Systems Improvements
01
Initiate Addiction Treatment in Emergency Departments
Between 2005 and 2014, opioid-related emergency department (ED) visits nearly doubled.1
Despite data indicating that patients treated for a nonfatal overdose are at significantly higher risk of experiencing a fatal overdose in the future, only 20% of emergency physicians have completed the Drug Addiction Treatment Act (DATA 2000; or “X waiver”) training required by the Food and Drug Administration (FDA) to prescribe buprenorphine.2,3 Initiating buprenorphine before discharge or providing a prescription for the medication increases engagement in addiction treatment and significantly improves patient outcomes. Buprenorphine is an FDA-approved medication to treat opioid use disorder that diminishes the symptoms associated with opioid withdrawal, including cravings. It is often the best option for EDs because methadone can only be dispensed by Opioid Treatment Programs and naltrexone (Vivitrol) requires a 7 to 10 day detoxification period. Post overdose initiation of the medication has been proven to reduce fatalities among opioid overdose survivors.
Communities can encourage hospital systems and emergency departments to begin utilizing and initiating buprenorphine in the ED, while partnering with community-based buprenorphine providers for linkage to care.
The Research
- Results from a randomized clinical trial by researchers at Yale University showed that people receiving buprenorphine and a referral at an ED were twice as likely to be engaged in treatment one month later compared to people who only received a referral.4
- In a Massachusetts study, buprenorphine was associated with a reduction in all-cause and opioid-related mortality among opioid overdose survivors.5
- Emergency department-initiated buprenorphine was associated with increased engagement in treatment and reduced use of illicit opioids during the two months after initiation when treatment was continued through primary care.6
Program Spotlight
Emergency Department-Initiated Buprenorphine Treatment Model, Yale School of Medicine
Researchers at the Yale School of Medicine conducted a National Institute on Drug Abuse (NIDA)-funded randomized clinical trial to compare the efficacy of three interventions for patients suffering from opioid use disorder.
The trial involved 329 patients who were treated in the Emergency Department and assigned to one of three intervention groups: 1) screening and referral to treatment (referral group); 2) screening, brief intervention, and facilitated referral to treatment (intervention group); and 3) screening, brief intervention, Emergency Department-initiated buprenorphine/naloxone treatment, and referral to primary care for ongoing treatment (buprenorphine group). The study found that patients in the buprenorphine group remained in treatment significantly longer compared to the referral group and the brief intervention group.
02
Expand Addiction Training for Doctors, Nurses, Pharmacists
Medical education on addiction for practicing healthcare professionals as well as those in training about the identification and treatment of substance use disorders (SUDs) is critical to improving patient outcomes.
According to a 2016 Surgeon General report, only 8% of U.S. medical schools have a separate required course on addiction and only a handful of medical schools have a robust curriculum on the diagnosis and treatment of SUDs.7
Unless a medical school student has chosen to specialize in addiction treatment, providers typically enter the workforce unprepared and ill-equipped to address the needs of the increasing number of patients with SUD. As a result, practicing healthcare providers who were not required to take addiction treatment courses in medical school may avoid engaging with patients about substance use due to their own unfamiliarity with the disease, ultimately, denying access to a large portion of evidence-based treatment options that are only available in medical settings.
of U.S. medical schools have a separate required course on addiction
It is essential that every medical, nursing, pharmacy, and dental school in the nation is trained to identify and treat SUDs and screenings as part of routine medical education. Introducing the evidence-based approaches, such as Screening, Brief Intervention and Referral to Treatment (SBIRT) and medications for opioid use disorder (MOUD), during residency programs will help to embed awareness, literacy, and competency concerning SUDs in the expectations set for general practitioners and will ensure earlier and more comprehensive patient identification. In addition to professional education and screenings, more has to be done to decrease the stigma surrounding addiction and to improve confidentiality assurance in the doctor-patient relationship so that patients feel comfortable being honest with their providers about their struggles with substance use.
The Research
- A study where researchers developed, implemented, and evaluated opioid overdose prevention and naloxone training for first-year medical school students (N=73) found that the students’ opioid overdose knowledge increased by 8 points and preparedness to respond increased by 15.09 points between the pre-and post-test evaluations.8
- A 2007 study surveyed first-year medical students before and after 3 weeks of a SUD education and fourth-year students following a 9-week curriculum. Results show there was a significant improvement in student attitudes toward SUD patients following the training, especially among the fourth-year students. Overall, negative attitudes and anticipated discomfort in dealing with patients decreased by half following the education, and attitudes toward patients particularly improved in the fourth year where there was more contact with patients.9
- A 2018 study of 67 dental hygiene students that participated in a SBIRT educational intervention found that there were significant improvements in their attitudes and acceptance of utilizing SBIRT delivery following the training, as well as, willingness to expand their roles in screening patients for SUDs.10
Program Spotlight
Yale School of Medicine Comprehensive Curriculum for Medical Students
In response to the growing need to improve addiction education in medical schools, the Yale School of Medicine developed, implemented, and evaluated a comprehensive addiction curriculum to better prepare students in responding and treating SUDs. The curriculum was designed as a supplemental course as part of the required 6-week psychiatry clerkship rotation and 3-week rotation at the ER and includes additional didactic and clinical learning components related to substance use.
The clinical component of the curriculum focused on gradually increasing students' exposure to patients and autonomy to conduct clinical interviews and develop treatment plans. Students were also able to apply what they had learned in the didactic lectures. Results from the program evaluation found that supplemental addiction curriculum had a positive impact on medical students’ attitudes, confidence, and knowledge.11 Students that participated in the program were more likely to endorse addiction as a chronic disease and reported feeling more confident in treating individuals with SUD.12
03
Implement Co-Responder and Community Responder Initiatives
Our nation’s first responders, such as law enforcement, emergency medical technicians (EMTs), and firefighters, serve daily on the front lines of the addiction crisis, encountering first-hand the effects substance use can have on our communities.
With approximately 20% of all police calls involving people with SUD and/or mental illness, first responders are well-positioned to play a critical role in connecting individuals to treatment and health care services.13
Many jurisdictions are implementing co-responder teams or community responder programs to help reduce harm, facilitate alternatives to arrest, and facilitate warm handoffs to community-based treatment and services for people who have experienced an overdose or who have a SUD. Community responder teams include health care professionals and community members trained in crisis response, whereas co-responder teams also include law enforcement and other first responders. These teams can include social workers, behavioral health, peer support specialists, community health workers, nurses, or other trained personnel.
The Research
- Research shows that co-responder models decrease arrests and hospitalizations; increase connection to SUD treatment and resources; reduce costs and the demand on the justice system; and reduce feelings of threat and stigma among individuals who interact with co-response teams compared to law enforcement alone.14-16
- In 2018, 65% of co-response calls to the Arlington Police Department in Massachusetts resulted in de-escalation, 10% in voluntary emergency room visits, and 25% in involuntary evaluation.17
- Between July 2020 and July 2021, co-responder teams in Colorado fielded over 25,900 calls. Of which, 98% avoided arrest and 86% involved co-responders providing health assessments and referrals to community resources.18
Program Spotlight
CAHOOTS (Crisis Assistance Helping Out On The Streets), Eugene, Oregon
CAHOOTS (Crisis Assistance Helping Out On The Streets) is a 24/7 mobile crisis intervention program that provides free, confidential services in the Eugene and Springfield area. The CAHOOTS program was established through a partnership between the White Bird Clinic, a local community health and response provider, and local law enforcement as a crisis intervention unit to respond to dispatch calls that involve substance use, mental illness, emotional crises, and family disputes that pose a small risk of violence.
What started as a grassroots effort soon expanded to provide comprehensive substance use, mental health, harm reduction, and public health services, as well as a dental clinic and a mobile crisis intervention program. Each CAHOOTS team consists of two trained personnel: a medic (nurse or EMT) and an experienced crisis intervention worker. The team is trained and experienced in handling non-violent resolution of crisis situations, immediate stabilization for urgent medical or psychological crises, and non-emergency medical care. They also can offer assessments, resource information, referrals, advocacy, and transportation to treatment. Since 2019, only 2% of CAHOOTS only calls have required backup from law enforcement.20
04
Implement Diversion Programs across the Criminal Justice Systems
The justice system can play a critical role in identifying individuals who are struggling with SUD and facilitating access to treatment and other support services that improve health and societal outcomes and reduce recidivism and the toll on the justice system.
Yet, people with SUD who come in contact with the justice system face significant barriers in accessing evidence-based treatment and healthcare services which can lead to job loss, unemployment, rearrest, (re)incarceration, homelessness, overdose, and death. These consequences can also result in avoidable financial burdens on the government.22
Diversion programs create alternative pathways for people with SUD by linking them to treatment instead of formal criminal proceedings.
In 2019, more than 1.5 million people were arrested for drug-related offenses, 87% of which were for drug possession, which was more than any other crime category; one in 13 people who are arrested have a SUD.23 The current scope of the opioid epidemic and escalation of people struggling with addiction makes it imperative that the justice system reevaluate their response to SUDs.
Diversion programs are an evidence-based approach that creates alternative pathways for people with SUD who are at risk of arrest or (re)incarceration by linking them to treatment and support services instead of formal criminal proceedings. These programs offer an opportunity to reduce the demand on the justice system, prioritize treatment, increase access to care, and provide a cost-effective way to support people with SUDs before and after becoming involved with the justice system.
New investments and resources must focus on early points of intervention and linkages to care across the entire justice system. By aligning systemic practices to intervene early and direct individuals with an SUD to community-based treatment and resources, the justice system can help prevent them from entering or perpetuating further into the justice system.
Many jurisdictions use the Sequential Intercept Model (SIM), an effective strategic planning tool, to help identify opportunities to intervene and link individuals to services across the justice continuum. The model identifies six interception points that serve as critical opportunities for programs to be implemented to divert people with SUD from the justice system.
Intercept 0
Community Services
Involves linking people to treatment and resources prior to contact with the justice system. Pathways include: self-referrals; crisis hotlines; mobile crisis outreach teams and co-responders; emergency departments triage services; and police and first-responder-friendly crisis services.
Intercept 1
Law Enforcement
Involves officers exercising discretion to redirect people engaged in low-level offenses to services and resources instead of formal arrest/citation and processing. This is also called pre-arrest/pre-booking deflection or diversion.
Intercept 2
Initial Court Hearings/Initial Detention
Initial Court Hearings/Initial Detention – Involves strategies led by prosecutors, defense attorneys, judges, jail clinicians, or social workers to connect people to services in lieu of prosecutor or detention. This can take place at several points during post-arrest, including intake, booking, initial hearings, plea bargaining, and probation before judgment.
Intercept 3
Jails/Courts
Involves court and jail-based diversion programs that divert people to services detention while awaiting their case decision. This is also called pretrial diversion and includes court-based (e.g., mental health or treatment courts), prosecutor-led, and jail-based programming.
Intercept 4
Reentry
Involves providing planning, support, linkages to services to people leaving jail or prison, including seamless access to treatment, housing, health care coverage, and community services.
Intercept 5
Community Corrections
Involves providing support and connection to services to people who are under community-based justice supervision, such as probation and parole.
The Research
- An evaluation of Seattle’s Law Enforcement Assisted Diversion (LEAD) program, a police-led diversion program designed to connect people with SUDs and/or mental health disorders with treatment and social services, found that individuals who participated in the program had 60% lower odds of arrest after six months and 58% lower odds after two years.24 The study also found that LEAD participants had 39% lower odds of being charged with a felony over two years.
- A 2018 multisite study was conducted to determine the impact and cost evaluation of 11 prosecutor-led diversion programs in the United States. Results found that all five programs participating in impact evaluations reported significant reductions in conviction rates and jail sentencing; and four of the five programs reported reductions in re-arrests amongst program participants after two years.25 The study also found that all four of the programs that participated in cost evaluation produced significant cost and resource savings.
- A meta-analysis of 19 different studies of treatment court outcomes found that these programs reduced incidence of incarceration from a base rate of 50% to 42% for jail, 38% for prison, and 32% for overall incarceration.26
Program Spotlights
Community Services and First-responder Diversion
Law Enforcement Assisted Diversion (LEAD)
Law Enforcement Assisted Diversion (LEAD) is a police-led diversion program designed to connect people with SUDs and/or mental health needs with social services rather than funnel them into the criminal justice system. LEAD allows law enforcement officers to redirect people suspected of low-level crimes, including drug-related offenses, to community-based services that attempt to address the underlying factors that drive criminal justice contact. Once enrolled, participants work with a case manager to identify their individual needs and get connected to appropriate supports, including housing, food, and employment support. LEAD was first launched in Seattle, Washington, in 2011, and has since expanded to over 20 states. A 2017 evaluation of the program found that LEAD participants are 58% less likely to be arrested compared to a control group.
Law Enforcement-led Diversion
STEER Program, Montgomery County, MD
The Stop, Triage, Engage, Educate and Rehabilitate (STEER) Program in Montgomery County, Maryland, is a pre-booking law enforcement and SUD treatment linkage program that aims to provide rapid identification, deflection, and access to treatment for drug-involved individuals as an alternative to conventional arrest. Individuals are assigned a care-coordinator who focuses on rapid treatment access, retention, motivation, engagement and completion, as well as conducts a full clinical assessment and referral. As of November 2016, STEER had diverted 133 individuals and has now become part of standard police protocol options for responding to people with SUDs. Of the 157 people referred to STEER, as of February 2017, 66 (42%) were assessed and 37 of those assessed (56%) agreed to participate in treatment.24
Prosecutor-led Diversion
District Attorney’s Drug Diversion Program, Essex County, MA
The Essex County District Attorney’s Drug Diversion Program is a program for young adult, non-violent offenders with substance use-related problems. This program seeks to reduce substance use and improve public safety by offering treatment rather than by prosecuting people charged with low-level drug-related offenses. Individuals are assigned a Case Manager who then helps them enroll for MassHealth, identify a primary care physician, and access job placement services and other services that could encourage stability and recovery. If the participant complies for at least six months, the DA’s office will either decline to prosecute or dismiss the charges. The program was launched in 2007 by Essex County District Attorney Jonathan Blodgett with assistance from former Massachusetts State Senator Steven Tolman, in response to a spike in heroin and prescription drug use. Program administrators report that about 60% of participants successfully complete the program, meaning that they finish their treatment program and remain drug-free so that the charges against them are dismissed.
Court-based Diversion
Opioid Crisis Intervention Court, Buffalo, NY
Unlike traditional drug courts, the Opioid Intervention Court in Buffalo, New York, has changed the traditional trajectory of criminal cases by putting treatment ahead of prosecution. The model is designed to connect non-violent individuals to treatment within hours of arrest instead of weeks and focuses on immediate initiation of medications for addiction treatment (MAT). Everyone arrested in Buffalo is screened for opioid use, and those who are struggling with SUD are directed to a treatment program, with their criminal cases put on hold. Treatment options depend on the level of care needed, but include inpatient or outpatient under daily supervision. Participants are required to meet with the judge one-on-one for up to 90 days and undergo random drug testing. The judge will only resume, or dismiss, cases after treatment is complete. An evaluation of the program found that participants that received MAT were 3-times more likely to complete the program and 4-times more likely to complete the program if they received MAT within the first 7 days compared to those who did not receive MAT.27
Community Corrections Diversion
TASC Specialized Case Management, Illinois
In Illinois, TASC, Inc.’s Specialized Case Management model facilitates linkages to treatment in the community and is an effective and cost-efficient alternative to incarceration for people charged with non-violent felony offenses who have substance use or mental health disorders. It was first applied as an alternative to incarceration for courts, and now is also applied to community reentry, juvenile justice services, probation, parole, family recovery and reunification services, and more. The program not only connects people to the services they need, but it also serves as a bridge between the referring system and treatment in the community. TASC conducts clinical assessments, places individuals in the right types and levels of services in the community, and provides ongoing case management to ensure accountability and client success. The core components of the TASC Specialized Case Management include: identification, screening, and assessment; service planning; service referrals and placement; education and advocacy; and ongoing monitoring, reporting, and service plan adjustments. The program has shown to produce 62% greater completion rates for addiction treatment among TASC’s justice-referred clients, compared to other individuals referred to treatment by Illinois’ justice and corrections systems. In addition, there has been to be a 71% reduction in arrests for drug and property crimes two years after program enrollment, among TASC’s court- and probation-referred clients.
05
Medications for Opioid Use Disorder for Individuals in Prison and Jail
The growing rates of substance use and overdose deaths, especially related to opioids, have significantly impacted the U.S. justice system.
Almost half of all individuals under correctional supervision meet the criteria of a SUD, with 17% reporting regular opioid use.28,29 Yet, less than 1% of individuals with SUDs receive treatment while under justice supervision, and only 5% are referred to treatment during reentry.29,30
As a result, many justice-involved individuals with SUDs remain untreated and reenter society without proper care or support services, creating risk factors for increased recidivism rates, continued substance use, and overdose death.31,32 The justice system can play an integral role in facilitating access to SUD treatment and other support services that can improve health, reduce justice system costs, and prevent recidivism.
60-70%
reduction in all causes of death when individuals receive MOUD during incarceration
The Research
- Research shows that initiating medications for opioid use disorder (MOUD) prior to release and continuation during reentry cuts the risk of overdose death by 75%.33
- A national study in England of over 12,000 justice-involved individuals with opioid use disorder (OUD) found that initiating buprenorphine and methadone programs prior to release and continuing treatment during reentry reduced all-causes of death by 75% and 85% for overdose deaths in the first month of reentry.34
- An Australian study of over 16,700 individuals with OUD found an overall 74% reduction in all-causes of death within prisons, primarily suicide, among those that participated in the buprenorphine and methadone program, and a 94% reduction within the first four weeks.35
- In the U.S., Rhode Island was the first state to offer all three MOUDs in prisons. After the first year of the program, there was a 60% reduction in overdose deaths among justice-involved individuals leaving custody.36
Program Spotlight
Pennsylvania Department of Corrections MAT Program
In March 2016, the PA DOC hired a full-time statewide coordinator who provides training and technical assistance to site coordinators (MAT Program Specialists) and liaises with the department, Bureau of Community Corrections, Probation and Parole, Single County Authorities, licensed treatment providers and other service providers. In January 2018, Governor Tom Wolf declared the opioid crisis in Pennsylvania a disaster emergency and directed that all FDA-approved treatment medications be provided within state prisons. By April 2018, naltrexone was offered in all SCIs and allowed up to three injections prior to release. A year later, the PA DOC started offering MOUD continuation for individuals who were on a verified prescription prior to admission to an SCI.
06
Expand Reentry Services for Individuals with Substance Use Disorders
People returning to the community face barriers to health care and social determinants of health such as employment and housing.37
Prior studies estimate that the risk of overdose death during reentry is 13-40 times higher compared to the general public, and 120 times higher during the first two weeks of release.38,39 As a result, many justice-involved individuals with SUD remain untreated and reenter society without proper care or support services, which is a risk factor for increased recidivism rates, continued substance use, and overdose death.37,40
Key recommendations for practitioners to improve reentry for individuals with SUDs include: screening and assessments, withdrawal management, evidence-based treatment (medication for addiction treatment and behavioral interventions), and proper release planning, which includes establishing linkages to community-based services, an individualized relapse prevention plan, and planning for critical basic services and naloxone upon release.
The Research
- A recent study found individuals who receive medications for OUD prior to release were 32% less likely to recidivate during the first year after release compared to those that did not participate in the program.49
- Research on peer navigators within reentry programs has shown promising results in reducing recidivism, increasing treatment engagement, and increasing utilization of community-based health and social services such as housing, employment, and support groups.21,37
- A 2019 study on the San Francisco County Jail’s overdose education and free naloxone distribution program, found that of the individuals that participated in the program, 34% reported reversing an overdose and 44% received naloxone refills after reentry.47
Program Spotlight
Kenton County Detention Center SAP (Substance Abuse Program), Kentucky
In response, Kenton County Detention Center implemented a Comprehensive Opioid Response with 12 Steps Jail Substance Abuse Program (COR-12 JSAP) that provides treatment for clients struggling with SUDs and facilitates their transition into community-based care up to and including intensive outpatient programming (IOP). The program aims to expand and improve SUD treatment pre- and post-release, decrease drug overdose morbidity and mortality, and reduce recidivism related to substance use and relapse. Kenton County employs a multi-faceted biopsychosocial approach to treatment combining medication, cognitive and behavioral therapies, therapeutic community living environments, and referral to community-based providers upon release.
