Public Health and the Criminal Justice System

Approximately two-thirds of America’s incarcerated population suffers with untreated or undertreated substance use disorders, and many of those individuals commit several crimes related to drug use and addiction on a daily basis prior to being incarcerated. To end the opioid epidemic in the United States we not only need to bolster our health care and public health response to substance use disorders, we need to engage the criminal justice system as a specific touchpoint for public health intervention in communities and states across the country. The principal argument in the chapter is that while individuals with opioid and/or other substance use disorders should get treatment before ever being involved in crime—if they are justice-involved, it is imperative that the criminal justice system serve as a belated but necessary public health and health care intervention supportive of treatment, recovery, and prevention of addiction.

A Comprehensive Approach to Addressing the Opioid Crisis

An effective public health response to the opioid crisis includes understanding the many different contributors to the crisis and the need for a comprehensive versus piecemeal approach to addressing it. In this chapter, the authors add to prior work that describes the essential elements of a comprehensive response to the opioid crisis. Building on their commentary published in 2018, the authors state that there is a need to propel the governmental public health agency response well beyond its traditional role as data broker and convener of primarily health care partners toward a more contemporary and much-needed focus on the primary prevention of opioid misuse and addiction that forges new ground with social service agencies, employment and housing programs, law enforcement and corrections, addiction treatment providers and substance abuse prevention agencies, and many other sectors equally engaged in ending the opioid crisis.

The Role of Public Health Agencies in Convening Partnerships and Collaborations to Respond to the Opioid Crisis

This chapter presents the role that public health agencies play as leaders and/or conveners of partnerships and collaborations in responding to the opioid epidemic at the state and local levels. “Partnership” is defined as a continuum of relationships between two or more entities ranging from informal engagement around topics of interest to formal, structured memoranda of understanding or contracts that govern resource exchange, the various roles and responsibilities of the partners, and performance metrics or other accountability metrics. The work of partnerships around opioid use and addiction requires intentional engagement of a variety of groups, many of whom have not traditionally worked with public health agencies before. Examples of various partners and their roles in ending the crisis are presented. The chapter includes a discussion of what makes for successful partnerships and key considerations when engaging collaborators in developing shared goals and objectives.

Engaging Payers to Transform Treatment of Substance Use Disorders

Changing how addiction treatment is paid for is critical to improving the quality of these services and increasing patient access to more effective care. Currently, several aspects of the payment system for substance use disorder treatment services perpetuate outdated care models through perverse incentives that hinder adoption of best practices—for example, fee-for-service payments that incentivize high-intensity acute treatment episodes rather than chronic disease management. These payment practices are undergoing scrutiny and many changes have already begun to transform treatment policies. Recognizing a turning point for the engagement of third-party payers and an impetus for progressive payment reform, Shatterproof, a national nonprofit organization, partnered with health insurers to advance the substance use disorder treatment system in the United States and developed eight principles of care. This chapter describes this work and changes to payment models to better support patient needs, community and public health, and the interests of private insurers and health care providers.

Introduction

A public health guide to ending the opioid crisis is needed to help frame efforts to go “upstream” and address the root causes of substance use disorder and addiction. In this introduction, the editors provide an overview of the book’s three parts (Fundamentals and Frameworks; Connecting Clinical Perspectives and Public Health Practice; Moving Upstream—Prevention, Partnership, and Public Health). While a great deal of prior work has focused on the clinical aspects of the opioid epidemic, more is needed to address the community-level aspects, including addressing the root causes of addiction, and where public health professionals can intervene at the primary, secondary, and tertiary levels of prevention. The case is made for increasing effort in the areas of primary prevention and policy change to support effective opioid stewardship at the local, state, and federal levels. The editors conclude by stating that communities will not “arrest” or “treat” their way out of this crisis. Instead, we have to redouble efforts to prevent addiction and address the clinical and community aspects of what drives an individual to become addicted in the first place.

Public Health Surveillance and the Opioid Crisis

The roles for public health surveillance are well established in the infectious disease surveillance literature; however, as they relate to noninfectious diseases and more specifically the current opioid epidemic, there is little standardization between states on what is being surveilled and there is a lack of definitions for some of the most important elements of the crisis, such as what constitutes an overdose death from opioids. Without standard definitions and processes, public health practitioners may develop response protocols based on incomplete data. As such, the opioid epidemic presents many challenges for public health surveillance by limiting the ability for case-based follow-up and stymies creation of a variety of shared indicators and metrics that make it difficult to capture the true burden of disease. In this chapter, the authors review prior surveillance activities related to substance use and share emerging consensus on opportunities to improve the surveillance among states and territories.

Building Effective Public Health and Public Safety Collaborations to Prevent Opioid Overdose at the Local, State, and Federal Levels

This chapter describes the public health role in the Overdose Response Strategy (ORS), a public health/public safety collaboration between the Office of National Drug Control Policy’s High Intensity Drug Trafficking Areas program and the US Centers for Disease Control and Prevention. The mission of the ORS is to reduce opioid overdose incidents by developing and sharing information about heroin, fentanyl, and other opioids across state and federal agencies. In addition, the ORS supports states in implementing evidence-based strategies to combat the opioid overdose epidemic, especially where those strategies are informed by local data. Teams comprising one drug intelligence officer and one public health analyst work in each of the 24 ORS states. Challenges and opportunities of public health and law enforcement collaboration are described.

Five Key Strategies for an “Upstream” Approach to Preventing Opioid Misuse and Addiction

In this chapter, executive leadership of Trust for America’s Health (TFAH) and Well Being Trust describe the need to move “upstream” in prevention efforts to address opioid and other drug-related deaths. This means addressing the broad social and economic factors that drive substance misuse and addiction, including racism and other forms of discrimination and poverty. TFAH and Well Being Trust’s National Resilience Strategy highlights the causes of “deaths of despair” and promotes prevention efforts that are aligned along a spectrum from early childhood throughout all stages of adulthood. This chapter highlight five major strategies for public health practitioners; focusing on children and their families, assisting adults who may be at elevated risk, incorporating routine screening in multiple settings, supporting community health and social service resource availability and promoting equity in broad terms.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a Public Health and Prevention Strategy to Address Substance Misuse and Addiction

SBIRT (screening, brief intervention, and referral to treatment) is a comprehensive and integrated public health approach that aims to address hazardous and harmful substance use in patients through universal screening for substance misuse risk and the subsequent delivery of appropriate evidence-based interventions to reduce this risk. SBIRT has been implemented throughout all 50 states in a wide variety of medical settings. Thus far, over one million people across the country have been screened for substance use using SBIRT practices. SBIRT has also been implemented internationally. SBIRT is predicated on the premise that, like other chronic diseases, substance use falls along a clinical spectrum ranging from low to high risk. Patient substance use can be stratified across increasing risk levels that correlate with an appropriate disease state extending from abstinence to a diagnosable substance use disorder. Implications for treatment and prevention programs are discussed.

Non-Opioid Alternatives to Managing Chronic Pain

While public health practitioners generally focus on the primary prevention of illness and disease by developing programs and policies that promote health and well-being, an understanding of chronic pain and its treatment is important for public health professionals working to address the opioid crisis. There are unintended consequences of well-intentioned policies that may restrict prescribing behavior or otherwise interrupt or change access to opioids. For example, one consequence of expanding state prescription drug monitoring programs has been concern by providers that “legitimate” pain patients may be subjected to increased suspicion and stigma and not able to obtain needed medications. State and federal efforts to shut down “pill mills” are vital to addressing diversion and criminal behavior, but pain patients who are also seen in these clinics may have an interruption in their treatment or access to medication. Understanding chronic pain treatment and non-opioid alternatives to pain management is an important part of developing sound public health policies to prevent opioid use disorder and its sequelae. This chapter presents these alternatives and the evidence base for each.