UW/ABRC
Harm Reduction
G. Alan Marlatt, Ph.D.
University of Washington
Addictive Behaviors Research Center
http://depts.washington.edu/abrc/
2
UW/ABRC
4
UW/ABRC
UW/ABRC
UW/ABRC
UW/ABRC
Harm Reduction: History
U.K. Model
Medicalization Approach
Netherlands
Normalization Approach
Junkie bond
6
UW/ABRC
UW/ABRC
UW/ABRC
UW/ABRC
8
UW/ABRC
UW/ABRC
UW/ABRC
UW/ABRC
10
UW/ABRC
UW/ABRC
UW/ABRC
Dutch Model
Realistic and pragmatic
Social/health approach
Openness, “Normalization” leads to access, control
Distinction between “soft” and
“hard” drugs
Low threshold treatment policies
UW/ABRC
Dutch vs. American Drug Policies
Low vs. High threshold access to prevention and treatment
programs
Public health vs. Criminal justice approach
Tolerance vs. Zero-tolerance
Normalization vs.
Denormalization policies
12
UW/ABRC
Harm Reduction: Central Assumptions
Public health alternatives to moral/criminal and disease
models of drug use and addiction
Recognizes abstinence as an ideal outcome, but accepts other
alternatives
Often partners with the group to obtain input on programs
UW/ABRC
Harm Reduction: Overview
Harmful consequences of drug use can be placed on a continuum
Goal: to move along this
continuum by taking steps to
reduce harm
UW/ABRC
Harm Reduction
“Habit is habit and not to be flung out of the window by any man, but coaxed downstairs a step at a time.”
Mark Twain,
Pudd’nhead Wilson’s Calendar,
Chapter 6
14
UW/ABRC
Harm Reduction: Methods
Safer route of drug administration
Alternative, safer substances
Reduce frequency of drug use
Reduce intensity of drug use
Reduce harmful consequences of drug use
UW/ABRC
Harm Reduction: Behavior Change
Individual
Environment
Policy
UW/ABRC
How was I supposed to know that the apple was a controlled substance?
UW/ABRC
16
UW/ABRC
UW/ABRC
UW/ABRC
UW/ABRC
18
UW/ABRC
UW/ABRC
UW/ABRC
Preliminary Evaluation of Low-Threshold Housing for Chronic Public Inebriates
Housing First
UW/ABRC
Estimated 1,000 in King County
Dying at rates greater than other homeless subsets
Consuming taxpayer-funded crisis services at elevated rates
Chronic Public Inebriates (CPIs)
20
UW/ABRC
Sobering/detoxification centers
Emergency Departments & Hospitals
Involuntary treatment
Jails / Criminal Justice
911 / EMS Calls
Crisis Services Frequently used by CPIs
UW/ABRC
Non-profit, based in Seattle, WA
5,000+ homeless adults per year
Serves sickest & most vulnerable:
emergency shelter
licensed mental health &
CD services
supportive housing
high level of integration across programs
Downtown Emergency
Service Center (DESC)
UW/ABRC
Housing is: People want:
a basic human right
not a reward for clinical success
a home to live in
to get better
Belief Experience
UW/ABRC
Move directly from the street /homelessness
(treatment acceptance/compliance not a precondition)
Harm reduction approach
(abstinence not mandated)
Leases and tenant protections under the law
(Continued housing not conditioned on services or treatment participation)
Housing First Principles
22
UW/ABRC
Designed as “Pre-recovery” housing for CPIs unable or unwilling to abstain from alcohol
Low-demand, flexible structure
Intensive 24/7 staffing focused on engagement
Goals:
Reduce use of alcohol
Reduce use of crisis services
1811 Eastlake
UW/ABRC
1811 Eastlake is Permanent Housing
Opened December 23, 2005
UW/ABRC
Local and national newspaper, radio, and TV coverage
Editorials and opinion pieces opposed to project
Smaller amount of favorable coverage
Steadfast support by funders, elected officials, and business community
1811 Eastlake is Controversial
UW/ABRC
24
UW/ABRC
1) Evaluate impact of 1811 housing program on utilization and cost of publicly funded services, prior to and following move-in
2) Evaluate impact of 1811 housing program on alcohol use outcomes
Research Aims
UW/ABRC
48 Recruitment
Residents recruited from list of high-utilizers of publicly-funded services.
Participants enrolled in the study after housing offer was made (79 housing offers extended to fill first 75 openings)
95 participants enrolled at least one year prior to the current analyses
68 (71.5%) of these participants remained in the house at least 1 year
Method
UW/ABRC
Assessment Procedures
Participants consented to release of
utilization records 3 years pre- and 3-years post-enrollment.
Participants completed extensive interviews of alcohol use and functioning at baseline, 3-, 6-, 9-, 12-, and 18-month follow-ups.
Method
UW/ABRC
Race/Ethnicity Caucasian
Native American/Alaskan Native
African American Hispanic/Latino/a Native Haw aiian/Pacific Islander
More than 1 race Other
Gender
Men Women
26
UW/ABRC
Reductions in Sobering Center Utilization
0 1000 2000 3000 4000 5000 6000 7000
Intent to Treat (n=70) Housed Full Year (n=55)
Sobering Center Utilization Days 1 yr prior
Sobering Center Utilization Days 1 yr post
UW/ABRC Reductions in Sobering Center Costs
$-
$100,000.00
$200,000.00
$300,000.00
$400,000.00
$500,000.00
$600,000.00
$700,000.00
$800,000.00
$900,000.00
$1,000,000.00
Intent to Treat (n=70) Housed Full Year (n=55)
Sobering Center Costs 1 yr prior
Sobering Center Costs 1 yr post
UW/ABRC
Reductions in Shelter Visits
0 500 1000 1500 2000
Intent to Treat (n=59) Housed Full Year (n=50)
Shelter Visits 1 yr prior Shelter Visits 1 yr post
UW/ABRC Shelter Cost Reductions
$-
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
$45,000.00
$50,000.00
Intent to Treat (n=59) Housed Full Year (n=50)
Shelter Costs 1 yr prior Shelter Costs 1 yr post
28
UW/ABRC Reductions in Medical Center Visits
0 200 400 600 800 1000 1200 1400
Intent to Treat (n=74) Housed Full Year (n=59)
Harvborview Medical Center Visits 1 yr prior
Harvborview Medical Center Visits 1 yr post
UW/ABRC Reductions in Medical Center Costs
$-
$500,000.00
$1,000,000.00
$1,500,000.00
$2,000,000.00
$2,500,000.00
$3,000,000.00
Intent to Treat (n=74) Housed Full Year (n=59)
Harborview Medical Center Charges 1 yr prior Harborview Medical Center Charges 1 yr post
UW/ABRC Reductions in Emergency Medical Service Calls
0 100 200 300 400 500 600 700
Intent to Treat (n=63) Housed Full Year (n=50)
Emergency Medical Service Calls 1 yr prior
Emergency Medical Service Calls 1 yr post
UW/ABRC Reductions in EMS Costs
$-
$50,000.00
$100,000.00
$150,000.00
$200,000.00
$250,000.00
$300,000.00
$350,000.00
$400,000.00
$450,000.00
$500,000.00
Intent to Treat (n=63) Housed Full Year (n=50)
Emergency Medical Service Costs 1 yr prior
Emergency Medical Service Costs 1yr post
30
UW/ABRC Reductions in Jail Bookings
0 20 40 60 80 100 120 140 160 180 200
Intent to Treat (n=74) Housed Full Year (n=58)
Jail Bookings 1 yr prior Jail Bookings 1 yr post
UW/ABRC Reductions in Jail Booking Costs
$-
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
Intent to Treat (n=74) Housed Full Year (n=58)
Cost of Jail Bookings 1 yr prior
Cost of Jail Bookings 1 yr post
UW/ABRC Reductions in Jail Days
0 500 1000 1500 2000 2500
Intent to Treat (n=74) Housed Full Year (n=58)
Jail Days 1 yr prior Jail Days 1 yr post
UW/ABRC Reduced Costs of Days in Jail
$-
$50,000.00
$100,000.00
$150,000.00
$200,000.00
$250,000.00
$300,000.00
Intent to Treat (n=74) Housed Full Year (n=58)
Cost of Jail Days 1 yr prior Cost of Jail Days 1 yr post
32
UW/ABRC Detox Admissions Stable
0 20 40 60 80 100
Intent to Treat (n=50) Housed Full Year (n=38)
Medical Detox Admissions 1 yr prior
Medical Detox Admissions 1 yr post
UW/ABRC
Reductions in Drinking Past 30 days
0 5 10 15 20 25
Days Drunk Days Abstinent
Drinking in Past 30 Days 1 yr prior
Drinking in Past 30 Days 1 year post
UW/ABRC
Findings to date focus on pre-post changes (Wait-list comparison group enrolled,
analyses not yet available).
Alcohol use data based on self-report.
Privacy policies serve as barriers to serving CPIs and evaluating outcomes of programs.
Future focus on more assertive engagement strategies to reduce alcohol consumption.
Limitations and Future Directions
UW/ABRC
