JAMA Forum: A Smarter War on Drugs

By Howard K. Koh, MD, MPH; R. Gil Kerlikowske, MA; and Michael P. Botticelli, MEd

Image: LeszekCzerwonka/Thinkstock

Since the United States first declared a war on drugs more than 40 years ago, the nation’s criminal justice system has largely implemented traditional strategies, including arrest, drug seizure, and incarceration. But the failure of such approaches alone has prompted an intense search for alternatives. One emerging approach explores having law enforcement officials collaborate more closely with health professionals to provide care and treatment.

Many law enforcement officers, who have a front row seat to the opioid crisis, see the futility of cycling drug users through a criminal justice revolving door, with little attention to health. New 2017 data, documenting that drug overdose deaths have quadrupled (since 2000) to reach 72 000, with two-thirds caused by opioids, underscore that “we can’t arrest our way out of this problem.” Prisoners—about 60% of whom have substance use or dependence disorders—encounter limited opportunities for community-based treatment that could have obviated incarceration.

Such findings have spurred efforts to better address substance use or dependence disorders by connecting the worlds of criminal justice and health. For example, the Police Executive Research Forum coconvened a 2018 Johns Hopkins Bloomberg School of Public Health summit proposing standards of care (for treatment, education, and prevention) for police departments, as well as a 2016 national summit with the White House Office of National Drug Control Policy (involving coauthors M. B. and G. K.) and the US Department of Justice’s Office of Community Oriented Policing Services program. Local collaborations, built on prior principles of multisector homicide review commissions, include the New York City–based RxStat Operations Group (high-ranking officials from various agencies, including public health and law enforcement), which meets quarterly to review overdose case histories and address gaps in response.

Areas of Collaboration
Meanwhile, over time, at least 4 additional areas of criminal justice and health collaboration have evolved:

Drug Courts. Established over the past 2 decades and now numbering more than 3000 nationwide, drug courts promote a rehabilitative approach to reduce recidivism. They offer postarrest opportunities for mandated treatment as part of a conditional plea bargain or incarceration alternative. However, formal evaluation remains minimal and programs vary widely. For example, only about half offer access to FDA-approved medication-assisted treatment. Courts also vary in their philosophies regarding drug abstinence, zero tolerance, and whether continued program enrollment should follow medication-assisted treatment initiation.

Naloxone for Overdoses. In 2010, police first piloted naloxone for overdose reversal, formerly restricted to health professionals. This strategy, which involves routinely equipping and training officers, has grown to include more than 1200 law enforcement agencies nationwide. Meanwhile, widespread adoption of Good Samaritan laws, now in 50 states, offers limited immunity from possession charges, thereby facilitating naloxone treatment access. One Ohio evaluation of a 3-year program involving more than 500 police officers found a nearly 80% survival rate among those administered naloxone; whether such efforts explain or contribute to recently documented slight declines in overdose deaths in 14 states remains unclear.

Diversion From Arrest and Treatment Referral. In 2011, the Seattle Police Department piloted a Law Enforcement Assisted Diversion (LEAD) prebooking program, developed in collaboration with health leaders, to move “low-level” drug offenders toward case management and support services and away from prosecution and jail. A 2017 nonrandomized controlled evaluation found that participants had significantly lower odds of arrest at 6 months and of being charged with a felony over the longer term. In 2015, the Gloucester, Massachusetts, Police Department piloted an “Angel Program,” in which police facilitated referral of voluntary participants to identified treatment sites, instead of arrest. A 2017 cross-sectional telephone survey of the 198 respondents who participated in 214 encounters found that 75% of those encounters resulted in referral placements, although abstinence rates (37% at 6 months) did not differ from nonparticipants.

LEAD now involves 20 US sites. At least 154 police departments in 28 states have adopted the Angel Program model, with technical assistance from the Police Assisted Addiction Recovery Initiative, a national nonprofit network of more than 400 police departments in 32 states offering customized support by clinicians, social workers, recovery coaches, or trained volunteers.

Postoverdose Outreach. Systematic engagement of overdose survivors in community-based settings may increase their likelihood of subsequently accessing treatment services. Some communities are exploring such “knock and talk” programs, where police, fire department officials, and health professionals jointly visit survivors in their homes immediately after an overdose to connect them to care and support. A recent online survey of police and fire departments in 351 Massachusetts communities found that 21% of respondents (23 of 110) had implemented such programs.

Criminal Justice Continuum of Care
Based on these and other efforts, Lauren Brinkley-Rubinstein, PhD, of the University of North Carolina, Chapel Hill, and colleagues recently conceptualized a criminal justice continuum of care for opioid users at risk of overdose: (1) interactions with law enforcement, (2) the courts, (3) incarceration, (4) community reentry, and (5) parole and probation. Any program in this continuum requires long-term rigorous evaluation. While initial studies indicate generally positive police attitudes to overdose education and training, concerns about precipitated withdrawal, cost, and long-standing cultural barriers remain. Merging criminal justice and health data bases to monitor outcomes will be critical, too, especially since illegal fentanyl and its analogs dramatically impact mortality. Here Health Insurance Portability and Accountability Act considerations and loss of privacy regarding personal information are highly sensitive issues; such information collected by law enforcement does not currently receive the same protections as in the health arena. Also, criminal justice officials, potentially influential community voices to promote health messages and reduce stigma, know that any efforts ending in involuntary commitment can erode trust.

Addressing substance use or dependence disorders as a health issue through the criminal justice system may be poised to become the new normal, but much more work is needed. Reaching this goal will require even greater progress in piloting and evaluating new models, while overcoming long-standing assumptions about roles, responsibilities, and strategies. The nation desperately needs a smarter war on drugs. Further investigations of how criminal justice and public health should work together can reframe the current societal response to a crisis that needs answers now more than ever.

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About the authors:

Howard K. Koh, MD, MPH, is the Harvey V. Fineberg professor of the practice of public health leadership at the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School. He is also the former Massachusetts commissioner of public health and the 14th assistant secretary for health for the US Department of Health and Human Services. He has earned board certification in internal medicine, hematology, medical oncology, and dermatology and has published more than 250 articles in the medical and public health literature, earned more than 70 awards for interdisciplinary achievements in public health, and has received 6 honorary doctorate degrees. (Image: Harvard T.H. Chan School of Public Health)

Gil Kerlikowske, MA, has a 4-decade career in law enforcement, serving as chief of police in Seattle and Buffalo. He was the director of the White House Office of National Drug Control Policy (May 2009–March 2014) and commissioner of the US Customs and Border Protection (2014-2017). He received the American Medical Association Nathan Davis Award in 2011. (Image: US Customs and Border Protection)

 

Michael Botticelli, MEd, is the executive director of the Grayken Center for Addiction at Boston Medical Center. Prior to this, he was the director of the White House Office of National Drug Control Policy for the Obama administration (March 2014-January 2017). He joined the White House as deputy director in November 2012 and was confirmed as director in March 2014. (Image: Michael Botticelli/Boston Medical Center)

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Health Policy, Law and Medicine, Substance Abuse/Alcoholism, The JAMA Forum

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