It has been said that in every crisis lies the seed of opportunity, and the opioid crisis presents an invaluable opportunity for city and county officials.
Pledge to Take Action
Letter from Task Force Co-Chairs
The epidemic of overdoses and deaths from the abuse of prescription painkillers and heroin has devastated countless families and communities across the country. In August, 2016 alone – as this joint task force convened by the National Association of Counties and the National League of Cities carried on its work – news reports informed us of 174 overdoses in six days in an Ohio city; 8 overdoses in 70 minutes in a Pennsylvania county and 26 overdoses in 3.5 hours in a West Virginia city. Although news outlets often provide little more than a running tally of the epidemic, leaders at the local level experience the human costs of this public health crisis one life at a time. We confront the tragedies of this epidemic in rural counties and in urban cities, and no portion of society is immune from the devastation. Families are shattered without regard to income, race, ethnicity, gender, educational attainment or family structure.
As city and county leaders entrusted with preserving the health, safety, and vitality of our communities, it is our duty to act with urgency to break the cycles of addiction, overdose, and death that have taken hold in so many corners of this nation. To that end, the report that follows features recommended policies and programs that are designed to help local leaders address the opioid epidemic. These recommendations reflect several core convictions: that addiction is an illness; that although law enforcement is critical to an effective response to this epidemic, we cannot simply arrest our way out of a crisis of addiction; and that to stem the tide of this epidemic and combat the stigma that often accompanies it, we must build partnerships across our communities and with our counterparts at the local, state and federal levels.
As we embrace these convictions, we recognize that they differ from those that informed our nation’s response to previous drug epidemics. During the crack cocaine epidemic of the 1980s and 1990s, addiction was criminalized – through policies like mandatory minimum sentences and three strikes laws – resulting in mass incarceration of African-Americans and Latinos. Our communities of color continue to feel the detrimental effects of these policies. It is important that we reflect upon past policies and their impact on our communities as we formulate our response to an epidemic that threatens every community across the country. Further, although it is not in our power to change the past, we can help to undo some of the damage caused by our prior responses. First, we can expand and replicate the compassion for those struggling with addiction and the public support for diversion and treatment programs to individuals throughout the criminal justice system. Second, we can support sentencing reform legislation that would retroactively apply to individuals still serving time for non-violent drug-related convictions.
It has been said that in every crisis lies the seed of opportunity, and the opioid crisis presents an invaluable opportunity for city and county officials: an opportunity to assess the way we respond to addiction and to formulate lasting and equitable responses that promote health, safety, and opportunity for all members of our communities.
Judge Gary Moore
Boone County, Kentucky
Task Force Co-Chair
Mayor Mark Stodola
Little Rock, Arkansas
Task Force Co-Chair
List of Taskforce Members
NATIONAL ASSOCIATION OF COUNTIES MEMBERS
Co-Chair – Judge/Executive Gary Moore, Boone County, Kentucky Commissioner Matt Bell, Weber County, Utah
Commissioner Doug Corcoran, Ross County, Ohio
County Executive Kathy Dahlkemper, Erie County, Pennsylvania Dr. Vidya Kora, Commissioner, LaPorte County, Indiana
County Council Member Waymon Mumford, Florence County, South Carolina Supervisor Leticia Perez, Kern County, California
County Executive Mark Poloncarz, Erie County, New York
Commissioner Greg Puckett, Mercer County, West Virginia
County Executive Steve Schuh, Anne Arundel County, Maryland Commissioner Judy Shiprack, Multnomah County, Oregon
NATIONAL LEAGUE OF CITIES MEMBERS
Co-Chair – Mayor Mark Stodola, Little Rock, Arkansas
Councilmember Walt Allen, Covina, California
Executive Director Geoff Beckwith, Massachusetts Municipal Association City Manager Lee Feldman, Fort Lauderdale, Florida
Councilmember Leta Mach, Greenbelt, Maryland
Council President Ceasar Mitchell, Atlanta, Georgia
Councilmember Joel Navarro, Tempe, Arizona
Mayor Nan Whaley, Dayton, Ohio
Police Chief Nick Willard, Manchester, New Hampshire
Councilmember Lavonta Williams, Wichita, Kansas
Mayor Stephen Williams, Huntington, West Virginia
Facts and Figures on the Opioid Crisis
Responding to a Crisis
As the opioid epidemic has taken hold, city and county leaders are taking action. The number and scope of programs in place are a testament to the problem-solving skills of local officials. With both determination and imagination, local leaders are expanding prevention and treatment programs and giving more flexibility to public safety personnel who interact daily with individuals struggling with addiction. Knowing that localities cannot end this epidemic alone, these leaders are actively seeking partnerships and exploring innovative strategies that challenge old conventions about the stigma of addiction.
In early 2016, the National League of Cities and the National Association of Counties convened a joint task force to identify the local policies and practices that reduce opioid abuse and related fatalities. The task force met twice, in Washington, D.C., and in northern Kentucky. These meetings, coupled with countless conversations with local officials from across the country, including public health directors, prosecutors, law enforcement officials and substance abuse directors, enabled the task force to produce this report and its recommendations.
The recommendations are aimed at city and county officials and are divided into four sections: 1) leadership, 2) education and prevention, 3) treatment and 4) public safety and law enforcement. Several of the recommendations are accompanied by existing local practices from cities and counties. The report also includes recommendations for state and federal officials, who are pivotal partners in local efforts to combat opioid misuse, diversion, overdose and death.
Leading in a Crisis
Recommendations at a Glance
City and county leaders must assume roles of leadership in local efforts to reverse the trends of the opioid crisis.
- Set the tone in the local conversation on opioids.
- Convene community leaders.
- Foster regional cooperation.
- Educate and advocate to state and federal partners.
- Ensure progress for all in formulating responses to addiction.
In early 2016, the Massachusetts Municipal Association published a report for local leaders on the opioid crisis aptly titled “An Obligation to Lead.” The opioid epidemic, wrote the association, “presents more than an opportunity,” and is a “moral duty that all of us who are privileged to serve in local government must embrace fully.”
We wholeheartedly echo those sentiments and call on city and county leaders to assume leadership roles in local efforts to reverse the trends of the opioid epidemic. It has become apparent that this epidemic can ravage any community in the nation regardless of its size or composition. In the face of such a threat, which has taken far too many lives and torn apart countless families, local officials must lead with energy, urgency and compassion. There is much to be accomplished in reversing the opioid epidemic, and few are better positioned to carry out this work.
Set the tone in the local conversation on opioids.
As local government officials, we are privileged to speak to our constituents with the authority and legitimacy that comes with public office and the trust and empathy derived from living daily in the communities we serve. From this invaluable position, we must set the tone in conversations about opioids by breaking the silence and speaking candidly and compassionately about the crisis in our cities and counties. However, we must also highlight and uplift local efforts to prevent further abuse of opioids and the overdoses and deaths that result from such abuse. In short, we must define our local struggles with the opioid crisis so that those struggles do not define our cities and counties.
By setting a constructive and compassionate tone in conversations on opioid abuse, we can achieve the imperative of chipping away at the stigma of opioid addiction. Stigma can prevent parents and teachers from speaking with children about the dangers of opioids, prevent individuals struggling with opioid addiction from seeking the treatments they need and prevent cities and counties from providing these treatments. As local leaders, we must normalize conversations about addiction and its treatment to empower individuals, families and governments to take actions needed to address the opioid crisis, without fear of the stigma that such actions may bring.
Convene community leaders.
It is imperative that local government officials be in regular contact with community leaders who work with populations affected by the opioid crisis and who are thus well positioned to contribute to effective local responses. City and county leaders should form or join local task forces of leaders from various sectors of local government and across the community to assess the causes and impacts of opioid abuse and the solutions needed to decrease rates of abuse. Elected officials, health officials—including behavioral health and substance abuse directors—judges, prosecutors, public defenders and law enforcement officials, among others, should be involved in the task forces. Joining them should be education officials, representatives from local medical societies, directors of treatment facilities, parent advocates and faith leaders.
The Community Anti-Drug Coalitions of America (CADCA) helps to establish or strengthen local coalitions to create and maintain safe, healthy and drug-free communities. CADCA can point to community coalitions in an area or walk local government officials through the process of starting a coalition. The organization also offers a variety of resources for local coalitions, including technical assistance and training and media and marketing strategies.
Foster regional cooperation.
Just as it imperative that local government officials establish regular communication with leaders in the community, it is also vital to establish or strengthen lines of communication with neighboring governments. Although the causes and impacts of the opioid crisis may differ in neighboring communities, solutions are more effective when coordinated among the various governments within a region. Regional cooperation is perhaps most important in law enforcement, given that drug trafficking often cuts across local lines. In northern Kentucky, the counties of Boone, Campbell and Kenton and the city of Bellevue have formed a regional task force that enables their law enforcement departments to work cooperatively in drug enforcement. Whether through formal task forces like northern Kentucky’s or through less formal regular meetings, regional cooperation should not be overlooked.
Educate and advocate to state and federal partners.
Although we firmly believe that the opioid crisis must be confronted and addressed locally, we are also cognizant that many important decisions that affect this crisis are made at the state and federal levels. City and county officials should educate their state and federal counterparts on the effects of the opioid crisis on local communities and advocate for actions from those levels of governments that can help reverse trends of opioid misuse. State and national membership organizations, like the National League of Cities and the National Association of Counties and their sister organizations in states, are well positioned to assist local officials with state and federal advocacy.
See the section on “Recommendations for State and Federal Officials” for specific state and federal actions that can help local governments address the opioid crisis.
Ensure progress for all in formulating responses to addiction.
Communities of color continue to feel the detrimental effects of the criminalization of addiction, which today is being replaced by a new focus on harm reduction and improved public health. Moving forward, we must give ongoing attention and action to the racial disparities relevant to addiction and to its treatment. Both the National League of Cities and the National Association of Counties should continue programs of research, information sharing, educational programming, advocacy and technical assistance in the fields of addiction and addiction treatment beyond the duration of this task force.
Focusing on Prevention and Education
Recommendations at a Glance
In order to stem the tide of the opioid epidemic, local leaders must approach prevention and education efforts with the same urgency and determination with which we work to reverse overdoses and arrest drug traffickers.
- Increase public awareness by all available means.
- Reach children early, in and outside of schools.
- Advocate for opioid training in higher education.
- Embrace the power of data and technology.
- Facilitate safe disposal sites and take-back days.
It is said that an ounce of prevention is worth a pound of cure, and this certainly applies to our efforts to fight the opioid crisis. Given the staggering number of overdoses and deaths from the opioid crisis, a heavy focus is placed, with good reason, on treatment. But that focus and urgency should not diminish our determination to prevent others from becoming addicted in the first place. Preventing individuals from abusing and becoming dependent on opioids will save lives, preserve the health and vibrancy of our communities and result in significant fiscal savings for local governments, many of which are struggling to fund addiction treatments. By approaching prevention and education efforts with the same urgency and determination with which we work to reverse overdoses and arrest drug traffickers, we can begin to create the cultural transformation needed to free our communities from the grip of the opioid crisis.
TOOLS AND EXAMPLES
Thinking Outside the Box
In Erie County, Pennsylvania, parents are educated about the symptoms of adolescent drug abuse through open-bedroom displays located in shopping malls.
Increase public awareness by all available means.
As local elected leaders, we are uniquely positioned to spread information about the dangers of prescription painkillers and the lethality of heroin and other illicit opioids. From traditional forms of communication, like town hall meetings and pamphlets, to newer forms, like Facebook and Twitter, we have numerous platforms through which to communicate with our constituents. We must fully use these platforms to increase public awareness about the dangers of opioids, and we must be thoughtful and creative in crafting our messaging.
Further, we must actively look for new opportunities to communicate with constituents, especially those who may be at greater risk of opioid abuse and addiction. The Ocean County, N.J., prosecutor’s office has done this through its “funeral cards,” which contain information about the dangers of prescription painkillers alongside instructions for proper disposal of remaining prescriptions. The prosecutor’s office gives these cards to funeral directors, who then hand them out to families of deceased individuals.
Reach children early, in and outside of schools.
Children should be educated at the earliest possible age about the dangers of prescription painkillers and illicit opioids. Classrooms provide an excellent opportunity to do so. The National Institute on Drug Abuse offers free resources for teachers, including lesson plans, activity finders and student-targeted pamphlets that answer questions like, How do opioids work? How do people get addicted to opioids? Out-of-school recreation programs also provide valuable opportunities to engage children and youth on these topics.
Local elected officials should also call on each parent in the community to speak regularly with their children about the dangers of prescription and illicit opioids. According to the Red Ribbon Campaign, an initiative of the National Family Partnership that asks parents to pledge to educate their children about drug abuse, children of parents who speak with their teens regularly about drugs are 42 percent less likely to use drugs than those whose parents do not, yet only one-fourth of teens report having these conversations.
Advocate for opioid training in higher education.
Students in health-related undergraduate and graduate programs, in addition to those in medical, pharmacy, nursing and dental schools, should receive appropriate training on pain management and substance use disorders. City and county leaders should assess the extent to which this training is provided in educational institutions within their jurisdiction and use their positions as elected leaders to advocate for greater training where needed.
Although the importance of opioid prescription training for medical and dental students is self-evident and overarching, local leaders should also advocate for drug abuse intervention training for all students in health-related fields. The Screening, Brief Intervention and Referral to Treatment (SBIRT) program is an evidence-based approach endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA). It promotes universal screening of all individuals to identify use, early risks and abuse in order to intervene appropriately. Basic SBIRT training is available via a free app developed at the Baylor College of Medicine.
Embrace the power of data and technology.
Local leaders must recognize the potential of data and technology to advance efforts in fighting the opioid crisis. When properly collected and analyzed, data can help cities and counties better understand the causes of opioid abuse in communities and fine-tune their responses. Data related to overdoses and deaths, for example, can help local leaders focus public awareness efforts on neighborhoods facing greater rates of opioid-related harm.
City and county leaders should assess where data is being collected within local government and to what extent it is being shared between different departments and local, regional and state governments.
In addition, city and county leaders should advocate for greater data collection and use of data and technology. Coroners should list with specificity the drugs that caused opioid-related deaths so public health and law enforcement officials can adjust responses accordingly. Administration of the overdose antagonist naloxone should be tracked closely to better target overdose prevention and treatment efforts. Mapping technology can also provide information to individuals about resources such as safe disposal locations, pharmacies that dispense naloxone and facilities that offer treatment services.
Facilitate safe disposal sites and take-back days.
Cities and counties must ensure that there are a sufficient number of accessible, safe disposal sites within their jurisdiction so members of the community can dispose of unneeded opioids. Local pharmacies, physicians and law enforcement can serve as important partners in efforts to provide and promote safe and convenient disposal sites. Information about these sites should be widely shared through traditional and web-based forms of communication. Cities and counties should also host periodic drug take-back days so community members can dispose of unneeded opioids at a convenient location while also creating public awareness about the dangers of prescription drugs. The Drug Enforcement Administration (DEA) partners with local communities across the country to host national take-back days. On April 30, 2016, Franklin County, Ohio, collected 4,000 pounds of prescription drugs, and the DEA reported that 447 tons were collected overall throughout the country.
Recommendations at a Glance
Local leaders should institute policies that expand treatment for individuals struggling with opioid addiction.
- Make naloxone widely available.
- Intervene to advance disease control by implementing a clean syringe program.
- Increase availability of medication-assisted treatments.
- Expand insurance coverage of addiction treatments.
- Employ telemedicine solutions.
As society has embraced the need to medically treat addiction rather than incarcerate those with a substance use disorder convicted of a crime, the need for treatment longer than 90 days has grown and overwhelmed city, county and state governments’ ability to respond. But we do know how to treat chronic illness. Nearly the same number need treatment for diabetes (29 million) as those needing treatment for substance use disorder (21 million). Yet roughly three of four diabetes patients receive treatment while only 12 percent of those with substance use disorder do, according to estimates from the Centers for Disease Control and Prevention. Society is in short supply of drug treatment specialists to carry out medication-assisted treatments and dispense methadone, buprenorphine and naltrexone. Training programs are necessary for health professionals, and more patients should be served by doctors in private practice. Arbitrary caps should be removed on the number of patients undergoing medication-assisted treatments, at least during the present epidemic.
Make naloxone widely available.
Local leaders should work to ensure that naloxone, an overdose recovery medication, is made widely available in each community and provided to all city and county first responders. Nearly 40 states now grant some broad authority to pharmacists—such as through a standing prescription order from the state’s public health director or by a collaborative drug therapy agreement—to distribute naloxone not only to those with an opioid prescription but to those who support or act as caregivers to people suffering with addiction, and in some cases to the general public. This practice should be operational in all 50 states and territories. Bulk purchasing agreements by organizations such as the U.S. Communities Government Purchasing Alliance can make this life-saving drug available to cities and counties at a significant discount, easing the cost burden on local government.
The administration of naloxone should be followed by medical holds, referrals or “warm handoffs” to counseling and treatment services that help individuals address the underlying drug abuse that led to their overdose. Without follow-up services, administering naloxone can amount to delaying a lethal overdose, rather than saving a life.
TOOLS AND EXAMPLES
Recovery coaches in Ocean County, N.J.
The Ocean County prosecutor’s of ce has launched the “Recovery Coach Program,” a voluntary program that connects individuals revived by naloxone with treatment options once they are stabilized in emergency rooms. Working with area hospitals, the program matches an overdose victim with a recovery coach, who, if the patient is willing, will work with the person for up to eight weeks and help steer him or her toward recovery. Free or subsidized treatment is available for willing participants. The coaches are typically in recovery themselves, which of cials say provides a perspective that doctors and law enforcement of cials cannot. Early in the program, up to 70 percent of overdose victims had agreed to participate in the program.
Intervene to advance disease control by implementing a clean syringe program.
Safe disposal of unused prescription medications and needles contaminated with blood are important steps to protect against outbreaks of HIV and hepatitis. Establishing places or programs to deposit used syringes and needles not only helps with disposal, but also opens a path for individuals seeking substance use treatment.
At a minimum, localities can provide information on hospitals, clinics or other health facilities and providers who will receive or exchange contaminated syringes and needles for new ones. One such program, The Point, developed by the Center for Health and Social Research at SUNY Buffalo in collaboration with the Erie County, N.Y., Department of Health, provides information on locations where an individual can access clean needles and syringes.
Increase availability of medication-assisted treatments.
A regimen of long-term (six months or more) medication exchange (such as methadone, buprenorphine or naltrexone replacing heroin), psychological counseling, peer-to-peer support networks and close patient monitoring is the evidence-based model to address addiction and co-occurring mental health problems. Such sophisticated medication-assisted treatment requires highly trained practitioners and access to often costly medication. At present there are too few drug treatment specialists to meet the growing demand. Progress can be made if more health professionals, such as licensed practical nurses, can undergo training to properly administer medications such as buprenorphine and naltrexone. Both the federal government and county governments (such as Erie County, N.Y.) have expanded the availability of such training programs.
Efforts are in place to make better use of community health centers to increase treatment services. Likewise, rules that limit the number of patients to whom any single physician can prescribe buprenorphine are barriers to increasing treatment. Instead of capping the level of physician treatment, doctors in private practice should be incentivized to treat more patients struggling with a substance use disorder.
Increasing the cooperation between city and county governments to enhance the number of beds for long-term medication-assisted treatment is critical to overcoming this health crisis.
Expand insurance coverage of addiction treatments.
Local leaders should advocate for including addiction treatments in all health insurance plans and removing limits on such treatments. In addition, city and county officials should work to ensure that the health plans of local government employees cover addiction treatments. Given that cities and counties together employ several million individuals, including addiction treatments in local government health plans represents a significant step toward enabling individuals to access affordable treatments for substance abuse.
Employ telemedicine solutions.
Although the nature of addiction treatment often requires in-person visits with medical professionals, telemedicine can enhance these treatments. Advances in technology have expanded access to health professionals and extended the capacity of each individual service provider to meet the growing needs of those with substance use disorders. For paramedics responding to calls, telemedicine can facilitate immediate support to patients. The technology is also useful in serving rural populations, where distance between first responders and patients is often a critical factor.
The U.S. Department of Agriculture has awarded Distance Learning and Telemedicine grants to establish telemedicine networks to provide treatment for medical conditions, including mental health and drug addiction treatment. These grants are also designed to expand and improve rural counseling centers with mental, behavioral and psychiatric care services and substance treatment services, and to support mobile health units providing onsite care and telemedicine video conferencing with doctors and specialists.
Local leaders should advocate for including addiction treatments in all health insurance plans and removing limits on such treatments.
Reassessing Public Safety and Law Enforcement Approaches
Recommendations at a Glance
Law enforcement agencies should focus resources on supply-reduction and aim to divert individuals struggling with addiction from the criminal justice system to appropriate treatments.
- Reduce the illicit supply of opioids.
- Consider alternatives to arrest.
- Divert from the criminal justice system.
- Facilitate treatment in jails.
- Support “Ban the Box” initiatives.
Cities and counties have been fighting the “war on drugs” for nearly five decades, and unlike many other wars, this war is waged on American soil. Because this war has largely failed to differentiate between individuals struggling with addiction and traffickers who profit from addiction, communities, and in particular communities of color, have suffered extensive casualties in the war. The end result of this criminalization of addiction has been a cycle of over-incarceration that fails to address the root causes of drug abuse in our communities and costs taxpayers trillions of dollars.
In recent years, and with the onset of the opioid epidemic, local governments are reassessing and shifting approaches to drug enforcement. Although law enforcement agencies continue to carry out the important task of aggressively pursuing the drug traffickers and cartels that are flooding our communities with illicit drugs such as heroin and fentanyl, they are placing a greater focus on alternatives to arrest for those whose low-level criminal behavior is rooted in addiction. Good Samaritan laws that provide legal protection for individuals who report overdoses have also been widely embraced.
Local law enforcement and public safety officials must continue to work closely with health care providers, addiction treatment facilities, and drug courts to identify such alternatives. Equipped with the discretion to use these alternatives, local law enforcement officials can continue to play a crucial role in helping to break the cycle of addiction that, as past efforts to criminalize addiction have made clear, cannot be solved through arrest and incarceration.
Reduce the illicit supply of opioids.
TOOLS AND EXAMPLES
Drug Market Intervention in High Point, N.C.
First piloted in 2004 in High Point, N.C., Drug Market Intervention (DMI) is a strategy for shutting down overt drug markets and improving life for residents in the surrounding communities. DMI identi es particular drug markets and stree -level dealers, arrests violent offenders, creates “banked” cases—or suspends prosecution—for nonviolent dealers and brings together dealers, their families, law enforcement of cials, service providers and community leaders for a call-in meeting that makes clear that selling drugs openly must stop. The strategy also includes a critical process of racial reconciliation to address historical con ict between law enforcement and communities of color.
City and county leaders should facilitate partnerships between local law enforcement and their state and federal counterparts to identify the flow of illicit drugs into communities. They should use all available law enforcement resources to incarcerate drug traffickers. Local law enforcement agencies should work closely with DEA’s State and Local Task Force Program. The program’s ability to combine federal resources with state and local officers’ detailed knowledge of their jurisdictions leads to highly effective drug enforcement investigations.
By targeting drug traffickers and the supply chain of drugs, local law enforcement can dramatically reduce the availability of drugs in communities. Reducing supply is especially important as drug dealers are increasingly lacing heroin with lethal drugs like carfentanil, which is used to sedate large animals. Drug users are typically unaware that the drugs they are purchasing are laced in this way, resulting in greater frequency of lethal overdoses. In August 2016, in a span of just two days, Cincinnati’s emergency services responded to more than 60 heroin overdoses, many of which resulted from batches of heroin laced with carfentanil. Active and collaborative drug enforcement is key to preventing further tragedies.
Consider alternatives to arrest.
City and county leaders should empower local law enforcement officials to use alternatives to arrest for individuals who commit low-level crimes associated with drug abuse and often co-occurring mental health issues. Illicit drug use and low-level possession of drugs continue to be treated as criminal behavior throughout the country, leading to millions of arrests each year. However, many local law enforcement agencies have taken the position that arresting users for possession is not an effective way to change behavior. Instead of criminalizing drug addiction, communities are now addressing the problem as a treatable disease that requires intervention and treatment. The International Association of Chiefs of Police states that law enforcement leaders “should strive to create innovative partnerships with public health providers and rehabilitation experts to help line officers respond more effectively to substance abusers with an increased array of alternative solutions to incarceration.”
Local law enforcement officers are among a community’s best resources in the effort to identify individuals with who need treatment for a substance use disorder and divert those individuals to needed treatment services. As an alternative to arrest and incarceration, local law enforcement officers should be able to refer drug addicts to local, community-based drug treatment programs to break the cycle of drug use. Local governments should train local law enforcement officials on resources that are available for drug treatment programs and how individuals who need treatment can access these programs.
TOOLS AND EXAMPLES
Seattle/King County LEAD Program
In 2011, Seattle and King County began piloting the Law Enforcement Assisted Diversion Program (LEAD) to address low-level drug and prostitution crimes in targeted city neighborhoods and parts of King County. The program’s goals are to improve public safety and public order and to reduce the criminal behavior patterns of people who participate in the program. LEAD is a coalition of law enforcement, public health, city and county of cials, community stakeholders and private-sector supporters.
LEAD is a pre-booking diversion program that empowers street-level public safety personnel to make decisions about arrests. Rather than moving persons with substance use disorder into the criminal justice system, LEAD participants begin working immediately with case managers and social workers. In the case of persons suffering from addiction, LEAD participants have access to trained clinicians who specialize in medication-assisted treatments and have been the key providers in the region for street-level outreach. Treatment services may include substance use disorder treatment, mental health support, housing and job training.
LEAD has been independently evaluated by researchers from the University of Washington. They nd that the program reduces recidivism signi cantly among participants (both on a pre/post-participant- only analysis and when compared with a selected group of controls) and also reduces criminal justice spending.
Divert from the criminal justice system.
City and county officials should advocate for diversion from incarceration for nonviolent individuals whose low-level criminal behavior stems from their drug addiction. Many communities throughout the country have established drug courts to help individuals struggling with addiction enter a substance abuse program instead of serving time in jail. Drug courts employ a program designed to reduce drug use relapse and criminal recidivism through risk and needs assessment, judicial interaction, monitoring and supervision, graduated sanctions and incentives, treatment and various rehabilitation services. A multidisciplinary team of judges, prosecutors, defense attorneys, community corrections, social workers and treatment service professionals often manages the courts and provides targeted treatment services to drug offenders.
Although drug courts have higher investment costs, especially in treatment services, many communities have experienced extensive savings associated with victim and criminal justice system costs because of fewer crimes, rearrests and incarcerations. On average, drug courts save an estimated $5,680 to $6,208 per offender.
Diversion courts have a particularly positive impact on our nation’s veterans. According to a 2011 study from the U.S. Department of Veterans Affairs (VA), veterans are nearly twice as likely to die from an accidental opioid overdose than their civilian counterparts. Veterans’ treatment courts offer an opportunity for those suffering with substance abuse or mental health issues to receive assistance in accessing their earned benefits, obtaining targeted treatment and connecting with a peer mentor who understands their challenges and pain. There are already over 200 such courts, and local jurisdictions can receive assistance in setting up their own veterans’ treatment court through the Justice for Vets initiative.
Facilitate treatment in jails.
Local leaders should work to ensure that inmates in local jails who struggle with addiction receive proper treatment for their illness, including medication-assisted treatments, with a special focus on pre-release treatment and service coordination. Treatment programs in jails offer an opportunity to break the cycle of drug abuse and criminal behavior that ensnares many individuals who come into contact with the criminal justice system. Jails can implement low-cost treatment programs to provide these individuals the treatment they need. Statistics demonstrate that incarcerated individuals who struggle with opioid addiction and receive little or no treatment are much more likely to relapse into drug use and criminal behavior on their release. These individuals also are more likely to suffer a lethal overdose shortly after being released. Treatment programs in jails have consistently been shown to reduce the costs associated with lost productivity, crime and incarceration caused by heroin use.
Providing treatment services to fit the needs of the individual is an important part of effective drug abuse treatment for criminal justice populations. Drug treatment should address issues of motivation, problem solving and skill building for resisting drug use and criminal behavior. Treatment programs during incarceration should also facilitate the development of healthy interpersonal relationships and improve the participant’s ability to interact with family, peers and others in the community.
TOOLS AND EXAMPLES
Kenton County detention center treatment program
It is estimated that roughly 80 percent of those booked into the Kenton County detention center in northern Kentucky are incarcerated for charges that are either directly or indirectly related to substance abuse disorders. In 2015, jail directors dedicated a 70-bed dormitory in their facility to substance abuse treatment, adding to the 30 beds already designated for such treatment.
The voluntary, application-based six-month program provides inmates with cognitive-behavioral therapy, intensive counseling individually and in groups, spiritual programming and, prior to their release, a naltrexone injection to block the effects of opioids for 30 days after release. Inmates are also connected to community services before they are released, including organizations that help them attain health insurance. As of mid-2016, nearly 200 inmates had completed the program, and the recidivism rate was less than 10 percent.
Support “Ban the Box” initiatives.
City and county officials should change hiring practices to prohibit questions regarding past criminal history on applications for local government jobs and hiring by vendors under government contract. Among the biggest challenges individuals convicted of drug offenses face is securing employment and housing after release from jail. The inability to find a job or a place to live leads many to return to their previous criminal activities and remain in the grip of opioid abuse and associated criminal behavior.
One program used in more than 100 cities and counties is the “Ban the Box” initiative. This initiative prevents prospective employers from asking about the criminal background history during the early stages of the application process. The goal of the initiative is to ensure employers first consider the job candidate’s qualifications without the stigma of a criminal record.
To support local efforts to enact “fair-chance” policies, the National Employment Law Project (NELP) has developed best practices and model policies for local governments. The NELP toolkit provides model administrative policies, sample resolutions, ordinances, state executive orders and model state legislation.
TOOLS AND EXAMPLES
Tallahassee Ban the Box initiative
In January 2015, Tallahassee moved to adopt a new set of municipal hiring guidelines for criminal background checks. City of cials recognized that in 2014, more than 1,700 formerly incarcerated individuals returned to Leon County, Fla., and almost 200,000 more are expected to be released in Florida during the next ve years.
To help remove employment barriers for people with criminal convictions, the city manager can now inquire about criminal history and conduct background checks later in the interview process, rather than at the start.
Of the 816 criminal background screenings conducted in 2014, excluding those for public safety jobs, 15 percent had criminal histories. Of those 15 percent, 11 percent were hired and 4 percent were denied on the basis of their background as it applied to positions.
Federal and State Recommendations
As we call on city and county officials to lead efforts to address the opioid epidemic across our local communities, we recognize that these local efforts will be far more effective when carried out in partnership with state and federal counterparts. The following recommendations call for state and federal actions that can complement local efforts to reduce the rates of opioid dependence, overdose and deaths in our communities. In the crafting the recommendations, the task force referenced the National Governors Association’s 2016 report, “Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States.”
Establish or strengthen prescription drug monitoring programs (PDMPs).
Most states collect data on controlled substances dispensed in the state, including opioids. States should require medical professionals to use PDMPs to assess potential abuse or diversion before prescribing opioids, and they should require those who dispense opioids to report each prescription to the PDMP within 24 hours.
Institute guidelines for prescribing opioids.
In March 2016, the Centers for Disease Control and Prevention (CDC) published opioid prescription guidelines with recommendations to help prescribers determine when to initiate opioids for chronic pain, how to select opioids, set their dosage, duration and discontinuation and how to assess risk and address the harms of opioid use. States should adopt the CDC guidelines or similar guidelines that achieve the same goal.
Support greater availability of medication-assisted treatments.
States should assess the factors that limit medication-assisted treatments in their cities and counties and take actions to help increase the availability of such treatments. Barriers to medication-assisted treatments in state statutes should be reassessed and training of primary care physicians in administering medication-assisted treatments should be required or incentivized.
Structure Medicaid programs to promote safe opioid prescription practices and access to treatments.
According to the National Association of Medicaid Directors, compared with their privately insured counterparts, Medicaid participants are twice as likely to be prescribed opioids and have six times the risk of opioid-related overdose deaths. States should address these disparities through their Medicaid plans by limiting opioid prescriptions, promoting the use of non-opioid pain management methods and optimizing timely access to medication-assisted treatments like buprenorphine and naltrexone.
Explicitly authorize or remove barriers to clean syringe programs.
In addition to protecting communities from the outbreak of infectious diseases like HIV and hepatitis, syringe exchange programs provide important opportunities to connect individuals struggling with drug addiction to treatment services. States should support these programs and remove statutory barriers to their establishment in cities and counties.
Expand access to medication-assisted treatments.
One of the greatest impediments to the treatment of individuals struggling with addiction is the limited number of practitioners who can prescribe buprenorphine. To prescribe buprenorphine, practitioners must apply for a special license that limits the number of patients they can treat. Recently, the federal government took action to increase the limit from 100 to 275 patients. The federal government must continue to make policy changes to allow other medical professionals (such as nurse practitioners) to dispense such medications.
Provide funding for local efforts to address the opioid crisis.
Local governments are struggling to find sufficient funding to provide medication-assisted treatment programs, expand drug abuse prevention and education efforts, purchase sufficient quantities of naloxone and implement useful drug take-back programs. The federal government must quickly pass legislation to provide emergency supplemental funding to assist local governments through grants that would help expand and improve existing efforts to address the opioid epidemic in local communities across the nation.
Partner with local and state officials to reduce the supply of fentanyl and carfentanil.
The increasingly lethal synthetic forms of opioid, which can be up to 10,000 times stronger than morphine, are quickly becoming the leading cause of opioid overdose in local communities as drug traffickers lace heroin with these stronger opioids to create a more potent product. First responders often have to use several doses of naloxone to revive persons who have overdosed on heroin laced with fentanyl and carfentanil. The federal government must devote extensive resources to federal, state and local law enforcement efforts to stop the illicit trafficking of fentanyl and carfentanil.
Allow individuals in custody to continue receiving Medicaid benefits until convicted, sentenced and incarcerated and require states to suspend, rather than terminate, Medicaid for individuals in jail.
Under current federal law, federal Medicaid matching funds cannot be used to pay for treatment of jail inmates—an estimated 64 percent of whom struggle with addiction. This statutory exclusion applies not only to individuals who have been convicted of crimes, but also to pre-trial inmates who make up a majority of jail populations and are presumed innocent until proven guilty. To avoid violating the federal exclusion, states typically terminate Medicaid benefits when an inmate is booked into jail, meaning he or she must reapply on release, further interrupting access to treatment in the post-release period when many individuals relapse and overdose. The federal government should provide greater flexibility in the Medicaid program for justice-involved populations and should require states to suspend, rather than terminate, coverage for incarcerated individuals. Doing so will allow counties and cities to better coordinate systems of care and treat previously undiagnosed individuals with substance
The federal government should provide greater fexibility in the Medicaid program for justice-involved populations and should require states to suspend, rather than terminate, coverage for incarcerated individuals.
In carrying out its work over the last several months, the task force was generously supported by several corporate sponsors of the National Association of Counties and the National League of Cities. We are grateful to Aetna, the Centene Corporation, the Consumer Healthcare Products Association, Esri and the U.S. Communities Government Purchasing Alliance for their support and partnership.
The task force is also grateful for the partnership of the many organizations that contributed to our work and the publication of this report, including the Of ce of National Drug Control Policy, the Substance Abuse and Mental Health Services Administration, the American Medical Association, the National District Attorneys Association, the National Association of County Behavioral Health and Developmental Disability Directors, the National Association of County and City Health Of cials and the National Association of State Alcohol and Drug Abuse Directors.
Lastly, we are grateful to the Kenton County Detention Center and the NKY Med Clinic in Covington, Ky., for allowing the task force to visit their facilities and observe their commendable work in treating individuals struggling with addiction.
Staff to the task force, primary report authors and ongoing points of contact for this report are: James Brooks and Yucel Ors for the National League of Cities and Hadi Sedigh for the National Association of Counties.
NACo-NLC Opioid Report PDF
Click here to download the report PDF