Essential purchases

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Buying alcohol for people with severe dependence during lockdown in Bristol has been a lifesaver, says Rachel Ayres.

Read it in DDN Magazine

On 26 March 2020 our city streets changed dramatically. Shops shut overnight, people went home and the world retreated. Bristol’s outreach workers became concerned at the speed with which vulnerably housed or homeless people with hazardous levels of alcohol consumption were catapulted into withdrawal, and unable to meet their drinking needs in the usual ways – nowhere to beg, shop or shoplift. As services retreated, retail outlets vanished and social distancing was enforced, people were left high and dry.

In Bristol, the government’s Everyone In scheme saw 427 people moved into emergency accommodation. Needs assessments indicated 35 requiring immediate alcohol treatment, 115 needing drug treatment and 24 with concurrent drug and alcohol dependency, and by April outpatient and inpatient detox facilities had closed, and GP appointments dried up. Dr Mike Taylor from Bristol’s Homeless Health Service and Dr Ben Watson from the ROADS alcohol and drug treatment service agreed that medically assisted detox within the new accommodations could not be managed safely – elective alcohol detoxification would not be possible for the foreseeable future and emergency admissions for delirium tremens would increase.

In an attempt to reduce the inevitable impacts, a simple alcohol harm reduction information sheet produced by the South London and Maudsley NHS Foundation Trust was adapted and distributed across the city via all available channels. However, severely dependent people remained chronically unwell, and some outreach workers confided to buying alcohol in small quantities as a life-preserving intervention. Something had to change. A donation of £5,000 to Bristol Drugs Project and a decision was made to provide the essential items needed to enable ‘at risk’ individuals to follow the harm reduction advice – to not stop drinking.

Two experienced outreach workers led the Essential Items Project – Darlene Wheeler from the Bristol Street Intervention Service (SIS) and Nicky Auguste, diverse communities link worker from BDP. The idea was to identify the highest risk guests from the Everyone In accommodation, and provide the alcohol needed to prevent precipitous withdrawals during lockdown.

Something more surprising emerged, however – a small cohort of people whose severe dependence on alcohol had previously been a barrier to secure accommodation found themselves with a safe place to live, round-the-clock support, food, and their alcohol needs met. Strong relationships with project workers and hostel staff, and reliable supplies of alcohol fostered autonomy and a desire for change, and the unexpected outcome was successful alcohol detox for 12-13 project participants.

The principles of the project were to buy people’s alcohol of choice and to use person-centred and trauma-informed approaches and the usual harm reduction tools to promote stable drinking and support safe reductions if requested. With clinical support from ROADS alcohol specialist Dr Janine Hale-Brown, Darlene and Nicky planned stabilisation regimes for hotel guests who were drinking 50-plus units per day. Darlene’s caseload included people previously known to her from street outreach work and Nicky’s caseload remained within his diverse communities remit, supporting people from Poland, Lithuania, and Italy, four of whom required a translator.

All the work was face-to-face and mainly outdoors – on walks and in parks – and often opportunistic. Participants completed alcohol diaries and devised SMART goals to map reductions. ‘Pros and cons of using’ and ‘delay, distract and decide’ ITEP maps kept focus and built refusal techniques, while participants recognised their opportunity for change and wanted to detox.

outreach workersWhere possible, alcohol was stored at the accommodation, date-labelled and available when requested. Prompt supervisory responses from clinical leads kept detoxes safe and on track and Darlene and Nicky worked flexibly, often meeting people several times a week. They provided an individualised and self-directed approach to reductions, pausing when people felt the need, speeding up during periods of confidence.

There were real challenges. Purchasing large amounts of the required brand of alcohol week after week required tenacity as shops were often shut and purchases sometimes rationed.

Some innovative provision of alcohol was required – James was drinking 12 litres of 5 per cent cider per day, and he couldn’t drink enough volume to reduce tremors when Nicky met him. By swapping to an alternative brand at 8.2 per cent he halved his fluid intake and could manage his withdrawal symptoms, fully engage with support and start a planned reduction.

Conversely, by the time Ivor had reduced to six cans of 7.5 per cent he was finding the reduced volume difficult – step one was to switch to cans containing 5 per cent alcohol and then to slowly increase the amount of water and soft drinks as the alcohol volume came down. Safety, security and a reduction in alcohol use also gave people space to resolve other barriers to recovery. One 28-year-old man discovered he had settled status and recourse to public funds. With housing benefit in place, onward referral for housing was made and he is now abstinent with his own tenancy.

Despite the challenges, outcomes were impressive. Twelve to 13 detoxed completely – eight of these finished with a brief chlodiazepoxide prescription from clinical leads, two went on to an inpatient detox and two reduced slowly without medication. One person withdrew from the project.

The cost of the project was £8,300. Keyworker time was estimated at £3,300 plus the essential items budget, resulting in a spend of £638 per person – specialist clinical supervision and detox costs are not included here. Each person received an average of 17 separate visits totalling 12.5 hours of harm reduction interventions, with the workers’ involvement with individuals ranging from four to 13 weeks, depending on the speed of alcohol reductions.

The Essential Items Project delivered life-saving harm reduction. It also offered an alternative to people with multiple previous attempts of medically assisted detoxification.

While the long-term outcomes for all of this small group are not known, Nicky met Jan for a ‘reunion’ in February 2021. Six months after detoxing he was still abstinent, attending Polish AA twice weekly and living in a shared house. Jan had been alcohol dependent for more than 20 years, and reflecting on his detox and subsequent abstinence he said, ‘I tried detox many times on my own, like Sisyphus, rolling the stone up the mountain. I was so sick at the hotel that staff helped me drink to stop me dying. Everyone was looking out for me and helping me control my drinking, and everyone was so friendly. Now I’m happy, I feel my power back. I still have good and bad thoughts in my head. I go to Polish AA, I have a room in a friendly house, I have my papers. I am alive.’

Nicky felt the project allowed him to work at Jan’s pace – ‘I had time and resources to work intensively with Jan, to get to know him and build trust,’ he said. ‘I appreciated his commitment and rock-solid desire to detox, through all the ups and downs. In addition to providing his alcohol and working out a reduction plan together we found English classes, and Polish AA.’

Asked how easy it was to buy the vast quantities of alcohol needed for thirteen project participants on a daily basis, at the height of lockdown Darlene and Nicky both laughed – ‘it was a challenge, lots of hunting, but we got it down to a fine art’. But when it came to job satisfaction, they both feel this was a bold initiative, high on reward for those they supported and good to feel effective as workers during such a difficult time.