This line of effort speaks directly to the front lines of the epidemic. It is designed to empower and focus law enforcement and justice policies and efforts related to users, dealers, and those who have been incarcerated. We also offer examples of successful programs for medical first responders and law enforcement to help transition users into treatment at every opportunity.
Increasingly, first responders recognize that “to protect and serve” and “to do no harm” requires a step beyond arrest or immediate medical attention. Whether in the aftermath of an opioid overdose reversal or while transitioning in and out of incarceration, those battling addiction must be presented with the opportunity for treatment so they can begin their road to recovery. The most common phrase you will hear from law enforcement leadership across the country is, “We recognize we cannot arrest our way out of this problem.”
We must provide our first responders and criminal justice system with the tools, resources, and support to ensure those fighting substance use disorder receive treatment and those profiting from their addiction and tragic deaths face harsh justice.
Expand the Access to Naloxone for Law Enforcement and First Responders
Drug overdoses are now the number one cause of death for Americans under the age of 50. Beat cops, sheriff’s deputies, and state highway patrol officers are often the first on the scene of an emergency response. Communities should work to dispel misconceptions that prevent access to the opioid-overdose-reversing drug naloxone for law enforcement and the broader community. There remains some reluctance among law enforcement and even some emergency medical response departments to carry and administer naloxone; some perceive it as medical care outside of their responsibility. Some fear being sued for giving a prescription drug without the victim’s consent. Others incorrectly believe that naloxone offers a “quick fix” and enables users, leading to more risky behavior. These are unfortunate misconceptions that communities should work together to address. A rapidly growing number of law enforcement agencies are allowing and even requiring officers to carry naloxone, most commonly sold as Narcan. There are no known side effects of naloxone, and with the easy-to-administer auto-injectors and nasal sprays available, there is really no reason that all first responders should not have ready access to the lifesaving drug. Naloxone can save the life of someone experiencing an opioid overdose, regardless of whether those opioids were prescribed or illicit. The idea that naloxone makes illicit drug users more willing to take higher doses or experiment with fentanyl is roundly rejected by former users. There are a number of programs that departments can utilize to obtain naloxone for free or at discounted rates. The Bureau of Justice Assistance created the Law Enforcement Naloxone Toolkitas a clearinghouse of resources to support law enforcement agencies in establishing a naloxone program.
- “Naloxone Toolkit Content.” Bureau of Justice Assistance. Accessed November 2018.
Train First Responders to De-escalate with Crisis Intervention Teams (CIT)
The lack of mental health crisis services across the U.S. has resulted in law enforcement officers serving as first responders to most crises. Training first responders in how to de-escalate and compassionately respond to citizens experiencing a mental health crisis is critical to ensuring the safety and health of not only that individual but of our communities as a whole.
A Crisis Intervention Team (CIT) program is an innovative, community-based approach to improving the outcomes of these encounters. In more than 2,700 communities nationwide, CIT programs create connections between law enforcement, mental health providers, hospital emergency services, and individuals with mental illness and their families. Through collaborative community partnerships and intensive training, CIT improves communication, identifies mental health resources for those in crisis, and ensures officer and community safety. CIT programs do not just bring community leaders together; they also help keep people with mental illness out of jail and in treatment, on the road to recovery. Diversion programs like CIT reduce arrests of people with mental illness while simultaneously increasing the likelihood that individuals will receive mental health services. The National Alliance on Mental Illness (NAMI) promotes the expansion of CIT programs nationwide by providing NAMI Affiliates and State Organizations, local law enforcement, mental health providers, and other community leaders with information and support on CIT implementation. NAMI also works with local and national leaders to establish standards and promote innovation in CIT.
- “Crisis Intervention Teams may prevent arrests of people with mental illnesses.” Taylor & Francis Online.Accessed November 2018.
- “Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study.” National Center for Biotechnology Information. Accessed November 2018.
- “Crisis Intervention Team (CIT) Programs.” National Alliance on Mental Illness. Accessed November 2018.
Find Common Ground Between Law Enforcement and Harm-Reduction Programs
In many communities, law enforcement and harm reduction seem to be polar opposites. Law enforcement personnel are perceived as thinking only about arresting and jailing people for the illegal possession of drugs, while harm reduction organizations are perceived as focused on the complete legalization of all drugs. While each group certainly applies a different approach, both of these perceptions are false. Ensuring that law enforcement and harm-reduction organizations (nonprofit groups that advocate for public access to naloxone, Good Samaritan laws protecting users from arrest if they call 911 to save a friend, needle exchanges, and in some cases safe- use zones) in your community are coordinating and collaborating is absolutely essential in the fight to end the opioid fatality epidemic. Harm-reduction coalitions have been essential in convincing law enforcement agencies to enact pre-arrest diversion programs. These programs provide low-level users the opportunity to seek treatment in lieu of facing charges or arrest. Law enforcement also must be at the table when harm-reduction organizations are planning new initiatives or programs. The Law Enforcement Action Partnership has compiled harm-reduction strategies supported by law enforcement professionals; its list is a great way to start the conversation between these two communities, both focused on saving lives.
- “Harm Reduction.” Law Enforcement Action Partnership. Accessed November 2018.
Implement Pre-arrest Diversion Programs
Law enforcement personnel must be a part of any community response to the opioid crisis. They work every day to try to get drugs and drug users off of the streets. Law enforcement leaders throughout the country have recognized they cannot arrest their way out of this problem, but they still have a critical role to play. We have learned that if a program is in place to get users into treatment instead of jail, law enforcement will embrace and use it. There are a wide variety of ways in which law enforcement can divert users away from the criminal justice system, from Good Samaritan laws to carrying naloxone to following up with overdose victims to directly coordinating with providers to get users into treatment. S.A.F.E. has determined that pre-arrest diversion (PAD) programs are one of the most impactful and lifesaving initiatives law enforcement can implement. To facilitate the rapid national expansion of PAD programs, S.A.F.E. is working with dozens of partners to develop the first Law Enforcement Pre-Arrest Diversion Resource Guide. This guide outlines and endorses the use of law enforcement PAD programs such as the Police Assisted Addiction and Recovery Initiative, Law Enforcement Assisted Diversion, Quick Reaction Teams, and Civil Citation Network among innovative programs being developed across the country. Pre-arrest diversion programs are meant to move those struggling with substance use into treatment and recovery services instead of the criminal justice system. S.A.F.E. is developing a companion toolkit to this playbook, which will provide law enforcement agencies an overview of the pre-arrest diversion programs being implemented, points of contact for those agencies, and an overview of the funding mechanisms and partnerships agencies have used to get their programs up and running. S.A.F.E. has made significant contacts with cities and counties that have implemented many types of these programs and will connect agencies with peers who have successful programs in place.
- The Police Assisted Addiction and Recovery Initiative. Accessed November 2018.
- LEAD National Support Bureau. Accessed November 2018.
- “FRHE: Requests for Proposals.” Interact for Change. Accessed November 2018.
- Civil Citation Network. Accessed November 2018.
Adopt a Sequential Intercept Model Approach to Criminal Justice and Behavioral Health in Your Community
Communities should ensure that law enforcement and criminal justice agencies are providing opportunities to those battling substance use and mental health issues to receive treatment and avoid the negative consequences of incarceration and criminal justice involvement. The Sequential Intercept Model provides an evidence-based framework for ensuring that citizens with mental health conditions, including substance use disorder, are afforded treatment alternatives at every opportunity available. Before entering and throughout involvement (or “zero intercept”) in the criminal justice system, there are numerous intercept points — opportunities for linkage to services and for prevention of further penetration into the criminal justice system. The Sequential Intercept Model has been used as a focal point for states and communities to assess available resources, determine gaps in services, and plan for community change. These activities are best accomplished by a team of stakeholders that cross over multiple systems, including mental health, substance use, law enforcement, pre-trial services, courts, jails, community corrections, housing, health, social services, peers, family members, and many others. This summary from the Substance Abuse and Mental Health Services Administration is a first step to understanding and implementing the framework in communities.
- “Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness.” Psychiatric Services. Accessed November 2016.
- “Developing a Comprehensive for Behavioral Criminal Collaboration: Sequential Model.” Substance Abuse and Mental Health Services Administration. Accessed November 2018.
Warm Handoff from Overdose into Medication-Assisted Treatment
Naloxone immediately saves lives by expelling opioid molecules from the receptors in our brains, causing a near immediate reversal of the primary cause of an opioid overdose. However, there is no miracle drug that clears the body of the urges, the underlying substance use disorder, that typically led the patient to take a dangerous dose of opioids. But there is evidence-based treatment that incorporates behavioral therapy with medication that works very well and should be the next step after administering naloxone — Medication-Assisted Treatment (MAT). Typically, after receiving a lifesaving dose of naloxone, patients are released with only information and numbers to call if they’re ready to start their recovery. Sometimes they are even introduced to a peer support specialist, a former user who encourages the patient to seek long- term treatment. Too infrequently, physicians also prescribe one of a handful of medications known as MAT. This is commonly referred to as a “warm handoff,” directly transferring overdose survivors from the hospital emergency department to MAT. There is growing evidence that these drugs can immediately reduce some of the symptoms of opioid withdrawal and the urges that usually lead active users to immediately search out more opioids to combat withdrawal.
- “MAT Overview.” Substance Abuse and Mental Health Services Administration. Accessed November 2018.
- “Warm Handoff Program Aims to Get Overdose Survivors Directly Into Treatment.” Partnership for Drug-Free Kids. Accessed November 2018.
- “Methadone and buprenorphine reduce risk of death after opioid overdose.” National Institutes of Health. Accessed November 2018.
Reduce the Number of People with Mental Illness in Jails
Approximately two million times each year, people who have serious mental illnesses are admitted to jails across the nation. Almost three-quarters of these adults also have drug and alcohol use problems. Once incarcerated, individuals with mental illnesses tend to stay in jail longer and upon release are at a higher risk of returning to incarceration than those without these illnesses. The human toll of this problem — and its cost to taxpayers — is staggering. Jails spend two to three times more money on adults with mental illnesses who require intervention than on those without such needs, yet they often do not see improvements to public safety or to these individuals’ health. Although counties have made tremendous efforts to address this problem, they are often thwarted by significant obstacles, including operating with minimal resources and needing better coordination between criminal justice, mental health, substance use treatment, and other agencies. Without change, large numbers of people with mental illnesses will continue to cycle through the criminal justice system, often resulting in tragic outcomes for these individuals and their families, missed opportunities for connections to treatment, inefficient use of funding, and a failure to improve public safety.
The Stepping Up Resources Toolkit provides a list of six key questions county leaders need to ask to evaluate their efforts and lead change to reduce the number of people with mental illnesses in local jails. Reducing the Number of People with Mental Illnesses in Jail: Six Questions County Leaders Need to Ask serves as a blueprint for counties to assess their efforts to reduce the number of people with mental illnesses in jail by considering specific questions and progress-tracking measures.
- “Resources Toolkit.” The Stepping Up Initiative. Accessed November 2018.
- “Reducing the Number of People with Mental Illnesses in Jail.” The Stepping Up Initiative. Accessed November 2018.
Create a Drug Court Docket
Drug Court is a docket in a county or district court that allows those charged with non-violent drug crimes to participate in a court-run recovery program in conjunction with treatment providers and peer mentors. Ultimately, if participants remain clean, successfully complete their treatment program, and adhere to the rules of the court, their charges will be dropped. The first Drug Court was created in the 1980s during the scourge of cocaine use in Miami, Florida. Since then, more than 3,000 specialty court programs have been adopted across the country. These programs allow for low-level offenders to be spared the curse of a criminal record and/ or incarceration, which we know does not deter future drug use. Drug Courts offer hope and a
community-led path to treatment. The National Association of Drug Court Professionals provides resources and training for communities interested in establishing a drug or specialty court.
- National Association of Drug Court Professionals. Accessed November 2018.
Increase MAT in County Jail and State/Federal Prison
Medication-Assisted Treatment (MAT) is the only evidence-based medical treatment for opioid addiction. Sixty-five percent of all incarcerated individuals are indicated to have substance use disorder. The most dangerous period of time for inmates suffering from substance use disorder, especially when untreated, is the first two weeks upon release — drug overdose is the leading cause of death post-incarceration. The structure and purpose of incarceration offer a productive setting for addressing this serious medical condition. Roughly 400,000 inmates nationwide might benefit from treatment of opioid use disorder while incarcerated; 20 percent of the nation’s 2.3 million inmates are incarcerated on drug offenses, and estimates of regular opioid use or addiction among inmates range from 17 percent a decade ago to 25 percent now. Starting MAT while incarcerated and continuing after release is a key policy change that will save lives. However, a strong stigma against prescribing MAT to incarcerated individuals persists, leading to unnecessary deaths from this untreated medical condition while inmates are under the care of the federal, state, or county government. Communities looking to impact their opioid overdose rate can have an outsize influence by focusing on expanding treatment, especially MAT, in jail settings. Some states offer inmates Vivitrol, an opioid blocker. But because methadone and suboxone are also opioids, corrections officials usually ban them as contraband, concerned that inmates might divert to other inmates. Changing this paradigm and linking inmates to community recovery supports will lessen stigma and increase opportunities to save lives in the crucial transition out of incarceration. One study in Washington state showed that inmates diagnosed with substance use disorder were 129 times more likely to overdose in their first two weeks after release than the general population was. In this study, the administration of MAT decreased the chance of death by 75 percent. The Kentucky Department of Corrections has successfully implemented a program, “Substance Abuse Medication Assisted Treatment,” to provide MAT in jail settings. Rhode Island is another successful model for this program.