Managed Alcohol Programs

Episode 5: Harm Reduction for Alcohol Use Disorder: Managed Alcohol Programs

Featuring:
Tanya Majumder, MD, MS 
Physician with the San Francisco Department of Public Health

Alice Moughamian, RN, CNS
Nurse Manager with the San Francisco Department of Public Health

Hosted by:
Soraya Azari, MD

In this episode, we present the San Francisco Department of Public Health’s Managed Alcohol Program (MAP), the first of its kind in the country. Managed alcohol programs offer the opportunity to improve the physical, mental, legal, and social health of patients with alcohol use disorder using harm reduction strategies. Guests discuss the theory behind MAP, the history of how the San Francisco program came to be, the ethical dilemmas that arise from this kind of work, and hopeful success stories. While research suggests that abstinence-based programs are not necessary for all individuals with alcohol use disorder--harm reduction strategies for alcohol use disorder have yet to gain prominence as treatment options. 

Find us online at amersa.org, and see our tweets at x.com/AMERSA_tweets.

Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Learn more about PCSS-MOUD at pcssnow.org.

Episode Transcript

Kinna Thakarar (00:13):
I'm Kinna Thakarar and welcome to the
podcast series, Harm Reduction,Compassionate Care for People
Who Use Drugs.
Harm Reduction is a socialjustice movement started by and
for people who use drugs, andit's a philosophy of care and
practical set of strategies tooptimize people's health,
safety, and rights.
We want to acknowledge and honorthe long history of street

(00:33):
medicine and healthcaredeveloped by people with lived
and living experience to keepone another alive and safe
through community care.
Whether you're a seasoned harmto the concept, we're glad
you're here and hope you'lllearn something new and are
curious to explore seeingpatient care through a harm
reduction lens.
This podcast series is broughtto you by the Providers Clinical
Support System, Medications forOpioid Use Disorder Project, and

(00:56):
AMERSA.
This week, we welcome Dr.
Soraya Azari in conversationwith Dr.
Tania Majumder and AliceMogamian to discuss Harm
Reduction for Alcohol UseDisorder, the managed alcohol
program.
Our host, Soraya Azari, MD, isan internist and addiction
medicine doctor based in SanFrancisco.
She currently works for the SanFrancisco Department of Public
Health as a primary care doctorand addiction medicine

(01:18):
specialist.
She is a volunteer professor atUCSF and assists with the
training of addiction medicinefellows.
She is interested in people withsubstance use disorders and
chronic pain, medicalmorbidities related to substance
use and collaboration acrossspecialties, and graduate
medical education.
Tanya Majumder is a primary carephysician with the SF DPH whole
person integrated care, streetmedicine, shelter health, and

(01:41):
urgent care, and the leadphysician for the WPIC managed
alcohol program and SoberingCenter.
She completed medical school andher master's in health and
medical sciences at the jointmedical program between Berkeley
and UCSF before attendingresidency in internal medicine
primary care at the Yale primarycare program.
She's greatly enjoyed being partof the whole person integrated

(02:02):
team for the past four and ahalf years.
Alice Mugamian serves as thenurse manager of the managed
alcohol program at the SanFrancisco Sobering Center for
the San Francisco Department ofHealth.
In addition to this role, shewas nurse manager and the
program director of the medicalrespite program, as well as
nursing services in permanentsupportive housing before
devoting full time to managedalcohol and sobering.

(02:23):
Alice has also served as a chairfor the National Healthcare for
the Homeless Council's RespiteCare Providers Network and
helped develop nationalstandards for medical respite
care.
She attended nursing school atJohns Hopkins University and
worked as a floor nurse at UCSFMedical Center for four years
while she did her clinicalstudies for her master's degree
at UCSF at Zuckerberg SanFrancisco General Hospital's

(02:44):
Positive Health Program.
The presenters reported nothingto disclose.
Thanks for joining us, Soraya,Tanya, and Alice.

Soraya Azari (02:51):
Welcome listeners.
So great to have everyone here.
We have a real treat in store,which is to talk about managed
alcohol programs today.
And we are hoping that this willbe educational for all the
people listening.
So I'm going to lay out threelearning objectives for this
podcast.
Hopefully these will be thingsthat you take away from the

(03:12):
session.
The first thing we want you tocome away with is understanding
three ways that managed alcoholprograms, fulfill harm reduction
tenants.
Secondly, we want you to knowwhat are three specific
components, that you would needto have your own managed alcohol
program.
Finally, what are two ethicalchallenges that might come up

(03:32):
from running your own managedalcohol program?
So listen to this podcast forthe next 30 to 40 minutes, and
hopefully you'll feelcomfortable answering these
questions at the end.
We have two wonderful expertswith us today.
We previously agreed that wewould use first names as opposed
to our professional titles.

(03:53):
Alice and Tanya.
It's wonderful to have you here,Hello to you both

Tanya Majumder (03:57):
hello.

Alice Moughamian (03:57):
It is great to be here.

Soraya Azari (03:59):
We're gonna start with a patient case a short
vignette because everything thatwe do is really motivated by our
patients So pretend we have anindividual KG who's 38 years old
Has a history of psychosis andsevere alcohol use disorder.
This individual has had multipleemergency department and

(04:20):
hospitalizations, including atone point registering a blood
alcohol content as high as 836.
He's also been repeatedlyhospitalized.
He's been referred toresidential programs, but has
directed his own dischargeseveral times.
And he's been given multiplemedication trials.
and behavioral interventions foralcohol use disorder with

(04:41):
limited effect.
I want all the audience membersto just pretend like this is
your patient and reflect for aminute on how you might manage
this individual's care.
Having said that now, I'd loveto hear from our experts.
We are here to talk about amanaged alcohol program just to
get started because a lot oflisteners may not even know what

(05:03):
you're talking about.
Can you start by just giving usa simplified explanation of what
a managed alcohol program
is?

Alice Moughamian (05:12):
At its core, a managed alcohol program provides
a safe and stable place forpeople with severe alcohol use
disorder to stay long term.
Clients receive a stable placeto live along with health and
social supports that alsoinclude doses of regularly
administered beverage alcoholthat is dosed by registered
nurses.
The goal is not necessarily tostop, taper, or decrease

(05:34):
drinking patterns, although thatoften does happen organically,
what we're really trying to dois meet clients where they're at
with their drinking.
We provide and dose clients withenough alcohol to meet their
addiction and craving needs, yetwe maintain a safe level of
intoxication so we're notmanaging the behavioral safety
and fall risks associated withover intoxication our journey to

(05:57):
having a managed alcohol programhere in the United States, in
its current iteration has beenlong and winding.
Here in San Francisco, we Alsooperate a 12 bed sobering
center, which is a place wherepeople who are acutely
intoxicated on alcohol cansafely sober, out of the
emergency departments, out ofthe jails and off the streets.
In May of 2020, we had a COVIDoutbreak in the sobering center,

(06:19):
and many of the clients who wereexposed to COVID at that time
could not be supported in thetraditional isolation and
quarantine sites that SanFrancisco had set up.
At that time, we set up many ofthe protocols we're still using
today to help our highestutilizers of the sobering center
safely isolate and quarantine,by being provided these doses of
alcohol and isolation andquarantine.

(06:40):
After just 9 days in isolationand quarantine, we actually had
clients that we saw, achievinglevels of stability that we had
never thought possible.
It was amazing and it was aweinspiring.
So at that time, we worked withthe department to continue the
Managed Alcohol Program and itsiteration at isolation and
quarantine through the durationof the shelter in place order.
It's been proven so successfulthrough that, that we've

(07:02):
actually built this brand newpermanent program for the
department.

Soraya Azari (07:05):
That's incredible.
Right, this all started in areally organic way.
You didn't have a plan thatpreceded this, right?
Then you just saw that peoplestopped using emergency medical
services and stopped going tothe emergency department right
before your eyes, which soundsabsolutely incredible.
I think that we want to get alittle bit more granular.

(07:25):
Where people, live if they areat the managed alcohol program
in San Francisco, where doesthat happen and how does a
person even get into this veryspecialized program?

Tanya Majumder (07:37):
Thank you for the question, Soraya.
So, answer your first question,clients in the managed alcohol
program live in a hotel, leasedby the city.
Each client has their own hotelroom, with their own bathroom
and most importantly, are theirown television, at least for our
clients, most importantly.
It's a closed model program,which means that folks can't
come and go from the site.

(07:59):
There are a lot of different,styles of managed alcohol
programs, particularly inCanada, including more open
programs where clients are ableto come and go as they please,
but need to check in prior togetting dosed to make sure that
they're not over intoxicated.
But our clinical decision wasthat it was most therapeutic to
have a closed model, so thatclients are not able to come and

(08:19):
go and purchase their ownoutside alcohol in addition to
the alcohol that we're providingthem and also to be able to
create a more therapeuticcommunity space.
Our population targets arepeople who are Latinx or
Indigenous, folks who are highutilizers of emergency services,
whether that's 911 or emergencyrooms, and clients who are
experiencing homelessness.

(08:41):
In addition to offering managedalcohol, we also offer regular
nursing check ins.
We offer, check ins with everydose of managed alcohol that
clients are receiving.
And we also have a nursepractitioner on site to talk
about medication assistedtreatment for alcohol use
disorder, as well as to helpmanage any urgent care and

(09:01):
chronic health concerns.
Our current staffing is we havea nurse seven days a week from 7
a.
m.
to 11 p.
m.
And then we also have a nursethree nights a week and patient
care assistance other nightswhen we don't have a nurse on
site.
Our funding comes from a coupledifferent sources one is through
our general fund.
San Francisco is lucky enough tohave a general fund where they

(09:23):
can support support projectsthat are important to the city,
but may not otherwise bereimbursed.
Our project managed alcohol wasinitially funded through the
general fund.
we have funding throughproposition C, which was a
measure that was passed by thevoters of the city and county of
San Francisco to fund programsfor people experiencing
homelessness.

(09:44):
Lastly, we've also started toget funded by Cal AIM.
Specifically, their communitysupports recuperative care
programs.
CalAIM is a really uniqueprogram within the state of
California that's a Medicaidwaiver, that allows, Medi Cal,
to reimburse for, care thathelps to manage social
determinants of health, whichwe're all aware are huge drivers

(10:06):
of health and people'swellbeing.
CalAIM funds 300 per day perclient for the first 90 days
while they're in managed alcoholprogram as a part of the Medi
Cal waiver program.
We also have a community basedorganization, which works with
our program to providehospitality services and also
provides the alcohol that wegive to clients on site.

(10:29):
We're also lucky enough to bothhave citywide policies that
support harm reduction and staffwho are interested in and
believe in this model of care.

Soraya Azari (10:37):
That's an incredible summary.
I think this really demonstrateshow you can create dynamic and
innovative programs when youhave a supportive Department of
Public Health, even if thesearen't healthcare services that
are easily billable by ourprimary insurance plans.
I suspect you might get followup questions from our listeners

(10:58):
about the funding.
So I encourage you all to pleasereach out to Tonya and Alice, if
you want to understand moreabout sort of the creative way
that this funding came about forthis program.
So now we have a sense of who'son the ground, right?
This is an incredibly wellstaffed program with a nurse
that's there from 7am to 11pmdaily.

(11:19):
That's incredible.
And those nurses are doing theadministration of alcohol.
I want to talk more specificallyabout the alcohol that's
provided to the clients, Alice,can you sort of walk us through
what a typical client mightreceive, how you determine what
they should get and anymonitoring, that happens for
individuals.

Alice Moughamian (11:40):
In order to answer that question, I'm just
going to give a couple ofdefinitions.
First, we treat alcohol as acontrolled substance.
The alcohol is poured and dosedby registered nurses for the
clients.
The other thing to think aboutis we use the term SDE as
standard drink equivalent.
We define 1 SDE as 12 ounces ofa 5 percent beer.

(12:04):
We define it as 50 cc of an 80proof liquor, often in the form
of vodka or gin.
5 ounces of a 12 percent wine.
The way we determine whatsomeone's dosing pattern is
going to be is that when someonecomes into our program, the
first 48 to 72 hours, we have aninduction period.

(12:24):
We use this time to determinebased on what the client's self
report is what their dosingschedule would be.
So a nurse will dose one to twoSDEs every two hours or so
throughout their inductionperiod throughout those first 48
to 72 hours using two differentscales.

(12:45):
First using our CWAS scale, butalso using a RAISE scale, which
stands for Rapid AlcoholIntoxication Scale.
And these are clinical markersthat help us determine
someone's, intoxication leveland also their risk for
withdrawal.
During the induction time, we dohave clients receiving one to
two STEs Q2 hours based on ifthey feel that they need it and

(13:06):
based on clinically objectivescales.
We do allow for PRNs if there isa client who needs it.
Throughout that period afterthose first to 72 hours, we do
figure out a dosing schedulethat is in line with, our
clinical schedule.
We generally have dosing timesat 7 a.
m, 10 a.
m, 12 p.
m, 2 p.
m, 6 p.m.

(13:28):
And 10 p.
m.
I am not saying that there issomeone who doses at every
single one of those dosingtimes, those are the times that
work with our clinical flow.
Our dosing starts at 7:00 AM andclients will come and get their
s STEs and we do require clientsto present to the nursing
station so that nurses can dotheir clinical assessments to
determine whether or not someonewill be able to get that dose at

(13:48):
that time.
Clients are allowed to get theiralcohol of choice.
Generally, we have seen that tobe beer or vodka or gin.
We have had some clients whohave preferred other alcohols.
I will say that wine hasgenerally not worked well
because it can often go badwithin a couple of days and also
can be quite expensive.
There are times when we have hadsomeone who either preferred

(14:11):
wine or also someone who wasvery brittle between managing
their cravings and quicklybecoming over intoxicated with a
very little bit of alcohol.
So we have taken those people tothe store to get mixers to help
them achieve their desired levelof intoxication in a way that
worked for them.

Soraya Azari (14:28):
Thank you, Alice.
What I'm understanding is thatthere's a lot of patient
centered harm reduction medicinehappening here in terms of the
patient's choice of preferredalcoholic beverage and then also
a really ample dosing schedule.
And then there's also a lot ofclinical rigor because the

(14:50):
patients are receivingassessment by a nurse, you're
using scales to understand howintoxicated they are so that you
don't cause excessive harm.
And just thank you for puttingsuch a clear picture in place of
what's happening at the site.
Any, success story that reallycomes to mind for you?

(15:13):
What does it mean to determineif a program like this is
successful in terms of datamanagement and quality
improvement?

Tanya Majumder (15:22):
I'll take your second question first, Sariah.
Which is talking a little bitabout data management and
quality improvement.
So as we started the program ourleadership was really trying to
think about these things fromthe moment of managed alcohols
inception.
Some of the things that we'vereally been trying to track
include things like 911utilization, ED admissions and

(15:43):
hospital admissions.
Alice was talking earlier aboutthe initiation of the program
and just to give some hardnumbers to what Alice was
mentioning before about,qualitatively noticing
stability.
Quantitatively, we saw that inthe first days of isolation and
quarantine, we eliminated 23 911calls and likely ED visits.

(16:05):
That allowed us to continue thepilot going beyond those two
weeks and allowed us to turn itinto a longer term program.
About a year later, we were ableto say that we had saved about
1.
3 million in 911 utilizationbetween May 2020 and May 2021

(16:25):
because of this program.
We were able to use that toadvocate to the board of
supervisors for gettingpermanent funding for our
program.
We were initially tracking thedata through a spreadsheet our
medical director at the time hadan Excel spreadsheet she was
using to track all of this.
Now we're lucky enough to haveEpic and we're now able to run
reports through Epic to be ableto get some of this data.

Soraya Azari (16:47):
That's incredible that you showed that much
reduction in utilization.
And I think many of us doctorsand practitioners think about
how do we sort of help thesystem as a whole.
That was a big deal, especiallyduring COVID times.
And so what foresight you guyshad to look at these numbers to
keep track of them.

(17:08):
So plug to the audience, ifyou're starting your managed
alcohol program, data collectionat the outset is such a good
idea to demonstrate really whatthe success can be.
Let's now talk more specificallyabout a patient story.
Alice, I believe you're gonnagive us some reflections on one
of the patients that you know,quite well.

Alice Moughamian (17:27):
Again, just to review, he is a 36 year old man
with a severe alcohol usedisorder plus a psychotic
disorder.
He actually arrived in SanFrancisco in September of 2021
and by June of 2022 had 36emergency department visits.
To give you an example of hisutilization prior to managed
alcohol and the three monthsbefore MAP, he had 40 EMS

(17:51):
activations.
He visited our sobering center58 times and had eight emergency
department visits.
He also had, visualhallucinations of bugs crawling
on people that he felt wereworse in shelter.
Due to our med managementprogram at the sobering center,
we were able to start him onpsych meds in February of 2022,
which helped him stabilize tothe point where he showed up in

(18:14):
sobering with a sprained ankleand we convinced him at that
time to just stay and give map atry.
Rest his ankle.
And that was now almost 2 yearsago, and I'm happy to report
that he has, just completelyblossomed and is doing so well
at managed alcohol.
He actually stopped drinking fora while after a period of
institutional sobriety.

(18:35):
He has had only, three emergencydepartment visits and two
hospitalizations since hestarted at MAP two years ago.
So if we're looking at the preand the post utilization
patterns for someone in managedalcohol, it really highlights
the success of this program.
He is also currently involved intherapy and various art groups
and learning life skills.
He does actually currently have,permanent supportive housing and

(18:59):
we are working with him totransition and to develop the
life skills to manage hisalcohol use disorder, in
housing.

Soraya Azari (19:06):
This anecdote is so remarkable.
I think everyone is picturing,you know, the individuals that
they've worked with that havereally struggled and not been
able to get the support and thetreatment that they need.
This is such an example where healso wasn't originally ready to
enter the managed alcoholprogram.

(19:26):
This comes back to what you guyssaid before, right?
About the program itself, right?
This is a closed program.
You can't come and go.
Sometimes we give those detailsto patients and they're not
ready for that level oftreatment experience.
But it sounds like there were somany longitudinal touches with
this individual and then thesprained ankle just led to the

(19:46):
change moment.
So what a beautiful example oflike really doing things on his
timeline and on his terms.
I don't know.
It's so exciting.
It makes me, makes me get alittle choked up.
you all are incredible.
I really look up to what you do.
I Along those lines, you bothhave shared with me that there

(20:07):
have been some tough cases thatyou've seen in the managed
alcohol program and that thereare just some real ethical
challenges that arise.
And I really want the audienceto think about what some of
those ethical challenges are,reflect on that a bit yourself,
and I would love if Tanya, youcould share with me a story

(20:29):
about an ethical dilemma thatyou all have faced.

Tanya Majumder (20:33):
I think that there's so many different
ethical dilemmas that we comeacross in the managed alcohol
program.
I'll highlight two specifically,in the context of one case,
which is how, how to think aboutpatients who are cognitively
impaired, and how to balance,patient clinical care needs with

(20:54):
staff moral distress.
So we have a client R.L Who'sbeen in the program.
He's an older gentleman withsevere alcohol use disorder,
that has likely led to, his nowcognitive impairment with
Alzheimer's disease-- eitherAlzheimer's disease or alcohol
related dementia, who has a lotof trouble remembering new

(21:14):
information.
Also has a lot of impulsecontrol issues in the setting of
his alcohol use disorder.
He's frequently had episodes ofgoing out and purchasing outside
alcohol, becoming overlyintoxicated, posturing towards
staff, becoming behaviorallydifficult to manage, and we have
really worked with himrepeatedly to try and learn new

(21:37):
behaviors and not to purchaseoutside alcohol and tried to set
up as many behavioral barriersas we could to make that happen.
But it's been continuing tohappen, partly because due to
his dementia, he's really notable to remember, these
behavioral contracts that we'veset up for him.
We've really struggled becausemap is often the safest place

(21:59):
that our clients have ever been,and leaving map, we often watch
them decline.
For this gentleman, about 6months ago, we gave him a break
from map for the weekend aftermultiple episodes of over
intoxication with behavioralissues.
And during that 48 hours, he wasnot at MAP he went to the
emergency room twice and had afall.

(22:21):
And so we understand thatclinically, because of his
dementia, he's not able tolearn.
Our staff is being put in a verydifficult situation where both
they're having to manage thesebehavioral challenges, and feel
like he's getting away with hisbehavior because there aren't
any consequences And to alsounderstand that when they leave

(22:41):
the program that real harm canbefall our clients and our staff
is amazing and how much theycare about our clients.
We're also trying to sort out atthe same time, like are these
behaviors related to hisdementia?
are these behaviors related tohis over intoxication?
How do we think about our rules,and how do we think about

(23:02):
creating flexibility within ourstructures, but also making sure
we have boundaries?
Then something else we're reallystruggling with, with not just
him, but a number of our clientsaround cognitive impairment that
I have to imagine our listenersare thinking about as well is;
many cognitively impaired olderadults with substance use
disorders aren't welcome athigher levels of care.

(23:23):
So often map is for us map isthe last stop for those clients.
we discharge him, they reallyhave nowhere to go that provides
the level of support that ourprogram does.
That is a real challenge for usthat we're thinking about on a
consistent basis as a team.

Soraya Azari (23:39):
Those are some really tricky challenges and as
a person that works in a nursinghome, it really resonates to
hear what you're saying aboutactive substance use being a
reason that people are excludedfrom higher levels of care.
So I appreciate you giving sucha clear example.
One quick follow up, before wesort of talk more generally.

(24:02):
In terms of the ethicaldilemmas, how do you all support
each other as a team to sort ofwork through those ethical
challenges?

Tanya Majumder (24:10):
Yeah, I mean, I actually going back to this
specific case, we actually hadto deal with this as a team
pretty recently because a coupleof weeks ago he had some
escalating behaviors again.
And what we assume is thesetting of over intoxication
where he made a comment about astaff member's body, and he also
was rubbing the back of anotherfemale client in the program

(24:31):
against her consent.
At that point, you know, wereally had to come together as a
team and say, how did we feelabout this?
A lot of folks on the team feltlike this really had crossed a
line in terms of behavior.
We had to come together asleadership and say, how are we
weighing the needs of our staffwith the clinical responsibility
to the client?
We did end up making a decisionto give him a break from the

(24:52):
program for two weeks to onemonth, to both try and create
some behavioral or learnedbehavior that what happened was
not okay, and also to, providethe staff with support like
before this happened during theprocess, and then also
afterwards watching outcomesthat may not feel ideal while
making sure that their concernswere being valid and being

(25:15):
listened to.
Alice, I don't know if you havefurther thoughts around this
too.

Alice Moughamian (25:19):
I think, for those of us in the leadership
positions in the program, a bigpiece of this is supporting the
staff because they're feelingthe pull both ways as well.
They're recognizing that it'screating a space where it's not
a safe work environment forthemselves or, a safe
residential community for ourclients.
yet, oftentimes when someone isdischarged from the managed

(25:41):
alcohol program, we then startseeing them in the sobering
center.
And so, and it's the same staffthat staffs the managed alcohol
program in the sobering center.
And so it is really hard forstaff to then know that they're
also going to be bearing witnessto some of the choices that this
gentleman might make on thestreet that's going to lead him
to severe over intoxication andin the sobering center.

(26:04):
The real fear, because thecompassion of our staff is so
great, the real fear that ourstaff feel of an adverse event
out on the street so there's alot of discussion and a lot of
support that we offer to thestaff.

Soraya Azari (26:16):
really appreciate you guys giving such a specific
example.
Just really paints a picture ofvery hard issues where you want
to do right by the patient, butyou also have to provide
equitable care to everybodythat's enrolled in managed
alcohol.
So, thank you both.
I think bigger picture, right?
What brings you to work everyday, right?

(26:37):
Like we just talked about verydifficult problems.
It sounds like the team is sucha tremendous form of support for
everyone, but what else, what,what's the secret sauce that
makes you want to keep doingthis work?

Alice Moughamian (26:54):
You know, I knew this question was coming
and I've really been trying toreflect on it.
I think 1st, Tanya and I areboth incredibly lucky.
And I know we've mentioned thismany times to have an absolutely
fantastic team.
We have nurses, health workers,social workers and also very
supportive leadership team.
What brings me at this point isI've been doing this work now

(27:17):
for almost 17 years with thispopulation, and it is so
wonderful to see a programthat's really working.
It is really amazing to see aprogram based in harm reduction,
really, truly meeting people'sneeds.
Exactly the needs that theyhave, and watching people

(27:37):
transform.
Also being able to developsomething that's new and I will
say personally using my brainand expanding my, my own
personal and professionalgrowth, with being able to think
about these hard topics andbeing able to think about the
really systematically, about howthis program is working, both
systematically and also on theground.

Soraya Azari (27:59):
Tonya, what would you say?

Tanya Majumder (28:01):
I echo everything that Alice said.
I mean, I really appreciatecoming to work with such a
thoughtful caring, hardworkinggroup of team members.
I really appreciate, in the ageof fentanyl-- I feel like I've
been really struggling withfiguring out how to do
meaningful harm reduction basedwork that actually saves lives.

(28:21):
With managed alcohol, it's beenone of the things that I've seen
where I'm like, Oh, this works.
Like people get to come in andthey don't have to have a goal
of, of stopping use.
They can just want to be stableand supported and cared for.
And there's a place for that andthat has felt so rewarding to
me.
I've had a long time patient whowas in my patient, before I was

(28:43):
part of the managed alcoholprogram, or he was part of the
managed alcohol program.
Watching him in MAP has beenlike one of the biggest treats
of my career.
watching him stabilize andthrive and feel supported-- it's
been a really wonderful thing towitness.
I'm really grateful to managealcohol program for giving him
that kind of it's and that kindof support.

(29:04):
Even though he wanted to keepdrinking and that was really
important to him and managedalcohol supported him in that
while still seeing him as awhole human.

Soraya Azari (29:15):
Beautiful.
Because this is a podcastfocused on harm reduction.
This entire recording has beenfilled with anecdotes about harm
reduction, but just to morespecifically, one of the things
we want the audience to learn,are just what are three aspects
of harm reduction that are coreto map?

(29:37):
Tanya, could you just sort oflist your top three, The three
things that map really,manifests.

Tanya Majumder (29:45):
I think the first one is that there's no
expectation of abstinence at anypoint during the program, but
instead we're focused onreducing the harms of use by
preventing severe intoxicationand withdrawal, as Alice had
spoken about earlier.
We're also working to create anenvironment where alcohol use is
not stigmatized and clients aresupported regardless of their

(30:09):
alcohol goals.
We're also providing onsitesupport for treatment of
substance use, includingmedication assisted treatment,
if that's something that clientsare interested in.

Soraya Azari (30:20):
You all talked about so many parts of your
successful program.
Alice, if you just had todistill down the three things
that are needed for a person torun a managed alcohol program.
Can you just summarize for ouraudience, what are those three
things that you would recommendto people if they were trying to
embark on this journey?

Alice Moughamian (30:43):
The program planning of my brain, says we
definitely need to understandwhat are the outcomes that we're
looking at from the get go, aswe mentioned earlier.
You also need to have verystrong and robust written
policies and protocols thatwe've put into place.
And you also need staff thatunderstand harm reduction, that

(31:05):
are willing to Learn more, andto creatively apply the concepts
of harm reduction in their dailywork.
You also need staff who areincredibly flexible and the
ability that, especially thisprogram is so new, the ability
to say we're putting into placethis policy and protocol.

(31:25):
We do want staff to givefeedback because we might need
to pivot and change it andreally being able to do PBSA
cycles on every policy andprotocol that we come up with,
because there's, alwayssomething that's changing,
especially in the development ofa program that's this novel.
On the ground, those robustpolicies and protocols that a

(31:47):
big part of the success of ourprogram is actually the
community building that we'redoing within them.
Map is a residential setting, weare meeting people where they're
at with their alcohol usedisorder.
We are really trying to makesure that their alcohol use is
not stigmatized and so whatwe're actively trying to do is
not lend our program more tosocial isolation.

(32:08):
We do not want our clients justgetting their SDEs and their
doses from the nurses and thengoing back to their rooms to
drink alone.
We want people to engage incommunity meetings and to engage
in activities, art groups,therapy groups that we're
hosting on site.
There are even special outingsthat we're doing.
We did last year and it was sosuccessful, we're taking several

(32:29):
clients to a Giants game, forexample.
In a couple of weeks.
The reports I got from the lastGiants game where our managed
alcohol clients actually endedup on the jumbotron, was really
one of the highlights I feellike for me, I'm hearing about
all of our clients on thejumbotron at the Giants game was
probably one of my careerhighlights, to be honest, in
doing this work.

(32:50):
so It's also making sure thatwe're creating that space for
our clients to know that theymatter.
That they are part of thisgreater San Francisco community.

Soraya Azari (33:01):
It's like the, the outcome that you actually want
to see from a programintervention or a study, right?
A decrease in ED utilization andEMS calls is a great thing, but
what does it mean to have aperson actually feel like they
belong to a community, right?
That they can function, thatthey're valued, that they have
worth.
So thank you for that anecdoteand I will forever be thinking

(33:24):
about the Jumbotron.
we're getting close to the endhere, you really love to hear
from you both.
what's next for the MAP program?
what are, Things that you mightwant to tinker with or add or,
are you expanding?
what's next for you all?

Tanya Majumder (33:39):
I think we're, we're definitely thinking about
expanding.
It's taken a while, but wefinally fully staffed up to
support 20 clients in theprogram.
And so we're actively workingboth to take in new clients via
referrals and also recruit fromsome of our target populations
and specifically our Latinx andindigenous populations, really

(33:59):
trying to build connections withthose communities to get more
folks, from those communitiesengaged in managed alcohol, if
they're appropriate for theprogram.
Alice, other things that we'retrying to expand on

Alice Moughamian (34:12):
I think what we're trying to do and what
we're always trying to do iseducating about managed alcohol.
It is a new and novel program.
So doing podcasts such as this,presenting on managed alcohol,
letting people know this can bedone in the United States and
that it is incrediblysuccessful, but I think it's
more about of what we're doingis we're very strategically

(34:33):
educating people about harmreduction and how harm reduction
is not just, available withopioid use disorder, stimulant
use disorders, that alcohol verymuch is It's still prevalent and
here and, needs its own form ofharm reduction.

Soraya Azari (34:48):
What a great note to end on, right?
Which is reminding us all aboutthe many ways we can do harm
reduction for people withalcohol use disorders, alcohol
use disorder is still moreprevalent than the other
substances that, we think of ascausing morbidity and mortality.
And so, honing all of thoseskills, even if it's not a

(35:09):
managed alcohol program, right?
How do we counsel patients aboutways that they can reduce harm?
Obviously the, real hope is tohave more managed alcohol
programs that are available topatients.
And I think you all have paintedthe perfect picture.
So other listeners can thinkabout creating this in their
communities.
Thank you both.
I think you absolutelyaccomplished all the learning

(35:30):
objectives.
You taught me a lot and I reallyenjoyed our conversation today.
Any final thoughts or partingwords before we leave?

Alice Moughamian (35:41):
I just really appreciate the opportunity to
speak about managed alcohol.
Again, as I mentioned, alwaystrying to educate and teach
about this new modality of carethat we're developing especially
because we've just seen howamazingly successful it is.

Tanya Majumder (35:57):
And really encouraging folks in your
communities to be thinking aboutmanaged alcohol and how, you can
support a managed alcoholprogram.
Please don't hesitate to reachout to us if there's any way
that we can be helpful in havingyou think through that.

Soraya Azari (36:13):
a great note to end on.
You heard it, everyone.
They are open to talking to you.
They might even share policiesand procedures with you.
These are parting gifts, I wouldcall them.
Thank you both so much and,have, great day to you all.

Kinna Thakarar (36:29):
That was Dr.
Tanya Majumder, Alice Mugamian,and Dr.
Soraya Azari in conversation onharm reduction, compassionate
care for people who use drugs.
Thank you for listening.
Be sure to tune in next timewhen we welcome Dr.
Simone Bays, Leah Warner, andJamie Lange to the series to
discuss putting harm reductionto the test, drug use,
pregnancy, and parenting.
Please take a moment to completeSAMHSA's post event evaluation

(36:51):
survey on the AMERSA podcastpage at www.
dot AMERSA dot.
Org forward slash harm reductionpodcast.
We welcome any comments,questions, or other feedback for
presenters.
You can send those directly toAMERSA through the contact us
form at AMERSA.
org.
To learn more about theprovider's clinical support
system, Medication for OpioidUse Disorder Project, and AMERSA
please visit our websites atPCSSMOUD.
org and AMERSA org.

(37:12):
Funding for this initiative wasmade possible by Cooperative
Agreement No.
1 H 79 TI 086 770 from SAMHSA.
The views expressed in writtenconference materials or
publications and by speakers andmoderators do not necessarily
reflect the official policies ofthe Department of Health and
Human Services, nor does mentionof trade names, commercial
practices, or organizationsimply endorsement by the U.
S.
government.
Thank you for listening.