout the day the alcohol is given by staff in controlled doses at fixed intervals. The dose is enough to prevent withdrawal symptoms, but not high enough to cause intoxication. Although there are many formal harm reduction programs for heroin users, it is less common for people who are alcohol dependent, despite the fact that withdrawing from alcohol can be lethal.
Like Canadian Managed Alcohol Programs the Dutch project is based on harm reduction principles but goes one step further. Participants receive 5 cans of beer for a whole day’s work, 2 to start the day, 2 at lunch, and 1 after work. In addition, they receive a half-packet of rolling tobacco and 10 Euro’s. They also received coffee in the morning, and a hot meal at lunch time. Eating healthily reduces the health risk an alcohol-only diet poses, and can slow the absorption of alcohol. However, the initiative to start this program was not so much driven by the self harm, but by the public nuisance street based drinkers were causing to the local community such as loitering in parks, public urination and often aggressive or loud behaviour. The idea was to give these people an opportunity to contribute to society in a meaningful sense, and feeling part of the community again. People living in the neighbourhood appreciate the cleaners a lot, and greet them as they go to work. This program offers more than harm reduction, it offers rehabilitation as well by providing people a structured day and a sense of belonging to the community and doing something meaningful. De Maeyer, and colleagues (2009; 2011) explored what quality of life meant for substance users, respondents named personal relationships, social inclusion, and self-determination. The inability to change one’s life was associated with lower quality of life. Having at least one good friend and a structured daily activity had a positive impact on quality of life. Harm reduction and treatment often merge into each other.
There are other reasons why giving alcohol to alcoholics might be a good idea. This has to do with the underlying reasons for alcohol use. When we look at the Dutch project, we see that one of the reasons people might drink is because they don’t feel connected to society. Once they feel part of society again, there is a chance they reduce their drinking. Another well accepted reason of why people drink is self-medication. Drinking numbs feelings of depression, anxiety, hopelessness, loneliness. Although there are other treatments for these conditions, maybe a structured administration of small amounts of alcohol will do the job as well, and with less side effects. Opioids are non-controversial used for pain medication, Ritalin (which is amphetamine based) can be an effective treatment for ADHD, alcohol was often used in cough medicine. In some countries (Austria and Italy) GHB is provided as a substitute for alcohol. Maybe there is some wisdom in the medicinal effects of alcohol, and maybe it is possible to administer it as a medicine: just enough to tackle the problem without negative side-effects. In the Netherlands there is also a trial to provide cannabis for people with mental health problems like anxiety, depression and psychosis.
Now what would be an interesting research is to compare this approach to the treatment of substance use with a type of treatment on the other side of the spectrum: forced treatment of people with alcohol use problems. The Involuntary Drug and Alcohol Treatment centre at Royal North Shore Hospital treats people who are on are at risk of serious harm and whose decision-making capacity is compromised, who regardless of vomiting blood still can’t stop drinking. One participant who was interviewed says the program saved his life. It would be interesting to compare the long term effects of this treatment to the one’s that provide alcohol to chronic alcoholics. It can be that the treatments are suitable for different patient groups. It would also be interested to compare both types of treatment with regard to restoring self-determination, which is so important to people according to De Mayer. The involuntary treatment surpasses self-determination in treatment at first, but only to restore people’s decision making capacities, so after the treatment, they can live the life they value. The structured administration treatment give people a lot of self-determination in the treatment, but in the long run can make them dependent on the alcoholic medicine they provide. Although different things might work for different people, it would be fascinating to have more accounts on how chronic dependent people experience these types of treatments.

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