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TREATMENT ON

DEMAND
PROPOSAL TO INCREASE
DETOXIFICATION SERVICES
IN WASHTENAW COUNTY

“If you want to treat an illness that has no easy cure,


first of all treat them with hope.”
(George Vaillant)

April 2006

Dawn Farm
502 West Huron
Ann Arbor, MI 48103

Phone: 734-485-8725
Fax: 734-485-6103
Web: www.dawnfarm.org
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

Table of Contents

Introduction ................................................................................................................................ 3
Overview ................................................................................................................................ 3
What Are We Proposing?....................................................................................................... 4
What is the Expected Impact of an Expanded Detox? ............................................................ 5
Treatment Works! ...................................................................................................................... 7
Existing Facilities, Program Models, Bed Capacities .................................................................. 8
Trends In Detoxification Needs .................................................................................................. 8
Rapidly Changing Landscape ...................................................................................................10
A Chronic Illness .......................................................................................................................11
Homelessness and Addiction ....................................................................................................12
What is the Current Dawn Farm Detox?....................................................................................14
Mission..................................................................................................................................14
Vision ....................................................................................................................................14
Services ................................................................................................................................15
Triage................................................................................................................................15
Admission .........................................................................................................................15
Recovery Planning ............................................................................................................15
Client Advocacy ................................................................................................................16
Volunteers .........................................................................................................................17
Joining the Recovering Community ...................................................................................17
Discharge..........................................................................................................................17
Outreach Program.............................................................................................................18
Population Served .............................................................................................................18
Location ............................................................................................................................19
Washtenaw County Detoxification Options................................................................................20
Definition of Detoxification.........................................................................................................20
Community Environment...........................................................................................................21
Prevalence of Addiction/Substance Abuse................................................................................22
Effects of Addiction ...................................................................................................................23
…On The Community............................................................................................................23
…On Health Care..................................................................................................................23
…On The Criminal Justice System........................................................................................23
…On Education.....................................................................................................................24
…On The Workforce .............................................................................................................24
…On Taxpayers ....................................................................................................................25
References ...............................................................................................................................27

Acknowledgement

This paper is modeled after Treatment on Demand: The Need For Substance Abuse
Detoxification In The City Of Boise/Ada County by the Center for Health Policy, Boise State
University entitled. W e relied heavily on the design of the report and their reporting of
national data. This report was retrieved on March 28, 2006 from
http://hs.boisestate.edu/CHP/reports/DetoxReportFinal4.pdf.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

INTRODUCTION

“You’re drunk, you’re high, you’re in big trouble. Maybe you’ve been committing crimes to
support a habit. Maybe you have tried to drive somewhere. Regardless of the circumstance,
you’re in a crisis situation, and you decide you’ve had enough—you’re ready to get help. What are
your options?

You could be arrested. If you really hadn’t committed a crime, they might let you dry out and then
let you go. Had you thought you might get some treatment, some hint of a direction for further
services? You won’t be offered any.

You could go to the local hospital ER. They’d take a history, check you over, and unless you
had “medical necessity”—fairly rare—they’d send you somewhere else. You’d waste your
time—and the ER staff’s as well. Did you know you could call the local referral service? And if
you have some time and lots of motivation, you might be lucky enough to get a bed. But don’t
count on it. Most people have to wait, many are referred to outpatient—and many just give up
trying. You know, if you don’t have insurance or money, you’re pretty much out of luck.”

••••••••••

This proposal documents the need for detoxification services in Washtenaw County. We will
attempt to summarize the problem on both a national and local level, identify gaps in treatment
and other problems, and recommend a solution we think the community might use.

OVERVIEW

Rates of alcohol and drug abuse in Washtenaw County are comparable to the rest of the state
and nation. Twenty-four percent of adults in the Washtenaw County reported binge drinking
(Community Health Committee, 2004). The highest rates of binge drinking were reported among
people with annual incomes of less than $30,000 (33.5 percent), adult males (34.2 percent), and
18-29 year olds (38.3 percent) (Community Health Committee, 2001). This compares to 24.5
percent binge drinking statewide and 23 percent nationwide. (Wright & Sathe, 2005) Chronic
drinking is defined as consuming 60 or more drinks of alcohol per month. Being at risk for acute
drinking is defined as consuming five or more drinks of alcohol (where a drink is defined as one
can or bottle of beer, one glass of wine, one can or bottle of wine cooler, one cocktail, or one
shot of liquor) on one or more occasions in the past 30 days.

Rates of illicit drug use statewide are similar to those of the rest of the country. A national study
found 9 percent of Michigan's population over age 12 reported past month use of any illicit drug,
while 8 percent nationwide reported such use (Wright & Sathe, 2005).

Both quantitative and qualitative data illustrate an unmet need for detoxification services in
Washtenaw County. An estimated 209,000 persons in southeastern Michigan (excluding
Detroit) met DSM IV diagnostic criteria for substance dependence in 2000, and an additional
269,000 were estimated to meet diagnostic criteria for substance abuse. Further, an estimated
223,000 Michiganders were in need of treatment for illicit drug use and did not receive it. An
additional 597,000 were in need of treatment for alcohol use and did not receive it (Aktan &
Calkins, 2003).

Dawn Farm Detox estimates that some 95 persons per month present in need of detoxification.
In 2005, Detox conducted 1144 admissions on 836 individuals—and 1630 people were placed
on a wait list after prescreen. Only 53% of prescreens who were placed on a waiting list actually
entered Detox. The 13–bed Detox site was full with a waiting list 336 days in 2005.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

Despite the need, Treatment Cost Data from 2004 shows that Washtenaw/Livingston had the
second lowest rate of dollars spent (per capita) for inpatient and residential substance abuse
treatment in the state.

In 2004, 0.24 percent of the $38.6 billion Michigan state budget, or $94.73 million, was spent on
programs related to alcohol and drug abuse (PA 349 Report to the Legislature, April 2005). Of
this amount, 2.4 percent ($2,406,741.00) was spent in Washtenaw County. Eighty-three percent
of these locally-used dollars were spent directly on treatment services. Less than 26% of these
dollars were spent on detoxification services.

This unmet need impacts the entire community through decreased quality of life, increased
costs for health care, decreased productivity of our work force, and increased taxes to pay for
public services to address the consequences of substance abuse. Less crime, reduced
suicides, less domestic violence, less child abuse, fewer deaths on the highways: all of these
are likely outcomes if the community can better address the problem of substance abuse.
Detoxification is an integral, critical step in a continuum of services that comprise the solution.

WHAT ARE WE PROPOSING?


We propose that the successful detox model currently operated by Dawn Farm be expanded and
enhanced to a “Mission-style” comprehensive treatment and referral site. Ideally, this site would
house three distinct-but-inter-related outreaches:
 A Sub-Acute Detox with between 15 and 20 beds, similar to the existing Detox but with
additional medical support from the two local hospitals. Med students and medical
residents could participate on the Detox treatment team. This arrangement would also
facilitate the admission of clients who previously required a medical clearance from one of
the ER’s – and expand our ability to treat opioid addicts with buprenorphine.
 10 to 15 Detox Outreach beds for individuals who need additional case management or
who are awaiting a referral to additional treatment or housing.
 Space/beds for individuals who are ambivalent about recovery but are willing to visit the
site and abide by basic behavioral expectations.
A physician and nurse or physician’s assistant would be on call, and there would be a daily
presence of medical personnel. The facility would be able to meet all types of non-medical
detoxification needs, including distribution of required medications.

We propose a location within the county located no more than 5 miles from one of the hospitals
and on the bus line, such that impaired people can successfully reach the facility. Ideally this site
would be within Ann Arbor city limits, and accessible on foot.

We believe that it is important that these three outreaches be housed together. The success of a
program for ambivalent people will depend heavily on the program being infused with hope and
recovery. Continuous exposure to recovering people and their success stories will be critical. We
believe that a combined site will attract significant involvement from the recovering community. A
combined site will also create opportunities for outreach clients to help detox and ambivalent clients.
Our experience is that such interactions benefit the client who is helping and motivate the client
receiving the help.

Effectiveness of detoxification services would be similar to the existing program, comparing


admissions to local demographics, comparing completions to national benchmarks, and
measuring outcomes by counting as successful those people that accept the next level of
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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

treatment progression.

WHAT IS THE EXPECTED IMPACT OF AN EXPANDED DETOX?

 The community would be a safer place to live. Since a high percentage of crimes locally
are committed with substance abuse as a factor, fewer actively addicted individuals in
the community should lead directly to a lower crime rate.

 Police officers and sheriff's deputies should get fewer calls related to acutely intoxicated
people and would have a safe place to bring them.

 The Washtenaw County Jail should actually see a reduction in jail overcrowding if
addiction treatment services become readily available.

 Downtown shopping districts would benefit from publicly intoxicated individuals having
immediate access to Detox.

 The hospital emergency departments should see a significant reduction in the time spent
assessing patients who present with detoxification needs. Reduced costs will follow.

 Psychiatric emergency should see reductions in time spent assessing and admitting
people in drug or alcohol related crises.

 There would be reduced stress on mental health services, homeless service providers
and other public services. Acutely intoxicated people (particularly the homeless and
"frequent fliers") significantly impact the staff morale, stress levels, and attitudes of the
systems with which they come into contact. Staff feel impotent and overwhelmed by the
number, chronicity, and severity of their problems. The result is that they become
pessimistic and resentful. We hope that expanded access to detox services would
reduce this stress and become a place where these professional helpers can witness
hope and recovery.

 The availability of the three detox tracks could make treatment and recovery support
services in the county more effective.

o Detox clients could be discharged more quickly if there were a safe place for them
to stay where a case manager had quick and easy access to them.

o The system could retain clients who relapse and have been discharged from
abstinence contingent housing.

o An expanded Detox would encourage more efficient use of existing treatment


resources by providing a safe place to refer clients when they are not benefiting
from treatment or making progress. For instance, the center might make
homeless clients stepping down to outpatient a more feasible option.

o The center would provide space and structure for maintaining engagement with
clients who slip back into the precontemplation stages of change.

o The center could address many questions about client motivations in seeking
residential care would be addressed. Dawn Farm does not share these concerns,
but some community members have repeatedly asserted that detox and

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

treatment are frequently used for shelter. Any client would have the opportunity
to get “three hots and a cot” without entering residential treatment.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

TREATMENT WORKS!
The data on treatment effectiveness is encouraging. The California Department of Alcohol and
Drug Programs (1994) sponsored a study of the effectiveness of their substance abuse treatment
programs. The study looked at outcomes for a randomly selected sample of program participants
and was conducted by the University of Chicago's National Opinion Research Center with Lewin-
VHI, Inc. in 1991 -1992. They found that the $209 million the state spent on treatment resulted in
an estimated $1.5 billion in savings for taxpayers. Most of the savings were due to reductions in
crime and in the need for medical care. Their findings included:
 Taxpayer’s saved $7 for every $1 invested – most significantly due to crime reduction.
 Criminal activity by patients in California treatment programs fell by two-thirds after they
had completed treatment.
 Drug use declined by 40 percent.
 Use of medical care declined (for example, hospital admissions among those in treatment
dropped by one-third).

The 1997 National Treatment Improvement Evaluation Study (NTIES, 1997) evaluated the impact
of drug and alcohol treatment on 4,411 people who participated in programs funded by the
SAMHSA's Center for Substance Abuse Treatment (CSAT). Participants in these programs
included underserved and vulnerable populations such as minorities, pregnant and at-risk women,
youth, public housing residents, welfare recipients and those in the criminal justice system. The
study found treatment to be cost effective. Treatment costs ranged from a low of $1,000 per client
to a high of approximately $6,800 per client per year. In contrast, the average cost of incarceration
in 1993 (the most recent year available at the time of the study) was $23,406 per inmate per year,
a three to 23-fold difference. The following findings were highlights of the study:
 Clients’ use of their primary drug(s) declined from 73 percent to 38 percent one year after
treatment.
 Among women in treatment, drug use declined by more than 40 percent for as long as a
year after leaving treatment.
 There was a sixty-four percent reduction in arrests for any crime.
 Before treatment, almost half the respondents reported "beating someone up." Following
treatment, that number declined to 11 percent; a 78 percent reduction.
 Those reporting being homeless at any time during the previous year declined by 43
percent.
 Participants reporting income from a job (employment) increased 19 percent.

A nationally representative study of substance abuse treatment outcomes sponsored by SAMHSA


(1998) confirmed that both drug use and criminal behavior were reduced following drug abuse
treatment—inpatient, outpatient and residential. From a 1990 sample of 99 drug treatment
facilities interviewed, 1,799 persons five years following discharge from treatment. Their survey
results confirmed those of previous studies showing that substance abuse treatment can
significantly reduce crime. The study showed that length of stay in drug treatment was associated
with decreases in drug use. Clients who stayed in treatment the longest were most likely to reduce
or eliminate their pre-treatment drug use. Other findings included shifts toward retaining and
regaining child custody, more reliable housing, and avoiding physical abuse. Attempted suicides
dropped from 15 percent to 9 percent.

The one treatment outcome predictor that stands out in the literature as the most important is
retention in both active treatment and aftercare. Dowd and Rugle (1999) identified nine studies
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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

dating from 1988 to 1995 in which retention clearly correlated with success.

EXISTING FACILITIES, PROGRAM MODELS, BED CAPACITIES

When Dawn Farm Detox is full, options are very limited. To illustrate the detox shortage and the
burden it creates, we submit the following often-proposed alternatives:

 People in need of detoxification can call Health Services Access to request services.
The WCHO contracts with three out-of-county detoxification programs in Canton,
Jackson and Memphis. Unfortunately, referrals to these programs are limited and there
is no transportation to these facilities.

 In the winter months, people who have been drinking but are not behaving in a disruptive
manner may stay in the Delonis Center warming shelter.

 People may be taken to one of the two hospital emergency departments. Hospital staff
report that very few of these people require medical supervision during detoxification.
These people may be given a bay, if one is available, or kept in a waiting room or
hallway. If they are disruptive, they may be sedated. If the person is at risk for seizures,
they may be given a prescription for a benzodiazepine. Once their BAL is low enough,
they are encouraged to leave. Emergency rooms are staffed to handle true medical
emergencies. Some research estimates that only 1% of those presenting for detoxification
are truly in significant medical need. The remaining 99% of people are referred to other
community services. An expanded Detox facility would still send the 1% to the hospital, but
would be able to focus on the true needs of the individual, and perhaps start them on the
road to recovery.

 If they are having suicidal thoughts, individuals may go to the psychiatric emergency
department. Sometimes these symptoms are feigned in order to seek shelter and
medical support, sometimes they are caused by a combination of AOD use and chronic
mental illness, and in some cases they are drug induced and/or situational. The
threshold for admission to the psychiatric unit is quite high. Only those considered likely
to act on their thoughts will be admitted.

 If a crime is involved, they may be taken to jail.

 If they are a veteran, they may go to the VA hospital.

 If the individual has comprehensive health insurance or money to pay for detox, they
may go to Brighton Hospital in Brighton, Washington Way in Jackson, Oakdale Recovery
Center in Canton, or Maplegrove in West Bloomfield.

TRENDS IN DETOXIFICATION NEEDS

A National Treatment Plan Initiative entitled “Improving Substance Abuse Treatment: The National
Treatment Plan Initiative. Changing the Conversation,” was published in November, 2000. This
national initiative points out a treatment gap that has been documented in numerous studies. Two
separate national studies indicate approximately 13 million substance abusers in the United States
with 10 million of those untreated. The reasons for this gap are noted as: 1) general denial by the
individual, 2) the stigma attached to substance abuse treatment, 3) poor access to services and
lack of linkages between services, 4) poor financing and resource allocation, and 5) a lack of true

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outcome measures to assure quality of care.

Nationally, between 1999 and 2000, emergency room episodes involving patients seeking detoxi-
fication increased 24 percent (SAMHSA, 2001). That trend was reflected as a theme in the inter-
views of key informants at the University of Michigan ER.

Local facilities/options for detoxification and treatment in the Washtenaw County area have
decreased markedly over the past few years. All area hospitals once operated inpatient substance
abuse facilities with detoxification components—all have closed in recent years. At the same time,
non-profit addiction treatment providers were profoundly affected by public funding cuts and
managed care initiatives—further diminishing the available treatment options for individuals
suffering from chemical dependency.

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RAPIDLY CHANGING LANDSCAPE

The field of addiction treatment entered a period of explosive growth and public acceptance
following Betty Ford’s public admission of alcoholism in 1978. This growth continued into the
mid-1980s until the crack cocaine “epidemic” and the “war on drugs” shifted public policy from
medicalization to stigmatization and criminalization. This trend, combined with the advent of
managed care has led to rapid declines in access to adequate addiction treatment.

Spending had decreased:


 Private SA spending per covered life fell by 73.6 percent in nominal dollars from 1992-
2001. (Mark & Coffey, 2004. Health Affairs 23:6)
 Substance abuse spending per covered life (in constant dollars) dropped from about
$21.16 in 1992 to about $4.46 in 2002. (Mark & Coffey, 2004)
 Private spending for substance abuse treatment declined by 28 percent from 1990-1994,
dropping from $3.37 billion to $2.43 billion, according to data from the National Drug and
Alcohol Treatment Unit Survey. (CSAT by Fax, July 5, 2000)
 Of the 1.2 million people in 2002 who felt that they needed SA treatment but did not
receive it, 37.5 percent reported that they made an effort but were unable to get
treatment and that a key reason was the cost of care. (Mark & Coffey, 2004)
 The value of addiction insurance coverage declined by 75% between 1988 and 1998 for
employees of mid- to large-size companies. (www.asam.org)
 The Washtenaw Community Health Organization reports that the treatment budget for
indigent Washtenaw and Livingston County residents has been flat for 15 years in spite
of population growth and inflation.

It’s worth noting that these cuts in spending have taken place during a period of explosive
growth of health care spending in general. It’s also worth noting that there have been efforts to
create mental health and substance abuse parity. (Laws prohibiting insurance companies from
limiting mental health and substance abuse healthcare by imposing lower day and visit limits,
higher co-payments and deductibles and lower annual and lifetime spending caps.) Some states
and the Federal Employee Health Benefits Program (FEHBP) have enacted parity. Actuarial
estimates and the experience of states and programs that have implemented parity all place the
increased cost of parity at around 1%. Some programs even experienced cost reductions due to
changes in care management. (CBO, 2001; Bachman, 2003; Lehmann, 2001; Harbin, 2002;
Sturm, 1997; Rosenbach, et al., 2003; Goldman, et al., 2006)

The level of care has been reduced by shortening lengths of stay in inpatient and residential
care and shifting to outpatient care:
 In 1992, 73 percent of spending was in inpatient settings, while in 2001 this figure was
only 44 percent. More people are now referred to outpatient (Mark & Coffey, 2004).
 Inpatient lengths of stay plummeted from 28 days in 1988 to 7.7 days in 1998. (NAPHS)
 In 1990, there were over 16,000 substance abuse treatment facilities operating in this
country. Approximately 55% of those were residential or inpatient hospital, approximate-
ly 30% were outpatient programs, and approximately 15% were methadone mainten-
ance programs (Uniform Facility Data Set, 1990). Figures from 2002 indicated that there
were less than 14,000 programs. Only 10% were residential or inpatient hospital,
approximately 12% were methadone maintenance programs, and approximately 78%
were abstinence-oriented outpatient programs (National Survey of Substance Abuse
Treatment Services, 2001).
 Mark and Coffey (2003) examined mental health and substance abuse (MH/SA)
spending from 1992 to 1997 and found that inpatient services dropped from 48% to 18%
of MH/SA spending during this period. During the same period, MH/SA spending on
psychotropics increased from 22% to 48%.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

Other examples of treatment system instability:


 McClellan (2003) found that within a 16 month period, 15% of facilities had closed or
stopped addiction treatment and an additional 29% had been reorganized under a
different agency. There was a 53% turnover among directors and a similar rate among
counselors within the previous year.
 From 1981 to 1993, there were significant decreases in the number of programs
providing support services that addressed medical, psychological, family, legal,
vocational, and financial problems. Such services have been demonstrated to help
people stay in treatment, reduce substance use, and improve other areas of social
functioning. (Etheridge R, et al., 1995)

Locally, the impact has been just as pronounced. In the 1980s and early 1990s, every hospital
in the community had a dedicated inpatient treatment unit, and some had residential facilities on
hospital grounds. At their peak, there were a total of seven inpatient/residential programs in
Washtenaw County (Dawn Farm, U-M Hospital, Chelsea Hospital, Beyer Hospital, St.
Joseph/Huron Oaks, Saline Greenbrook & Share House). Dawn Farm is the only residential
treatment program left in the county. There had been two inpatient programs for adolescents;
today there are none, and even outpatient adolescent services are limited. Local outpatient
programs have eliminated most of their intensive outpatient programs (IOP) and have reduced
the number of sessions. Most recently U-M has merged its Chelsea Arbor program—an
independent addiction specialty program—into the medical system’s behavioral health program.
Anecdotally, all of the local outpatient programs appear to struggle financially.

The result of the restricted access to treatment and the contraction of the treatment system is
that addiction goes untreated or inadequately treated. As with other illnesses, addiction
progresses and the medical problem gets more resistant to treatment. Additionally, other
psychosocial problems accumulate, making recovery more difficult.

A CHRONIC ILLNESS

Traditionally, alcoholism and drug addiction have been thought of and treated within an acute
care paradigm. Treatment providers justified their existence with recovery rates based on 3, 6, 9
or 12 month follow-up abstinence rates. Clients, families, communities and third party payers
were told to expect lifelong, uninterrupted recovery from a single, time-limited dose of treatment.

While this treatment model created a path to recovery for hundreds of thousands of Americans,
it is not an adequate response to the needs of most people seeking treatment. People who do
not achieve uninterrupted abstinence following treatment are viewed as treatment failures and
their treatment as a waste of resources. This has resulted in the widely held belief that treatment
is ineffective and that its outcomes don’t justify the expense.

The reality is that treatment works, but we have been applying an acute care model to a chronic
health problem (McLellan AT, et al., 2000). Recently, drug and alcohol addiction has been more
widely accepted as a chronic illness like type II diabetes, hypertension and asthma. Addiction—
like these other chronic illnesses have strong genetic and behavioral components, can be
identified with reliable diagnostic methods, can be effectively managed with behavior change
and medication, and show similar patterns of symptom control and relapse. The standard of
care for chronic illnesses such as these is an approach commonly referred to as disease
management. White (2002) described the approach and an analogous approach for addiction:

“Persons suffering from chronic, incurable disorders need models of intervention


that focus on the management of these disorders rather than the cure or

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

treatment of these disorders. Disease


management or, as we prefer, recovery
management, provides an alternative to
the traditional mode of reacting to life-
impairing and life-threatening episodes of
chronic disorders with unrelated, serial
episodes of acute, emergency-oriented
care.

“Recovery management implies a longer


term vision of influencing the course of a
disorder to enhance length and quality of
life. It is about learning, in the absence of
a cure, to contain a disorder and to
optimize personal and family health over
time.

The combination of this shortage of accessible


treatment and the acute care paradigm has
created a client population whose addiction is
more advanced, that utilizes services at higher
rates, that has accumulated additional bio-
psycho-social problems (unemployment, legal
problems, secondary psychiatric problems, family
estrangement, poor family planning, The effectiveness of treatment for acute
homelessness, etc.), and that has less faith in the illnesses is measured by pre-treatment and
ability of the system to respond to their needs and post-treatment measures. This has been
help them recover. The SAMHSA Treatment the tradition outcome measurement model
Episode Data Set reported that in 2002, 56% of for addiction treatment. The effectiveness of
reported treatment admissions and 65% of detox treatment for chronic illnesses is measured
admissions reported at least one prior treatment by pre-treatment and during treatment
episode (SAMHSA, 2004). Unfortunately, clients measures.
who present for treatment with multiple prior
treatment episodes are seen as lacking authentic motivation and are given a poor treatment
prognosis. The reality is that these clients have often been undertreated and were given time-
limited and disconnected doses of treatment for a chronic problem. Practitioners who treat
chronic illnesses view supporting patient compliance and keeping the patient engaged in
treatment as goals. Symptom recurrence is viewed as an opportunity to re-engage the client
with treatment and to review the treatment plan.

HOMELESSNESS AND ADDICTION

The relationship between homelessness and addiction is well documented. The Washtenaw
Housing Alliance reports that 51.2% of homeless people in Washtenaw County have
experienced a substance abuse problem in their lifetime. A 1999 national survey (Burt 1999 and
Zerger 2002) found that 62% of respondents reported a lifetime history of alcohol problems
(46% in the past year) and 58% reported a lifetime drug problem (38% in the last year). These
people have a difficult time accessing treatment due to factors that include 1) lack of an address
and phone number, 2) lack of transportation, 3) lack of identification 4) hopelessness, and 5) a
preeminent need for survival and shelter. An additional barrier to treatment is that the American
Society of Addiction Medicine Patient Placement Criteria (ASAM PPC 2R) does not explicitly
identify homelessness as a factor in determining the appropriate level of care. As a result, it is

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not uncommon for homeless addicts to be referred to once a week outpatient treatment that
does nothing to address their lack of shelter or transportation needs. The inevitable results are a
high dropout and relapse rate. These dropout and relapse rates are frequently considered a
reflection of the treatment program’s effectiveness, the motivation level of the client and his poor
prognosis. Treatment programs must address the addiction as well as the complex multidimen-
sional needs of this population. Research also supports the importance of long term interven-
tions for this population. (Zerger, 2002)

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WHAT IS THE CURRENT DAWN FARM DETOX?

MISSION

The goal of Dawn Farm is to assist addicts and alcoholics in achieving long term recovery.
Dawn Farm will identify and remove barriers that prevent addicts
and alcoholics from joining the recovering community.

To meet this goal, Dawn Farm offers a continuum of services designed to meet client needs.
Dawn Farm Detox is just one part of a community of programs, including residential, outpatient,
transitional housing, and jail outreach.
VISION

Our vision for each Detox client is to assist them in achieving long term recovery. Dawn Farm
Detox believes that every client has the potential to achieve long term sobriety. Withdrawing
from alcohol and drugs is the first step towards lasting sobriety. Detox strives to provide a safe
and compassionate environment in which to begin this process.

“Safe” means a place free from drugs and alcohol where a client’s basic needs are met while his
withdrawal symptoms are monitored. Safe also means a place where each addict or alcoholic is
treated in a humane way, where the experience of addiction is met with compassion instead of
stigma, and where the fundamental attitude toward each client is one of hope.

Because every client has varying circumstances, history, and experience with recovery, their
motivations and goals may be very diverse. Detox staff use a variety of approaches to meet
each client where they are and to help them reach their goals. Short term success is based
upon simple completion of the Detox program—staying for a minimum of 72 hours and
developing an aftercare plan. Long term success is measured through follow-up phone calls to
see if the client followed through with the aftercare plan and has been successful in maintaining
sobriety.

Although Detox clients may relapse one or more times before achieving long term recovery, we
believe the experience of relapse is a symptom of the chronic nature of the disease of
addiction—we do not perceive it as failure on the part of the client. We work to develop a new
recovery plan based on the client’s recent experience of recovery.

We offer a safe and supportive foundation for individuals who are ambivalent about recovery but
are willing follow basic program expectations. Because of this view of relapse, there is no limit
placed on the number of times a client may return to Detox. Even when there is no discernable
change in the behavior, attitude or apparent ability to stay sober, repeated exposure to the
recovering community can plant the seeds of recovery in the client.

Detox measures its performance through specific goals and objectives that are annually
measured and disseminated in a Management Report. In addition, program evaluation
questionnaires are given to all clients at intake and during the follow-up process. Client
comments and suggestions are taken seriously in order to provide the best possible care.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

SERVICES

Triage

Dawn Farm Detox is open for admissions and fully staffed 24 hours a day, 365 days a year.
Whenever possible, clients are asked to call first for a pre-screen.

All clients are evaluated by the Dawn Farm Detox Triage prior to admission in order to
determine whether it is safe for them go through withdrawal in a non-medical setting.
Considerations include the type, quantity, and frequency of the drugs the potential client is
abusing, medications prescribed, presence of a seizure history, active psychosis or suicidal
ideation, and the presence of more acute medical concerns. Staff works closely with the Detox
physician to ensure that no clients are admitted with who have a high risk of complications.

The majority of clients who are unable to come in immediately after the initial screening due to
apparent medical risks are able to be admitted after obtaining a medical clearance or necessary
medications. A small percentage of potential clients (less than 5%) require a medically
managed detoxification. These people are always given resources to assist them in finding the
appropriate level of care.

Admission

Upon completing triage requirements, clients are admitted on a first come, first served basis.
There are currently ten male beds and five female beds, with a maximum occupancy of 13
beds. This site is commonly full, and a waiting list is in place to accommodate the increasing
demand for our services.

Upon admission, clients undergo a thorough intake assessment, which includes a detailed
assessment of drug history, substance dependence, treatment history, legal status, economic
and insurance resources, and medical status. Clients are also given a through biopsychosocial
assessment. This information is used by counselors to help the client identify barriers and
patterns of behavior which prevent them from achieving their goals, and to emphasize client
strengths and community resources to help remove those barriers.

A mental status assessment may be given to clients who identify or show signs of mental
illness. Staff tends to prolong the mental status assessment until inebriated clients are more
coherent, typically during their individualized recovery planning.

All clients have their vital signs monitored at admission and for at least the first 24 hours of
withdrawal. Due to the higher risk of withdrawal complications, those in alcohol or sedative
withdrawal are monitored at a higher frequency. When medical concerns arise, staff, in
consultation with the Detox physician, may send clients to the emergency room for treatment
and/or medical clearance. Clients are also seen during their stay by a nurse or physician for a
basic physical evaluation, during which clients may review their medications and ask questions
about any health concerns they may have, including sexually transmitted infections, HIV/AIDS,
and hepatitis.

Recovery Plan

Every client develops an individualized recovery plan with a detox counselor. The recovery
planning process is based on the following principles (Boyle & Loveland, 2005):
1. The focus is on individual strengths rather than pathology. The emphasis is on
identifying and nurturing strengths rather than treating and minimizing pathology and
deficits. Detox staff frequently ask clients questions like “How have you survived?” or
15
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

“How did you do that?”


2. The community is viewed as an oasis of resources. Dawn Farm emphasizes that the
community is what heals our clients and maintains their recovery. Dawn Farm focuses
on removing barriers that prevent clients from joining the recovering community.
3. Interventions are based on client self-determination. Recovery plans are built upon the
client’s goals, and clients make decisions about treatment versus transitional housing
and about level of care. Detox counselors serve in a consultant role rather than a
directive role. It is not uncommon for us to see resistance and suspicion evaporate when
clients understand that we are only promoting recovery.
4. Aggressive, community outreach is the preferred model of intervention. Ideally, recovery
support should be provided in the person’s own environment. Dawn Farm has developed
programs such as transitional housing and roles such as a Recovery Support Specialist
to provide community based recovery support.
5. People suffering from a substance use disorder or a mental illness can continue to learn,
grow, and change. Hope is the crux of all Dawn Farm programs. Conventional wisdom
says that addicts must hit bottom to recover. We know that our clients do not suffer from
an absence of pain and crisis – they suffer from an absence of hope.

The recovery plan is based on the goals, strengths/resources, barriers and recommendations
identified by the client and staff in psychosocial assessment. The assessment addresses areas
such as recovery, finances, employment and education, social and family support, medical
health, leisure and recreation, legal issues, emotional well-being, and spirituality. Staff help the
client frame the information collected as recovery capital or barriers to recovery. Recovery
capital is defined as the internal and external resources to initiate and support recovery. The
sources of recovery capital may be human capital (e.g. communication skills; assertiveness;
problem solving; managing stress/relaxation skills; spirituality; managing pain, anxiety,
depression, etc.; job skills; educational/vocational knowledge), social capital (e.g. supportive
spouse, family, clergy or church members, mutual-aid group members, employer, doctor, etc.)
or physical capital (e.g. access to money, employment, housing, transportation, access to health
care, access to healthy food, access to fulfilling hobbies, etc.).

Staff work to help clients make their goals achievable and concrete and then to identify
resources and options that the client may be able to use in achieving them, as well as to
increase the client’s motivation towards these goals. Most often these goals are related to
finding further treatment or a sober living environment, and staff is skilled in assisting clients in
procuring increasingly limited resources for treatment or transitional housing. Other goals are
often related to working a twelve step program and joining the recovering community. To assist
a client in beginning to move into a culture of recovery, staff attempt to serve as experienced
guides and role models. Counselors continue to provide assistance, encouragement, and
feedback for the clients as they work towards these goals during their stay.

Client Advocacy

Clients who are seeking further treatment after Detox often have difficulty accessing and
utilizing the resources available to them. Utilizing either private insurance or public funding can
be a difficult process, requiring knowledge about the process, communication skills, and
accurate self reporting. Clients are often deficient in one or more of these areas under normal
circumstances, and can be more compromised during the withdrawal process. Staff works with
clients before they begin their aftercare planning to ensure that they are informed enough to
advocate for themselves in the best possible way, often by walking them through the process
before any calls are made.

Staff continue to help clients as they work with a county agency or private insurance. Often
clients run into difficulties or are unsatisfied with their referrals. By continuing to monitor a
16
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

client’s progress, staff are able to continuously reinforce hope and present assistance and
alternative options clients may not know about. Staff are very familiar with how to obtain a
second opinion from a county referral agency, and have assisted many clients who feel that the
care they been offered is inadequate. Staff will also work directly with referral agencies or
insurance companies when a client is having trouble communicating. By continuing to offer
assistance and options when clients run into road blocks, staff are able to prevent many clients
from losing hope and returning to drugs or alcohol.

Advocacy does not end after a referral is given. Referrals to long term treatment or transitional
housing often have a wait list, and clients may not have a safe place to stay during the interim.
In addition, drug and alcohol problems rarely occur in isolation from other problems. Clients
commonly need assistance with family disintegration, homelessness, lack of job skills, domestic
violence, grief and loss issues, and mental illness. Staff typically work with local community
services such as the Delonis Center, SafeHouse Center, and Peace Neighborhood Center to
assist clients in finding safe places to stay and to meet their varying needs more completely.

Volunteers

Detox benefits greatly from the work of volunteers who help staff with cooking, cleaning,
transportation to AA meetings and various other tasks. Volunteers not only help with the care of
the clients, but are important role models, providing encouragement and hope.

Volunteers come to Detox from a variety of backgrounds. Most are members of the recovering
community, many are former Dawn Farm clients. Detox has also had a longstanding relation-
ship with the University of Michigan Nursing School, which uses us as a field placement site.
Other volunteers come through the University of Michigan and Eastern Michigan University
class requirements.

Detox maintains a log of over 50 potential volunteers. Approximately half keep ongoing commit-
ments at Detox, offering over 100 hours of volunteer time each week. With a limited number of
staff and increased client admissions each year, volunteers play a pivotal role in the overall
functioning of Detox. Without volunteers, staff would have much less time to work with clients,
less personal interaction with them, and an overall lessening of their ability to offer individualized
care.

The impact of volunteers cannot simply be measured in time, or in meals cooked, beds made or
dishes cleaned. Volunteers also bring with their personalities, enthusiasm and hope for clients
to witness. It is common for clients to develop a meaningful rapport with volunteers which
sometimes can develop into ongoing support or 12 step sponsorship, continuing long after the
client’s stay at Detox. Volunteers also serve as excellent role models, solid examples of a
recovering lifestyle and of the importance of service to others in recovery.

Joining the Recovering Community

One of the main goals for every client is to promote participation and membership in the
recovering community. This is accomplished each day through attendance at two off-site 12-
step meetings, an AA book study group facilitated by Detox staff at the Delonis Center, and
additional recovery-focused groups each day. In addition, counselors encourage clients to build
a support system of recovering people they meet at meetings and provide information and
encouragement for 12-step sponsorship.

Discharge

Upon discharge, an aftercare plan is developed with specific goals and referrals. Clients are
17
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

provided with a completion letter and a list of twelve step meetings in their area. Detox is
unable to provide transportation to the client’s next step, but is often able to direct clients
towards resources which may be able to assist them.

Outreach Program

In addition to the standard detoxification program, Detox offers an Outreach program. This
program provides an extended stay in Detox for clients who have a short wait before the “next
step” in their recovery and who have no other safe place to go. Although many clients want and
could benefit from this service, admission to this program and length of stay are limited by our
constant shortage of beds. While in Outreach, clients have the opportunity to further engage in
the recovering community by going to meetings with support persons, as well as to continue
their recovery in a safe supportive environment until their “next step” becomes available.
Outreach clients are also expected to play a peer support role, develop an Outreach recovery
plan, and continue to explore other options for a safe place to stay. This short term intervention,
which operates without any public assistance, dramatically increases the likelihood that a client
will make it safely to their next destination without relapse.

Population Served

Dawn Farm Detox serves all adult populations regardless of race, gender, sexual preference or
economic status. To be eligible, individuals must have used drugs or alcohol within the past 72
hours, and pass through our triage process.

We strive to accommodate all special populations. Minors who are seventeen years of age may
be admitted with parental/guardian permission. Clients with co-occurring disorders are admitted,
provided they are capable of participating in the program and have a five day supply of essential
medications if necessary. A summary of demographics follows:

Client Demographics 2001 2002 2003 2004 2005


Total admissions 835 922 1038 1111 1144
Average Age 36 35 35 37 36
Race/Minorities 32% 34% 29% 30% 27%
Gender/Male 72% 70% 76% 72% 71%

Residence/Washtenaw-Livingston 68% 70% 68% 66% 63%


Drug of Choice - Alcohol 47% 47% 42% 37% 36%
Drug of Choice - Heroin/Opiates 19% 21% 21% 24% 27%
Drug of Choice - Cocaine 28% 30% 34% 31% 33%
Drug of Choice - Marijuana 2% 2% 3% 8% 2%

Average # Prior Treatments 4.7 4.4 5.4 6.4 8.5


Unemployed/Indigent at Admission 91% 97% 67% 68% 78%
Homeless 64% 56% 55% 59% 64%

The program has documented more than 95% annual utilization of its 13 beds. In our most
recent study, 17% of Detox clients left against staff advice—76% completed. This statistic
reflects a higher-than-average ASA rate for opiate addicts—whose withdrawal symptoms are
often severe. Removing these addicts from this statistic improved Detox completions to 82%.
These completion rates exceed national averages. The 2002 Treatment Episode Data Set
reported that the national average completion rate for participating detoxification programs was
56%. (SAMHSA, 2005)

Detox also evaluates outcomes of discharges. Fifty-eight percent of 2004 Detox admissions

18
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

who requested referrals successfully engaged in other forms of treatment. Of those who
participated in the Detox Outreach program, 94% made the next treatment step.

Persons deemed unable to withdraw safely are referred to a higher level of care. Finally, the
program is voluntary, and for completion, clients must be willing to stay for a minimum of three
days.

Sixty percent of Detox admissions were known to be abstinent from drugs and alcohol two
weeks after their stay.

All of these benchmarks demonstrate that Detox is effective at helping addicts and alcoholics—
but it appears that the lack of additional resources (treatment, transitional housing) is increasing
the chronic nature of our admissions to Detox. We are deeply troubled by these apparent
trends.

Location

The current Detox facility is located at 544 North Division in Ann Arbor, convenient for
individuals in the city and is on the bus line.

19
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

WASHTENAW COUNTY DETOXIFICATION OPTIONS

Detoxification Service Capacity Issues/Comments


Dawn Farm Detox  3-5 days  Approved by ACCESS
 13 beds after admission
 1144 admissions in 2005  No one turned away due
to lack of funds or
residence
Washtenaw County Jail  No designated beds;  Staff of SecureCare report
detoxification takes place at least 1 inmate per day
in holding cells with up to need medical intervention
20 to 30 prisoners for Detox
 Mostly opiates/alcohol
University of Michigan  No dedicated detox beds  Staff report frequent visits
Hospital  Some are treated in the by a relatively small
emergency department number of chronic
 Some are admitted to addicted patients
psychiatric unit
St. Joseph Mercy Hospital  No dedicated detox beds Had a medical Detox in the
 Some are treated in the 1970’s
emergency department
 Some are admitted to
psychiatric unit
Sacred Heart Contract with WCHO Located in Macomb County –
no ready transportation
Oakdale Recovery Center Contract with WCHO Located in Wayne County –
no ready transportation
Brighton Hospital Requires insurance or $$
Washington Way at Foote Contract with WCHO Located in Jackson County –
Hospital no ready transportation

DEFINITION OF DETOXIFICATION
Detoxification may be defined as “the process through which a person who is physically depen-
dent on alcohol, illegal drugs, prescription medications, or a combination of these drugs is with-
drawn from the drug or drugs of dependence” (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2001). ”Detoxification …is not a treatment for drug-seeking behavior.
Rather, it is a family of procedures for alleviating the short-term symptoms of withdrawal from drug
dependence (Gerstein & Harwood, 1990).” It must also include a “period of psychological readjust-
ment designed to prepare the patient to take the next step in ongoing treatment” (Czechowicz,
1979). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2001) notes
three immediate goals of detoxification:

 To provide a safe withdrawal from alcohol and/or other drug(s) of dependence and enable
the patient to become drug free;

 To provide withdrawal that is humane and protects the patient’s dignity; and

 To prepare the patient for ongoing treatment of his or her alcohol or other drug
dependence.

For purposes of this proposal, a medically-managed model of detoxification services is distin-


guished from a social model. They are defined as:
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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

Social Model Detox – Social model treatment programs concentrate on providing psychosocial
intervention, with limited medical support services. Social workers and other clinicians provide
services such as individual counseling and coordination of care. Patients receive attention from a
physician or nurse, and regular monitoring by support staff. Patients who need a physician’s
immediate care or present with certain symptoms (see Triage Addendum) may be referred to a
nearby emergency department. Some programs that provide detoxification services have a
physician on call who can prescribe detoxification medications. Social model programs use a
variety of approaches to detoxification, but the emphasis is most often on non-pharmacological
management of withdrawal.

Medically-Managed Detoxification – Medical model programs are directed by a physician and


staffed by other healthcare personnel. They range from hospital-based inpatient programs to free-
standing medically-based residential programs in hospitals or in community facilities that can draw
on various medical resources.

COMMUNITY ENVIRONMENT

Washtenaw County has already shown an increased commitment to the issue of homelessness
through the development of the Washtenaw Housing Alliance, the construction of the Delonis
Center and the initiation of the 10-Year Plan to End Homelessness.

A similar community awakening and greater public attention is needed to address the need for
more comprehensive recovery support and addiction treatment. Washtenaw County leaders
must develop effective strategies to address alcohol/drug problems and the lack of available
services.

Increasing Detox capacity is not the final solution to our community's needs, but it is an
important first step. Communities across the country are initiating bold initiatives to address drug
and alcohol problems:
 San Francisco has implemented treatment on demand.
 The state of California passed Proposition 36, which provides treatment as an alternative
to incarceration for nonviolent offenders. A recent UCLA study found that Proposition 36
saved the state $176 million in its first year. (Curley, 2006)
 Des Moines, Iowa, developed a protocol for people on treatment waiting lists designed to
reduce drop out rates. Seventy-three percent of those in the program made it to
treatment, and completed treatment.
 San Diego has trained lay people in who are now screening and providing brief
interventions with thousands of patients in the region.(Join Together, 2006)
 In January 2005, Kentucky Governor Ernie Fletcher announced “Recovery Kentucky,” a
plan to open ten new treatment programs focused on treating homeless addicts and
alcoholics. The programs will be modeled after The Healing Place in Louisville and Hope
Center in Lexington. Both are shelters and treatment providers.
Four sites have already opened. One recently announced site in Erlanger will include 62
beds and 38 efficiency apartments for graduates. The graduates who live in the
apartments (which can be rented for up to two years) serve as mentors.
 Nine states have passed substance abuse parity laws that prevent insurers from
imposing unfair copayments, deductibles, day limits, visit limits and cost limits. In 1999
the Federal Employee Health Benefits Plan also instituted parity. The cost of full parity
(mental health and substance abuse) is approximately 1%.

Locally, the 15th District Court in Ann Arbor has implemented the county’s first Sobriety Court.
The Sobriety Court offers treatment as an alternative to incarceration and requires that
participants submit to intensive monitoring. Most important, the Court is recovery informed.

21
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

Court hearings and probation reporting is infused with the language and symbols of addiction
recovery. Not only is there accountability, every week is a celebration of recovery.

The Ann Arbor Downtown Development Authority, the City of Ann Arbor and Washtenaw
County have all financially supported the creation of sober transitional housing. These
transitional houses have succeeded in getting chronically homeless addicts off the street, active
in the recovering community, employed, and self-sufficient. Dawn Farm alone has opened 82
beds since 1998.

These are a great beginning, but Washtenaw County still does not have a drug court,
transitional houses always have waiting lists, appropriate treatment is far too often out of reach,
and the homeless shelter is not an option for people who are still in active addiction.

PREVALENCE OF ADDICTION/SUBSTANCE ABUSE

The Michigan Department of Community Health 2000 Michigan Drug and Alcohol Population
Survey provides estimates of the prevalence of alcohol and drug abuse1, and alcohol and drug
dependence2 in Michigan. These estimates are based on the DSM IV diagnostic criteria for
dependence and abuse. The 2000 Michigan Drug and Alcohol Population Survey (MDAPS)
Main Findings (Aktan & Calkins, 2003) reported that:

Overall, about 5.3 percent (392,000 persons) of the adult Michigan population
was diagnosed as dependent on alcohol and another 10.7 percent (760,000
persons) were diagnosed as alcohol abusers. For each of the study regions, the
proportion of alcohol abusers is larger than the proportion of dependents. The
ratio of dependents to abusers varies by region, sometimes by a factor of two or
three abusers for each dependent.

About 8.3 percent of the Michigan adult population (611,000 persons) is


dependent on one or more substances and 9.6 percent (708,000 persons) are
abusers of one or more substances. It is important to keep in mind that these
estimates pertain to lifetime diagnosis. From estimates of dependence and abuse
by substance discussed earlier, it is clear that the primary substance most often
involved is alcohol.

1
According to DSM-IV, for psychoactive abuse disorders, there are four relevant symptom (or problem) categories. To receive a
diagnosis of substance abuse, the person must meet one or more of the of the following four criteria within a 12-month period:
 Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home;
 Recurrent substance use in situations in which it is physically hazardous;
 Recurrent substance-related legal problems; and,
 Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or
exacerbated by the effects of the substance (e.g., fights).
2
For a diagnosis of substance dependence, a person has to manifest three or more of the following seven criteria occurring at any
time in the same 12-month period:
 Marked tolerance: need for markedly increased amounts of the substance in order to achieve intoxication or desired
effect, or markedly diminished effect with continued use of the same amount;
 Characteristic withdrawal syndrome for the substance, or the same or a closely-related substance is taken to relieve or
avoid withdrawal symptoms;
 Substance often taken in larger amounts or for a longer period than the person intended;
 Persistent desire or one or more unsuccessful efforts to cut down or control use;
 A great deal of time spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g., drinking all
day or night), or recovering from its effects;
 Important social, occupational, or recreational activities given up or reduced because of substance use; and,
Continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is
caused or exacerbated by the use of the substance (e.g., keeps using heroin despite family arguments about it, cocaine-induced
depression, or having an ulcer made worse by alcohol consumption.)

22
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

EFFECTS OF ADDICTION

…ON THE COMMUNITY


Substance abuse has a marked and measurable impact on society. Research has repeatedly
documented this impact. In a study of the national costs of alcohol and drug abuse to society,
researchers estimated the total costs to be $245.7 billion in 1992, increasing to $276.3 billion in
1995 (Harwood, Fountain, Livermore et al, 1998). The largest impact of alcohol and drug abuse
was on lost productivity due to premature death, illness, and criminal victimization. The health
care costs for alcohol abuse were about twice those for drug abuse.
Studies of the link between parental substance abuse and child maltreatment suggest that chem-
ical dependency is present in between 40-80 percent of all cases in the child welfare system
(Young, N.K., Gardner, S.L. & Dennis, K., 1998). This places an enormous burden on medical,
social and education systems and incurs state costs for out-of-home foster care, court hearings,
and social services.

…ON HEALTH CARE


Research confirms that substance abuse is a contributing factor for many acute and chronic
health problems. Addiction increases behavioral risk factors, including acute drinking, marijuana
use, chronic drinking, and drinking and driving—among the most prominent identifiable behavioral
risk factors for morbidity and premature death. The following diseases and conditions are major
causes of premature death in Michigan that are associated with substance abuse:

 Unintentional injuries, including motor transport accidents, as well as non-transport


accidents and work-related injuries
 Cancer
 Cardiovascular diseases
 Suicide
 Conditions originating in the perinatal period including low birth weight
 Birth defects
 Homicide, including deaths due to child abuse and neglect and intimate partner
violence
 Chronic liver disease and cirrhosis
 Blood-borne diseases, including HIV/AIDS, Hepatitis B and Hepatitis C; and
 Enteric diseases, including Hepatitis A.

Claims data quantifying health care expenditures for treatment of substance abuse-related
conditions are not readily available from health insurers. Substance abuse is inconsistently identified
as the primary diagnosis on the claim. The diagnoses listed more often reflect consequences of
substance abuse, for example, AIDS, trauma, hepatitis, or cirrhosis, etc., but those diagnoses can
also occur without substance abuse being involved. More than 60 medical conditions involving
1100 diagnoses were identified in a study estimating the Medicaid costs of substance abuse (Fox,
Merrill, Chang, & Califano, 1995). That study found one out of five Medicaid-paid hospital days
was spent on substance abuse-related care in 1991.

…ON THE CRIMINAL JUSTICE SYSTEM

The Bureau of Justice Statistics Profile of Jail Inmates (2002) reported that nationally 24.7% of
jail inmates were held for a drug related crime. Further, 68.7% of inmates reported regular drug
use and 49.7% were reported to have been using drugs or alcohol at the time of their offense.

The Michigan Department of Corrections 2003 Statistical Report reported 12,289 criminal court

23
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

felony dispositions (offenders) statewide whose worst offence was a drug offense and 16% of all
prison sentences were for drug offenses. Washtenaw County reported 184 dispositions (18.6%)
whose worst offense was a drug offense.

In addition, the Justice Policy Institute reported that 63% of all Michigan prisoners have been
assessed as having substance dependence.

These data reflect only the tip of the iceberg concerning the relationship between substance
abuse and crime. A national study conducted in 1999 of drug use among arrestees found that
more than 64 percent of the male- and 67 percent of female-adult arrestees tested positive for the
presence of at least one of a battery of illicit drugs, including cocaine, marijuana, methampheta-
mine, opiates, and PCP (National Institute of Justice, 2000). In 1999, about 1 in 4 convicted
property and drug offenders in a national study reported committing their crimes to get money for
drugs (U.S. Department of Justice, 2000).

Local corrections officials report that 61% of Washtenaw County Jail inmates surveyed reported a
substance abuse problem. At a cost of approximately $85.71 per day per inmate, this equates to
more than a $16,600 per day cost to Washtenaw County taxpayers (Rick Visel/personal
communication, April 11, 2006).

A local official from the Michigan Prisoner Re-entry Initiative reports that there are approximately
200 parolees released to Washtenaw County each year. They estimate that approximately 60% of
these parolees have substance use disorders. They report that the recidivism rate of 70% in
Washtenaw County is significantly worse than the statewide average of 50%. (Mary King/personal
communication, April 25, 2006)

Nationally, driving under the influence occurs more frequently than all other reported criminal
offenses except larceny and theft (National Highway Traffic Safety Administration, 1999).
Approximately one-third of all drivers arrested for DUI are repeat offenders (Hedlund, 1995).
Washtenaw County’s DUI arrest rate is 40% higher than the national average. (Community
Health Committee, 2004)

…ON EDUCATION

Grant (2000) found that one in every four children in the U.S. was exposed to alcohol
abuse or dependence in the family. Although the majority of children who grow up in
homes where drugs and alcohol are a problem will eventually overcome the obstacles
they face as a result, many of them carry life-long scars or go on to develop serious drug
and alcohol problems of their own. Children of addicted parents run the highest risk of
becoming drug and alcohol abusers, due to both genetic and family environment factors
(Kumpfer, 1999). They are also at risk for school failure and dropping out (Frymier, 1992).

In addition to their exposure to substance abuse in the home, data from the National
Institute of Drug Abuse (1988) survey indicate that about one out of every 10 newborns in
the United States is exposed prenatally to one or more drugs. Problems with learning, attention,
memory, and problem solving occur more frequently among children exposed in-utero to alcohol
(Center for Substance Abuse Prevention, 1994). These children are more likely to require special
education services in the school system, adding to the cost of education.

…ON THE WORKFORCE

The anecdotal problems reported by local employers and employee assistance program providers
are borne out by research. Untreated drug- and alcohol-related problems greatly affect an
employer's bottom line in the form of decreased productivity, increased on-the-job accidents,
24
THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

absenteeism, turnover and medical costs. These costs are not just associated with employees who
themselves have a problem. The on-the-job performance of workers whose family members or
friends have drug and alcohol problems is also affected.

 Compared to the average employee, a typical employee experiencing problems with


alcohol or other drug use:
o Is 3 times more likely to be late for work.
o Requests time off 2.2 times more often.
o Has 2.5 times as many absences of eight days or more.
o Uses three times the normal level of sick benefits.
o Is 5 times more likely to file a workers' compensation claim.
o Is involved in accidents 3.6 times more often (How Drug Abuse Takes Profit Out of
Business. How Drug Treatment Helps Put it Back,1991), and
o Uses 2.5 times more medical benefits (Sheridan & Winkler, 1989).
 Twenty-one percent of workers report being injured or put in danger, having to re-do work
or cover for a co-worker, or needing to work harder due to others’ drinking (Mangione et
al., 1998).
 Up to 40 percent of industrial fatalities and 47 percent of industrial injuries can be linked to
alcohol consumption and alcoholism (Bernstein & Mahoney, 1989).
 The average cost per case of work-related death is estimated at $940,000, and per
disabling work injury, $28,000. These costs include wage and productivity losses, medical
expenses, administrative expenses related to claims, and employer costs including money
value of time lost by uninjured workers spent investigating and reporting injuries and giving
first aid, production slowdowns, training of replacement workers, and the extra cost of
overtime for uninjured workers (National Safety Council, 2001).
 Non-alcoholic members of alcoholics' families use 10 times as much sick leave as
members of families in which alcoholism is not present (Bernstein & Mahoney, 1989).
 Eighty-two percent of family members of alcoholics are employed, and 80 percent of them
report that their ability to function at work and home is impaired as a result of living with an
alcoholic (Al-Anon Family Groups, 1999).

…ON TAXPAYERS

A study by Columbia University (2001) found that throughout the nation in 1998, states spent 13.1
percent of their total $620 billion budgets dealing with substance abuse and addiction. Of every
dollar spent on substance abuse, only 4 cents were spent on prevention and treatment while 96
cents were spent dealing with the results of alcohol or drug abuse – social services, family courts,
foster care, prisons, etc. This study provides an excellent perspective, as it is difficult to ascertain
the true amount taxpayers spend on substance abuse. This study collected extensive data
nationally, pulling out specific funding within state programs related to drug and alcohol abuse.

The National Center on Addiction and Substance Abuse (Columbia University) reports that in
1998 (the latest year for which comparable data are available) all states spent a total of $81
billion—more than 13 percent of their collective budget—on problems related to substance
abuse and addiction. Michigan spent $2.7 billion, just over 12 percent of its budget. Michigan's
per capita spending related to the burden of substance abuse on public programs is 12th
highest in the nation. (Michigan is third from the bottom in spending on substance-abuse
prevention, treatment, and research.)

Of every substance-abuse dollar spent by the state, one cent was for prevention and treatment
programs and 99 cents paid for the burden the problem imposes on public programs—e.g.,
criminal justice, Medicaid, child welfare, and mental health. Of the $1.3 billion spent on justice-
related programs in Michigan, $1.1 billion was linked to substance abuse.

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

“The biggest opportunity to cut Medicaid costs is by preventing and treating


substance abuse and addiction. Governors who want to curb child abuse, teen
pregnancy and domestic violence in their states must face up to this reality:
unless they prevent and treat alcohol and drug abuse and addiction, their other
well intentioned efforts are doomed.”

Joseph Califano (foreword of the Columbia University study, 2001, p.ii)

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THE NEED FOR INCREASED COMMUNITY DETOXIFICATION SERVICES

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