The impacts of the opioid overdose epidemic are devastating communities nationwide. The Centers for Disease Control and Prevention estimated 100 306 overdose deaths, including 75 673 opiate overdose deaths, for the 12 months ending in April 2021.1 While overdose deaths continue to increase in the United States, opportunities to prevent and respond to the overdose epidemic also continue to grow. Local response efforts have led to enhanced cross-sector collaboration, particularly between public health and public safety. Public safety agencies hold real-time data on overdoses, arrests, and emerging drug threats and have frequent frontline contact with high-risk individuals, while public health agencies bring a scientific data-driven approach to responding to public health crises.
These collaborative interventions can be conceptualized using the Sequential Intercept Model (SIM) (Figure), a theoretical framework representing points in the criminal justice (CJ) continuum as opportunities to provide harm-reduction services and treatment of substance use disorders (SUDs)/opioid use disorders (OUDs).2 The SIM supports interventions by depicting intercepts, which are points in the CJ system where OUD treatment can be provided.2 Originally theorized to inform interventions for individuals with serious mental illness (SMI), the SIM has been expanded to involve individuals with SUD or OUD. Around 2017, “intercept 0” was introduced to the model.3 Intercept 0 reflects referral to treatment before an arrest could occur. This theory reframes the issues of SMI and OUD in the context of expanding the roles of health care and public health and challenges attitudes about substance use and criminality.
This article focuses on early intercept programs and interventions alongside intercepts 0 and 1, which often create the opportunity to link people at risk of overdose to care and serve as a deflection point. Deflection is defined as “the practice by which law enforcement or other first responders (ie, fire and EMS) connect individuals to community-based treatment and/or services when arrest would not have been necessary or permitted, or in lieu of taking no action when issues of addiction, mental health, and/or other need are present.”4 Crisis Intervention Team (CIT), Law Enforcement Assisted Diversion (LEAD), and Quick Response Teams (QRT) are just a few examples of the many local collaborative programs currently addressing the opioid overdose epidemic at these early stages.
First responder deflection (FRD) programs, unlike most previous law enforcement approaches, provide referral to treatment of individuals experiencing an overdose or using substances, facilitated by police officers or other first responders.7 As these programs have evolved, referrals can now be provided by community health entities or other individuals and are not limited to police departments.7 These interventions could be classified as reflective of intercept 0. They involve team overdose response and can include interdisciplinary collaborations with social work and health care professionals, public health departments, and hospitals.4
In the Report of the National Survey to Assess First Responder Deflection Programs in Response to the Opioid Crisis, a national survey of 329 FRD programs, it was found that nearly 60% of respondent organizations had law enforcement as leadership.4 Only one of 6 programs conducted formal evaluations to assess their impact on health outcomes.4 About 88% of all respondent organizations had implemented deflection interventions in states that chose to expand Medicaid.4
QRTs were initially created as an interdisciplinary team approach to critical incidents involving crisis interventions. This model uses a 4-person team to triage and engage with individuals in need of treatment.6 Peer Support Specialists, who have lived experience of SUD/OUD and are qualified first responders, and other health care professionals are members of the response team.
CIT is an example of an intercept 1 intervention. Intercept 1 describes interaction with law enforcement in which arrest can function as a pathway to treatment and services.7 In 1987, Joseph DeWayne Robinson, who had SMI and was African American, was shot and killed by a police officer; CIT was developed in response “to reduce officer and citizen injuries.”7 CIT has been a voluntary police education program since it was developed in Memphis, Tennessee, in 1988. With 40 hours of training provided by community mental health professionals, and a curriculum emphasizing de-escalation,8 CIT represents one of the oldest successful police interventions with a public health approach. It has been adapted to inform post–overdose response efforts, in which police officers reversing opiate overdose (with naloxone) can then connect that individual to treatment options.7 A central component of CIT is a mental health facility drop-off location with automatic acceptance.7
LEAD originated in Seattle, Washington, in 2011, and is now implemented in more than 50 cities. A successful example of an FRD program, LEAD has combined overdose education and naloxone training for police officers with community partners in collaboration to provide treatment.5 Multiple evaluations have shown improvements for participants referred to treatment through the LEAD program, in rates of rearrest, homelessness, and employment.9,10 LEAD's mission statement refers to “utilizing non-coercive and non-punitive public health based intensive case management.”5
Originally Law Enforcement Assisted Diversion, this intervention has recently added meaning to its acronym with Let Everyone Advance with Dignity.5 LEAD intends to evaluate its approach to include considerations of racialized inequities that are systemic. The court systems, law enforcement departments, and medical institutions still contain structural and systemic racism.11
Health Equity and Stigma Intersections
In the national survey report previously introduced, close to three-fourths of the individuals diverted to treatment by the respondent FRD programs have been White.4 In contrast, LEAD evaluations have shown demographic breakdowns in cities where the majority of participants are African American, with significant Native American participation.11,12 Among prison populations, African Americans are disproportionately represented, as are people with SUDs and those with SMI.2 Many individuals have a dual diagnosis, with both SMI and SUD/OUD. Intersectionality describes the combination of multiple identity factors, such as race and income class, that can compound discrimination or vulnerability to prejudicial treatment. When considering how best to deflect individuals to treatment and harm-reduction services, issues concerning health equity must be acknowledged, including the War on Drugs, which ramped up beginning in the 1980s, resulting in racialized profiling and mass incarceration of low-income African American and Latinx communities.13
Stigma surrounding substance use and mental illness intersects with implicit racial bias and can influence the outcomes of interactions with those on the front line. Stigma attaches negative, prejudicial connotations to a person's characteristics. It stems from the collective of social norms and language choices that can be degrading, especially for individuals with SUD/OUD. Stigma can also be racialized or associated with SMI. When associated with stereotypes and/or assumptions of criminality, stigma can manifest through discriminatory practices. Ultimately, stigma can lead individuals with SUD to avoid services and treatment. It can also contribute to violence committed by others against them.14
Cross-sector collaborations have expanded to better leverage public safety and public health data, identify opportunities for policy and programmatic improvements, and maximize impact in the near term. Acknowledging the intersection of equity and stigma allows for an informed approach to interventions jointly implemented by public health and public safety. Meaningful cross-sector collaborations are crucial to creating robust and equitable solutions, including those highlighted in the early SIM intercepts. However, interventions are not limited entirely to intercepts 0 and 1. The remaining intercepts describe additional opportunities to reach and engage people with SUD/OUD who are involved in the CJ system.
1. Centers for Disease Control and Prevention. Drug overdose deaths in the U.S. top 100,000 annually. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
. Published November 17, 2021. Accessed December 17, 2021.
2. Brinkley-Rubenstein L, Zaller N, Martino S, et al. Criminal justice continuum for opioid users at risk of overdose. Addict Behav. 2018;86:104–110.
3. Abreu D, Parker TW, Noether CD, Steadman HJ, Case B. Revising the paradigm for jail diversion for people with mental and substance use disorders: intercept 0. Behav Sci Law. 2017;35(5/6):380–395.
4. Ross J. Report of the National Survey to Assess First Responder Deflection Programs in Response to the Opioid Crisis. https://www.cossapresources.org/Content/Documents/Articles/CHJ-TASC_Nation_Survey_Report.pdf
. Published 2021. Accessed November 1, 2021.
5. LEAD Let Everyone Advance with Dignity. Community care and coordination, an alternative to traditional law enforcement. https://leadkingcounty.org/#data
. Published 2021. Accessed December 18, 2021.
7. Rogers MS, McNiel DE, Binder RL. Effectiveness of police crisis intervention training programs. J Am Acad Psychiatry Law. 2019;47(4):414–421.
8. Compton M, Bakeman R, Broussard B, et al. The Police-Based Crisis Intervention Team (CIT) model: II. Effects on level of force and resolution, referral, and arrest. Psychiatr Serv. 2014;65(4):523–529.
9. Clifasefi SL, Lonczak HS, Collins SE. LEAD Program Evaluation: The Impact of LEAD on Housing, Employment and Income/Benefits. Seattle, WA: Harm Reduction Research and Treatment Lab, University of Washington–Harborview Medical Center; 2016.
10. Collins SE, Lonczak HS, Clifasefi SL. LEAD Program Evaluation: Recidivism Report. Seattle, WA: Harm Reduction Research and Treatment Lab, University of Washington–Harborview Medical Center; 2015.
11. LEAD National Support Bureau. LEAD evaluations. https://www.leadbureau.org/evaluations
. Accessed December 18, 2021.
12. Hinton E, Henderson L, Reed C. An Unjust Burden: The Disparate Treatment of Black Americans in the Criminal Justice System. Brooklyn, NY: Vera Institute of Justice; 2018. https://www.vera.org/downloads/publications/for-the-record-unjust-burden-racial-disparities.pdf
. Accessed December 18, 2021.
13. Rosino ML, Hughey MW. The War on Drugs, racial meanings, and structural racism: a holistic and reproductive approach. Am J Econ Sociol. 2018;77:849–892.
14. National Academies of Sciences, Engineering, and Medicine. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press; 2020.