Developing Policies & Procedures

Establish Treatment And Recovery Pathways Before The Start Of Any Program. Direct connection to community resources is critical to program success.

Promising Practice Recommendation: Direct connections to treatment and recovery resources (harm reduction, detox, inpatient, outpatient, telehealth, counseling, co-occurring -serious mental health disorders, recovery residences, etc.) should be developed before launching. Basic needs resources, such as housing, food, clothing and finding employment, are critical to include in the list of resources. The list of resources and connections to care will expand as the program grows and more resources are identified.

Establish Key Staff And Engage Persons With Lived Experience. Many programs include persons with lived experience (paid), volunteers with or without lived experience (unpaid), and/or clinicians/social workers working with law enforcement to help people access resources.

Promising Practice Recommendation: The key to these public health and public safety relationships is a warm handoff to recovery resources and support through the recovery process. Persons with lived experience (peers) can provide vital support for participants throughout the process. ^[47]Peer personnel can be embedded directly with law enforcement or contracted with an outside agency to provide support.

Some programs use a combination of trained volunteers and a hotline staffed by peers or have Mobile Crisis Units (CIT officer, care coordinator, and/or clinician) that respond to a call in the field or when there is not a designated walk-in location. (See Hope Not Handcuffs NY and Anne Arundel County)

Most Angel Initiatives Are Not Solely Focusing On Self-Referral And Have More People Referred To Treatment When They Provide A Variety Of Entry Points Into Recovery.

Promising Practice Recommendation: Most programs find that Angel Initiatives/Walk-In Models are more effective when officers are able to refer people to the program in the normal course of their duties. In addition to officer referral, some programs broaden their scope to include post-overdose outreach (teams refer people to treatment and resources after they have overdosed), active outreach (teams actively seek out individuals who use drugs, have co-occurring mental illness, and/or at risk for overdose and refer to treatment) or Hub Situation Tables (multiple community service organizations and first responder organizations meet to develop interventions for persons at risk for overdose or other issues that lead to increases in hospitalization, suicide, arrest, etc.).

No-Arrest Policy. Individuals seeking assistance by showing up at intake sites, such as police departments, may be in possession of drugs. This type of program’s intent is clearly to aid without any threat of arrest.

Promising Practice Recommendation: Make clear in all documentation promoting the program, policy and procedures, that arrest is not a possibility for anyone that seeks assistance. The purpose of these programs is to connect persons in need to treatment and recovery resources. These programs are voluntary and are not to be used for enforcement and intelligence gathering purposes. Special considerations on active warrants should be clear in the program description. A good example of this practice is the Hope Not Handcuffs program that includes explicit guidance in their procedures prohibiting the gathering of intelligence.

Medical Information Privacy. Protecting the privacy of people who overdose is a concern. While police do not have the kinds of legal constraints on sharing 911 or other police data with any partners involved in the response, medical providers do have legal barriers to sharing protected information, for example substance use disorder or mental health related information. Additional guidance on privacy regulations in public health and public safety partnerships is here.

Plymouth County Outreach model county-wide case information management system is a model example of sharing information between partners within their Critical Information Management System (CIMS). Program staff have set up extensive protocols that describe access, information to be shared, training on the system, security, and other details.

Hamilton County (OH) Quick Response Team and LEAD programs utilize a Cordata data platform to record clients’ demographics, contact information, dates and outcomes of communications with clients and other parties, and case management. The system is secure and limited to key team members.

Legal Violations. During an overdose event, the person that overdosed and those around the individual may be in violation of drug laws based on their possession of drugs and paraphernalia. As discussed in the target population section, there is no public health justification for seeking arrest of the individual that overdosed or those present. Arrest in these instances is antithetical to deflection programs. Many states have adopted Good Samaritan Laws – or laws that offer immunity to individuals experiencing overdose or bystanders – to promote seeking emergency medical assistance.  Check this resource to find the laws in your state as you develop your policy.

Multiple Outreach Attempts. Sometimes, individuals and/or their families/friends are unable to be reached during first, second, or even third attempts. Many departments conduct multiple outreach visits before deciding to discontinue their efforts. If an individual cannot be located at the address listed in the most recent report, some agencies will comb through other reports to find other known addresses for the individual, or they will try reaching out to other parties listed in the report to see if they might know where an individual can be located.

Outreach in Uniform and Marked Cruisers or in Plain Clothes and Unmarked Cruisers. The intention behind post-overdose outreach is to offer services and resources to individuals who are at heightened risk of subsequent overdose and other harms. Although there is no evidence that uniformed officers or marked cruisers can negatively affect the outreach event, some departments have opted to have officers in plain clothes and in unmarked cruisers. Officers accompanying outreach workers or clinicians may be dressed in plain clothes and drive in unmarked cruisers, both so individuals feel more comfortable, and so that undue attention is not drawn to citizens receiving help, potentially revealing that they are struggling with substance use disorder to their neighbors. Nonetheless, many outreach teams and Quick Response Teams respond in uniform and marked cruisers and have successful engagement with the community.

Secondary Outreach. The focus of most outreach models is the individual that overdosed. However, in one community, family members and third parties administered a dose of nasal naloxone to a person overdosing before first responders arrived on the scene in 26% of overdose cases.^[49] Therefore, many implementing agencies do extend outreach to others around the individual who are also at risk for harms associated with drug use.^[50] Research shows the social proximity to an overdose is also associated with increased risk for an overdose.^[51] This makes outreach extending outreach to individuals around those a valuable opportunity to offer harm reduction services and connection to treatment. This is not only because an individual’s opioid tolerance can become rapidly reduced within just a few days without intake, but individuals may also obtain drugs from an unknown source whose supply is more potent with fentanyl.

When there is a drug market disruption, like a large illicit drug seizure, there is a unique opportunity to provide outreach and engagement to people who are most vulnerable to overdose. PAARI developed a Public Safety Action Guide: Addressing Overdoses After Drug Seizures, adapted from procedures that the CDC’s Opioid Rapid Response Program (ORRP) employs in the aftermath of a legal drug market disruption (i.e. a prescriber’s license is revoked), to address heightened risks of overdose after an illicit opioid seizure.

Medical Information Privacy. Protecting the privacy of people’s medical information is a concern. While police do not have the kinds of legal constraints on sharing 911 or other police data with any partners involved in the response, medical providers do have legal barriers to sharing protected information, for example SUD or mental health related information. Additional guidance on privacy regulations in public health and public safety partnerships is located here.

Promising Practice Recommendations. With the Hub/Situation Table Model, there is an explicit requirement for non-disclosure agreements that partners sign to only take notes and be involved with situations that relate to the services provided by their respective agency/department. In addition, individual agencies determine if/when they disclose recognition based on the limits of their respective legal and ethical requirements. The Hub/Situation Table does not record or share any personal identifiable information, and, instead, connects agencies who can share that information with each other to ensure anonymity. 

Collaboration Between Multiple Agencies. Collaboration in human services involves professionals from different disciplines working together toward a common goal. It includes sharing resources, adapting practices, and strengthening collective capacity. Collaboration benefits both service providers and clients across sectors such as mental health, social work, education, addiction, policing, and corrections. These benefits include increased support for key issues, closing service gaps, strengthening agency capacity, improving service delivery, and enhancing community resilience and understanding.^[54]

Promising Practice Recommendations. Tap into existing coalitions with various organizational partnerships already developed. Educate and encourage these organizations to participate in the Hub/Situation Table Model. Effective collaboration requires structured support at both practical and systemic levels. To facilitate this, tools, training, and ongoing support are essential. Regularly requesting feedback from organizations and departments, tracking resource gaps using de-identified data, and disseminating educational resources for new table members will assist in maintaining relationships and offering essential services.

Data Collection and Ongoing Growth. The final element of the Hub/Situation Table model is data collection, which serves multiple purposes, including identifying systemic issues, supporting discussions, ensuring privacy, enabling evaluation, and aiding in model replication. To assist Hub/Situation Table members, Nilson, Winterberger, and Young developed guides outlining the benefits of systematic data collection, key variables to track, and best practices for conducting data-friendly meetings.^[55] These resources provide guidance for Table Chairs, participants, and data-recorders.

Promising Practice Recommendations. In Plymouth County, Massachusetts, new partnerships are periodically added to meet the gaps in services, thus improving the outcomes of the table situations. As an example, Plymouth County Hub/Situation Table noted that housing had been a factor in 64.3% of the situations presented.^[56] Due to this, the coordinator connected and trained participants from the region’s shelter/housing support provider. As a result, more individuals are able to gain access to the resources from this provider.

Direct Navigation to Program & Treatment. Process evaluations of diversion programs and previous program guidance emphasize the importance of the immediate connection to case managers and treatment providers.^[58] This process is typically described as a “warm handoff.” For example, officers divert the person to a case manager, who then can involve treatment providers and other recovery resources. Delays related to treatment and recovery resource connection, travel, and other barriers can reduce the likelihood of engagement in treatment.^[59]

Promising Practice Recommendations.

1. Dedicate program staff that are available at all times of day to receive referrals from officers and continue the program process.
2. Establish opportunities to provide for travel from contact location to relevant staff or vice versa.

Conditions to Maintaining Diversion Status. In pre-arrest, and more frequently in post-arrest diversion programs, there can be explicit conditions for maintaining diversion status. Since some form of arrest information is documented and “held in abeyance,” police and/or prosecutors can reinitiate the legal process if conditions are violated. For example, the LEAD program in New Bedford, MA generally requires individuals to complete the intake process within 7 days, unless participants are engaged with program staff and explain why they need an extension. MARI program in Madison, WI requires individuals to a) adhere to treatment and b) not re-offend for 6-months before the arrest is voided. Implementers must consider the implications of such conditions.

Promising Practice Recommendations.

1. Create minimal standards for treatment participation as a condition of the diversion status. Conditions are inherently coercive and if arrest is imposed, it ultimately leads to the harms associated with justice-system processes and incarceration. Treatment is unlikely within jail or prison and reentry after incarceration places people who use drugs at heightened risk for overdose.^[60]
2. Creating opportunities for re-engagement in treatment processes is central to pre-arrest diversion programs. Program staff can document information about the potential arresting offense and program progress through case management data, which then can be included as part of the intake assessment. According to studies, approximately 40-60% of individuals with a substance use disorder will relapse at some point in their recovery journey, increasing their risk of being caught possessing drugs and/or committing crimes related to their drug use.^[61] Individuals who have substance use disorder will have periods where they are engaged in treatment followed by periods where they return to using.^[62] Having this information on hand can help foster meaningful treatment re-engagement discussions after a relapse.

Potential for Net Widening. Net widening is a potential unintended consequence for any diversion program, especially post-arrest diversion. Net widening is well known in diversion research and refers to the idea of imposing a higher level of involvement or sanctions than would typically be the case in an effort to provide alternatives.^[63] For example, in post-arrest diversion programs, officers might respond to incentives created by program adoption to engage in more arrests of people who use drugs than would normally be the case in their routine discretionary decisions/ This often results in the unintended consequences of greater exposure to arrest, prosecution and incarceration for individuals and higher criminal justice-related costs.

Promising Practice Recommendations.

1. Monitor arrest data for unintended increases. Increasing frequency of arrests for offenses that would be eligible for diversion may be a sign that officers are engaging behaviors consistent with net widening and reducing the effectiveness of the program.
2. Wherever possible, emphasize the use of pre-arrest diversion, rather than post-arrest diversion. The arrest experience has negative consequences for people who use drugs.
3. Differentiate the target populations for pre-arrest and post-arrest procedures such that individuals that are ineligible for a pre-arrest diversion due to the offense at contact might be eligible for a post-arrest diversion. One aim of pre-arrest is to avoid arrest for individuals eligible and likely to be arrested; the goal of post-arrest is to avoid the adjudication process. Because the post-arrest diversion takes place at a more significant decision point (e.g., booking and potential prosecution), agencies may see it as more appropriate to have individuals with more serious offenses diverted at this point than through pre-arrest.

Officer Engagement with Program Practices. Pre-arrest (and post-arrest) diversion programs rely in most circumstances on patrol officers initiating the process. Departments can develop buy-in and support from officers in a variety of ways, including training and awareness efforts, but they can also promote engagement through policy and protocol.

Promising Practice Recommendations.

1. Regular review of arrest reports made for eligible offenses to determine if the case might have been appropriate for diversion. New Bedford P.D.’s protocol explicitly calls for district attorneys receiving arrest reports of potentially eligible cases to refer them back to the department for assessment of program participation.
2. Build appropriate diversion activities into the performance evaluation of officers. The evaluation should not be based on frequency metrics alone to avoid creating incentives for net widening and should also include an examination of the diversions relative to arrest levels and their appropriateness for the program.
3. Consider having regular meetings or a feedback loop that updates officers on the follow-up status of individuals they deflect or divert to help with buy-in and connection to the program.^[64] Not only will semi-regular meetings update officers on participants’ status, but it will also allow them the chance to offer feedback about the program to leadership. A review of Seattle’s LEAD program found that police officer buy-in and participation in that program was significantly improved when officers felt that they had a voice in the program and could give their input.^[65]