April 2020

This report was developed under grant number SJI-20-T-016 from the 

State Justice Institute. The points of view expressed are those of the 

authors and do not necessarily represent the official position or policies of 

the State Justice Institute.
1

Executive Summary

St. Louis County, designated a High Intensity Drug Trafficking Area in November 2019, ranks third in heroin and 

opioid overdose deaths in Minnesota. 1 Despite having a relatively small population, 10.5% of all opioid overdose 

deaths within Minnesota have occurred in SLC. Treatment admissions for opioid use disorder (OUD) are greater 

in SLC than the state (28% in SLC vs. 19% statewide). 2

St. Louis County has steadily worked to address this crisis both within and outside of the justice system. Several 

initiatives are underway that implement evidence-based practices to serve SLC residents and the unique 

challenges they face. In January 2020, with funding from the State Justice Institute, Rulo Strategies initiated an 

assessment of SLC's gaps and opportunities to improve the community's criminal justice response to the opioid 

epidemic and make the connections between arrest, incarceration, and reentry to support individuals with

treatment and recovery services.

The thirteen recommendations outlined in this report are designed to provide a framework for SLC to further 

address OUD and other substance use disorders (SUD), and reduce overdose deaths among justice-involved 

individuals by utilizing evidence-based practices and strengthening inter-agency stakeholder partnerships.

Thirteen Recommendations for a Comprehensive Response to 

Substance Use Disorders in the Justice System

1. Establish a cross-sector team to prioritize, 

coordinate, and implement prevention, 

treatment, and recovery efforts across the 

judiciary, public safety, public health, and 

behavioral health.

2. Expand the existing focus on opioid-related 

efforts to more broadly encompass initiatives 

that establish sustainable systems of care that 

support all individuals with substance use 

disorders.

3. Explore the implementation of a mobile clinic to 

provide immediate access to treatment and 

recovery support services.

4. Enhance services in the St. Louis County 

corrections system to fully respond to the needs 

of inmates with substance use disorders.

5. Standardize law enforcement diversion 

protocols and integrate with other efforts 

underway in St. Louis County and the 

surrounding counties.

6. Further explore court models, like the Buffalo 

Opioid Intervention Court, that triage 

individuals entering the justice system at highrisk for overdose death.

7. Monitor the impact of the new Safe 

Babies Court on children within the 

foster care system.

8. Evaluate St. Louis County's approach to 

providing on-demand medically 

managed detoxification and identify the 

resources required to maintain this 

capability.

9. Identify clinical training opportunities 

and resources needed to support and 

expand medication-assisted treatment 

prescribing.

10. Expand the use of community health 

workers to link individuals to services and 

resources in the community.

11. Recruit, train, and retain peers to work at 

all intercepts in the criminal justice 

system, including the jail and reentry, 

and expand their presence in health 

settings.

12. Develop a multi-sector campaign to 

address, diminish, and prevent addictionrelated stigma. 

13. Distribute intranasal naloxone rather 

than injectable naloxone as new funding 

opportunities arise.
2

Introduction 

St. Louis County (SLC) is the largest county in the 

state of Minnesota, covering 7,092 square miles. 

Portions of the Fond du Lac Band of Chippewa and 

the Boise Fort Band of Chippewa Reservation 

borders are within SLC boundaries. Duluth is SLC's 

county seat; larger towns in rural SLC include 

Hibbing, Virginia, Chisholm, and Ely.

The County has a population of approximately 

200,000 people, which is 3.7% of the state 

population. Despite the County's relatively small 

population, 10.5% of all opioid overdose deaths 

within Minnesota have occurred in SLC, and it ranks 

third in heroin and opioid overdose deaths in 

Minnesota. 3 The headline "Overdose Deaths Jump in 

Duluth, St. Louis County" in the local newspaper, the 

Duluth News Tribune (January 9, 2020), indicated 

that although overdoses in the state are dropping, 

the number of overdoses in Duluth increased from 

106 to 174—an increase of 64%—in 2018, and the 

number of fatalities increased from eight to 14. The 

number of overdoses for all of SLC (which includes

Duluth) increased by 52% (from 151 to 230), with 

fatalities growing from 13 to 21. In 2019, three of the 

fatalities involved inmates who died within days of 

being released from one of the local correctional 

facilities.

In the fall of 2019, Minnesota's Sixth Judicial District 

applied for, and was awarded, a grant to complete a 

comprehensive needs assessment and identify 

opportunities to strengthen the justice system's

response to the opioid epidemic. In particular, SLC

was motivated to develop a plan to 1) provide 

support for the implementation of medicationassisted treatment (MAT) in the jail setting, with a 

multidisciplinary team, policies, and leadership; 2) 

effectively transition individuals from jail to the 

community using a "hot handoff," and 3) identify the 

Court's role in connecting clients with an opioid use 

disorder (OUD) quickly to life-saving MAT. The Sixth 

Judicial District contracted with Rulo Strategies to 

complete the assessment. Information contained in 

this report reflects findings from interviews 

conducted between January and March 2020 and 

follow-up discussions completed between March 

and May 2020.

Existing Coalitions and Collaborations 

Multiple agencies are working on initiatives

designed to strengthen the justice system's 

response to SUD in St. Louis County.

St. Louis County's Public Health and Human Services

Department created the Substance Abuse

Prevention and Intervention Initiative (SAPII) to

provide community education, outreach,

professional development training, and consultation

services throughout the county. The SAPII team also

coordinates the North and South OARS (Opioid

Abuse Response Strategies) workgroups, bringing

together a variety of community organizations that

work together to combat the opioid crisis. Through

harm reduction, treatment and recovery, and law

enforcement sub workgroups, OARS is working to

ensure that treatment, including MAT, is available at

every location where individuals are using opioids:

the medical system (emergency departments,

hospitals, clinics), the criminal justice system, drug

treatment programs, and in the community.

A broader Substance Use Disorder Collaborative

(SUDC), including providers from SLC, Carlton

County, and surrounding Tribal Nations, also exists. 4

SUDC's mission is to provide services to people with

a SUD, reduce the number of substance use-related

deaths, and increase the number of people in

recovery.

Tribal Communities 

Tribal communities are disproportionately impacted

by SUD across the United States. According to the

Minnesota Department of Health, American Indians

in Minnesota are six times more likely to die of a

drug overdose than their white counterparts. In 2016,

population death rates per 100,000 individuals stood

at 64.6 for Native Americans compared to 11.7 for

whites. Between 2014 and 2016, 70% of the overdose

deaths in American Indian Minnesotans involved

opioid drugs, making opioids the leading cause of

overdose death in this population. The Human

Services Division of the Fond du Lac Band of Lake

Superior Chippewa focuses on addressing SUD and

serves over 7,200 American Indian people living in

Southern SLC and Carlton County. The Fond du Lac

Center for American Indian Resources (CAIR), which

serves Duluth and the surrounding area, provides a

range of SUD services to include Rule 25

assessments, outpatient treatment services,

individual counseling, and community education.

CAIR also offers behavioral health services such as

mental health standard testing, therapeutic

interventions, and counselors in area schools.

 
3

Law Enforcement 

The St. Louis County Sherriff's Office and the Duluth

Police Department sit on the Lake Superior Drug

and Violent Crime Task Force (LSDVCTF), partially

funded through the Minnesota Violent Crimes

Enforcement Teams (VCET) initiative. In 2018, the

Duluth Police Department was awarded funding

from the U.S. Department of Justice, Bureau of

Justice Assistance (BJA), to develop a post-overdose

response program. Under this program, peer

recovery specialists, who are paired with law

enforcement officers, follow up with survivors of

overdoses and offer support and connections to

treatment, recovery support, and/or harm-reduction

services. The goal is to develop and maintain a

connection that supports the individual's well-being

and hopefully prevent a future overdose.

The Duluth Police Department is also an active user

of the Overdose Detection Mapping Application 

Program (ODMAP). ODMAP is designed to easily and 

quickly track the locations of suspected fatal and 

nonfatal overdoses and the administration of 

naloxone. ODMAP provides overdose data within 

and across jurisdictions to support communitybased efforts to mobilize responses to overdose 

spikes. The state of Minnesota is one of eight states 

participating in a national demonstration project 

designed to support statewide adoption of ODMAP

and enhance the ability of local communities to 

effectively leverage ODMAP data, identify "hot spots"

and trends of concern, and develop coordinated 

public safety, public health, and behavioral health 

intervention strategies. St. Louis County recently 

received a sub-award from the state to support 

these activities.

Court-Based Responses 

St. Louis County has five treatment courts serving 

the community:

• South SLC Drug Court (Duluth Drug Court)

• North SLC Hybrid Court (Hybrid Court) 

• DWI Court 

• Mental Health Court

• Veterans Treatment Court

In February 2020, the Sixth Judicial District launched 

two Safe Babies Courts, in partnership with SLC's

Public Health and Human Services Department,

Human Development Center, Center for Alcohol and 

Drug Treatment, St. Luke's Health Care System, 

Partners in Recovery, Fond du Lac, and Law 

Enforcement partners. One court serves the north 

side of the county and the other serves the southern 

area of the county. The Safe Babies Courts are

designed to help parents in child protection cases 

maintain healthy relationships and, ultimately, 

reunite with their young children in foster care.

Jail-Based Responses 

St. Louis County Jail has three facilities: 1) The 

licensed Class III facility in Duluth (197 inmates) 

holding pre-arraignment, presentenced, and 

sentenced male and female adult offenders; 2) Two 

licensed Class I lockup facilities in Hibbing (eight 

inmates); and 3) The Virginia City Jail and Holding 

Facility (12 inmates), detaining offenders awaiting 

arraignment for up to 72 hours. 

In August 2017, 42% of jail inmates who completed 

an anonymous survey reported using heroin prior to 

their arrest, with 14% daily and 6% receiving MAT in 

jail. In August 2019, 55% of inmates completing a 

survey had used heroin/opioids; 37% used daily, 29% 

considered themselves addicted to heroin/opioids, 

and 13% were receiving MAT prior to arrest. 

In 2019, SLC was one of 16 sites selected to 

participate in a BJA and Arnold Venture's Planning 

Initiative to Build Bridges Between Jail and 

Community-Based Treatment for Opioid Use 

Disorder. The Bridges project began with a ninemonth planning process to assist communities in 

implementing MAT in their jails and enhancing 

collaboration between jails and community-based 

treatment providers. After the planning process, 

which ended in February 2020, each community 

received one year of funding and support from the 

Centers for Disease Control and Prevention to 

support implementation. 

Peer Recovery 

In 2019, Recovery Alliance Duluth (RAD), the first

Recovery Community Organization (RCO) developed

north of the Twin Cities metro area, was launched.

RAD fills a critical gap in peer-based recovery

support services for individuals residing in the

Northeast Region, especially St. Louis County. RAD

hosted its first peer recovery training in February

2020 and is currently building its direct delivery of

peer recovery support services with local emergency

departments, treatment providers, community

agencies, and outreach services. RAD is focused on

connecting SLC service recipients and individuals
4

entering or transitioning the criminal justice system

with recovery support asevidence shows that

extended access to recovery services increases the

quality of outcomes.

Needs Assessment  

As part of this comprehensive needs assessment, 

Rulo Strategies met with representatives from the 

following agencies: • Law enforcement • Corrections • Courts • Probation and Parole • Public defenders • Public Health and Human Services • Medical providers • Chemical dependency service providers • Tribal representatives • Recovery community organizations

This report provides recommendations for building 

on existing SLC efforts to implement a 

comprehensive response to SUD within the justice 

system. 

The thirteen recommendations have been 

organized into the following key areas: • Foundational Coordination • Corrections • Law Enforcement and the Judiciary • Treatment and Recovery Services • Community-Based Engagement and 

Prevention

It is critical that the systems established for 

addressing opioid misuse, addiction, and overdose 

also address other substances of concern, including 

methamphetamine and alcohol misuse, to support 

improved health for all residents and improved 

quality of life for the entire community. 
5

FOUNDATIONAL RECOMMENDATIONS 

Recommendation 1: Establish a cross-sector team 

to prioritize, coordinate, and implement 

prevention, treatment, and recovery efforts across 

the judiciary, public safety, public health, and 

behavioral health.

Effectively responding to the needs of individuals 

with a SUD who encounter the justice system 

requires alignment between law enforcement, the 

courts, corrections, social and human service 

agencies, behavioral health providers, medical 

providers, and other community providers.

Effectively supporting the coordination of services 

across these sectors that are largely autonomous 

and diverse in political and cultural norms requires 

more than a set of protocols or a standing meeting.

Some of SLC's initiatives addressing OUD are less 

than one year old and will need ongoing attention to 

be sustained. In order for cross-sector collaboration 

to be institutionalized, communities must establish 

a formal infrastructure designed to support this 

work with the goal of coordinating existing and 

future efforts under this structure.

This work is typically led by a coordinator who spans

the work of multiple agencies that has responsibility 

for:

• Establishing and maintaining formal and 

informal mechanisms to facilitate the 

communication and sharing of expertise, 

linking groups who might otherwise be 

separated by function or location.

• Leveraging existing relationships and forging

new relationships to reduce barriers to 

service and align and/or integrate programs 

and services when appropriate.

• Facilitating knowledge transfer by creating a 

forum for each group of professionals to 

present their specific expertise in a structure 

and format that can be understood and 

integrated by the larger group. 

• Supporting agencies and organizations with 

program implementation and addressing 

anticipated cross-sector impact as well as 

unintended consequences.

• Creating a venue to discuss emergent needs 

and shifting priorities. 

• Supporting data collection and data sharing 

across agencies.

• Tracking all key initiatives and planning for 

sustainability.

To be successful, a coordinator must possess

interpersonal skills, technical skills, and knowledge 

to work with multiple teams and systems. The ideal 

candidate would possess an in-depth knowledge of 

public safety, behavioral health, and public health, 

and understand the formal and informal norms of 

the agencies that comprise those sectors. The ideal 

candidate should possess the skills to perform the 

honest broker role, have the perceived legitimacy to 

act objectively and openly for others, and the 

capacity to develop credibility with diverse 

organizations.

The planning committee that oversaw the needs 

assessment prioritized this recommendation and 

incorporated it into a funding request submitted to 

BJA in a 2020 Comprehensive Opioid, Stimulant, and 

Substance Abuse Program (COSSAP) grant 

application.

Recommendation 2: Expand the existing focus on 

opioid-related efforts to more broadly encompass 

initiatives that establish sustainable systems of 

care that support all individuals with substance 

use disorders.

Local, state, and national efforts to coordinate care, 

improve access to treatment, monitor and track 

opioid prescriptions, and expand access to overdose 

reversal medications have contributed to a decrease 

in overdose deaths. However, changing substance 

use patterns, including the resurgence of 

methamphetamine use, and the mixing of opioids 

with methamphetamine and cocaine in the illicit 

drug supply, have continued to make the drug 

overdose landscape more complicated and 

surveillance and prevention efforts more 

challenging.

The opioid epidemic has been explained as hitting 

our nation in three distinct waves—with a fourth

wave, the widespread use of stimulants in 

combination with opioids, well on its way. The first 

wave appeared in the 1990s with the introduction of 

OxyContin and the rapid spread of prescribed 

opioids. The second wave is described as the

migration from prescription pills to injected heroin, 

and the third wave was the arrival of fentanyl. 5 The

fourth wave, or threat, which appears as increased

availability of psychostimulants, particularly 

methamphetamine, must be considered alongside 
6

existing opioid-related efforts. 

Although alcohol remains the primary substance 

used at admission to SUD treatment for adults in 

Minnesota, in 2018, methamphetamine was the 

second leading substance used at admission to 

treatment. 6 During stakeholder interviews, agency 

representatives frequently spoke of the need to 

pivot from primarily an opioid-related focus to a 

broader focus on building systems of care that serve 

all individuals with a SUD. As the SLC planning 

efforts move forward, it will be important to re-brand 

any opioid-specific efforts that may exist to a 

broader focus on social determinants of health.

Recommendation 3: Explore the implementation 

of a mobile clinic to provide immediate access to 

treatment and recovery support services.

Mobile clinics are rapidly becoming a best practice 

as a strategy for reducing barriers to care and 

improving access to treatment for individuals with 

SUD. Access to treatment and continuity of care can 

be especially difficult for justice-involved individuals 

who live in rural areas, like SLC, where treatment 

resources and facilities are limited and difficult to 

access. Transportation is frequently cited as a barrier 

to care, and in response, many states are turning to 

mobile models of care. Two examples include 

BestSelf's Recovery Connections Mobile Team in 

Western New York and Colorado's mobile health 

units initiative.

BestSelf, the largest community-based behavioral 

health organization in Western New York, 

implemented a Recovery Connections Mobile Team 

to provide SUD treatment in the community. On a 

typical day, the van starts with scheduled follow-up 

appointments for patients and then takes on new 

assessments. For example, the van frequently parks 

outside the Buffalo Opioid Intervention Court to 

meet with referred patients and create linkages. The 

Recovery Connections Mobile Team works with jails 

to get inmates the care they need inside the facility, 

as well as linking them with care providers postrelease and facilitate rapid access to medicationassisted treatment (MAT). The Recovery Connections 

Team also dispatches peer advocates to see patients 

who aren't ready to go into treatment to talk with 

them and encourage them to get help.

Colorado's Department of Human Services, Office of 

Behavioral Health, oversees six mobile health units 

to improve access to MAT, distribute naloxone, and 

provide referrals to recovery resources in rural and 

underserved areas. The units are staffed with a 

nurse, a counselor, and a peer specialist with lived 

experience, and medications may be prescribed by a 

medical provider via telehealth services.

A mobile unit is a viable strategy for implementing a 

bridge clinic designed to directly coordinate incustody and community-based treatment, deploy 

wrap-around services including peer recovery 

support, integrate behavioral health care with MAT,

and follow-up with patients. To better serve the 

needs of justice-involved individuals, the bridge 

clinic may be integrated with a substance use triage 

court (see Recommendation 6). Prior to COVID-19 

travel restrictions, a team from SLC was scheduled 

to visit Buffalo, New York, to, in part, meet with the 

mobile clinic staff. Since travel restrictions are likely 

to remain in place, a virtual meeting with BestSelf 

staff may be an ideal next step to better understand 

how this service operates.

RECOMMENDATIONS FOR CORRECTIONS 

Recommendation 4: Enhance services in the St.

Louis County corrections system to fully respond 

to the needs of inmates with substance use 

disorders.

A significant impetus behind the needs assessment 

was SLC's participation in the Bridges project. 

Numerous opportunities exist to fully scale and 

strengthen the implementation of MAT within the 

jail. These opportunities include:

• Sustaining the MAT navigator position 

initially funded by the CDC Bridges project 

funding.

• Implement peer recovery in the SLC jail. The 

planning team prioritized this 

recommendation and incorporated funding 

for a jail-based recovery program specialist in 

their 2020 COSSAP application. The jailbased recovery program specialist will form 

connections with inmates with SUDs and 

make referrals to community resources, help 

with transportation, housing, insurance 

navigation, and/or education—including 

information about naloxone. This individual 

will also facilitate communication and 

collaboration between jail personnel and 

community partners to support individuals 
7

throughout their incarceration—from 

booking to their release (along with their 

friends and/or family members)—to sustain 

recovery, reduce recidivism, and lead to 

better outcomes.

• The planning team also recognized that as 

they move towards full implementation of a 

jail-based MAT program, it was necessary to 

reassess the level of medical staffing in the 

SLC Jail and Northeast Regional Corrections 

Center (NERCC) needed to support a fullyscaled and clinically appropriate jail-based 

MAT program. Funding for a full-time nurse 

to work in the SLC Jail was included in the FY 

2020 COSSAP application.

Implementation of MAT in the SLC Jail has resulted 

in the need for some protocols and practices to 

change. As of March 2020, the various components 

of the justice system were still working through 

these changes. For example, males are transferred 

from the SLC Jail to NERCC following sentencing. As 

the jail was implementing MAT, coordination was 

needed with NERCC to ensure that medications 

would be continued and that practices would be 

implemented that would be supportive of MAT. The 

stakeholders are to be commended for their efforts 

in this area.

Additional opportunities for the SLC Jail include:

• Adopting protocols for the timely and 

consistent review of inmate requests for 

MAT.

• Providing training on the use of naloxone via 

the video monitors in the jail waiting rooms.

• Expanding treatment opportunities, recovery 

support services, and reentry coordination in 

the SLC Jail to support individuals with SUD.

• Ensuring that the curricula and treatment 

approaches used by providers are based on 

best practices and responsive to the inmates'

diverse needs. 

 

RECOMMENDATIONS FOR LAW ENFORCEMENT 

AND THE JUDICIARY 

Recommendation 5: Standardize law enforcement 

diversion protocols and integrate with other 

efforts underway in St. Louis County and the 

surrounding counties.

Law enforcement and other first responders are on 

the front lines of addressing illicit substance use and 

misuse, frequently encountering individuals with 

SUD and responding to drug overdose calls. A 

variety of multidisciplinary overdose prevention, 

response, and diversion and referral pathways, led by 

law enforcement and other first responders, have 

emerged in communities throughout the nation. 

These pathways often include first responders 

working in partnership with SUD treatment 

providers and peer recovery coaches to help 

individuals access treatment and recovery support 

services.

Five pathways have been most commonly 

associated with opioid use disorder. These pathways 

are listed below:

• SELF-REFERRAL PATHWAY: An individual 

voluntarily initiates contact with a first 

responder (a law enforcement, fire services, 

or EMS professional) seeking access to 

treatment (without fear of arrest) and 

receives a referral to a treatment provider.

• ACTIVE OUTREACH PATHWAY: A law 

enforcement officer or other first responder 

identifies or seeks out individuals in need of 

substance abuse treatment; a referral is 

made to a treatment provider, who engages 

them in treatment.

• NALOXONE PLUS PATHWAY: A law 

enforcement officer or other first responder 

engages an individual in treatment as part of 

an overdose response.

• FIRST RESPONDER/OFFICER PREVENTION 

REFERRAL PATHWAY: A law enforcement 

officer or other first responder initiates 

treatment engagement, but no criminal 

charges are filed.

• OFFICER INTERVENTION REFERRAL 

PATHWAY: A law enforcement officer 

initiates treatment engagement; charges are 

filed and held in abeyance, or a citation is 

issued.

As noted, the Duluth Police Department has 

established a program based on the Naloxone Plus 

Pathway over the last year. This program is 

continuing to grow, and the Duluth Police 

Department submitted its own 2020 COSSAP grant 

application to support this expansion. At this stage 

of implementation, it is essential that front-end 

diversion efforts become fully integrated with other 
8

initiatives taking place in other intercepts, especially 

if new funding is received in 2020. By establishing biweekly touch-base meetings, stakeholders can 

identify opportunities to collaborate, fill gaps, and 

share resources. Institutionalizing these efforts 

through structure, protocol, and coordination will 

assist with long-term program sustainability.

Recommendation 6: Further explore court 

models, like the Buffalo Opioid Intervention Court, 

that triage individuals entering the justice system 

at high-risk for overdose death.

The Buffalo Opioid Intervention Court is an 

innovative model in which program staff screen 

participants or clients (individuals are intentionally 

not referred to as defendants to instill hope and 

pride) who are booked in the jail using a brief survey 

developed by the court to identify those at risk of 

overdose. After arraignment, individuals identified as 

being at risk are offered an opportunity to 

participate in a treatment program. Once enrolled,

an onsite team of caseworkers and treatment 

professionals work together to link the individual to 

an appropriate treatment provider. Screening, 

referral, and linkage to treatment all occur within 

the first 24 hours of arrest. Program staff provides

case management, and participants are required to 

check in with the court every day for 90 days. While 

enrolled in the program, the prosecution of the case 

is suspended. Upon successful completion, 

participants enter into a plea agreement and may 

be diverted to a formal drug court, mental health 

court, veteran's treatment court, or have their case 

dismissed.

The Buffalo Opioid Intervention Court is a 

groundbreaking model that uses the court as a 

method of expediting and monitoring treatment 

access to services at the point of arrest. It is not 

necessary to replicate all components of the Buffalo 

Opioid Intervention Court (e.g., daily appearances) to 

rapidly triage individuals with substance use

disorders who are justice-involved. Before the 

COVID-19 travel restrictions, a team from SLC was 

scheduled to visit the Buffalo Opioid Intervention 

Court. In lieu of traveling, it may be useful to set up a 

call with the Buffalo Coordinator to better 

understand how this model works and whether 

components of this approach could be useful in 

providing rapid access to services.

Recommendation 7: Monitor the impact of the 

new Safe Babies Court on children within the 

foster care system.

SLC is initiating a pilot Safe Babies Court in 2020

through a partnership with the national non-profit 

program called Zero to Three, which focuses on the 

early development of children and the effects of 

early attachment into adulthood. Safe Babies Courts 

are designed to ensure very young children and 

their parents receive expedited, comprehensive 

services and support that prevent children's removal 

and placement in foster care; promote reunification 

and other lasting permanency outcomes;

strengthen family protective factors; and protect 

and build safe, stable, and nurturing early 

relationships.

The program will be voluntary for six to eight 

families in its first year in SLC. Safe Babies Court 

Teams provide structure for cross-sector teamwork. 

The Family Team uses a trauma-informed lens to 

ensure very young children and their parents receive 

expedited, comprehensive services and supports. 

Parents are able to invite their own support people—

including family or close friends—into the process. 

They meet with a social worker, the child's 

appointed guardian ad litem, an attorney for the 

parents, and a county attorney every other month. 

The team will check in with a judge on alternate 

months.

As this is a new program with the potential to 

provide important lessons for all stakeholders, it will 

be important to monitor the impact of this valuable 

project.

RECOMMENDATIONS FOR TREATMENT AND 

RECOVERY SERVICES 

Recommendation 8: Evaluate St. Louis County's 

approach to providing on-demand medically 

managed detoxification and identify the 

resources required to maintain this capability.

A recent 2020 Substance Abuse and Mental Health 

Services Administration (SAMHSA) publication titled 

National Guidelines for Behavioral Health Crisis Care 

- A Best Practice Toolkit presents three core 

elements for an effective crisis system of care. The 

three elements include Crisis Call Centers (someone 

to talk to), Crisis Mobile Teams (someone to 
9

respond), and Crisis Receiving Centers (someplace 

to go). Although hospital systems, law enforcement 

agencies, and public health organizations 

independently have their own policies and 

procedures for crisis care, more and more 

communities are recognizing the need for additional 

cross-system coordination and strategies that 

ensure every patient receives "the right treatment, 

at the right place, at the right time."

Many programs strive to embrace a "no wrong door"

philosophy to ensure procedures and resources are 

in place to respond to a crisis wherever it presents 

itself—during an arrest, upon booking in jail, during 

a court proceeding, in a hospital, or in the 

community. Receiving Centers or drop-off locations 

are especially useful for this purpose, and even more 

so for law enforcement who frequently encounter 

individuals with severe SUDs and/or mental illness. 

Drop-off Centers, also called Receiving Centers or 

Assessment Sites, are designed to serve as part of a 

larger system of care, where individuals can be 

taken in lieu of arrest for assessment, treatment, or 

referral. One of the most valuable aspects of a dropoff model of care is that it allows a responding law 

enforcement officer to quickly return to his or her 

duties. 

The Center for Alcohol and Drug Treatment (CADT) 

currently provides this service for SLC. CADT offers 

many critical services, but most notably, they 

operate a Detoxification Unit consisting of 24 beds 

for medically managed sub-acute detoxification 

from alcohol and drugs and a Pathfinder Unit that 

consists of six beds for acute opioid-related disorders 

that require medical management including opioid 

intoxication, opioid overdose, and opioid withdrawal.

Ensuring the long-term financial viability of these 

services in SLC is a critical component of a 

comprehensive system of care.

Recommendation 9: Identify clinical training 

opportunities and resources needed to support 

and expand medication-assisted treatment

prescribing.

Like many communities, SLC continues efforts to 

expand access to MAT. Medical providers identified 

several opportunities for improvement. These 

include:

• Identifying and publishing a single point-ofcontact to address questions that arise about 

appropriate referrals to providers.

• Building the skills of new MAT prescribers by 

providing consultation services, particularly 

for cases where additional support may build 

confidence.

• Establish a network of MAT prescribers to

share best practices.

SAMHSA funds the Providers Clinical Support 

System (PCSS) to train primary care providers in the 

evidence-based prevention and treatment of OUD

and treatment of chronic pain. PCSS is made up of a 

coalition, led by American Academy of Addiction 

Psychiatry (AAAP), of major healthcare organizations

whose mission is to increase healthcare providers’ 

knowledge and skills in the prevention, 

identification, and treatment of SUDs with a focus 

on OUD. The program provides clinical mentors and 

matches them with clinicians. There is also a 

discussion forum, moderated by an addiction expert.

Recommendation 10: Expand the use of 

community health workers to link individuals to 

services and resources in the community.

Community Health Workers (CHWs) can be an 

enormous asset to justice-involved individuals with 

SUD. A CHW serves as a link between health/social 

services and the community to facilitate access to 

services and improve the quality and cultural 

competence of service delivery. Services offered by 

CHWs include health education, system navigation, 

case coordination, and outreach. Peer recovery 

specialists, who are often in recovery, are more 

narrowly focused on providing recovery assistance, 

mentorship, and advocacy in support of individuals 

with a mental health condition or SUD.

The CHW profession has seen substantial growth in 

recent years as the need for ensuring continuity of 

care in the community increases. CHWs work in a 

variety of settings, including hospitals, nonprofit 

organizations, and government agencies. The 

benefits of utilizing CHWs are especially significant 

for individuals with SUD who are justice-involved as 

they are often disconnected from their own 

communities and unaware of resources that might 

be available to them. CHWs can assist these 

individuals by connecting them to resources and 

providing a path to community healthcare and SUD 

treatment programs without fear of stigma or 

judgment.

Ely, a rural community in SLC, illustrates the value of

leveraging CHWs to support individuals with SUD. 

Of note, one of the CHWs is funded through 
10

donations from a local church. The CHWs use a 

shared release of information so that they can 

coordinate care and address patients’ social 

determinants of health. 

The planning committee that oversaw the needs 

assessment seeks to expand the use of CHWs to 

address SUD and incorporated funding for one CHW 

into a funding request submitted to BJA in a 2020 

COSSAP grant application. If awarded, this CHW will 

be placed in the Duluth Family Medicine Clinic.

Recommendation 11: Recruit, train, and retain 

peers to work at all intercepts in the criminal 

justice system, including the jail and reentry, and 

expand their presence in health settings.

Peer recovery specialists (PRSs) are individuals in 

recovery from a mental health condition or SUD who 

provide support and resources to others on their 

path to recovery. PRSs are employed and work in a 

variety of settings, including hospital emergency 

rooms, community behavioral health organizations, 

law enforcement agencies, courts, corrections, and 

probation/parole agencies. Effective integration of 

PRSs requires considerable planning and existing 

staff buy-in to ensure a supportive environment for 

the PRSs and the individuals they serve, and this is 

especially true in criminal justice settings.

As noted previously, RAD is working alongside other 

stakeholders, including the Human Development 

Center, to expand access to peer recovery in SLC. As 

part of the 2020 COSSAP application, one jail-based 

peer recovery specialist and one community-based 

peer recovery specialist was requested. As SLC 

grows its peer recovery community and integrates 

this service more broadly at every intercept of the 

criminal justice system, it will be important to think 

about the need for training. It is not unusual for 

PRSs working in the justice system to come in 

contact with or even work alongside former 

probation officers, judges, prosecutors, and others 

that may have presided over their own criminal case. 

It is also not unusual that a PRS might encounter 

individuals from their own past, even individuals 

with whom they may have engaged in criminal 

activity. Peer certification training provides 

preparation for these scenarios, but training and 

preparation must also occur for the staff themselves 

to address any known or unknown biases and 

concerns they may have towards working side by 

side with individuals in recovery who have a criminal 

past. 

RECOMMENDATIONS FOR COMMUNITY-BASED 

ENGAGEMENT AND PREVENTION 

Recommendation 12: Develop a multi-sector 

campaign to address, diminish, and prevent 

addiction-related stigma. 

There are three potential focus areas for anti-stigma 

campaigns. The first addresses self-stigma (how an 

individual feels about him or herself which prevents 

them from seeking and/or embracing their 

recovery). The second addresses social stigma (a 

group or community's unwillingness to change their 

opinion of addiction and/or of individuals who 

experience addiction). Finally, anti-stigma 

campaigns may address structure (policies or 

programs that discriminate against or exclude 

participation in opportunities as a result of an 

individual’s addiction or criminal justice history). An 

effective campaign should incorporate components 

of each of the three areas of focus.

SLC stakeholders identified a need to continue to 

educate on stigma and there is some evidence the 

community is willing to be engaged on this topic. 

For example, an evening workshop hosted by rural 

providers in SLC on stigma and addiction was very 

well attended. 

Stakeholders also identified the need to further 

educate medical providers as there can be perceived 

stigma towards individuals with SUD both within 

primary care settings and the emergency 

departments. Including individuals in recovery into 

educational campaigns directed towards the 

medical community is incredibly powerful and 

something that SLC has some experience with. It 

would be particularly powerful for the key medical 

providers to come together as a community to 

address stigma.

Several interventions have demonstrated success 

addressing stigma towards individuals with SUD in 

the criminal justice system and across multiple 

sectors:

• Therapeutic interventions, such as groupbased acceptance and commitment therapy 

to reduce self-stigma.

• Motivational interviewing and 

communicating positive stories of people 

with SUD to reduce social stigma.
11

• Contact-based training and education 

programs targeting medical students and 

professionals (e.g., law enforcement) to 

reduce structural stigma.

7

Examples of campaigns can be found on the

American Society of Addiction Medicine website

,

and information on developing a campaign can be 

found here: Anti

-Stigma Toolkit: A Guide to 

Reducing Addiction Related Stigma.

Recommendation 13: Distribute intranasal 

naloxone rather than injectable naloxone as new 

funding opportunities arise.

Take-home naloxone (THN) programs are an 

effective public health intervention to prevent 

deaths from opioid overdose. St. Louis County has 

embraced the value of distributing naloxone to 

individuals discharged from correctional facilities 

and through community-based initiatives in support 

of individuals with OUD.

Naloxone can be administered through two 

methods: intramuscular, by way of an injection, or 

internasal, by way of a nasal spray or nasal atomizer.

Injectable naloxone was not developed for layperson 

use, and non-injectable naloxone is considered to 

have several advantages for take-home naloxone

programs. Injectable medications can be 

intimidating for laypersons, require product 

assembly, and pose a risk of needle-stick injury.

Administering naloxone by way of a nasal spray 

allows medically untrained people to safely and 

effectively use the medication when overdose 

symptoms are observed.

Conclusion 

St. Louis County has demonstrated a strong 

commitment to addressing OUD/SUD among 

justice-involved individuals. The leaders in the

judiciary, public safety, public health, and behavioral 

health sectors, as well as medical providers and 

community organizations, are to be commended for 

their collaborative approach and willingness to 

identify gaps and consider opportunities to enhance 

their community's criminal justice response to 

OUD/SUD. The planning committee that oversaw 

this needs assessment is well-positioned to become 

the foundation of a formalized cross-sector team 

focused on prioritizing and coordinating resources 

from across the County to successfully implement 

the recommendations contained in this report.
12

Individuals Interviewed 

 

Arrowhead Regional Corrections, Northeast Regional Corrections Center

• Phillip Greer

• Katy O'Sullivan

Board of Public Defense, Sixth Judicial District, Chief Public Defender

• Dan Lew

Center for Alcohol and Drug Treatment

• Melissa Latimore

• Tina Silverness

Community Corrections Act – St. Louis County Probation

• Kathleen Lionberger

• Focus group of current probation officers

Duluth Bethel

• Dennis Cummings

• Lisa Rindal

• Randi Shea

Duluth Police Department

• Craig Lindberg

• Jess McCarthy

Essentia Health and St. Lukes

• Katie Bauman

• Dr. Joe Bianco

• Dr. Beth Bilden

• Kelly Black

• Dr. Nick Van Deelan

• Dr. Kristi Estabrook

• Dr. Ifeyinwa Igwe

• Dr. Allison Juba

• Amber Marten

• Dr. Kelly McKinnon

• Dr. Lisa Prusak

• Dr. Adam Riutta

• Dr. Hannah Salk

• Dr. Erik Sather

• Dr. John Woods

Fond du Lac Community Health Services, Center for American Indian Resources

• Taylor Boesel

• Richard Colsen

• Fredericka DeCoteau

• Debra Mallery

• Caitlyn Taylor

• Terri Tidaback
13

Human Development Center

• Cody Lindquist

• Cara Walt

Recovery Alliance Duluth

• Beth Elstad

• Julie Vena

Rural AIDS Action Network

• Deb Hernandez

• Sue Purchase

Sixth Judicial District

• The Honorable Shaun Floerke

• Bri Sathre

• Lindsay Snustad

St. Louis County Jail

• Dr. Todd Leonard (MEnD Correctional Care PLLC)

• Jessica Pete

• Mary Roling

St. Louis County Public Health and Human Services Department

• Erin Bolton

• Gena Bossert

• Kyle Heyeson

• Dusty Letica

1 The data was collected from St. Louis County 

Computer Aided Dispatch (CAD), the 

Minnesota Department of Health, and the 

Shield Records Management System (RMS). 

2 Minnesota DHS 2016 DAANES Report

3 The data was collected from St. Louis County 

Computer Aided Dispatch (CAD), the Minnesota 

Department of Health, and the Shield Records 

Management System (RMS). 

4 https://www.stlouiscountymn.gov/departments-az/public-health-human-services/boardscommittees/substance-use-disorder-collaborative 5 https://www.bmc.org/healthcity/populationhealth/polysubstance-use-dangerous-fourth-waveopioid-crisis 6https://www.health.state.mn.us/communities/opioids/o

pioid-dashboard/index.html 7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC327222

2/