Note: This article from April, 1980 is historically notable as the second cover-story for the then-new JEMS (Journal of Emergency Medical Services). It was my pleasure to write for JEMS for many years after this first article, which was written with my maiden name!

Access to the medical system for the public inebriate often follows the usual pattern for anyone out in public in distress: call an ambulance.

A prehospital team soon finds itself en route on a call which has been designated as "man down." Depending on the system and the available information about the call, the down-and-out drunk may awake to the smell of ammonia and the sight of two paramedics, four firefighters, and a couple of cops looking on with frustration, even disgust.

What is the expense to a city for the full response in this situation? (No one knew it wasn't a cardiac arrest.) What is the expense to a system which does not send a full response on a "man-down" call which is, in fact, a cardiac arrest? The statistics to this dilemma can only be hypothetically offered.

What is the toll taken in psychological energy and anticipatory adrenaline for the responding EMS crews, who might go a hundred times to such calls to net just three true emergencies requiring their skills?

Stress: using lights and sirens increases the chance of an accident 300 percent. Burn-out: "just another drunk." Frustration: this ambulance is not a drunk van. Danger: can any person be expected realistically to give 100 percent to his twentieth public inebriate for the week? Will even the most conscientious paramedics give a thorough physical exam to an abusive, belligerent drunk who is crawling with lice and smells so bad it makes them gag?

Public inebriation, historically a is slowly being criminal act, recognized as a social condition to be run through health-care instead of criminal systems. It is hoped by now that health care workers acknowledge that alcoholism is a disease process and as such requires a medical solution.

However, the inherent problems remains Chronic alcoholism, particularly along "skid row," evokes a variety of emotional responses from the EMS workers who find they are now the ones chosen to clean the public inebriates off the streets. The job is made difficult by symptoms masked by high blood alcohol levels, belligerent actions from the patient, abusive language, and poor physical grooming. And even more distressing to EMS workers is to find themselves continually picking up the same persons who have returned to their drunkenness again and again.

Literature on public inebriation from the EMS viewpoint is remarkably nonexistent, but research into its criminality, life on skid row, and modern trends for treatment has provided some interesting facts which could help EMS workers better cope with this segment of the population.

Relevant points for exploration include the status of decriminalization of public inebriation, detox program developments in various parts of the country, available estimates of cost factors, the statistically "average" public inebriate, and how continual contact affects EMS workers.

Of the estimated nine million alcoholics in the U.S. (plus 20 million persons labeled "problem skid row inebriates drinkers"), number an estimated four to six percent. The legendary skid row dwellers have been typically described as aggressive and independent working men with a great sense pride and self-reliance. These were seasonal workers on America's frontiers who came to the cities in winter from remote logging camps; proud men who enjoyed blowing three months' pay in three days, and then "getting along" until steady labor came again.

Modern skid row dwellers are more likely found to be passive, inept and largely dependent on the government or public institutions for support. They bear a very diminished sense of self-worth and will usually attribute their position to their own personal faults before blaming the "injustices of the social system" as claimed by the old-time hobo ballads. (1)

A Denver study of public inebriates contacted in a three-month period in 1978 showed an average age of 44 years (85 percent over 31 years), 93 percent male, 60 percent with high school education, and 76 percent being Denver residents. Many had some college education. Many received monthly VA pensions or Social Security checks, and often received no local welfare check.

Public attitudes towards the public inebriate have begun to change only slowly and recently. "Throughout the history of our great country, the alcoholic... has been treated as a common criminal rather than the medically ill person that he is. This individual has been thrown at the police and jail system only to be received grudgingly... simply because there was no alternative. (2)

In 1966, alternatives got their first firm foothold when, in Easter vs The District of Columbia, the U.S. Court of Appeals decided that "the public drunkenness of a chronic alcoholic was involuntary and not subject to criminal prosecution." (3)

The federal Uniform Alcoholism and Intoxication Treatment Act which followed states that "alcoholics and intoxicated persons may not be subjected to criminal prosecution because of their consumption of alcoholic beverages, but rather should be afforded a continuum of treatment in order that they may lead normal lives as productive members of society." (4)

The Act, as it is passed within each individual state, provides for special federal funds to implement appropriate continuum of care programs.

Adding to the momentum of change were official statements issued by the American Medical Association (in 1956) and the American Bar Association (in 1975) stating that alcoholism and public intoxication is a disease.

Of some surprise, therefore, is the fact that twenty states have not yet decriminalized public inebriation. In these states (see Figure l), the law enforcement agencies must still spend time, money, and emotional energy dealing with an element of the population recognized by national organizations as sick people.

As taxpayers, health professionals might be interested to know where many of their law enforcement dollars are going while public inebriates still endure the no-treatment, criminal route.

For example, in a six-month study in 1971 in New Orleans, two and a half to four hours of police time were required for each "drunk arrest." At an annual average of 7,500 to 9,000 arrests, this totals 20,000 to 36,000 police hours per year.

Public inebriates interviewed there (average age 46.4 years, 86 percent Caucasian, average education 9.3 years) showed a "severe lack of existential concern," and 52 percent had been arrested more than 50 times in New Orleans alone. Their average conviction rate was fourteen times annually.

According to the study, "at any given time, approximately 60 percent of the offenders in Central Lock-up and 75 percent of those in the House of Detention in New Orleans are 'revolving-door' alcoholics."

The estimated cost to New Orleans in 1971 for these "criminals" was between $700,000 and $1,100,000- "an extraordinary expense for a 'no-treatment' program." (5)

Public inebriation is still considered a crime in Louisiana in 1980. Nationally, in 1971, the number of arrests strictly for "drunkenness numbered 1,804,900 for a total cost to the criminal justice system of $108,300,000. (6)

The need for decriminalization of public inebriation, then, seems obvious; criminal handling is detrimental to society by cost and effectiveness, and to the public inebriate, who needs medical treatment, not stigmas.

But how is this access to medical treatment to be gained? The expedient answer for many is to call an ambulance—a call often taken as "man down." While not necessarily a criminal, neither is the public inebriate automatically an emergency patient, and the consequences of labeling him as such can be seen in the frustrated and angry attitudes of the prehospital responders.

These attitudes are illustrated in Salt Lake City, where four paramedic squads operate, but only one in particular covers skid row. Dr. Jeff Clawson, medical advisor to the paramedics and former paramedic himself, senses a difference in the attitudes of the paramedics who work skid row. "Dealing with this population takes its toll," he said. "It wastes a lot of energy and sours the men because they see a less appreciative population."

A recent newspaper article about a seminar dealing with burn-out cited a case where two EMS workers, angry at having to transport a wino, decided to take him for a never-to-be-forgotten ride. The ride precipitated a heart attack and killed the wino. (7)

Paramedics are angry, perhaps, because they are frustrated that the old revolving door concept has been "dumped" on them. Few can deny that they have at least witnessed aggressive dealings with the public inebriate because of this frustration. "Aggression (is)... the motor counterpart of the affect of rage, anger, and hostility... It is pathological when it is unrealistic... non-problem-solving, and the outcome of unresolved emotional conflict." (8)

The emotional side of coping with the public inebriate is, granted, subjective and unsubstantiated. Many theories can be offered regarding the attitudes of people in EMS—extending beyond paramedics to emergency department nurses and physicians—toward the public inebriate. But anyone whose system contacts this segment of the population frequently will probably agree there is a distinct attitude reserved for the public inebriate. "Low levels of satisfaction are significantly related to jobs with repetitive kinds of tasks or to tasks in which the employee has little choice.” (9)

What EMS personnel can take to heart, perhaps, is that there is a slowly expanding ray of social enlightenment improving the outlook for the inebriates and EMS workers alike.

Concomitant with the transfer of public inebriate status from criminal to societal responsibility has been the implementation of some impressive programs for alcoholics.

"One of the most important concepts for many people to grasp is that alcoholism is a chronic disease which is no easier to learn to deal with than diabetes or heart said Jean Bauman of the disease," Denver CARES (Comprehensive Alcohol Rehabilitation and Evaluation Services) project.

Colorado enacted its statute decriminalizing public inebriation in 1974, and established the continuum of treatment called for by the federal Uniform Alcoholism and Intoxication Treatment Act it is based upon.

Of particular pertinence to the rest of Denver's EMS community was the institution of the Emergency Service Patrol, commonly known as the "Van" in March, 1978. The service began 24-hour patrol in 1979. The Van is November, manned by two state-certified EMTs. It transports "clients" (as they are called) to one of two RN-staffed evaluation units, one at Denver General Hospital, the other at the nonmedical detox center at another location.

Clients find themselves transported when the Van spots a down-and-out inebriate while on patrol of the three skid row areas, or when it is called by the Denver police.

The Van provides an invaluable service to the rest of Denver's EMS system by picking up an average of 22 to 25 clients each day who would otherwise have to be transported by ambulance. The Denver paramedics are called by the EMTs or police only if they are concerned about the public inebriate's immediate condition.

Thus, a crew whose job description entails picking up the public inebriates has precisely that expectation for their work hours, while the paramedics are alleviated at least partially from the task and can provide better medical coverage to the city. In the event that the Denver paramedics are the first to contact a person who is "just drunk," they can call in the Van. Another option available is to transport the public inebriate sitting up, leaving the paramedics "in service" for an emergency call while en route to the hospital.

Once clients reach the Denver CARES system, options are provided to actively motivate them to detoxify, or merely to seek "shelter" where they are safely off the street for the night. Of the sixty non-medical detox beds, ten are for women; of the forty shelter beds, two are for women.

After initial evaluation by an RN, if a client wishes to detoxify, there follows an impressive program of multi-faceted treatment geared to help the client stay motivated to stay off the booze.

If a person's condition warrants medical intervention (i.e. seizure history, cardiovascular or pulmonary disease or anything requiring any medication), the client is evaluated at Denver General's Alcohol Emergency Room, established in 1973 to lighten the workload of the regular ER staff. The AER is staffed' by nurses specially trained in problems related to alcoholism who provide medical and psychological screening of alcoholies. Of the 400 patients seen each month, 58 percent are involved in "enough physical and psychosocial crisis to require in-patient treatment" (10) The average stay in medical detox is five days per patient.

Does this seem like a lot of effort for what in the minds of many EMS workers amounts to the same public inebriates rotating through the system month after month?

According to statistics offered by Jean Bauman of Denver CARES, 33 to 35 percent of the clients want only to stay in the shelter. Some of these people are seen 14 times a year, others as often as weekly or nightly. These are the true "revolving door" alcoholics, the ones with whom EMS workers find themselves on a first-name basis.

Encouraging, however, is that 60 to 65 percent of the clients (note: not all necessarily alcoholics from skid row) choose the detox program, go on to halfway houses, and very often do "get better" within three or four trips back to detox.

What does "get better" mean? The skid row inebriate is "... at the bottom of the social and economic ladder: he is isolated, uprooted, unattached, disorganized, demoralized, and homeless.. (11) If any program can return a person to even a small level of productivity, then that person, and society in general, is a little better off. Many return to work; indeed, says Bauman, "Few of our clients are on welfare. They want to work."

Denver CARES is patterned closely to the federal model, according to Bauman. There are other excellent treatment-oriented systems, too, even in states which have not yet decriminalized public inebriation. Other programs cited for their continuum of care include: New York City's Manhattan Bowery Corporation; the Crossroads Center in Erie County, Pennsylvania (a non-decriminalized state); and the Comprehensive Alcoholism Rehabilitation Program (CARP) in West Palm Beach, Florida.

Salt Lake City's Dr. Clawson states that last year's effort to decriminalize in Utah failed, and that a public inebriate is currently delivered to jail for booking, and the magistrate later makes a decision whether to send the inebriate to detox.

In several locations which still find public inebriation illegal, local efforts to provide "alternatives to incarceration" show encouraging attitudes. In Virginia Beach, Virginia, a public inebriate died in jail for lack of proper medical attention. The family sued the city, and won an undisclosed sum of money in an out-of-court settlement.

The family then told the city that for each city dollar spent on "alternative to jail" services for public inebriates, it would reduce the settlement by three dollars. If a treatment-oriented system becomes fully implemented in Virginia Beach, the city can also expect to save the $75 per day cost of jailing the public inebriates (total cost in 1978: $100,000), as well as the cost of repairing damage to police cars, jail cells, and injuries to police officers. (12)

In Montgomery County, Pennsylvania, southwest of Philadelphia, the 600,000 residents are served by a small, 27-bed hospital oriented strictly to alcohol, drug, and psychiatric emergencies. Police in the 57 included precincts are made aware of the hospital to the point that 46 percent of its clients come through law enforcement channels. When necessary, an ambulance staffed by Advanced Red Cross first aiders and EMTs can go into the field to medically stabilize a patient for transport. If advanced life support is needed, an RN joins the team.

"We are an alternative to incarceration," said Naomi Dank, Ph.D., Acting Executive Director of the service. "All we ask is at least to evaluate the person first" before going to jail. "We are fully licensed as a detox center, and have a psychiatrist on duty twenty-four hours a day,” she said.

The Mental Health and Mental Retardation (MHMR) Emergency Service described here is funded mostly by third party payments, most notably Medicare, Medicaid, Blue Cross, and other health insurors.

Dollars spent to medically treat the public inebriate can only be estimated. The Denver CARES budget for 1978 was $2,301,200 ($70,000 for the Van). In 1971, total social welfare expenditures nationally were $259.9 billion (24.2 percent of the Gross National Product). Of this, the total estimated expenditures for alcoholism treatment and rehabilitation by governmental, public, VA, and general institutions was $643.8 million. (13) Costs attributed to alcohol abuse in general are noted in Figure 2.

Public inebriation is a lifestyle which will always present to society, and especially to health care workers, the challenge of finding tolerance and understanding despite other overriding attitudes.

Alcoholism, as a chronic disease, does not really have a place on the roster of acute illness or injury; public inebriates who have been assaulted, have head trauma from stumbling to the pavement, or are otherwise medically decompensating, of course, have a definite place in the emergency medical services.

Yet, to an extent, EMS specialists will continue to discover public inebriates frequenting their ambulances and emergency departments when "just drunk."

As the 1980s begin, three options of care for the public inebriate are jail without medical notable: evaluation and care, detox as an alternative to jail in some non-decriminalized locations, and continuum of care, treatment-oriented services.

As this last level of care crawls into first place on the list of options, it is hoped EMS workers will see more singularly focused transport systems bypass the ambulances and emergency departments altogether, except when their services are needed. People trained in, and paid specifically for, dealing with people from skid row will assume the task now usually performed by the people trained and paid for delivering sophisticated emergency medical services.

And, in the long run, the public inebriates will find themselves better able to cope with their disease of alcoholism, because for the first time ever, their treatment will be strongly bolstered by an element of humanism.

Bibliography

Bahr, Howard M. , ed. Disaffiliated Man: Essays and Bibliography on Skid Row, Vagrancy, and Outsiders. (Toronto: University of Toronto Press, 1970).

Berry, Ralph and Boland, James. The Economic Cost of Alcohol Abuse. (NYC: The Free Press, 1977).

Brennan, Tim, Ph.D. Final Report: General Population Survey on Alcohol and Drug Abuse (Boulder, Colorado, February, 1974).

Dilts, Steven, MD and Berns, MD and Casper, Edmund, MD. "The Alcohol Emergency Room in a General Hospital: A Model for Crisis Intervention." Hospital and Community Psychiatry. (Vol. 29: 12, December, 1978).

Lathrop, Vallory G. "Aggression as a Response." Perspectives in Psychiatric Care (Vol. XVI:5-6, 1978).

Mello, Nancy and Mendelson, Jack. Recent Advances in Studies of Alcoholism (Washington, D.C.: National Institute of Mental Health, 1971).

Moser, Joy. Problems and Programmes Related to Alcohol and Drug Dependence in 33 Countries. (Geneva: World Health Organization, 1974).

Pittman, David J. and Gordon, C. Wayne. Revolving Door: A Study of the Chronic Police Case Inebriate. (Glencoe, Illinois: The Free Press, 1958).

Siegel, Harvey H. Alcohol Detoxification Programs: Treatment Instead of Jail. (Illinois: Charles Thomas, 1973).

Stamps, Pauta L., et al. "Measurement of Work Satisfaction among Health Professionals.” Medical Care. (Vol. XVI:4, April 1978).

Footnotes

1. Howard M. Bahr, Disaffiliated Man: Essays and Bibliography on Skid Row, Vagrancy, and Outsiders (Toronto: University of Toronto Press, 1970), p. 29.

2. Harvey H. Siegel, Alcohol Detoxification Programs: Treatment Instead of Jail (Illinois: Charles Thomas Publisher, 1973), p. V II.

3. Pamphlet: "Jail is the Wrong Place to be for Public Inebriates," (National Coalition for Jail Reform, Washington, D.C., 1979)

4. Ibid.

5. Nancy Mello and Jack Mendelson, ed., Recent Advances in Studies of Alcoholism (Washington, D.C.: National Institute of Mental Health, 1971), pp. 732-36.

6. Ralph Berry and James Boland, The Economic Cost of Alcohol Abuse (New York City: The Free Press, 1977), p. 172.

7. ' 'Workshops Treat Burn-out," The Sunday Denver Post, December 30, 1979.

8. Vallory G. Lathrop, ' 'Aggression as a Response," Perspectives in Psychiatric Care (Vol. X VI: 5-6, 1978), p. 203.

9. Paula L. Stamps, "Measurement of Work Satisfaction Among the Health Professionals,” Medical care, (Vol. XVI:4, April, 1978), p. 339.

10. Steven Dilts, et al., ' 'The Alcohol Emergency Room in a General Hospital: A Model for Crisis Intervention," Hospital and Community Psychiatry (Volume 29: 12, December, 1978), pp. 795-796.

11. David J. Pittman and C.W. Gordon, Revolving Door: A Study of the Chronic Police Case Inebriate (Glencoe, Illinois: The Free Press, 1958), p. 145.

12. Interview with Judith Johnson, Executive Director, National Coalition for Jail Reform, January, 1980.

13. Berry and Boland, pp. 160-167.