January 22, 2009 News » Cover Story

Drunk tank 

Emergency rooms will soon be the only safe local place for chronic substance abusers to crash.

Come Feb. 1, Colorado Springs will lose its detox facility, the Lighthouse Assessment Center.

In part, the closure will happen because back in 2007, El Paso County pulled more than $200,000 in annual support from the $3 million-a-year operation. In larger part, it will happen because voters decided in November against County Initiative 1A, which, among other things, would have pumped $900,000 into detox in 2009 and 2010 and more than $1.5 million annually thereafter.

In largest part, it will happen because Pikes Peak Behavioral Health Group has been running the 30-year-old operation at a loss since 2002, when it was re-configured as a community collaborative. The model, they decided, was not sustainable.

"Even if 1A had passed, it would have been a Band-Aid," says Joe Michaels of PPBHG. "We were still losing north of $1.4 million a year on that service."

The beleaguered program, which also has relied on state funding and contributions from local hospitals and charities, still was insufficient for the needs of Colorado Springs, rated by Men's Health magazine in November 2007 as having the nation's third-worst alcohol abuse problem. According to PPBHG data, El Paso County provided only .44 detox beds per 10,000 adults, as compared to Boulder's .87, Pueblo's 1.66 and Denver's 1.71.

Detox community partners have conceded the battle to keep the Lighthouse afloat. Now those partners, including local law enforcement and health care providers, are scrambling to put another facility in place with an existing fund structure of only $1.5 million. While they work out details in the coming months, local emergency rooms will have nowhere to divert chronic substance abusers.

Assuming you aren't one of these "frequent fliers," why should you care?

If you have an accident or illness, you could see longer waits in ERs and delays in police, fire and ambulatory services. On the back end, you can expect your health insurance premiums to rise, beyond the usual yearly increase, to cover the cost of those inebriates unable to settle their hospital bills.

"If you talk to the general citizen on the street, they're going to say, 'What alcohol problem?'" says Jeannine Holt, executive director of the Harbor House Collaborative, a program that houses and helps rehabilitate chronically homeless substance-abusers. "Unfortunately, or fortunately depending on how you look at it, we do a really good job of hiding those people. As a result, the general population doesn't really think it's an issue."

According to every industry person with whom I spoke for this story, that will change Feb. 1.

'Amateur night'

It's just past 10 p.m. on Saturday, Jan. 3, and Penrose Hospital's main ER, just south of Fillmore Street, has yet to see its first drunk. This is odd. Across downtown, Memorial Hospital, which handles more volume, already has processed its fourth.

But the cold, snowy night is young. It's usually not until the last bars close at 2 a.m. that there's a rush.

Registered nurse Erica Prescott checks a large, flat-screen patient monitor hung over the main nurses' station, a long island of open office space from which private rooms, hallways and the ambulance bay jut off. With five years of ER experience at Memorial and another year at Penrose, she's familiar with our city's substance-abuse problem. On an average night, she says, she sees between five and 10 drunks, who far outnumbers other substance abusers. At one point three nights ago, on New Year's Eve which she calls "amateur night" she says she and nine other nurses and co-workers babysat 12 drunks at once, on top of caring for other emergency patients.

That night, the Lighthouse, which is a $6 cab ride away from Memorial's ER off Pikes Peak Avenue, had long since gone on "divert" and refused to take any more patients. Memorial main and Prescott's own ER had done the same. That forced eight ambulances north to the new St. Francis Medical Center.

Chronics arrive mostly by ambulance or police car; overzealous partiers often have a friend drop them off. All first require a triage assessment. Doctors and nurses check for injuries that patients may not be aware of or able to communicate, and rehydration begins.

Usually, says Prescott, patients' pulse rates are elevated and their blood sugar is low. Some people just need to eat some cheese and crackers, throw up "yes, I've been painted a time or two," she says and sleep it off. Others may need something more aggressive, like a stomach-pumping. As they start withdrawing, chronic drunks could have seizures or develop DTs (Delirium Tremens), a hallucination-prone fit that can be fatal if not treated properly.

(According to Matt Parkhouse, a registered nurse and Harbor House board of directors member, withdrawing from alcohol is worse than withdrawing from heroin, cocaine and meth: "Two to four days post-last-drink is the scary time," he says.)

When inebriated patients turn belligerent or violent a daily occurrence hands converge to provide restraint and deliver calming medication. The longer that ties up staff, the longer other patients with less urgent needs wait. In extreme cases, that could be three to four hours. (Patients experiencing serious trauma still are treated immediately, Prescott assures.)

Drunk patients commonly spend two to four hours in the ER. To earn a discharge or ticket to detox, they don't have to be literally sober, just clinically sober a call made by the nurses and docs. Usually when they're walking straight and talking without slurring, they're good to go.

"Professional drinkers leave with pretty high blood alcohol [content]," says Prescott.

Once the ER has stabilized a chronic, his or her next stop is the Lighthouse. If the Lighthouse's 20 beds are full which happens roughly 200 hours a month, according to emergency physician and American Medical Response (AMR) medical director Dr. David Ross patients have nowhere else to go, and the ER turns into one expensive flophouse.

Ross has broken away from scribbling documentation at the main nurses' station to cram into a small office with me and my Penrose guides, director of emergency services Teri Mandell and public information officer Stacey Knott. In his day shift, Ross says, he managed four acute (and belligerent) alcohol patients out of 25 total patients. By nightfall, he'd put three back on the street and forwarded one to detox. On busier nights, when the drunk load spills out of a closed-door, somewhat isolated, four-bed psychiatric unit, Ross and the ER staff place the drunks in hallway chairs.

"It's not good care, and it puts us at a liability risk ... we hope we don't miss some pathology," he says, referring to, say, a bump on the head or underlying illness.

ER physician Dr. Shawna Langstaff, who happened to be the one lucky doc who started the new year with those eight, near-simultaneous drunk arrivals at St. Francis, voices the same concern that everyone in the ER has echoed: After the Lighthouse closes, and before something else is in place, the drunks will solely be the ER's burden.

"Even those with serious medical issues are going to be waiting longer," Langstaff says. "That'll be frustrating for everyone patients and staff. The concern I have is that, literally, we won't have enough space or staff to care for all the people we need to. That's a little frightening. When we get dozens [of drunks] sitting in the hallway in chairs, it's a bottleneck for the entire system."

Don't say the Q word

At 11 p.m., I arrive at Memorial Hospital to meet with my PR escort, Chris Valentine. Soon after, a 20-something wheels his way to a house phone. He reaches a dried-blood-stained hand to dial, then begins bragging to a friend about how he busted a window. When the person on the other end says something he doesn't like, his loud "Fuck you, then!" raises brows over a few bored eyes in the waiting area.

Valentine arrives, and as we enter the ER, we're passed by an older, slightly grizzled man who I can only assume is one of the chronic drunks tied into this detox debacle. (Because of the Health Insurance Portability and Accountability Act, or HIPAA, with which hospitals are very strict, I've agreed not to pursue individual patient information.) A staff member in scrubs is escorting him to an awaiting taxi outside, bound for the Lighthouse.

Once inside, I learn that the older man is the second-to-last patient admitted to detox. Another of Memorial's current drunks will depart shortly thereafter to fill the last bed, prompting a divert order around 11:45.

Memorial's two-year-old ER stands in stark contrast to Penrose's, which is smaller and more conventionally designed. Having replaced an outdated space designed to serve 25,000 patients annually (versus the 100,000 that Memorial actually was serving, according to Valentine), this new one treats roughly 300 patients a day and boasts 62 beds and a lock-down, six-bed intoxication and psychiatric unit removed from the pediatric, trauma and "fast-track" areas.

"In the old days," says Valentine, "there'd be a child, a drunk and a heart attack side by side. The kid would learn a few new words."

When Valentine and I arrive, the only drunk in the unit naps on his side in one of the beds, hooked by finger to a pulse oximeter for monitoring. When I comment that it appears to be a quiet night, a nearby security guard says, "We don't usually use the 'Q' word."

That word, unlike my presence, tends to be a jinx. And as for an entire night of quiet on the alcohol front, the guard says she's only seen it maybe 10 times.

She's been at Memorial for eight years.

When chronics arrive, she searches them for weapons and tobacco (both of which can be reclaimed upon exit). She tries to de-escalate situations as they arise, but says she has to use restraints almost every shift. When the staff drugs patients to calm them, she notes, that usually creates a longer stay and occupancy of the bed.

Soon, John Altenburg, the charge nurse on duty, joins us. If ER were an orchestra, Altenburg would be conducting. He carries a walkie-talkie, which he raises to his ear every time a dull bell sounds over the intercom, signaling the arrival of a new ambulance. Twice while we speak, he excuses himself to relay orders.

Altenburg repeats many of the concerns I've just heard at Penrose and says that he, too, is apprehensive about the transition coming with the Lighthouse's closure.

"Then again," he says, as if reaching for reassuring words, "we can only take so many."

What happens if both main hospitals, as well as their sister operations up north, fill up and go on divert?

"Then we all have to come off divert and make do," he says.

Asked what he'd wish for in a Lighthouse replacement, if he could wave the proverbial magic wand, Altenburg replies, "I'd like to see the ones who come in and really want the help, get the help. More social services. With trying to change your life, it's an individual thing. It takes a big individual to decide that. A lot of them just aren't ready."

Valentine can speak about that portion of the drunk population. Prior to his eight years in PR, he worked for five years in the field with AMR. He saw plenty of substance-abusers who cracked the system uninsured people who got free care, and who, together, force the insured to pay more.

"You'd pull up and you wouldn't have time to get out," he says. "They'd already opened the back door and they were already getting in, because they do this every day. They know the taxi just pulled up. They'd climb in and lay in the bed by the time you get around and turn the lights on."

Valentine says the paramedics, like the doctors and nurses, have to treat each call seriously, in case a patient is suffering from more than intoxication.

"And it takes a physician to make that call, not a paramedic," he says. "We always brought them to ER first. If you save one patient by treating everybody that way, I think it's worth it."

AMR general manager Ted Sayer agrees.

"These are real people we're dealing with," he says in a later interview. "Yeah, they've got alcohol problems. But they're someone's son, daughter, mom, dad they're still people, who need to be treated with respect and compassion."

As for a magic-wand wish, Valentine says he'd offer beds in a "downstream place" that would never go on divert. The ER, then, would remain a safe assessment point and filter, rather than a "roadblock."

When the light goes out

At 12:30, I meet my next handler, Kevin Porter, outside the Lighthouse. Snow falls heavily around the nondescript, brick complex that houses a mental-health facility (which will stay after Feb. 1) and detox. Few probably know they're here.

We're greeted inside by shift nurse Brenda Roberson, who tours us through the mental health unit, which is separated by a long nursing station from the detox area. Roberson says it's a "miracle" that it's so peaceful at the moment. Her 18 months' experience tells her it won't be long until someone's up and roaming around outside a TV room, flanked by tables and chairs bolted down so they can't be thrown. At this hour, patients can sip Gatorade or read a magazine. Smoking on the patio can resume at 6 a.m.

There are 22 beds in the detox unit, though the Lighthouse goes on divert at 20 to allow for a couple of late walk-ins, should they show withdrawal symptoms that don't require medical intervention, or blow above a .04. (By contrast, .05 earns a DWAI, .08 a DUI.) Incoming patients must also answer "no" on a checklist to 25 other condition symptoms, such as dehydration and uncontrolled nausea, vomiting and/or diarrhea. Detox can administer medications: Ativan for high blood pressure, benzodiazepines for muscle spasms, Flexeril to treat cramps that accompany meth detox.

"This place is here to help people come down safely," says Roberson.

This night, she says, 10 of her patients are chronic. A few doors remained cracked for those on suicide watch. She says many patients mutter things about harming themselves when upset, which earns them 15-minute check-ins throughout the night. In rooms as spartan as these unfurnished except for a bed it's hard to imagine how they could carry through with such threats.

Roberson says her job changes depending on just how drunk the patients arrive, and in what spirit. Like at the ER, the chronic abusers require more care than the accidental college drunk or overzealous payday soldier.

If he or she hasn't been placed on a five-day emergency commitment by an ER doctor (again for being seen as a threat to the self or others), a patient's stay usually ends at 7:30 a.m., after breakfast. Many return after getting liquored up again.

"Ninety-nine percent don't want to be rehabilitated," says Roberson. "They want a hot and a cot. There's some of them that are very entitled. No embarrassment whatsoever. Some call 911 on themselves: 'I'm drunk. Take me to detox.'

"'I know I can always go to the Lighthouse at night,'" she mimics dryly.

"Well, in about 25 days there's gonna be some people I'm afraid's gonna die," she says, voice cracking, "because they're so chronic, they're here all the time."

That was then ...

On Jan. 9, the Detox Coordinating Council, comprised of local law enforcement, heath care and human services representatives, discussed in a closed meeting how to allocate the existing $1.5 million in funding $860,000 from Connect Care (that's state money), $460,000 from Memorial, $150,000 from Penrose and $70,000 from the United Way.

The "cornerstone of the proposed plan," according to a press release issued that afternoon, "is the creation of a 35- to 40-bed social model detox program (minimal medical attention) at Harbor House Collaborative and the potential creation of another 20 to 40 sobering (minimal attention) beds at two local shelters."

The release acknowledged this arrangement will provide "lower levels of medical attention than existing detox services," with the tradeoff being greater capacity outside ERs.

The detox council says Pikes Peak Mental Health will "bolster its intensive outpatient treatment plan, which provides long-term solutions for drug and alcohol abuse and reduces the number of community members in need of detox services." It projects that phase one of the program might be operational by April. But Harbor House's Holt calls that a "very ambitious" projection.

When I visit with her Jan. 12 at Harbor House's downtown office, she notes that nothing from the council's meeting is in any way certain. She's still searching for an appropriate building to house 35 to 40 beds, and she can't enter into a lease agreement until all the paperwork is in place.

"Yet the longer we hold off on acquiring a building," she says, "the farther out we'll be, because we still have to go through city planning, and the building will have to be rehabbed to fit our needs."

She believes she can have a building renovated in less than eight weeks. But first, there's the issue of neighborhoods and businesses that point to another failure of our community: "Nobody wants this in their area. People say, 'Well they're alcoholics, we don't want them in our neighborhood.'

"Well, you know what? They're the only ones in the neighborhood who aren't drinking."

Realistically, she says new detox beds could come as late as summer's end.

"If we'd had six months to plan this and put it in place, we'd have been in a much better place," she says. "Now it's a crisis issue. And that's a problem. There are going to be some people who are left on the streets."

Is that legal?

"Being intoxicated in public is not against the law," says Colorado Springs Police Department Deputy Chief Ron Gibson, a detox council member. "But do we want a community where there's no place to take intoxicated people? If they're intoxicated on the street corner, are we willing to accept that? ...

"At some point, we need to decide what the standard of living is that we want."

Though he's in a very different field, Gibson struggles with the same issue that ER doctors and nurses have allocation of resources. He says police protocol is to send two officers to calls, and that those officers often have to wait for an ambulance to show up for a medical assessment.

"My officers shouldn't be transporting someone not in custody," he says. "As tight as our resources are, when we're running high calls for service, tying up two officers for 30 minutes keeps us from going to other emergency calls."

Gibson points to a program that operates in what Men's Health determined to be the No. 1 city for alcohol abuse in 2007. When confronting public drunks, police in Denver call Denver CARES (which stands for Comprehensive Addictions Rehabilitation and Evaluation Services). The clinically managed treatment facility sends an "emergency service patrol" van with a medically trained person to assess the situation and deliver those not needing ER care to a 100-bed, non-medical treatment center.

"A warming bed that costs 20 to 40 bucks a night when prorated out is a better fit than the ER," says Gibson.

Denver CARES is run by the Denver Health and Hospital Authority, a "safety-net" health system that counts a number of members and operates independently from city government.

"This isn't a single-agency issue," notes Holt. "It never should have been just Pikes Peak Behavioral Health's problem. And it won't become Harbor House's problem. It's a community problem."

Safe harbor

Harbor House was birthed in 2003, out of a community-wide study looking at gaps in social services.

"One of the major gaps," says Holt, "was behavioral health primarily alcohol and substance abuse to the chronically homeless. We were formed to fill that gap. Harbor House is kind of a last resort for people who burned all the bridges everywhere else. They have to be really ready to commit to a change in lifestyle."

As in, no drinking or you're out.

Harbor House functioned for a few years as a "project," fiscally under the umbrella of the Pikes Peak Community Foundation. It incorporated into a nonprofit in February 2007. Since then, it's provided 22 beds in a facility near Knob Hill. The average rehabilitant stays one year, and because of intensive case management, says Holt, Harbor House boasts roughly an 80 percent success rate, which she calls "very high." When participants leave, they leave with a living-wage job as well as deposit and first month's rent.

Last year, Harbor House launched a sister operation, Housing First, which helps chronic substance abusers who are also mentally or physically disabled. In that 35-bed program, participants are placed in permanent housing units and case-managed. They stay until they choose to leave, or until they die, and may continue to drink; not surprisingly, there's usually a three-month wait list.

Holt cites data gathered seven years ago by CSPD's Jim Barrantine and Homeward Pikes Peak's Bob Holmes: It costs the community an average of $54,000 per year to leave a chronically homeless substance abuser on the street. Barrantine says that figure may be a low estimate today.

"In either one of our programs," says Holt, "we can house, case-manage and treat that same person for about $15,000 or less a year."

With programs like these, Holt says most clients have success because they're not dealing with the added stresses of living on the street.

"Yes, they're still costing the community money, but it's charities' funds. It's an appropriate use of the money, and it's a whole lot less expensive than it is if they're using the emergency room all the time."

To those who would naysay these public services as catering to a demographic that chooses to abuse, Holt says, "There comes a point, particularly with the chronically homeless, where it's no longer a choice. It's a coping mechanism."

She, like many in public-service industries, interprets the failure of 1A as a message from people in her community.

"They want all the comforts and a high quality of life, but for some reason, they're proud of not paying for that," she says. "Being the lowest taxing entity on the Front Range is nothing to be proud of. That just says we don't care about our quality of life and our public safety."


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