By Mallory O’Brien, Assistant Professor, Medical College of Wisconsin
In Milwaukee, we’ve taken a two-pronged approach to the opioid crisis: building comprehensive datasets and conducting event reviews of opioid fatality cases. Our responses take a collaborative, all-stakeholder approach that parallels the cross-cutting and complex nature of the opioid epidemic. None of the entities involved in response — law enforcement, public health, the courts, behavioral health, treatment providers, corrections, and others — can do it alone.
The Power of Data
The work we’ve done on the opioid crisis in Milwaukee is all based on data. As this crisis has emerged over the past years, we realized that we couldn’t understand the true scope of the problem because we lacked a centralized platform to capture data across agencies and departments. We were only seeing the crisis through the narrow lens of law enforcement data, medical data, drug court data, or EMS data alone. These data silos seriously restricted our ability to understand the crisis or consider a multiagency response.
We now link datasets and data sources, to the extent possible, to give a more holistic view of the crisis. Combining datasets can be helpful both in examining population-level data and looking at specific cases to identify when a person suffering from addiction came into contact with law enforcement, EMS, hospitals, behavioral health, and others. Examining both population and specific-case data can help us better understand the nature of the problem and how we can better prevent and intervene.
The biggest issues we face in compiling these datasets are HIPAA restrictions and other legal confidentiality concerns. We have been able to do this in Milwaukee by de-identifying health data. Under Wisconsin privacy and information-sharing laws, it’s fairly straightforward to link datasets that fall under a criminal justice umbrella — such as law enforcement, corrections, prosecution, and drug court data — but it can be tricky to bring in health information. Although criminal justice data is helpful, one of the clearest lessons of this crisis is that a purely criminal justice response is not effective — it has to be in partnership with public health.
We faced similar information-sharing issues while working on a project to reduce jail bed days and provide better services for our large population of mentally ill prisoners. In that instance, we were able to have prisoners sign release forms to allow data sharing between behavioral health and law enforcement. We are discussing a similar release form for individuals suffering from addiction, which will allow us to share and compile their criminal justice and health data.
Data-sharing challenges will vary across jurisdictions and depend, in large part, on local policies. In Milwaukee, waivers have been a helpful work-around, but we are also looking at statewide legislation that would facilitate cross-agency information sharing.
All-Stakeholder Reviews for System Improvement
We conduct all-stakeholder, non-blaming reviews of overdose fatality cases to identify system weaknesses that might have contributed to a fatality. We then consider how we might create partnerships, change policies, or otherwise adjust to prevent similar outcomes. In these reviews, we convene representatives from every system point of contact an individual suffering from addiction had prior to death. In the cases we’ve reviewed so far, this has included law enforcement, public health, the medical examiner, behavioral health, EMS, and individuals who can speak to addiction from personal experience, such as family members of an individual who struggles with addiction.
These reviews are an invaluable tool because they bring together diverse stakeholders in a single room to examine real cases. Population-level data is important and can tell us there is a problem — e.g., Milwaukee County had 397 overdose deaths in 2017, up from 343 in 2016 — but it fails to give us specific insight into how we can take relevant steps to fix it. It’s in the detailed review of individual cases that each agency can understand the work of other entities and how their work fits into the greater response. The reviews take a holistic, multiagency view of a fatality case and put forward concrete recommendations to strengthen the system and prevent its recurrence.
In Milwaukee, we had already seen the value of this style of review in looking at a juvenile justice case. Judges, county probation and parole, delinquency and court services, public defenders, district attorneys, corrections, and law enforcement all participated. Although the majority of the agencies worked in the same building on the same issues, it was immediately clear they rarely interacted, didn’t understand each other’s acronyms, missed opportunities for partnerships, and weren’t familiar with the relevant work of other agencies. Participation in reviews informed them on the work of other entities, how they fit into the larger scale response, and how they might better work together. Reviews have led to relationships and greater trust not only between agencies, but between the people within agencies. When we have this information and understanding, we can identify systems gaps and opportunities for agencies to partner to better address these weaknesses.
The key to these reviews is that they are collaborative, all-stakeholder, non-blaming, and forward-looking, with the goal to identify system weaknesses and use a worst-case scenario — an overdose death — as an opportunity for system improvement. Of course, this can be easier said than done, but I urge police executives to reach out to criminal justice and public health partners and ask relevant questions about establishing overdose fatality reviews: How can we do something like this? Where do we start? What kind of statues do we have in place for information sharing? What do we currently do that resembles this that we can make modifications to, in order to fit an opioid case context?
In Milwaukee, our work on opioids draws from lessons learned and models developed to respond to other issues, such as homicides, juvenile deaths, jail bed shortages, and mental health. Our emphasis on data stems in part from my work developing the National Violent Death Reporting System for the Centers for Disease Control, and later work helping the state launch the Wisconsin Violent Death Reporting System. The overdose death reviews we conduct are based on a model we developed through the Milwaukee Homicide Review Commission as well as Milwaukee’s time as a pilot site for NIJ’s Sentinel Events Initiative, which promotes a similar approach of using all-stakeholder reviews to learn from criminal justice error. This cross-sector, multidisciplinary learning behooves us as we consider the opioid epidemic. This crisis is complex and necessitates an equally multifaceted response.
About “Notes From the Field”
The National Institute of Justice (NIJ) is the research, development, and evaluation arm of the U.S. Department of Justice. NIJ aims to address the critical questions of the criminal justice field, particularly at the state and local levels.
NIJ Director David Muhlhausen developed the “Notes From the Field” series to allow leading voices in the field to share their strategies for responding to the most pressing issues on America’s streets today.
“Notes From the Field” is nota research-based publication. Instead, it presents lessons learned by law enforcement executives and other on-the-ground leaders, from years of experience and thinking deeply about law enforcement issues.
About the Author
Dr. Mallory O’Brien is the Founding Director of the Milwaukee Homicide Review Commission. Dr. O’Brien is trained as an epidemiologist and has worked in the field of violent injury prevention for the past 20 years. In 1994, she began her work developing, implementing, and evaluating a regional tracking system for firearm deaths, the Firearm Injury Reporting System, at the Medical College of Wisconsin.
From 2001 through 2007 she continued her work, expanding to the national level as the Associate Director of the National Violent Injury Statistics System at the Harvard Injury Control Research Center, at Harvard University.
From 2007 through 2011, as a researcher with Duke University, Terry Sanford Public Policy Institute, she worked on a randomized control trial of re-entering gang-involved offenders. Dr. O’Brien has served as a consultant to the Wisconsin Department of Health and Family Services, Wisconsin Violent Death Reporting System, the Centers for Disease Control and Prevention, National Violent Death Reporting System.
She is currently a member of the WI Attorney General’s Crime Victim Council, Governor’s Criminal Justice Coordinating Council, Partnership Council of Milwaukee, and the Milwaukee Community Justice Coordinating Council. Dr. O’Brien is currently employed at the Medical College of Wisconsin in the Institute for Health and Equity. Dr. O’Brien has been honored with awards from the Federal Bureau of Investigation (Director’s Community Leadership Award) and the U.S. Department of Justice, Project Safe Neighborhoods (Outstanding Contribution by a Researcher).
Writing and editorial support was provided by Rianna P. Starheim, a writer with a federal contractor, on assignment at the National Institute of Justice, U.S. Department of Justice.