ISIH S2 E6 / The Opioid Overdose Crisis: Cops as social workers?

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Amy Kroll: It’s one thing to get somebody doing very well in here, get their education, get them to start making wiser choices, but if they're going home to a sinking ship, we know that they're going to go down with that ship.

Celine Gounder: This is Amy Kroll. She’s the administrator for re-entry services at the Allegheny County Jail Cooperative.

Amy Kroll: We started family support because of seeing the intergeneration of brothers and fathers and uncles and mothers and daughters coming in here. …children of incarcerated parents stand a higher percentage of going to jail themselves.

Celine Gounder: Welcome back to “In Sickness and In Health,” a podcast about health and social justice. I’m your host Dr. Celine Gounder. In this season, we’re considering some out-of-the-box solutions to the opioid overdose epidemic, asking you to consider the evidence and form your own opinions about our drug policy in the U.S., where we’ve been with our thinking, and where to go next.

Celine Gounder: In our last episode, we learned about how adverse childhood experiences can be a major risk factor for drug use and addiction and many other health problems later in life. One of those adverse childhood experiences is having a parent in jail or prison. It makes sense for doctors, nurses and social workers to ask people about childhood traumas and to do what they can to address them; but what about law enforcement: cops, wardens, even prison guards? Can they help break the cycle of trauma, drug use and addiction?  To understand more, we’ll head overseas to learn about decriminalization in Portugal and hear about Seattle’s new approach to dealing with low-level drug crimes. But first, we take you to Pittsburgh.

Amy Kroll: [00:06:46 ] …90 percent of our inmates in this jail will go home. We want to make sure that these inmates have a better quality of life and better family life returning to the community.

Celine Gounder: In 2009, the Allegheny County Jail Cooperative started a family support program for inmates who’d be in jail for more than 90 days. The idea was to strengthen parenting and relationship skills to make families stronger, so kids don’t inherit the same problems that have plagued their parents and grandparents before them.

Amy Kroll: The big thing behind the family support program is you may be a parent behind these walls, but it doesn't mean that you're not involved with your children.

Celine Gounder: It starts with a free phone call home.

Amy Kroll: Unfortunately for a lot of families, they don’t get the collect call system because they can not afford for that person to call home. Because all the phone calls here, you have to make a collect call.  But through this, they call home once a week a week to talk to their children… It’s a coached phone call with the instructors kinda helping them talk to their children… So this is not a hardship to their family, it’s not a phone call that is collect… that is collect, that is high charges for their family.

Celine Gounder: That’s something I’d never really thought about until I talked to Amy: the cost of making collect calls home while someone’s in jail or prison can really add up. And traveling for a face-to-face visit can seem like an insurmountable hurdle when you’re already struggling to get by and have kids to look after.

Amy Kroll: … we actually have a van that we can pick people up because in Allegheny County you may have to take two buses. So if you're trailing around with three infant children, let's just say, I know a lady that comes in with a 10 month-old a 2 year-old and a 3 year-old. And she brings them in for the 8:30 to 9:30 contact visit. She takes two buses just to get down here.

Celine Gounder: So just providing free calls home, helping with transportation — these kinds of things help keep families together. And the coaching helps parents learn how to communicate with their kids — skills their own parents may never have learned or role modeled.

Amy Kroll: … as we work with the inmate on the inside we learn about the problems that the family's having. Is it childcare issues, is at work issues? Is it developmental delays you know with their children? Are the children having issues in school, because you have a parent in this jail? In turn, Mercy can send out people to the home.

Celine Gounder: Mercy is the Pittsburgh Mercy Health System.

Amy Kroll: There's a lot of programs that go into the home... they in-reach into the home and begin to work with the children and the caregiver to make sure that they also have a healthier life and that these children’s issues are being addressed way ahead of time.

Celine Gounder: A parent being in jail can help shine a light on problems a child’s having a home or at school and get that child the help they need. Most challenging are adolescents. As we all know, those teenage years are formative, critical. A young person’s life can get derailed, their trajectory curtailed, when that teen tests boundaries, rebels, engages in risky behavior. Connecting and engaging with teens is hard under normal circumstances, but it’s especially challenging when a parent is incarcerated.

Amy Kroll: Teenagers have a lot of anger that there's a parent in jail — or embarrassment. And we've seen it in many situations where children come in… they’re you know middle school, they’re teenage kids... they're very angry at their parent. They sit away from them. You can see it, and then we slowly work with both the caregiver and the incarcerated parent to give them time to talk to these teenagers because it’s better to begin to address them in here than we have an explosion in the community when Mom or Dad come home.

Celine Gounder: Allegheny County’s family support program doesn’t just teach parenting skills. It also teaches relationship skills. Because kids do better when both parents are involved, even if they aren’t together. When parents function as a team, not on opposing sides.

Amy Kroll: If we see during these phone calls there is relationship issues, we know that family's only going to be as strong as that unit, even though you know the inmate may not be returning back to the caregiver's house. Let's just say, I have three children to this woman but… we're never going to be together. We still work on how do be a good parent even though you'll never be with the biological mother of your children? So we work very hard on what is a healthy relationship. You may never be in this woman's life again but you will be in your children's life.  

Celine Gounder: The Allegheny County Jail Cooperative understands the importance of the family unit in shaping a child’s life. They understand that trauma and addiction go hand in hand and get passed on from generation to generation. So they work hard to help families stay together, to communicate better, and to identify kids in crisis at a critical moment in their lives, when there’s an opportunity to break toxic patterns.

Celine Gounder: European countries made treatment and social services a focal point of their drug strategies much earlier than we did in the U.S., and none, perhaps, more radically than Portugal. Until the 1970s, Portugal was under authoritarian rule. The country was isolated from the rest of Europe, and with the exception of its colonies in Africa and Asia, the rest of the world. There was heavy censorship and the country was relatively insulated from drug-related problems on the rise elsewhere. But after the revolution in 1974, the country became a democracy, and things changed fast. In the setting of newfound freedoms and profound changes in government and society, Portugal experienced a boom in drug use.

João Castel Branco Goulão: My name is João Goulão, which I know it's quite difficult for you to pronounce. I am a family doctor.

Celine Gounder: Since 2005, João Goulão has been the national coordinator for drug addiction and alcohol related problems in Portugal. He told me how the country changed rapidly after the revolution.

João Castel Branco Goulão In just a matter of a few years we had everything available in our market — heroin, cocaine, you name it..and completely unprepared society to deal with it.

Celine Gounder: The spike in drug use cut across all classes and social groups — the working class, middle class, the rich — were all affected. Problems associated with drug use roiled Portuguese society, which really wasn’t prepared to deal with them. Then came a surge of HIV and hepatitis infections and overdose deaths. And very quickly, Portugal was facing one of the worst drug epidemics in the world.

Celine Gounder: At the time, drug use was criminalized and people were thrown in prison, but that seemed to only make things even worse. The government decided they needed to address the emerging problem, so they convened a group of experts to create a drug strategy for Portugal.

João Castel Branco Goulão: So there was a group who built the first Portuguese strategy in '98. It was presented to the government with a set of recommendations in terms of prevention, treatment, harm reduction, reintegration policies.

Celine Gounder: In other words, the recommendations adhered to a certain understanding of the escalation in drug use: hat it was a health and social problem, not a criminal one. So with that in mind, and after much study and debate, the Portuguese government decided to try something different. They decided to decriminalize drug use. Treating it as a crime wasn’t working and the cost of that failure — both in terms of lives and money — was deemed too high.

João Castel Branco Goulão: I do not attribute any magical properties to decriminalization itself. ... Of course decriminalization only works if you have treatment easily accessible. if you are able to reach someone, comes to you and seek for treatment you can offer the next day, for free, for everybody.

Celine Gounder: There’s a lot of confusion in the U.S. about what decriminalization really means. First of all, drugs were not legalized. It’s still against the law to have or use drugs in Portugal. But instead of being locked up, drug users might be subject to fines or treatment requirements. They might lose their right to practice a licensed profession,like medicine or taxi-driving. They might face prohibitions on travel. Drug trafficking, selling drugs to minors or people with mental illness are still considered criminal offenses.

Celine Gounder: And that brings us to the second point. Decriminalization is not a standalone policy. It’s not a free-for-all. The idea is to make it easier to get people into treatment, which they’re less likely to seek if they’re afraid of being arrested and prosecuted. But for the system to work, treatment has to be available, accessible and affordable. I know all too well from my own work as a doctor in the U.S., that it’s really hard to get patients the drug treatment and other help they need. Only 10% of Americans struggling with addiction get treatment. In Portugal, treatment is the norm. And the Portuguese have found treatment to be a lot cheaper  than incarceration. And that means there’s that much more funding available for treatment, for harm reduction strategies like methadone and syringe exchange programs. Transmission of HIV and hepatitis related to injection drug use plunged, as did deaths from overdose. Today, Portugal’s drug-related death rate is one-tenth that of the UK, and one-fiftieth that of the U.S. Decriminalization of drug use has, of course, changed the way law enforcement does business too: where they get their information and who they go after and how they relate to the communities they police.

Kris Nyrop: …one of the things that's interesting… is that law enforcement police officers... routinely coming into people at their absolute worst, and they're coming into contact with them when those individuals are in crisis and really doing bad stuff.

Celine Gounder: This is Kris Nyrop. He’s the national support director for law enforcement assisted diversion — also known as LEAD — at the Public Defender Association in Seattle-King County. The Portuguese policy of drug decriminalization is, in some respects, the granddaddy to LEAD. Treating drug use as a call for help rather than a crime and using that point of contact with the police to get people services rather than punishing them.

Kris Nyrop: …LEAD really grew out of more than a decade of fairly contentious conversations here in Seattle about racial disparity and drug arrests. …in a city where about 8 percent of the population was African American, you know, somewhere north of 60 percent of those being arrested for low level drug possession and sales offenses were black.

Celine Gounder: But critics of the Seattle Police Department didn’t have a good answer to the problem. How to shut down public drug use — largely among the homeless — and how to address concerns about racial injustice when African Americans were far more likely to be homeless than whites.

Kris Nyrop: I mean there were two sort of rhetorical answers, one of which was end the war on drugs, which was slightly above the paygrade of a captain in a mid-level police department out in the northwest corner of the United States, and the second answer was, well, start arresting white drug users like four or five times as many as you're arresting now, and neither of those answers was going to float.

Celine Gounder: And it’s at around this time that Kris got pulled into the conversation. Kris comes from a background of public health and frontline social service, working with injection drug users at needle exchange programs and on the streets. Though Kris wasn’t an expert on law enforcement, he was an expert on homeless people who used drugs. He and others tried to think through the problem: what could the Seattle PD do differently?

Kris Nyrop: …we started asking ourselves some questions, one of which was what if we could make arrest the strategy of last resort for low level drug offenses. … what if we could take that and change it into something that was potentially positive… And what if it actually yielded better public safety results and made the community happier, and … what if it actually ended up being cheaper. And so that was really sort of the starting point… And after three years of discussion, LEAD was born in October of 2011.  

Celine Gounder: Seattle was the first city in the U.S. to try this approach.

Kris Nyrop:  …most of the diversion programs that were around were really sort of, court-based diversion. So you know drug court is the model that's been around the longest. … But our model of doing and diversion right at the point of contact between police officers and individuals was the new thing.

Celine Gounder: And that’s an important distinction. LEAD is a “post-arrest, pre-booking” diversion program. With LEAD, so long as an offender doesn’t have a violent criminal record, an officer has the discretion to send them to jail or divert. That officer can call a case manager, who comes immediately and performs a brief intake to figure out what’s going on with that person. Then they have thirty days to complete the intake at the LEAD office so case managers can figure out what help they need. Very often, their first priority isn’t to stop using drugs. It’s to get a place to stay.

Kris Nyrop: …82 percent of the folks that are diverted into Seattle are homeless at the time of their diversion. So, this issue of finding people a place has been by far our biggest challenge from day one. And it remains our biggest challenge to this day. What do you do with individuals who are homeless and who are also using substances?  

Celine Gounder: It can take months to get someone housing or a bed at a drug treatment facility. And in the meantime, if they end up in jail, the plan can get derailed and they’ve got to start all over. LEAD helps people get on the path to recovery and stay on it. Three years in, researchers evaluated LEAD, comparing people who were arrested and sent to jail with those who were diverted to case management and support services. LEAD program participants were 60% less likely to have been arrested again.

Celine Gounder: It’s important to understand that diversion isn’t a “get out of jail free card.” Cops can, will and do still arrest drug users. And diversion isn’t just about keeping someone out of the criminal justice system. It’s also got to be about diverting someone to someplace else.

Kris Nyrop: … when we're talking with jurisdictions who are interested in doing LEAD, one of the first questions that we ask them are, 'do you actually have services to give people?' And specifically do you have treatment for people because you need to make sure that that system is in place before you even think about doing LEAD, because for LEAD to work it has to be a referral to something real. It can't just be go and talk with the case manager. It's got to be, and this case manager has access to things that can help and treatment is primary among them.

Celine Gounder: Frontline officers with the Seattle PD were pretty skeptical at first. They didn’t see how diverting people away from the criminal justice system and into housing and other services would reduce drug-related crime. Why would a drug user change his behavior if there weren’t a deterrent, if he wasn’t being penalized for his drug use?

Kris Nyrop: … We did a focus group with about 20 some officers … prior to doing LEAD. And these were going to be the ones that were the frontline officers, and that's where we realized that a lot of them really either didn't understand what chemical dependency was or what they did think they knew was wrong, and they didn't understand the treatment world, and they actually thought that treatment was available for individuals and that individuals were out on the street being homeless and using drugs sort of as a choice rather than, you know, a systemic condition.

Celine Gounder: Many participating in the initial trainings and rollout of LEAD didn’t think it would work. But they operated in good faith. They didn’t want LEAD to fail because of them.

Kris Nyrop: … the first turning point came the very first night we did LEAD, and the officer that did the very first arrest was an officer who had been quite openly skeptical about LEAD. …in the meetings …she was sitting with her arms and legs crossed and her head tilted back and… you could see occasional eye rolls. And I actually heard her mutter one time, "yeah right, like that's ever going to happen." And it turned out she was …the first one to do an arrest, and she recognized the individual that she was arresting, and she ran his records check, and the guy had 56 prior drug arrests. …and she had an epiphany moment where she thought: I don't think 57 is going to make a difference here. …so she did divert the person… and it took a while… but a couple of months later, the person entered drug treatment, got housing …years down the line, the guy has not been an issue for law enforcement.

Celine Gounder: Several years into the experiment, Kris is now the point person for police departments all over the country who want to try LEAD where they are. He learned a lot getting LEAD off the ground in Seattle, from the mistakes they made, and from his experience advising other cities.

Kris Nyrop: … the motivation for jurisdictions to adopt LEAD is sometimes radically different, but the common kernel is… that this status quo is not working.

Celine Gounder: In other cities, where police-community relations are especially tense, where there’s a lack of trust the police are there to serve and protect them, LEAD can be transformational, which makes it easier for cops to do their jobs and makes communities safer for everyone.

Kris Nyrop: … they report that prior to coming into LEAD distrusted the police. … after their diversion they report that they like the police officers. They go up and talk to them. They're proud to show them their first paycheck. …one of the chiefs that we work with who said, you know, we'd like people to wave to us when we drive through. Right now they're waving to us with one finger. ... We prefer it to be all five.  

Celine Gounder: LEAD gives police additional tools… options… for dealing with a situation.

Kris Nyrop: … community members get really upset by seeing public drug use, and they put pressure on the police to do something… unless the police have programs like LEAD, that the thing they can do is arrest people.

Celine Gounder: So LEAD helps get the homeless drug users off the street, into housing, into services, and out of the criminal justice system. A lot more cities across the U.S. are taking an interest: Ithaca, Atlanta, Houston, Los Angeles, Philadelphia and more. They’re reaching out to Kris for advice on how to start their own LEAD programs.

Celine Gounder: Washington State pioneered many of the tools we use to deal with drug use and addiction. The nation’s first legal syringe exchange program was run out of the trunk of a car in Tacoma, just south of Seattle. The LEAD program is getting people off the streets, into housing, and into drug treatment. And Seattle-King County is poised to be the first in the country to open supervised consumption sites — where drug users bring in their drugs and use under medical supervision, and if they overdose, someone’s there to help them. We’ll talk about supervised consumption sites — whether they save lives and help get people into treatment, or perpetuate addiction and crime — on our next episode of “In Sickness and in Health.”

Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Nora Ritchie and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at, that’s

Celine Gounder: If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at, that’s

Celine Gounder: I’m Dr. Celine Gounder. This is “In Sickness and in Health.”