Alcohol abuse is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) as a destructive pattern of alcohol use occurring within a 12 month period, resulting in repetitive maladaptive behaviour and leading to significant social, occupational, or medical impairment. The alcohol abuser still has control over his/her use of alcohol and has not developed tolerance. Alcohol dependence (alcoholism) occurs when an individual has lost control over his/her use of alcohol and its consumption becomes the dominant focus in his/her life, causing deterioration of occupational, psychological, and/or social functioning.
DSM‐IV diagnosis of alcohol dependence requires users to meet the criteria for alcohol abuse plus have three or more of the following: (1) Tolerance ‐ the need to increase amounts of alcohol consumed to achieve the desired effect; (2) Withdrawal ‐ the experience physiological and psychological symptoms when alcohol consumption is stopped and/or use alcohol consumption to avoid or reduce specific symptoms; (3) Uncontrolled behaviour ‐ alcohol is consumed in larger amts or for longer than intended; (4) Cravings ‐ persistent desire or unsuccessful efforts to cut down or control alcohol use; (5) A lot of time is spent to procure, use, or recover from the effects of alcohol consumption; (6) Important social, occupational, or recreational activities given up or reduced because of alcohol use; (7) Continues alcohol use despite knowledge of persistent physical or psychological problems worsened by alcohol.

Alcohol dependence is a fairly common disorder, with a prevalence of 2.6% in the general Canadian population (Tjepkema 2004). This prevalence increases in vulnerable populations to 5.1% in low income households (annual income <$10,000), and 16.2 % in mentally ill (Kandel 2001; Tjepkema 2004). The World Health Organisation states that approximately 76.3 million persons have alcohol use disorders worldwide (WHO 2007).

Alcoholic dependence is three to four times higher in individuals with a family history of alcohol abuse compared with the general population (DSM‐IV). Furthermore, studies have found that alcohol abuse is as high as 53‐73% in the homeless adult (Cordray 1993; Farrell 2000; Gelberg 1993).

These figures are clinically and socially significant because alcohol misuse (abuse or dependence) influences not only the health and social outcomes of these individuals but also impact their families, local communities and society at large. Alcohol dependence contributes to binge drinking, consumption of non‐beverage alcohol (i.e. mouthwash, cleaning products, cough and cold remedies), violent and/or criminal behaviors, suicide, job instability, poor compliance with treatment, longer hospital stays, homelessness, public inebriation, increased emergency room visits and mortality (Caton 2005; D'Amore 2001; Egbert 1985; Hibbs 1994; Kushel 2001; Mandelberg 2000). The World and Health Organisation (WHO 1999; WHO 2002), estimates that alcohol causes 3.2% of deaths worldwide, with a global cost to health above that of tobacco. Medical consequences of alcoholism include oesophageal cancer, liver cancer, chronic ulcers, cirrhosis of the liver, epilepsy, psychotic breakdown, increased rates of hospitalization, and shorter life expectancy (Hibbs 1994; Kushel 2001; WHO 2002).

Currently, a number of different behavioural interventions are used to treat individuals suffering from alcohol dependence. These include: Traditional Abstinence (zero tolerance), Screening and Brief Intervention, Moderate Drinking, and Managed alcohol (harm reduction).

Alcoholics Anonymous (AA) is the classic example of a traditional abstinence program, whereby a self‐help group of recovering alcoholics offer emotional support and an effective 12 step model for the achievement of abstinence (A.A. 2001). The 12 steps for personal recovery, assume that alcohol dependence is a spiritual and medical disease. It is a zero‐tolerance program that consists of a structured approach to facilitating recovery from alcohol abuse ([A.A. 2001).

Brief interventions involve a time‐limited motivational intervention focusing on changing an individual's alcoholic behaviour. It uses counselling skills to encourage a reduction in alcohol consumption and the problems associated with alcohol misuse. A brief intervention can range from five to ten minutes of information and advice to a maximum of three sessions of motivational interviewing or counselling by a health care professional.

Moderate Drinking is a self‐help program that supports non‐abstinence goals. It relies on the ability of an alcoholic to return to a decreased or more controlled pattern of alcohol consumption due to their own initiative (Doufor 1999). In this program, the onus is on the individual to examine how drinking has affected their life, identify their life priorities, and set moderate drinking limits once they understand what their "drinking pattern" has been (i.e. how much, how often, and under what circumstances). Often the decision to control their alcohol intake is induced by health concerns, family or relationship problems, poor work productivity, or driving difficulties (Saladin 2004).

The successful treatment of alcoholism using traditional abstinence, brief Intervention, or moderate drinking methods is dependant on positive prognostic factors such as good social functioning (i.e. established/functional family relationship, lack of legal problems, employment), motivation, and/or good health status. In contrast, characteristics commonly found in vulnerable populations, such as psychiatric co‐morbidity, lack of stable housing, unemployment, lack of motivation, and/or the presence of chronic medical conditions are negative prognostic factors (Stahler 1995). In order to combat this, harm reduction approaches to the treatment of alcoholism, such as Managed Alcohol Programs (MAP), have gained more attention as traditional treatment methods are not as successful in treating vulnerable populations (i.e. chronically homeless) (Ambrogne 2002).

Harm reduction programs meet the individual "where they are at" to help them (a) understand the risks involved in their behaviour and (b) make decisions bout their own treatment goals. Instead of making abstinence from alcohol an objective, the harm reduction approach seeks to (1) minimize the personal harm and adverse societal effects that alcohol dependence can lead to, (2) provide an alternative to zero‐tolerance approaches by incorporating drinking goals (abstinence or moderation) that are compatible with the needs of the individual, and (3) promote access to services by offering low‐threshold alternatives, which enable clients to gain access to services despite continued alcohol consumption (Marlatt 2002). Following these objectives, MAPs serve alcoholics controlled amounts of alcohol on a daily schedule, as a way to ensure that individuals consume safe alcoholic beverages in a safe environment (Hass 2001; Podymow 2006; Wilton 2003).

Studies have found that MAPs can reduce drinking, the number of hospital admissions, ER visits, and police incidents, while improving the overall health of homeless individuals suffering from alcoholism (Hass 2001; Podymow 2006; Wilton 2003). These studies demonstrate that controlled access to alcohol, in a safe environment may be the most effective treatment for: (1) retaining vulnerable populations in treatment programs, (2) decreasing their alcohol consumption, and (3) show some evidence of effectiveness towards other relevant outcomes such as decreasing criminal activity, seeking regular medical care, and improving quality of life.
To date, there has been no systematic, controlled analysis of the effects of harm reduction programs on treatment of alcohol dependence among individuals classified as vulnerable.

The question of whether harm reduction approaches (i.e. MAP) in the treatment of alcohol dependence results in better outcomes versus more standard treatment regimes (traditional abstinence‐based, brief interventions, or moderate drinking) remains unanswered. In addition, whether the harm reduction approach is more effective in vulnerable populations than the general population is also unknown.

The aim of the present review is to identify, synthesize, and evaluate the effectiveness of a harm reduction approach as compared to the standard treatment programs, in reducing the incidence of harmful behaviours in vulnerable individuals suffering from alcohol dependence.