To limit potentially life-threatening effects of alcohol withdrawal, including seizures, hallucinations, and injuries, DESC (formerly Downtown Emergency Service Center) in Seattle, Washington decided to implement alcohol management as a harm reduction strategy.

DESC serves “formally homeless men and women with chronic alcohol addiction.” Alcohol management is offered to eligible residents who are at risk of harm during periods of alcohol withdrawal or other dangerous behavior associated with their alcohol use. Not without controversy in the local community, DESC is committed to improving the quality of life for program participants, increasing their housing stability, and reducing the harm of alcohol withdrawal. Currently, about 16 out of 75 residents at the supportive housing facility participate in alcohol management, indicating it's not an intervention suited for everybody.

At the 2014 Housing First Partners Conference in Chicago, DESC explained how alcohol management works.

Using motivational interviewing, staff approach potential program candidates to discuss the client's goals regarding their drinking. Staff ask questions, such as: Do you drink more in the morning to stave off withdrawals? How many drinks do you need to avoid feeling sick? How much time passes between drinks before you begin to go into withdrawal? What is your goal? Do you want to cut back? Based on the client's responses, an individual alcohol management plan is developed and signed by the participant and DESC.

The plan details the dosage of alcohol to be administered by staff at certain intervals. For example, the plan may detail two beers at 8:00am, 12:00pm, 4:00pm, and 8:00pm every day. At the agreed-upon times, the alcohol management participant receives the agreed-upon amount of beer.

To implement alcohol management, a number of processes and infrastructure and training need to be developed or be in place. Clients need to have a steady income source and a payee. Program funds are not used to purchase alcohol, and both the participant and their payee agree to provide needed funds according to the alcohol-purchasing schedule. Purchasing, storing, and dispensing alcohol dosages also require a number of processes and safeguards that DESC has developed over the last seven years, including locked cabinets, staff training, and dosage tracking charts.

DESC collects anecdotal data on outcomes from the alcohol management program and reports the following:

1. Increases stability. The chaos of binging and withdrawing occurs less often and provides participants with a sense of stability and control they have not experienced in a long time. This increased stability is often associated with the development of new goals, including changing long-standing drinking patterns.
2. Allows for intervention in case of alcohol withdrawal. With dosage tracking documentation sheets (that is, if a participant misses his/her dosage for 24 hours) staff check to be sure that the individual is not experiencing harmful effects due to withdrawal.
3. Fosters engagement. Regular conversations that increase awareness and lead to goal-setting allow engagement around alcohol use to be a central part of ongoing treatment planning.
4. Slows health decline. Alcohol management is not a magic bullet, less intoxication may mean more engagement with health providers to address chronic and acute health needs.
5. Likelihood of a decrease in alcohol use over time for some participants. While often not the initial goal, a number of residents participating in alcohol management have cut back or even stopped drinking altogether.
6. Risk of loss of independence. Some participants become dependent on staff through structured alcohol dosage. DESC recognizes that loss of independence is not necessarily a positive outcome. However, the same participants may also rediscover abilities to better integrate with community members or service providers by gaining stability through alcohol management.

DESC staff discussed the need for research to determine if Alcohol Management results in better health outcomes such as improved safety, including fewer falls and reduction of instances of brain injury, and less victimization.

Find more information on the DESC website or contact Noah Fay at nfay@desc.org or Hector Herrera at hherrera@desc.org.

This article was originally published as Voices from the Field blog post to highlight the theme of Alcohol Awareness. Find the latest SAMHSA Blog posts about behavioral health and homelessness.

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