Perceived Harms and Harm Reduction Strategies Among People Who Drink

International Journal of Drug Policy 59 (2018) 85–93

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International Journal of Drug Policy

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Research Paper Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, T Canada ⁎ Alexis Crabtreea,b, , Nicole Lathamc, Rob Morganc, Bernadette Paulye, Victoria Bungayd, Jane A. Buxtona,b a School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada b British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada c Eastside Illicit Drinkers Group for Education, 380 E Hastings St, Vancouver, BC, V6A 1P4, Canada d School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada e Centre for Addiction Research of British Columbia, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada

ARTICLE INFO ABSTRACT

Keywords: Background: There has been increasing interest in harm reduction initiatives for street-involved people who Harm reduction drink alcohol, including non-beverage alcohol such as mouthwash and hand sanitizer. Limited evidence exists to Non-beverage alcohol guide these initiatives, and a particular gap is in research that prioritizes the experiences and perspectives of Illicit alcohol drinkers themselves. This research was conducted to explore the harms of what participants termed “illicit Surrogate alcohol drinking” as perceived by people who engage in it, to characterize the steps this population takes to reduce Ethnography harms, and to identify additional interventions that may be of benefit. Methods: This participatory qualitative research drew on ethnographic approaches including a series of 14″town hall"-style meetings facilitatied and attended by people who self identify as drinking illicit or non-beverage alcohol (n = 60) in Vancouver, British Columbia. This fieldwork was supplemented with four focus groups to explore emerging issues. Results: Participants in the meetings described the harms they experienced as including unintentional injury; harms to physical health; withdrawal; violence, theft, and being taken advantage of; harms to mental health; reduced access to services; and interactions with police. Current harm reduction strategies involved balancing the risks and benefits of drinking in groups and adopting techniques to avoid withdrawal. Proposed future initiatives included non-residential managed alcohol programs and peer-based supports. Conclusions: Illicit drinkers describe harms and harm reductions strategies that have much in common with those of other illicit substances, and can be interpreted as examples of and responses to structural and everyday violence. Understanding the perceived harms of alcohol use by socially marginalized drinkers and their ideas about harm reduction will help tailor programs to meet their needs.

Introduction phrase “illicit drinking” to refer to consumption of non-beverage alcohol (alcohol not intended for human consumption, e.g. mouthwash Harm reduction is an approach to psychoactive substances that in- and rubbing alcohol) and consumption of potable alcohol in stigma- volves working to reduce the negative impacts of substance use without tized and criminalized ways (e.g. public consumption by homeless necessarily requiring a reduction in use. The primary focus of the ﬁeld drinkers). This term, while unconventional, was in use in the commu- has been reducing the harms of illicit drugs, particularly those asso- nity where this research was conducted1 and was enthusiastically ciated with injection drug use. Less attention has been focused on ad- adopted by research participants as their descriptor of choice in order to dressing problematic alcohol use, particularly among those who drink emphasize the criminalization and social marginalization they experi- alcohol and live in marginalizing conditions. In this paper, we use the ence as a result of their use of alcohol.

⁎ Corresponding author at: School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z9, Canada. E-mail address: [email protected] (A. Crabtree). 1 The term originated with the Western Aboriginal Harm Reduction Society (wahrs.ca). https://doi.org/10.1016/j.drugpo.2018.06.020 Received 30 October 2017; Received in revised form 18 June 2018; Accepted 25 June 2018 0955-3959/ © 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). A. Crabtree et al. International Journal of Drug Policy 59 (2018) 85–93

People experiencing unstable housing have high rates of proble- seven steering committee meetings, a series of 14 town hall meetings matic alcohol use (Palepu et al., 2013) and have a mortality rate from and four follow-up focus groups. alcohol-related causes that is more than six times higher than that of the general population (Hwang et al., 2009). Non-beverage alcohol is used Procedures in this population as a surrogate alcohol for reasons of affordability and accessibility (Egbert, Reed, Powell, Liskow, & Liese, 1985; Erickson We conducted weekly “town hall” meetings with illicit drinkers over et al., 2018; Kort, Stuart, & Bontovics, 2005). Although poorly char- a four month period in 2011. These were large meetings (up to 30 acterized, the risks appear to be similar to potable alcohol participants) in which facilitators from VANDU worked with a staff (Lachenmeier, Monakhova, Markova, Kuballa, & Rehm, 2013; member to guide discussion. The phrase “town hall” was chosen to Lachenmeier, Rehm, & Gmel, 2007). Socially marginalized drinkers highlight some key features of the meetings: their size, the desirability have disproportionately high health service utilization (Holtyn et al., of audience participation, and the planned discussion of topics of 2017; Svoboda & Ramsay, 2015), although this should be understood in community importance. Each meeting lasted one hour, and participants the context of sturctural barriers to achieving good health and often were provided $3 to offset the opportunity costs of participating. undesired transportation to emergency departments by first responders Subsequently, four focus groups with specific populations (women, who lack other options to ensure their safety (Hwang, 2001; Indigenous people, young people, and a general focus group) were held McCormack, Hoffman, Norman, Goldfrank, & Norman, 2015). to explore in more detail specific themes raised during the townhall Although several studies (Evans, Semogas, Smalley, & Lohfeld, meetings. The focus groups were semi-structured, two-hour sessions, 2015; Pauly et al., 2016) have investigated the experiences of illicit and participants received $20 compensation. drinkers already engaged in managed alcohol programs (MAPs, pro- Although our definition of “illicit drinking” includes drinking bev- grams in which potable alcohol is provided to those with severe alcohol erage alcohol in criminalized or stigmatized ways (e.g. public drinking use disorders and homelessness), and research has addressed the per- by people who are homeless), participation in this research was received needs and goals of people who engage in street drinking (Collins stricted to people who identified as at least occasionally drinking non- et al., 2016; Collins, Grazioli, et al. 2015), no research to date has fo- beverage alcohol. This was done because the research was conducted at cused specificially on illicit drinkers’ own perceptions of the alcohol- a drug users’ organization, and there was concern from steering com- related harms they experience and their beliefs on how these could best mittee members that people who primarily use drugs and only occa- be addressed. Understanding the harms of illicit drinking from the sionally use beverage alcohol would participate and potentially dom- people who engage in it is important to contextualize and support fu- inate the meetings. Restricting the inclusion criteria to people who have ture harm reduction strategies and design programs that best meet their consumed non-beverage alcohol (although it may not be their alcohol needs, and is particularly vital given the marginalization of this popu- of choice) was done to encourage participation by highly marginalized, lation and the many barriers they face to having their voices heard. street-involved drinkers. Recruitment initially was conducted by Our study addressed this identified gap through a qualitative, par- members of the steering committee to public spaces where people ticipatory research project with illicit drinkers designed to answer the gathered to drink alcohol. Later recruitment was primarily word of following questions: (a) What harms do marginalized people who drink mouth from current participants. alcohol perceive are associated with illicit drinking? And (b) What do illicit drinkers suggest would reduce these harms, particularly (i) what Data analysis steps are they already taking and (ii) what other actions do they believe would be helpful? Community-based participatory research was chosen Fieldnotes, much of which were verbatim, were produced by AC for as a research approach in order to align project methods with the study all town hall meetings and steering committee meetings, and transcripts aim of centering illicit drinkers’ own experiences and knowledge. were made from recordings of the focus groups. These data were ana- lyzed for themes in NVivo 8 using techniques drawn from interpretive Methods description, which is a pragmatic approach to data analysis with its origins in nursing scholarship (Thorne, 2008). The analysis, conducted Setting and approach by AC and JB, involved several rounds of coding. Initially results were categorized into themes by content with attention focused on illicit Vancouver’s (British Columbia, Canada) Downtown Eastside was drinkers' own perceptions of harms and harm reduction, rather than on the site of this research. This is an intensively researched urban a priori assumptions about illicit alcohol from the health professions. neighbourhood known for its history of political activism, concentra- An additional level of analysis attended to how participants' suggestions tion of single-room occupancy hotel rooms and social service organi- of harms and harm reduction strategies were linked to social, political, zations, and current struggles with gentrification (Linden, Mar, Werker, and economic forces affecting people who use illicit substances. All Jang, & Krausz, 2012; Masuda & Crabtree, 2010). quotations are from town hall meetings unless otherwise noted. The A community based participatory research (CPBR) approach was initial results were presented to the steering committee, and their used. In this collaborative research approach, researchers and com- feedback was incorporated into the results presented below. munity partners work together in the co-production of knowledge that begins with a question of interest to the community and a shared goal of Participants social action as an outcome (Wallerstein & Duran, 2010). For this project, the Vancouver Area Network of Drug Users (VANDU) partnered Sixty individuals participated in the town hall meetings; most of with the British Columbia Centre for Disease Control. VANDU is an these attended multiple meetings. The majority of meetings had 30 activist group located in the heart of the Downtown Eastside, and had participants, and the smallest had 11 participants. Twenty-five people both physical proximity and organizational linkages to organizations participated in the focus groups. serving illicit drinkers in the neighbourhood. The impetus for this study Demographic information was not formally collected with partici- was a previous participatory research project with people who use pants, as VANDU leadership noted that this would hinder participation drugs that identified an opportunity for drug users’ organizations to and engender mistrust of the research project. Based on AC’s observa- better engage with people who use alcohol (Crabtree, 2015). The tions and participant comments, however, we are able to report on steering committee, made up of people who used illicit substances, general characteristics to provide context to interpret their statements. functioned to advise on project logistics, develop meeting agendas, and The meetings were overwhelmingly attended by men, with only a few provide facilitators for the town hall meetings. Data were collected at women at each including one individual who identified as

86 A. Crabtree et al. International Journal of Drug Policy 59 (2018) 85–93

Table 1 Perceived harms associated with illicit drinking.

Harm Description

Unintentional injury Included minor to significant injury: from “bruises and bumps” to “bleeding to death”; participants were particularly concerned about choking Harms to physical health Participants recognized negative effects of illicit drinking on the liver and memory, but had many questions about other physical effects Withdrawal Seizures, delirium tremens, and shakiness were all mentioned as specific harms participants faced from alcohol withdrawal Violence This included physical assault, theft and exploitation. These dangers are exacerbated by drinking outside. Harms to mental health Particularly depression and isolation; illicit drinkers were seen at particular risk of suicide Reduced access to services Participants reported being turned away from health care services when intoxicated Interactions with police Drinkers are criminalized by having alcohol poured out, being given tickets, and being taken into police custody transgendered. The predominant ethnicities were white and Violence, theft, and exploitation Indigenous. Ages appeared to range from twenties to fifties. Participants A set of related harms of illicit drinking that was frequently men- identified as living in single room occupancy hotels, supportive social tioned included experiencing violence, being a victim of theft, or having housing and homeless shelters, or sleeping outside. Most indicated that someone take advantage of an intoxicated drinker (“We have dirtbags they were receiving social income assistance through welfare or dis- taking advantage”). Violence was first discussed as follows: ability payments. Oral consent was obtained for all town hall meeting The facilitator asks if people find themselves on the receiving end of participants, and written consent was obtained for steering committee a lot of violence. meetings and focus groups. Participation in the meetings and receipt of “Yes, absolutely,” is the first answer. financial compensation was not contingent on research participation: Someone else says, “You have to defend yourself all the time.” comments were not recorded for those who declined to participate in “Every day,” echoes a third participant. the research. Ethics approval was granted by the University of British Columbia Behavioural Research Ethics Board (certificate H10-01257). Theft was strongly endorsed as a reason for experiencing violence, with theft of alcohol from people drinking alone as a particular risk. Violence from police and sexual assault were also mentioned. In the Results women's focus group, one participant described the pervasive risk of sexual assault women illicit drinkers face, "When you’re by yourself and Harms from illicit drinking you get totally hammered, things happen to you. Like, for instance, I guess one day I was passed out beside the church and two guys were In describing the alcohol-related harms they experienced, meeting trying to feel me up while I was passed out" (Women's focus group). participants drew few distinctions between non-beverage and beverage A related harm mentioned by participants is that, when intoxicated alcohol. The perceived harms of illicit drinking are summarized in and especially when desperate for money, they are vulnerable to ex- Table 1. While some are primarily bodily harms (e.g. withdrawal, in- ploitation. As examples, participants described incidents in which they jury), others are psychosocial in nature (e.g. damage to mental health) had been offered cash after being hit by a car in exchange for not filing or relate to the social welfare system (e.g. reduced access to services). insurance or police reports; being “ripped off” if selling goods to obtain The breadth of participants’ conception of harm differs from more money for alcohol; being given inert substances instead of drugs by traditional biomedical notions of harm as disease or injury, and pro- dealers; and paying excessive prices for alcohol (including purchasing vides an important starting point for delivery of services that meets on credit, with payment due on the day social assistance cheques are illicit drinkers’ perceived needs. distributed).

Unintentional injury Harms to mental health Unintentional injuries were seen as a significant risk of illicit Damage to mental health was presented more as a risk of the life- drinking. These ranged from “bruises and bumps” to “bleeding to style associated with consuming alcohol than something inherent to the death,” with falling and cuts most frequently mentioned as potential substance itself. In particular, participants mentioned drinking alone in injuries. Choking on one’s own vomit was also raised as a concern. one’s room (a strategy for avoiding theft and police attention) as a contributing factor to depression (“You’d be depressed sitting alone in your room”). The worst possible outcome of the negative effects on Harms to physical health mental health was suicide, which participants saw as a particular risk There was lay understanding of the effects of alcohol on the liver in for illicit drinkers due to stigma and isolation. particular. One participant said that a group like this is important for drinkers like him, but also to help people like his brother. He explained Reduced access to services that his brother’s stomach “is already getting big from his liver giving Participants highlighted their difficulties accessing health casre. out.” Kidney damage and vision loss were mentioned specifically as This occurred when people were intoxicated and subsequently refused well. Participants did have many questions about other effects of non- service at medical clinics (“We went over there, but she’s got to go there beverage alcohol (“I don’t know what it’s doing to my body”). sober. But I can’t keep her sober till nine-thirty in the fricking morning” (General focus group)). As one participant described it: Withdrawal “You have to be sober, at least half-ass sober” to see a doctor. If not, Withdrawal and delirium tremens (“the DTs”) were seen as risks they kick you out and say go back tomorrow, but often after that specific to alcohol. Several participants reported experiencing seizures, experience when you sober up you don’t want to go back. and many more had witnessed them in others. Less major symptoms, such as tremors, were also commonly reported, particularly in the In follow up to this statement, one of the facilitators asked who in mornings after overnight abstinence (“A lot of us are shaky as hell in the the audience had similar experiences. Over half of the participants mornings”). Participants described withdrawal in very serious terms answered in the affirmative. Access to hospitals was also an issue, and had a variety of strategies for coping with it (see section on current particularly if people had taken hand sanitizer in the past (“The hos- harm reduction strategies below). pitals were refusing people medical attention because they’re stealing

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Microsan [hand sanitizer]”). Access to medical services is already dif- participants advocated keeping money or alcohol in reserve so that ficult for this population due to past experiences of stigma, difficulties some would be available when needed. navigating the bureaucracies of medical care (such as scheduling ap- A related harm reduction strategy involved managing conditions to pointments, providing identification, etc.), and class and cultural dif- promote a steady pace of alcohol consumption. This helps limit the ferences with health care providers. Adding the barrier of being denied likelihood of withdrawal, but also helps avoid over-intoxication and service while intoxicated, especially to the subset of participants who associated harms. It may also lead to less alcohol being consumed are intoxicated most days, contributes to an inadequate standard of overall. This sometimes entails planning ahead, by not purchasing large medical care. amounts of alcohol or by drinking with someone who drinks less (and therefore using them to pace oneself). Alternatively, participants Criminalization mentioned enforcing this on others when drinking in a group by cutting ff “ Finally, criminalization was mentioned as a significant harm of il- a person o or having a shared bottle bypass them ( When someone ” licit drinking (“Being busted all the time”). Participants described how becomes really drunk, the bottle just passes them without stopping ). police target known illicit drinkers to pour out their alcohol, give tickets Diluting alcohol with water or juice was suggested as an additional “ ” for being drunk in public, and take them to the "drunk tank" (Steering pacing strategy ( Three quarters to a quarter Listerine to water ). ff committee meeting). They felt this targeting exceeded that faced by Taking days o from drinking was also mentioned as a strategy to re- other substance users (“They really target drinkers”) and that mis- duce harm, although one that risks withdrawal symptoms. treatment (e.g. theft and violence) is common while in custody. Illicit On days when abstinent by choice or necessity, some participants drinkers' interactions with police often occur in the context of home- reported the use of pharmaceutical drugs, by prescription or otherwise, “ ” lessness or residing in dwellings with restrictions on visitors; in these to manage withdrawal symptoms ( Take pills, like Valium ). Most circumstances, public intoxication and interaction with police is more participants were familiar with the use of medication to manage ff likely. The substantial history of police mistreatment and targeting of withdrawal, having been o ered it in detox or while incarcerated. A Indigenous people should also be acknowledged when discussing illicit small minority had extended their use to non-institutional situations, drinkers' experiences of criminalization, as Indigenous people made up either by obtaining a prescription from a physician in the community or a significant fraction of meeting participants and their experiences of by buying pharmaceuticals on the street. While benzodiazepines were criminalization as illicit drinkers are exacerbated by their frequent the most commonly cited medication for this purpose (and the type of criminalization based on indigeneity. medication suggested by medical experts (Amato, Minozzi, & Davoli, 2011)), atypical antipsychotics were also mentioned. Harm reduction strategies currently in use Balancing the risks of drinking in groups and drinking alone Recognizing that there are harms they experience from illicit Much discussion ensued at the meetings on the risks and benefits of fi drinking, participants identi ed a number of strategies they employ to drinking alone versus drinking in groups. Drinking alone was described reduce these harms. These results are summarized in Table 2. as feasible only if a person had a private room somewhere (i.e. was not homeless), as drinking alone in public invites violence and theft: Enacting strategies to avoid withdrawal “You get the shit pounded out of you,” a participant says. There are Participants described avoiding the harms of alcohol withdrawal noises of agreement. A person drinking alone will get “jacked up” primarily through social networks in which sharing alcohol played an [robbed] because “you can’t just sit down here with a case of beer,” important role. The first of these involved sharing one’s own alcohol someone else says. He explains that people want it and will take it with others, particularly those in withdrawal, which increases the away. There’s a lot of agreement with this. likelihood alcohol would be available to the person offering should they ever need it. This was described at a town hall meeting: “‘Even if it’s While drinking alone in public carries one set of risks, drinking somebody that you don’t know,’ if they have ‘the shakes,’ you should alone in one’s room was seen as risking unintentional injuries, de- ‘share!’ The person suggesting this says that ‘what goes around, comes pression, and choking on vomit. Drinking in a group was not seen as around’”. Additionally, participants described using “chip-ins,” perfectly safe, however: participants mentioned that group members meaning pooling money to purchase a bottle of alcohol, so that alcohol who become over-intoxicated or pass out are at risk of theft and sexual could be purchased even when an individual did not have sufficient assault. As well, due to restrictions on the types of indoor drinking funds by him- or herself. This most commonly took place in the context spaces available to participants, drinking in a group almost always of drinking in a group and has important implications for controlling occurs outside, raising the risk of police attention. the pace of alcohol consumption (see below). Alternatively, several A show of hands at one meeting revealed that slightly more

Table 2 Current and proposed harm reduction strategies for illicit drinking.

Current harm reduction strategies Drinking in groups vs. drinking alone – This is a balancing act between the risks of being alone and the risks of groups; those without secure housing are more likely to choose groups Ensuring one has enough alcohol – Sharing with others and pooling money are common strategies to ensure access to alcohol, especially in case of withdrawal Limiting the amount or pace of alcohol consumption – Strategies illicit drinkers use to reduce the amount they drink include purchasing smaller volumes, drinking with friends who drink less, and mixing alcohol with non-alcoholic beverages Looking after other illicit drinkers – Particularly taking overly intoxicated people somewhere safe Pharmaceutical management of withdrawal symptoms – Some participants mentioned using physician-prescribed or street-purchased pharmaceuticals when experiencing withdrawal Proposed harm reduction strategies Safe space – A place where illicit drinkers would be protected from victimization and criminalization Managed alcohol program – Speciﬁcally a non-residential managed alcohol program with strong connections to other services such as detox and housing Peer-based services – Programs, particularly managed alcohol programs, in which illicit drinkers would be decision makers were seen as more likely to meet the community’s needs Education – Of illicit drinkers by illicit drinkers, of health professionals by illicit drinkers, and of illicit drinkers by topic experts (e.g. toxicologists)

88 A. Crabtree et al. International Journal of Drug Policy 59 (2018) 85–93 participants preferred to drink in a group. Given that certain harms are The goal of MAPs, according to participants, is to provide enough minimized and others are maximized by drinking with others, how do alcohol for people to avoid withdrawal, to function in their daily lives, participants navigate this decision? A key factor in decision-making and to be intoxicated enough to prevent them from drinking additional seemed to be participants’ desire and need to share alcohol and funds to non-beverage alcohol. The following suggestion illustrates this: obtain alcohol. That is, most groups of drinkers in which our partici- The young man suggests that they could have a logo that would pants spent time had a usual practice of sharing alcohol among group provide some clarification about the purpose of the facility. “‘Here members. This was seen as a harm reduction practice (see above), but to get fixed and not shit-faced,’” he suggests that it could say. The one that leaves an individual with little control over the pace of alcohol facilitator writes this down and people clap. consumption. Some participants, therefore, while acknowledging the potential harms of drinking alone, still preferred this strategy if they Participants cautioned, however, that maintenance levels of alcohol had the funds and private space available to do so. for them would likely be higher than some might expect. Participants expressed concern that non-drinkers would underestimate their needs Looking after other illicit drinkers (“It just won’t be strong enough”), and pointed out the need for alcohol Participants repeatedly emphasized that many of the harms of illicit dosing to be tailored to individual tolerances. drinking could be reduced by taking care of one another. Participants An area of debate among participants was whether MAPs should described taking people who are particularly intoxicated to a safer ideally involve consumption of alcohol on-site or whether it should be environment, such as a low barrier shelter (“If someone’s too drunk, provided to use elsewhere. A benefit participants saw to consuming walk them over to First United [church shelter]”). Other specific stra- alcohol on site echoed their calls for a "safe space" for alcohol con- tegies for reducing harms to others included asking after people who sumption: that is, consuming alcohol at a MAP would reduce exposure had not been seen recently and placing people in safe positions (on their to victimization and criminalization that occurs when drinking in sides, not in wheelchairs) to sleep. These suggestions reflect the limited public spaces (“This thing would keep a lot of people out of the drunk supports available to illicit drinkers; expressions of care are severely tank”). A drawback to requiring that alcohol be consumed on site was constrained in the context of their economic and social marginalization. that this was seen as restricting a person's freedom and interfering with a person's daily activities. "People deserve to have lives," as one parti- Proposed harm reduction strategies cipant put it. As well, some participants were concerned that requiring alcohol be consumed at the facility would limit the program's reach and In response to the harms they experienced and the gaps in the exclude some particularly marginalized illicit drinkers, particularly strategies they currently employed to reduce these harms, meeting those who are accustomed to drinking in local parks. Encouraging participants suggested four principal harm reduction initiatives that people using the facility to leave after consuming their alcohol and to they desired for their community: safe spaces, managed alcohol pro- come back throughout the day as necessary was seen as a compromise grams, peer-based programs, and educational programs. These results position that would balance needs for safety and freedom. are summarized in Table 2. Much discussion from participants centered on the need to have connections between managed alcohol programs and other supportive Safe space services, such as housing, counselling, and detoxification. They stressed Participants were well aware of Vancouver’s supervised injection that MAPs by themselves would not be that helpful to a person who site (Insite, a facility in which drugs can be injected under medical remained homeless and in need of medical care. They also desired supervision) and frequently suggested it as a model for how harms such immediate access to detox services so that people could begin the as violence, theft, and unintentional injury could be reduced for illicit process of safely withdrawing from alcohol whenever they were ready drinkers. As one put it, “What about, see, if we have safe injection sites (“Why is there not more detox services?”). down over there, why can’t we have our own place to drink?”. Of note, A repeated suggestion from participants was that MAPs be offered this suggestion involves a space (“designated areas”) where participants separately from supportive housing (“I don’t think you should have to could bring their own alcohol, similar to how injections at Insite involve live there” (Women’s focus group)). At the time of the meeting series, a person’s own supply of drugs. The presence of non-intoxicated per- the only MAP in Vancouver was offered through a supportive housing sonnel who “know exactly what they’re doing” was seen as a way of facility to residents only. A non-residential alternative was desired by avoiding some of the physical and emotional harms that occur when some participants for several reasons. First, living in permanent sup- drinking out of doors especially. Importantly, a supervised space for portive housing was not seen as feasible or desirable by all participants. drinking was also highlighted as a way to avoid the attention of police Some felt that the rules and restrictions these facilities imposed (in- (“That would keep us from being arrested, big time”). In keeping with cluding splitting up partners and friends) made this type of housing this, it was felt to be necessary that police support the safe space and undesirable. Others expressed concern that they could not comply with leave users of it alone both while inside and when entering or exiting. A the rules and expectations of the facility and would lose both their related issue raised at multiple meetings was the need for supervised housing and MAP access. transportation home from such a space (thus helping to reduce unin- A second reason for suggesting non-residential MAPs was that they tentional injuries and encounters with police) and securing housing for were seen as largely restricting a person's activities to a single building. those who would otherwise be consigned to the street after the facility Below, one participant who described a program in his home province: closed. [He tells the facilitator] that there is a place in Alberta that has been doing a program like that successfully for years, but that it's a pilot Managed alcohol programs project. He describes it by saying you have to live there to receive Many harms from illicit drinking, such as those acquired in accruing alcohol and says, "You get all the booze you want but you're not it or to drinking non-beverage alcohol specifically, are not reduced by leaving." simply providing a supervised space to drink. Some participants therefore suggested that free alcohol (“a free bottle”) should be pro- Especially for participants who were used to drinking in groups, the vided in conjunction with a supervised space. Methadone maintenance, restriction of locations for drinking and of people to drink with (i.e. in which methadone is provided replace other opioids, was well-known only others in the housing facility) was seen as a significant drawback to participants and provided an important model as they envisioned to residential MAPs. how managed alcohol programs might be implemented (“like heroin Third, non-residential MAPs appealed to participants because they addicts get methadone”). thought it the system most likely to lead to a non-clinical atmosphere.

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While accepting that some clinical oversight of a program might be concerns, and long-term health consequences were perceived by their necessary and desirable, participants discussed how a "drinkers' lounge" subjects as negative outcomes of alcohol use. As well, the emphasis on might be structured to make it a welcoming, friendly place (“You can harm reduction and services to meet basic needs rather than abstinence- come in, you can socialize”). Ideas included having inviting places to sit based treatment echoes Collins et al. regarding a similar population’s and socialize, showing movies, and having a quiet space to which cli- desired pathways to recovery (Collins et al., 2016). The harm reduction ents could remove themselves if necessary (rather than being asked to strategies that participants already employ support the practical sug- leave the facility if they were engaging in conflict with other clients). gestions of Grazioli et al. of ways that people who are homeless and Finally, participants suggested a non-residential managed alcohol drink alcohol can maintain their physical health, ensure their safety, program was desirable because it seemed the most likely route to a and reduce their drinking (Grazioli, Hicks, Kaese, Lenert, & Collins, peer-run facility: that is, controlled in a meaningful way by illicit 2015), and our results complement theirs by highlighting some of the drinkers themselves. barriers to implementation faced by this population. Our results also support a number of interventions for illicit drinkers that have been Peer-based services identified in the literature. The reduction of homelessness through a Participants strongly expressed the belief that control by illicit housing first model (Collins et al., 2012; Larimer et al., 2009), ideally drinkers over a MAP was both possible and desirable. Having a peer- supplemented with supportive and harm-reduction focused program- based element was seen as making the service more accessible, as the ming (Clifasefi, Collins, Torres, & Grazioli, 2016), fits well with the following comment illustrates: harms described by participants, as many of them (violence, theft, etc) are caused or compounded by lack of safe housing with space for so- “Me, myself, if I was going to a drinkers’ lounge, I’d like to see cializing. someone that I kind of knew serving peanut butter and jelly sand- Managed alcohol programs (MAPs), an intervention strongly sug- wiches.” He elaborates that there could be health workers behind gested by our participants, have been established in Canadian cities this person, but that he needs to see some people that he knows. over the past 20 years. An evaluation by Podymow et al (Podymow, Beyond simply having illicit drinkers as staff members, participants Turnbull, Coyle, Yetisir, & Wells, 2006) of one community-based MAP expressed a desire to have illicit drinker control over the manner in showed improved health outcomes, fewer emergency department visits, which services are offered. This was seen as a way to keep the services fewer police contacts, reduced on-site alcohol consumption, and im- relevant to their needs and to reach the people who need them most. proved quality of life. In 2012, a Cochrane review concluded there is not enough evidence to draw conclusions about the efficacy of MAPs Education (Muckle, Muckle, Welch, & Tugwell, 2012). To contribute to the evi- An additional harm reduction strategy suggested by participants dence base, a national evaluation of Canadian managed alcohol pro- was education. Three types of educational activities were proposed: (1) grams is underway (http://www.uvic.ca/research/centres/carbc/ by illicit drinkers, for illicit drinkers; (2) by experts, for illicit drinkers; projects/map/index.php). Early results are promising, with several and (3) by illicit drinkers, for service providers. For the first type, long- programs demonstrating reductions in alcohol related harms, police term illicit drinkers were seen as a source of valuable information about contact, and/or health service utilization (Stockwell, Pauly, Chow, how to reduce harms from drinking. Specific strategies mentioned in- Vallance, & Perkin, 2013; Vallance et al., 2016),and qualitative re- cluded recipes for mixing alcohol to promote a steady state of in- search showing that MAPSs can provide places of safety, stability and toxication, rather than over-intoxication and withdrawal, (“Mixing connectedness and act as “enabling places” for healing and self-man- drinks would be like going to school” (Steering committee meeting) and agement (Evans et al., 2015; Kidd, Kirkpatrick, & George, 2011; Pauly teaching placement of drinkers in the recovery position when over-in- et al., 2016). A related intervention, provision of a safe drop-in space toxicated to reduce the risk of choking. Education by experts was re- for alcohol consumption paired with harm reduction counselling, also quested for topics about which participants felt they lacked knowledge, has been shown to be associated with a reduction in alcohol-related such as the specificeffects of non-beverage alcohol on the body. Finally, harms among clients (Grazioli, Collins, Paroz, Graap, & Daeppen, participants suggested that education of service providers, specifically 2017). As an alternative or complement to these programs, injectable health care providers, about the needs of illicit drinkers and the barriers naltrexone to reduce binge drinking shows promise: a recent open-label they face in obtaining health care could improve the quality of services trial of injectable naltrexone and harm reduction counselling for people offered to illicit drinkers. with alcohol dependence and a history of chronic homelessness found a Participants in the meeting series identified a range of harms and decrease in alcohol cravings, use, and reported alcohol-related pro- strategies they used to reduce these harms. They also suggested several blems (Collins, Duncan et al., 2015). promising ideas for future alcohol harm reduction initiatives, including MAPs were raised by participants as a desirable harm reduction non-residential MAPs. When initial results were presented, however, strategy, although they contrasted their desire for separate supportive they cautioned that harm reduction should not be the only focus of housing and non-residential managed alcohol programs with the in- efforts to work with illicit drinkers to improve their health and well- tegrated residential MAPs described in the literature (Kidd et al., 2011; being. On-demand detoxification and low-barrier supportive housing Pauly et al., 2016; Podymow et al., 2006; Stockwell et al., 2013; were emphasized as key areas in which urgent improvements are Vallance et al., 2016). Medication to decrease heavy drinking (Collins, needed to support illicit drinkers. Duncan et al., 2015; Marlatt & Witkiewitz, 2002), as opposed to ease withdrawal, was not raised as a current or desired strategy. It is also Discussion notable that many other evidence-based alcohol harm reduction strategies are not well targeted to the poor and marginalized illicit drinkers Situating participants’ views within the evidence about alcohol harm who participated in this research, particularly programs to improve reduction safety and reduce violence at bars and drinking and driving reduction (Herring, Thom, Beccaria, Kolind, & Moskalewicz, 2010; Ritter & The harms identified by participants hold much in common with the Cameron, 2006; Stockwell, 2006). While they would likely benefit from disadvantages of alcohol use identified by homeless individuals with thiamine supplementation (Stockwell, 2006), another promising al- alcohol use disorders in a study by Collins et al. (Collins, Taylor et al., cohol harm reduction intervention, brain damage was not raised as a 2018), particularly that study’s finding that physical effects, legal harm that participants identified from illicit drinking.

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Exploring structural factors in shaping the perceived harms of illicit drinking drinkers can be viewed as an example of everyday violence that occurs along lines of gender. Meeting participants identified looking after In general, participants identified that the harms of being poor and other illicit drinkers as a current harm reduction strategy, but it is clear marginalized are of greater concern than harms specific to illicit from their other statements that internalized and reproduced everyday drinking of both beverage and non-beverage alcohol. As such, they can violence interferes with achieving this ideal. be seen as examples of how structural violence is manifest in substance During presentation of initial results to participants, however, they users’ lives, similar to those experienced by people who use illicit drugs. cautioned that although the types of harms faced by illicit drinkers hold Structural violence refers to suffering caused by political, economic, and much in common with those encountered by other people who use il- social forces external to the individual and distributed along lines of licit substances, the degree of those harms is often intensified for illicit power (Farmer, 1996). Substance use is often a response and coping drinkers, who are generally even more economically and socially strategy to difficult life circumstances such as trauma, anxiety, stress marginalized than people who primarily use illicit drugs. The visibility and abuse that is a consequence of systemic processes of colonization, of illicit drinking was also perceived to be higher, primarily because of economic processes of capitalism and policies of exclusion that dis- the characteristic breath odor occurring with alcohol use. And there are criminate on the basis of gender, sex, and race (Alexander, 2000; clearly some substance-specific harms and strategies suggested by Farmer, 2009). The difficulties in accessing health services that illicit participants: the dangers of withdrawal and the pharmaceutical stra- drinkers described mirror the difficulties people who use drugs face in tegies to manage it are unique to alcohol, and, while unintentional accessing medical care that is of adequate quality and free from dis- injuries occur in the context of substandard living conditions, their crimination (Brener, Von Hippel, Kippax, & Preacher, 2010; Livingston, likelihood is increased by alcohol's effects on the brain. Overall, it is Milne, Lan Fang, & Amari, 2012; Lloyd, 2013; Merrill, Rhodes, Deyo, important to balance identifying struggles common to many people Alan Marlatt, & Bradley, 2002; Neale, Sheard, & Tompkins, 2007; who use illicit substances and highlighting the unique harms faced by Neale, Tompkins, & Sheard, 2008; Siegal, Draus, Carlson, Falck, & illicit drinkers. Wang, 2006; Simmonds & Coomber, 2009). Harms of illicit drinking such as violence, theft, and being taken advantage of are also not Peer-based programs to reduce harm and challenge structural violence specific to people who use alcohol. Instead, they flow from lack of access to safe and dignified housing, negative relationships with police, Pauly suggests expanding our ideas of the harms addressed by harm and lack of economic opportunities. The political and economic climate reduction to include "poverty, violence, and other effects of political that interferes with illicit drinkers' access to housing, protection, and and economic disenfranchisement" (Pauly, 2008). This dovetails with health care also denies these needs to (poor and marginalized) people our findings that the harms experienced by illicit drinkers have much in who use illicit drugs, and it is therefore not surprising that many of the common with those experienced by poor and marginalized users of il- harms described by illicit drinker participants relate only loosely to the licit drugs, because political and social disenfranchisement is how many specific substance in question. of the harms they experience are enacted. The harm reduction strategies illicit drinkers employ are also re- Participants' calls for peer-based programs provide an inportant flective of their economic and social positioning. Pooling resources and insight into how MAPs could be structured to reduce immediate harms sharing alcohol as strategies to avoid withdrawal are responses to ex- (such as violence and theft) while also countering marginalization and treme economic marginalization; Bourgois and Schonberg (Bourgois & promoting mutual accountability and substance user control of services. Schonberg, 2009) describe similar strategies occurring among homeless Such an approach would complement, not preclude, meaningful en- people who use drugs in California. Drinking in groups for protection is gagement with service providers, which participants felt was particu- also a strategy that reflects the structural violence in place against illicit larly important to assist them in learning more about alcohol and how drinkers, as it highlights the lack of other options they have to ensure they might minimize harms from it. It is striking that participants their safety. And while the use of benzodiazapines to avoid withdrawal identified the potential of peer-based programs to support them in re- symptoms is relatively specific to alcohol harm reduction, that parti- cognizing and challenging their roles in reproducing the violence they cipants reported purchasing them on the street is indicative of the face. Applied thoughtfully, peer-based programs could therefore play a barriers they face in accessing medical care that they see as meeting role in challenging structural and everyday violence against illicit their needs. A corollary of this strategy also exists among people who drinkers. use drugs: opioid users on occasion turn to illicit methadone when they lack access to adequate methadone maintenance through formal med- Limitations ical channels (Harris & Rhodes, 2013). Also similar between these situations is the potential dangers of such self-management, particularly Several limitations of this study should be noted. Detailed demo- if street-purchased medications are combined with alcohol or other graphic information was not collected as it was felt this would dis- sedating substances, which further highlights the need for low-barrier courage participation by a very marginalized population. The purpose models of care where patients and health professionals can work col- of demographic information, however, is to contextualize the data laboratively to identify solutions. gathered, and we believe observation of the group over the period of Everyday violence refers to the ongoing indignities and "little data collection provided sufficient information to situate the discus- abominations" (Scheper-Hughes, 1993) that marginalized people ex- sions. The large group format of the town hall is unusual for academic perience, which they may internalize and reproduce on one another. research, in which data is often collected in groups of 6–10 participants There are common themes of everyday violence between participants’ (a legacy of market research techniques (Morgan, 1996)). Departing statements and the circumstances of people who use drugs, who are also from tradition is not itself a limitation, when done with intention: the pitted against one another through their marginalization despite their intention here was to support the participation of many people, in- desire for connection and mutual support (Bourgois & Schonberg, 2009; cluding more marginalized individuals who might not participate if Simmonds & Coomber, 2009). Reproduced everyday violence com- there was more competition for spaces. A drawback of the large format mitted by marginalized people on one another is especially important in is that a small number of participants, primarily men, tended to be the the interpretation of participants' insights about the threats of violence most vocal, and it is possible that the size of the meetings may have and theft they face and the strategy of drinking in groups to avoid this hindered the expression of unpopular ideas or discussion of sensitive harm: this helps us to understand how illicit drinkers can depend on topics. We attempted to ameliorate this by exploring some issues in groups for protection from outsiders and yet face victimization from more depth at the smaller steering committee meetings and in inter- within the group. Furthermore, sexualized violence among illicit views and focus groups, including a women-only focus group.

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A strength of this research is the action that has been taken as a perspectives on single site housing first program enhancement. Journal of Community result. The meetings for illicit drinkers continued after data collection Psychology, 44(7), 845–855. https://doi.org/10.1002/jcop.21812 John Wiley & Sons Inc. concluded. Now called the Eastside Illicit Drinkers Group for Education Collins, S. E., Jones, C. B., Hoffmann, G., Nelson, L. A., Hawes, S. M., Grazioli, V. S., et al. (EIDGE), they have been meeting on a weekly basis for several years (2016). In their own words: Content analysis of pathways to recovery among in- and are involved in a variety of initiatives, including providing support dividuals with the lived experience of homelessness and alcohol use disorders. The ’ International Journal on Drug Policy, 27,89–96. https://doi.org/10.1016/j.drugpo. and education to members, developing a drinkers rights card, ad- 2015.08.003. vocating for the establishment of a non-residential MAP, and partici- Collins, S. E., Clifasefi, S. L., Dana, E. A., Andrasik, M. P., Stahl, N., Kirouac, M., Welbaum, pating in a national study of MAPs. EIDGE members have also joined C., King, M., & Malone, D. K. (2012). Where harm reduction meets housing first: ’ fi several external committees of organizations such as Vancouver Native Exploring alcohol s role in a project-based housing rst setting. The International Journal on Drug Policy, 23(2), 111–119. https://doi.org/10.1016/j.drugpo.2011.07. Health Society and the City of Vancouver to advocate for policy changes 010 Netherlands. to reduce the stigmatization of illicit drinkers. Collins, S. E., Clifasefi, S. L., Stanton, J., The Leap Advisory Board, Straits, K. J. E., Gil- kashiwabara, E., et al. (2018). Community-based participatory research (CBPR): Towards equitable involvement of community in psychology research. The American Conclusion Psychologist, (January), 1–17. https://doi.org/10.1037/amp0000167. Collins, S. E., Duncan, M. H., Smart, B. F., Saxon, A. J., Malone, D. K., Ron Jackson, T., Participants perceived the chief harms of illicit drinking to be un- et al. (2015). Extended-release naltrexone and harm reduction counseling for chronically homeless people with alcohol dependence. Substance Abuse, 36(1), 21–33. intentional injury; harms to physical health; withdrawal; violence, https://doi.org/10.1080/08897077.2014.904838 United States. theft, and being taken advantage of; harms to mental health; reduced Collins, S. E., Grazioli, V. S., Torres, N. I., Taylor, E. M., Jones, C. B., Hoffman, G. E., et al. access to services; and criminalization. Current harm reduction strate- (2015). Qualitatively and quantitatively evaluating harm-reduction goal setting fi among chronically homeless individuals with alcohol dependence. Addictive gies involved balancing the risks and bene ts of drinking in groups and Behaviors, 45, 184–190. https://doi.org/10.1016/j.addbeh.2015.02.001 Elsevier Ltd. adopting techniques to avoid withdrawal. Potential future harm re- Collins, S. E., Taylor, E., Jones, C., Haelsig, L., Grazioli, V. S., Mackelprang, J. L., et al. duction initiatives proposed by participants included offering managed (2018). Content analysis of advantages and disadvantages of drinking among individuals with the lived experience of homelessness and alcohol use disorders. alcohol programs in a non-residential format and expanding peer-based Substance Use & Misuse, 53(1), 16–25. https://doi.org/10.1080/10826084.2017. supports. 1322406. CBPR holds promise as an important mechanism to explore the Crabtree, A. (2015). It’s powerful to gather: A community-driven study of drug users’ and illicit ’ needs and experiences of illicit drinkers and to co-create inclusionary drinkers priorities for harm reduction and health promotion in British Columbia, canada. University of British Columbia. programming (Collins, Clifasefi et al., 2018). Harm reduction practi- Egbert, A. M., Reed, J. S., Powell, B. J., Liskow, B. I., & Liese, B. S. (1985). Alcoholics who tioners may use this research in several ways. By better understanding drink mouthwash: The Spectrum of nonbeverage alcohol use. Journal of Studies on – the perceived harms associated with illicit drinking of beverage and Alcohol, 46(6), 473 481 United States. Erickson, R. A., Stockwell, T., Pauly, B., Chow, C., Roemer, A., Zhao, J., Vallance, K., & non-beverage alcohol, harm reduction initiatives can be better tailored Wettlaufer, A. (2018). How do people with homelessness and alcohol dependence to meet the priorities of affected communities. Moreover, by building cope when alcohol is unaffordable? A comparison of residents of canadian managed on the strategies already in use and those suggested by our participants, alcohol programs and locally recruited controls. Drug and Alcohol Review(January), https://doi.org/10.1111/dar.12649 John Wiley & Sons Australia, Ltd. with attention to the systemic constraints faced by people who engage Evans, J., Semogas, D., Smalley, J. G., & Lohfeld, L. (2015). This place has given me a in illicit drinking, we can create opportunities to improve the health reason to care’: Understanding ‘Managed alcohol programs’ as enabling places in and well-being of this vulnerable population. Canada. Health & Place, 33, 118–124. https://doi.org/10.1016/j.healthplace.2015. 02.011. Farmer, P. (1996). Women, poverty, and AIDS. Women, poverty, and AIDS: Sex, drugs and Funding structural violence, edited by Paul Farmer, Margaret Connors, and Janie Simmons. Series in health and social justice. Monroe, Maine: Common Courage Press. fi Farmer, P. (2009). On suffering and structural violence: A view from below. Daedalus, This research did not receive any speci c grant from funding 125(1), 11–28. https://doi.org/10.1353/rac.0.0025. Social Suffering (Winter, 1996), agencies in the public, commercial, or not-for-profit sectors. AC was pp. 261–283 https://www.jstor.org/stable/20027362?seq=1#page_scan_tab_ supported by a CIHR-UBC MD/PhD award. VB is supported by the contents. Canada Research Chair program and the Michael Smith Foundation for Grazioli, V. S., Collins, S. E., Paroz, S., Graap, C., & Daeppen, J. B. (2017). Six-month outcomes among socially marginalized alcohol and drug users attending a drop-in Health Research Scholar Award program. center allowing alcohol consumption. The International Journal on Drug Policy, 41, 65–73. https://doi.org/10.1016/j.drugpo.2016.12.015 Elsevier B.V. Conflicts of interest Grazioli, V. S., Hicks, J., Kaese, G., Lenert, J., & Collins, S. E. 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