Advocating for Alcohol Harm Reduction Policy in Regina Saskatchewan
Understanding Chronic Addiction and Responsible Public Health Practices
Nicholas Olson – Housing Support Worker – Carmichael Outreach
Background
Severe alcohol dependence is common in individuals experiencing or at risk of homelessness in Regina, Saskatchewan. For individuals who have experienced violent or psychological trauma, alcohol is often used as a way to cope with the mental and physical pain that comes when this trauma is left untreated. Aboriginal populations overrepresent those experiencing homelessness in Saskatchewan and Canada, and many of the traumas they have experienced are directly related to unstable family settings caused by the lasting effects of residential and public schools and other programs created under colonial policy. Homeless populations have a high rate of alcohol dependence and for this reason face significant barriers to stable and safe housing, and are often unable to access shelter systems. In Regina, the few housing support programs that are willing to work with individuals with severe alcohol dependence are finding that the Housing First model is not always enough to keep individuals housed, healthy, and stable. Alcohol harm reduction is the next clear step to support Regina’s most vulnerable.
What is Alcohol Harm Reduction?
Alcohol Harm Reduction aims to reduce the harms associated with the use of alcoholic substances in people that are unable or do not desire to stop (International Harm Reduction Association). Harm reduction functions under the idea that all individuals deserve the dignity and respect to be treated in a manner that best supports them as a whole person, not just as an addict, and to be treated medically in a way that is understanding, empowering, and compassionate to their specific needs as a person experiencing an alcohol addiction. For many, the traditional abstinence model is unrealistic and does not take into account the desires of the individual who may not want, or be able, to discontinue use. Alcohol Harm Reduction aims to support the individual to live a healthy life regardless of whether they intend to become abstinent. This may be done by assisting them to consume healthy forms and volumes of alcohol through different programs tailored to the individual, supporting them to be safe during and after consumption, and working with them to maintain good health and, if desired by the individual, to reduce their alcohol consumption overall.
Alcohol Treatment
The development of Alcohol Harm Reduction through a Managed Alcohol Program (MAP), Alcohol Swap Program, Beer Co-op, and/or Prescription Alcohol is the best practice in supporting the addictions of a marginalized population in Regina primarily between the ages of 30-55. Since individuals experiencing or at risk of homelessness often have fixed or no incomes, beverage alcohol is unaffordable due to the high cost of controlled substances in Saskatchewan. This, coupled with the marginalization of individuals experiencing poverty, addiction, and mental health, has made beverage alcohol even more inaccessible because these individuals are often not permitted to enter establishments that sell beverage alcohol, and in many cases are unable to even access basic health and emergency services. Non-beverage alcohol (NBA) purchased in grocery stores, convenience stores, and pharmacies including mouthwash, hand sanitizer, hairspray, and rubbing alcohol is being consumed in large quantities because of its potency and availability.
Non-beverage alcohol can be any form of alcohol that is not fit for human consumption. Ethanol, or ethyl alcohol, is found in beverage alcohol and is safe to consume in moderate amounts. Denatured ethanol, or alcohol denat, found in products such as mouthwash, hairspray, and some hand sanitizers, is ethanol with chemical product added to make the alcohol unfit for human consumption. The chemical additives also allow the producer to avoid the product being designated as a controlled substance. Methanol, or methyl alcohol is toxic and has caused death when consumed through hand sanitizer (CBC). Isopropyl alcohol, found in rubbing alcohol and some hand sanitizers, is toxic if ingested as well. While it is often stated that the extremely high alcohol content in non-beverage alcohol is the most toxic ingredient, with sustained use and high dosage, serious risks are present from the other toxic ingredients in each solution. Hairspray, for example, can have long term effects such as internal bleeding, kidney and liver damage, respiratory problems and death (CBC). Each receptacle of non-beverage alcohol clearly warns of the risks of consumption and strongly advises to contact poison control if consumed in any volume (Pauly 10).
Alcohol Contents and Types
(costs listed are based on saskliquor.com)
(approximate calculations were done at http://www.cleavebooks.co.uk/scol/ccalcoh4.htm and should not be used as a substitute for medical advice)
1 The LCBO is recalling four brands of sherry (LONDON XXX SHERRY INCLUDED) that tested positive for a potential carcinogen. “This is not like E. coli or botulism where you’re acutely affected. To be affected by something like this, you would have to consume it for a long time for many years, so there is no risk at all,” he said. “It’s very, extremely difficult for anyone to get cancer from this type of chemical, unless you’re consuming it on [a] daily basis and you’re drinking large amounts of it.” (http://www.cbc.ca/news/lcbo-recalls-sherry-for-carcinogen-risk-1.619474)
(costs listed based on retail prices at given locations)
(approximate calculations were done at http://www.cleavebooks.co.uk/scol/ccalcoh4.htm and should not be used as a substitute for medical advice)
2 Medicinal Ingredients: Eucalyptol (Eucalyptus Clobulus-Leaf) 0.092%W/V, Menthol 0.042%W/V, Methyl Calicylate 0.060%W/V, Thymol 0,064%W/V
Notice: If more than used for rinsing is accidentally swallowed, get medical help or contact a poison control centre right away.
3 Ingredients: Aqua, Ethyl Alcohol, Denatonium Benzoate, Camphor
Notice: For External Use Only, Poison, Inflammable. If swallowed, do not induce vomiting. Call a physician immediately. If patient is unconscious, give them air. Danger: Harmful or fatal if swallowed.
4 Ingredients: Alcohol denat, water (aqua), acrylates copolymer, aminomenthyl propanol, fragrance, octylacrylamide/acrylates/butylaminoethyl methacrylate copolymer, PEG-12 dimethicone, tritely citrate, hydrolyzed silk, hydrolyzed keratin. Alcohol content TBD but could be between 50-70%.
5 Medicinal Ingredient: 62% Ethyl Alcohol. Non-Medicinal Ingredients: Aqua, polysorbate 20, carbomer, aminomethyl propanol, glycerin, tocopheryl acetate (vitamin E acetate), denatonium benzoate.
Warnings: For external use only, do not ingest. In case of accidental ingestion contact your physician or a Poison Control Centre.
Limiting availability of these products has proven to be an ineffective means of managing the consumption of the toxic forms of alcohol, as many or all of those accustomed to drinking non-beverage alcohol regularly travel to the suburban areas of the city to purchase from larger box stores and centres where they haven’t yet been banned. When individuals don’t have to spend their energy finding their next source of alcohol and managing their withdrawal symptoms, it allows them to begin to spend that energy on developing life skills, focusing on housing, setting goals, and working on improving their overall health.
The only responsible, healthy, and compassionate way to support those who consistently consume non-beverage alcohol is to understand that in these cases abstinence is potentially a dangerous, unhealthy, and unrealistic treatment, and that reducing the harm they are causing to themselves means assisting them with the consumption of safe forms of alcohol. This can be done with Managed Alcohol Programs where individuals are given a regulated amount of alcohol at regular intervals during the day to help them deal with withdrawal symptoms and feel normal and well, Alcohol Swap Programs where individuals not necessarily receiving comprehensive housing supports can swap out certain quantities of non-beverage alcohol for beverage alcohol, a Beer Co-op where individuals are trained in proper and safe ways to brew their own alcohol for safe consumption, and Prescription Alcohol, which like a MAP, would regulate volumes and quantities based on medical assessments and administered in similar harm reduction models such as methadone. These programs, specifically MAPs, have been implemented across Canada and the US to reduce both the harms inflicted upon alcohol-dependent individuals, and the subsequent costs upon the health and justice systems.
While other potential treatments for alcohol dependence include medications such as benzodiazepines, which include diazepam, or Valium, the lifestyle and the desires of the patient must be taken into account, and for many, discontinuing alcohol use is not desired and is not a possible solution. Using diazepam as a treatment for alcohol withdrawals does not respond to the fact that many individuals would rather not discontinue alcohol use, and even with regulated and prescribed diazepam treatment, many individuals will continue to drink different forms of alcohol when it is presented to them. This would lead to an increased risk of addiction to diazepam, and a “high risk of overdose, loss of consciousness, coma, and death.”(American Addiction Centers) Benzodiazepines are also used as a short term treatment option, with only 1-2 percent of adults continuing treatment for 12 months or longer, and carry substantially higher risks of dependence and misuse in populations with a history of substance abuse (Longo). When supporting an individual living in community, monitoring all the substances that enter the home is impossible, therefore it is best to prescribe that which reduces the most risk and harm to the individual.
The harm reduction framework aims to support individuals to make healthy choices and this begins with offering assistance in managing quantities of beverage alcohol, and accessing beverage alcohol in a cost-effective manner, while at the same time being careful not to perpetuate the stigma of using non-beverage alcohols that is often present in community supports and medical services. Many populations are stigmatized even within social circles for drinking non-beverage alcohol, and this stigma is magnified in many professional health settings. Following the harm reduction framework means focusing on the needs and desires of the individual, not reducing addictions to a moral or ethical choice, and understanding the barriers that have led to less-safe alcohol consumption. It is important that harm reduction treatments are in place and practiced by health professionals, as professional knowledge is needed to create public health policy that can be safely and confidently administered by community entities.
Understanding
Each individual receiving alcohol harm reduction support will consume a different variety, style, and amount of beverage and non-beverage alcohol each day. It is important to understand what the approximate quantities of non-beverage alcohol are to ensure that the proper volume of beverage alcohol is supplied to each individual. Having a set schedule of beverage alcohol consumption would ensure that a moderated amount of alcohol is consumed, which, ideally could be lessened over time based on the desires of the individual. Clinical medical advisement through a MAP or prescription may be required to ensure that the individual is getting a safe dosage, and that an understanding of the individual’s history with addiction and their personal and traumatic history is taken into consideration. In an evaluation of a MAP in Vancouver, BC, alcohol consumption did not necessarily decline in six months for all of the participants, however the consumption of non-beverage alcohol did decline, and most participants reported improvements in mental health, social connectedness, and general well-being, and consumed alcohol in a safer setting with less harms that come from drinking large quantities at one time (Stockwell 6,7).
Below are some comparisons of alcohol contents. Though it is clear that the ethanol present in beverage alcohol is different than the types of alcohol present in non-beverage alcohol (denatured alcohol/ethanol, isopropyl alcohol) and the “high” achieved through using non-beverage alcohol would therefore be different, the comparisons below are a guideline for quantities consumed knowing that the denatured alcohol and isopropyl alcohol have added chemicals that are toxic for human consumption.
For example, as shown in Table 2.1, one litre (1L) of Antiseptic Mouthwash has an alcohol content of 270mL, which is equivalent to 12.5 cans (4.4L), of strong percentage beer, or nearly two bottles of a strong sherry wine. Similarly, as shown in Table 2.2, it takes nearly 10 times as much strong beer to equal the same alcohol content of 449mL that is obtained through 725mL of Hand Sanitzer Gel. While the point of alcohol harm reduction isn’t necessarily to meet the alcohol content that an individual would consume drinking non-beverage alcohol, it is important for service providers and community supports to understand just how much beverage alcohol it takes to help cope with withdrawal symptoms.
Conclusions
It is clear both to the uneducated outsider and to the affected individual that the consumption of non-beverage alcohol is extremely damaging to one’s physical and mental health. By offering support to individuals in their addiction through alcohol harm reduction programs, the dignity of these individuals is upheld as they are receiving compassionate medical treatment that views them as a whole person. Through these programs, these individuals would be able to access supports that are often only accessible to less-stigmatized populations, including detoxification programs that in Regina are inaccessible to many with reduced mobility and high physical needs.
Access to inexpensive, clinically regulated and adequately strong forms of beverage alcohol is key to the physical and mental health and well-being of the individual. Regulated quantities of alcohol must be customized to each individual based on their own personal symptoms and histories. While having professional medical advice involved is clearly the best practice, disallowing access to safe forms of alcohol because of lack of confirmed policy is irresponsible and lacks the compassion necessary in the human services sector and in a responsible community.
Policy driven by the Regina Qu’Appelle Health Region, monitored and planned by medical professionals, delivered by community organizations, and tailored to the needs of the individual are imperative to the success of an alcohol harm reduction program, and the timely nature of its implementation is extremely important to ensure the safety, health, and survival of a large population of vulnerable people. A responsible community and health region would not allow the continued consumption of controlled poison when clear, simple, and practical alternatives exist.
Sources
Pauly, B., Stockwell, T., Chow, C., Gray, E., Krysowaty, B., Vallance, K., Zhao, J. & Perkin, K. (2013) Towards alcohol harm reduction: Preliminary results from an evaluation of a Canadian managed alcohol program. Victoria, BC: Centre for Addictions Research of British Columbia.
Carnahan RM, Kutscher EC, Obritsch MD, Rasmussen LD. Acute ethanol
intoxication after consumption of hairspray. Pharmacotherapy. 2005 Nov;25(11):1646-50. PubMed PMID: 16232026.
Longo LP, Johnson B., Addiction: Part I. Benzodiazepines–side effects, abuse risk and alternatives. Am Fam Physician. 2000 Apr 1;61(7):2121-8. Review.,
Stockwell, T., Pauly, B., Chow, C., Vallance, K., Perkin, K. (2013). Evaluation of a managed alcohol program in Vancouver, BC: Early findings and reflections on alcohol harm reduction. CARBC Bulletin #9, Victoria, British Columbia: University of Victoria
Balls of Rice 