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.

Transcript

Kinna Thakarar: 0:13

I'm Kinna Thakarar and welcome to the podcast series, Harm Reduction, Compassionate Care for People Who Use Drugs. Harm Reduction is a social justice movement started by and for people who use drugs, and it's a philosophy of care and practical set of strategies to optimize people's health, safety, and rights. We want to acknowledge and honor the long history of street medicine and healthcare developed by people with lived and living experience to keep one another alive and safe through community care. Whether you're a seasoned harm to the concept, we're glad you're here and hope you'll learn something new and are curious to explore seeing patient care through a harm reduction lens. This podcast series is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project, and AMERSA. This week, we welcome Dr. Soraya Azari in conversation with Dr. Tania Majumder and Alice Mogamian to discuss Harm Reduction for Alcohol Use Disorder, the managed alcohol program. Our host, Soraya Azari, MD, is an internist and addiction medicine doctor based in San Francisco. She currently works for the San Francisco Department of Public Health as a primary care doctor and addiction medicine specialist. She is a volunteer professor at UCSF and assists with the training of addiction medicine fellows. She is interested in people with substance use disorders and chronic pain, medical morbidities related to substance use and collaboration across specialties, and graduate medical education. Tanya Majumder is a primary care physician with the SF DPH whole person integrated care, street medicine, shelter health, and urgent care, and the lead physician for the WPIC managed alcohol program and Sobering Center. She completed medical school and her master's in health and medical sciences at the joint medical program between Berkeley and UCSF before attending residency in internal medicine primary care at the Yale primary care program. She's greatly enjoyed being part of the whole person integrated team for the past four and a half years. Alice Mugamian serves as the nurse manager of the managed alcohol program at the San Francisco Sobering Center for the San Francisco Department of Health. In addition to this role, she was nurse manager and the program director of the medical respite program, as well as nursing services in permanent supportive housing before devoting full time to managed alcohol and sobering. Alice has also served as a chair for the National Healthcare for the Homeless Council's Respite Care Providers Network and helped develop national standards for medical respite care. She attended nursing school at Johns Hopkins University and worked as a floor nurse at UCSF Medical Center for four years while she did her clinical studies for her master's degree at UCSF at Zuckerberg San Francisco General Hospital's Positive Health Program. The presenters reported nothing to disclose. Thanks for joining us, Soraya, Tanya, and Alice.

Soraya Azari: 2:51

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 will be educational for all the people listening. So I'm going to lay out three learning objectives for this podcast. Hopefully these will be things that you take away from the session. The first thing we want you to come away with is understanding three ways that managed alcohol programs, fulfill harm reduction tenants. Secondly, we want you to know what are three specific components, that you would need to have your own managed alcohol program. Finally, what are two ethical challenges that might come up from running your own managed alcohol program? So listen to this podcast for the next 30 to 40 minutes, and hopefully you'll feel comfortable answering these questions at the end. We have two wonderful experts with us today. We previously agreed that we would use first names as opposed to our professional titles. Alice and Tanya. It's wonderful to have you here, Hello to you both

Tanya Majumder: 3:57

hello.

Alice Moughamian: 3:57

It is great to be here.

Soraya Azari: 3:59

We're gonna start with a patient case a short vignette because everything that we do is really motivated by our patients So pretend we have an individual KG who's 38 years old Has a history of psychosis and severe alcohol use disorder. This individual has had multiple emergency department and hospitalizations, including at one point registering a blood alcohol content as high as 836. He's also been repeatedly hospitalized. He's been referred to residential programs, but has directed his own discharge several times. And he's been given multiple medication trials. and behavioral interventions for alcohol use disorder with limited effect. I want all the audience members to just pretend like this is your patient and reflect for a minute on how you might manage this individual's care. Having said that now, I'd love to hear from our experts. We are here to talk about a managed alcohol program just to get started because a lot of listeners may not even know what you're talking about. Can you start by just giving us a simplified explanation of what a managed alcohol program

5:10

is?

Alice Moughamian: 5:12

At its core, a managed alcohol program provides a safe and stable place for people with severe alcohol use disorder to stay long term. Clients receive a stable place to live along with health and social supports that also include doses of regularly administered beverage alcohol that is dosed by registered nurses. The goal is not necessarily to stop, taper, or decrease drinking patterns, although that often does happen organically, what we're really trying to do is meet clients where they're at with their drinking. We provide and dose clients with enough alcohol to meet their addiction and craving needs, yet we maintain a safe level of intoxication so we're not managing the behavioral safety and fall risks associated with over intoxication our journey to having a managed alcohol program here in the United States, in its current iteration has been long and winding. Here in San Francisco, we Also operate a 12 bed sobering center, which is a place where people who are acutely intoxicated on alcohol can safely sober, out of the emergency departments, out of the jails and off the streets. In May of 2020, we had a COVID outbreak in the sobering center, and many of the clients who were exposed to COVID at that time could not be supported in the traditional isolation and quarantine sites that San Francisco had set up. At that time, we set up many of the protocols we're still using today to help our highest utilizers of the sobering center safely isolate and quarantine, by being provided these doses of alcohol and isolation and quarantine. After just 9 days in isolation and quarantine, we actually had clients that we saw, achieving levels of stability that we had never thought possible. It was amazing and it was awe inspiring. So at that time, we worked with the department to continue the Managed Alcohol Program and its iteration at isolation and quarantine through the duration of the shelter in place order. It's been proven so successful through that, that we've actually built this brand new permanent program for the department.

Soraya Azari: 7:05

That's incredible. Right, this all started in a really organic way. You didn't have a plan that preceded this, right? Then you just saw that people stopped using emergency medical services and stopped going to the emergency department right before your eyes, which sounds absolutely incredible. I think that we want to get a little bit more granular. Where people, live if they are at the managed alcohol program in San Francisco, where does that happen and how does a person even get into this very specialized program?

Tanya Majumder: 7:37

Thank you for the question, Soraya. So, answer your first question, clients in the managed alcohol program live in a hotel, leased by the city. Each client has their own hotel room, with their own bathroom and most importantly, are their own 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. There are a lot of different, styles of managed alcohol programs, particularly in Canada, including more open programs where clients are able to come and go as they please, but need to check in prior to getting dosed to make sure that they're not over intoxicated. But our clinical decision was that it was most therapeutic to have a closed model, so that clients are not able to come and go and purchase their own outside alcohol in addition to the alcohol that we're providing them and also to be able to create a more therapeutic community space. Our population targets are people who are Latinx or Indigenous, folks who are high utilizers of emergency services, whether that's 911 or emergency rooms, and clients who are experiencing homelessness. In addition to offering managed alcohol, we also offer regular nursing check ins. We offer, check ins with every dose of managed alcohol that clients are receiving. And we also have a nurse practitioner on site to talk about medication assisted treatment for alcohol use disorder, as well as to help manage any urgent care and chronic health concerns. Our current staffing is we have a nurse seven days a week from 7 a. m. to 11 p. m. And then we also have a nurse three nights a week and patient care assistance other nights when we don't have a nurse on site. Our funding comes from a couple different sources one is through our general fund. San Francisco is lucky enough to have a general fund where they can support support projects that are important to the city, but may not otherwise be reimbursed. Our project managed alcohol was initially funded through the general fund. we have funding through proposition C, which was a measure that was passed by the voters of the city and county of San Francisco to fund programs for people experiencing homelessness. Lastly, we've also started to get funded by Cal AIM. Specifically, their community supports recuperative care programs. CalAIM is a really unique program within the state of California that's a Medicaid waiver, that allows, Medi Cal, to reimburse for, care that helps to manage social determinants of health, which we're all aware are huge drivers of health and people's wellbeing. CalAIM funds 300 per day per client for the first 90 days while they're in managed alcohol program as a part of the Medi Cal waiver program. We also have a community based organization, which works with our program to provide hospitality services and also provides the alcohol that we give to clients on site. We're also lucky enough to both have citywide policies that support harm reduction and staff who are interested in and believe in this model of care.

Soraya Azari: 10:37

That's an incredible summary. I think this really demonstrates how you can create dynamic and innovative programs when you have a supportive Department of Public Health, even if these aren't healthcare services that are easily billable by our primary insurance plans. I suspect you might get follow up questions from our listeners about the funding. So I encourage you all to please reach out to Tonya and Alice, if you want to understand more about sort of the creative way that this funding came about for this program. So now we have a sense of who's on the ground, right? This is an incredibly well staffed program with a nurse that's there from 7am to 11pm daily. That's incredible. And those nurses are doing the administration of alcohol. I want to talk more specifically about the alcohol that's provided to the clients, Alice, can you sort of walk us through what a typical client might receive, how you determine what they should get and any monitoring, that happens for individuals.

Alice Moughamian: 11:40

In order to answer that question, I'm just going to give a couple of definitions. First, we treat alcohol as a controlled substance. The alcohol is poured and dosed by registered nurses for the clients. The other thing to think about is we use the term SDE as standard drink equivalent. We define 1 SDE as 12 ounces of a 5 percent beer. We define it as 50 cc of an 80 proof liquor, often in the form of vodka or gin. 5 ounces of a 12 percent wine. The way we determine what someone's dosing pattern is going to be is that when someone comes into our program, the first 48 to 72 hours, we have an induction period. We use this time to determine based on what the client's self report is what their dosing schedule would be. So a nurse will dose one to two SDEs every two hours or so throughout their induction period throughout those first 48 to 72 hours using two different scales. First using our CWAS scale, but also using a RAISE scale, which stands for Rapid Alcohol Intoxication Scale. And these are clinical markers that help us determine someone's, intoxication level and also their risk for withdrawal. During the induction time, we do have clients receiving one to two STEs Q2 hours based on if they feel that they need it and based on clinically objective scales. We do allow for PRNs if there is a client who needs it. Throughout that period after those first to 72 hours, we do figure out a dosing schedule that is in line with, our clinical schedule. We generally have dosing times at 7 a. m, 10 a. m, 12 p. m, 2 p. m, 6 p.m. And 10 p. m. I am not saying that there is someone who doses at every single one of those dosing times, those are the times that work with our clinical flow. Our dosing starts at 7:00 AM and clients will come and get their s STEs and we do require clients to present to the nursing station so that nurses can do their clinical assessments to determine whether or not someone will be able to get that dose at that time. Clients are allowed to get their alcohol of choice. Generally, we have seen that to be beer or vodka or gin. We have had some clients who have preferred other alcohols. I will say that wine has generally not worked well because it can often go bad within a couple of days and also can be quite expensive. There are times when we have had someone who either preferred wine or also someone who was very brittle between managing their cravings and quickly becoming over intoxicated with a very little bit of alcohol. So we have taken those people to the store to get mixers to help them achieve their desired level of intoxication in a way that worked for them.

Soraya Azari: 14:28

Thank you, Alice. What I'm understanding is that there's a lot of patient centered harm reduction medicine happening here in terms of the patient's choice of preferred alcoholic beverage and then also a really ample dosing schedule. And then there's also a lot of clinical rigor because the patients are receiving assessment by a nurse, you're using scales to understand how intoxicated they are so that you don't cause excessive harm. And just thank you for putting such a clear picture in place of what's happening at the site. Any, success story that really comes to mind for you? What does it mean to determine if a program like this is successful in terms of data management and quality improvement?

Tanya Majumder: 15:22

I'll take your second question first, Sariah. Which is talking a little bit about data management and quality improvement. So as we started the program our leadership was really trying to think about these things from the moment of managed alcohols inception. Some of the things that we've really been trying to track include things like 911 utilization, ED admissions and hospital admissions. Alice was talking earlier about the initiation of the program and just to give some hard numbers to what Alice was mentioning before about, qualitatively noticing stability. Quantitatively, we saw that in the first days of isolation and quarantine, we eliminated 23 911 calls and likely ED visits. That allowed us to continue the pilot going beyond those two weeks and allowed us to turn it into a longer term program. About a year later, we were able to say that we had saved about 1. 3 million in 911 utilization between May 2020 and May 2021 because of this program. We were able to use that to advocate to the board of supervisors for getting permanent funding for our program. We were initially tracking the data through a spreadsheet our medical director at the time had an Excel spreadsheet she was using to track all of this. Now we're lucky enough to have Epic and we're now able to run reports through Epic to be able to 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 doctors and practitioners think about how do we sort of help the system as a whole. That was a big deal, especially during COVID times. And so what foresight you guys had to look at these numbers to keep track of them. So plug to the audience, if you're starting your managed alcohol program, data collection at the outset is such a good idea to demonstrate really what the success can be. Let's now talk more specifically about a patient story. Alice, I believe you're gonna give 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 use disorder plus a psychotic disorder. He actually arrived in San Francisco in September of 2021 and by June of 2022 had 36 emergency department visits. To give you an example of his utilization prior to managed alcohol and the three months before MAP, he had 40 EMS activations. He visited our sobering center 58 times and had eight emergency department visits. He also had, visual hallucinations of bugs crawling on people that he felt were worse in shelter. Due to our med management program at the sobering center, we were able to start him on psych meds in February of 2022, which helped him stabilize to the point where he showed up in sobering with a sprained ankle and we convinced him at that time to just stay and give map a try. Rest his ankle. And that was now almost 2 years ago, and I'm happy to report that he has, just completely blossomed and is doing so well at managed alcohol. He actually stopped drinking for a while after a period of institutional sobriety. He has had only, three emergency department visits and two hospitalizations since he started at MAP two years ago. So if we're looking at the pre and the post utilization patterns for someone in managed alcohol, it really highlights the success of this program. He is also currently involved in therapy and various art groups and learning life skills. He does actually currently have, permanent supportive housing and we are working with him to transition and to develop the life skills to manage his alcohol 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 have really struggled and not been able to get the support and the treatment that they need. This is such an example where he also wasn't originally ready to enter the managed alcohol program. This comes back to what you guys said before, right? About the program itself, right? This is a closed program. You can't come and go. Sometimes we give those details to patients and they're not ready for that level of treatment experience. But it sounds like there were so many longitudinal touches with this individual and then the sprained ankle just led to the change moment. So what a beautiful example of like really doing things on his timeline and on his terms. I don't know. It's so exciting. It makes me, makes me get a little choked up. you all are incredible. I really look up to what you do. I Along those lines, you both have shared with me that there have been some tough cases that you've seen in the managed alcohol program and that there are just some real ethical challenges that arise. And I really want the audience to think about what some of those ethical challenges are, reflect on that a bit yourself, and I would love if Tanya, you could share with me a story about an ethical dilemma that you all have faced.

Tanya Majumder: 20:33

I think that there's so many different ethical dilemmas that we come across in the managed alcohol program. I'll highlight two specifically, in the context of one case, which is how, how to think about patients who are cognitively impaired, and how to balance, patient clinical care needs with staff moral distress. So we have a client R.L Who's been in the program. He's an older gentleman with severe alcohol use disorder, that has likely led to, his now cognitive impairment with Alzheimer's disease-- either Alzheimer's disease or alcohol related dementia, who has a lot of trouble remembering new information. Also has a lot of impulse control issues in the setting of his alcohol use disorder. He's frequently had episodes of going out and purchasing outside alcohol, becoming overly intoxicated, posturing towards staff, becoming behaviorally difficult to manage, and we have really worked with him repeatedly to try and learn new behaviors and not to purchase outside alcohol and tried to set up as many behavioral barriers as we could to make that happen. But it's been continuing to happen, partly because due to his dementia, he's really not able to remember, these behavioral contracts that we've set up for him. We've really struggled because map is often the safest place that our clients have ever been, and leaving map, we often watch them decline. For this gentleman, about 6 months ago, we gave him a break from map for the weekend after multiple episodes of over intoxication with behavioral issues. And during that 48 hours, he was not at MAP he went to the emergency room twice and had a fall. And so we understand that clinically, because of his dementia, he's not able to learn. Our staff is being put in a very difficult situation where both they're having to manage these behavioral challenges, and feel like he's getting away with his behavior because there aren't any consequences And to also understand that when they leave the program that real harm can befall our clients and our staff is amazing and how much they care about our clients. We're also trying to sort out at the same time, like are these behaviors related to his dementia? are these behaviors related to his over intoxication? How do we think about our rules, and how do we think about creating flexibility within our structures, but also making sure we have boundaries? Then something else we're really struggling with, with not just him, but a number of our clients around cognitive impairment that I have to imagine our listeners are thinking about as well is; many cognitively impaired older adults with substance use disorders aren't welcome at higher levels of care. So often map is for us map is the last stop for those clients. we discharge him, they really have nowhere to go that provides the level of support that our program does. That is a real challenge for us that 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 nursing home, it really resonates to hear what you're saying about active substance use being a reason that people are excluded from higher levels of care. So I appreciate you giving such a clear example. One quick follow up, before we sort of talk more generally. In terms of the ethical dilemmas, how do you all support each other as a team to sort of work through those ethical challenges?

Tanya Majumder: 24:10

Yeah, I mean, I actually going back to this specific case, we actually had to deal with this as a team pretty recently because a couple of weeks ago he had some escalating behaviors again. And what we assume is the setting of over intoxication where he made a comment about a staff member's body, and he also was rubbing the back of another female client in the program against her consent. At that point, you know, we really had to come together as a team and say, how did we feel about this? A lot of folks on the team felt like this really had crossed a line in terms of behavior. We had to come together as leadership and say, how are we weighing the needs of our staff with the clinical responsibility to the client? We did end up making a decision to give him a break from the program for two weeks to one month, to both try and create some behavioral or learned behavior that what happened was not okay, and also to, provide the staff with support like before this happened during the process, and then also afterwards watching outcomes that may not feel ideal while making sure that their concerns were being valid and being listened to. Alice, I don't know if you have further thoughts around this too.

Alice Moughamian: 25:19

I think, for those of us in the leadership positions in the program, a big piece of this is supporting the staff because they're feeling the pull both ways as well. They're recognizing that it's creating a space where it's not a safe work environment for themselves or, a safe residential community for our clients. yet, oftentimes when someone is discharged from the managed alcohol program, we then start seeing them in the sobering center. And so, and it's the same staff that staffs the managed alcohol program in the sobering center. And so it is really hard for staff to then know that they're also going to be bearing witness to some of the choices that this gentleman might make on the street that's going to lead him to severe over intoxication and in the sobering center. The real fear, because the compassion of our staff is so great, the real fear that our staff feel of an adverse event out on the street so there's a lot of discussion and a lot of support that we offer to the staff.

Soraya Azari: 26:16

really appreciate you guys giving such a specific example. Just really paints a picture of very hard issues where you want to do right by the patient, but you also have to provide equitable care to everybody that's enrolled in managed alcohol. So, thank you both. I think bigger picture, right? What brings you to work every day, right? Like we just talked about very difficult problems. It sounds like the team is such a tremendous form of support for everyone, but what else, what, what's the secret sauce that makes you want to keep doing this work?

Alice Moughamian: 26:54

You know, I knew this question was coming and I've really been trying to reflect on it. I think 1st, Tanya and I are both incredibly lucky. And I know we've mentioned this many 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 is I've been doing this work now for almost 17 years with this population, and it is so wonderful to see a program that's really working. It is really amazing to see a program based in harm reduction, really, truly meeting people's needs. Exactly the needs that they have, and watching people transform. Also being able to develop something that's new and I will say personally using my brain and expanding my, my own personal and professional growth, with being able to think about these hard topics and being able to think about the really systematically, about how this program is working, both systematically and also on the ground.

Soraya Azari: 27:59

Tonya, what would you say?

Tanya Majumder: 28:01

I echo everything that Alice said. I mean, I really appreciate coming to work with such a thoughtful caring, hardworking group of team members. I really appreciate, in the age of fentanyl-- I feel like I've been really struggling with figuring out how to do meaningful harm reduction based work that actually saves lives. With managed alcohol, it's been one of the things that I've seen where I'm like, Oh, this works. Like people get to come in and they don't have to have a goal of, of stopping use. They can just want to be stable and supported and cared for. And there's a place for that and that has felt so rewarding to me. I've had a long time patient who was in my patient, before I was part of the managed alcohol program, or he was part of the managed alcohol program. Watching him in MAP has been like one of the biggest treats of my career. watching him stabilize and thrive and feel supported-- it's been a really wonderful thing to witness. I'm really grateful to manage alcohol program for giving him that kind of it's and that kind of support. Even though he wanted to keep drinking and that was really important to him and managed alcohol supported him in that while still seeing him as a whole human.

Soraya Azari: 29:15

Beautiful. Because this is a podcast focused on harm reduction. This entire recording has been filled with anecdotes about harm reduction, but just to more specifically, one of the things we want the audience to learn, are just what are three aspects of harm reduction that are core to map? Tanya, could you just sort of list 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 any point during the program, but instead we're focused on reducing the harms of use by preventing severe intoxication and withdrawal, as Alice had spoken about earlier. We're also working to create an environment where alcohol use is not stigmatized and clients are supported regardless of their alcohol goals. We're also providing onsite support for treatment of substance use, including medication assisted treatment, if that's something that clients are interested in.

Soraya Azari: 30:20

You all talked about so many parts of your successful program. Alice, if you just had to distill down the three things that are needed for a person to run a managed alcohol program. Can you just summarize for our audience, what are those three things that you would recommend to 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 understand what are the outcomes that we're looking at from the get go, as we mentioned earlier. You also need to have very strong and robust written policies and protocols that we've put into place. And you also need staff that understand harm reduction, that are willing to Learn more, and to creatively apply the concepts of harm reduction in their daily work. You also need staff who are incredibly flexible and the ability that, especially this program is so new, the ability to say we're putting into place this policy and protocol. We do want staff to give feedback because we might need to pivot and change it and really being able to do PBSA cycles on every policy and protocol that we come up with, because there's, always something that's changing, especially in the development of a program that's this novel. On the ground, those robust policies and protocols that a big part of the success of our program is actually the community building that we're doing within them. Map is a residential setting, we are meeting people where they're at with their alcohol use disorder. We are really trying to make sure that their alcohol use is not stigmatized and so what we're actively trying to do is not lend our program more to social isolation. We do not want our clients just getting their SDEs and their doses from the nurses and then going back to their rooms to drink alone. We want people to engage in community meetings and to engage in activities, art groups, therapy groups that we're hosting on site. There are even special outings that we're doing. We did last year and it was so successful, we're taking several clients to a Giants game, for example. In a couple of weeks. The reports I got from the last Giants game where our managed alcohol clients actually ended up on the jumbotron, was really one of the highlights I feel like for me, I'm hearing about all of our clients on the jumbotron at the Giants game was probably one of my career highlights, to be honest, in doing this work. so It's also making sure that we're creating that space for our clients to know that they matter. That they are part of this greater San Francisco community.

Soraya Azari: 33:01

It's like the, the outcome that you actually want to see from a program intervention or a study, right? A decrease in ED utilization and EMS calls is a great thing, but what does it mean to have a person actually feel like they belong to a community, right? That they can function, that they're valued, that they have worth. So thank you for that anecdote and I will forever be thinking about the Jumbotron. we're getting close to the end here, you really love to hear from you both. what's next for the MAP program? what are, Things that you might want 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 we finally fully staffed up to support 20 clients in the program. And so we're actively working both to take in new clients via referrals and also recruit from some of our target populations and specifically our Latinx and indigenous populations, really trying to build connections with those communities to get more folks, from those communities engaged in managed alcohol, if they're appropriate for the program. Alice, other things that we're trying to expand on

Alice Moughamian: 34:12

I think what we're trying to do and what we're always trying to do is educating 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 be done in the United States and that it is incredibly successful, but I think it's more about of what we're doing is we're very strategically educating people about harm reduction and how harm reduction is not just, available with opioid use disorder, stimulant use disorders, that alcohol very much is It's still prevalent and here and, needs its own form of harm reduction.

Soraya Azari: 34:48

What a great note to end on, right? Which is reminding us all about the many ways we can do harm reduction for people with alcohol use disorders, alcohol use disorder is still more prevalent than the other substances that, we think of as causing morbidity and mortality. And so, honing all of those skills, even if it's not a managed alcohol program, right? How do we counsel patients about ways that they can reduce harm? Obviously the, real hope is to have more managed alcohol programs that are available to patients. And I think you all have painted the perfect picture. So other listeners can think about creating this in their communities. Thank you both. I think you absolutely accomplished all the learning objectives. You taught me a lot and I really enjoyed our conversation today. Any final thoughts or parting words before we leave?

Alice Moughamian: 35:41

I just really appreciate the opportunity to speak about managed alcohol. Again, as I mentioned, always trying to educate and teach about this new modality of care that we're developing especially because we've just seen how amazingly successful it is.

Tanya Majumder: 35:57

And really encouraging folks in your communities to be thinking about managed alcohol and how, you can support a managed alcohol program. Please don't hesitate to reach out to us if there's any way that we can be helpful in having you 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 policies and procedures with you. These are parting gifts, I would call 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 on harm reduction, compassionate care for people who use drugs. Thank you for listening. Be sure to tune in next time when we welcome Dr. Simone Bays, Leah Warner, and Jamie Lange to the series to discuss putting harm reduction to the test, drug use, pregnancy, and parenting. Please take a moment to complete SAMHSA's post event evaluation survey on the AMERSA podcast page at www. dot AMERSA dot. Org forward slash harm reduction podcast. We welcome any comments, questions, or other feedback for presenters. You can send those directly to AMERSA through the contact us form at AMERSA. org. To learn more about the provider's clinical support system, Medication for Opioid Use Disorder Project, and AMERSA please visit our websites at PCSSMOUD. org and AMERSA org. Funding for this initiative was made possible by Cooperative Agreement No. 1 H 79 TI 086 770 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. Thank you for listening.