This feature is part of the eBook, “Evolving strategies to win the war on opioids.” Download your copy here.
The COVID-19 pandemic has occupied our minds and most aspects of our lives for the last year and a half, but the rest of the world’s problems didn’t get furloughed or even worked from home, as many of us did.
Fatal overdoses of opioids, especially fentanyl, continue to rise. Washington state experienced a 10% increase in opioid-related deaths in the first three months of 2021 as compared to the same period in 2020.
Both the Police Executive Research Forum and the RAND Corporation produced comprehensive reports on the role of law enforcement in dealing with the opioid problem. This article summarizes the major points contained in the reports.
OUD: Opioid Use Disorder
The misuse of opioids is so widespread that it has its own diagnostic code in the “Diagnostic and Statistical Manual of Mental Health Disorders,” known more conveniently as the DSM-5. Codes F11.10 through F11.21 describe opioid use disorder (OUD) in its various severities. An opioid is a drug derived from the opium poppy, to include chemically similar drugs produced synthetically. Opioids include the most powerful painkillers known to medical science.
Many OUD victims started down the path to addiction through lawfully prescribed drugs such as OxyContin. OxyContin, known generically as oxycodone, is a long-acting analgesic that requires fewer doses per unit time than other opioid painkillers such as Vicodin/hydrocodone. OxyContin is easily abused by grinding up the tablets to defeat the time-release mechanism, resulting in a short but intense “high.” Addicts resort to obtaining prescriptions from multiple prescribers and buying OxyContin or other opioids like heroin and fentanyl on the street.
MAT: Medication-assisted treatment
A major theme that appeared in the studies’ recommendations was to expand the availability of medication-assisted treatment (MAT) for OUD. Traditional substance abuse treatment modalities are mostly “cold turkey” approaches. The drug abuser is forced to undergo withdrawal to get treatment. Part of this method is to imbue the abuser with the withdrawal experience as a kind of object lesson so that they will not want to repeat the experience that will inevitably follow the resumption of drug use if they don’t overdose.
This approach often backfires. Many abusers experience the early stages of withdrawal when their drug supply is temporarily interrupted. They “get sick” for a bit, which only magnifies their resolve to get another dose and resume the addiction treadmill. Medication-assisted treatment with drugs like buprenorphine and methadone eases the pain of withdrawal and makes the treatment more tolerable and attractive. Abusers are more likely to accept MAT, and more abusers complete the MAT program.
For any treatment program to be effective, it must be immediately available. Overburdened and underfunded treatment programs often have a waiting list for available beds. The promise of a treatment program bed in a week or two might as well be no promise at all for the addicted user. If they can’t get into a treatment program the same day, they will go looking for their next dose of the drug as soon as they are free to do so.
Use the police as a delivery system
Many communities are already clamoring for police to turn over to mental health professionals the handling of incidents involving people who appear to be mentally ill. Opioid abusers can also be considered mentally ill, either due to their substance abuse, or because they suffered from some disorder that led them to abuse opioids. The RAND report advocated greater use of mental health professionals in law enforcement responses to opioid-related incidents. PERF’s take was more reserved. The PERF report also recommended the formation of partnerships and cooperatives with mental health and substance abuse professionals, but not by defunding police to finance such programs.
Projects pairing mental health professionals with police patrol officers have been successful, but continued funding for such programs is uncertain. This is an area where local governments need to commit to continued budgeting for mental health and substance abuse personnel to work closely with police and even ride as partners in patrol cars.
Expanding the patrol officer’s options in making an arrest may provide the necessary impetus for an OUD victim to start treatment. In most cases, an arrest is followed by booking at the local jail. If the officer had the option to offer a choice between jail and immediate entry into a MAT program, some users would opt for the program. Certainly, some will go for nearly any option that doesn’t involve jail. However, if the officer makes it clear that any lack of cooperation at the treatment center means an immediate one-way trip to the drunk tank and a “cold turkey” detox, the drug user has considerable incentive to get with the program.
The PERF report urged agencies to nominate at least one officer or other employee to be the coordinator for all things opioid-related. That officer should serve as the subject matter expert, in-service trainer, grant writer and intra-agency communications facilitator. That last role ensures that different factions of the agency aren’t at odds with their opioid-related efforts and that the agency is working in concert with other community resources.
Support harm reduction measures
Programs such as needle exchanges, safe injection facilities, methadone clinics and other harm reduction programs seldom sit well with law enforcement officers. They tend to view them as only facilitating further drug abuse and associated crime and social problems. The police don’t necessarily have to support harm reduction programs directly, but they can make them safer to operate. Predators who are either willing to buy the drugs received at the methadone clinic or who are just looking for another drug customer should be made to feel unwelcome by the police. This signals to addicts that the police are there to keep them safe, not to just arrest them.
It also helps to revise the ongoing narrative by having police describe opioid use as a medical issue and a type of victimization, and characterizing dealing and trafficking of illicit drugs as a predatory criminal activity. Encouraging officers to speak from this perspective reinforces their role as protectors, rather than only enforcers.
Officers should be encouraged to follow up and maintain a line of communications with people who have been involved in some opioid-related incident. This underscores the police role as caring and protecting and can encourage citizens to relay to the officer any potential intelligence they learn of.
Finessing community alerts
From time to time, police become aware that a supply of drugs, opioids especially, is unexpectedly potent and lethal. This usually stems from the adulteration of a drug with something considerably more powerful. Heroin that is even slightly salted with fentanyl can be deadly when consumed in what the abuser believes to be a normal dose. When opioid fatalities spike and responding police find samples of the new shipment in evidence, the first reaction might be to issue a press release to warn citizens of this new and deadly combination on the streets. Heavy abusers may interpret warnings like this as a form of advertising, as they are looking for the most potent high possible. Anyone charged with composing warnings like this needs to be aware of how they may be interpreted.
Make naloxone available
Law enforcement officers are often the first responders to an opioid overdose situation. Traditionally, police who recognized an opioid overdose would request assistance from emergency medical services personnel who were equipped with naloxone (brand name Narcan) that can reverse most overdoses. Overdose situations have become so common and the effect of the opioids so severe that the victim might die while waiting a few minutes for the ambulance to arrive. In many areas, law enforcement officers carry naloxone on patrol, often packaged in a nasal spray that can be administered by an officer with minimal training.
Adding naloxone to the law enforcement officer’s standard kit can also have a more self-serving benefit. A lethal dose of heroin is comparable to the amount of sweetener in a pink single-serving packet. A lethal dose of fentanyl can be a fraction of that, and just a few grains of another opioid analog called carfentanil can kill.
The overwhelming demand has had a predictable economic effect, resulting in short supplies and inflated prices. There was a point when a single-dose package of naloxone was priced well into three figures, placing it out of reach for many public safety agencies. Pricing is now around $37.50 per single-dose package, although there is still considerable variation from one place to another.
An administration of naloxone in the field should always be followed by a hospital visit. When naloxone is given to an addicted user looking for a “high,” the naloxone blocks the euphoria and puts them into immediate withdrawal. That’s not going to be pretty. Further, if the user has enough opioids in their system, they will resume the overdose when the naloxone wears off. They need to be monitored in a hospital, where this situation is best managed.
Expand field and laboratory testing
Officers don’t always test suspect drugs found in the field. Sometimes, this is because they don’t have any test kits. The most common test kits marketed to law enforcement use pre-measured chemicals in sealed glass ampules. The officer drops a bit of the suspect drug into a clear pouch, then breaks the ampule to release the reagent. A color change indicates the nature of the sample.
Test kits typically cost $2-$5 each, but they may not be immediately replenished when they are used up. If they are left in a hot patrol car, they may lose effectiveness and become unreliable. Chemists working for distributors of illicit drugs may produce chemical analogs of opioids that produce the desired high in users but won’t change the reagent color in the police test kit.
Some officers have become wary of handling suspect drugs, fearful of being overcome by a trace amount of a powerful opioid. They may not make an arrest or place charges for non-drug offenses because they lack the probable cause that comes from the result of a field test. The PERF report acknowledged this issue, but also remarked that “there is also strong evidence that the actual risks of an inadvertent exposure are far less than many believe, especially when officers receive proper training and equipment.”
One partial solution is to replace the chemical test kits with a handheld Raman spectrometer. These devices scan chemicals while they are still sealed in a clear container and analyze the reflected light for comparison against spectral profiles loaded in the device’s memory. A single device can be used to test for suspect drugs, explosives, and potentially hazardous materials encountered in the field, all without touching the substance itself, and the memorized profiles can be updated as new substances are discovered.
Even when field officers can test suspect drugs and be reasonably sure of their illicit nature, a confirmatory test performed in a qualified laboratory is needed before the substance can be introduced as evidence in court. Some crime labs have backlogs of work that all but guarantee that the analysis won’t be completed before the accused can have the charges dismissed via a “speedy trial” motion.
Take care of the caretakers
A law enforcement officer who saves the life of an overdose victim by administration of naloxone or some other method will likely feel pretty good about the outcome, but not all opioid-related incidents are going to end that way. Some opioid users will die, despite an officer’s best efforts. Innocents, such as children, may be exposed to illicit and dangerous drugs and either die or suffer lifelong consequences. Treatment program beds won’t always be available when they’re needed. Officers will encounter the same addicted people again and again, with the same song and only a different verse.
These incidents will affect even the most resilient officer, who may not speak up out of fear of ridicule or loss of respect by his colleagues. Law enforcement agencies need to have mental health assistance readily at hand for every officer, even those who do not ask for help. The ones who do not ask for help might be the cops who need it most. If periodic visits with a mental health professional are mandated for every officer, the stigma associated with being the weak one in the group is eliminated.
Officers can better respond to the opiate problem if they understand how opioids affect the body and mind. Training toward this goal can include practical exercises such as how to use personal protective equipment (PPE) properly, but officers can also benefit from training that gives insight into addictive behaviors. By understanding more about how addiction works, they are likely to see OUD victims as people, rather than just another problem for them to handle.
Data sharing
All these treatments and harm-reduction efforts require a demonstration of efficacy if they are to remain being funded. Part of the difficulty in data-sharing is the disparity of record types and availability between the different stakeholders. Police document their activities through routine and easily available reports, but the hospital that receives overdose victims may be limited by the Health Insurance Portability and Accountability Act (HIPAA) that restricts sharing of medical records. Treatment centers may have similar confidentiality issues that make it difficult to assess the efficacy of any program.
Sharing of data may require a new standard of data collection that is embraced by all the participants. The RxStat Operations Group is a partnership of 25 public health, safety and social service agencies in New York City. They have collaboratively developed a data collection method that tracks cases while not revealing the names or other identifying characteristics of individuals. Another program is the Overdose Detection Mapping application (ODMAP) developed by the Washington/Baltimore High Intensity Drug Trafficking Area (HIDTA). Agencies involved with the project update the location and nature of overdose cases in near-real-time, and all participants can view incident spikes as they occur, to shift remediation measures as needed.
In Wisconsin, stakeholder agencies were persuaded to share data by comparison of epidemiological and problem-oriented policing data collection methods. The “epidemiological triangle” focused on the disease-causing agent, the host of the agent, and the environment that fosters transmission of the agent. Problem-oriented policing uses a similar triad of potential offenders, targets of crime, and the availability of capable guardians to prevent crime. A Vermont chief of police, moved by these similarities, hired a full-time epidemiologist to help coordinate the response.
While the RAND and PERF reports are voluminous, they contain solid, actionable information for law enforcement agencies of any size.
