Section IV: Putting It All Together

ES 1. Assess and monitor population health 

In the years prior to DART’s launch, Northampton had been seeing growing numbers of overdoses, many occurring in public places. Community members were at a loss of how to respond and desperate for resources. The police department knew that arresting people who used drugs was neither compassionate nor appropriate. They knew how often they were arresting the same individuals, and were aware of the trauma that these individuals—and their families—were experiencing as a result. But they also understood the fear and frustration that many community members were feeling from dealing with drug-related crime and by routinely encountering people overdosing in their parks, libraries, and public restrooms. 

“We needed to navigate caring for people, households, families, and business community members who were concerned for loved ones, friends, and colleagues who were using use drugs, and who were at increased risk of overdosing, with the needs of the broader Northampton community,” said Farry. “We needed to find a solution that worked for everyone.”  

ES 2. Investigate, diagnose, and address health hazards and root causes

DART was initially championed by the Northampton Police Department. At the time, coalition staff were not accustomed to working closely with law enforcement. 

“We were usually on opposite sides of the aisle as public health and public safety servants,” said Farry. “We weren’t sure how much we could trust each other. We didn’t understand our roles, or the needs and challenges we both faced. We wanted to learn from each other, but didn’t want to risk losing our identities in the process.”

So, the sectors worked together to develop an approach that would work for both groups—one that aligned public health and harm reduction frameworks with the realities of where law enforcement was bound by regulations. The first training they convened was for about 30 community stakeholders—police officers, as well as EMS, harm reduction specialists, dispatchers, behavioral health, treatment, recovery coaches, and social services providers. The response was overwhelmingly positive.

“People were candidly honest,” says Farry. “They said they were willing to do this together and showed up ready to be all in—because the problem was so significant and they were exhausted. Their motivation really was ‘How do we make our job easier? For the police officers, witnessing and responding to the devastation and painful tragedies in the community was taking a toll. They were expressing what we know as secondary trauma. So, the training provided a space to begin talking about what they were experiencing, and to begin the process of mutual healing.” 

Members of that initial training became DART’s first Advisory Council, providing guidance and recommendations on DART protocols and strategic priorities, and informed perspectives based on the group’s collective lived experience. The Advisory Council continues to meet two to four times a year. Members are not expected to have any specific formal educational pre-qualifications but must be willing to have open, and sometimes difficult, conversations. 

ES 3. Communicate effectively to inform and educate 

Following the initial training, DART went on to conduct more—and larger—trainings throughout the county. They developed a training framework that explored topics such as the physiology of addiction and the importance of a harm reduction approach, and that examined the impact of substance-related stigma, bias, and equity. By naming the systemic power dynamics, treatment system deficits, and multitude of barriers to health and wellness, the trainings provided ample opportunity for cross-sector relationship building. The training also explored key intersections and challenges to care, such as partner-based violence, implicit bias, mandated treatment, and many controversial but important topics. 

“By the end of the meetings, everyone was hugging and having conversations,” says Farry. “When you bring people together to learn in a multi-disciplinary way, amazing things can happen. Many of these relationships become long-term friendships and allies.” 

DART has also worked hard to shape the public narrative around opioid misuse and overdose. For example, when working with the media, they routinely share talking points in advance: this allows them to message and modeling the use of non-stigmatizing language, and highlight the importance of mitigating harm. They also always share their cell phone number, and invite the journalist to call with questions or for clarification.

ES 4. Strengthen, support, and mobilize communities and partnerships 

One of the factors that contributed to DART’s early success was the county’s existing commitment to collaboration. In 2016, the Northampton Board of Health had received a Massachusetts Overdose Prevention Collaborative (MOAPC) grant. One of the unique aspects of the grant program was that it provided financial support to not only a lead community—in this case, Northampton—but also to groups of neighboring “cluster” municipalities to enter into formal, long-term agreements to share resources and coordinate activities. 

The MOAPC funding, together with an accomplished health director and strong and dynamic coalition leader, provided the foundation for countywide collaboration. When the health department was ready to launch DART, all of the right people were already at the table. 

Today, DART has subcontracts with more than 150 uniquely different first responder and service organizations across Western Massachusetts. “We are very diligent about reaching out and forming partnerships, and very conscientious of key champions and supporting them as cheerleaders. But the return on our investment is huge. When new needs arise, we are prepared to mobilize as a region,” says Farry. “That’s what makes us unique.”

Commitment to a person-centered approach and relationship building has also helped DART engage community partners—including people who use drugs and their families. 

“Our focus is on the participant experience; it’s our participants who help us to build referrals when they engage. They tell us what they need, not what we think they need,” says Farry. “When you talk to someone who uses drugs, they’ll tell you who they trust, who they don’t, and why not.” 

DART is also committed to remaining politically neutral. This can be challenging when dealing with topics as charged as substance misuse, but important for building trust. 

“It’s important to name your differences, but then you need to put them aside and get over it,” says Farry. “COVID shined a light on the fragile mental health of people across the board, and it brought out a lot of anger. But the only way we’re going to achieve health, wellness, and happiness in our communities is by working together. DART is a public health-led, public safety multi-system collaboration. We’re working with police departments and agencies from many communities—each with its own culture, provider landscape, and pathway to recovery. DART is a big family and big families argue. But we care about each other and almost always find resolutions that value our different voices.”

As DART has expanded regionally, the team has worked hard to respect the autonomy of its neighboring communities. “We do our best to avoid stepping on toes or coming across as paternalistic,” says Farry. “We never come in unless we’re invited by a community who would like to establish a DART program. This is typically the police department chief. But we still need to be careful about overstepping and respectful.” 

ES 5. Create, champion, and implement policies, plans, and laws 

Another factor that helped DART gain acceptance was having a strong program champion. Adam Van Buskirk, one of DART’s founding police members, was their champion. Local media described Van Buskirk by as a “hero cop” with a “raw, natural way of building rapport and lots of street credibility.” 

DART was also led by two strong community organizers—Farry and former coalition director J. Cherry Sullivan—who were strong public health advocates and understood how to mobilize diverse groups. “We became the connectors of the problems people throughout the committee were seeing in their households. They were craving a supportive infrastructure so they didn’t have to operate in isolation,” said Farry.

ES 6. Utilize legal and regulatory actions

One of DART’s key roles was to work with the district attorney’s office and police and fire departments to create policies to guide the distribution of Narcan. Having clear policies in place helped build support for the initiative, as many officers were concerned about liability and associated risks. DART also worked to allay EMS concerns about non-medical professionals (i.e., law enforcement) administering what they perceived as a medical intervention. 

In addition, DART has developed clear policies to protect its name and mission. The team recognized the challenge that police officers might face serving as both law enforcers and referral to care providers. It was therefore important that officers understood the parameters of administering Narcan and/or providing overdose supports, and that DART not be associated with drug or other police investigations. To that end, DART is adamant about not allowing police narcotics detectives to join post-overdose outreach teams. This was hard for many officers who were very committed to the work, but important in terms of conflict of interest. 

ES 7. Enable equitable access 

DART is continually expanding the services it provides to respond to emerging client needs. For example, the team is currently working with new partners to address issues such as partner-based violence and partner-based use. They are also working to better support individuals involved with the criminal justice system and additionally those who have caused harm.

“We’ve thought a lot about people that do harm, such as sex offenders, and how excluded they are from different programs. Trauma is the root of so much pain felt by victims of violent crime, but we know the root of perpetrator harming behaviors is often an extensive traumatic history. All people should have the same access to care and wellness. Otherwise, how will the cycle be broken?,” says Farry.

DART has also spent significant time educating about the value of medicated-assisted treatment (MAT), working with providers to help people using MAT regain employment and address the stigma directed toward people using MAT. 

ES 8. Build a diverse and skilled workforce 

DART currently provides quarterly training for the broad range of practitioners involved in their programming—harm reduction, police officers, behavioral health and peer support, first responders, crisis clinicians, social workers, recovery coaches, child protective services, justice partners, and concerned employers, to name just a few. Some are licensed, some are not. Everyone is cross-trained to ensure a shared understanding of the program’s mission and approach. These large trainings are often accompanied by smaller, cohort-specific trainings. 

DART is also committed to systems-level change. For example, staff worked closely with Professor Kim Dion, a harm reduction champion, to train hospital emergency department staff on supporting substance-involved patients. They also worked with hospital leadership to examine and revise ED protocols to put the systems in place to support and sustain practice change. 

“Kim would face these incredibly hard subjects, like how to ask patients about safe injection practices, or potential sexual exploitation? Clinicians often don’t ask these questions because they don’t know how, and don’t know what to do with the answers. Our training provided them with the tools to start to introduce these concepts,” said Farry.

ES 9. Improve and innovate through evaluation, research, and quality improvement  

Data ethics are the foundation for all of the work DART does. To ensure access to the timely and comprehensive data it relies upon, it has established data-sharing agreements across multiple sectors and organizations in Hampshire and Hampden counties, and developed a HIPPA-compliant centralized data platform that combines data from these multiple partners. The platform enables DART to produce customized reports, share data for action with partners, identify gaps in services (e.g., related to high-risk times for overdose), and better understand some of the unique risk factors for overdose, such as occupation, age, gender, housing, and health insurance.

“We value a wide range of data—on overdose, Narcan distribution, emergent toxicity of substances, poly-substance use. On the timeliness of the response. On touch points. On the demographics of people who have overdosed. Every data point is revealing. We do however employ data and electronic ethics, and consider accessibility and literacy best practices in what we do with the team and how they engage with their community,” said Farry. 

DART’s data managers also work with partners to develop data collection protocols and policies that honor and respect the experience of the respondent. Ethics is at the forefront of all their efforts. For example, they had to remind first responders that respondents may not always be accurate or what some consider as honest in their responses, but to always honor whatever the respondent discloses and not seek the “facts.” They are committed to respecting the privacy of the people with whom they interact, while also capturing often sensitive information about individual and community needs.

ES 10. Build and maintain a strong organizational infrastructure for public health

Like so many aspects of the program, DART has been intentional about building a strong organizational infrastructure and planning for sustainability. The team worked with consultants to define the goals for each component of their outreach program, figure out what’s needed to achieve these goals, and develop corresponding protocols to ensure fidelity. And then they revisit these protocols regularly to ensure that they are still relevant. 

“We have to be nimble,” says Farry. “We have a strong mission, but we are learning new things all the time. We meet regularly with partners to capture lessons learned. We ask them questions. And then we refine our approaches accordingly.”

For example, DART is currently supporting the development of a Berkshire County post-overdose response program that uses harm reduction specialists and EMS to conduct outreach rather than police officers. The approach recognizes the complicated relationship that many overdose survivors have with law enforcement—and vice versa. Other communities have their own protocols for who they refer for service or the types of supports they provide. 

“People need different things. So, we need to offer a menu of options and ask ourselves, when triaging and assigning participants, who is the best person to respond? Who is the right champion for the individual?,” says Farry. 

DART has also begun putting their training presentations on video, and posting them to a DART Google classroom. Each presentation addresses a specific aspect of their work—such as how to use fentanyl strips. The videos are meant to supplement, not replace, their in-person training. The team will continue to bring partners together once, twice, or more a year, but the time will be devoted to relationship-building, collaboration, and to sharing a meal.