Do managed alcohol programmes work to help homeless people with long-term alcohol dependence
What is it about?
Managed alcohol programmes (MAPs) are harm reduction services that provide regulated doses of alcohol throughout the day to people experiencing both homelessness and severe alcohol dependence, alongside support for housing, physical and mental health, welfare and social connections. Developed in Canada in the 1990s and now operating internationally, MAPs exist because abstinence-based treatment is frequently inaccessible or unsuitable for this population. This realist review drew on 60 studies and grey literature sources to identify 11 programme theories explaining what works, for whom, and under what circumstances. Key findings show that MAPs succeed by enabling autonomy, meeting clients' basic needs, creating hope and purpose, and connecting people to healthcare, and that they consistently produce positive outcomes including reductions in alcohol consumption, emergency service use, and legal harms.
Why is it important?
Homelessness and alcohol-related deaths are rising across multiple countries, yet the dominant treatment model still requires abstinence as a condition of accessing housing and support, actively excluding the people most in need. MAPs represent a direct response to this gap, and this review provides the most theoretically detailed analysis of how and why they work to date. By moving beyond simple effectiveness data to explain the mechanisms and conditions that drive outcomes, it gives commissioners, policymakers and service designers a practical framework for implementing and optimising MAPs. The findings carry direct relevance for the UK, where alcohol harm reduction approaches for people experiencing homelessness remain scarce, and for any country seeking evidence-based, non-abstinence alternatives to reduce preventable deaths and healthcare system burden among the most marginalised.