The opioid crisis is capturing attention across the United States as the sharp spike in overdose deaths continues its upward trend. In fact, accidental death from drug overdoses now far exceeds fatal car crashes and shooting deaths.1 This is, tragically, a historic “first.” As those on the front lines can attest, this public health emergency is being driven primarily by prescription opioids, heroin, fentanyl, and fentanyl analogs. Two critical elements of efforts to “bend the curve” downward on the current opioid crisis are becoming apparent. First, it is essential to quickly identify individuals who are using opioids and get them into the services that will address their drug use, as well as any related criminal behavior, and ultimately help save their lives. Second, law enforcement and drug treatment providers must do this work together.
The good news is that there are a variety of effective treatment approaches for individuals who are addicted to opioids, and who also may be using other drugs. For example, a continuum of treatment services that includes the use of medications—such as buprenorphine and naltrexone (brand names Suboxone, Subutex, and Vivitrol) and methadone—along with counseling and other behavioral therapies can be effective in reducing drug use and criminal activity, as well as decreasing risk for death from overdose.2 Already, local probation departments and drug courts routinely incorporate these practices into their comprehensive approaches aimed at changing behaviors associated with drug use. These same solutions can and must now be brought to the world of law enforcement to help reduce the opioid use and overdose deaths that are tragically affecting communities.
Doing It Together: The TCU 5 Drug Screen for Opioids
One of the primary challenges in introducing at-risk individuals to treatment is to accurately identify opioid use disorders in advance of an overdose. (If a person overdoses, it can be safely said the person has an opioid use disorder.) Sometimes, decisions about whether someone needs treatment is based on a “gut feeling” or an informal conversation. While well intentioned, these subjective identification processes can be highly biased and, more critically, highly inaccurate. This could lead to a misapplication of limited treatment resources and missed opportunities to provide appropriate services to those who truly need them. A better approach is to supplement subjective judgements with more objective approaches to identify problematic use and a need for treatment services.
It is easy to forget that those individuals who successfully address their drug use and criminal behavior are not the ones whom law enforcement officers encounter on a daily basis. When officers, first responders, and other criminal justice authorities see the same individuals repeatedly leave treatment and return to a life of drugs and crime, they can easily feel defeated and experience compassion fatigue. But, with effective screening, along with critical partnerships with treatment and other service providers in the community, law enforcement and other first responders can be instrumental in stopping this cycle.
So how can opioid use be identified earlier? The screening and assessment process for drug use often occurs later in the criminal justice process because of a prevailing view that it takes more time than what is available up front to conduct the screening. It is also often coupled with a belief that screening needs to be done by highly trained professionals. While comprehensive clinical assessment does need to be conducted by highly trained professional staff and does take a significant amount of time, the initial screening process can be brief, conducted by non-clinicians, occur in a variety of settings, and take place more quickly after arrest—or perhaps occur even prior to arrest (with or without a subsequent arrest).
To this end, the TCU Drug Screen 5—Opioid Supplement has been developed. Taking approximately 10 minutes total to administer, this screening is brief and designed to be administered by those on the front line as well as by clinicians. Created by researchers at the Institute of Behavioral Research (IBR) at Texas Christian University (TCU), along with the Center for Health and Justice (CHJ) at Treatment Alternatives for Safe Communities, Inc. (TASC), this new self-report screening tool is available to assist justice and health professionals determine an initial or immediate need for services to address opioid use problems. It is free for non-commercial use and can be downloaded directly from TCU IBR’s website.
Screening for a drug use disorder using the TCU Drug Screen 5 should occur first and be administered as soon as possible after arrest or during pre-arrest (without the need for an arrest to follow as best determined by the situation). Based on current DSM classification criteria, the items in the screen should be read aloud while the respondent follows along and responds to each item. After responses are collected, the items are easily scored, resulting a single score that provides an indication as to whether an individual might have a drug use disorder. If the screening indicates a drug use disorder, the score will specify whether that disorder is likely to be mild, moderate, or severe. This information can then be used to determine the need for further assessment and referral to the most appropriate level of treatment services.
The Opioid Supplement is designed to be administered to those who report recent opioid use on the TCU Drug Screen 5. It consists of 17 questions asking about the frequency, purposes, and methods of opioid use. It asks about overdoses as well as the individual’s access to naloxone. Collectively, responses to these items can then be used to determine the level of urgency in getting an individual referred to treatment. For example, someone who self-reports daily injection heroin use along with a recent overdose experience should be identified as having the highest level of priority for immediate clinical assessment and potential placement into an intensive treatment option. Conversely, someone who occasionally misuses oxycodone and does not have a prior overdose experience can be viewed as having a lower priority for immediate clinical assessment and possible placement into a treatment program.
As with any self-report instrument, obtaining honest responses can be challenging, particularly from respondents who believe that being honest will result in unwanted outcomes (e.g., arrest). To address this, it is important to provide the respondent with the true reason they are being screened for substance use—trying to determine potential need for treatment —as well as advising them that other information (e.g., prior criminal records involving drug use) will be considered as part of the referral decision-making process. It is important to understand that the initial screening process may be one of the few times an individual can get access to the help they need to turn their life around. The administration of the TCU Drug Screen 5 and the Opioid Supplement should be administered by someone who has been trained on basic interviewing skills such as developing rapport with respondents. It is important to repeat, however, that this person does not need to be a clinician. In fact, even criminal justice officials the department lock-up or involved in the booking process can conduct the screen. This does not mean the person will be processed into the justice system, but it does speak to a safe, secure physical location where this interview can take place. The safer and more secure the environment, the better for the officer and the individual.
Research is under way currently to assess the psychometric properties of the TCU Opioid Supplement and to develop a scoring algorithm to assess overdose risk. The ultimate goal is to be able to efficiently use responses from the screening to quickly identify those who may need further assessment and treatment, as well as those at risk for overdose.
Doing It Together: Pre-Arrest Diversion
After identifying individuals with drug use disorders (particularly an opioid disorder), the next step is to quickly get them treatment services. The very best opportunities to begin the process of engagement is within minutes or hours of the first encounter. Longer lag times—especially after an overdose—can lead to untreated individuals returning to the community, engaging in further drug use, and likely experiencing another overdose, as well as continuing to pose a public safety threat while at risk in the community. Recognizing that individuals may not be willing to start treatment immediately after naloxone has reversed the effects of opioids, it is nonetheless the very best time to begin engagement efforts to open the door to treatment services.
Pre-arrest engagement and diversion can allow law enforcement to serve as a referral source to treatment and services for people who have identified behavioral health challenges. Although having a criminal background or being involved in current criminal activity is not a requirement for pre-arrest diversion, the behavioral health challenges (i.e., substance use and mental health conditions) often present among people with criminal backgrounds are likely to have some intersect with why such individuals are encountering law enforcement in the first place.
What separates pre-arrest diversion from other types of diversion is that pre-arrest diversion is guided by behavioral health; its longer-term success relies mostly on the efficacy of the behavioral health services being provided. Other types of diversion are driven much more by the justice system, justice decision-makers, and gatekeepers. In pre-arrest diversion, law enforcement is the referral source to community service providers. Utilizing a futures perspective, with 800,000 police officers in 18,000 departments across the United States, pre-arrest diversion by law enforcement could serve as the largest referral source to treatment and, thus, diminish the opioid crisis.
Pre-arrest diversion can be broken down into five pathways or approaches.3
• Self-Referral (Prevention): Drug-involved individuals initiate engagement with law enforcement without fear of arrest, and an immediate treatment referral is made. Examples: Angel (Massachusetts)
• Active Outreach (Prevention): Participants are identified by law enforcement, but they are engaged primarily by a treatment expert who actively contacts them and motivates them to engage in treatment. Examples: Arlington Model (Massachusetts); Chicago Westside Diversion (Illinois)
• Naloxone Plus (Prevention): Engagement with treatment occurs following an overdose reversal. Examples: QRT – Quick Response Teams (Ohio); STEER – Stop, Triage, Engage, Educate, Rehabilitate (Maryland), DART – Drug Assistance Response Teams (Ohio)
• Officer Prevention Referral (Prevention): Law enforcement initiates the treatment engagement, but no charges are filed. Examples: LEAD – Law Enforcement Assisted Diversion(Washington); STEER
• Officer Intervention Referral (Intervention): Law enforcement initiates the treatment engagement, and charges are held in abeyance or citations issued. Examples: Civil Citation (Florida); LEAD; STEER
Putting It Altogether: The Naloxone-Plus Pre-Arrest Diversion Framework
Of these five pathways, the Naloxone Plus pathway is the one specifically designed to respond to opioids, including preventing opioid overdoses and overdose deaths.4 The Naloxone Plus pathway provides a standard for pre-arrest diversion efforts designed to address opioids. It can operate as a stand-alone initiative or it can be incorporated into other pre-arrest diversion pathways. Naloxone Plus is comprised of the following 10 elements:
• Naloxone carried by or easily accessed by law enforcement, fire, emergency medical services, community, businesses, and individuals.
• Rapid ID of overdose and overdose risks via 911 or screening tools such as TCU Drug Screen 5 with Opioid Supplement
• Immediate contact with individual as close as possible to point of overdose
• Rapid engagement in person and accompanied by daily follow-up until the individual is engaged in treatment
• Rapid access to treatment that is measured in minutes and hours
• Screening and clinical assessment to ensure the correct individual approach
• Continued tight integration between the police, behavioral health providers, and community
• Medication-Assisted Treatment (MAT) with all appropriate medications made available
• Recovery support services that transitions individuals from treatment into continuous recovery support
• Naloxone accessibility for the individual and his or her household due to the increased risk of a second overdose
Initiating a Naloxone Plus effort in a jurisdiction first requires securing leadership commitments from within the law enforcement department along with support from elected or appointed officials. The second step is to engage the local treatment community, including public health departments and hospitals, particularly emergency departments.
Day in and day out, officers are acutely aware that much more can and needs to be done to be in the fight against opioids. Access to tools for early opioid identification and a series of activities to connect a person quickly to treatment through the Naloxone Plus framework means law enforcement need not be in this fight alone.
Kevin Knight, PhD, deputy director of TCU’s Institute of Behavioral Research, has focused his research on HIV and substance using criminal justice populations. His primary research interests include screening and assessment strategies, targeted and adaptive interventions, and implementation strategies of evidence-based practices within justice-involved organizations.
Patrick M. Flynn, PhD, professor of psychology and director of TCU’s Institute of Behavioral Research has focused his research on co-occurring disorders, treatment costs, benefits, and technology transfer. He has been recognized by the American Psychological Association and American Educational Research Association through conferral of Fellow status and honored as a Science, Technology, Engineering, and Mathematics (STEM) Research Exemplar.
Jac Charlier, MPA, is the national director for Justice Initiatives for the Center for Health and Justice (CHJ) at TASC. He specializes in solutions to reduce crime and drug use by successfully bridging the criminal justice and behavioral health systems from police to prosecutors to courts to probation to parole. Jac is a nationally recognized expert in pre-arrest police diversion and is the co-founder of the Police, Treatment and Community (PTAC) Collaborative. Jac served as deputy chief in the Illinois State Parole Division, overseeing 19 district commanders and 225 officers and is a U.S. military veteran.
1Rose A. Rudd et al., “Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014,” CDC Morbidity and Mortality Weekly Report 64, no. 50 (2016): 1378–1382.
2Principles of Drug Addiction Treatment: A Research-Based Guide, 3rd ed. (Washington, DC: National institute on Drug Abuse, 2012).
3Jac Charlier, Pre-Arrest Diversion: A Public Health Solution to Better Public Safety, slide presentation (Chicago, IL: Center for Health and Justice at TASC, 2018).
4Jac Charlier, Solutions to Our Nation’s Opioid Crisis: The Naloxone Plus Pre-Arrest Diversion Framework, slide presentation (Chicago, IL: Center for Health and Justice at TASC, 2018).