Demonstration of a mixed social/medical model detoxification program for homeless alcohol abusers

Abstract

Typically, insurance carriers and the federal government (through Medicare and Medicaid) have paid for alcohol detoxification only in hospital settings. This approach, known as the medical or the clinical model, controls detoxification almost exclusively through medication and with medically trained professional staff (DenHartog, 1982). Yet the far less expensive, already widespread for alcohol detoxification may be a viable alternative. Since the early 1970s, studies have documented the safety and efficiency with which most patients can undergo alcohol withdrawal without the use of medications (Whitfield, 1978). Social detoxification also has been demonstrated to be much less costly than medical detoxification (Shaw and Borkman, 1990). Non-medical alcohol detoxification programs have become accepted in the western U.S., especially in California (Sadd and Young, 1986). In 1986, about one-third of persons using detoxification services for alcohol withdrawal received them in residential programs labeled social model programs (Sadd and Young, 1986). However, there have been no published studies of such detoxification programs specifically designed for homeless persons with alcohol-related disorders. The has been described as viewing alcoholism as correctable through behavioral change (Shaw and Borkman, 1990). Distinctions between staff and participants are minimized, and shared responsibility is maximized (Shaw, 1990). There is ample use of reassurance, orientation to the here and now, frequent monitoring of signs and symptoms, and general supportive care (Wartenberg et al., 1990). In practice, most detoxification programs in operation today, such as the one described in the present report, are mixedmodel programs, combining elements of both and medical models. For example, programs may require patients to undergo a medical examination before they can be admitted. The present paper describes and evaluates a mixed social/ medical detoxification facility instituted in a metropolitan area as part of a national research demonstration program for homeless urban alcoholics (Conrad et al., 1993). We describe our experience regarding the safety of medicationfree detoxification of urban homeless alcoholics and discuss the implications of our findings with respect to the establishment of similar programs in other localities. Methods The medical approach treats patients almost exclusively through medication and uses medically trained professional staff (DenHartog, 1982). Treatment of alcohol withdrawal includes abstinence from alcohol, the use of benzodiazepines and/or other medications to treat withdrawal symptoms and vitamin supplements to improve nutritional status, medical surveillance, and treatment of co-morbid medical illnesses (Klerman, 1989). The model, on the other hand, proposes detoxifying in a non-medical setting, does not utilize medications for treating alcohol withdrawal symptoms, and uses medical services only if needed. Such programs are characterized by the following (Wright, 1990): 1. First-hand knowledge and experience are valued as much as knowledge gained through formal education. 2. The relationship between the individual and the program is emphasized. 3. Participants not only receive help but also give it. 4. An AA framework is utilized. 5. Great importance is given to the program's positive, alcoholfree environment. 6. Alcoholism is seen as pertaining not just to the individual, but to his or her relationships as well. The Albuquerque project was one of 13 National Institute on Alcohol Abuse and Alcoholism (NIAAA)-funded demonstration programs for treating homeless alcohol abusers located in metropolitan areas throughout the U.S. (Conrad et al., 1993). Clients were recruited into the Housing and Alcohol Research Team Project (Project H&ART) by staff of a day shelter for homeless persons, by outreach or clinic staff of Albuquerque Health Care for the Homeless (HCH), and by other local agencies that provide services to homeless clients. …