Does your city need a wet house for homeless alcoholics?

When you sleep with your bottle, you've passed a milestone in your addiction. You've got to have it against your chest, all night, easy to reach. Your relationship to it is like other people's relationships with their smart phones; it's crucial to your existence, always clutched in your hand. You feel unsettled when you can't see it, until it's easier to just sleep with it.

But there are other, worse stages to come. As I ask my clinic patients about them, I hear a ding in my mind, like an elevator does each time a door opens, each time a patient answers yes.

Do you wake with the shakes? That means that you're so addicted that you begin to withdraw every night as you sleep. Ding.

Do you wake up in the night to take a drink? Your brain must be bathed in alcohol, awash in the acrid sea of it, at all times. You can no longer make it to morning. Ding.

Do you seize if you stop drinking? Deprived of alcohol, your tender brain begins to crackle and sizzle, and then ignites like a gas-explosion -- ka-whoom -– as a depth charge of neurons fires. Ding.

Can you remember how this happened? It looks like something hit you pretty hard, sir, the way your cheekbone is caved in here under all this blood. Do you remember? You never remember what happens when you're drinking. Ding. Ding. Ding.

At what point does society decide that someone has become a danger to himself because of his addiction? And what can be done about it?

The large numbers of public inebriates on our sidewalks represent a financial, ethical, and moral crisis in cities across America. These suffering humans also represent a public health crisis. Mortality rates are sky high, with life expectancies equal to, or worse than, those of people living in the most devastated, violence-riddled pockets of our globe.

The issue of people drinking themselves to death on a sidewalk is one that unites and divides us in unpredictable ways, crossing "normal" divisions of politics, compassion, and fiscal conservatism. There are those who want a person slowly dying in plain sight to at least have a roof over his head. There are the more law-and-order, throw-the-bums-out types, who just want public inebriates off the streets. And no one can look at the eye-popping cost of this public, drawn-out suffering and death without thinking that, at $8 million dollars a year in health care costs for 100 people, there has to be a better - and cheaper - way.

Which means that people coming at this problem from all directions often end up at the same place, asking a question that seems obvious: heck, at this cost, can't we just put a roof over their heads?

We've tried a number of approaches to the issue of housing severe alcoholics. We tried demanding sobriety before housing, and that was (and is) about as unsuccessful as all demands for sobriety are. We tried tying increased benefits to moving towards sobriety. But anyone who will drink himself to the point of lying in his own stool, with a cheekbone caved in from a baseball bat to the face, is unlikely to be permanently changed by, say, the offer of warm meals or fewer roommates.

Which is not to say that these approaches have not helped many people. These programs just don't seem to be able to deal with the worst of the worst. Even if a severe alcoholic made it past detox and into a program, almost inevitably there would be infractions of the rules, or an outburst, or an episode of unconsciousness - and the recourse would be to throw him out of the program - and back onto the street.

Those of us with money can quietly sit in our own homes and drink ourselves to death. So the question became, why not just get the roof first, and then, away from the street's violence and provided with basics like water, toilets, and food, maybe then we could address the alcoholism.

Welcome to the "wet house." Or the "housing first" movement. The strategy has different names, depending on who's talking about it. But no matter what you call it, it's surprisingly effective.

The first, and best studied, wet house opened in 2005 in Seattle. There are five in Minnesota, with others being considered in Anchorage, Memphis, and Philadelphia.

From the viewpoint of its harshest critics, a "wet house" is a taxpayer-paid home where a hopeless alcoholic can drink himself to death. Although the name implies it, wet houses do not supply alcohol. Some even require that clients drink off-site, or agree to have their alcohol locked up and accessible only through a counselor. Whatever the minimal restrictions, you don't have to be clean and sober to keep your place. You can drink to the point of passing out all you want.

That image can rankle pretty much anyone who just lost a job or who's struggling to keep his home or pay for health insurance. And it rankles those who think that housing someone who won't quit drinking is a form of enabling. But the unarguable result is that it saves a ton of money, gets a public inebriate off your sidewalks at minimal cost, and saves lives.

For those who are proponents of "housing first," the issue is a no-brainer. Profound addiction is a form of profound impairment, with a high mortality rate. As we see people literally die in front of us from various types of self harm due to fluctuating, but severely impaired judgment, it is testing our limits of individual freedom and the right to choose.

Housing first is, so far, one of the only ways to consistently offer treatment for this refractory, terminal illness. Once they normalize to life under a roof, severe alcoholics will often also normalize their drinking and sometimes even begin to move toward sobriety. Of all the programs we've tried, and then found to have failed, housing first is the one approach that seems to work more than any other.

But housing first does raise uncomfortable issues for many people, even if it saves millions of dollars a year as well as lives. Who would want to live next to a facility like this? Are we creating ghettos for alcoholics? When people who live there become violent, who's responsible, and what is the recourse? Do we place people in units and then leave them there forever?

These types of questions may be what are keeping us from moving forward. Is it the fact that we don't know where to go next that keeps us from taking a first step?

Is there a wet house in your city? Is one being considered? If there is one, how's it doing, and what's the plan?

Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.

See more of Doc Gurley's posts here.

Photo credit: George Erws via Flickr