Partnering to Prevent Overdoses

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, public health, public safety, and harm reduction working together to support overdose prevention activities.

CATHY SLEMP:
Anytime we approach folks to think about how to do something differently, it's challenging because everybody's dealing with workforce issues and workload issues.

BRANDON DEL POZO:
It's true that public health is very frustrated with the criminal justice system because when you look back on its reaction to drugs, it's been so flat footed.

JOY RUCKER:
Our traditional treatment—abstinence-based—approach has not worked.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Overdose prevention depends on partnerships to be successful. But how do you get public health, public safety and harm reduction on the same page? They all want to reduce overdose, but often differing approaches can create conflict and slow progress. Our guests today know the challenges of getting everyone to work together and the benefits that can result when they do.

Brandon del Pozo is a former New York City police officer who now is an assistant professor of Medicine and Public Health at Brown University. Joy Rucker has a lifetime of experience in harm reduction and is part of the Black Harm Reduction Network. They're along later.

But first, we visit with Dr. Cathy Slemp, the former state health commissioner in West Virginia and current co-chair of a new statewide coalition called the West Virginia Hope in Action Alliance. We kicked off our conversation by asking her if these partnerships are common today.

SLEMP:
I have to say no, because I think we often all operate in our own sectors and our silos. We tend to speak with those with similar views of the world or approaches to problems. And right now we're also in a world that is so polarized, and we become polarized in our own expertise and in our own worldviews. You know, people are busy, and they deal with very diverse situations. So, I think it's easy to separate and kind of do our own thing, but we really miss opportunity to connect and really be more effective by really listening to each other, learning with each other, and moving forward together.

JOHNSON:
Everyone is definitely busy, and you've outlined the problem. What is the solution?

SLEMP:
Yeah, there's lots of ways you can approach it and it has to be relevant to your own community. But I think first is creating space to really understand each other's work can be really helpful. So, if we can go out and learn from and with law enforcement and harm reduction folks, if we can invite them in.

I've seen some of our communities have really great success by bringing folks into the harm reduction program: walking them through it to really understand experientially what's happening and the importance of relationships and how change happens, getting our public health folks out with law enforcement or working with them to really hear what they're dealing with every day on the ground. So, I think that creating space can be really helpful.

I think we also have to think about the language that we all use. You know, words don't always mean the same in our different communities. So, surveillance in law enforcement might mean something very different than surveillance in public health, or justice gets used in different ways. I think beginning to hear and understand how we use terminology and then just bridging those different worldviews to kind of understand where the other person is coming from, and why they might react the way they might react, or why they might have an underlying belief or view that provides that approach. So, I think we have to really just listen to each other and hear and understand and work to align efforts where we can.

JOHNSON:
How do you go about that? How do you make those connections that get people talking to each other so that communities can benefit?

SLEMP:
Yeah, you know, I think it starts with building relationships, especially at the leadership level, so that way you can kind of trust each other and begin to listen and understand. So whether it was really trying to get to know our director of corrections, or our homeland security folks, or others. We had worked together a lot in public safety with emergency preparedness, and so those relationships that are already established through other work can feed into this one as well. So, I think that's one area.

I think partnering around policy and working with our colleagues at the policy level—whether it's that of pharmacy, or public safety, or others—to really address how do we set policy around naloxone distribution, or around drug paraphernalia, or Good Samaritan laws. So, that kind of partnership that we can use to find common ground and move forward—that helps all of our work advance.

I think the other areas, it's just so important to keep revisiting and coming back so it's not a one-time thing. It really is ongoing work and checking in with each other regularly.

JOHNSON:
We're talking to you because you bring the public health aspect to this conversation. What does the team in public health in the agency need to keep in mind as it goes about trying to facilitate these connections?

SLEMP:
I think besides building the relationship is having specific concrete solutions that you can implement together and develop together.

Some of the interventions that we were able to get operationalized included things like quick response teams. So, that was a partnership between public health, and law enforcement, and EMS, and, in some settings, faith-based communities so that within 24 hours after an overdose or an attempted overdose—and now expanding that out to people who are at risk of overdose—they can be referred in.

A team, a cross sector team, was made of a law enforcement person, a public health person—the law enforcement was plain clothes—a public health person, in some settings a faith-based leader to kind of link to talk about what gives life meaning for you, and social work so they can understand what are the other issues going on. They meet with that person to say, what's the context this happened in? What can we help you with? How can we form relationships? And from there, begin to work more holistically with the person.

So, we now have 38 QRTs [quick response team] across 35 counties, or something along those lines. So we have a lot of those that we need to keep building more of.

JOHNSON:
I assume that some people who are involved in these conversations need to be convinced that all of this extra work really is worth it in the end.

SLEMP:
Yeah, you know, I think anytime we approach folks to think about how to do something differently, it's challenging because everybody's dealing with workforce issues, and workload issues, and—especially this arena—compassion fatigue, and burnout, and frustration. But we also know that doing the same thing the same way gets the same results.

And so, sometimes I think we just have to kind of work across to say, okay, let's try something different. Here's some evidence this has worked in other communities. Let's try it, see what works, see how it applies to our community, and go from there. And I think over time, if you can begin to get that buy-in, not just at the leadership level but on the street through experience, then people begin to be more open to it.

And then you have to look for champions—folks that have made that shift or are seeing it differently, who can speak peer-to-peer to each other. You know, it's the police officer who has worked in the harm reduction program and really made a difference for that program, met folks on the street where they are, understand the concept, and can speak practically about it to partners. Because I think we all hear best from our peers.

JOHNSON:
If you work at a public health agency, and you're listening to this, and you haven't tried it yet, what do you need to keep in mind? What are some of the considerations that need to be examined before you get started?

SLEMP:
Yeah, I think it takes time and it takes staffing. So that's going to be an important piece. It takes funding and thinking about use of funding creatively. It's always helpful to reach out when you're developing proposals to partners and to use opportunities to think creatively about how you can approach it together.

And I do think messaging matters—the words that we use and the messages that we use with partners and with communities. So I think there are some things, like really starting with why, using shared values. We all care about safer communities, and common good, and innovation, and practicality—those can be really helpful as starting messages. Focusing on solutions, not the problems, can really be more motivating.

JOHNSON:
Some people listening right now are probably doing this work, but they've found how hard it is to keep everyone together on the same page. Do you have any advice to them about how they can sustain these relationships among all of these different entities?

SLEMP:
I think one of the most critical things is regularly reaching out proactively.

I think of a local harm reduction program that, from early on, really took the initiative to constantly go out in the community and chat with business owners: what do you make of it, is it having any implications for you? Talking to their law enforcement folks to proactively say: are there concerns that you have that are rising, are there positive effects that you're seeing? Just to keep those channels open so that you hear issues early and can address them, whether that be addressing it through changing how you're doing something or explaining a piece of the work that you're doing and why it might be that way.

So, I think the first thing is just proactively doing that. That was a community that actually had less pushback on harm reduction because of that, I think, than some other communities.

JOHNSON:
Building relationships, keeping people together on the same page—it's a lot of work. So, wrapping up here, tell us why it's necessary.

SLEMP:
At the end of the day, we do a better job at saving lives, and creating safer and healthier communities, and creating opportunities for all of us to thrive if we understand each other and we do that work together.

JOHNSON:
Brandon del Pozo spent 19 years as a cop in New York City, then four years as chief of police in Burlington, Vermont. Along the way, he decided to take that experience to Brown University, where he now tries to build partnerships between police and public health.

DEL POZO:
There are two reasons why a good relationship between public safety and public health is critical to the overdose crisis, as hard as it can be in many cases to attain.

One is that so much of problematic drug use manifests as a public safety problem. The things that people resort to, to stay supplied with drugs—from sex work to property crimes, to more serious crimes, as well as things like homelessness and domestic violence—all circulate around problematic drug use. And so, you'll find police getting called to these things even if drugs are decriminalized or not. There'll still be police calls for service for things that people are doing to stay supplied with the drugs. And so, to have police enter those situations with an understanding about addiction, about the best responses, how those often aren't punitive responses—that's critical, that requires a partnership.

And then second, police are and will continue to be one of the biggest sources of government infrastructure out in our communities. When you need to get to the scene of something quickly 24/7, 365, regardless of weather or circumstance, and you need to get the government out there, police, fire, and EMS are the ingredients to that response. And so, to rebuild a system that that doesn't include police is to engage in a years-long effort that probably won't work when today we have this apparatus that can get out there. And when it gets out there, we want it to do as much good as possible and as little harm as possible—and that takes a good partnership.

JOHNSON:
So, we're talking about breaking down silos. That seems to be the theme here.

DEL POZO:
Unfortunately, it's fair to say over the last several decades that public safety, public health, harm reduction, even fire, EMS, and police have evolved in silos. That tends to be how funding works, it tends to be how bureaucracy works. And, in theory, a lot of these actors had in mind the idea that their jobs were in fact different. You know, police deal with “crime,” and public health and harm reduction deals with things like substance use and overdose. But we see in practice that the overlaps are really quite strong and persistent. And the silos might be bureaucratic, but in practice it's anything but a silo. And we need the bureaucracies to acknowledge that.

JOHNSON:
Are silos the only barrier getting in the way of a better partnership between public health, public safety, and harm reduction?

DEL POZO:
I think we have to overcome some cultural conditioning across the sectors to truly get this right. I mean, police have often the biggest budget among their peers and they have the criminal law to fall back on, and that puts them in a position of not always having to compromise or sacrifice or change the way they see things. That's a problem.

And if you want to know who thinks it's a problem, ask the rank-and-file officers that are responding to overdose again and again, responding to problematic drug use again and again, and knowing that what they're doing isn't working. I've talked to countless officers who say, listen, I always feel like I'm two steps behind. I feel like what I'm doing is futile. It's not working, but it's what I'm being told to do.

I think that acknowledging that, giving them reasonable alternatives, or taking some of that responsibility and onus away, and then having that cultural transformation not only happen in the field but off the chain of command is a big obstacle and an important thing to address if we want to get this right.

JOHNSON:
We mentioned in the introduction that you're a professor at Brown University, but for a long time you were in law enforcement. Talk about switching careers and how it's impacted your thinking, your approach, to this whole area of policy.

DEL POZO:
I became a police officer in 1997 when crime was finally getting under control in New York City. It was a terrible, terrible place to live as a teenager. I had high school friends who were killed randomly in shootouts by stray bullets. I've been robbed on the train. A teacher was assaulted on the way home from school and sent to the hospital.

So finally New York City is seeing a crime reduction, and there was a belief that policing had something to do with it, and it did. It wasn't everything, but it did contribute, and I wanted to put my time and effort into that. But rising through the ranks and going to graduate school at the same time, I began to see two things: that policing was a very powerful institution, but it was more responsive to politics than to science; and a lot of the shortcomings in our approach to overdoses—which was the number one cause of death, even more so than homicides—was not a failure of science or evidence. It was a failure of systems, it was a failure of bureaucracy, of governance.

And so, after being a cop for 23 years, all the way up to the rank of chief in Vermont, I said, you know, I could try to piecemeal make change agency by agency, or city by city, or town by town as I go to be a chief. But I've been doing that for a while, I'll get a little tired of it. Or I could try to take a step back and a step up and look at how evidence and systems come together in government and really try to attack this issue from the meta level. Maybe even have a bigger effect, maybe give people alternatives that they can implement across several agencies. And that took me headlong into research. And it's been extremely challenging, but it's so gratifying.

JOHNSON:
Most of the people listening to this conversation right now are working in public health. So, speaking to them, how can they facilitate a better partnership with law enforcement on the issue of overdose?

DEL POZO:
It's true that public health is very frustrated with the criminal justice system because, when you look back on its reaction to drugs, it's been so flat-footed. And I mean, there's all sorts of evidence that what it does increases harm rather than helps. But the fact that there's so much latent potential energy and potential for real progress in the criminal justice and the systems of policing means that you got to make that jump.

And the irony is it involves the first tenant of harm reduction, which is meeting people where they're at, right? Which is going to police understanding, from a leadership perspective down to the rank-and-file, what their thinking is, what their priority is. And I say, you're going to find, in principle, a lot of overlap, right? Cops that are willing to try new things as long as they reduce crime, as long as they protect lives. And they need to be reassured that it makes a difference. But you don't come in there, gangbusters, shaking your finger and blaming them and saying you've screwed everything up, now give us the range.

Say, no, we're in this together. I want to understand your way of thinking and understand your sensibilities, and let's work toward the evidence that's worked toward the science, right? And I think that if you come with that approach, there's a lot of police leaders in America that are hungry for it, right. They're hungry for it, but they worry that the relationship has been oppositional when, in fact, it could be collaborative.

JOHNSON:
So like any other relationship, then, it really has to do with a few things: listening, understanding who you're talking with, being flexible. Are those the ingredients?

DEL POZO:
Police have to understand that, although they feel like they've had a rough ride over the last few years, that there are historical precedents for that and there are partners out in the community don't necessarily see it that way.

You have harm reduction agencies and public health agencies that have a tiny fraction of the police budget, that have to fight for funding, that see budget cuts whenever there's austerity. And they look at the police and say, listen, you guys and gals are saying how hard it is, but your level funded or increased every year. You're getting all the funding and you're still lionized and depressed. And, you know, the pendulum is swinging back in your direction again, when we look at law enforcement and the initiatives coming out of a lot of legislatures. And I think that the police have to understand that that's how they're seen, have self-awareness about how other people see their situation.

And then on the other side of things, I think that the people coming to work with law enforcement and police need to understand that police—every single one I've ever talked to—has the goal of saving lives. None of them say, you know, listen, I wake up to make life harder on people and put people in jeopardy. I think they genuinely don't see how a lot of what they do doesn't accomplish that. And I think that's because they've lived in that bubble and haven't engaged in the collaboration. And I think if you can show them how to partner and actually save lives, I think there's an appetite for that. But it doesn't come from fighting each other, it comes from collaboration.

JOHNSON:
How do you sustain this sort of thing given the realities of being in any community where priorities, leadership, funding, politics are changing all the time?

DEL POZO:
One of the most striking things about my time as the chief of police of Burlington, Vermont, is that I was asked by the mayor on day one to lead a public health response to the opioid crisis. I wasn't expecting that role. It turned out that it was pivotal in my life, and I embraced it.

But I will say this: I got there thinking—when the mayor asked me to do it—why isn't he asking the department of health to do this? And that's because, despite Burlington being a city of 50,000 in a metro area of 200,000, despite it being the biggest city in Vermont, despite it being a very, very progressive overtaking city, Burlington did not have and never had a department of health. And it was so striking to me that a small to midsize city in America has no department of health. And the idea that the police and health are in opposition, fighting for dollars, when there isn't even a public health department, I think shows big gaps across America.

To get this right, we need to really at the municipal level—not just at the state level, but the municipal level—cultivate our public health capacity. In a perfect world, the mayor of Burlington never would have asked his new chief of police to run the public health response to the opioid crisis, because he would have had a department of health in which to do so. And I think that's playing out in countless, countless cities across America. There's just—the capacity is not even there.

JOHNSON:
If agencies want to solve this problem, they have to look locally, because every department is different. If you've met one, you've met one, right?

DEL POZO:
Yeah.

JOHNSON:
The bridging the gaps, the relationships, all of this: as you've thought about it, as you reflect on it and look ahead, why do we need to take the time to get this right?

DEL POZO:
I think that the opioid crisis and our struggles in keeping overdoses down are an example of a much larger issue we have to tackle in American government, which is our bifurcation of safety and of health, and our bifurcation of different offices and systems and government, where they're all in the silos that we talk about.

The overdose crisis is the most acute evidence of a much more general problem, which is that when we're faced with a crisis, we just take a lot of different agencies and throw them at the crisis without asking them to really take the evidence and use that evidence to work together to make meaningful progress. I think if you really follow the science of overdose, and you follow places that have made strides in reducing overdose, or made strides in elevating public health, it's always been collaborative. It's always been by breaking down silos. And when you follow the evidence, the evidence is going to tell you, you need fire, police, EMS, harm reduction, public health, the medical system, schools, and community groups to work together, right. That's not just ideology. That's what the evidence tells you about what works—when you take the evidence and build a system, it's going to be this multi-layered, multi-jurisdictional, multi-agency system.

I would argue that if we would have responded to COVID better, had we done a better job up front of responding to the opioid crisis, we would have built the relationships and the muscles that gets the type of interagency collaboration that we need when crises happened.

JOHNSON:
Joy Rucker got into harm reduction during the HIV crisis when too many of her friends were getting sick. It was the lack of resources available to help them that led her to a career of working with people in the communities where she's lived. Today, she's a consultant on these very same topics, and she's not surprised that it's so hard to get all sides together.

RUCKER:
No, no, I'm not. There's so much stigma around using drugs. And people have a perception about people that use drugs. And if they overdose a few times, you know, I've heard law enforcement say, why should I bother? They're just going to go and use again and overdose.

They don't really understand the full spectrum of what the issue is. It's not that simple. I don't think anybody wants to overdose. But it is what's going on, and people should not be punished for what they put in their body. So, I think it's a lot of education that has to happen.

JOHNSON:
I think we should get into the barriers to getting everybody together. So, let's do that by group. Start with public safety.

RUCKER:
So, public safety. You have to have someone that is a champion within public safety to come to the table, and then talk to other public safety members in a way, in a language, that they understand. And I think the biggest thing is, when we first started doing syringe exchange, our approach was, look, we want to make sure you guys are safe and you don't get stuck by syringes. So, if we're doing syringe exchange, you know, it's most likely people aren't going to have old syringes in their pockets if you stop them and search them. So, from our perspective, it was like, look, we're concerned about your opportunity to get stuck with a dirty needle, and how can we reduce that harm?

JOHNSON:
Basically, looking for common ground?

RUCKER:
Yes, yeah.

JOHNSON:
Public health is next on the list. Are there any difficulties getting public health on board with this idea?

RUCKER:
What's difficult in a lot of places that I see is that public health has decided that they are the experts in doing harm reduction and doing syringe exchange. And they've set it up in a way that people will not go into a public health department to exchange syringes.

So, I think they would be better suited in funding community-based programs that have relationships with people and that they're—in communities where there's no stigma, if I come into a building that's just in my community and we're providing a number of different services—that no one's going to pinpoint me as an injector.

JOHNSON:
The last group is harm reduction. Do they have any issues to address?

RUCKER:
Oh, sure, for sure. I think that we are at this place where we have a number of underground harm reduction programs working, syringe exchange programs working, and I'm not always sure that everybody is using universal precautions and providing the safety that they need for themselves in order to do the syringe exchange. So yeah, I think we still have a lot of work to do.

JOHNSON:
If I asked you right now to get all three sides together, how would you do that? How do we get them working side by side?

RUCKER:
I mean, there certainly is movement through CDC funding, the National Harm Reduction Coalition, NASTAD, and University of Washington to provide technical assistance to harm reduction programs. I think that the money is going to flow through public health departments from the opioid settlement money. So, there's opportunity there for them to partner with community-based organizations.

I think people just have to care about the issue and understand that people are really dying and get past the stigma of people using drugs. We are not going to stop people from using drugs. We have how many years of a war on drugs that has done absolutely nothing but incarcerate people.

JOHNSON:
When someone calls you to get your help addressing this kind of situation, is there a strategy that you prefer or recommend?

RUCKER:
I really like community-based approaches. If community safety is going to be involved, then I say have somebody on your team that has experience with the community and outreach and who you're working with, have them on your team as a first responder as well. And I think public health can be a good partner if they work with the community and the harm reduction agencies that have been doing this work for a long time, and help them grow to the place where they can get the level of funding that makes them functional.

JOHNSON:
Let's fast forward a little bit. Let's assume this relationship is working. How do you keep it going?

RUCKER:
Well, I think you have to continuously meet and talk about the issues that come up and what the strategies are for every single issue that comes up because there will always be issues. There will always be a different opinion on how to approach a situation or handle a situation. You know, public health, they have their restrictions based on a system, and so does public safety. Harm reduction programs have less restrictions on them, and so they're more nimble when it comes to responding to things in a quicker way.

JOHNSON:
You mentioned earlier the opioid settlement dollars, and a lot of people in public health are thinking about that right now. From your perspective and your life's work in this area of harm reduction, how do you think those dollars should be spent? What's the best way to spend them?

RUCKER:
I think that they would be best spent going to the community and through an agency—or, you know, perhaps CDC—that is now in touch and supporting syringe exchanges around the country.

What I'm afraid of with this money is that it's not going to go directly to the communities that need it. It's going to go to the infrastructure of safety, it's going to go everywhere else. And by the time it gets down to the people that really could utilize it and make a difference, it's going to be very little money.

JOHNSON:
I'd like to zoom out here a little bit as we start to wrap up. You've been at this a long time. You've seen a lot, you've done a lot. What's at stake? Why is this work so important?

RUCKER:
We need to keep at that because we want to keep people alive. And I don't believe people should die because they put something in their body, and they should not be punished for that. And I think that we should look at the non-traditional ways that we have tried to provide support services to people that use drugs. Our traditional treatment—abstinence-based approach—has not worked.

JOHNSON:
Thank you for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.