The scope of the opioid crisis is without precedent, in terms of lives lost and families and communities devastated. An average of 130 people in the United States die every day from an opioid overdose – a factor contributing to the now declining life expectancy of Americans.
Law enforcement agencies across the country have responded to the crisis with a multitude of ideas and initiatives. More broadly, the Department of Justice (DOJ) and other federal agencies recognize a need for a stronger national response that can distill from those local initiatives promising general practices, identify and promote new answers to national needs, and develop strategies to reduce opioids’ national impact.
A working group of law enforcement leaders and other experts, called by the National Institute of Justice (NIJ), DOJ’s research arm, has spotlighted effective practices and identified priority research needs as well as opioid-related challenges.
The expert group, convened by NIJ in concert with the RAND Corporation (RAND) and the Police Executive Research Forum (PERF), isolated 13 high-priority needs, most of which are not yet fully understood, requiring more research, according to RAND’s report of the expert group’s work. Four of those needs, however, were deemed ripe for immediate implementation:
- Use of medication-assisted and other treatment modes in institutional and community corrections.
- Same-day access to treatment with a medication-first model of care.
- The use of syndromic surveillance or “sentinel indicators” to spot or predict spikes in overdoses, the appearance of new opioids, or new drug crises.
- Mental health intervention for law enforcement officers affected by stress from responding to the opioid crisis.
New, effective agency partnerships and collaborations were also identified as vital to the national opioid response. Partnerships would include diversion programs, medication administration programs, and data sharing efforts, with multi-disciplinary dimensions, such as embedding social workers and mental health professionals in law enforcement organizations.
Fighting the crisis means, first, getting medication-related support to those in the grip of opioids, it was agreed. Notably, no fewer than seven of the 13 high-priority needs are related, one way or another, to medication-assisted treatment (MAT), the report said. MAT is the combination of one or more of medications used to treat opioid use disorder and behavioral interventions.
The opioid epidemic has evolved in three stages, with increasingly deadly effects. Fatalities from opioid prescriptions for chronic pain began to rise in 1999. Heroin-related deaths soared in 2010. The current crisis phase emerged in 2013, with the availability of highly lethal synthetic opioids, primarily fentanyl and its analogues, the RAND report said. Three characteristics of opioids make them devastating to individuals and communities: They induce feelings of euphoria, they deliver potent pain relief, and they can be lethal in miniscule amounts, even through unintended contact with skin or mucous membranes. In 2017, the Center for Disease Control and Prevention reported, opioids accounted for 47,600 overdose deaths in the United States, out of 70,236 total drug overdose deaths that year. The opioid crisis has been declared a national public health emergency.
Of all segments of society engaged with the opioids problem, law enforcement’s response is especially critical because of its vital role in keeping illicit drugs out of the country, driving up the price for actual and potential users, cracking down on suppliers, and reducing access to the purest, deadliest drugs, the working group noted.
Two existing initiatives of the Justice Department directly targeting opioid prescription and street commerce are:
- The Opioid Fraud and Abuse Detection Unit, a program using data analytics to aid federal prosecutors in cracking down on health care providers engaged in opioid-related health care fraud.
- Operation Synthetic Opioid Surge, a program to crack down on opioid trafficking in some of the hardest-hit districts, in terms of overdose rates.
Other DOJ agencies, the FBI and DEA, are fighting the opioid crisis on multiple fronts, with more personnel dedicated to the problem. DEA’s 360 Strategy for combating heroin and opioid use is a three-pronged approach focused on: (1) coordinated law enforcement efforts against cartels and traffickers; (2) diversion control actions against suppliers; and (3) community outreach helping to empower communities to take back neighborhoods.
The NIJ-supported workshop, held in September of 2018, convened four panels addressing separate critical aspects of the epidemic: (1) law enforcement leadership in combating addiction and overdose; (2) the importance of stakeholder partnerships; (3) keeping officers and analysts safe from opioid effects; and (4) the impact of forensic science on detection, interdiction, and surveillance
Law Enforcement Leadership on Opioids
A primary, often life-saving response to opioid overdose is direct administration of naloxone by officers and other first responders. The report noted that naloxone, often identified by the brand names Narcan and Evzio, can reverse the respiratory depression caused by prescription opioids or heroin, thus preventing fatal overdoses. More than 2,500 law enforcement agencies equip their officers with naloxone.
The broader MAT umbrella covers promising programs developed by law enforcement to connect users with programmed treatment. Two of the most prominent programs are:
- “Angel” programs, where law enforcement agencies working with volunteers serve as a direct entry point for opioid users into treatment programs, while diverting qualifying individuals away from the criminal justice system.
- Law Enforcement Assisted Diversion, or LEAD, a program giving officers discretion to divert individuals who warrant arrest for low-level crimes to treatment or social service programs. Though the individual is arrested, a case manager works with law enforcement and prosecutors to maintain a recovery plan.
Naloxone unquestionably is saving lives, and naloxone programs have been shown to strengthen community-law enforcement ties, the report said. The working group further found that law enforcement-led treatment programs such as Angel and LEAD have shown positive effects. But more study is needed on the efficacy of law enforcement serving as an entry point to treatment, the expert working group concluded. Moreover, “additional research is needed to understand the effects of these law enforcement-led initiatives among diverse populations, particularly over the long term,” the report said.
The Importance of Stakeholder Partnerships
The working group examined three leading types of opioid partnerships: (1) diversion programs, (2) naloxone programs, where law enforcement partners with state or local partners or nonprofits, and (3) data sharing efforts. The report noted that in many communities, stakeholders have found ways to share information to help surveil the influx of dangerous drugs, identify lethal batches entering circulation, target at-risk populations for service, and inform prompt responses to problems. Partnerships are essential to the sharing of information critical to solving the opioid crisis, the report said. “The best response to this crisis is to have available evidence drive strategy, as was seen during efforts to reduce violent crime,” it said. Some workshop attendees cautioned however, that information sharing can be limited by the Health Insurance Portability and Accountability Act, or HIPAA.
One challenge presented by the proliferation of opioid responses across the country is a general lack of reliable outcome data to differentiate best practices from others. One workshop participant stressed the importance of involving researchers before new programs are created, the report said. “Many programs have been implemented across the country in response to the opioid crisis, yet rigorous evaluations are difficult or impossible to carry out due to lack of planning for research and evaluation,” it said. More research is needed on opioid program models designed to yield reliable, evidence-based data.
Protecting the Guardians
A third focal point of the workshop was keeping officers safe from the opioid crisis. First responders often put themselves at risk by engaging in direct, physical contact with opioid users. For example, naloxone, an opioid antagonist, is commonly administered by injection to an overdosing user, with law enforcement, paramedics, or firefighters typically delivering the dose. The workshop participants addressed two significant officer safety and health concerns: (1) health risks from physical exposure to fentanyl, tiny amounts of which can be deadly, and (2) the mental health toll on officers and other responders of frequent interactions with overdosing drug users.
The report noted that studies have long shown that officers generally experience worse health outcomes than the general population. That occupational risk has ramped up with the advent of drugs containing fentanyl, “extremely powerful synthetic opioids with a high likelihood of causing overdose,” the report noted. The National Institute for Occupational Safety and Health has developed safe handling guidelines for responders facing possible physical fentanyl exposure. One workshop participant, Lieutenant James MacGillis of the Milwaukee Police Department, noted that development of standardized training, policies, equipment, and oversight practices are critical for the safe handling of opioids, yet are still lacking in some agencies. He stressed the need for consistent, evidence-based mitigation strategies during the opioid crisis.
The participants agreed that the scope of the problem of accidental officer exposure to opioids is unknown, pointing to a need for research as well as standardized case reporting. Participants also stressed that officer safety training is paramount. The report said that when officers do not properly understand their risk, it can unnecessarily inflate fears, stress, and anxiety and even lead to PTSD. Participants urged that agencies track incidents of PTSD or other mental health issues among officers responding to opioid-involved incidents.
Science and Response
Finally, the opioid working group emphasized the crucial role of forensic scientists in combating opioids. The chemical composition of new synthetic opioids is constantly evolving, and forensic laboratories are charged with quickly identifying new drugs to help surveillance and enforcement and to alert all stakeholders to new trends in opioid-linked deaths. One forensic science panelist, Barry Logan, Ph.D., of the Center for Forensic Science Research and Education, said that for forensic laboratories keeping up with new drug profiles is critical, as the rate of proliferation of new opioid types is resulting in weekly changes to laboratory testing scopes. Better information sharing is key to determining which drugs are currently in communities, and which permutations are causing significant damage necessitating a greater response, Logan said. Yet many labs face analytic backlogs due to inadequate funding and other resources, forensic experts agreed.
One identified high priority research need is the use of syndromic surveillance or sentinel indicators to recognize spikes in overdoses, new opioids, or emerging drug crises. Syndromic surveillance is a public health term of art referring to surveillance using health data in real time for the early detection of outbreaks. Sentinel indicators are not measures of discrete results but bellwethers indicating greater change in a complex system. In these aspects, the working group is calling for research into better early warning mechanisms for spotting shifts in or new aspects of the opioid epidemic.
Conclusion
A constant theme from the experts at the two-day NIJ event on responding to the opioid epidemic was the need for diverse partnerships and collaborations to attack the problem. “Indeed, many of the high-priority strategies can only be implemented through such collaboration,” the report urged. The convened law enforcement experts, government and community stakeholders, and public health professionals also agreed that defeating the opioid crisis will also require more research and programming to protect responding officers from physical and mental health risks of encountering the tragic effects of opioids on the streets every day.
About this Article
The research described in this article was funded by NIJ award 2013-MU-CX-K003, awarded to the RAND Corporation. This article is based on the grantee report Law Enforcement Efforts to Fight the Opioid Crisis: Convening Police Leaders, Multidisciplinary Partners, and Researchers to Identify Promising Practices and to Inform a Research Agenda (2019), Sean E. Goodison, Michael J.D. Vermeer, Jeremy D. Barnum, Dulani Woods, and Brian A. Jackson. The two-day NIJ event underlying the report was supported by RAND Corporation in partnership with the Police Executive Research Forum. The program is part of the Priority Criminal Justice Needs Initiative of NIJ in partnership with RAND, PERF, RTI International, and the University of Denver.