Interventions to Improve Linkage to Care for People Who Use Drugs

First responders can improve outcomes for individuals who use drugs by consistently connecting them to evidence-based services, such as medications for opioid use disorder (MOUD) and naloxone, and social support services known to enhance treatment and recovery.

Overdose deaths are an ongoing crisis in the United States. The estimated number of overdose deaths reached 108,000 in the 12 months ending in May 2022, increasing 55 percent since the 12 months ending in May 2018. Providing access to evidence-based treatments for substance use disorders (SUDs), including medications for opioid use disorder (MOUD), is a key overdose prevention strategy. First responders (eg, fire, police, and emergency medical services) can help put this strategy into practice. Considering their regular contact with individuals who use drugs while patrolling or responding to 911 calls, first responders can connect willing individuals to treatment and other services. The number of first responder agencies offering linkage to care have increased in recent years, with most new linkage programs beginning around 2018, after deaths from synthetic opioids began to rise sharply.

The Centers for Disease Control and Prevention is committed to addressing the drug overdose crisis by partnering broadly, including with first responders, and supporting evidence-based action to save lives and prevent overdose and related harms. This prompted us to review studies of first responder linkage programs to learn:

• How first responders make treatment and service connections
• To what extent they have successful outcomes
• What factors help or hinder their operations

We limited the review of studies to programs that assertively make linkages, such as postoverdose and prebooking programs. Assertive linkage is defined as anything more than passively sharing information about where individuals can seek help (eg, providing phone numbers for individuals to call). Little is known about the impact of these strategies when enacted by first responders, and questions of privacy concerns and unintended consequences have been raised. Given this, our goal in conducting this review was to identify how programs could scale and improve successful programs.

Based on the search criteria, we identified 22 studies that describe 34 programs involving first responders assertively linking individuals to treatment and other services.

What we found:

• Programs demonstrated use of 9 assertive linkage strategies. Each program used more than 1 strategy concurrently, providing a layered approach in an effort to improve linkages.
• Assertive linkages strategies are described favorably in studies or directly referenced as possibly associated with positive outcomes. Some assertive linkage strategies, however, are not well supported by evidence. An example of a strategy that warrants further research concerning potential harm is the use of external pressure by family or providers to encourage or force treatment connections.
• Assertive linkage programs can be less effective, even counterproductive, to the goals of linkage when they involve eligibility criteria that bars participation or results in unexpected arrest for an active warrant.
• Relatively few programs reported linking individuals to evidence-based services. Only 6 programs link to MOUD and only 3 programs distribute naloxone, a life-saving medication that can reverse an opioid overdose.
• Programs may be more successful when they can establish effective partnerships and first responder buy-in. Programs may also face challenges associated with funding availability as well as availability and access to evidence-based linkage options.

How can first responder linkage programs improve?

• Some assertive linkage strategies, like unsolicited home-based outreach and coerced treatment, warrant more careful evaluation and modification, as needed, to minimize unintended consequences.
• More robust study designs are necessary to measure the impact of first responder assertive linkage programs.
• Programs can consistently link to evidence-based services, such as MOUD and naloxone, and social support services known to enhance treatment and recovery.
• Increased access to evidence-based treatment options and sustainable resources could help programs expand access and improve.

Read the full review in the Journal of Public Health Management and Practice:

• First Responder Assertive Linkage Programs: A Scoping Review of Interventions to Improve Linkage to Care for People Who Use Drugs

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Nancy Worthington, PhD, MPH, is a Health Scientist in the Division of Overdose Prevention at the Centers for Disease Control and Prevention where her research and related work focuses on public health/public safety partnerships, harm reduction, linkage to care, and overdose spike response. 

Talayha Gilliam, MPH, graduated from the University of Virginia master’s in public health program. A fellow in the Research Participation Program at the Centers for Disease Control and Prevention administered by the Oak Ridge Institute for Science and Education, she strives to advance her knowledge and work in health equity and overdose response and prevention.

Sasha Mital, PhD, MPH, is a Health Scientist in the Division of Overdose Prevention at the Centers for Disease Control and Prevention. She holds a PhD in Behavioral Sciences and MPH from Emory University. Her work focuses on improving public health/public safety partnerships to reduce overdose deaths.

Sharon S. Caslin, MPH, is a doctoral student in the Department of Biostatistics at Harvard University. She is interested in the development of statistical methods to combat societal inequities.