It was an unusually warm afternoon at the end of May 2015, and Steve Lesnikoski was sitting in his car in a convenience store parking lot in Oakland, California, waiting for his heroin dealer to show up.
Lesnikoski had been addicted to Vicodin at first, after it was prescribed for a torn Achilles tendon—a football injury—during his senior year of high school. Then he began using oxycontin through his roommate at Arizona State University, who was dealing out of their dorm room. When Lesnikoski returned to California after college, he continued the oxys while working at IBM as a sales technician. And when a friend convinced him that heroin was cheaper and the high was better, he switched again, using more after he was fired. Eventually his lucid life became almost non-existent. He bounced from couch to couch, sometimes sleeping on the street.
As his dealer was taking longer than usual that day, Lesnikoski began scrolling through Reddit on his phone. That’s when he saw an unusual advertisement. The Gloucester, Massachusetts police department—over 3000 miles away—was asking him to join the “Angel Program.”
“I was a bit surprised… it read something like, ‘Join us and we’ll help you if you are having trouble beating your addiction, and if you want help.’ I don’t know what it was that day, but I called them right then and there,” he recalls.
He reached Chief Leonard Campanello, head of the Gloucester police department and co-founder of the program. When Lesnikoski told him he lived in San Jose, Campanello made an exception for him to fly out to the small suburb on the fringes of Boston. Lesnikoski left two days later.
STATNews, a Boston-based publication, recently projected that 500,000 Americans will die from opioid use over the next ten years. Here in Canada, the forecast is also grim: Almost 2,500 Canadians died of an opioid overdose in 2016, a number that appears to be increasing this year. Only a small percentage of people who currently need treatment receive it. In an effort to curb the epidemic, some US states are turning to police officers, with the hope that they can help those with addiction seek treatment before a deadly overdose.
Gloucester’s Angel Program is part of a network of law enforcement agencies across the US called the Police Assisted Addiction and Recovery Initiative (PAARI-USA), which provides a “no-arrest, direct referral for drug detoxification and rehabilitation treatment.”
In Massachusetts, participation in PAARI-USA programs may be covered through state insurance, which is similar in many ways to Canada’s single-payer healthcare system. Some applicants can also utilize private insurance or scholarships provided by around 300 individual treatment centres across the country. (Lesnikoski’s flight was covered by a private donor and he received some funding through the Gloucester Department from a fund established when Campanello was Chief, though this is no longer provided for most applicants.)
On the surface, the PAARI-USA approach is simple. Someone with an addiction approaches an officer on the street or at the police department, states that they want to seek treatment for their addiction, and the officer coordinates placement at a detoxification centre and a subsequent referral for long-term rehabilitation.
Instead of simply arresting people for drug possession, then, some police officers are becoming front-line social workers. Supporters of the program cite the high percentage of people who are referred to treatment as evidence of PAARI-USA’s success. However, critics argue that involving police comes with its own complications, and that a solution to the opioid crisis is more complex than simply referring people to detox and rehab programs.
This past December, a team at the Boston University Medical Center presented the initial year’s worth of data on the Angel Program in the New England Journal of Medicine. The findings were striking—they boasted a 95 percent referral rate to detoxification and/or rehabilitation facilities within the greater Boston area. This is significantly higher than referral through hospitals (typically emergency rooms), where the researchers found only around 21 percent of those with addiction receive treatment.
“The fact is, we know the medical care system has historically not been welcoming or effective for people with addiction,” says David Rosenbloom, a member of the Boston University Medical Center study team. “Many providers still refuse to see addiction as a disease. Cops wouldn’t send them to the street, but emergency room doctors do.”
Indeed, studies have found that people with mental health disorders and/or substance use disorders often experience barriers to seeking care while in the emergency department. Last December, a University of Toronto study found that emergency patients with these disorders frequently experienced discrimination and stigma, and specifically felt “dismissed, misdiagnosed, or generally unwelcome.”
Given the situation, it could be argued that PAARI-USA is filling a void as it expands rapidly across the US. “PAARI-USA-affiliated programs are now in 160 police departments in eight states, and I get at least ten inquiries a week,” Rosenbloom says. Since we last spoke, that’s been upped to over 260 participating police departments in thirty-one states—an increase of almost 60 percent in just six months.
Could a similar program work in Canada? The government seems keen to take a fresh approach. The health minister, Jane Philpott, has urged a more compassionate approach to opioid addiction in Canada, and provincial governments have increased investment to beat the epidemic. Meanwhile, safe injection sites are expanding across Canada, and first responders are being trained to administer the opioid antidote naloxone. The PAARI-USA model could be one more tool in a multi-pronged approach to address the opioid crisis here in Canada. But first, it must answer to critics who believe that extending the role of addiction treatment to law enforcement could do more harm than good.
Police forces across the country are grappling with what reforms are necessary to deal with the challenges of modern policing. Toronto Police Services recently revamped their strategic direction, with the launch of their new report and even a mobile app, which they hope will allow them to better integrate with public services such as healthcare and mental health services. The Vancouver Police Department has followed suit—it recently unveiled its own report that includes strengthening ties with mental health partners. And last week, Edmonton Police Services announced a scale-up of their Heavy Users of Services (HUoS) program, which focuses on partnering with social services organizations to better serve those with addictions and mental health issues.
Currently, however, most police forces across Canada do not have a formal process for facilitating access to addictions treatment for those who request it. According to Toronto Police, there would be a risk of arrest should someone approach an officer and admit to illicit drug use, even if they seek help. On the other hand, the Vancouver Police Department says they informally assist those suffering from addiction. “As it stands today, our officers are limited by available health resources [to] where they can refer and physically transport (voluntarily) those seeking treatment,” they wrote in an email. “Our department continues to lobby our Provincial Government for treatment-on-demand programs.” In a separate email, they added: “We do have individuals who approach our officers and ask for help with their addiction. Our officers will do their best to do what they can but the system in BC for treatment and recovery is very difficult to navigate.”
In Edmonton, police chief Rod Knecht has his own ideas about how to help people with addiction—many of which he expressed earlier this year in a controversial op-ed about safe injection sites. Knecht speaks from the perspective of both an officer (he’s been with the department for forty years) and as someone who has been personally touched by drug addiction; several close colleagues in his department have suffered addictions to cocaine or prescription drugs. He agrees that new solutions are needed.
When asked about the PAARI-USA network, he’s optimistic. “I like the model […] of having the police be facilitators to connect those with addictions to get help,” he says. “But I would want to emphasize the wellness aspect. It’s more than just rehab and detox. Housing is also a big part of it.”
Knecht thinks a holistic approach to addiction is needed. Safe injection sites, for example, should be accompanied by mandatory “wrap around services” like those offered through Edmonton’s HUoS program—that is, access to housing and other services that improve health outcomes. “I can’t support or advocate that someone just goes into a facility, uses drugs and just leaves again,” he says. “I support a place where someone can go in, get their drugs, but also be connected with medical personnel, healthy lifestyle, permanent housing, and a support network they need to get off addictions and become a contributing member of society.”
Addictions doctors, while eager to find novel solutions to the ever-pressing issue of opioid addiction, are not easily convinced by either Knecht’s views or the PAARI-USA model. Some, like Edmonton’s Hakique Virani, a specialist in addiction medicine at the University of Alberta, are cautious about the idea of expanding police interactions with vulnerable populations, as well-intentioned efforts could nevertheless come across as coercive. Instead, Virani is a vocal supporter of expanding safe injection sites, an initiative that he feels has the most potential to reduce overdoses related to the opioid epidemic.
“Not every person with an addiction is ready to get help right now, and they shouldn’t be forced to . . . and that’s the danger with police-led initiatives,” Virani says. “The implied message could end up being, ‘this can keep you out of jail.’”
As well, the “detox and rehab approach” to opioid addiction isn’t without fault. A STATNews exposé found that some referral programs to expensive rehabilitation centres out-of-state have become big business, for example. Other researchers have found that those participating in inpatient (i.e., in-hospital) programs may lose tolerance to the drug, which increases risk of death during a relapse. As such, community-based outpatient programs—that is, continued treatment at home or at a local health centre—could be just as effective.
Shortly after Rosenbloom and his colleagues published their NEJM article, a researcher named Stephen Wood wrote a letter to the journal pointing out the flaws of a “detox-for-all approach.” Programs like the Angel program have high relapse rates—81 percent of those surveyed in the dataset had previous detox attempts, and a large number were recurrent users of the program.
In medicine, there’s a term for patients who end up in the revolving door of the emergency department: “frequent flyers.” These people get short-term help but fall short of long-term health improvement, due in large part to a systematic failure to address the issues that underlie addiction: mental illness, lack of housing, underemployment, and food insecurity, among others.
Wood estimates that only 8-10 percent of the participants in the Angel program got long-term help, and there was little to no mental-health support during or after discharge. “We need to be thinking: what are our next steps for making sure there is continuity into long-term recovery?” Wood says. “We would never tell someone with a heart attack that we need to keep them institutionalized forever—they get long-term outpatient management once they leave the hospital. This is key, and that’s what we need to be doing for the opioid epidemic.”
One of the other serious challenges facing PAARI-USA and similar programs is trust. Over the years in the US and Canada, the relationship between police officers and community members—particularly those in underserved or racialized communities—has eroded. There is overlap in some of these communities with those that suffer from opioid and other addictions. And in places like the downtown East side in Vancouver or inner-city Edmonton, interactions between police and underserved groups such as those with an addiction, visible minorities, and Indigenous people continue to be strained. As such, it’s unlikely and possibly even unwise for these populations to actively seek an officer for help. (Though hospitals are not necessarily better—Indigenous people seeking emergency care, for instance, often report experiencing discrimination while interacting with healthcare providers.)
So where does this leave us with respect to police-led referral programs in Canada? One major barrier in most of Canada is not having enough rehab and treatment options to refer to in the first place, so a police-led referral process could be futile. But if a PAARI-USA-type of program were tried here, Virani says there would need to be checks and balances. “It’s interesting to have police officers involved so there are more touchpoints to care. We just want to be sure it takes more of a ‘we are there for you’ approach, so it’s not coercive. Perhaps [making it] less formal [would be] better,” he says. “Not everyone’s ready for change. It’s about meeting people where they are.”
Lesnikoski didn’t last long in his initial stint in detox. He completed the required five days, and felt he was ready to return to San Jose to complete a thirty-day rehabilitation program. A few days into it, he broke down on the floor of his residential room in San Jose and left.
Chief Campanello called Lesnikoski several times. When he finally got through, Lesnikoski was lying on a bathroom floor coming down from another high, in tears. It was August, two months after he left Gloucester.
“I said, ‘Chief, I can’t do it . . . maybe I’m not cut out for [it].’ By then my sister and brother and eventually even my parents stopped speaking with me, I was broke, couch surfing again, hopeless and unsure of what I was living for between the highs,” Lesnikoski recalls. Campanello convinced him to give it another try.
So Lesnikoski boarded another plane back to Boston a few days later, and made it onward again to Gloucester. He completed a thirty-day treatment program and stayed at a sober house for ninety days. He found a job cleaning sewers in the city of Cambridge—another Boston suburb—for six months, and rented a room month-to-month until he could save up for a tiny bachelor apartment. He’s currently studying at North Shore Community College, focusing on Drug and Alcohol Studies, and hopes to transfer to a state school to do a Bachelor of Social Work, and perhaps a Master of Public Health down the line.
Police-led referral programs for addiction treatment may not be a panacea, but they are not without promise. At the very least, they represent an innovative effort that seems to be working in communities that have mutual trust and commitment with law enforcement, and perhaps there are places in Canada where this is also the case. In these communities, these programs might reach those who might not otherwise be reached—another door into the same room, as it were.
Lesnikoski now assists others suffering from drug addiction. Since completing his certification in recovery coaching in February, he helps patients admitted to three Boston-area hospitals. A lot of them are surprised, he says, when he divulges his own history with opioids. But Lesnikoski believes he’s paying forward the results of an even more unusual situation: that a phone call twenty-one months ago with a police officer guided him away from his addiction.