| Summary: | Alcoholism is a major social and medical problem in Scotland and convictions for drunkenness offences increase each year; there is evidence that most drunken offenders are alcoholics. A minority of vagrant alcoholics are known to medical sources and penal management of drunken offenders has resulted in the offender repeatedly passing through courts and prison, receiving little if no help with his alcoholism. Legislation in England and Wales has been enacted, but not implemented, to remove the penalty of imprisonment for drunk and disorderly behaviour, and a Home Office Working Party has recommended the establishment of detoxification centres to deal with public drunkenness. The aims of the project on which this thesis is based were to assess the feasibility and effect of adding a detoxification service to a Regional Poisoning Treatment Centre and to a psychiatric hospital, and to evaluate the effectiveness of this detoxification, assessment and referral service for socially deteriorated alcoholics. The cohort consisted of 100 Edinburgh males who were alcoholics, were receiving no current treatment for alcoholism and who had a history of convictions for drunkenness offences. The cohort were randomly allocated to proband and control groups, the latter receiving no treatment. The probands were able to use the detoxification facility when intoxicated or having alcohol withdrawal symptoms, and police agreed to waive their right to prosecute a proband if found drunk and incapable, instead to take him to the detoxification centre. This experimental period lasted one year. The characteristics of the subjects are described and compared with the findings in other studies, the individuals being found to have a high degree of medical, psychological and social pathology. The detoxification programme is described - the management of withdrawal symptoms, medical investigations and methods of assessment and referral. Difficulties were encountered when the project was located in the Regional Poisoning Treatment Centre and these are described and discussed together with a review of the literature on attitudes of doctors and nurses towards alcoholics. Relatively few problems were encountered after transfer to the psychiatric hospital. Data is presented on admissions for detoxification, and medical morbidity over and above detoxification and withdrawal was recorded in about 50% of the admissions. Eleven of the cohort died in a 2-year period, twice the rate for the general population. Evaluation of the results showed that during the experimental year the change from the penal to the medical system was effective with a greatly diminished penal record among the proband group, while the controls continued to be prosecuted and imprisoned at the same rate as in the pre-experimental year. The assessment and referral service was likewise effective, the number of admissions to, and time spent by, the proband group in psychiatric hospitals and rehabilitative hostels being greatly increased with respect to both their own pre-experimental year and when compared with the controls. Eighty-five per cent of the cohort were followed up one year after enrolment and a questionnaire assessment showed the probands to have improved with respect to health, accommodation, drinking habits and their subjective impression of the quality of their lives. An additional survey of random drunken offenders showed that two-thirds had had three or more previous convictions for drunkenness, half had been in prison on that account and probably two-thirds were alcoholics. Three-quarters would have preferred a detoxification centre to a police cell when arrested for drunkenness. It is concluded that it is feasible to manage drunken offenders in a medical and rehabilitative system rather than by the penal system. The effects of adding a detoxification service to a Regional Poisoning Treatment Centre and to a psychiatric hospital led to the conclusion that the former, in our experience, is not a suitable location, and that staff trained in psychiatric methods are necessary. It is recommended that detoxification centres should be based in hospitals, with a close social work liaison. It is further concluded that the detoxification and assessment facility was effective for the individuals, though long-term benefit can only be assessed when better rehabilitative facilities are available than was the case in this project. Some implications for the management of future detoxification centres are discussed. A superficial costing exercise indicated that a change from penal to medical management of drunkenness need not be more expensive, and can probably be carried out in Scotland under existing legislation.
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