Wine-ing the winos

A friend sent me a link to a story on CNN on a study recently published in the Canadian Medical Association Journal entiled "Shelter-based managed alcohol administrion to chronically homeless people addicted to alcohol". From the abstract:

Background: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle.

My friend commented that it was likely to be controversial. My response was that so is methadone treatment, but I know first hand* that for some people methadone is an effective means of breaking a narcotic addiction. Like the Managed Alcohol Project, methadone works as a control on an addiction and most (possibly all, but I try not to back myself into corners) methadone treatment centers are based on a harm reduction philosophy. But I'm digressing..

Or maybe not. See, methadone has long been established as an effective treatment for opiate addiction, but despite a 30-year history of rigorous testing, it remains controversial because many people see it as simply the substitution of one drug for another. And while that's technically true, the purpose of substituting methadone for, say, heroin is that methadone eliminates the opiate high and reduces the effects of chemical withdrawl. Additionally, the production of methadone is controlled (there may be a black market for it, but I can't imagine why when heroin and cocaine would likely be cheaper and methadone, for those in approved programs, is actually legal and, well, doesn't produce the effects for which most users take opiates) so those using it have to report somewhere - usually a social service agency - on a daily basis to get their dose. This means they have to walk through the door, which also means they can receive other types of social service assistance while they're trying to break their drug addiction.

The MAP study follows this model fairly closely, except that it focuses on chronic alcoholism in a homeless population instead of opiate addicts. But it's still based on the idea of having to come in and get your dose, and oh, while you're here, let's find out if we can help you with anything else, like that cough that might become pneumonia otherwise, or your insulin shot, or even just let you thaw your fingers and take a nap in the heat for a little while.

So great! Proof of concept, all good.

But MAP gave alcoholics alcohol. Oops.

It would never fly in America. (Okay, so maybe *never* is too strong.. but not likely ever in my lifetime.) First, it's anathema to the War on Drugs(tm) to facilitate an addict getting their drug of choice. Methadone escapes this criticism because it doesn't result in the opiate high, so you're not giving an addict the thing that got her addicted to begin with. In a country with a still-not-controlled HIV pandemic spread in no small part through contaminated needles, we can't even get safe needle exchange programs established, and that's not even giving addicts their drugs, just a safe(r) way to use them so they don't contract a fatal disease. There's no way the moralists in Washington would ever agree to give alcoholics alcohol just because it might save their lives.

Second, that whole shelter-based idea.. yeah. As much as we American talk the talk - the idea of homeless shelters is great and necessary and of course people need shelters to help them get back on their feet - we don't really walk the walk - as long as they're not in *my* neighborhood because *those* people are dirty/criminals/depraved/deserve to be homeless/(and let's not forget the ones no one ever admits to) minority/foreigners. And then there's the whole too-much-demand issue in the shelters that do exist. You know, the one that results in shelters kicking people out after 30 days and tells them not to come back for a month. There's also that fear issue - the one that says that male children over the age of 12 can't go with their mothers to many domestic violence shelters. Oh, and there are also those little rules about how you can't stay at the shelter during the day - because you know, you should be out getting a job so you can afford to pay rent and for food and, don't forget, childcare for your three children so you can .. keep a job.. uh, yeah. When was the last time you spent consecutive 12 hour days outside with three kids and no money (so no stopping in at a cafe to sit down for a few minutes over a cup of cocoa) in the northern United States in January..?

There is a possibility, though, that the spectres of hospital crowding and increased demand on emergency departments by uninsured patients unable to access preventative care, might win a few votes over. But in order for the savings from reduced medical visits to really have an impact, a much more comprehensive social service delivery mechanism needs to be created and integrated with our health care system. And that - guess what - costs money. Not a huge amount, but enough that in the era of increasing dependency on insurance payments, hospitals are unlikely to take the risk that the dollar spent will result in a six bits saved.

So, while I applaud the research team for braving the courts of public opinion (and ignore for the moment that they're in Canada, with state-run health care, which has a whole different modus operandi), I can't help but let the inner cynic rage a bit on the pointlessness of it all.

(I'll spare you all, at least for the moment, my rant about how broken the American health care system is and how exceedingly large the holes in the so-called "safety net" are. Herds-of-elephants large. Really. Herds.)

*Before anyone gets carried away, let me explain *how* I know this first hand. My AM is in Social Service Administration (a longer and somewhat fancier name for "social work") and my first year internship was with the Chicago office of the United States Probation Office. My mentor was an amazing woman who worked exclusively with dual diagnosis** offenders. As part of my internship, I worked with a small handful of her offenders, including two who had heroin addictions. For one of them, methadone worked - he was able to stick to the schedule and go through the drill to come clean throughout the course of his probation. For another, it didn't. She often wasn't able to get transportation to the clinic to get her doses, which was the first step in a spiral that resulted in her continued violation of the terms of her probation as she sought out heroin to satisfy her cravings instead. Methadone is not for every addict, but for those with sufficient resources and support, it can work.

**Dual diagnosis means that the person has both a mental health diagnosis and a substance abuse history.