The Community Paramedic Response and Overdose Outreach with Supportive Medical-Legal Services (CROSSROADS) Study - ABSTRACT Overdose continues to be a leading cause of death in the US with certain social and structural vulnerabilities increasing risk. People who are exposed to or impacted by the criminal legal system (CLS) disproportionately report using substances and experience high rates of overdose. In recent years, deep investment in assuaging the impact of the CLS on overdose risk has been made. However, less work has been done to uncover how best to deploy and optimize community interventions at earlier points of the sequential intercept model (e.g., preventing arrest and incarceration) to prevent adverse substance use and CLS outcomes for those at greatest risk. Community paramedic (CP) programs have launched nationally in response to the overdose epidemic in large part due to the acknowledgement that non-punitive interventions are effective. While different models exist, a main component of CP programs is the deployment of non-armed first responders via 911 after an overdose call, a de-facto alternative to police. CPs provide life-saving intervention (e.g., naloxone), MOUD, linkage to community-based health and social services, and follow-up after the initial interaction. Early results of these programs show promise as a non-carceral oriented substance use intervention that also reduces further CLS penetration. CPs outreach is not limited to one-time encounters, and the longevity of contact with people who overdose is important to establish trust, “meet people where they’re at” and provides consistent post-overdose follow-up after the initial interaction. However, CP programs intervene primarily on the individual level and, increasingly, research indicates that, for optimal impact, structural-level factors must be considered. Particularly relevant to CLS populations is the need to address health harming legal needs (HHLN) including lack of access to public benefits, housing issues, and other unmet legal needs. Medical Legal Partnerships (MLP) are a collaboration between legal and healthcare professionals that attempt to bridge structural, social, and individual needs, and in this context, specifically those that increase the likelihood of further adverse substance use harms. To our knowledge, few CP programs incorporate services traditionally offered via MLPs. Therefore, we propose the Community Paramedic Response and Overdose Outreach with Supportive Medical-Legal Services (CROSSROADS) Study. CROSSROADS will take place in Durham, NC; Pittsburgh, PA; Miami, FL; and Portland, ME. Our aims are to: 1) Determine the core components of the proposed CROSSROADS intervention (CP program + MLP); 2) Compare the CROSSROADS intervention versus standard of care (SOC) CP programs across the four locations on 1) frequency opioid and/or stimulant use, and 2) CLS (police, incarceration, and probation/parole involvement); and 3) Identify the acceptability, appropriateness, penetration, and sustainability of the CROSSROADS intervention and multilevel factors that affect overdose and future interactions with the CLS.
