Public Intoxication: Sobering Centers as an Alternative to Incarceration, Houston, 2010–2017

Abstract

In 2010, the Houston police department admitted 20 508 publicly intoxicated individuals into its jail. To address jail overcrowding, the city created a jail diversion policy that allowed law enforcement to admit publicly intoxicated individuals into a new sobering center. By 2017, public intoxication jail admissions had decreased by 95%, freeing valuable resources. A promising public health intervention, sobering centers offer an alternative to incarceration and relieve overuse of emergency services while assisting individuals with substance use issues.

Misuse of substances has a significant impact on public health, directly contributing to crime, health issues, and lost productivity.¹ In 2010, the City of Houston Police Department (HPD) had 20 508 public intoxication admissions into its jail (Table 1). Although public intoxication is a low-level misdemeanor offense, it creates collateral consequences that can negatively affect a person’s employment, housing, and access to government programs,² often initiating a downward economic and social spiral.

TABLE 1—

Annual Public Intoxication Admissions: Houston, TX, 2010–2017

	Admissions, No.
Location	2010	2011	2012	2013	2014	2015	2016	2017	Totala
Houston city jailb	20 508	16 365	15 357	6 345	2 093	1 450	1 187	835	11 910
Sobering centerc	0	0	0	3 753	5 700	5 799	5 398	4 632	25 282
Clients with < 3 admissions	0	0	0	3 252	4 523	4 366	3 879	3 448	19 468
Clients with ≥ 3 admissions	0	0	0	501	1 177	1 433	1 519	1 184	5 814

^aTotal 2013–2017 admissions.

^bReports of public intoxication admissions into the city jail.

^cReports of the Houston police department and other law enforcement agency admissions.

INTERVENTION

Houston’s goal in 2010 was to create a public health intervention that reduced public intoxication arrests, relieved jail overcrowding, and helped individuals whose substance use compromised their well-being and the welfare of their community.

PLACE AND TIME

In April 2013, the Houston Recovery Center launched a sobering center to serve the city of Houston and Harris County, Texas, with a growing population of more than four million residents. Sobering centers are “local, grassroots solutions [that] provide value-based services that crosses [sic] traditional medical and social boundaries.”^3(p1854) Per new HPD policy,⁴ officers can admit publicly intoxicated individuals into the sobering center so that they can get sober in a safe environment without legal consequences, or can release them to a responsible adult. Client admissions are voluntary, confidential, and free of charge. Individuals sober up in gender-specific dorms with the capacity to serve 68 men and 16 women, where they are periodically monitored. The average length of stay is four to six hours.

PERSON

To be admitted, individuals must be 18 years of age or older, ambulatory, and noncombative and must not be in a mental health crisis. In addition, they must pass a brief medical screen conducted by a staff emergency medical technician. Individuals can be impaired on alcohol or other drugs with the exception of synthetic cathinones (bath salts) or phencyclidine (PCP). If they do not meet the admission criteria, they are triaged to jail, an emergency psychiatric hospital, or a hospital emergency medical department. Those accused of driving while under the influence are directly admitted to jail.

The sobering center employs psychiatric technicians to manage behavioral issues, although the primary workforce is composed of state-certified peer recovery support specialists.⁵ Having achieved personal recovery for two years or more, peer recovery support specialists create a nonthreatening environment by sharing their personal experiences and encourage clients to see recovery possibilities. Their discussions identify clients’ substance use patterns and their readiness for change. On the basis of the results, clients can choose to be referred to community services or enroll in the Houston Recovery Center’s Partners in Recovery (PIR) program (Figure 1).

FIGURE 1—

Houston Recovery Center Current Proactive Intervention for Public Intoxication and Substance Use: Houston, TX

IMPLEMENTATION

In 2010, a team of Houston stakeholders toured the Restoration Center in San Antonio, a behavioral health facility operated by the local mental health authority. Subsequently, armed with the sobering center concept, they defined a business plan and gained city council approval to create, fund, and renovate a centrally located downtown warehouse to accommodate the Houston Recovery Center. As a result of the city of Houston’s support, the implementation was smooth, with a span of three years from concept to opening.

When the sobering center launched, it accepted jail diversions from the HPD special operations unit for four months and then opened to all HPD divisions. One year later, all law enforcement agencies were able to make referrals to the sobering center, and the community could walk-in for assistance (Figure 1). Other sobering centers receive admissions from emergency medical departments and emergency medical service (EMS) transports. The literature demonstrates that a level 2 emergency medical technician can effectively identify intoxication in the field and make referrals.⁶ However, the Houston sobering center does not receive EMS transports owing to an inadequate supply of ambulances, a city ordinance dictating EMS transport to hospitals, and a lack of onsite medical staff. Strategies for overcoming these obstacles include hiring paramedics, modifying the city ordinance, and providing EMS alternative transport options. Apart from transport issues to the sobering center, EMS does refer medically cleared public intoxication cases to street outreach staff (Figure 1).

In April 2014, Houston Recovery Center staff launched the PIR, which is designed to address substance use among low-income, uninsured clients with complex needs and three or more sobering center admissions. The PIR’s flagship program pairs a client with a case manager and peer recovery support specialist. This team supports the client for 18 months through a recovery service continuum of care based on the client’s unique needs. Once the PIR was implemented, the Houston Recovery Center’s service model shifted to a proactive intervention strategy that involved working with individuals who had active substance use disorders in criminal justice and street outreach settings (Figure 1).

EVALUATION

During the period the sobering center was being planned (2010–2012), public intoxication jail admissions decreased from 20 508 to 15 357 (Table 1). After the opening of the sobering center, HPD public intoxication jail admissions decreased by 95% over the period 2012 to 2017, from 15 357 to 835. Because the new diversion policy allowed officers community options to manage public intoxication, the sobering center did not absorb the entire decrease in jail admissions. The city views this jail diversion program as a cost offset as opposed to a cost savings. A jail admission costs $286 per day. At full use, the sobering center would cost $127 per admission, yet it currently operates at 18.5% capacity. Given its budget and 84-bed capacity, the sobering center would have to operate at 42% capacity to break even with an equivalent number of jail admissions. Law enforcement agencies are the primary source of admissions and emergency department referrals are limited (Figure 1), so receiving EMS transports would improve rates of use.

Of the 25 282 clients admitted to the sobering center, 19 468 (77%) were admitted once or twice. Critically important, there were 5814 frequent clients (23%), those admitted three or more times; this population contributes to the major social and economic costs attributable to public intoxication. The gender breakdown of clients was 84.1% male and 15.9% female, with the 18- to 30-year age bracket exhibiting the fastest growth in admissions. Thirty-five percent of clients who responded to survey questions reported that they had low incomes and were either uninsured or enrolled in Medicaid. The top substances of use were alcohol (82%), synthetic cannabinoids (12%), marijuana (6%), cocaine (5%), and opiates (< 3%).

Forty-eight percent of all clients admitted accepted a referral to services, requested housing assistance, or enrolled in treatment upon discharge. The PIR enrolled 849 clients, including 23% of the sobering center’s frequent clients; this program had a 54% community walk-in rate, with 22% of these clients having a prior sobering center admission and requesting recovery assistance. Our evaluation was descriptive and did not include efficacy data.

ADVERSE EFFECTS

No adverse effects were observed.

SUSTAINABILITY

The sobering center has a $1.64 million budget that is funded by the city of Houston. The PIR, implemented with Medicaid section 1115 waiver funds, is now transitioning to private funding with an $800 000 annual budget. Providing individuals an effective intervention to sober up relieves a community’s public intoxication problems at a much lower operational cost. If clients are connected to recovery resources, the cost burden shifts from high-cost public services to community service providers.⁷

PUBLIC HEALTH SIGNIFICANCE

Publicly intoxicated individuals are traditionally admitted into a jail or medical emergency department. Once stabilized, they are discharged to the street. Although misuse of substances is a health issue that involves safety concerns, these settings are not equipped to screen and refer individuals to services. However, when individuals are diverted to Houston’s sobering center, their pattern of use is disrupted. Clients without a serious substance use issue become more aware of the consequences of overuse, and clients with problematic substance use issues gain access to appropriate recovery services and care.