Social Model Detoxification in Colorado Background and Issues

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					                                             Colorado Association of
                                               Alcohol and Drug
                                               Services Providers

                               Social Model Detoxification
                                      in Colorado:
                                 Background and Issues

                                                       Adopted: March 2008

Social Model Detoxification in Colorado - March 2008                         1
                                      Contributing Members
                                                  of the
                                       Treatment Committee

                                          Michael Allen, Chair
                                             Connect Care

                                          Marc Condojani
                              Colorado Alcohol and Drug Abuse Division

                                                BJ Dean
                                             Arapahoe House

                                         Mary Joy Kogovsek
                                       Crossroads Turning Points

                                       John Lundin-Martinez
                                   Denver Behavioral Health Services

                                             Sandy McFall
                                             West Slope Casa

                                          Maryann Stanley
                                     Boulder County Public Health

Social Model Detoxification in Colorado - March 2008                     2

In 1973, the Colorado General Assembly passed legislation decriminalizing public intoxication
and creating a system of care to address the problem of alcohol abuse and alcoholism in the state.
This legislation provided for the formation and funding of “Emergency Treatment Facilities,”
using public and private resources to serve individuals who were intoxicated or incapacitated by
alcohol. The statute also established the process for both emergency (short-term) and
involuntary (long-term) commitments for individuals intoxicated or incapacitated by alcohol. In
1991, legislation was passed creating a parallel system for drug intoxication and abuse.

These emergency treatment facilities, known as detoxification programs, were created and
funded as outlined in the original legislation using partnerships between state, regional, and local
governments. These facilities were non- medical programs designed to monitor withdrawal and
refer individuals for ongoing treatment and support. The intent of these non-medical or social
model detoxification programs was to remove intoxicated individuals from the streets and jails to
a setting that protected the client and community at a low cost to the taxpayers. Detoxification
facilities served as economical alternatives to placing the individual in jail or hospitals.
Detoxification facilities often employed recovering alcoholics entering the substance abuse
counseling field and rarely employed individuals with any kind of medical background.

Following the passage of legislation, a number of detoxification facilities were opened across the
state. These principal programs were jointly funded by counties and the state. However, through
the 1980s, communities became increasingly reliant on detoxification facilities. Local law
enforcement became particularly dependent on the detoxification programs as a way to
effectively manage law enforcement officer’s time in dealing with public intoxication. As DUI
enforcement was expanded, the detoxification programs served an increasing number of
individuals who were charged with drinking and driving offenses. Hospitals also felt the benefit
of these programs as the detoxification facilities performed triage functio ns freeing emergency
departments to serve the most medically compromised individuals.

The number of individuals is staggering - over 47,000 people are served each year in the state’s
detoxification programs. Most people (82%) entering detoxification have no prior admissions
and as a result may not meet substance dependence criteria (requiring formal treatment). The
remaining 18% of people entering detoxification have received these services before and are
likely to need treatment and support for their substance abuse or dependence issues.

While not treatment itself, detoxification is a critical part of a larger continuum of substance
abuse services, tackling important individual and public safety needs. The primary goals of
detoxification programs are to manage intoxication and to ensure safe withdrawal from drugs or
alcohol. An important secondary goal of detoxification programs is to assess the nature of the
individual’s substance abuse problem and help motivate them to seek ongoing treatment and
support services.

Social Model Detoxification in Colorado - March 2008                                               3
Issues and Challenges
        Medical Treatment
Over the past three decades, non-medical detoxification programs have served hundreds of
thousands of individuals statewide with a relatively low contribution from state and federal
resources. Although non-medical detoxification programs efficiently serve tens of thousands of
individuals each year, for a small group of people entering detoxification, a social setting is
inadequate. This group is generally composed of uninsured and indigent individuals with serious
medical or mental health problems independent of alcohol or drug use, and those who have
medically complicated withdrawal that places them at grave risk of harm if not medically
supervised during withdrawal. Since detoxification programs are often the first contact with
medically ill people, the increase in medical and mental health acuity has caused strife between
the hospitals and detoxification facilities. This increased acuity has also illuminated the shortage
of services for individuals with more severe medical and mental health issues that complicate
their substance dependence.
        Statewide Accessibility
The availability of social detoxification beds varies by geographic area. Detoxification centers
are generally located within an hour of a major population center; however in rural areas of the
state, people may have to travel for hours to access these services.

Detoxification facilities are a tremendous resource for local law enforcement officials. The time
away from the street protecting the public is greatly increased when a police officer is required to
wait at an emergency department to have someone who is intoxicated admitted, or to even place
such a person in their municipal or county jail.

It is important to have detoxification facilities throughout the state, even in the rural and frontier
areas. In places where they are not available, law enforcement is forced to make the choice
between long transports from their community to the nearest detoxification facility, or to risk
public safety and the safety of the individual by not offering service. Local detoxification
facilities, and/or support for transportation outreach would help to lessen the strain on local law
enforcement, allowing them to concentrate on public protection.
        Appropriate Services for Adolescents
Adolescents are not well served by the current social detoxification programs. Due to their
patterns of use, adolescents are at higher risk to reach dangerous levels of intoxication quickly
and to have other medical and behavioral complications that require management. When
encountering intoxicated youth, law enforcement officers usually choose to contact the parent or
guardian to pick up the youth, take the youth to an emergency department, or to transport the
youth to an adult detoxification program that is not designed to supervise these young people.
This represents a missed opportunity to intervene early with the family on the youth’s substance
use, may be unnecessarily expensive, and in some cases may expose youth to an adult-oriented,
potentially unsafe environment.

Social Model Detoxification in Colorado - March 2008                                                     4
        Treatment Capacity for Follow-up Services
As mentioned earlier, the primary goals of social detoxification programs are to provide a safe
environment for detoxification and to manage withdrawal symptoms. Detoxification centers
serve as a cost-effective and safer alternative to emergency rooms, jails, or the streets for
intoxicated individuals. As such, they serve a public safety function intertwined with law
enforcement and help to preserve community medical resources for those who most need
medical care. An important secondary goal for detoxification centers is to help motivate clients
to move toward ongoing recovery through accessing treatment and support services. They strive
to assess clients’ needs for ongoing treatment and link them with such treatment in the
community. Unfortunately, shrinking treatment resources statewide create particular challenges.
Since the bulk of publicly supported treatment capacity is dedicated to the state and federal
priority populations of pregnant women, IV drug users, involuntary commitments, and child
welfare referrals, very little capacity exists for individuals who are unable to pay for services in
the private system of care. This creates a situation where detoxification centers must release
individuals knowing that it may be weeks or months before adequate follow-up care is available.
In recognition of the heterogeneity of needs and issues across the state, local communities have
worked creatively to fund detoxification services through state and local partnerships. The
primary sources of funding for the detoxification programs are the Colorado Department of
Human Services, Alcohol and Drug Abuse Division (ADAD), counties, municipalities, fees from
clients, and contributions from local hospitals and foundations. Despite the creative efforts of
local communities, funding for detoxification has not kept pace with the increasing demand and
problem severity encountered in detoxification programs. As a result, detoxification programs
across the state struggle to meet the community demands for these services and some are in
jeopardy of closure due to inadequate funding.

Approaches to these Challenges
Over the past ten years, detoxification providers along with hospitals, mental health centers, and
other local organizations, have attempted to address the problems mentioned above in a variety
of ways:
     Ø Crossroads' Turning Points, serving Southern Colorado has 10-bed detoxification units in
       Trinidad and Alamosa and a 20 bed unit in Pueblo. Locating these facilities in less
       densely populated areas increases access to detoxification programs for those who reside
       in rural areas.      All Crossroads' Turning Points detoxification programs work
       collaboratively with area hospitals to provide appropriate medical services and medically
       supervised withdrawal if necessary. Law enforcement agencies, social services agencies,
       mental health agencies, and other community-based organizations all collaborate
       regarding referrals to aftercare services in this area of the state.

Social Model Detoxification in Colorado - March 2008                                               5
        In conjunction with each of their three detoxification facilities, Crossroads' Turning
        Points, Inc. ha s implemented Outpatient CAR (Career Adjustment Required) programs
        for chronic substance abusers who have had multiple detoxification episodes. CAR is an
        intensive case management program including individual, family, and group therapy,
        community referral services, and a shelter component. The CAR program is particularly
        helpful to homeless chronic substance abusers. Over the course of the past 5 years, CAR
        has increased the number of clients who enroll in treatment following a detoxification
        stay demonstrating that specialized efforts to engage individuals who are repeat users of
        detoxification can be effective.
    Ø Western Slope detoxification centers have a long history of collaboration in funding and
      in-kind resources with municipalities, county governments, and local hospitals.
      Detoxification centers in Frisco, Steamboat Springs, Glenwood Springs, Grand Junction,
      Durango, and Cortez are operated by mental health centers and private substance abuse
      treatment providers. Cooperative working arrangements with local hospitals provide
      appropriate medical services and medically supervised withdrawal when necessary. Law
      enforcement, community corrections, and municipal governments collaborate with each
      detoxification facility to avoid duplication of services. The detoxification center in
      Grand Junction is partially funded by ADAD and operated in a mental health facility,
      enabling the provision of mental health services in addition to follow-up services for
      substance use. Similarly, the Detoxification Center of La Plata County in Durango is co-
      located in an Acute Treatment Unit, providing integrated services for clients with co-
      occurring substance abuse and mental health disorders.
    Ø Northern Colorado: Island Grove Regional Treatment Center, Acute Care Services (ACS)
      is the detoxification center serving twelve counties in the northeast corner of Colorado.
      Presently ACS is collaborating with North Range Behavioral Health to integrate mental
      health acute treatment services and detoxification services to create a Crisis Stabilization
      Unit. It is expected that this integrated program will be operational toward the end of
      2007 and will enhance the services available to individuals with co-occurring intoxication
      and mental health symptoms.
    Ø   Denver C.A.R.E.S. (Comprehensive Alcohol Rehabilitation and Evaluation Services) has
        provided detoxification, assessment, education, motivational counseling, and referral for
        intoxicated individuals in the City and County of Denver since 1976. As the only
        detoxification center for public inebriates in the City of Denver, Denver C.A.R.E.S.
        admits nearly 500 clients per week – many of whom have previously received
        detoxification services. The majority of repeat clients have severe alcohol and other drug
        abuse problems in addition to chronic physical and mental illness. A large portion of
        human and fiscal resources are spent on a small number of clients who are admitted
        repeatedly and have issues with chronic homelessness, escalating substance abuse and
        declining health. Denver C.A.R.E.S. has been successful with a portion of these clients
        and has engaged them in treatment by developing community collaborations to address
        their specific needs. Recently, Denver C.A.R.E.S., in collaboration with the Denver

Social Model Detoxification in Colorado - March 2008                                             6
        Department of Human Services, Arapahoe House, the U.S. Dept of Veterans Affairs and
        the Colorado Coalitio n for the Homeless, has added an additional 63 residential treatment
        slots as well as 45 housing vouchers designed to address the needs of this hard-to-reach
    Ø In 1990, Arapahoe House developed the Program to Reduce Over-Utilization of
      Detoxification (PROUD) under contract with ADAD. Case managers work in
      conjunction with the three detoxification centers operated by Arapahoe House in Aurora,
      Wheat Ridge and Commerce City to identify and assist individuals with severe substance
      dependence that rely on detoxification for food and shelter. PROUD has been successful
      in reducing detoxification admissions among individuals with substance dependence
      through intensive case management. PROUD serves the metropolitan Denver area.
    Ø Also within the metropolitan Denver area, Arapahoe House has developed partnerships
      with hospital emergency departments to transport intoxicated individuals who no longer
      require medical care from the hospital to the local detoxification centers. This provides a
      more cost effective and clinically appropriate alternative to monitoring these individuals
      in emergency departments.
    Ø Boulder County has one detoxification center in the City of Boulder serving the county.
      The Detoxification Center is operated as part of Boulder County Public Health (BCPH).
      Funding is blended from the state MSO contract, county and client fees. There is a strong
      history of collaboration among service providers within the county and very close
      working relationships with the agencies who serve similar populations such as the
      homeless shelter, hospital, jail, and local health clinic. In addition, relationships with the
      City of Boulder, Boulder Police Department, Boulder Community Hospital, and the
      Mental Health Center of Boulder and Broomfield Counties have been critical to safe and
      responsible services. The Boulder County detoxification center co- located on the
      grounds with the Boulder County Jail in October 2007 thus increasing opportunities for
      collaboration between these systems. Transitional Residential Treatment (TRT) beds
      located on site allow for an extended stay during the transition to treatment services.
    Ø In 2003, Pikes Peak Mental Health, plagued with financial and social detoxification
      challenges, turned to their main stakeholders in the community in order to: (1) identify
      the special needs of the community specific to a continuum of care for substance abuse;
      (2) identify a model of care to meet the needs of all users of the service; (3) identify
      financial options and commitments; (4) formulate a Community Coordination Council to
      assure accountability, outcome measurement and future collaboration; and (5) develop a
      project targeting chronic recidivists.
        The resulting community collaborative (including emergency rooms, law enforcement,
        and city and county partners) includes a modified medical detoxification program
        designed to serve the medically compromised individual as well as treating those in need
        of a social model detoxification setting. The model provides a continuum of care for

Social Model Detoxification in Colorado - March 2008                                              7
        chronic recidivists which includes intensive outpatient programming (with a co-occurring
        diagnosis focus) and wraparound services with intensive case management.

Moving Forward
Despite the creative and diligent efforts of local substance abuse, mental health, and primary
health facilities, serious gaps remain in services available to individuals across the state that need
detoxification. These gaps create problems for citizens, local law enforcement agencies,
hospitals, and clients who are too sick for non- medical detoxification but have no access to
medical or mental health care outside hospital emergency rooms. These problems are
exacerbated by the lack of information about the role and funding of detoxification programs in
the state; therefore, clients are shifted between systems without receiving adequate care in any
system. Solutions to these problems require both creativity and resources. The approaches
outlined above are only partial solutions.

As an attempt to provide momentum to a statewide effort to address these problems, the
Colorado Association of Alcohol and Drug Services Providers will be working on the following
initiatives over the next year:
      1)    Enhance the awareness of the public on the critical role of detoxification
            services in their community;
      2)    Expand our understanding of the nature and scope of the treatment needs for
            individuals in detoxification programs statewide;
      3)    Pilot a screening, brief intervention and referral to treatment protocol in select
            detoxification facilities that will decrease the frequency and severity of drug and
            alcohol use, and increase the percentage of clients who enter substance use
            disorder treatment;
      4)    Advocate for increases in treatment funding for people transitioning from
            detoxification centers;
      5)    Advocate for increases in funding for detoxification services statewide; and
      6)    Continue to improve partnerships with local law enforcement and primary
            healthcare agencies.

Social Model Detoxification in Colorado - March 2008                                                 8
                                              Appendix A
                             Colorado Managed Services Organizations
The Managed Services Organizations (MSO) responsible for funding social model detoxification
services in the State of Colorado are listed below:
§   Boulder County Public Health serves Boulder County.
§   Connect Care serves El Paso and the surrounding counties.
§   Signal Behavioral Health Network serves the metropolitan Denver area, Northeastern
    Colorado, and Southeastern Colorado.
§   West Slope Casa serves the Western Slope of Colorado.
                                  Colorado Detoxification Providers
The social model detoxification providers for the State of Colorado are listed below:
§   Arapahoe House is the detoxification provider in Adams, Arapahoe, Broomfield, and
    Jefferson Counties.
§   Boulder County Public Health provides detoxification services in Boulder County.
§   Colorado West Regional Mental Health Center operates detoxification programs in
    Frisco, Glenwood Springs, Steamboat Springs, and Grand Junction serving ten northwestern
    Colorado counties.
§   Cortez Addictions Recovery Services: Currently, detox services are offered on an
    emergency basis at the Montezuma County Detention Center or at Southwest Memorial
    Hospital. In 2007 construction will begin on a new homeless shelter/detoxification center
    funded by the community.
§   Crossroads Turning Points provides detoxification services in nine counties including
    Alamosa,    Conejos,    Costilla,    Huerfano,  Las    Animas,    Mineral,    Pueblo,
    Rio Grande and Saguache in southern Colorado
§   Denver CARES provides detoxification services in the City and County of Denver.
§   Island Grove Regional Treatment Center provides detoxification services in Northeastern
    Colorado including Larimer, Weld, Lo gan, Morgan, Washington, Sedgwick, Philips, Yuma,
    Elbert, Lincoln, Kit Carson, and Cheyenne Counties.
§   Pikes Peak Mental Health Center operates one detoxification facility in Colorado Springs,
    serving the seven counties of the Pikes Peak Region.
§   Resada operates a detoxification program in Las Animas serving the Arkansas Valley.
§   Southwest Colorado Mental Health Center operates a detoxification program in Durango
    in conjunction with a mental health acute treatment unit, serving the Four Corners area.

Social Model Detoxification in Colorado - March 2008                                        9