Sobering centers offer a safe place to recover from intoxication. Every community should have one

Every day, thousands of individuals across the United States call 911 due to concern about someone who is intoxicated in public. Their concern is warranted: The potential harms from public intoxication are significant. They are at risk of being the target of assault, violence, or theft or may suffer injury or death from an underlying health condition. In addition to risk of death in custody, there may also be a heightened danger for some racial or ethnic groups when law enforcement becomes involved.

In most communities, police or ambulances have just two options: They can bring the intoxicated person either to jail or the emergency department. Most people with drug or alcohol intoxication require neither a criminal response nor the level of critical care offered in an ED. Yet, the number of people brought to the emergency department and to jail increases annually.

There is a third choice, though, one that more communities should make available: the sobering center.

Sobering centers are short-term (less than 24-hour), nonpunitive care facilities where people can safely recover from the effects of acute alcohol and/or other drug intoxication.

My own journey with sobering care started in 2007 as a registered nurse at the San Francisco Sobering Center and the co-located Medical Respite, a supportive shelter for medically frail adults experiencing homelessness. Today, I have completed my doctoral work on sobering care, have visited over 30 sobering centers in the United States and Canada, started a nonprofit, and conducted research investigating how and why sobering works and ways to implement this care model. The primary function of a sobering center is to provide a safe, monitored environment for people to sober up. A center may offer basic medical services such as wound care, access to treatments like naltrexone or buprenorphine (medications that help reduce substance use and related harms), and access to staff who specialize in substance use disorders — many of whom are themselves in recovery. Additionally, staff can refer and directly transfer interested clients to stabilizing services such as treatment, harm reduction programs, or shelter.

There are approximately 60 sobering centers in the United States. People arrive there from ambulances, law enforcement, clinics, emergency departments, other community programs, or even via self-referral. Also known as stabilization or recovery programs, crisis receiving, or sobriety stations, sobering centers may operate as stand-alone facilities or be co-located with other programs.

Before sobering centers existed, people who were intoxicated were sent to “drunk tanks” — jails designed to hold people who were intoxicated in public. Not only do drunk tanks fail to address substance use, they also have been the site of violent victimization, deaths from medical conditions, and high rates of suicide.

Since the 1950s, health care providers and others worked to change the view of substance use from one of a moral failure, to one of a clinical condition. These ideas led to the 1971 Uniform Alcoholism and Intoxication Treatment Act, a federal effort aimed to improve care for people with alcohol use that also helped establish the first sobering centers. Fifty years later, they are only now beginning to gain in popularity.

Various sobering center models have developed in response to the needs of the specific communities and populations served, resulting in different settings, service delivery approaches, referring parties, and community collaborations. Established primarily for law enforcement use, the 84-bed Houston Recovery Center opened in 2013 and is staffed with peer recovery support specialists, EMTs, and psychiatric technicians. In its first five years, the Houston sobering center had over 25,000 visits for short-term sobering — many of which would have instead been jail visits. In addition to operating a dedicated Public Intoxication Transport service, Houston Recovery Center now offers an 18-month recovery program accessible to people seen in the sobering center.

Research also suggests that sobering centers can safely care for intoxicated people who are transferred in by ambulances instead of going to the emergency department. The San Francisco Sobering Center, in operation since 2003, is the longest-standing sobering service receiving individuals directly from ambulances. With a capacity for 12 clients, the center offers registered nurses and peer recovery support staff who provide ongoing monitoring, basic medical care, and referrals to detoxification and treatment services. Additional sobering centers accepting ambulance referrals have opened in Austin, Texas, Baltimore, Maryland, St. Louis, Missouri, and most recently Washington, D.C.

Considering the expense of an emergency department visit compared with a sobering center visit, sobering care may offer substantial cost savings in national health care spending.

Importantly, research has found certain core components of sobering care are essential to its success. Specifically, best practices from sobering care leaders across California stress the critical role of peer professionals in client engagement; low-barrier, compassionate, flexible service model; coordination with city- and county-wide agencies; and a harm reduction focus for recovery.

The path to recovery often requires a comprehensive, individualized approach. A central function of sobering care is to take the opportunity to engage, motivate, and link individuals to community resources that may provide ongoing stabilization and recovery. Many visitors may not change their consumption patterns after their first — or even their 12^th — visit to a sobering center. Thus, particularly for clients with chronic substance use disorders, creating an environment to support long-term client relationships is critical to successfully stabilizing individuals and impacting rates of public intoxication.

Although supportive services and referral capacity may be available on-site, sobering centers are not intended to be treatment facilities nor provide rehabilitation for substance use disorders. Sobering programs are considered an upstream intervention service with respect to the recovery continuum-of-care because they work with individuals engaged in active and symptomatic use, many of whom may be in the pre-contemplative stage of change.

There are a few core challenges to opening new sobering centers. Sobering care intersects with numerous entities — health care, law enforcement, recovery, homeless services, business districts, to name a few — and many communities struggle to agree on who should pay for the services. California offers one model for how to handle this: The CalAIM Sobering Center Benefit offers reimbursement for a sobering stay that may allow additional communities statewide to offer this individualized, compassionate care model.

Second, emergency response laws and policies may restrict the ability of paramedics to transport their patients to sobering care. The most detrimental restriction may be one dictated by insurance companies, which will not reimburse ambulances unless they go to an emergency department. A recent effort by the Centers for Medicare and Medicaid Services attempted to evaluate ambulance payment models; however, the study is ending early and long-term impact is unclear.

Lastly, community members who are worried about having a center in their midst may push back aggressively. But research suggests that the programs are more often recognized to be a good neighbor.

As both a nurse and researcher, I have spent years caring for individuals who, through their substance use, have lost nearly everything: their jobs, homes, family, and friends. Their sobering visit started them on a new path. Sometimes it was immediate — the young adult who, with their first and only sobering visit, realized their alcohol use had gotten out of control. Others, over the course of dozens of visits to sobering care, began to slowly but surely make changes in their lives and gain hope for a future no longer dictated by their substance use.

Shannon Smith-Bernardin Ph.D., RN is associate professor with the University of California, San Francisco School of Nursing and co-founder of the National Sobering Collaborative, a 501(c)3 nonprofit. Shannon is a public voices fellow of The OpEd Project in partnership with the UCSF Benioff Homelessness and Housing Initiative.