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Voices of Homeless Alcoholics Who Frequent Bellevue Hospital: A Qualitative Study

      Study objective

      We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.

      Methods

      We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.

      Results

      Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants’ perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.

      Conclusion

      Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.
      SEE EDITORIAL, P. 187.

      Introduction

      More than one third (38%) of the approximately 100 million homeless people in the world are alcohol dependent.
      • Fazel S.
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      The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis.

      Kothari M. United Nations Press Briefing by Special Rapporteur on Right to Adequate Housing. New York, NY: 2005. Available at: http://www.un.org/News/briefings/docs/2005/kotharibrf050511.doc.htm. Accessed June 14, 2014.

      Chronically alcohol-dependent, homeless individuals are fixtures in many emergency departments (EDs) and disproportionately affect health care infrastructure and the increasing costs of public health.
      • Bharel M.
      • Lin W.C.
      • Zhang J.
      • et al.
      Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act.
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      • Kohn M.A.
      Epidemiologic analysis of an urban, public emergency department's frequent users.
      • Hansagi H.
      • Engdahl B.
      • Romelsjö A.
      Predictors of repeated emergency department visits among persons treated for addiction.
      • Thornquist L.
      • Biros M.
      • Olander R.
      • Sterner S.
      Health care utilization of chronic inebriates.
      • Shumway M.
      • Boccellari A.
      • O'Brien K.
      • Okin R.L.
      Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial.
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.
      • Larimer M.E.
      • Malone D.K.
      • Garner M.D.
      • et al.
      Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.

      Caton C. People who experienced long-term homelessness: characteristics and intervention. The 2007 National Symposium on Homelessness Research 2007. Available at: http://aspe.hhs.gov/hsp/homelessness/symposium07/caton. Accessed June 14, 2014.

      • Kertesz S.G.
      • Weiner S.J.
      Housing the chronically homeless: high hopes, complex realities.
      • McCormack R.P.
      • Williams A.R.
      • Goldfrank L.R.
      • et al.
      Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders.
      Despite their repeated ED and detoxification unit admissions, this group experiences poor health and appears incapable of escaping social circumstances that perpetuate and exacerbate their problems.
      What is already known on this topic
      Little is documented about the subjective experience of homeless alcoholics who frequently use emergency departments (EDs).
      What question this study addressed
      Researchers interviewed 20 homeless alcoholics at length to understand their life, goals, history, and views on their ED usage.
      What this study adds to our knowledge
      This study may increase emergency physicians' awareness of these patients' predicament and may inform the types of interventions to be studied to help them manage their illness.
      How this is relevant to clinical practice
      It will not at present change clinical practice.
      The National Institute on Alcohol Abuse and Alcoholism emphasizes the importance of studies that differentiate subtypes of alcohol use disorders to better understand factors associated with the development and progression of illness and to more effectively tailor treatment to the stage-appropriate needs of the individual.

      National Institute on Alcohol Abuse and Alcoholism, US Department of Health and Human Services. Five year strategic plan FY09-14: alcohol across the lifespan. Available at: http://www.niaaa.nih.gov/about-niaaa/our-work/strategic-plan. Accessed June 14, 2014.

      Research spanning genetic and environmental interactions, neurobiology, and metabolism has produced a preponderance of evidence that addiction is a chronic brain disease
      • Uhl G.R.
      • Grow R.W.
      The burden of complex genetics in brain disorders.
      • Volkow N.D.
      • Wang G.J.
      • Fowler J.S.
      • et al.
      Addiction circuitry in the human brain.
      • Chandler R.K.
      • Fletcher B.W.
      • Volkow N.D.
      Treating drug abuse and addiction in the criminal justice system: improving public health and safety.
      and has led to novel behavioral and pharmacotherapeutic treatment approaches.

      Raistrick D, Healther N, Godfrey C. Review of the effectiveness of treatment for alcohol problems. November 2006. Available at: http://www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf. Accessed December 5, 2013.

      Intensive case management and low-barrier supportive housing, for which abstinence is not requisite, have yielded promising psychosocial and economic outcomes.
      • Shumway M.
      • Boccellari A.
      • O'Brien K.
      • Okin R.L.
      Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial.
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.
      • Larimer M.E.
      • Malone D.K.
      • Garner M.D.
      • et al.
      Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.

      Caton C. People who experienced long-term homelessness: characteristics and intervention. The 2007 National Symposium on Homelessness Research 2007. Available at: http://aspe.hhs.gov/hsp/homelessness/symposium07/caton. Accessed June 14, 2014.

      • Kertesz S.G.
      • Weiner S.J.
      Housing the chronically homeless: high hopes, complex realities.
      • Palepu A.
      • Patterson M.L.
      • Moniruzzaman A.
      • et al.
      Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders.
      • Tsemberis S.
      • Kent D.
      • Respress C.
      Housing stability and recovery among chronically homeless persons with co-occuring disorders in Washington, DC.
      However, there are few data from the perspective of the individual describing the evolution, environment, and psychosocial context of the disease, and many of these qualitative studies have aimed to evaluate and inform components of interventions.
      • Davis E.
      • Tamayo A.
      • Fernandez A.
      “Because somebody cared about me. That's how it changed things”: homeless, chronically ill patients' perspectives on case management.
      • Dyson J.
      Experiences of alcohol dependence: a qualitative study.
      • Järvinen M.
      Accounting for trouble: identity negotiations in qualitative interviews with alcoholics.
      • Thurang A.
      • Bengtsson-Tops A.
      Living an unstable everyday life while attempting to perform normality—the meaning of living as an alcohol-dependent woman.
      • Thurang A.
      • Rydström J.
      • Bengtsson-Tops A.
      Being in a safe haven and struggling against alcohol dependency. The meaning of caring for male patients in advanced addiction nursing.
      • Collins S.E.
      • Clifasefi S.L.
      • Andrasik M.P.
      • et al.
      Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      • Yeh M.Y.
      • Che H.L.
      • Wu S.M.
      An ongoing process: a qualitative study of how the alcohol-dependent free themselves of addiction through progressive abstinence.
      • Straus R.
      Alcohol and the homeless man.
      The purpose of this phenomenological study was to explore the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent persons who frequent Bellevue Hospital Center in New York City. Because of the considerable stigma that persists in society and within the medical profession about this population, we chose a phenomenological approach and set aside our assumptions to more accurately reveal the cause, progression, and attempts to manage the disease from these individuals’ perspectives.
      • Creswell J.W.
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
      Our goal was to expand the field of study by examining their subjective accounts of their life histories, the lives they are leading today, and where those lives are heading. The primary research question was, how do individuals identifying as homeless alcoholics describe their lives? Three subquestions guided the study: What is the daily experience of alcoholics who live on the streets? What role does the hospital play in their lives? How do they envision their future?

      Materials and Methods

       Study Design and Setting

      From January through August 2012, we interviewed 20 chronically homeless, alcohol-dependent persons who were frequent ED users of an urban, public, academic, tertiary care hospital. We chose the sample size according to the phenomenological approach, which traditionally involves fewer than 25 individuals,
      • Creswell J.W.
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
      and continued enrollment until theoretic saturation was achieved (point at which concepts in the theory are well developed and further observations yield minimal new data)
      • Giacomini M.K.
      • Cook D.J.
      Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group.
      and typical and atypical “cases” were represented in the sample.
      We obtained institutional review board approval and a certificate of confidentiality from the National Institute on Alcohol Abuse and Alcoholism. Written informed consent was obtained from each participant, including permission to audio record the interviews and to publish the data with identifying information removed.

       Selection of Participants

      Eligible participants spoke English or Spanish, had more than 4 annual ED visits for 2 consecutive years, and met both the federal definition of chronic homelessness and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for alcohol dependence. Participants were identified and recruited with an administrative database search, chart review, and a previously tested registration-linked alert system.
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.

      American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: 2000.

      Office of Community Planning and Development, Office of Special Needs Assistance Programs. Defining chronic homelessness: a technical guide for HUD programs. 2007. Available at: https://www.onecpd.info/resources/documents/DefiningChronicHomeless.pdf. Accessed December 5, 2013.

      Potential participants were approached only if they had or once they had a Richmond Agitation Sedation Scale score of –1 (drowsy), 0 (alert and calm), or +1 (restless).
      • Ely E.W.
      • Truman B.
      • Shintani A.
      • et al.
      Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).
      Individuals who were physically or psychologically unstable or unable to demonstrate capacity to consent were excluded. We attempted to approach individuals who were unable or unwilling to participate (primarily because of alcohol intoxication or withdrawal) in the same or a future visit to help ensure that more challenging cases were included. We used purposive sampling to obtain a range of ethnically diverse subjects representing typical and atypical cases, including subjects with and without medical and psychiatric comorbidities, inpatient and ambulatory care use, US citizenship, and care managers or housing caseworkers. Study participation did not affect medical care; some participants had an extended ED visit length of stay to reach a greater degree of sobriety. Participants received a $20 gift card. When possible, we revisited subjects on a subsequent day with a small gift (eg, clothing) to express our appreciation, receive feedback, and build trust, which had previously been identified to be lacking in this population.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      To minimize the risk of introducing professional and personal biases, the principal investigator assembled a diverse, multidisciplinary team with complementary areas of expertise. The team was composed of 5 members, 3 men and 2 women, with ages ranging from the midtwenties to early seventies, who collectively represented 6 departments from 4 schools of graduate education programs at New York University. Each person brought different training and experience: 2 physicians are board certified in emergency medicine and internal medicine, one of whom is also certified in addiction medicine; a PhD-prepared nurse with 3 decades’ worth of qualitative research experience who teaches these methods as a professor of humanities and social science; and 2 nonmedically trained individuals, one of whom is fluent in Spanish and whose qualitative work has focused on Latin American prisoners, and the other a journalist who teaches qualitative interviewing and narrative writing. Three team members have alcoholics (both active and in remission) in their immediate families. No research personnel provided clinical care for subjects during their study visits. The principal investigator, a practicing emergency physician, was aware of the power differential between the participants and himself, and offered to recuse himself from the interviews and attempted to diffuse any perceived coercion. We used our clinical and research experience with this population as context and bracketed our personal and professional biases in the interviews and analysis.
      • Creswell J.W.
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
      We spoke regularly about completed interviews and reviewed field notes to minimize bias.

       Data Collection and Processing

      We structured the study to include a single interview to last approximately 60 minutes, using a semistructured guide that was informed by existing medical, social, and public health research on addiction and homelessness. We conducted face-to-face individual interviews in private hospital spaces with 1 primary interviewer and 2 observers. Audio recordings were transcribed verbatim, with identities removed and stored on password-encrypted computers. To capture important nuances in communication, the interviewer and observers made independent field notes, including nonverbal behaviors that may not be captured by audio recordings. We reviewed medical records from at least 5 hospital visits (ED, inpatient, or clinic) pertaining to each subject’s early, middle, and late visit periods in the most recent 7 years. We also reviewed at least 1 assessment by psychiatry and social work for each participant for whom an assessment had been conducted.

       Outcome Measures and Primary Data Analysis

      In qualitative research, investigators strive to achieve credibility in their studies, a concept that is similar to reliability and validity in quantitative research. Credibility is attained through the application of several steps and processes.
      • Giacomini M.K.
      • Cook D.J.
      Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group.
      • Mays N.
      • Pope C.
      Qualitative research in health care. Assessing quality in qualitative research.
      We triangulated data from different sources, including interviews, field notes, and medical records, to help corroborate findings. We posed the same 25 questions to all subjects, 15 open-ended and 10 closed questions. This consistency boosted study credibility by allowing us to obtain a variety of responses for the research questions. These responses gave us rich descriptions to answer these questions, a basic component to study credibility. We used peer review with 2 qualitative experts who commented on the progress of the study. We minimized the introduction of assumptions and personal or professional bias by talking about the interviews and bracketing our bias in memos that became part of the data. Finally, we compiled an audit trial so others could replicate this study.
      Interviews lasted an average of 50 minutes (range 25 to 90 minutes). Two subjects agreed to second interviews so that we could clarify information. Interviews yielded 800 pages of transcript. Three team members used ATLAS.ti (version 7; Atlas.ti Scientific Software Development GmbH, Berlin, Germany) to assist in processing and analyzing transcripts. With this software, data were downloaded and examined for frequent and relevant words and quotations. These texts were then highlighted, copied, and aggregated in a column as codes. Codes are labels given to similar text and allow the researcher to winnow hundreds of pages of data into manageable and relevant categories. For example, one subject said, “I started drinking when I was 9, the same day I started smoking cigarettes.” We placed this quote under the code “alcoholism: first drink.” See Appendix E1 (available online at http://www.annemergmed.com) for selected quotations organized by codes for each theme. Some codes were a priori, coming from the literature or from experience; most codes emerged from the data themselves. As the analysis progressed, codes were combined, deleted, or retitled. The 3 team members continually reviewed the codes and their content. At the study conclusion, we had an intercoder agreement on 98% of the code names and interview quotes associated with the codes. Intercoder reliability is assessed by having 2 or more coders categorize units (eg, names, quotations) and then using these categorizations to calculate a numerical index of the extent of agreement between or among the coders (ie, reliability=[sum of names and codes for which there is agreement among researchers]/[sum of names and codes]).
      • Lombard M.
      • Snyder-Dutch J.
      • Bracken C.C.
      Content analysis in mass communication: assessment and reporting of intercoder reliabiality.
      At completion of analysis, we had 50 codes grouped under 4 major themes: alcoholism, homelessness, health care, and envisioning the future, which provided a framework for answering the research questions.

      Results

      The sample was demographically similar to that of studies of alcohol-dependent individuals with frequent ED use, including studies conducted within our institution: male predominance, mean age of 46.5 years (SD 9.1), and a median of 1.6 ED visits and 0.4 hospital admissions per month in the last 3 years
      • Thornquist L.
      • Biros M.
      • Olander R.
      • Sterner S.
      Health care utilization of chronic inebriates.
      • Shumway M.
      • Boccellari A.
      • O'Brien K.
      • Okin R.L.
      Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial.
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.
      • Larimer M.E.
      • Malone D.K.
      • Garner M.D.
      • et al.
      Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.
      • McCormack R.P.
      • Williams A.R.
      • Goldfrank L.R.
      • et al.
      Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders.
      • Hamilton B.H.
      • Sheth A.
      • McCormack R.T.
      • McCormack R.P.
      Imaging and head injury in frequent emergency department users with alcohol use disorders.
      (Table). Twenty of the 25 patients approached for study participation were included in the study; 2 patients refused to participate; 3 patients were too intoxicated to provide informed consent and were not captured on a later visit. Four participants initially declined to participate but consented when approached later on inpatient wards (3) or during a subsequent ED visit (1). The PI removed 2 patients from the potentially eligible list because of known cognitive deficits. Analysis revealed unique differences, which are discussed under each theme, among individuals who lacked US citizenship, were women, were placed in low-barrier housing supported by care management, and who reported abstaining from alcohol in the days or weeks before the interview.
      TableParticipant characteristics.
      CharacteristicPatients
      Data are presented as mean (SD), median (interquartile range), or No. (%).
      N20
      Age, y46.3 (9.3)
      Female sex3 (15)
      Ethnicity
       White9 (45)
       Latino8 (40)
       Black2 (10)
       Asian1 (5)
      Education
       <High school1 (5)
       Some high school8 (40)
       High school graduate or equivalency6 (30)
       Undergraduate education5 (25)
      Of the 5 participants having undergraduate education, 2 were awarded associate’s degrees, 1 was awarded a bachelor’s degree, and 2 did not complete college.
      Legal: US citizen documentation17 (85)
      Housing history
      Homelessness for >9 of most recent 24 mo20 (100)
      Shelter use, within lifetime19 (95)
      Shelter use, within 6 mo2 (10)
      Homeless outreach client within 12 mo9 (45)
      Health
      Age-adjusted Charlson comorbidity score4.2 (2.4)
      Psychiatric illness11 (55)
      Traumatic brain injury9 (45)
      Health care use and services (Bellevue Hospital)
      ED visits/month (3-y average)1.6 (IQR 1.4–2.3)
      Hospitalizations/month (3-y average)0.4 (IQR 0.3–0.6)
      Ambulatory care visits (3-y total)
       None11 (55)
       0–2 (all specialty services)5 (25)
       >2 (all specialty services)4 (20)
      Primary care provider established3 (15)
      Intensive care manager client3 (15)
      ED-based housing/care management
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.
      8 (40)
      Substance use
      Alcohol dependence20 (100)
      Drug use within 12 mo11 (55)
      Tobacco use within 12 mo18 (90)
      Age of first drink, y14.0 (3.9)
      Parent with alcoholism
       Yes13 (65)
       No5 (25)
      IQR, Interquartile range.
      Data are presented as mean (SD), median (interquartile range), or No. (%).
      Of the 5 participants having undergraduate education, 2 were awarded associate’s degrees, 1 was awarded a bachelor’s degree, and 2 did not complete college.
      All twenty subjects began drinking as children or adolescents and reported becoming dependent shortly thereafter. Eleven subjects believed that they were predisposed to alcoholism: “I think it’s genetic because my father was a drunk and I am a drunk.” One woman’s mother “never wanted to recognize that she was an alcoholic…. [S]he would go on these 3- or 4-day binges where we would come home from school and she would be passed out drunk.” “My father said…everyone drinks, so he told me ‘drink it.’ I felt pretty good that first time and I was 8 years old…. When I was 12, I started to drink a little more. And then when I was 15, I’d pretty much get drunk.”
      Four reported having supportive parents. Thirteen others spoke of abuse in their households, which many associated with leading to truancy, lost jobs, or a series of low-paying jobs with no future. One man described his dysfunctional home: “It was a party…or just a lot of yelling, a lot of screaming.” Another man's mother “drank and let men beat on” him. “At fourteen,” he continued, “my brother and I were put into foster care. Mom and her boyfriend were prosecuted for child abuse.” One woman was an adolescent when she had a child by her father. Nineteen subjects were either forced or chose to leave home by age 18 years. Their alcohol use escalated with independence: “I got kicked out of the house by my father at 16. I started to drink regularly.”
      Alcoholism destroyed relationships, ended employment, forced eviction, and short-circuited futures and dreams. Relatives had limits to the behaviors they would tolerate from their alcoholic kin. One woman said, “[My sister] took me in…but when I started drinking again she didn’t appreciate that so I took off.” Many subjects did not want their families to see them “looking the way I am right now. They would be disgusted by me.” The stigma of being seen as an alcoholic and the last remnants of self-esteem prompted them to turn away from home and family. Subjects expressed regret about separation from their parents, siblings, or children. Two women talked in detail about this loss: “I would love to see [my children], but I don’t want them seeing me drinking…with the shakes in the morning.” The other said, “I [wish I could] leave them something, something to look back on. I don’t even have a life insurance policy.” Three undocumented men voiced frustration knowing that they cannot visit their families. One said, “I could have qualified for a green card, but…there wasn’t time because I started this drinking.”
      Only 1 man was currently married or with a partner. Eleven others said it was impossible to maintain a relationship because their drinking led to violent behavior. “She told me I had to lay off the drinking, which I had gotten down to a 6-pack a day, which I thought was pretty reasonable, and she didn’t. We got in a big argument…. I never hit her, but I flipped the refrigerator over and trashed the house. That was the end of that.”
      Individuals associated alcoholism with their truncated education (Table) and challenges maintaining employment, which included work in restaurants, business, acting, banking, outdoor recreation, skilled trades, construction, and transportation. When interviewed, none were employed. All 3 veterans said that military life amplified their alcohol use: “When I joined the military…they were all drinking. It wasn’t new to me; I was like, ‘Oh! I know how to do this.’”
      Subjects reported that, in adolescence, getting drunk made them feel accepted. Sober, they felt abandoned or bored. One woman recollected, “The first time I took a drink [at aged 19 years], it was the first time in my life I felt normal.” Every subject was asked, “Why do you drink today?” The most common answer was “because I like it” or “to feel good.” Others drink to dull their physical pain, their sense of desolation and loneliness; to enable sleep; to avoid “the shakes”; or “to pass the time.” One woman drank mouthwash to prevent hallucinations because wine was too expensive; she “sees images, ugly images, and then start[s] to shake. It happens quite often…. [She] feel[s] like garbage afterwards.”
      All 20 had previously entered detoxification programs, including 6 individuals admitted to our program when interviewed. Three reported “return[ing] to the bottle” soon after being discharged from rehabilitation centers. Some subjects denied wanting to stop drinking, “I never want to quit drinking. I come for detox because I hope something will happen…to change me.” Despite having attended several detoxification programs, another man said, “I am a drunk, not an alcoholic. I am not looking to recover. I’m just looking to get another drink. An alcoholic goes to meetings. A drunk don’t. He goes to the liquor store; that’s the way it is.”
      Fourteen people felt trapped in a cycle of sobriety and drunkenness: “I tried to stay sober. Getting sober is not the problem. Staying sober is the problem.” “I get a little money and get cocky-headed and say, ‘I’m going to have a beer or couple drinks.’ And that’s when it starts all over again for me.” One man stopped attending Alcoholics Anonymous because he thought he was cured. Another believed himself to be too old: “When I was younger it was fun,” he said. “Now I’m at the age [at which] I’m alone and I’m having a hard time to stop drinking.”
      Alcoholism was cited as the primary reason they live on the streets. “I was drunk and I had a fight with my landlord” and “I lost my job” were common responses. They sleep in subway cars, stations, and tunnels, under building overhangs, and niches where they are not seen. Many sleep on sidewalk heat grates during the winter and on patches of grass during the summer. But finding a safe, dry place to sleep or a hot meal is not their first thought of the day: “Drinking is all that matters…. I don’t care about eating food.”
      “It’s easy to get a drink in NYC.” One man who grew up in rural America said, “At home you’ve got to go out of your way to get it. Here I can go to any corner and find a liquor store.” How do they pay for their alcohol? Five of the subjects collect Social Security disability: “Anytime I need money, I walk over to any ATM machine, pop out a 20. A 20 will hold you for a half gallon.” Another person “shoplifts whenever [he] relapses,” and 3 others spoke about hustling or panhandling: “I use a little cup, but I never have anything in there; everything goes in my pockets, so people think I’m not doing well.”
      One man spoke of the freedom of the streets: “No worries, no responsibility, just who is going to buy me the next bottle.” Almost every subject avoided city shelters where “you can’t get no peace” and “[you’ll find] a lot of psychos…fighting all the time, and a lot of theft.” They were dissatisfied by shelter restrictions, bans on drinking, curfews, and the lack of privacy. The few having experience with case management and low-barrier housing related more positive experiences. “They talked me into going to a safe haven, which is a little bit different than a shelter cause you don’t have a curfew…. [Y]ou can go 3 nights without losing your bed.”
      Chart reviews confirmed patients’ assertions that they were more customarily brought to the ED for public intoxication rather than actively seeking care. When subjects became ill, were injured, or lost consciousness on the streets, they came or were transported to Bellevue. Subjects learned they could get a sandwich, a place to rest, and clean clothes. The ED staff and subjects often recognized and greeted one another by name. One woman stated, “A part of me feels like I’ve abused the services, but I feel like after a while they kind of look at you—‘Oh you again’—and they stick you in a corner and let you sleep it off, and then once they see that you can get up and walk around, they let you go home.”
      Medical records indicate that the majority consistently left before the completion of care. Five spoke of leaving against medical advice: “I don’t want to be here to be honest with you,” a man said. “I’m about a half inch away from fighting to get out.” Most expressed grievances about how they were treated at times (medically and personally). Yet they also conveyed that the ED, and often specifically the Bellevue ED, is where they turn when they are in dire straits. One man stated, “I don’t want to come in here, but I’m afraid to go someplace that don’t treat me good.” Many vividly described experiences when they came to the ED desperate for help or motivated for change, but that they seemed to be unable to sustain this willingness. Medical records confirmed they needed care for myriad comorbidities associated with alcoholism, such as cirrhosis, chronic obstructive pulmonary disease, cardiovascular diseases, gastrointestinal ailments, and brain injuries. Eleven subjects had definitive psychiatric diagnoses in the psychotic, mood, or anxiety spectrums. Five of the 20 individuals in our cohort died within a year of their interview of liver and lung cancers, vehicular trauma, assault, and hypothermia or intoxication.
      Questions about their future surprised many of the subjects. “Right now I can’t even think about that…. I think in a very short-term way.” They described hard lives on the streets that have left them locked in the present: “I am so beaten up, I can’t take it anymore.” Two undocumented subjects said that they plan to get healthy, return to their countries of origin, “and never come back.” Most of all, they wanted their suffering to end. “If you’d told me 15 years ago that I would end up in this situation, I’d have laughed and called you a damn liar. No way it could happen to me! …[I]t takes all your strength just to survive the day. You can’t have friends. You can’t do this forever.”
      A few seemed fatalistic. “I already died so many times that I am not scared.” One said, “Something is going to get in my way eventually and I’m going to stop [drinking] or I’m going to die. Either one of those 2 is going to happen, and I just don’t care. Either way, this isn’t going to last forever.” Additional perspectives are included in the Figure.
      Figure thumbnail gr1
      FigureViews on the future. The figure includes selected responses to the following questions: “How do you see your future?” “If you could be granted a wish for the future, what would it be?”

      Limitations

      Our themes were derived from a cohort of individuals having chronic alcohol dependence, homelessness, and frequent ED use who were recruited from a single hospital and thus may not be applicable to persons in other geographic areas or alcoholics with a different profile.
      To minimize selection bias and ensure that more challenging cases were included, we purposively sampled typical and atypical cases and attempted to enroll individuals who initially were unwilling or unable to provide consent. Nonetheless, bias is introduced by the enrollment process, in which patients had to be willing to participate and able to consent to and participate in a study that required a relatively high degree of alertness and cooperation.
      In retrospect, we also believe that the study would have benefited from a more validated, structured capacity assessment than the clinical gestalt and consent quiz used; we have used the University of California, San Diego Brief Assessment of Capacity to Consent in subsequent studies.
      • Jeste D.V.
      • Palmer B.W.
      • Appelbaum P.S.
      • et al.
      A new brief instrument for assessing decisional capacity for clinical research.
      • McCormack R.P.
      • Gallagher T.
      • Goldfrank L.R.
      • et al.
      Including frequent emergency department users with severe alcohol use disorders in research: assessing capacity.
      Social desirability bias is also often introduced in face-to-face encounters. Participants may have felt more compelled to tell interviewers “what they wanted to hear” because of the reimbursement and gifts of appreciation they received.
      None of the information derived from these patients and reported here was verified as to accuracy, but instead is their own subjective account of what they state has happened to them. In keeping with a phenomenological approach, we attempted to not introduce our assumptions and prejudices; however, our influence on the interviews and analyses can only be minimized.

      Discussion

      The 20 subjects’ perspectives support a multifactorial hypothesis of how they came to be alcohol-dependent, homeless, frequent ED attendees. Their stories underscore and put in sharp relief the hopelessness that reinforces their slide. As their capacity to envision a different future diminishes, they increasingly lose motivation for personal recovery. Their difficulty maintaining hygiene practices, the chronic relapsing nature of their alcoholism, and often limited impulse control all contribute to the stigma that attaches itself to them in public and in medical communities. The stigma, in part, comes from a lack of knowledge about this cohort and addiction.
      • Williamson L.
      Destigmatizing alcohol dependence: the requirement for an ethical (not only medical) remedy.
      • Wood E.
      • Samet J.H.
      • Volkow N.D.
      Physician education in addiction medicine.
      Previous studies typically have focused on characterizing individuals who are high users of costly health care services, are homeless, or have received a diagnosis of a substance use disorder. Although these populations often overlap, our study helps explain differences unique to the distinct subset having each of these characteristics. Many of the existing qualitative analyses were designed to evaluate and inform aspects of interventions, such as low-barrier housing.
      • Davis E.
      • Tamayo A.
      • Fernandez A.
      “Because somebody cared about me. That's how it changed things”: homeless, chronically ill patients' perspectives on case management.
      • Collins S.E.
      • Clifasefi S.L.
      • Andrasik M.P.
      • et al.
      Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      • Raven M.C.
      • Doran K.M.
      • Kostrowski S.
      • et al.
      An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study.
      • Stergiopoulos V.
      • O'Campo P.
      • Gozdzik A.
      • et al.
      Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups.
      Participants in these studies may differ from ours because all agreed to participate in interventions, were receiving specialized services or housing, and were identified primarily through community rather than hospital referral. Yet these and other studies provide important insight into how structured, supportive environments and various means of approaching these individuals and caring for them helps to empower them by addressing factors that have contributed to their loss of self-identity and self-determination.
      • Davis E.
      • Tamayo A.
      • Fernandez A.
      “Because somebody cared about me. That's how it changed things”: homeless, chronically ill patients' perspectives on case management.
      • Järvinen M.
      Accounting for trouble: identity negotiations in qualitative interviews with alcoholics.
      • Thurang A.
      • Bengtsson-Tops A.
      Living an unstable everyday life while attempting to perform normality—the meaning of living as an alcohol-dependent woman.
      • Thurang A.
      • Rydström J.
      • Bengtsson-Tops A.
      Being in a safe haven and struggling against alcohol dependency. The meaning of caring for male patients in advanced addiction nursing.
      • Collins S.E.
      • Clifasefi S.L.
      • Andrasik M.P.
      • et al.
      Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      • Kidd S.A.
      • Kirkpatrick H.
      • George L.
      Getting to know Mark, a homeless alcohol-dependent artist, as he finds his way out of the river.
      Other researchers have explored the perspectives of medical professionals and others who encounter this population rather than directly studying the individuals of interest.
      • Doran K.M.
      • Vashi A.A.
      • Platis S.
      • et al.
      Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless.
      • McNeil R.
      • Guirguis-Younger M.
      • Dilley L.B.
      • et al.
      Learning to account for the social determinants of health affecting homeless persons.
      Incorporating a wide range of different perspectives through purposive sampling and exploring negative cases that may contradict prevailing theories strengthened our study.
      • Mays N.
      • Pope C.
      Qualitative research in health care. Assessing quality in qualitative research.
      It forced us to mine for meaning by listening more closely to a population that either is often silent or unheard.
      The disease model of addiction has supplanted the historic perspective of alcoholism as a moral failing.
      • Kosten T.
      Addiction as a brain disease.
      Yet it is often rejected because of an unfounded belief that to treat alcoholism as a disease is to absolve alcoholics of all responsibility.
      • Williamson L.
      Destigmatizing alcohol dependence: the requirement for an ethical (not only medical) remedy.
      • Erikson C.K.
      The Science of Addiction: From Neurobiology to Treatment.
      The prevalence of addiction among first-degree relatives and the chaotic homes in which our participants were raised corroborates the contributing effects of genetic predisposition and environmental influences during their formative years. Their early exposure to alcohol and progression to dependence, as well as their poor mental and physical health, are characteristic of the chronic, severe subtype of alcohol dependence.
      • Moss H.B.
      • Chen C.M.
      • Yi H.Y.
      Prospective follow-up of empirically derived alcohol dependence subtypes in wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC): recovery status, alcohol use disorders and diagnostic criteria, alcohol consumption behavior, health status, and treatment seeking.
      Subjects vividly described the transformative effect of alcohol, which evoked profound emotional responses uncharacteristic of nonalcoholics.
      Alcoholics Anonymous
      Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholism.
      Increasingly, they experienced sudden and intense responses to drinking cues, which led to impulsive behaviors and the loss of sobriety, relationships, housing, and employment: “All of sudden I’ll have a flashback and I’m right there; I’ll go and get a bottle.” As soon as alcohol was consumed, the compulsion to drink overpowered their self-will or instinct to find food, seek shelter, or work to rebuild their lives. These reactions and behaviors correlate strongly with the neuroadaptive changes that produce the “hijacked reward system” of the disease model of addiction,
      • Volkow N.D.
      • Wang G.J.
      • Fowler J.S.
      • et al.
      Addiction circuitry in the human brain.
      • Chandler R.K.
      • Fletcher B.W.
      • Volkow N.D.
      Treating drug abuse and addiction in the criminal justice system: improving public health and safety.
      and with the description of alcoholism in the text Alcoholics Anonymous.
      Alcoholics Anonymous
      Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholism.
      Once families, jobs, and homes were lost, our subjects reported their perceived inability to recover. Consistent with that in previous research, our cohort had difficulty navigating social systems and developed lowered expectations and a lack of trust in them.
      • Davis E.
      • Tamayo A.
      • Fernandez A.
      “Because somebody cared about me. That's how it changed things”: homeless, chronically ill patients' perspectives on case management.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      • Doran K.M.
      • Vashi A.A.
      • Platis S.
      • et al.
      Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless.
      The perception that these individuals present repeatedly to the ED for food and shelter often leads providers to question the validity or severity of their medical complaints.
      • Doran K.M.
      • Vashi A.A.
      • Platis S.
      • et al.
      Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless.
      However, the exceptionally high morbidity and mortality of this population should give us pause.
      • McCormack R.P.
      • Hoffman L.F.
      • Wall S.P.
      • Goldfrank L.R.
      Impact of a resource-limited collaborative intervention for chronically homeless, alcohol dependent frequent ED users.
      • McCormack R.P.
      • Williams A.R.
      • Goldfrank L.R.
      • et al.
      Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders.
      • Hamilton B.H.
      • Sheth A.
      • McCormack R.T.
      • McCormack R.P.
      Imaging and head injury in frequent emergency department users with alcohol use disorders.
      • Hwang S.W.
      • Lebow J.M.
      • Bierer M.F.
      • et al.
      Risk factors for death in homeless adults in Boston.
      • Hwang S.W.
      • Wilkins R.
      • Tjepkema M.
      • et al.
      Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study.
      Because the success of treatment for addiction is highly correlated with internal motivation, these individuals in their current state of indifference have little chance of recovery.
      • McCormack R.P.
      • Williams A.R.
      • Goldfrank L.R.
      • et al.
      Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders.

      New South Wales Parliament Legislative Council, Standing Committee on Social Issues. Report on the Inebriates Act 1912, Legislative Council, Standing Committee on Social Issues. Sydney, New South Wales: The Committee, 2004:xi.

      • Simpson D.D.
      Modeling treatment process and outcomes.
      How, then, do we engage these individuals who, despite repeated presentation to EDs, are in fact not seeking help and are often refusing it? We wonder whether perhaps there is something to be learned from one participant’s success story—a woman who has now been housed, sober, and adherent to outpatient care for more than a year. Before this, her story was more typical of that of others in the cohort: hundreds of ED visits from which she left against medical advice. A multidisciplinary effort on her behalf involved 2 civil commitments, extended-release addiction pharmacotherapy, and discharge to permanent housing with the support of intensive care management.
      Insight into how and why these individuals have become trapped in the revolving door between city sidewalks and ED stretchers helps us appreciate the shortcomings of current approaches that focus on abstinence and lack coordination between health and social service institutions. We hypothesize that more accessible, lower-barrier, patient-centered interventions that support alcohol harm reduction and quality-of-life improvement can be translated to the ED setting and this population. Harm reduction approaches with more achievable goals that provide structure and alleviate the demands of street survival are likely to be more acceptable to these individuals who have diminished self-efficacy and motivation for treatment.
      • Thurang A.
      • Bengtsson-Tops A.
      Living an unstable everyday life while attempting to perform normality—the meaning of living as an alcohol-dependent woman.
      • Thurang A.
      • Rydström J.
      • Bengtsson-Tops A.
      Being in a safe haven and struggling against alcohol dependency. The meaning of caring for male patients in advanced addiction nursing.
      • Collins S.E.
      • Clifasefi S.L.
      • Andrasik M.P.
      • et al.
      Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications.
      • Jost J.
      Street to home: the experiences of long-term unsheltered homeless individuals in an outreach and housing placement program.
      • Kidd S.A.
      • Kirkpatrick H.
      • George L.
      Getting to know Mark, a homeless alcohol-dependent artist, as he finds his way out of the river.
      This underscores the need for the ED to participate in the development and evaluation of multidisciplinary, transinstitutional interventions that incorporate components of efficacious interventions such as care management, housing facilitation, and pharmacological and behavioral therapy. Implementation strategies, such as expanding the role of observation units and partnering with agencies in the community that are invested in finding treatments to address high users of publicly funded services, should be explored to enhance the feasibility and efficiency of delivering integrated care. Finally, we must also consider a palliative approach, rather than abandonment, for those in whom constructive approaches are unsuccessful.
      Allowing these individuals to speak for themselves forces others to remember that an alcoholic is first a human being. Before succumbing to their disease and becoming, as one man said, “nuisances…wast[ing] [our] time,” many described noble aspirations; they married high school sweethearts, were building careers, and wrote poetry. As providers, we often feel powerless in our repeated encounters with these individuals, and our failure to engage them or intervene can leave them feeling dehumanized.
      • Williamson L.
      Destigmatizing alcohol dependence: the requirement for an ethical (not only medical) remedy.
      • Doran K.M.
      • Vashi A.A.
      • Platis S.
      • et al.
      Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless.
      Our study highlights questions for further exploration about the difficulty in engaging these patients who repeatedly present to the ED but are not actually seeking care, and who are simultaneously incapable of envisioning a future for themselves beyond their next drink.
      The authors acknowledge Matthew Williams, MS, and Jessabeth Medina, MBA, of the New York University School of Medicine, Department of Emergency Medicine, for their assistance with transcribing interviews.

      Appendix

      The participant interviews yielded more than 800 pages of transcript. With Atlas.ti (version 7) software, these data were downloaded and examined for frequent and relevant words and quotations. The texts were then aggregated into a manageable number of relevant categories containing similar texts, ie, codes. At the completion of analysis, we had 50 codes grouped under 4 major themes: alcoholism, homelessness, health care, and envisioning the future, which provided a framework for answering the research questions. The appendixes include our final selection of quotations, organized by codes, for each theme.

      Appendix E1.

       Theme 1: Alcoholism—“If you had my life you’d drink too” (encompasses childhood, parents, first drink).

      First Drink
      My father said, “I don’t know if you have heard that in Mexico everyone drinks,” so he told me “drink it.” I felt pretty good that first time and I was 8 years old. And then I drank a beer…when I was 12…. I started to drink a little more, and then when I was 15 I was drinking—and I’d pretty much get drunk.
      There was always booze in the house. I probably started drinking before I was 10. I consciously took a drink when I was 10. That was the first time I consciously got drunk.
      By the time I was 14, I was a regular drinker.
      I got kicked out of the house by my father at 16. I started to drink regularly.
      I drank the liquor [that] was left over from my father’s parties. Always left a lot of liquor and beer behind, so I’d come home and do my homework and find it and…turn on the MTV.
      I was hanging out with the wrong people [in southeast Asia].
      I started drinking; I joined a gang. …[T]he gang was like my family, and it was older people, and they showed me love, and they showed me things I didn’t know, whatever, and they used to take care of me. And I felt like they were more of a family than the family I already had.
      I drank occasionally on the weekends, throughout high school and college, but I didn’t drink that often, because whenever I drank, I drank too much.
      I was 9 years old. I stole [Fleischmann’s Vodka] from my father. He had locked [it] in the closet. I took a pack of cigarettes from my mother; went up to the roof; I got drunk. I puked my guts out. Man, I was dizzy as hell from smoking the cigarettes. After a few trials, it started to go good.
      I wanted to act like an adult.
      I was 7 years old. My dad…gave me a few good swigs of his beer.
      And our parents were home and we went downstairs and I saw the bar. I just poured myself a couple fingers of Seagram’s VO. My mouth started watering! I remember the feeling a couple minutes later; it was just like wow! I was picked on as a kid, so I always felt…[e]veryone was rich and we were the poor kids.
      The first time I took a drink [at aged 19 years], it was the first time in my life I felt normal.

       Family: Father

      I was in jail; my father was in jail.
      I think it’s genetic because my father was a drunk and I am a drunk.
      My father remarried when I was 8. She [stepmother] had me kicked out of the house by the time I was 14. She wanted a female household. My father was never there anyway.
      He drank 24 hours a day.
      My dad was driving [our car] and I bugged the hell out of him to let me drive, and he finally let me drive and gave me a few good swigs of his beer.
      Yeah, he came visit us most of the week, like on the weekends, like a Saturday or Sunday type, but he worked all his life; he was a functional alcoholic, my dad.

       Family: Mothers

      She never wanted to recognize that she was an alcoholic.
      At 14 [years of age] my brother and I were put into foster care. Mom and her boyfriend were prosecuted for child abuse.
      With my mother, it was, like, really not good; it was, like, dysfunctional. She started drinking too at a young age.
      [When] [w]e were growing up, she would go on, like, these 3- or 4-days’ binges, where we would come home from school and she just would be passed-out drunk.
      My mother was strict. I caught my father beating my mother when I was 14 and I beat the crap out of him.
      I spent my childhood with my mother and her boyfriends.
      [My mother’s] preferred way was choking me until I passed out or holding me underwater until I lost consciousness.
      [My mother would say] stay home and drink that so you don’t get in trouble next time.
      Beer, liquor, everything. [My mother] did little dabs of cocaine here and there too. It was dysfunctional; it was a dysfunctional house; it was party…either party in the house or it was just a lot of yelling, a lot of screaming.
      When she saw me, she just started crying and I started crying and she said, “You know how long you’ve been in the streets!” I told her, “Don’t worry. I’m the man of the house! I’m going to take care of you!”

       Family: Siblings (The Sample Had Many Siblings—7 Sisters, 4 Brothers, Youngest of 9. No One Was an Only Child)

      I would come by and see my brothers and my 2 sisters; I would see them every day…. I used to rob the supermarket and stuff like that, and I used to bring them cakes and things like that, things I knew kids like.
      My siblings say it’s a shame that I’m living off the government.
      My sister took me in. I was living with her for a while. I wasn’t homeless, you know…my room and everything, you know what I’m saying. But when I start drinking, she don’t appreciate that so I took off.
      I don’t have any of my brother’s or sister’s phone numbers.
      I didn’t want [my sister] to see me because I look raggedy…. [If I] was clean enough, you know, I’d to go and talk to her.

       Marriages/Relationships=Drinking

      [My wife] left to go live with her mother and I stayed in the apartment. But it hurt a little bit…. I started drinking each day more, each day more, each day more until there were days were I would have the shakes, and there would be days were I would hallucinate, wake up in the morning, alone, sweating; then it would bring it down, it would calm my nerves, and yeah, that’s how it went.
      Me and my wife mutually decided to separate.
      Things didn’t work out after 10 years.
      [I was married] about a year and 6 months. Maybe not even that long. She kicked me out of the house.
      She told me I had to lay off the drinking, which I had gotten down to a 6-pack a day, which I thought was pretty reasonable, and she didn’t. We got in a big argument and I said some things, and did some things. I never hit her, but I flipped the refrigerator over and trashed the house. That was the end of that.
      I found my wife cheating and I left.
      I am divorced.
      Was with my wife for 2 years.
      I married her partly for the green card and partly because I liked her. We were married 7 years. I could have qualified for a green card, but…there wasn’t time because I started this drinking.
      I got married to my high school sweetheart but we split up.

       Family: Overall Contact

      Mom and Dad. There are times I’d think about them; as far as I know, they think I’m a jerk.
      I last spoke with my family 2 years ago.
      They did—they did every[thing] possible, but they got tired they couldn’t stop it [drinking], so they couldn’t stop it.
      It’s not fair for my family to see me the way I am right now! They would be disgusted by me.
      As soon as they know that I am drinking, they don’t want to hear from me.
      I call my mother on Sundays.

       Family: Difference With the 3 Women in the Study

      I would love to see them, but I don’t want them seeing me drinking. I don’t want them to see me with the shakes in the morning. You know, I [wish I] could leave them something, something to look back on. I don’t even have [a] life insurance policy. So you know what? When I die, they just going to throw me probably in the river somewhere.
      I couldn’t keep a promise that I had made to the kids.
      If a bus was coming and one of my kids were standing in front of a bus, my first instinct would be to jump, push my kid, and get hit by the bus! Automatically! But I can’t put down the bottle for my kids. It doesn’t mean that you don’t love anybody. It just means that once you stop you can start.
      I think if I had gotten happily married somewhere along the line things would have been a lot different.

       Drink of Choice

      Georgi vodka [the hands-down favorite of the sample].
      Hard liquor; it’s never been my thing until I came to New York; it’s kind of hard to walk around Midtown Manhattan with a 12-pack. You find it much easier to get a pint of vodka, plus it’s much cheaper.
      I could drink beer like crazy and um…and wine…. I fell in love with vodka.
      Listerine. My drink of choice would be chardonnay, but that gets expensive.
      I’d start to drink alcohol from the pharmacy; I drank it with water.

       Comorbidity With Drugs

      I wanted to hang out with the guys, so I got into drugs. I was [a] stone junky from the age of 16 to 19.
      You name it, I did it. The only drug that I have never done is the Vicodin and crack.
      I got 2 choices: go [to] jail, go to the grave, or give up. I gave up. I quit drugs.

       School

      I dropped out of school because I wanted money.

       Jobs and Drinking

      You know, after work I was drinking.
      Not showing up to go to work, ’cause I started drinking too much! “Do it one more time and you’re not coming back to work!” And they finally…here’s your pink slip….after 12—10 or 12 years.
      They [bosses] wouldn’t get it, and I was able to function…so it wasn’t like I was a sloppy drunk. I wasn’t. I was a pretty good drunk, you know.
      When I joined the military and they were all drinking. It wasn’t new to me; I was like, ‘Oh! I know how to do this.’

       Present

      I am a drunk, not an alcoholic. I am not looking to recover. I’m just looking to get another drink. An alcoholic goes to meetings. A drunk don’t. He goes to the liquor store; that’s the way it is.
      I wake up trembling, shaking…drink 2 beers or 8-oz alcohol and I’m okay.
      I drink alone because I want to feel the effect alone. Other people do worse things.
      Now I feel content when I admit that I’m an alcoholic. I don’t feel guilty admitting it. And you know alcohol is legal. It’s not like other drugs because the other drugs are illegal versus alcohol which is legal. You pay a tax when you buy it, and the guy who sells it pays a tax too.
      When I was younger it was fun; you know what I mean? I never thought of it…. [N]ow I’m at the age [at which] I’m alone and I’m having a hard time to stop drinking.
      Drinking is all that matters…. I didn’t care about eating food.
      I know how to go into the liquor stores when I’m not looking terrible and steal bottles.
      I’ve gone 6 to 9 months sober; my body is not demanding it. My brain can’t handle all the crap that’s going on and I pick up a drink.
      There are no friends. My best friend is 100 dollars.
      I’m a drunk. I drink. Once I start drinking, I can’t stop, you know, I don’t stop. I can stop, but I don’t.
      I’ll haven’t drank for a couple of days and I don’t even think about drinking that day. I’ll be sitting there reading the newspaper or I'll get to the library and read a book. And all of sudden I’ll have a flashback and I’m right there. I’ll go and get a bottle, because at least for those few hours I’ll feel a lot better. And I always say some relief is better than none.
      I never want to quit drinking. I come for detox because I hope something will happen…to change me.
      It’s easy to get a drink in NYC…at home you’ve got to go out of your way to get it. Here I can go to any corner and find a liquor store.

       Relationship With Police

      I mean I had a captain once pour out a bottle of vodka on me. And the reason was, he told me, [was that] “[participant’s name] it’s 6:30 in the morning! It’s Sunday! You need to go to church!” And he poured the vodka in the garbage can. Of course he didn’t know I had another one in my pocket. So I just went with the flow and I went, “All right! I’ll go to church!” He walked away with his boys and I just went right into the park sat down and finished the bottle.
      I told the cops, “Do me a favor and call an ambulance,” because I was having massive stomach cramps. I just went over [to] the cops and told them, “Get me out [of] here.” They called an ambulance and took me in.
      I’ve been locked up for a couple of hours just for open containers.

       Present: Reasons for Drinking Today

      I like to.
      It makes me feel good.
      To relax, something to kill time with.
      I just want to have fun.
      If I am good and drunk and passed out without being blacked out, then I could get better sleep.
      I just drank to feel nice.
      Now when I have a few drinks, I feel nice and I go to sleep comfortable.
      When you [got] nowhere to go and nothing to do, you end up hanging with the wrong people. And that’s what people do. You drink. You do drugs. Whatever.
      I’m drinking because it’s necessary. My body demands it.
      I try to forget the pain that I’m going through with being homeless in the streets.
      I tried to stay sober. Getting sober is not the problem. Staying sober is the problem.
      I get a little money and get cocky-headed and say, “I’m going to have a beer or couple drinks.” And that’s when it starts all over again for me.

       Delirium Tremens

      I see images, ugly images, and then I start to shake. It happens quite often…. I feel like garbage after. I felt like my heart was going to explode.

       Theme 2: Homelessness—“It takes all your strength just to survive the day.”

      How They Ended Up Homeless
      I started drinking too much. I got my pink slip. I messed up.
      I was drunk and I had a fight with my landlord. The landlord told me to get out, and so I left. I was living on 30th Street between Eighth and Ninth (Avenues).
      My wife threw me out of the house. I was spiraling downward [with my drinking].
      I lost my job in 2010. I found work on 27th street in a restaurant…for 3 months, and I was going to AA, and then I broke my foot, so I couldn’t pay my rent…. I didn’t have a place to live.
      Being homeless, I won’t take out my medications. I am a diagnosed schizophrenic.

       Self-image and Homeless

      You’ll lose track of keeping yourself cleaned up and stuff.
      Everything in the world is right there. I can wear everything I own….
      If I got anything in me that won’t fit in my backpack or on me, whatever, it’s going to the trash.
      I have absolutely zero ID. There’s no way to prove who I am.
      If you’d told me this, you know, 15 years ago that I would end up in this situation, I’d have laughed and called you a damn liar. No way it could happen to me! To get to a certain point and it just—it takes all your strength just to survive the day. You can’t have friends. You can’t do this forever.
      One of the favorite things people do is throw urine on you.
      I’ve been pushed and I’ve been hit.

       Food

      I know where you get served great food for free. There’s a church on 46th; there is a church on 42nd; there is a church on 28th and 9th; there is another church on 31st street between 7th and 6th. You got them all over.
      There’s a particular nun that comes by, and she hands out sandwiches, you know, stuff like that.
      At 1st Street at 7 o’clock in the morning, they hand out sandwiches.
      I eat out of trashcans. Yeah, I’m lucky, and you know, going on 13 years of being homeless, I’ve never gotten sick.
      I mean restaurants throw away food all the time, and they are more [than] happy to give it to people who are on the streets. It’s almost like [a] system. You know, it’s amazing.
      I’ll eat greens just as long I know where I got it from.

       Routine of Homelessness

      In the summertime, I drink with my buddies in the streets. 11th Street between Avenue D and Avenue C. That’s where we have the tables and the benches. We kill time over there and play dominos….
      We [the group he drinks with every day] talk about sports, mostly sports and politics.
      We call each other friends, but I don’t see nobody looking for me.
      I wouldn’t call the people on the streets my friends. I call them my associates.
      There are no friends. My best friend is 100 dollars. On the Upper West Side, I call that my summer home, ’cause it is easier to survive in Midtown during the winter. A lot more traffic. It’s a lot more heat. A lot more places are open longer.
      [When] it’s cold outside, you can go to places like Grand Central, Port Authority, Penn Station, whatever. The only thing is that you have to keep moving around, and that is stressful right there, when you can’t sit down.
      I always carry a knife on me.
      I fell asleep and they dug in my pocket and stole my [money], and took my ATM card.

       Sleeping

      And there is someone always riding the A Train. Some of the trains, they get deserted at night, and they cut your pockets. They take things away from you they shouldn’t take. And if you got clothing…or they take your bags, which is worth nothing. They just do it out of spite. Mainly they do it to look through your things.
      I sleep with one eye open because…3 or 4 dudes jump you for a pack of cigarettes. They might kill you. That’s what they did to an old man: they beat him up and took his cigarettes.
      You just never get sound sleep.
      [Sleeping is] when alcohol comes in or out…. [S]ometimes I’ll just be so tired that I won’t have trouble getting asleep. I’ll just constantly wake up…and I just wake up and wake up.
      Even if I am sober, I’ll just wake up. But if I am good and drunk and passed out without being blacked out, then I could get better sleep.
      That’s what I hate about sleeping, because it takes me a while. Now when I have a few drinks, I feel nice and I go to sleep comfortable. That’s why I drink.

       Relationship With Police/Emergency Medical Technicians

      Penn Station—the cops say, “Get out of the station or else we will arrest you!”
      At Riker’s [jail] they say, “Welcome home…next time bring a friend.”
      Because you’re drunk and if you drink too much, you are not going to know who did anything to you.
      My telephone stolen, my bags stolen….
      I had an accident [urinated] and decide[d] to shoplift clothes. I was ready to walk out the door and there was security to stop me, so I got arrested for that. I had to do 45 days.

       Getting Money

      Anytime I need money, I walk over to any one of the [ATM] machines, pop out a 20; a 20 will hold you for a half gallon.
      [If] you’re just standing up against the building smoking a cigarette, there’s a chance I’ll hit you up. It all depends on the feel, how you look, your appearance. If you have children, or [you are] talking on the phone, I don’t approach you.
      I would collect cans and bottles, but I started learning very fast that is a lot of wear and tear on your feet, and it was just so painful to walk. Now I just stick with my trivia games, somebody gives me 2 bucks.
      I shoplift whenever I relapse and start drinking.
      Panhandling—I use a little cup, but I never had anything in there; everything goes in my pockets, so people think I’m not doing well.

       Shelters

      You can’t get no peace. A lot of psychos. Lot of “What! Oh you did this.” “No I didn’t.” “Yes you did.” Next thing, fists flying. There’s security, but they don’t really give a damn. It’s just a job to them.
      I was in and out of the shelter system for about 10 years. Fighting all the time, arguments all time. People turning on other people’s beds. The crazy [stuff]…cursing out the case workers, stuff like that. A lot of theft, breaking in your locker, all that stuff.
      I can’t find no friends in there [shelter]. I always fight with someone in there.
      I just don’t want to live inside now. I just go up the block on 30th Street to a single room occupancy—a nice place. You got a little kitchenette, a bedroom, a refrigerator, a table. That’s all you need. Cost you a whopping hundred and twenty-five a week. [He uses his Supplemental Security Income-Disability check to pay for the room.]
      They talked me into going to a safe haven, which is a little bit different than a shelter ’cause you don’t have a curfew, you don’t have to signed for your bed… You can go 3 nights without losing your bed.

       Theme 3: Health Care in Bellevue Hospital Center—“Oh, you again.”

      Why did I come [to Bellevue]? Because I felt like my heart was going to explode. I had heart palpitations, and I just couldn’t take it no more. I started to hallucinate and starting to like…my head was going to…and I knew I was going to…it was just a matter of time before I would’ve fainted. So I said to myself, “Hah…hah! This time I’m going to have to go [to Bellevue].” The hospital let me stay here, so that’s why I’m here right now.
      A part of me feels like I’ve abused the services…because I was in [and] out so many times…but I feel like after a while they kind of look at you, “Oh, you again,” and they just kind of, like, stick you in a corner and let you sleep off. And then once they see you can get up and walk around, they let you go.
      I called 311 and they said Bellevue is the only hospital that can help you. They asked me if I had been drinking, and I said yes. Trembling [with delirium tremens], I came here [to Bellevue]. First, I went through the DTs. Then they took me to the 20th floor to detox. From there I lost my job.
      I needed something to eat. Couldn’t make no money. Couldn’t get a drink. Shaking like a leaf. Guy I know has been sober for a while, he bought me 3 beers so I could get here [Bellevue].When [I’m] coming out of it, I’m up in a bed somewhere, and I’m looking around, and I realized I’m at the hospital.
      I walk in and I ask them, “Please take care of me.”
      I don’t know what happens when I drink. I drink too much and then I just collapse. So, yeah, I would be just, like, pass[ed] out on the streets, and somebody would call 911.
      Majority of the times, I don’t even know. Because when I’m coming out of it, I’m up in a bed somewhere, and I’m looking around, and I realize I’m at the hospital.
      Every hospital has, you know, nurses and doctors that really don’t give a damn. But they also have some that do give a damn.
      They treat me good. They got tired of me: “Oh! This guy again.” But they have to do what they have to do. I don’t want to come in here, but I am afraid to go someplace that don’t treat me good.
      I used to go up to Bellevue ’cause I knew I could eat 3 meals here, and I knew I had a roof over my head, and I didn’t have to be out there in the streets.
      I didn’t want to be in the streets, so I would come to Bellevue.
      I come here [to Bellevue] because they don’t care I’m illegal [undocumented].

       Detoxification

      I started drinking heavy. I started ending up in the hospital [a] little bit more. And this time the doctor recognized me. “You came here a couple of times?” he asked me. “You want to go to detox?” And I said yes.
      The doctor, he kind of encourage[d] me. I was tired. I’m still tired of drinking, you know. I thought, I could come here [and] relax my mind. Try to get my bearings together and whatever.
      And I come in walking, and I say, “Look, I’m drunk and I need detox because I can’t stop.”
      I’ve been coming 14 months on my own [to the outpatient clinic]. I like it because they have, like, a nice variety of groups. Like, they have, like, the cognitive behavior therapy groups. Then they have, like, a home group, where you can talk about any kind of…. It’s like when you branch off into smaller groups, and you can talk about anything that is on your mind or any issues that you are going through. Or that nobody has anything to talk about, he’ll have, like, just the general topic. They have heart groups, recovery groups; they have cooking groups—that’s my favorite, the cooking group.

       Negative About Bellevue

      I don’t like this hospital. You know why? ’Cause this hospital is a city-run hospital and it’s, like, a really bum hospital. It’s, like, you come into the emergency hospital and all you see [is] its dirt around you.
      They don’t want me there, so I’m a waste of their time. I’m taking up their time. Till now I know! Logically, I am an annoyance to them. ’Cause I’m doing it to myself. I’m repeatedly in there. There’s regulars. So I’m annoying, taking away legitimately from sick people that genuinely need their services.
      That’s the reason why, you know I should stay here a couple of more days. I just want to get the hell out of here, and I don’t like hospitals.
      I don’t want to be here, to be honest with you. I’m about [a] half inch away from fighting to get out. The decision to leave is strictly I want another f***ing drink! Cause by the time you get ready to let me leave, my head is starting to hurt. I’m angry, bitter, I can’t stand being here…. I want to sign out sometimes; sometimes I know it’s not right.

       Theme 4: Their Views on the Future—“I’m just very tired. I can’t go on living like this anymore.”

      Right now, I can’t even think about that [the future]. I think in a very short-term way.
      I’m tired of fighting it. I give up!
      Sometimes I just get so beat up that I just can’t take it anymore.
      Killing me. It’s killing me. It’s killing me. I already feel it. I’m skating on thin ice.
      Just as long there is no pain. I don’t expect anything out of my life at this point.
      Sometimes I think I don’t deserve good things in my life!
      Probably still frickin’ impoverished still.
      I am old and I got to live with that. And if I can’t enjoy my life, what the hell am I existing for? That’s all I am doing is existing. I want to live. I want to have a little fun. I want to enjoy myself. Don’t want to sweat anything. That’s the way it is.
      My future is over with. I’ve lived mine, and I’m happy with what I’ve done. I’m happy with the way my life [has] gone. Sometimes it sucked, but generally it was pretty good. I had a nice family, and I was happy. Now I am hanging around with a bunch of guys that I know I can trust. I’m still happy, and that’s the key to it all: no worries, no responsibility. Just who is going to buy me the next bottle.
      I am a drunk. I am not an alcoholic. I am not looking to recover. I’m just looking to get another drink. An alcoholic goes to meetings; a drunk don’t. He goes to the liquor store. That’s the way it is.
      [Interviewer: “Where do you see yourself headed at this point?”] To hell if I’m not lucky.
      I’m so beaten up I can’t take it anymore.
      I’ve already died so many times that I am not scared.
      Something is going to get in my way eventually, and I’m going to stop [drinking] or I’m going to die. Either one of those 2 is going to happen, and I just don’t care. Either way, this isn’t going to last forever.

       Positive Outlook on the Future (or at Least a Plan for the Future)

      Well, I am going to try and live to be about [a] hundred, but you know, I got to go with the flow. You know, when He calls I got to go. You have no choice in the matter.
      I always have hope.
      What I see is going back down South, living the rest of my life.
      I want to go back to Mexico and never come back.
      When I get my medicine and the doctors tells me everything is perfect, that I’m OK and I say bye-bye America and I go back and never come back. [I want to go home to my family in Central Asia.]
      If I get my own place, I’ll be happy.
      When I got sick and tired…and I said, this [is] it. I don’t want to do it no more. Now, I go to the gym. I try to work out. I try to keep my body. I work out every day. That’s true what they say, “You are what you eat.” That’s why I try to eat good things. I changed my diet and drink soda. I drink a lot of water and stuff like that. So I change my diet. I take vitamins. And, yeah, I want to do a lot of things, but sometimes you can’t. It's only one…only God can judge, you know! He’s is that higher power, so He’s the one—that either He does for you…. He opens up [the] door for you. I guess when you do do good, you do receive rewards. I mean, I go to a place now that, that here in the hospital… They take my urine to see if—to make sure that I’m not doing drugs or nothing. And I’ve been clean. The doctors told me, “Man! You did such a…such a change it’s unbelievable!” You know what I’m saying. But every day I feel good. I feel better. I find that I feel young! I feel like a little kid, whatever, whatever. I’m 56 and a lot of people tell me that I don’t look 56.

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