Expand First Response and Crisis Intervention Teams

Introductory Paragraph

Law enforcement officers and other first responders, such as emergency medical technicians, firefighters, and paramedics, are on the front lines of the illicit substance use epidemic. They frequently respond to drug overdoses and calls for services involving individuals with substance use and co-occurring disorders. As a result, a variety of law enforcement-led diversion and fire/emergency medical services (EMS)-led responses have emerged across the country. In partnership with substance use disorder (SUD) treatment providers, peers, and recovery personnel, these multidisciplinary programs are helping to reduce overdoses by connecting individuals to community-based treatment. Law enforcement and first-responder diversion program models represent a pivotal opportunity to redirect individuals with SUDs, mental health disorders, and co-occurring disorders away from jails or emergency departments and toward community-based treatment for substance use, mental health services, recovery support, housing, and social services.

Key Information

There are two approaches used by first responders- “deflection” and “pre-arrest diversion.” It is important to note that deflection and pre-arrest diversion are two sides of the same coin. They are complementary practices of a systems approach at the intersection of first responders, behavioral health service providers, recovery support, and community. These two types of program are related, but distinct. Deflection is the practice by which law enforcement or other first responders, such as fire and EMS, connect individuals to community-based treatment and/or services when arrest would not have been necessary or permitted. This is done in lieu of inaction when issues of addiction, mental health, and/or other needs are present. Deflection is performed without fear by the individual that if they do not “accept the deflection” they will subsequently be arrested. Pre-arrest diversion is the practice by which law enforcement officers connect individuals who otherwise would have been eligible for criminal charges to community-based treatment and/or services, in lieu of arrest. This diverts them from the justice system into the community. Some pre-arrest diversion programs have policies that mandate holding charges in abeyance until treatment or other requirements, such as restitution or community service, are completed, at which time the charges are dropped. Although pre-arrest diversion is facilitated by justice system stakeholders (usually police and sheriffs), clients are diverted to community-based services. Pre-arrest diversion programs should not be confused with prosecutorial diversion, which occurs after individuals have already been arrested and become involved in the justice system. In contrast, pre-arrest diversion occurs before the filing of charges. These programs are collaborative interventions connecting public safety with public health systems to create community-based pathways to treatment and services for people who have SUD, mental health disorders, or co-occurring disorders. In partnership with SUD treatment providers, other service providers, peers, deflection specialists, and recovery personnel, these multidisciplinary programs help reduce overdoses through connection to community-based treatment and services.

The Five Pathways to Treatment Model.

In 2014, Treatment Alternatives for Safe Communities (TASC) and Center for Health and Justice (CHJ) developed the first iteration of the Five Pathways to Treatment. This offered different pathways for deflection that first responders could use to move someone from the justice system at the point of contact with law enforcement to community-based treatment. Each pathway has unique characteristics that make it appropriate to address particular problems such as SUD, mental health disorder, homelessness, and other issues. Identifying and naming these pathways created a common language for practitioners to use in the new, emerging field of deflection. For each pathway listed below, the targeted population or circumstance appropriate for the pathway is elaborated.

• Self-Referral: Drug–involved individuals are encouraged to initiate the engagement with law enforcement without fear of arrest, and an immediate treatment referral is made.
• Active Outreach: Participants are identified by law enforcement, but are engaged primarily by an outreach team, often with a clinician and/or a peer with lived experience, who actively contacts them and motivates them to engage in treatment. Individuals with SUDs are targeted population.
• Naloxone Plus: A first responder and program partner (often a clinician or peer with lived experience) conducts outreach specifically to individuals who have experienced an overdose recently to engage them in and provide linkages to treatment. Individuals with opioid use disorder are the targeted population.
• First-Responder/Officer Prevention: During routine activities such as patrol or response to a service call, a first responder conducts engagement and provides treatment referrals. If a law enforcement officer is the first responder, no charges are filed or arrests made. The targeted population are persons in crisis, or with non-crisis mental health disorders and SUDs, or in situations involving homelessness or sex work.
• Officer Intervention: (applicable only for law enforcement) During routine activities such as patrol or response to a service call, a law enforcement officer engages an individual and provides treatment referrals or issues noncriminal citations for that individual to report to a program. Charges are held until treatment and/or a social service plan is successfully completed. The targeted population are persons in crisis, or with non-crisis mental health disorders and SUDs, or in situations involving homelessness or sex work.

Relevant Research

PTACC published a research report on the benefits of diversion programs. Key findings indicate that despite the lack of large-scale and multi-site evaluation efforts, there are important trends emerging from early research on pre-arrest diversion initiatives across the US. Here are some key results drawn from empirical research on a variety of pre-arrest diversion programs.

• Pre-Arrest Diversion represents the first intercept with the criminal justice system, making it a prime opportunity to redirect adults with mental health conditions and substance use disorders from jails and connect them with community-based service providers.
• The majority of adults booked into local jails require mental health services and treatment for SUDs, which are typically not provided in local facilities.
• Behavioral health conditions are associated with repeat criminal justice contact with SUDs being the strongest predictor of jail readmission.
• Pre-arrest diversion programs assess and address behavioral health needs associated with continual involvement in the criminal justice system.
• Preliminary results indicate participants who fully engage in pre-arrest diversion programs tend to have low rates of recidivism for extended periods of time.

Impactful Federal, State, and Local Policies

Communities are subject to state laws and regulations that directly impact their ability to institute pre-arrest diversion and other crisis response strategies. Often, strategies are locally designed and implemented and do not operate in a legal or political vacuum. Laws that grant local officials noncriminal responses to crises can propel diversion efforts or provide alternative, supplemental crisis responses. Laws that require criminal responses or otherwise circumscribe when and how non-law enforcement responders are able to intervene can impede them. Current statewide barriers exist in pre-arrest diversion and crisis response strategies.

R Street has a Statewide Policies report which reviews legal status and legislative actions in all fifty states relating to pre-arrest diversion and crisis response. Policies relating to pre-arrest diversion and crisis response include:

• Emergency Mental Health Hold laws which authorize certain first responders to take an individual experiencing a mental health crisis into a form of civil custody in order for them to be evaluated by appropriate mental health or medical personnel.
• Protective Custody. These procedures operate as the substance use analog to emergency mental health holds by authorizing first responders to place an individual experiencing an acute substance use episode in temporary civil custody.
• Citation Authority statutes permit or require law enforcement officers to issue a citation to individuals alleged to have committed certain specified offenses, instead of placing them under arrest, booking or detaining them.
• Good Samaritan laws offer immunity from arrest, criminal charges, prosecution or conviction for limited, drug-related offenses as an incentive for individuals to call for assistance for someone experiencing a suspected overdose.
• Ambulance Transport laws and regulations can influence where emergency medical services may take an individual experiencing a crisis, potentially by requiring transport to a hospital emergency department or otherwise discouraging the use of alternative destinations.

Illinois Senate Bill 3023 is one example of legislation on deflection. The 2018 Community-Law Enforcement Partnership for Deflection and Substance Use Disorder Treatment Act, authorizes and encourages local law enforcement leaders to partner with treatment and community members on programs that deflect individuals who have overdosed or who have substance use problems away from the justice system and into addiction treatment services.

Available Tools and Resources

SAMHSA provides a guidebook titled, "Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice: A Step-by-Step Guide.

Crisis Intervention Team International published "A Best Practice Guide for Transforming Community Responses to Mental Health Crises."

The National League of Cities offers "Working Across Systems for Better Results: City Efforts to address Mental Health, Substance Use and Homelessness Through Emergency Response and Crisis Stabilization" highlighting case studies in cities in Kansas, Texas, and West Virginia.

The Center for Prison Reform published "Jail Diversion Programs in America."

Advanced Recovery Systems University provides an online library of webinars specific to mental health and substance use within the first responder community.

Promising Practices

• Alabama -- The Mercy Project. Walker County had the fifth-highest per capita rate of overdoses in the United States and the highest overdose rate of any county in the state. As a result, Sheriff Nick Smith wanted to create a program to help people struggling with SUD and reduce the recidivism rate resulting from substance misuse. Interested participants fill out an application and then receive consultation. People are ineligible for program entry if they are facing drug charges or have outstanding warrants. However, the consultation allows a potential participant to turn in any drugs or drug paraphernalia without the threat of arrest, and although the individual must still enter the justice system, drug court is an option. If the person is accepted into the program, consultation determines individual treatment needs.

• Illinois -- Safe Passage. People who realize they need help can go to one of the participating law enforcement agencies in Lee and Whiteside Counties without fear of being arrested. If they ask for help with their drug addiction and turn in their drugs, they will be placed in a treatment facility, usually within 24 hours. Once initial paperwork is completed, persons will be paired with a volunteer who will guide them through the process. Safe Passage partners with treatment centers throughout Illinois and the Midwest.

• Maryland. Safe Stations is an innovative new program in Anne Arundel County. It shifts barriers to treatment for those members of our community who are eager to recover from drug addiction. Persons seeking treatment for addiction can visit any police or fire station across the county, day or night, to dispose of any paraphernalia and find assistance gaining access to care.

• New Hampshire. The Safe Station Program offers help to anyone with substance use disorder at any Manchester Fire Department. The firefighters will arrange for or provide a medical assessment within their scope of training. If there is cause for concern that there is something else medically wrong with the patient, transportation to an appropriate level medical facility will be provided. Each individual seeking assistance will be required to drop any needles and/or paraphernalia into a collection bin located at each fire station prior to speaking with coaches or seeking treatment.

• New York. Hope Not Handcuffs is an initiative started by Families Against Narcotics (FAN). It aims to bring law enforcement and community organizations together in an effort to find viable treatment options for individuals seeking help to reduce dependency with heroin, prescription drugs, and alcohol. A person struggling with any drug addiction can come to any of the participating police agencies and ask for help. They will be greeted with support, compassion, and respect. If accepted into the program, the individual will be guided through a brief intake process to ensure proper treatment placement.