A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants' experiences

Law enforcement-led, pre-arrest diversion-to-treatment may reduce crime recidivism, incarceration, and overdose deaths: Program evaluation outcomes

INTRODUCTION

Substance use disorder (SUD), overdose, and drug use-related crime continue to increase in the U.S. Pre-arrest diversion-to-treatment programs may decrease crime recidivism and overdose deaths. We assessed the impact of a community-wide diversion-to-treatment initiative on crime, incarceration, and overdose.

METHODS

This article reports on the prospective evaluation of a law enforcement-led, pre-arrest diversion-to-treatment program on crime, incarceration, and overdose deaths compared between participants who did not engage (non-engaged; n = 103), engaged but did not complete (non-completers; n = 60) and completed (completers; n = 100) the program. Participants included 263 adults apprehended by police officers for low-level, drug use-related crimes between September 1, 2017 and August 31, 2020. The program offered eligible persons participation in a six-month program consisting of a clinical assessment, referral to addiction treatment services based on each individual's needs, connection to recovery peer support, and treatment engagement monitoring. Completers had their initial criminal charges 'voided,' while non-engaged and non-Completer participants had their original charges filed with local prosecutors. The project collected participant-level data on arrests and incarceration within 12 months before and 12 months after program enrollment and data on fatal overdose within 12 months after program enrollment. Logistic regression predicted outcomes using baseline demographics (sex, age, race, housing status) and pre-index crime arrest and incarceration indices as covariates.

RESULTS

After accounting for baseline demographics and pre-enrollment arrest/incarceration history, logistic regression models found that the non-engaged and the non-Completer groups were more likely than completers to be arrested (odds ratios [ORs]: 3.9 [95 % CI, 2.0-7.7] and 3.6 [95 % CI, 1.7-7.5], respectively) and incarcerated (ORs: 10.3 [95 % CI, 5.0-20.8] and 21.0 [95 % CI, 7.9-55.7], respectively) during the 12-month follow-up. Rates of overdose deaths during the 12-month follow-up were greatest in non-engaged (6/103, 5.8 %) and non-Completer (2/60, 3.3 %) groups; completers had the lowest rate (2/100, 2.0 %), with all deaths occurring after completion of the six-month treatment/monitoring program.

CONCLUSIONS

Collaboration between law enforcement, clinicians, researchers, and the broader community to divert adults who commit a low-level, drug use-related crime from criminal prosecution to addiction treatment may effectively reduce crime recidivism, incarceration, and overdose deaths.

Moving Beyond Referrals: Addressing Multilevel Barriers to Substance Use Treatment Engagement Through Police-Led Recovery Management Check-Ups

The opioid epidemic in the United States (US) has prompted innovative responses from law enforcement agencies including specialized units to refer overdose survivors to substance use treatment following an overdose. However, traditional law enforcement outreach does not address the multilevel barriers to treatment engagement that lead to repeat overdose-related calls for service. The current evaluation explored the process components and outcomes of a Comprehensive Opioid Abuse Program (COAP) initiative within a local law enforcement agency in the Southeast US. COAP funding supported a police-led recovery management team (RMT) to connect overdose survivors to substance use treatment. The RMT also utilized recovery management check-ups (RMCs) to provide sustained support to enhance substance use treatment engagement beyond the initial treatment referral. A mixed-methods approach was employed to examine participant demographic, substance use, mental health, treatment, and criminal justice characteristics (N = 65) and explore perceptions of programmatic strengths and potential areas for improvement (N = 15). The quantitative and qualitative analyses were informed by the Recovery Capital Model. Quantitative analysis revealed that the RMT connected many participants with various support services, notably including housing assistance and health insurance. Qualitative findings highlight program effectiveness in improving social, community, and personal recovery capital. These findings contribute to expanding research on police-led post-overdose initiatives and suggest that police-led RMCs can address multilevel barriers to treatment engagement and minimize law enforcement stigma.

Offering recovery rather than punishment: Implementation of a law enforcement-led pre-arrest diversion-to-treatment program for adults with substance use disorders

BACKGROUND

The opioid epidemic has strained the US criminal justice system. Law enforcement frequently encounters persons with substance use disorder (SUD). Law enforcement-led, pre-arrest diversion programs linking individuals with SUD to addiction treatment instead of arrest and prosecution has the potential to reduce crime, overdoses, and other community harms. We implemented a pre-arrest diversion-to-treatment program-the Madison Addiction Recovery Initiative (MARI)-from September 2017 to August 2020, and describe the key components of MARI's effective implementation.

METHODS

Adults who committed an eligible, drug use-related crime were offered a 6-month MARI participation with referral to treatment in lieu of arrest; criminal charges for that crime were "voided" upon the successful MARI completion. Formative evaluation, with stakeholder feedback and team meeting minutes, assessed key factors influencing implementation. Process evaluation consisted of tracking participant referrals, enrollment, and engagement. Police officers, MARI participants, and treatment center staff members were surveyed about program experiences and attitudes. The study used descriptive statistics to describe quantitative survey responses; thematic qualitative analysis identified major themes in qualitative responses.

RESULTS

Of 263 participants, 160 initiated program engagement, with 100 successfully completing MARI. Interim evaluations and community partner feedback informed program protocol adjustments to increase participant enrollment, retention and diversity, streamline the referral processes, and transition to telehealth during the COVID-19 pandemic.

CONCLUSION

Rigorous evaluation and community partner feedback are essential components of effective implementation and sustainability of a law enforcement-led pre-arrest diversion-to-treatment program, which has the potential to both reduce crime and overdose, and change the lives of people with SUD.

The police paradox: A qualitative study of post-overdose outreach program implementation through public health-public safety partnerships in Massachusetts

BACKGROUND

Post-overdose outreach has emerged in the United States as an increasingly common response to non-fatal overdose. This qualitative study investigates the implementation of such programs through public health-public safety partnerships in Massachusetts.

METHODS

We conducted semi-structured interviews with post-overdose outreach team members, overdose survivors, and family members who received outreach. Interview transcripts were inductively analyzed to identify emergent themes and subsequently organized within the framework of Ecological Systems Theory.

RESULTS

Forty-nine interviews were conducted, including 15 police officers (80% male, 100% non-Hispanic White); 23 public health partners (48% male, 87% non-Hispanic White); 8 overdose survivors who received outreach services and 3 parents of survivors who received services (collectively 27% male, 64% non-Hispanic White). Implementation factors identified across all levels (macrosystem, exosystem, mesosystem, and microsystem) of Ecological Systems Theory included key program facilitators, such as access to police data and funding (macro), interagency collaboration (exo), shared recognition of community needs (exo), supportive relationships among team members (meso), and program champions (micro). Common barriers included inherent contradictions between policing and public health mandates (macro), poor local treatment and service capacity (exo), divergent staff views of program goals (exo), overdose survivors' prior negative experiences with law enforcement (meso), difficulty locating overdose survivors (meso), and police officers' lack of qualifications or training in providing psycho-social services (micro).

CONCLUSIONS

Most post-overdose outreach programs in this study were dependent on funding and data-sharing partnerships, which police agencies largely controlled. Yet, police participation, especially during outreach visits presented numerous challenges for engaging overdose survivors and establishing non-coercive linkages with evidence-based services, which may undermine the public health goals of these programs. These findings should inform state and federal efforts to expand the role of law enforcement in behavioral health initiatives.

Guiding officers to deflect citizens to treatment: an examination of police department policies in Illinois

BACKGROUND

The U.S. overdose crisis has motivated police departments to enact policies allowing officers to directly deflect individuals to substance use disorder treatment and other services shown to reduce recidivism and subsequent overdose risk, as well as refer people who voluntarily present at police facilities with a desire for treatment. As a new way of operating, and one that relies on an officer's use of discretion for successful implementation, the practice benefits from guidance through written directives, training, and supervisory support. However, there is little information on the establishment, content, and execution of police department deflection policies, which hampers the implementation and dissemination of this promising practice. We analyzed 16 policies of Illinois police department deflection programs. Using content analysis methodology, we coded the policies for language and terminology, as well as program components and procedures. We aimed to examine how the policies were written, as well as the content intending to guide officers in their work.

RESULTS

We found the policies and programs had notable differences in length, detail, terminology, and reading level. Only one policy mentioned the use of any type of addiction treatment medication, many used stigmatizing language (e.g., "abuse" and "addict"), and few mentioned "harm reduction" or training in the practice of deflection. Many policies restricted participation in deflection (i.e., no minors, outstanding warrants, current withdrawal symptoms), and critically, a majority of policies allowed police officers to exclude people from participation based on their own judgment.

CONCLUSIONS

We recommend police departments consider the readability of their policies and reduce barriers to deflection program participation to engage a larger pool of citizens in need of substance use disorder treatment. Since there is limited research on police policies generally, and the field of deflection is relatively new, this study offers insight into the content of different department policies and more specifically, how officers are directed to operate deflection programs.

A scoping review of community-based post-opioid overdose intervention programs: implications of program structure and outcomes

BACKGROUND

An emergent intervention to address the opioid epidemic is the use of multidisciplinary outreach teams which connect an individual in the community to healthcare resources after the experience of an opioid overdose. While these interventions are receiving federal funding, less is known empirically to inform future interventions. Understanding the process and outcomes of these interventions is advisable due to the novel partnerships of public health and law enforcement agencies who sometimes hold divergent goals. The objective of the present review was to describe program structure and evaluated outcomes of community-based post-overdose interventions.

RESULTS

A search of PubMed, PsycInfo, and Web of Science yielded 5 peer-reviewed articles that detail the implementation and outcomes of interventions delivered in the United States published from 2001 to July 2021. Most interventions used a multidisciplinary outreach team and referenced first responder data to contact individuals who recently experienced an overdose at their residence. Services offered often included referral to substance use treatment, recovery coaches, and social services. Method of outreach, evaluation measures, and outcomes varied. From the available literature, facilitators of program engagement included communication, information sharing, and leadership buy-in among multidisciplinary partners.

CONCLUSIONS

Future studies could benefit from exploration of service provision in rural areas, for family affected by overdose, and for minoritized populations. Community-based post-overdose interventions utilizing a law enforcement partnership are emergent with promising yet limited examples in empirical literature.

Addressing Substance Use and Misuse in East Texas: Stakeholder-Driven Needs and Priorities

Background-This project sought to assess needs, perceived challenges, and priorities regarding substance use disorder (SUD) in East Texas and develop a community-driven research agenda to address those challenges. Methods-Data were gathered through nine focus-group discussions (FGDs) with stakeholders: people living with SUD, families, medical providers, counselors, representatives of community-based organizations, and law enforcement officers. We asked participants how substance use manifests in their communities, which challenges they confronted in coping with substance use and misuse, and in which order their needs should be prioritized. Findings were reported at community forums to confirm the list of challenges and prioritize needs. Results-Five themes emerged from the FGDs indicating major challenges: (a) access to SUD treatment and recovery resources, (b) mental health and resiliency, (c) education, training, and professional development to facilitate treatments, (d) care and service coordination, and (e) community/social support for people living with SUD and their families. Conclusions-Significant resources such as financing, collaboration across silos, and community education are needed to effectively manage this public health problem. Our findings can inform research and outreach to help East Texans develop interventions, research programs, and educational opportunities for clinicians, community-based organizations, law enforcement officers, and counselors to build capacity for SUD prevention, treatment, and recovery.

First Responder Assertive Linkage Programs: A Scoping Review of Interventions to Improve Linkage to Care for People Who Use Drugs

CONTEXT

In response to the drug overdose crisis, first responders, in partnership with public health, provide new pathways to substance use disorder (SUD) treatment and other services for individuals they encounter in their day-to-day work.

OBJECTIVE

This scoping review synthesizes available evidence on first responder programs that take an assertive approach to making linkages to care.

RESULTS

Seven databases were searched for studies published in English in peer-reviewed journals between January 2000 and December 2019. Additional articles were identified through reference-checking and subject matter experts. Studies were selected for inclusion if they sufficiently described interventions that (1) focus on adults who use drugs; (2) are in the United States; (3) involve police, fire, or emergency medical services; and (4) assertively link individuals to SUD treatment. Twenty-two studies met inclusion criteria and described 34 unique programs, implementation barriers and facilitators, assertive linkage strategies, and linkage outcomes, including unintended consequences.

CONCLUSIONS

Findings highlight the range of linkage strategies concurrently implemented and areas for improving practice and research, such as the need for more linkages to evidence-based strategies, namely, medications for opioid use disorder, harm reduction, and wraparound services.

The relationship between police contacts for drug use-related crime and future arrests, incarceration, and overdoses: a retrospective observational study highlighting the need to break the vicious cycle

BACKGROUND

Individuals with substance use disorder often encounter law enforcement due to drug use-related criminal activity. Traditional policing approaches may not be effective for reducing recidivism and improving outcomes in this population. Here, we describe the impact of traditional policing approach to drug use-related crime on future recidivism, incarceration, and overdoses.

METHODS

Using a local Police Department (PD) database, we identified individuals with a police contact with probable cause to arrest for a drug use-related crime ("index contact"), including for an opioid-related overdose, between September 1, 2015, and August 31, 2016 (Group 1, N = 52). Data on police contacts, arrests, and incarceration 12 months before and after the index contact were extracted and compared using Fisher's exact or Wilcoxon signed-rank tests. County-level data on fatal overdoses and estimates of time spent by PD officers in index contact-related responses were also collected. To determine whether crime-related outcomes changed over time, we identified a second group (Group 2, N = 263) whose index contact occurred between September 1, 2017, and August 31, 2020, and extracted data on police contacts, arrests, and incarceration during the 12 months prior to their index contact. Pre-index contact data between Groups 1 and 2 were compared with Fisher's exact or Mann-Whitney U tests.

RESULTS

Comparison of data during 12 months before and 12 months after the index contact showed Group 1 increased their total number of overdose-related police contacts (6 versus 18; p = 0.024), incarceration rate (51.9% versus 84.6%; p = 0.001), and average incarceration duration per person (16.2 [SD = 38.6] to 50 days [SD = 72]; p < 0.001). In the six years following the index contact, 9.6% sustained a fatal opioid-related overdose. For Group 1, an average of 4.7 officers were involved, devoting an average total of 7.2 h per index contact. Comparison of pre-index contact data between Groups 1 and 2 showed similar rates of overdose-related police contacts and arrests.

CONCLUSIONS

The results indicated that the traditional policing approach to drug use-related crime did not reduce arrests or incarceration and was associated with a risk of future overdose fatalities. Alternative law enforcement-led strategies, e.g., pre-arrest diversion-to-treatment programs, are urgently needed.

Diverting people who use drugs from the criminal justice system: A systematic review of police-based diversion measures

BACKGROUND

Previous reviews of the effectiveness of measures to divert those who use drugs from the criminal justice system have focused mainly on post-conviction or post-sentence programs and report mixed results. The present systematic review synthesizes evidence on the effectiveness of police-based diversion measures in reducing criminal offenses and other harms related to drug use and then summarizes evidence from qualitative studies to identify facilitators and barriers associated with the implementation of such measures.

METHODS

Eight databases were searched to find evaluations of police-based diversion measures for drug-related offenders. Twenty-seven studies were identified. The vote-count method and the Maryland Scientific Method Scale were used to assess the impact of police-based diversion measures. Themes related to barriers or conditions facilitating the implementation of these measures were extracted from qualitative studies.

RESULTS

Evidence from quantitative studies indicates that in general police-based diversion measures are effective in preventing criminal offending and show promising results for improving participants' health and diminishing social costs as well as costs associated with processing drug-related offenses. There was insufficient evidence to draw conclusions about the effect of police-based diversion measures on drug use, drug accessibility, or changes in participants' socioeconomic conditions. Findings from qualitative studies suggest that program acceptance by police officers, constructive intersectoral collaboration, clear eligibility criteria, and timely access to services seem to facilitate the implementation and delivery of police-based diversion measures.

CONCLUSION

Police-based diversion measures can be effective in preventing drug-related criminal offenses and harm. Additional research is needed to evaluate their effect on participants' socioeconomic conditions and drug use as well as drug accessibility.

Perspectives from law enforcement officers who respond to overdose calls for service and administer naloxone

BACKGROUND

Many law enforcement agencies across the United States equip their officers with the life-saving drug naloxone to reverse the effects of an opioid overdose. Although officers can be effectively trained to administer naloxone, and hundreds of law enforcement agencies carry naloxone to reverse overdoses, little is known about what happens on scene during an overdose call for service from an officer's perspective, including what officers perceive their duties and responsibilities to be as the incident evolves.

METHODS

The qualitative study examined officers' experiences with overdose response, their perceived roles, and what happens on scene before, during, and after an overdose incident. In-person interviews were conducted with 17 officers in four diverse law enforcement agencies in the United States between January and May 2020.

RESULTS

Following an overdose, the officers described that overdose victims are required to go to a hospital or they are taken to jail. Officers also described their duties on scene during and after naloxone administration, including searching the belongings of the person who overdosed and seizing any drug paraphernalia.

CONCLUSION

These findings point to a pressing need for rethinking standard operating procedures for law enforcement in these situations so that the intentions of Good Samaritan Laws are upheld and people get the assistance they need without being deterred from asking for future help.

Methamphetamine use in the United States: epidemiological update and implications for prevention, treatment, and harm reduction

Recent attention has focused on the growing role of psychostimulants, such as methamphetamine in overdose deaths. Methamphetamine is an addictive and potent stimulant, and its use is associated with a range of physical and mental health harms, overdose, and mortality. Adding to the complexity of this resurgent methamphetamine threat is the reality that the increases in methamphetamine availability and harms are occurring in the midst of and intertwined with the ongoing opioid overdose crisis. Opioid involvement in psychostimulant-involved overdose deaths increased from 34.5% of overdose deaths in 2010 to 53.5% in 2019-an increase of more than 50%. This latest evolution of the nation's overdose epidemic poses novel challenges for prevention, treatment, and harm reduction. This narrative review synthesizes what is known about changing patterns of methamphetamine use with and without opioids in the United States, other characteristics associated with methamphetamine use, the contributions of the changing illicit drug supply to use patterns and overdose risk, motivations for couse of methamphetamine and opioids, and awareness of exposure to opioids via the illicit methamphetamine supply. Finally, the review summarizes illustrative community and health system strategies and research opportunities to advance prevention, treatment, and harm reduction policies, programs, and practices.

Impact of a community-policing initiative promoting substance use disorder treatment over criminal charges on arrest recidivism

BACKGROUND

Overdose deaths, addiction, and drug-related crime have increased in the United States over the past decade. Treatment improves outcomes, including reducing crime, but few individuals with addiction receive treatment. Here, we determine whether the Madison Addiction Recovery Initiative (MARI), a community policing program implemented by the City of Madison (Wisconsin) Police Department (MPD) that diverts adults who committed a non-violent, drug use-related crime from criminal prosecution to addiction treatment, reduces the risk of recidivism (i.e., an arrest) in the 6-month period following the index crime.

METHODS

Observational data were collected by the MPD for 12 months before through 6 months after an index crime from participants in the MARI program (n = 263) who referred to MARI between September 1, 2017 and August 31, 2020 and a Historical Comparison group (n = 52) who committed a comparable crime between September 1, 2015 and August 31, 2016. Average effects were estimated using intention-to-treat (ITT), a per-protocol, and a complier average causal effects (CACE) analyses, adjusted for covariates.

RESULTS

ITT analysis did not show that MARI assignment lowered adjusted odds of 6-month recidivism (aOR = 0.59 [0.32, 1.12], p = 0.11). Per-protocol analysis showed that completing MARI lowered the adjusted odds of 6-month recidivism (aOR = 0.23 [0.10, 0.52], p < 0.001). CACE analysis indicated that assignment to MARI among individuals who would complete the MARI program if assigned to the program lowered the adjusted odds of 6-month recidivism (aOR = 0.85 [0.80, 0.90], p < 0.001).

CONCLUSIONS

Diverting adults who committed a non-violent, drug use-related crime from criminal prosecution to addiction treatment may reduce 6-month recidivism.

Municipal police support for harm reduction services in officer-led referrals of people who inject drugs in Tijuana, Mexico

BACKGROUND

Police constitute a structural determinant of health and HIV risk of people who inject drugs (PWID), and negative encounters with law enforcement present significant barriers to PWID access to harm reduction services. Conversely, police may facilitate access via officer-led referrals, potentiating prevention of HIV, overdose, and drug-related harms. We aimed to identify police characteristics associated with support for officer-led referrals to addiction treatment services and syringe service programs (SSP). We hypothesized that officers who believe harm reduction services are contradictory to policing priorities in terms of safety and crime reduction will be less likely to support police referrals.

METHODS

Between January and June 2018, police officers (n = 305) in Tijuana, Mexico, completed self-administered surveys about referrals to harm reduction services during the 24-month follow-up visit as part of the SHIELD police training and longitudinal cohort study. Log-binomial regression was used to estimate adjusted prevalence ratios and model policing characteristics and attitudes related to officers' support for including addiction treatment and SSP in referrals.

RESULTS

Respondents were primarily male (89%), patrol officers (86%) with a median age of 38 years (IQR 33-43). Overall, 89% endorsed referral to addiction services, whereas 53% endorsed SSP as acceptable targets of referrals. Officers endorsing addiction services were less likely to be assigned to high drug use districts (adjusted prevalence ratio [APR] = 0.50, 95% CI 0.24, 1.08) and more likely to agree that methadone programs reduce crime (APR = 4.66, 95% CI 2.05, 9.18) than officers who did not support addiction services. Officers endorsing SSPs were younger (adjusted prevalence ratio [APR] = 0.96 95% CI 0.93, 0.98), less likely to be assigned to high drug use districts (APR = 0.50, 95% CI 0.29, 0.87), more likely to believe that methadone programs reduce crime (APR = 2.43, 95% CI 1.30, 4.55), and less likely to believe that SSPs increase risk of needlestick injury for police (APR = 0.44, 0.27, 0.71).

CONCLUSIONS

Beliefs related to the occupational impact of harm reduction services in terms of officer safety and crime reduction are associated with support for referral to related harm reduction services. Efforts to deflect PWID from carceral systems toward harm reduction by frontline police should include measures to improve officer knowledge and attitudes about harm reduction services as they relate to occupational safety and law enforcement priorities.

TRIAL REGISTRATION

NCT02444403.

Contextual challenges in police-assisted substance use referral programs: Impact of COVID-19 and Black Lives Matter movement

Background: Police assisted referral (PAR) programs provide people with substance use disorders (SUD) with a non-arrest treatment pathway, yet systemic barriers, including stigma and access to treatment services, may limit engagement. We sought to understand how the dual contextual challenges of COVID-19 and the Black Lives Matter movement have impacted PAR programs. Methods: Participants completed semi-structured interviews between July and September 2020. Transcribed interviews were analyzed qualitatively to extract emergent codes and themes. Results: Key themes included: adoption and reach of adapted remote services, and barriers to access; and questions on the role of police as health service providers, including police embeddedness in the community. COVID-related social distancing demands undermined police engagement with people with SUD. Treatment providers and advocates reported moderate success in utilizing remote interventions as workarounds. While participants acknowledged the Black Lives Matter movement's criticism of police, many saw continued value in police involvement in substance use interventions, due to their accessibility in communities and capacity for rapid response. Conclusions: PAR programs quickly adapted to a largely remote format, increasing longer-term accessibility. While Black Lives Matter had little direct impact on PAR programs, concerns about police-community relations were acknowledged. Recommendations include further police training to enhance trust and reduce stigma, and wider integration of digitally-based substance use referral options.

Moving Beyond Narcan: A Police, Social Service, and Researcher Collaborative Response to the Opioid Crisis

The opioid crisis is the most persistent, long-term public health emergency facing the United States, and available evidence suggests the crisis has worsened during the COVID-19 global pandemic. Naloxone is an effective overdose response that saves lives, but the drug does not address problematic drug use, addiction, or the underlying conditions that lead to overdoses. The opioid crisis is at its core a multidisciplinary, multisystem problem, and an effective response to the crisis requires collaboration across those various systems. This paper describes such a collaborative effort. The Tempe First-Responder Opioid Recovery Project is a multidisciplinary partnership that includes police officers, social workers, substance use peer counselors, public health professionals, police researchers, and drug policy/harm reduction researchers. The project, 10 months underway, trained and equipped Tempe (AZ) police officers to administer Narcan. In addition, a 24/7 in-person "Crisis Outreach Response Team" rapidly responds to any suspected overdose and offers follow-up support, referrals, and services to the individual (and loved ones) for up to 45 days after the overdose. We present preliminary project data including interviews with project managers, counselors, and police officers, descriptions of Narcan administrations in the field, and aggregate data on client service engagement. These data highlight the complexity of the opioid crisis, the collaborative nature of the Tempe project, and the importance of initiating a multidisciplinary, comprehensive response to effectively deal with the opioid problem.

Examining the implementation of police-assisted referral programs for substance use disorder services in Massachusetts

BACKGROUND

In response to the dramatic increase in opioid overdose deaths in recent years, police departments and community partners across the United States have begun to implement programs focused on connecting individuals to substance use disorder services. We examined the implementation of police-assisted referral programs from the perspectives of different team members to understand the key components of these programs and strategies used to implement them.

METHODS

Qualitative research methods were used to examine the implementation of police-assisted referral programs in five Massachusetts communities between June 2019 and March 2020. Focus groups and interviews were conducted with 33 individuals, including 5 police chiefs, 12 police officers, 6 outreach workers, 4 community-based organization (CBO) directors, 2 interns, 1 clinician, 1 program manager, 1 religious representative, and 1 prevention specialist.

RESULTS

Five key themes emerged regarding the implementation of police-assisted referral programs across the communities: 1) program development was an ongoing process; 2) partnerships between police departments and community stakeholders were essential for starting and sustaining a program; 3) high-level leadership influenced program priorities and facilitated implementation; 4) program success was defined in multiple ways; and 5) programs contributed to shifts in beliefs about substance use and addiction among police officers.

CONCLUSIONS

Police-assisted referral programs in Massachusetts have adopted a variety of models of service delivery, evolving from post-overdose outreach and walk-in models to more complex hybrid forms. Implementation was facilitated by the support of departmental leadership, particularly the police chief, and the development of key partnerships across institutional boundaries. Communities continue to develop their programs to incorporate additional components, such as new mechanisms of outreach, harm reduction services, and long-term engagement activities. Further evaluation of these programs is needed to understand how each of these unique components may influence a program's impact on future overdoses, entry to treatment, and long-term recovery.

Law enforcement assisted diversion: Qualitative evaluation of barriers and facilitators of program implementation

BACKGROUND

Despite widespread interest in adoption, there has been limited systematic examination of Law Enforcement Assisted Diversion (LEAD) implementation, a model for police-led arrest diversion for those with substance use disorders (SUD). In the fall of 2017, the City of New Haven started a LEAD program. During the first 9 months of the pilot, only 2 clients were successfully diverted from arrest. Therefore, we examined the and barriers and facilitators of LEAD implementation.

METHODS

We conducted semi-structured interviews and field observations of LEAD police officers and health care providers between August 2018 and June 2019. Interviews and field observations were analyzed using directed content analysis and guided by the Integrated Promoting Action on Research Implementation in Health Services framework.

RESULTS

Lead professionals participated in 19 semi-structured interviews and three field observations. Barriers to arrest diversion implementation included procedural complexity of arrest diversion, concerns about reduced penalties for substance use among officers, stigma of SUDs, and a belief in a punitive role for policing. Facilitators included a positive longitudinal relationship with potential clients and an understanding of SUD as a chronic disease.

CONCLUSION

We identified several barriers to LEAD implementation. Our results suggest promotion of SUD as a chronic disease, ongoing training of officers, and positive incentives for entering substance use treatment should be utilized to facilitate implementation.

Pre-arrest diversion to addiction treatment by law enforcement: protocol for the community-level policing initiative to reduce addiction-related harm, including crime

BACKGROUND

Despite evidence that treatment reduces addiction-related harms, including crime and overdose, only a minority of addiction-affected individuals receive it. Linking individuals who committed an addiction-related crime to addiction treatment could improve outcomes.

METHODS

The aim of this city-wide, pre-arrest diversion program, Madison Addiction Recovery Initiative (MARI) is to reduce crime and improve health (i.e., reduce the overdose deaths) among adults who committed a minor, non-violent, drug use-related offense by offering them a referral to treatment in lieu of arrest and prosecution of criminal charges. This manuscript outlines the protocol and methods for the MARI program development and implementation. MARI requires its participants to engage in the recommended treatment, without reoffending, during the six-month program, after which the initial criminal charges are "voided" by the law enforcement agency. The project, implemented in a mid-size U.S. city, has involved numerous partners, including law enforcement, criminal justice, public health, and academia. It includes training of the police officer workforce and collaboration with clinical partners for treatment need assessment, treatment placement, and peer support. Program evaluation includes formative, process, outcome (participant-level) and exploratory impact (community-level) assessments. For outcome evaluation, we will compare crime (primary outcome), overdose-related offenses, and incarceration-related data 12 months before and 12 months after the index crime between participants who completed (Group 1), started but not completed (Group 2), and were offered but did not start (Group 3) the program, and adults who would have been eligible should MARI existed (Historical Comparison, Group 4). Clinical characteristics will be compared at baseline between Groups 1-2, and pre-post the program within Group 1. Participant baseline data will be assessed as potential covariates. Surveys of police officers and program completers, and community-level indicators of crime and overdose pre- versus post-program will provide additional data on the program impact.

DISCUSSION

By offering addiction treatment in lieu of arrest and prosecution of criminal charges, this pre-arrest diversion program has the potential to disrupt the cycle of crime, reduce the likelihood of future offenses, and promote public health and safety.

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

BACKGROUND

The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities.

METHODS

A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation.

CONCLUSIONS

The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.

Preferences and acceptability of law enforcement initiated referrals for people who inject drugs: a mixed methods analysis

BACKGROUND

Law enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico.

METHODS

We assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico.

RESULTS

Among potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30-45%) who endorsed these service referrals was significantly lower (p <  0.01). Regarding referral acceptability, 71% of PWID reported they would be very likely or somewhat likely to make use of a referral compared to 94% of LEOs reporting that they thought PWID would always or sometimes utilize them. These results were echoed in the qualitative analysis, although practical barriers to referrals emerged, whereby PWID were less optimistic that they would utilize referrals compared to LEOs.

CONCLUSIONS

We identified strong support for LEO service referrals among both LEO and PWID respondents, with the highest preference for substance use treatment. LEO referral programs offer opportunities to deflect PWID contact with carceral systems while facilitating access to health and social services. However, appropriate investments and political will are needed to develop an evidence-based (integrated) service infrastructure.

Developing interagency collaboration to address the opioid epidemic: A scoping review of joint criminal justice and healthcare initiatives

BACKGROUND

With the current opioid epidemic impacting well over half of all counties across the United States, initiatives that encourage interagency collaboration between first responder organizations appear necessary to comprehensively address this crisis. Police, fire, and emergency medical services (EMS) are in a unique position to identify substance users and provide necessary resources to initiate treatment, yet there is not sufficient evidence of joint collaborative programs between law enforcement/first responders and healthcare providers.

METHODS

In this scoping review we examine the current state of joint criminal justice and healthcare interventions, specifically, opioid and substance use pre-arrest initiatives via emergency first responders and police officers. We relied on data from the last 10 years across three major databases to assess the extent of criminal justice (CJ) and healthcare collaborations as a response to individuals with opioid use disorder (OUD). We specifically focused on interventional programs between criminal justice first responders (pre-arrest) and healthcare providers where specific outcomes were documented.

RESULTS

We identified only a small number (6) of studies involving interventions that met this criteria, suggesting very limited study of joint interagency collaboration between law enforcement first responders and healthcare providers. Most had small samples, none were in the southern states, and all but one were initiated within the last 5 years.

CONCLUSIONS

Although studies describing joint efforts of early intercept criminal justice responses and healthcare interventions were few, existing studies suggest that such programs were effective at improving treatment referral and retention outcomes. Greater resources are needed to encourage criminal justice and healthcare collaboration and policies, making it easier to share data, refer patients, and coordinate care for individuals with OUD.

An assessment of officer attitudes toward the training and use of a pre-booking diversionary program

The opioid epidemic in the United States has led police departments and other professionals to examine the current approach to drug enforcement. Different law enforcement diversionary programs, centered on public health approaches, have emerged. One such program, the "pre-booking" diversionary program, has been the subject of limited research. The current research assessed officer attitudes toward the training and execution of one such diversionary program in two urban police departments. Results from more than 100 surveys provide officers' perceptions of the training they received and their involvement in the program. We provide their detailed feedback and suggestions for law enforcement, outreach workers, and treatment program personnel in hopes that such diversionary programs will become widespread and effectively utilized in more communities.

Police Officers’ Views of Naloxone and Drug Treatment: Does Greater Overdose Response Lead to More Negativity?

Police officers and emergency personnel are on the frontlines of the opioid crisis. This research examines police officer attitudes about naloxone administration, drug treatment, and their role in handling drug-related incidents through an online survey. Although officers view themselves as adequately trained in administering naloxone/Narcan, almost half (43%) believe there should be a limit on how often someone who overdoses receives Narcan and the majority (83%) view naloxone/Narcan as providing an excuse to continue drug use. Officers also view drug treatment as ineffective. Negative attitudes differed as a function of frequency of overdose responses; officers who responded to more overdose calls and administered naloxone more frequently demonstrate more pessimistic attitudes toward drug treatment and the use of naloxone/Narcan. Officers more frequently exposed to drug overdoses need education and training about drug addiction issues to decrease stigma and elicit greater empathy toward people struggling with addiction.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Post-overdose interventions triggered by calling 911: Centering the perspectives of people who use drugs (PWUDs)

BACKGROUND

Opioid overdose deaths have increased exponentially in the United States. Bystander response to opioid overdose ideally involves administering naloxone, providing rescue breathing, and calling 911 to summon emergency medical assistance. Recently in the US, public health and public safety agencies have begun seeking to use 911 calls as a method to identify and deliver post-overdose interventions to opioid overdose patients. Little is known about the opinions of PWUDs about the barriers, benefits, or potential harms of post-overdose interventions linked to the 911 system. We sought to understand the perspectives of PWUDs about a method for using 911 data to identify opioid overdose cases and trigger a post-overdose intervention.

METHODS AND FINDINGS

We conducted three focus groups with 11 PWUDs in 2018. Results are organized into 4 categories: willingness to call 911 (benefits and risks of calling), thoughts about a technique to identify opioid overdoses in 911 data (benefits and concerns), thoughts about the proposed post-overdose intervention (benefits and concerns), and recommendations for developing an ideal post-overdose intervention. For most participants, calling 911 was synonymous with "calling the police" and law enforcement-related fears were pervasive, limiting willingness to engage with the 911 system. The technique to identify opioid overdoses and the proposed post-overdose intervention were identified as potentially lifesaving, but the benefits were balanced by concerns related to law enforcement involvement, intervention timing, and risks to privacy/reputation. Nearly universally, participants wished for a way to summon emergency medical assistance without triggering a law enforcement response.

CONCLUSIONS

The fact that the 911 system in the US inextricably links emergency medical assistance with law enforcement response inherently problematizes calling 911 for PWUDs, and has implications for surveillance and intervention. It is imperative to center the perspectives of PWUDs when designing and implementing interventions that rely on the 911 system for activation.

Interactions between Police and Persons Who Experience Homelessness and Mental Illness in Toronto, Canada: Findings from a Prospective Study

OBJECTIVE

We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions.

METHOD

We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status.

RESULTS

This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73).

CONCLUSIONS

For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

Timely linkage of individuals to substance use disorder treatment: development, implementation, and evaluation of FindHelpNowKY.org

Background

Substance use disorders (SUD) have steadily increased over the last two decades. Seeking SUD treatment involves searching SUD treatment facility types (inpatient, outpatient and intensive outpatient, residential and family residential, and detoxification facilities) that offer specialized SUD treatment depending on individual needs and preferences. Referrals to SUD treatment require innovative strategies that rapidly link individuals to SUD treatment when they are at the critical stage of readiness. The aim of this study was to develop, implement, and evaluate a user-friendly SUD treatment facility opening availability website called FindHelpNowKY.org. The objectives of the study were to 1) recruit SUD treatment facility and partner participation; 2) develop platform, content, and analytics for the FindHelpNowKY.org website intervention with an information repository; 3) assess barriers and facilitators to implementation; and 4) evaluate the development and implementation of FindHelpNowKY.org.

Methods

Website development stakeholders were identified and the website concept was developed. The logic model for FindHelpNowKY.org outlined resources, activities, and outputs as well as the associated short-term, medium-term, and long-term objectives, along with a website evaluation plan. Website usability and focus group testing was conducted. Information repository resource documents were compiled and categorized. An inventory of Kentucky-based SUD treatment facilities was compiled using various state and federal resources.

Results

Development/implementation barriers were addressed, facilitators were identified, and the website was implemented; 83% of SUD treatment facilities were indexed on the website, and average website user time was 7 min. From February to October 2018, there were 29,000 visitors, and 30,000 unique searches. The most common website query was a friend or family member seeking long-term residential or outpatient treatment facilities accepting Medicaid or Medicare.

Conclusions

FindHelpNowKY.org has the potential to fill a critical need for timely access to available SUD treatment in the state. The website may be a valuable resource for health professionals that can enhance clinical workflow and reduce staff time conducting phone and website searches for available SUD treatment. The website is a promising tool for assessing current SUD treatment capacity vs. SUD treatment need. The FindHelpNow model can be used by other states to increase timely access to SUD treatment.

Peer-delivered harm reduction and recovery support services: initial evaluation from a hybrid recovery community drop-in center and syringe exchange program

Background

Recovery from substance use disorder (SUD) is often considered at odds with harm reduction strategies. More recently, harm reduction has been categorized as both a pathway to recovery and a series of services to reduce the harmful consequences of substance use. Peer recovery support services (PRSS) are effective in improving SUD outcomes, as well as improving the engagement and effectiveness of harm reduction programs.

Methods

This study provides an initial evaluation of a hybrid recovery community organization providing PRSS as well as peer-based harm reduction services via a syringe exchange program. Administrative data collected during normal operations of the Missouri Network for Opiate Reform and Recovery were analyzed using Pearson chi-square tests and Monte Carlo chi-square tests.

Results

Intravenous substance-using participants (N = 417) had an average of 2.14 engagements (SD = 2.59) with the program. Over the evaluation period, a range of 5345–8995 sterile syringes were provided, with a range of 600–1530 used syringes collected. Participant housing status, criminal justice status, and previous health diagnosis were all significantly related to whether they had multiple engagements.

Conclusions

Results suggest that recovery community organizations are well situated and staffed to also provide harm reduction services, such as syringe exchange programs. Given the relationship between engagement and participant housing, criminal justice status, and previous health diagnosis, recommendations for service delivery include additional education and outreach for homeless, justice-involved, LatinX, and LGBTQ+ identifying individuals.

Commentary on "Gaps in the Substance Use Disorder Treatment Referral Process: Provider Perceptions"

: Blevins et al describe dysfunction in the referral process for substance use disorders. Their recommended solutions, however, are unlikely to address many of the underlying reasons for the dysfunction they describe.