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‘Everyone should have a home and experience safety and dignity. That is a pathway to healing.’

Researcher Bernie Pauly has devoted her career to harm reduction

By Laura Eggertson
November 27, 2023
Trevor Townsend
“We have complicated cultural feelings about addiction — that ‘people are doing this to themselves’ — rather than understanding addiction as a result of disconnection, or a response to trauma, colonization, and other systemic issues,” Bernie Pauly says.

When Canada released the world’s first guidelines for managed alcohol programs in July, the groundbreaking document was due in large part to nurse/researcher Bernadette (Bernie) Pauly and the Canadian Managed Alcohol Program Study.

For more than a decade, Pauly, a professor at the University of Victoria and a scientist at the Canadian Institute for Substance Use Research, has been the co-leader of the initiative. The community-based participatory research project evaluates the implementation and impacts of alcohol harm reduction, known as managed alcohol programs.

In these programs, people with severe alcohol use problems receive scheduled doses of a safe supply of alcohol, tailored to their individual needs. The programs were developed to reduce the harms of long-term and chronic heavy drinking.

Instead of binge drinking — or drinking mouthwash or rubbing alcohol because they can’t afford anything else — and being denied shelter or other services because they are drinking, participants receive alcohol administered like medicine, delivered in an atmosphere of dignity and respect.

They also receive food, shelter or housing, and have access to other services such as primary care and social and cultural supports.

“The managed alcohol approach is a harm reduction approach, because you don’t have to stop drinking to receive supports and services,” Pauly says. “The goal is to reduce the harms of drinking and homelessness combined. Everyone should have a home and experience safety and dignity. That is a pathway to healing.”

Managed alcohol programs are gaining traction in Canada and around the world. They fill an important gap in services for people experiencing the harms that heavy drinking and homelessness can cause. The programs can also lead to other services, including treatment.

The Canadian guidelines are designed to help policymakers, health-care leaders, affected communities and organizations establish other managed alcohol programs.

Programs double

When Pauly began evaluating the programs, in 2011, there were fewer than a dozen across the country. By 2019, there were 20 managed alcohol programs in Canada. Today, there are more than 40.

“Canada is considered a world leader in this work,” Pauly says.

COVID was partly responsible for the growth in managed alcohol programs. Public health officials endorsed the need for the programs to prevent people from experiencing severe withdrawal symptoms and providing space for them to self-isolate and practise social distancing.

Pauly’s team, whose research showed the programs’ effectiveness, is another significant driver of the expansion in managed alcohol programs.

She and her colleagues demonstrated that people in managed alcohol programs experience fewer life-threatening consequences of withdrawal, such as seizures and delirium tremours. Their legal problems diminish because they have fewer encounters with police.

Without the daily need to figure out how to get enough money to support their need for alcohol — survival drinking — participants can reconnect with family and friends.

Most powerfully, the programs also increase people’s quality of life, stabilized their health, reduced their emergency room visits, and provided them with hope for the future, Pauly says.

The programs fill a critical need for people for whom abstinence either hasn’t worked or those who are experiencing harms and are unable to stop using alcohol, she adds.

Lived experience critical

Pauly credits the advocacy of people with lived experience who work with the research team for leading the hard work of changing systems to better meet their health and harm reduction needs.

Participatory research means communities of people who use alcohol and other drugs shape research questions and guide the research. They identify barriers to accessing housing and other services and highlight the need for changes.

“Communities recognized that they were coming to harm because they were outdoors and they were drinking, and they would be robbed, and often assaulted,” Pauly says. “They realized their histories of drinking were long, they had trauma histories and, in some cases, had been to residential school and were experiencing the consequences of colonialism.”

“There was a need for a program to fill a gap.”

Pauly is committed to the participatory research method — working with communities of people affected by substance use, poverty, and homelessness — to generate new research questions and knowledge in addition to her evaluation of managed alcohol programs.

Her work has had far-reaching policy impacts. She led the development of the Canadian Nurses Association’s (CNA’s) first discussion paper on harm reduction, which informed the association’s position statement on the topic. CNA drew on Pauly’s research during arguments before the Supreme Court in support of Insite, the Vancouver supervised consumption facility.

She chose to work on these issues because she believes everyone is entitled to be treated with dignity and respect and has a right to housing and health services.

Patients denied dignity

Early in her career, Pauly watched as people using substances were denied dignity and respect. As a young nurse in an emergency department, she was deeply affected by the attitudes and treatment of people who required care after they overdosed or because of alcohol intoxication.

“People would say ‘Oh, don’t waste your time with that person. Just get it done quickly, and move on’,” Pauly remembers. “There wasn’t a lot of sympathy or empathy for individuals who presented with substance use related issues or injuries.”

The attitude was systemic, she says. It didn’t jibe with CNA’s Code of Ethics for Registered Nurses, in which promoting dignity, health and justice are fundamental principles that all nurses are expected to uphold.

“We have complicated cultural feelings about addiction — that ‘people are doing this to themselves’ — rather than understanding addiction as a result of disconnection, or a response to trauma, colonization, and other systemic issues,” Pauly says.

The lack of empathy for people using substances didn’t correspond to the values Pauly grew up with, either. There were fewer than 100 people in Major, Sask., where she grew up, but everyone looked out for each other and there was a strong sense of community.

“That was built into my DNA,” she says.

Pauly was worried that if she continued to work in hospitals, she would adopt the behaviours and attitudes she knew were not aligned with her values or the values of nursing. She decided to return to graduate school, where she earned a PhD. She became a professor with an ongoing commitment to building relationships with organizations and groups of people who use drugs locally and beyond.

In Victoria, she has worked with the peer led harm-reduction organization SOLID Outreach for more than 15 years on program and research initiatives. She works closely with East Side Illicit Drinkers for Education, a group committed to improving the lives of people who use alcohol. She also works in partnership with groups throughout the province on other harm reduction research, including evaluating provincial initiatives to introduce prescribed safer supply to reduce harms of a toxic and unrregulated drug market.

The influence of the East Side Illicit Drinkers for Education is reflected throughout the new guidelines for managed alcohol programs, including in the inclusion of a client bill of rights (p. 120).

Research is change

The members of these communities are “amazing individuals who have incredible knowledge,” she says. “They are able to critically analyze systems, and they can quickly tell you what the issues are. That wisdom focuses the research we’re doing and informs practice and policy guidance.”

“We’ve worked as a partner for over a decade together.”

Hearing their stories is a privilege, Pauly says — but it can also take a toll. To keep herself physically and mentally healthy, she walks, hikes, cycles, reads legal thrillers, listens to alternative, folk, and classic rock music. She enjoys spending time with her husband, James, children Brenna and Ethan, and her many “amazing” friends.

Pauly also draws strength from her research partnerships. That’s the reason it meant so much to her when a community member in one of the programs she was evaluating recently thanked her for doing this work.

“Research is change,” the woman told her.

The woman’s acknowledgment of evidence as the pathway to change has become a treasured moment of affirmation for Pauly.

“Meeting the woman outside one of the harm reduction programs — that’s my inspiration to continue,” Pauly says. “I’m not just producing a published paper that sits somewhere, I’m producing something that can be used by and for people, to make changes that can save lives.”

Laura Eggertson is a freelance journalist based in Wolfville, N.S.