Nov. 15--At the city sleep-off center next to the jail on Fourth Avenue, a young guy shakes uncontrollably. His alcohol level tested out above .30, enough to put most people into a coma if not kill them.

It's 8:30 a.m., the first crisis of the day for case manager Deb Flowerdew.

Flowerdew worries that if she can't wrangle some help for this young man, he'll be drinking on the streets again within hours. Outside the sleep-off station, the city's designated safe place for dangerously drunk people, she sits in her red Chevy pickup and works her cell phone, trying to find a place for him to go through supervised detoxification, the next step.

"Please. He's so sick. You got anybody leaving today?"

But detox was all full.

More people than ever need help getting sober in Anchorage, and they're running up against a tapped out system still reeling from a squeeze in state funding for treatment during the Murkowski administration. The number of homeless alcoholics and addicts jumped 16 percent from January 2008 to one year later, a period when detox beds in the city were chronically behind demand.

More alcoholics are staying on the streets, unable to get sober on their own, city health officials say. Without monitoring, people trying to withdraw from alcohol can suffer seizures, heart attacks, even death.

Just as the system seemed to break down, some relief has come. Armed with $1 million from the state, the Salvation Army's Clitheroe Center has recently ramped up with 10 new detox and treatment beds in a special unit.

Clitheroe's expansion comes with a twist: Those beds are set aside for severely addicted people who refuse to seek help on their own. To save themselves, they are being held involuntarily for treatment under a new state policy.

"If we don't do something differently, how can we expect different results?" said Robert Heffle, director of Clitheroe Center.

As it stands, Anchorage's homeless alcoholics consume millions of dollars worth of community services: Ambulance rides and Community Service Patrol pickups, outreach by caseworkers and transports by police, nights at sleep-off and emergency room visits. A 2007 city report called "The Chronic Inebriate Problem in Anchorage" put the cost at $4 million in 2006.

"Mostly, I'm dealing with people so wasted they can barely talk or walk," said Dr. Kathy McCue, who works in emergency departments at Providence Alaska Medical Center and Alaska Native Medical Center. "They come in with alcohol levels of .700, .640, .650." She said she sees people dangerously intoxicated every night.

Some don't make it. Thirteen homeless people have died this year on Anchorage streets, in parks, in tents barely hidden in patches of woods. Many were alcoholics and most died in the warm spring and summer, which is unusual.

"When you have so many people die in a short period of time, that constitutes a crisis," said Westley Clark, director of the federal Center for Substance Abuse Treatment, who was in Anchorage in September.

BROKEN PEOPLE

The rash of deaths frightened people still on the streets and brought new attention to the vexing, decades-old problem of Anchorage's homeless alcoholics. The city hired its first full-time homelessness coordinator. The mayor named a task force to reduce the violence and deaths, as well as the problems created by the homeless in neighborhoods and public spaces. State and federal officials are offering help.

Clark said he learned about the deaths during a Cook Inlet Tribal Council workshop in September. Everyone appears concerned about homeless alcoholics, he said, but solutions are complicated when the idea is to save people from themselves.

"It's not always true that if you build it they will come," Clark said.

Many of Anchorage's public inebriates are frail and weary from hard drinking and life on the street, their souls broken from the troubles that brought them there: Rape and incest and family dysfunction. Crushing divorces. Records of criminal behavior that make it hard to get a job or find an apartment. Many are mentally ill, with depression, anxiety, schizophrenia or post traumatic stress. Most don't see themselves as deserving anything better than this tattered life.

The last official count of Anchorage's homeless in January found 343 homeless substance abusers, up from 295 just a year ago. Fifty-two were sleeping in camps, under stairwells, in abandoned cars and buildings. Another 147 were in shelters, and 144 were one step off the streets, in transitional housing programs that help the homeless move into their own places.

While the city and private agencies are getting dozens of people into treatment and housing, for every person ready to get sober, someone new is sucked into the street routine, advocates say. And in the past couple of years, help often wasn't there.

More are ending up at sleep-off, and they are drunker than they used to be, according to a January city report on Pathways to Sobriety, the program that Flowerdew works under. Twenty years ago, no one blew a .300 when being admitted to sleep-off, according to a limited study cited in the Pathways report. Last year, one in nine topped .300 in breath tests, nearly four times the level considered too drunk to drive.

From 2004 to 2008, the number of people resorting to sleep-off at least once increased by 1,080, according to a July city report on homelessness in Anchorage.

During much of that time, state funding for treatment either stayed flat or dropped.

The most chronically homeless alcoholics -- the 51 most frequent users of sleep-off -- ended up there every three or four nights on average last year, according to the Anchorage Fire Department, which oversees the sleep-off center and the Community Service Patrol. The four men who relied on sleep-off the most stayed there at least 183 nights. The closest thing they have to a home is a barren room next to the city jail where people pass out on mats on the floor.

"They have been lost," said Carrie Longoria, manager of the city Safety Links program, which includes services for the homeless. "They've been on the streets for about 15, 20 years."

'IT'S WINTER COMING'

One sunny Friday morning this fall at Bean's Cafe, people with alcohol on their breath mobbed Flowerdew for a shot at treatment.

"Debbie, how long is the list?" asks a homeless man in a big yellow jacket outside the soup kitchen.

"Which list?"

"The list for me to sober up," he says.

"Three weeks," she tells him.

"Oh. Three weeks."

She asks why he hasn't called her.

"I'm busy drinking," he says.

"You're going to die out here," Flowerdew warns. "It's winter coming."

Flowerdew's job as a case manager is pivotal to the city's plan for getting homeless alcoholics off the streets. Her home base is at the sleep-off station, but she's rarely in the office.

She scoots around town in her truck, stopping at soup kitchens and shelters, treatment centers and apartments, homeless camps and panhandler street corners. With winter setting in, she rounded up three big bags of coats, sweats and socks. She keeps a supply in her truck.

Wherever she can find a slot for treatment, she grabs it, even if it's in Seattle or San Francisco.

Not everyone she gets off the streets stops drinking, but many do and others cut way back. Among Pathways clients who got housing in 2006 and 2007, admissions to sleep-off dropped a dramatic 72 percent, the January report said.

A DEPLETED SYSTEM

During the four years of former Gov. Frank Murkowski, grants for substance abuse treatment stagnated even as costs were rising.

The state was increasingly pushing agencies to bill Medicaid for services to shift some of the costs to the federal government. At the same time, some conservatives in the Legislature were cutting the separate state grants directed at treatment for addicts.

"There was sort of a feeling that it was a moral failing and the programs the state funded weren't very successful," said state Sen. Johnny Ellis, a Democrat who remembers getting crossways with Senate President Lyda Green and other conservatives over the cuts.

Medicaid, a state-federal insurance program for the poor, was supposed to pick up where direct grants left off, but that plan failed. Most of the addicts on the street didn't qualify for Medicaid, according to a 2007 report for the Alaska Mental Health Trust Authority.

Detox services were especially hard hit because they couldn't compete with hospitals and other facilities for nurses needed to monitor patients around the clock during the dangerous first days of withdrawal, said Melinda Freemon, who oversees RurAL CAP's Homeward Bound residential program for homeless alcoholics and used to run Clitheroe.

Nugen's Ranch, a long-term substance abuse treatment program in Wasilla, shut down its detox service in 2003. Clitheroe scaled back and then in 2007 closed its detox unit, which only now is reopening. This year, the state shut down the Fairbanks Native Association's detox center for lack of an advanced registered nurse practitioner.

As space in detox evaporated, more people became repeats at sleep-off, Longoria said.

"Because there's no place for them to go," she said.

According to funding and client summaries provided by state health officials, in 2003-04, the first budget year of Gov. Murkowski's term, $16 million was spent through state grants for substance abuse treatment. The next year it shot up to $19 million but by the time his last budget went into effect, the total was back to $16 million despite rising costs in the field.

"So for a number of years new money wasn't coming into the system and the system was contracting," said Stacy Toner, deputy director of the state Division of Behavioral Health.

For detox, the number of people served dropped steadily, from 1,300 in the 2004-05 budget year to a low of 476 three years later, according to state figures. The count doubled to 925 last budget year.

At the Alaska Federation of Natives convention in October, delegates passed a resolution lamenting the homeless deaths and reduced treatment. The resolution called for more services, housing and research.

STEPPING UP

Agencies are now trying to rebuild what was lost. The Palin administration supported putting more money into treatment, and the Legislature responded with increases the last three years, Toner said. This year, $28 million is budgeted for substance abuse treatment.

Alaska Native agencies are doing more, too. When Clitheroe's detox unit shut down in 2007, Cook Inlet Tribal Council, the social service arm of Cook Inlet Region Inc., expanded its existing detox service to include non-Natives. It kept adding slots and now has 12 detox beds at its Ernie Turner Center, 11 of them state funded for whoever needs them.

Cook Inlet Tribal Council also has doubled the number of case managers at Ernie Turner Center to four, and is expanding their role so that they'll now do outreach in homeless camps, shelters and soup kitchens, said Rebecca Ling, director of recovery services for CITC.

Meanwhile, Southcentral Foundation, CIRI's health-care agency, is pouring millions of federal grant dollars into treatment services for Alaska Native clients in Anchorage and the Valley. So far, 883 people have gotten help, according to Southcentral Foundation. The grant ends this budget year but Southcentral hopes to get another.

FORCED TO SOBER UP

On West End Road, past Stevens International Airport, past the city sewage treatment plant, is Clitheroe Center, Alaska's biggest substance abuse treatment facility.

The most significant new effort may be Clitheroe's experiment to force out-of-control alcoholics into treatment whether they want it or not. A judge must approve of any forced treatment that lasts longer than 48 hours.

The state is providing $1 million this budget year for four detox beds and six treatment beds for people who have refused help, plus another $200,000 for two detox beds for anyone.

Its champion in the Legislature was Ellis, the Anchorage Democrat who once couldn't have imagined forcing people into treatment. It is being done under existing state law through procedures like those used to commit people with mental illness when they pose a danger to themselves or others.

"When I came into public service (more than) 20 years ago, the community would have been up in arms that we're locking people up for alcoholism," Ellis said recently. "We're not locking up people for alcoholism. We are temporarily detaining people under the law at a judge's discretion so that they can sober up and go into treatment or go on their merry way."

Still, all the new help doesn't match what Anchorage used to have, and is far short of what is needed, Freemon of Homeward Bound said.

At Clitheroe, 49 people were waiting for residential treatment in early November. Even more were waiting for outpatient help. Waits last from three weeks to three months.

One man in treatment at Clitheroe said he had been on the streets for eight years and liked it. There, everything was simple. "You don't have to listen to anybody. It's just a easy way of life to live by," he said. The only worry was how to get that day's half gallon of cheap Monarch vodka, he said.

"That program is saving lives right now," Flowerdew said. "When they've been there a while, they come to their senses, and they want to do treatment."

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Find Lisa Demer online at adn.com/contact/ldemer or call 257-4390.

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