Located in the southeast panhandle of the state, the small city of Juneau serves as the Alaska state capital. Dzántik'i Héeni (Base of the Flounder's River in Tlingit), or Juneau, is home to just under 32,000 people  and is only accessible by boat or air, having no roads that connect the city to the rest of the State. During the January 2020 homeless point-in-time count, a total of 244 adults were identified as homeless including 46 unsheltered, 82 living in transitional housing, and 116 staying in emergency shelter . In March of 2020, like other communities around the world, community leaders assembled an emergency operations team to respond to the emergent COVID-19 outbreak including members of local government, administrators from the one local hospital, the one State public health office, and local fire, ambulance, homelessness service providers, and facilities/building maintenance. One task of this group included how to address quarantine and isolation needs if the virus spread among community members experiencing homelessness.
Members of the team responsible for developing a plan for individuals who were homeless formed a special task force. The task force was keenly aware from the onset that issues related to substance use would be a primary challenge among the population. Even in the earliest meetings, general discussions began about how they might manage substance dependence among those without housing in the context of city supported alternate care sites.
Fortunately for the community, case counts of COVID-19 were comparatively lower than in many other areas of the world and remained relatively low throughout the spring and early summer of 2020. The task force charged with responding to COVID-19 among those experiencing homelessness initially secured a school gym to temporarily serve the small numbers of individuals who needed to quarantine while awaiting test results. Fortunately, none of the individuals housed in quarantine at the gym tested positive or required isolation, and no issues around substance use or withdrawal presented themselves during these early days. Once this small number of initial suspected cases was managed, the city closed the temporary gym location and began to look at other more accessible and better-equipped locations.
Despite the absence of early cases, the task force continued to anticipate potential challenges. As the local rates of COVID-19 began to grow over the late summer of 2020, the task force secured a larger, more centralized homeless quarantine shelter at the city-owned convention center. Since opening a large quarantine center required extensive setup and staffing, the first few cases of COVID-19 among those experiencing homelessness were managed through a contract with a local hotel that could provide a handful of rooms for individuals to isolate. The city then worked directly with the hotel to coordinate safety protocols and food delivery. This temporary solution was met with a great deal of tension, as hotel staff had difficulty monitoring isolation, and conflict often arose when the quarantined residents attempted to share their temporary housing with others in the community who had nowhere to stay. One participant noted:
The management at the [hotel] were very concerned about the evolving situation and their staff are not medical professionals. They don’t know how to manage it. They just see people coming and going. They didn’t know who was positive, who was not, and they really kind of hit a wall and their ability to manage situation.
It was during this time that an individual who was quarantining in one of the secured hotel rooms was admitted to the hospital with severe alcohol withdrawal symptoms. He proceeded to have a complex, medically managed withdrawal, complicated by his COVID-19 diagnosis, and required several weeks of hospitalization. With no local, medically managed withdrawal services in the community outside of this small regional hospital, the case highlighted the need to have an alternative system in place to avoid filling hospital beds with patients who were withdrawing from alcohol. At this point, the task force began to discuss in earnest how they would manage the risk of alcohol withdrawal and began looking at the academic literature on managed alcohol programs already in place in other communities. Swiftly and collaboratively, hospital administrators, city officials, emergency room providers, and community emergency service workers determined that a plan that provided alcohol withdrawal prevention or management through the supervised administration of alcohol was the best course of action.
While the one withdrawal-related hospitalization highlighted the need to act swiftly, the task force had already laid the groundwork for implementing a harm reduction strategy. Early on, they worked through concerns from members who were less familiar with alcohol dependence, educating them about why alcohol withdrawal is not just uncomfortable, but potentially life-threatening and often requires hospitalization. Members of the task force who were familiar with harm reduction also held early discussions to address potential legal concerns around the liability of a government organization both purchasing and providing alcohol, and protocol concerns about how to prescribe and administer alcohol. One stakeholder noted:
We wanted to bring them articles about this being done in other places. People were worried about what would happen if more harm came to people after we administered them alcohol – like what would happen if the city gave someone alcohol and then they had a negative outcome?
They went on to explain that existing peer reviewed literature on the approach was used with skeptical city officials to demonstrate that MAPs were in fact in practice in other communities.
While planning for a MAP approach was still discussed, Juneau experienced its first significant COVID-19 outbreak among community members experiencing homelessness. At the same time, it became clear that the hotel contract was neither working effectively, nor were there enough rooms to meet the growing need. A decision was made to quickly move the small number of residents temporarily housed at the isolation hotel to the larger community convention center. Given the speed with which the new shelter site needed to be set up, the City collaborated with the local hospital to temporarily staff the site. Registered Nurses acted as “site supervisors” and behavioral health techs and other medical paraprofessionals, along with members of the city task force, staffed initial shifts at the facility.
At this point, the task force was actively working with medical providers and had discussed a general protocol for MAP implementation. However, the mechanisms and details of this protocol were not yet developed, and this lack of detail raised several questions, such as Who would buy the alcohol? Where and how would the alcohol be stored? What tool would be used to assess need? How would this be documented?
While task force members were drafting protocols, the need to immediately implement the program presented itself. One city official and task force member reported that, “within six hours [of opening the isolation quarantine site] there was somebody actively detoxing, and the skilled nursing didn't really want to watch that happen.” After a brief consultation with the medically licensed members of the team, one task force member went to the local liquor store, purchased some alcohol using his personal money, and administered a measured shot of alcohol to the COVID-19 positive shelter resident entering active withdrawal; the individual quickly improved. This marked the beginning of administering small amounts of alcohol to COVID-19 positive individuals to both prevent withdrawal and support residents’ ability to quarantine by eliminating any need to leave the center to obtain alcohol. A study participant noted:
We couldn't run the risk of people having an adverse event because they didn't have alcohol or taking upon themselves to voluntarily leave and go out into the community with a communicable virus. Okay, so we were trying to ensure that they would stay there and that their needs were met, you know.
Study participants felt that by providing medically recommended amounts of alcohol to alternative shelter residents this intervention reduced both the risk of withdrawal and the risk of increased community transmission by COVID-19 positive patients.
As the number of individuals at risk of severe alcohol withdrawal and needing quarantine shelter increased, the task force set about finalizing MAP administration protocols. Up to this point, the City and the Hospital had already consulted with their legal departments about risk management concerns. Interviewed stakeholders reported that legal counsel acknowledged the unique circumstances COVID-19 presented, as well understanding that a MAP approach provided for less risk than did the alternatives of hospitalization or failure to isolate while positive for COVID-19. An emergency room doctor who was consulting with the task force issued a standing set of orders, a general “prescription” for up to four two-ounce doses of whiskey or vodka to be administered every 24 h, three with meals, and the remaining dose available as needed.
Participants reported that the task force adopted a set of screening questions to determine MAP eligibility: (1) Do you drink alcohol?; (2) Do you drink more in the morning to stave off withdrawals?; (3) How much time passes between drinks before you begin to go into withdrawal?; (4) Have you ever had a seizure? If yes, was it while you were withdrawing from alcohol?; and (5) What are your goals related to your alcohol use? Do you want to cut back? Individuals answering “yes” to both question “1” and any of questions “2” through “4” were determined eligible for the program. During assessment, if an individual was believed to already have alcohol in their system, either because they had just arrived and endorsed use or demonstrated significant slurred speech, unstable balance, erratic behaviors, and a strong smell of alcohol, the protocol allowed the team to delay administering doses of alcohol. If site staff or the site manager were ever in question about the appropriateness of administering a dose of alcohol, they were able to call on city Emergency Medical Technicians (EMTs) to come and assess the patient for levels of intoxication or withdrawal. One participant commented on the decision to co-locate the local EMT COVID-19 response team in the ballroom in the same building as the temporary quarantine site:
[the EMTs] are now on one of the conference rooms and so that added, you know, another 24 seven medical presence and it's like a home base for the mobile integrated health and care so they'll stop by as needed on routine checks…it has been great to be able to communicate between, you know, [quarantine shelter staff] and mobile integrated health to say hey you know something's going on. Maybe you can go and check on this person. And it's been great, you know, they just stopped by and it's been really beneficial for the site assistance and the site managers to know they're there in the neighborhood too.
Hospital officials quickly created a data collection system that included the ability to document a person’s withdrawal risk at admission, MAP eligibility, alcohol administration, resident symptoms related to both COVID and withdrawal, and instances of community EMT calls to check on or monitor patient symptoms.
Successes and challenges
Despite initial task force concerns, there were no negative reactions from the larger community about the MAP. The task force proactively informed the EOC leadership and city officials about the program and armed them with talking points they could use if they received constituent phone calls about the program. The city authored a press release that was posted to their Facebook page. Somewhat surprisingly, there was very little response, garnering just 11 comments, all of which were positive and complementary of the city’s efforts. One commenter even stated, “wise use of harm reduction strategies” as her reaction to the program overview.
Several factors seemed to have contributed to community acceptance and quick implementation of the MAP harm reduction approach. In this case, necessity may have become the mother of implementation. First and foremost, the gravity of the COVID-19 pandemic had already highlighted the need for a “whatever it takes” mindset, perhaps allowing for initiatives and interventions that would previously have been viewed as unacceptable. Within the context of transitioning public schools to online learning, rapidly shifting business strategies, and most community members working from home, the community’s expectation was already in place to understand and accept that what was once taken for granted would need to be addressed differently. Second, despite having no prior plans to implement a MAP, interviewed task force members reported that because they talked “early and often” about the challenges substance use, and in particular alcohol use, would have on residents who were chronically homeless, it may have served to prime all members to act quickly when action was required, enabling consideration of a MAP as a part of a viable and rapid response. Finally, with a community limited to 57 regional hospital beds, with the next closest option requiring a medical evacuation and a two-hour flight, one of the most pressing goals for the community was to keep hospital beds as free as possible to be ready to meet the need should there be a surge in COVID-19-related hospitalizations.
Despite this success, implementation was not free of bureaucratic challenges, the first of which being how to purchase alcohol. Corona Virus Aid, Relief, and Economic Security Act (CARES) funding prevented the purchase of alcohol, and long-standing city policy and procedures also restricted the purchase. After consultation with city finance, it was decided that the best route was to use the city petty cash system and city general funds, which allowed for internal approval and did not require the use of city purchase orders, checks, or purchase cards. The task force received administrative level support for a short-term approval to purchase alcohol, and one task force member took the lead on purchasing and seeking reimbursement through the EOC approved process.
It was not surprising that a broad concern among stakeholders was how residents of the quarantine shelter facility would react to having alcohol available. Study participants wondered: Would there be conflict between residents on the alcohol protocol and those who weren’t? Would it be challenging to set limits on the amount of alcohol that could be administered? Would there be pushback they would have to manage regarding access to other legal drugs such as tobacco and cannabis? How would they know if residents were only taking the staff provided alcohol and not consuming their personal alcohol? Several participants described a vague feeling of holding their breath waiting for something to disrupt the process. One task force member noted that there was an initial period where alternative shelter staff felt some of their concerns were materializing:
By the next morning word on the street was that there was alcohol being provided at Centennial Hall, and so people would just be walking by the parking lot and coming up to the outdoor area and saying, hey, can I have some and so we had to be like, no, we're, we're working on the protocols to make sure that it's for this program and prescribed by a health care physician.
Despite initial participant concerns that people might seek to abuse the system, this did not occur. Another study participant, one who provided direct services noted:
I'll just tell you, overall, like I remember it being this big deal like, oh you know even when I would tell people that I know like, well, we're giving people shots of alcohol at this center people would say “wait you're doing what?” you know? But my overall impression was we never had any issues, really. I mean, there was nobody that I saw abusing the protocol and it kept them happy. And it kept them there. We never had anybody go into withdrawals. It seemed to work really well.
Shelter staff noted that some residents asked why the city did not also provide cannabis. However, after a few days even these gentle pushbacks ceased, and the general, and the general response to the MAP, both from those receiving the protocol and those who were not, was gratitude for the option. Once alternative shelter residents understood there was a screening process and medical reasoning behind administering the protocol to some residents, requests to be issued alcohol by non-protocol recipients reportedly diminished. Staff had to remain alert to new shelter residents bringing in alcohol with them and adjusted alcohol doses accordingly. Shelter staff further reported that they had strong support from non-drinking residents who were extremely supportive of the provision of alcohol for their friends who needed it. Once site supervisor stated:
I will say one thing, okay, that residents were hugely supportive of those people who needed to be on the protocol being on the protocol. So, there was a little situation apparently overnight. There was a sick gentleman...… and he was extremely symptomatic when I saw him first thing in the morning and his peers who were there with them were so upset that he had not been given alcohol at like a four o'clock in the morning.
Another factor that likely mitigated negative responses from residents was the overall philosophy and approach by the staff. Under the leadership of the task force chair, and because all participation was voluntary and COVID-19 positive residents could leave at any time, the mission of the quarantine facility was to make residents as comfortable as possible so they would choose to stay, keeping themselves isolated and the community safer. The shelter staff developed an outdoor smoking area and provided cigarettes to residents. The outdoor area was setup with double fencing so that residents could be outside, could even see friends or family, but the second set of fencing was set more than six feet out so that quarantine residents and passersby remained physically distanced. Residents that had special food requests were also accommodated, and books, games, and television were all provided to encourage COVID-19 positive alternative shelter residents to remain in isolation for the 10–14-day period. Task force members described how this responsiveness served to build positive relationships with alternative shelter residents and that some were making independent decisions to scale back even the small amount of alcohol they received. Indeed, one site staff member stated:
I noticed that there were people who, from the time they started to when they left, that they kept on their four shots, but there were some that weren’t by the time they left, they weren’t doing as much. We talked to quite a few of them about going into treatment.
Another study participant noted that the client-centered, needs focused way the entire program delivered was different from many of the more restrictive or even punitive systems alternative shelter residents engage with on a regular basis. She noted:
…There's already a sense of defensiveness and push away... but when they can be humanized again --- I think that there's going to be all sorts of benefits --- for everyone. When you can relate to people and connect with people, it is a way of building connection and relationship and trust that and also that people matter, having people have a sense that they matter. That's only going to help them, you know, with the choices that they're making in their lives when people feel better about themselves or feel that connection --- you have so much more potential.
From this participant’s perspective, the program model allowed alternative shelter residents to experience a staff committed to meeting resident needs wherever possible, and believed staff held a genuine concern for the health and well-being of residents. Additional study participants noted they felt this foundation of meeting resident needs could be linked to high compliance, low conflict, and possibly even created the space for some residents to choose to cut back on their alcohol consumption.
Through frequent COVID-19 testing and providing a quarantine site for those who needed to isolate, the virus was successfully managed as envisioned. In total, the Centennial Hall quarantine shelter operated for eight weeks serving 37 individuals, nine of which were provided MAP services. Of those housed, none required hospitalization for either alcohol withdrawal or COVID-19 symptoms. Additionally, no COVID-19 positive shelter residents decided to leave the facility prior to the end of their quarantine period, experienced seizures, or any significant withdrawal symptoms. Local hospital beds were protected during a significant outbreak among individuals experiencing homelessness. During the alternate shelter operation, extensive testing was conducted each Friday to ensure that members of the homeless community as well as the 35–40 staff that were employed at the shelter remained COVID-19 negative. During the eight-week period, no staff tested positive and no new cases were identified among the unhoused. Finally, after approximately two weeks without any new cases among those experiencing homelessness, the site was able to close (but remains ready to be quickly re-opened if needed).
All of these successful outcomes were possible due to a complex systems approach on many levels. Rhodes  discusses risk as being socially situated and that a variety of factors on multiple levels are interacting to increase or decrease risk. In this study, there were several individuals from a variety of systems that worked together to mitigate and decrease risk. A discussion on physical outcomes is shared above, however, there were additional benefits that emerged in other areas. Economically, this intervention had the potential to save on extensive medical costs had there been a surge in COVID19 related hospitalizations, not to mention social-emotional costs to families and community members. The social-relational impacts highlight important relationships and connections made between service providers and between service providers, the unhoused individuals, and local community members. These relationships created valuable awareness, increased compassion, and decreased stigma related to those who are unhoused and experience high needs. Finally, politically, there were individuals who navigated this challenge in a way that decreased tension and found solutions around policies where before there were long-standing barriers. Although the COVID-19 pandemic created and highlighted inequities in health care and access to services for many vulnerable populations, community leaders took all these moving parts into account and found a real and innovative solution.