One2One took place in two US states with differing histories of public health and public safety responses to drug overdoses, Maine and Massachusetts. In Maine, fentanyl was present in about 67% of drug overdose deaths in 2020.24 Maine launched a statewide public health initiative in 2021 called OPTIONS (Overdose Prevention Through Intensive Outreach Naloxone and Safety).25 Under the OPTIONS initiative, the state contracted for recovery liaisons in each county; part of their work was to be a resource to local law enforcement.
In Massachusetts, drug overdose deaths rose sharply between 2012 and 2016 as illicit fentanyl entered the drug supply. In 2020, the proportion of overdose deaths with fentanyl present increased to 92%.26 The spike in overdose deaths led to the introduction of the nation’s first police-directed post-overdose outreach response models as well as diversion programs where the police department served as an entry point into drug treatment.23 Massachusetts also has been a U.S. innovator in funding community-based harm reduction programs, such as overdose education and naloxone distribution and, more recently and fentanyl-specific, a pilot project on FTS distribution by police departments. The pilot study demonstrated the feasibility of enrolling police departments to distribute FTS kits and it found that police departments and their collaborators distributed over 300 FTS kits (kits contain 3 test strips) and provided nearly 300 referrals.27 This approximate 1-to-1 ratio of kits to referrals became the namesake and motivation for the current One2One project. The logic model of public safety officers providing FTS to PWUD, as articulated in the preliminary study, is that FTS distribution to people in the community improves their awareness of fentanyl risks and facilitates engagement in programming and extends “warm hand-offs” to treatment and recovery services, participation in which ultimately reduces overdose in the community. The goal of this study was to test this logic model by replicating the previous pilot and expanding it to more geographically, racially, and ethnically diverse sites in two states over a one-year implementation and evaluation period.
The One2One Intervention
The One2One approach had aims similar to harm reduction policing: “where police seek to build the capacity of systems to address needs while validating the police mission to protect public and individual safety, security, order, and rights”.28 In One2One, police and collaborators used FTS distribution as a low barrier tool to engage with PWUDs. Implementation activities were led by PAARI, a nonprofit headquartered in Boston, Massachusetts that works nationwide to provide training, support, and resources regarding non-arrest pathways to treatment and recovery with a board of directors comprised of former police chiefs and recovery support experts.
PAARI emailed all police departments in Massachusetts and Maine and invited participation in the study. One2One had three components that occurred January 1 to November 30, 2021: (1) development of FTS materials and capacity-building with participating departments, (2) local police department activities to implement new or revised procedures and community partnerships to distribute an initial allotment of 50 FTS kits (150 strips); and (3) monitoring and evaluation activities. Participating departments were offered incentives of $500 to $1,000 to offset costs of personnel time in monitoring and evaluation activities.
Capacity-building was comprised of training on FTS use and kit distribution strategies, delivery of prepackaged kits, and establishment of a learning collaborative among all participants comprised of quarterly convenings and monthly drop-in sessions. Departments were trained by PAARI on FTS kit use through webinar and videos that instructed users to place the test strip in a small container, add 10 milliliters of water (50 ml if testing methamphetamine) to small amounts (e.g., half of a grain of rice) or even remnant drug, and dip the strip in the mixture for 15 seconds and wait 5 minutes to read the result.29 The FTS is activated and shows one line when any quantity of fentanyl is detected and will show two lines if not detected. Each FTS kit included 3 test strips, each with a 2 x 3-inch instruction card on its use (English one side/Spanish one side), and preprinted contact cards with phone numbers for the outreach worker at the department, all in a small resealable plastic bag.
The purpose of the evaluation was to measure outcomes consistent with the One2One logic model and document implementation successes and challenges. For evaluation purposes, we developed indicators that reflected participation in training activities and police participant achievements, as well as two principal outcome measures that reflected One2One’s logic model: a kit distribution impact rate and an engagement ratio. We calculated the outcome “kit distribution rate” as the number of FTS kits distributed divided by the community’s fatal opioid overdose rate per 100,000 population in 2021 (Computed by evaluators for towns in Massachusetts and counties in Maine).26,30,31) This outcome reflected the uptake and public health impact of kit distribution to highly affected communities. The “Engagement Ratio” was calculated as the sum of referrals and direct services to kit recipients divided by the number of kits distributed, and reflected the productivity of the engagement. We calculated engagement ratios and kit distribution rates, plotted the outcomes pairs on a graph, and then classified sites into outcome quadrants as high versus low classification relative to all participating sites. A high engagement ratio was defined as 0.91–4.15 engagements per kit distributed; high kit distribution was defined as 3.73–15.36 kits per fatal overdose rate. Participation process measures included attendance at project activities, counts of technical assistance requests, and additional FTS kit requests beyond the initial allotment. Community awareness was assessed with a short stakeholder survey. We also obtained and created contextual variables. Specifically, we classified sites as racially or ethnically diverse if they exceeded the median proportion among sites on two of three population indicators: percent Black (median = 18.3), percent Hispanic (median = 6,7) and the percent two or more racial/ethnic groups (median = 3.2). We classified population size as urban (> 50,000), metro (< 50,000 but within large metro area), and non-metro/rural (less than 25,000 and not within large metro area). Finally, we classified overdose rates (defined as fatal opioid overdoses per 100,000 population in 2021) as very high (50–69), high (40–49), average (30–39) or lower (11–29) relative to all participating sites.
While monthly monitoring to obtain indicator data occurred at all sites, more in-depth evaluation involving semi-structured interviews, field observations, and site visits occurred only at 12 selected sites. In-depth evaluation sites were selected to ensure a range-maximizing sample and representation across site characteristics: 1) balance on Maine and Massachusetts and rural and urban geographic areas; and 2) diversity of police community engagement history and models (described elsewhere in the paper); and 3) diversity in prior experience with PAARI. Brandeis University’s Institutional Review Board approved the study protocol.
Each department reported the total number of FTS kits distributed and the total number of referrals or direct services on a monthly basis from March to October 2021 via an online survey. Respondents were asked for comments on successes and barriers or challenges. Evaluation departments reported additional information on distribution strategy/method, types of recipients, and types of referrals and direct services. Response rates by month ranged from 71–95%, with 17 of 21 departments submitting a report each month. evaluators computed the total number of kits distributed per 100,000 population, per fatal overdose (obtained from state public health fatality data), and overdose rate (computed by team from state data).30–32 Participation statistics included attendance at sessions and requests for FTS kits classified as top-, middle-, and bottom-tier relative to other participants.
Community stakeholder survey
A short survey was administered to stakeholders not involved in implementation of the One2One program in project-hosting communities. Six prompts asked open-ended questions about the program and posed nine Likert scale agreement items on the respondents’ assessment of police department involvement with and attitudes towards PWUD adapted from the original pilot study.
Interview and Site Visit Qualitative data
In-depth, semi-structured interviews were conducted with program staff and affiliates between April 2021 and October 2021. Additionally, participant observation was conducted at staff meetings, program offices, and during active outreach when research staff accompanied program staff.
Program staff participants were recruited for qualitative interviews using purposive and snowball sampling strategies so that our sample included a diverse range of occupations including police officers, social workers, recovery coaches, and harm reduction specialists. All participants provided verbal consent. All interviews followed a semi-structured interview guide which included the following a priori domains: program history and mission; approach to contacting recipients; partner organizations; resources offered by staff; program goals; challenges/barriers to implementation. In addition, 2 site visits (video or in-person) were conducted at each evaluation site to observe first-hand the day-to-day operations including staff meetings and street outreach (n = 24 visits).
Qualitative Data Analysis
Transcripts and detailed field notes were read and free coded using ‘memoing’ techniques.33 An initial set of narratives and themes were identified, after independently reviewing interview transcripts the research team refined initial themes, and axial coding was used to elaborate the views of program staff in different roles. Alongside this, Atlas.ti was used to create a deductive codebook using a priori domains from a semi-structured interview guide.