Episode 25_Zgierska_Balles_Nachtigal Part 2
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[00:00:08] Michael Donovan: Welcome back to the Evidence to Impact Podcast, the podcast that brings together academics and their research partners to talk about insights and real world policy solutions in Pennsylvania and beyond. I'm Michael Donovan, the Associate Director of the Evidence to Impact Collaborative here at Penn State. 

[00:00:23] Michael Donovan: Today's episode is part two of Bridging the Gap, community Policing's Role in Recovery and Crime Reduction. And we're just gonna jump right into the conversation. 

[00:00:30] Aleksandra Zgierska: I believe the police workforce was larger when we started, potentially, but it was a big effort to start from scratch because we had to train everybody at the same time because there was no training prior to that. But, uh, the, one of the. Innovative components, but also not typical components in the didactics, especially 10 years ago, was to bring and introduce a person in recovery who walked in those shoes through the justice system and to show police officers.

[00:01:08] Aleksandra Zgierska: That recovery is possible because there was a lot of burnout, but also sense of futility of those efforts when you see someone coming back and back and back through those revolving doors. So, um. Our, so after this initial training, uh, there was more hope that recovery is possible, which also boosted positive motivation among police officers to engage in it and be a part of the solution, not just part of the revolving doors.

[00:01:41] Joe Balles: Yeah. Michael, I'm gonna just jump in here. Mm-hmm. And kind of. Bridge, Alexandra is referencing what we started with our, we had a two hour in service. Everybody in the department went through in 2017 when, uh, we launched MARI officially on September 1st, 2017. And where officers, they actually were able to start.

[00:01:59] Joe Balles: Diverting and deflecting and filling out the MARI form and sending it to our central, um, our criminal intelligence section at the police department. It's where it's gone from 2017 to present, as Diana alluded to, is the incorporation of this now at the. Every police officer gets hired. We, Madison Police Department hires anywhere from 35 to 45 officers a year.

[00:02:22] Joe Balles: Um, that's the kind of turnover we have in the department. And when you look back at the people in, in patrol today, those 300 plus people that, that captain articles talking about, a lot of those people weren't anywhere around the police department 2017, and some of 'em were probably in high school. And so we have had this iteration of MA 1.0, MARI 2.0.

[00:02:42] Joe Balles: I wanna talk about just briefly, because that was when we got a pretty significant grant. The CEP program was first stood up, um, by the, uh, US Department of Justice to combat the opioid epidemic in 2019. That's when we got our next grant to help fund Murray 2.0. But COVID hit. Hit our program hard, and then we had all the social justice unrest.

[00:03:05] Joe Balles: And Madison was one of the epic centers here in the Midwest, in the aftermath of the George Floyd's killing in Minneapolis, not too far away from here, And we had a lot of people decide they, they no longer wanted to be part of policing and there was this anti-police sentiment, in our community and even amongst our own elected officials.

[00:03:22] Joe Balles: In some cases. And so we've managed to go through the depths of that and now we just recently, in November last year, got another $1.6 million grant from the Justice Department to expand what we're doing to, we have multiple different path strategies that we're attempting to implement to create a comprehensive community-wide approach with regards to the opioid, epidemic and substance use disorder.

[00:03:48] Joe Balles: But outreach now is a big part of that and that's why this sits underneath Captain Nautical at the police department because I think today when you look at our numbers, we are still diverting in people to the pre-arrest diversion part of MARI, but we're having contact with far more many far more numbers of people out in the community at specific locations. 

[00:04:07] Joe Balles: We identify through data analysis, hotspot mapping and stuff like that where, people, that are struggling with addiction substance disorder tend to congregate, in our community. So we're having a lot of success that way. But Diana, maybe you wanna speak a little bit about the MARI, resource team and some of the things we're doing there today.

[00:04:25] Diana Nachtigal: Sure. Yes. And, and thank you, Dr. Zgierska for mentioning, you know. When this program first began, it really was a, a shift in mindset for the, for the officers to use this diversion approach. And you know, now, now in Dane County, we actually have a. Plethora of other diversion programs, but we were really on the forefront as far as creating this diversion program from scratch and getting the officers, the buy-in from the officers to begin with.

[00:04:58] Diana Nachtigal: And like Joe said, we are a young department now, probably a conservative estimate is over half of our patrol officers, weren't around in 20, even 2020. So we're a very young department. But I think that also helps that we're getting in on the ground floor from day one when they start and really institutionalizing this program, this mindset of diversion for people with substance use disorders.

[00:05:22] Diana Nachtigal:, And we're also using diversion efforts in other areas. But this, again, this is, has been very sec, a very good buy-in from the officers and where we are now, we do have, uh, some. Dedicated resources that we didn't have at the beginning of the program. So we have a dedicated officer now that runs our MARI outreach team, and we have embedded peers from Safe Communities that go out at least four or five days a week in the community.

[00:05:50] Diana Nachtigal: We do tabling events, we have lists of people that have recently, you know, either suffered an overdose, or had some kind of police contact that was maybe driven by substance use disorders and we're going out and doing follow up, knocking on their doors, teaching them about the referral process, you know, teaching them about MARI and trying to get those, assessments sometime even same day.

[00:06:16] Diana Nachtigal: And really trying to push them through, help them go through the system of getting that assessment and en entering the program. We're trying to reduce those barriers. We're trying to meet people where they are, so we've built some very strong partnerships and we have dedicated, a lot of resources we've created.

[00:06:37] Diana Nachtigal: Not only this one officer that is dedicated to doing outreach, but we have now trained a pool of officers that are willing to come in and also participate in this program and so just the buy-in from the department at the patrol level is just, it's great to see and that's really contributed to the success of this program so far.

[00:07:01] Aleksandra Zgierska: And Diana mentioned teams going out to people's houses essentially, or residence area and this is really interesting for me as a researcher, but also not surprising though, as a clinician because those initial stages, we had to regroup because we were surprised by, the fact that not all people accepted the program, but even if they accepted, they didn't show up, they didn't follow up. 

[00:07:36] Aleksandra Zgierska: We thought it was such a good deal, It's like jail time versus treatment and no criminal charges. It seemed like the, balance of benefits versus harms was really clear, everybody will say yes, and yet I believe those initial stages, about half of the people we enrolled into the program who agreed initially, and signed consent form, they actually, we lost track of them.

[00:08:01] Aleksandra Zgierska: They didn't make the outreach that they were supposed to do. So what happens when the mountain, can't come to wherever it's supposed to go. The police department and connections counseling treatment provider, developed a plan to go to the residence area. And what did we find out? Well, many people, first of all, maybe they were in the midst of addiction crisis.

[00:08:26] Aleksandra Zgierska: Maybe they overdosed. Some of them just didn't remember. They misplaced the sheet with contact information, but, surprisingly, a large proportion. They just thought this was, there was a catch, this was a trick. This was too good to be true. What do you mean police? The police officers are telling me that they will not arrest me, but they will take me to treatment.

[00:08:49] Aleksandra Zgierska: Where's the catch? But this knocking on the door brought a large portion of those people who otherwise wouldn't have shown up, engaged, back to the program and they successfully completed it. The other aspect, and I think this is where the subsequent iterations of MARI build upon the police officers discovered that going in with peer recovery, peer support specialist was really critical.

[00:09:23] Aleksandra Zgierska: The same applied to the recovery specialist, for myself as a clinician and researcher, I would feel deeply uncomfortable sending my research staff on their own out there to the community, because that's like, we can't guarantee the safety, but sending them with a police officer was a different story. Yes, we can do it.

[00:09:43] Aleksandra Zgierska: So the police officer was the person who knocked on the door and persuasively, said, open up please, like you see in the movies. And people mostly opened the door, but then the peer support recovery specialist took over and had this, person centered conversation. Over time, the report from the police officers was that they learned better how to better talk about it.

[00:10:12] Aleksandra Zgierska: While the peer recovery specialist appreciated the police approach as well, but that gave rise to later all the response teams that went to overdose that were dually staffed by police officer and a recovery peer specialist to really better bridge. The gap in trust, but also in, ability to relate, so that was the very initial experience that, made me realize how important it is to just go door to door.  

[00:10:50] Michael Donovan: right.

[00:10:50] Aleksandra Zgierska: And not wait for people to come to us exclusively. 

[00:10:54] Diana Nachtigal: I just wanted to mention too, that we also look at data, so we're looking at where, the overdoses are occurring and we are act going out to those areas and seeing if we can set up a tabling event to reach people in those areas that, you know.

[00:11:09] Diana Nachtigal: Where we're seeing some spikes in numbers, in addition to that and going door to door, we also go to where people are seeking services, so we're going to the shelters, we're going to, you know, the job centers, we're going to public libraries, we're going to other places. and just allowing and setting up a table with, and we're handing out, you know, harm reduction supplies, but we're also handing out information on our program. 

[00:11:34] Diana Nachtigal: And so we have also incorporated now a self-referral process, and trying to, you know, again, in that expansion mode and trying to reach a new pool of people with that are coming in without any charging that is kind of an incentive for them, but we're all also offering them a self-referral process now as well.

[00:11:55] Joe Balles: Yeah, and that's, I wanna jump in there. That self-referral process is just something we've started doing the last few months, We also had a breakthrough with the Department of Corrections here in Wisconsin where people on probation and parole now are able to, enroll in MARI. That was a huge breakthrough for us because we were, screening out, a lot of times people of color who happen to be on probation and parole.

[00:12:14] Joe Balles: From MARI and now we're able to take and, bring them in as well, And Michael, a couple things I just wanna point out too with regards to data and, our overdose epidemic here in Dane County peaked around, December of 2022 and, countywide, we have 26 EMS agencies in Dane County, but the Madison Fire Department probably responds to 80, 85% of all the overdoses here in the city of Madison.

[00:12:39] Joe Balles: But we were peaking out at about 400 a quarter, it was like 390. Since then we have done seen nothing but a steady downline. You've kind of probably aware of the information that's been in the New York Times and other places about overdose, deaths, going down. We've seen both, EMS responses to overdose calls and overdose deaths going down the last two years here in Madison, pretty significantly. 

[00:13:03] Joe Balles: It's great to see, It's just downward trend. We're kind of back to where we were, uh, I would say around two, 2019, 'Cause we've everybody experienced that big peak, post COVID, but and the drug supply is different today too, Fentanyl is such a scary thing and it's so prevalent out there in our communities.

[00:13:21] Joe Balles: And Diana was referring to the tabling events at those known spots. Well, what's part of those tabling events is we have Hope Kits and Narcan, that we give out dozens, if not hundreds of, boxes of Narcan on a weekly basis, to people in Madison. So I think that a combination of all this is why we're seeing the decrease in the overdose trends here. 

[00:13:41] Joe Balles: But there's still a lot of work to do and we know it. And, that's, but we're happy to see some of the things that we, we've been seeing here over the last few years. 

[00:13:51] Diana Nachtigal: Yes. In addition to Narcan, we're also giving out Fentanyl test strips as well as Xylazine test strips because that is also, you know, the trends that we're seeing in the Madison community as well. 

[00:14:03] Joe Balles: And if, Michael, if I can just jump in with one more thing talking, I'm looking down the road, two things that, um, are kind of on our radar screen right now in our new grant, but one is to develop a contingency management, component to MARI and for those that don't know, but contingency management's kind of a, it's a bad word in terms of, doesn't really describe really well what it is, but basically it's how do you create incentives for people to take and go to treatment? 

[00:14:30] Joe Balles: And there's, and Dr. Rossin and some others out there, he's from UCLA, they've written, there's a lot of published around evidence that sort of stimulant users and how, contingency management are having incentives is very high motivator for people, struggling with stimulant, use disorder to get them to, treatment.

[00:14:48] Joe Balles: And now there's a kind of a interest among people that are addicted to opioids, um, fentanyl or other substances that how can we can incorporate the practices of contingency management, creating more structure, so we're kind of looking at that in our, for our MARI pre-arrest diversion self-referral program right now. 

[00:15:05] Joe Balles: The other thing is to, for more for the officers, but how do we incorporate aspects of motivational interviewing, um, when we're having that contact with people? Because I think that when you talk about community policing and what we're trying to do here, the essence of it is that police officer having contact with a person who's in the depths Despair of their addiction. 

[00:15:24] Joe Balles: We, we, Aleksandra was referring to it earlier about how we had to go back and we, we, we call it the mobile outreach team back then. Um, MOT, um, where basically a police officer in plain clothes along with someone from connections counseling, was knocking the door, was somebody who didn't show up for their MARI assessment.

[00:15:45] Joe Balles: And, um, how do we train officers to have a very good conversation with them, so when they leave that conversation that they know that MARI's legit, MARI's for real. It's not a trick, but we really want to try to connect them to treatment. And so I think there's some, I think there's some growth and room, uh, for improvement we can do there too.

[00:16:06] Joe Balles: But those are two things that we're kind of working on here over the next 12 to 24 months. 

[00:16:13] Michael Donovan: Yeah, that really points me in the direction of, you know, how has the movement towards MARI 3.0 and orientation towards the inclusion of health equity and other dimensions of challenges that, those suffering from substance use disorder are facing. 

[00:16:34] Michael Donovan: You know, what does the future hold for MARI? And I also am very curious about the application of similar programs in other contexts. Have you experienced or have your colleagues around the country had any success or challenges in applying similar programs knowing that that Madison seems to have been very much on the front edge here. 

[00:17:00] Joe Balles: So there, there is a huge growth nationwide in the area of deflection. And I just want to throw out two organizations. The PAR out on the East coast, the police addiction resource, um, group, they are, they kind of implemented out east years ago, a thing called the Angel Program, it started in Chester, um, Massachusetts. 

[00:17:21] Joe Balles: Then the other group is called PTAC, it's the center for help health and justice in Chicago. Um, PTAC does a lot of work promoting the use of deflection. In fact, I think this week is actually National Deflection Week 'cause we're recording this podcast, come to think of it. But yeah, there are hundreds of police departments around the country today and, and Madison PD.

[00:17:43] Joe Balles: We've been fortunate to be participants at the national conferences for both PTAC and PAR this past year, and we're very, very tied into those groups, but those groups are important because they bring us all together, and then I'll just give a shout out to the Wisconsin Department of Justice because they received a $7 million closeup grant.

[00:18:00] Joe Balles: And now in Wisconsin, just Wisconsin, we have over 20 different communities that have implemented diversion or deflection, um, practices in their police departments, and we meet every third Thursday of the month for an hour and a half, and trust me that 90 minutes is just absolutely packed with information and going through what everybody's, uh, trying to do from Superior down to Milwaukee, to do county to Madison.

[00:18:25] Joe Balles: It's, uh, just, uh, fantastic. So there's a lot going on, Michael. 

[00:18:31] Aleksandra Zgierska: And maybe you could mention also that hopefully, uh, the Governor's Association First Place Award can further spread, uh, the information about it as well as your now role as the, uh, experts with the CNA. 

[00:18:53] Joe Balles: Yeah. 

[00:18:53] Aleksandra Zgierska: Which is Center for Naval. 

[00:18:58] Joe Balles: Mm-hmm.

[00:18:59] Joe Balles: Arlington, so CNA has been the long time technical assistance provider to the Justice Department in this area, and they helped us early on, um, 2017 to 2019. And then as we were nearing the end of MA 1.0, and Alexander and I were writing the final report, CNA asked me to come on board. 

[00:19:17] Joe Balles: So I've now been technical assistance work that the other places around the country, um, helping CNA out, so that's been a great kind of connection with us, but the, um, the award that, uh, Aleksandra was referring was actually the US Conference of Mayors, um, last summer in their, um, they have a large city, Mid-City, small city, uh, award that they do around equity and justice and MARI was recognized with a $100,000 award. 

[00:19:39] Joe Balles: No strings attached for, uh, the number first place or midsize city. So we actually, um, had some representatives from the police department that got to go out to Kansas City last summer for that. But that was just great recognition, um, for, um, Madison, the City of Madison. 

[00:19:59] Joe Balles: Because our public health department plays a big role, um, in this too, as part of our collaborators. So, um, it's really a team effort, but there is so much going on in this space right now. It's just really, my job basically is just to try to keep us all tight tied together and, um, stay focused on what we said we were gonna do in our grant.

[00:20:19] Joe Balles: Um, but it's easy with, there's so many things going down. You can go down a rabbit hole pretty quick if you don't stay focused.  

[00:20:26] Aleksandra Zgierska: Yeah and there is a program as well in Pennsylvania established by Governor Wolf. It's a law enforcement treatment initiative that is, uh, building upon these kind of efforts that we initiated as well. 

[00:20:44] Michael Donovan: This is wonderful, I'm so, happy that you were recognized for this excellent work and that you're also, imparting your best practices, to other communities around, around the country. We've covered, a lot of topics today, all centered around, this, very core program, thinking about public sentiment and community partnerships, thinking about trust building. 

[00:21:05] Michael Donovan: Bringing in peer recovery specialists and trying to, undo, damage, to law enforcement's, identity, trying to leverage data, and, both ex extent and new sources to, to be more, adequately. Approaching the challenges that are in front of us, incentivizing recovery in various ways, some really, experimental and some growth, in this space.

[00:21:28] Michael Donovan: And really looking towards including, equity, and other challenges to the story here. I want to think as we start to come to a close here, if there are any topics that, we haven't been able to discuss today that, we wanted to make sure we lift up, And I also want to be thoughtful of Captain Nachtigals, opportunity, as, the newest member of the MARI team holding the mantle with MPD, what future plans there are for the program, and you know, challenges that might be coming down the future.

[00:22:02] Michael Donovan: The first point of the question for everybody. 

[00:22:05] Diana Nachtigal: Yeah. So as far as opportunities going forward, uh, you know, again, we're always looking to expand. We're always looking to do better, to reach more people. Um, to increase the referrals would be great too, but that only tells part of the story, right? We'd like to see more completers, more successful completers in the program.

[00:22:27] Diana Nachtigal: So how do we do that? And we're looking at ways like Captain Balles said as far as maybe incentivizing participation, so I'm always eager to see what else we can do and we're, you know, we're learning new practices, we're looking at other programs that are going on and how we can incorporate some things that, you know, into our program.

[00:22:48] Diana Nachtigal: But we're really also looking at can we get buy-in from other law enforcement agencies in the Dane County area? Um, that is something that we really want to strive, that we're striving for and trying to build those relationships. And showing the other law enforcement agencies that, you know, this program does work when it's successfully implemented and now that we have a framework.

[00:23:13] Diana Nachtigal: We've done some of the hard lifting, can we also share that information with other law enforcement agencies and, um, get them on board. And we have, you know, some of our Dane County, uh, district attorney's office on board. So now we just need other law enforcement agencies to participate. That would be my hope.

[00:23:35] Joe Balles: I'm gonna jump in Michael and piggyback on Captain Nachtigal two ways. One is speak a little bit about the outcomes that we actually realized with RES and MA 1.0 that allows us to kinda continue to further this work. But in MA 1.0 and I talked about that group that was not engaged, didn't engage in assessment, there was 103 of them, there was 160 that engaged in assessment and then there was 100 completers. 

[00:24:01] Joe Balles: But one of the things that we saw, um, in one of their paper that was published in the Journal of Substance, uh, use and treatment that the non-engaged and non completers were more likely to be rearrested or incarcerated than completers were. So that non-engaged group, non completers, the evidence was very clear and we used, uh, MPD arrest, uh, data to examine that.

[00:24:25] Joe Balles: And, uh, bookings over 12 months before and 12 months after their referral date MARI, um, in the Dane County Jail. So that was the other one. And then just respect to overdose desks. We also work with our medical examiner's office here in Dane County to look at that group of 263. 

[00:24:45] Joe Balles: But, um, uh, clearly in this one way to almost think this, but the non-engaged and the non completer groups had far higher rates in incidents of overdose death. Um, 12 months after, um, their Murray encounter, um, with the police department and the completer group had the lowest, we actually did have two completers, um, that relapsed and died of a fatal overdose Of those 100. 

[00:25:05] Joe Balles: So, but that happens and that's why recovery is such, um, such an ongoing lifetime, um, thing and that people we try to support people that six month mark, but we also try to, in that period, give them the tools and make them aware of the resources that are available in the community to support them as they continue on in their journey and recovery. 

[00:25:27] Joe Balles: Um, and lastly, if I could just give a shout out to the opioid settlement dollars that are at the various states around the country today, our uh, state Attorney General Josh call was part of the 38, I think it was, um, other state that worked so hard these last several years on these pharmaceutical company settlements.

[00:25:47] Joe Balles: And Wisconsin has recently received upwards of 30 to $40 million. That's now being funneled out to communities in Wisconsin through our Department of Health Services and the Joint Finance Committee and our legislature. Um, but Madison PD now has a contract with the Department of Health Services and we're just about to enter our third contract, um, with for some opioid settlement dollars.

[00:26:09] Joe Balles: It's not a lot, it's a couple hundred thousand bucks, but it allows us to do things that we might not have otherwise been able to use U-S-D-O-J grant dollars for. So I just encourage people, don't forget about these, especially law enforcement agency, don't forget about these opioid settlement dollars that are out there today and be aggressive and go after them because there's not many strings attached to them and it's out there and there's a lot of it that's available. 

[00:26:34] Michael Donovan: I'm proud to say that the EIC was actually part of the team to try to understand the damages during that large multi-district litigation, uh, for AGS. So that was, that was a, a very interesting and valuable project. 

[00:26:50] Aleksandra Zgierska: So to summarize, clearly the program works but not for everyone. 

[00:26:54] Aleksandra Zgierska: Mm-hmm. And that's not unique to just this program. That's just how life works. We, the cookie cutter approach is not the right way. So it works for some people and a large proportion of people. That's why it's worth having it as a part of our, toolbox for a response to this, public health crisis.

[00:27:17] Aleksandra Zgierska: But also what's, is really unique, what worked is this academic, partnership with our community, members and organizations because without that, it would have been, challenging, if not impossible to evaluate in a rigorous way, And that's where many programs do great job, but if they can't show it, publish it. 

[00:27:42] Aleksandra Zgierska: Like the information about it is not out there. And, uh, this might, the work might go unnoticed on the broader level. So the University of Wisconsin at that time at MARI 1.0 when I was there with support from the Department of Family Medicine and Community Health, uh, was instrumental in making it happen. 

[00:28:05] Aleksandra Zgierska: And the UW is still the partner, correct. 

[00:28:11] Joe Balles: That's correct. Um, our research partner is now the UW Population Health Institute. Janae Goodrich is, uh, the main contact there, but, um, you know, with Janae's, give this another thing, I talk about all those communities in the state now that are doing diversion flexion.

[00:28:27] Joe Balles: They actually work with our legislature to develop statewide performance measures for deflection practices. And Janae was one of the lead people on this. Um, uh. Multi-agency people from the legislature involved. So, I mean, that's really cool. So Michael, it just continues to evolve here. Um, but again, the relationship between academia and practitioners is really the spirit of this and what it's all about.

[00:28:52] Joe Balles: In Wisconsin, we call it the Wisconsin idea. It's been around for over a hundred years, But for policymakers. And, academics and practitioners out there in the streets like Diana and myself and many other police officers, That's the beauty of it, and that's how it all comes together.

[00:29:10] Michael Donovan: I think that's, a wonderful, capstone to our conversation today, Thank you so much for the opportunity to discuss this important work today. We're so grateful for all that, you all do in this important area, I will note also, several of the items we discussed today in terms of documents and scholarly journal articles and organizations that were referenced.

[00:29:30] Michael Donovan: We can include links to those organizations and documents in our show notes following the the podcast publication, so, we'll make sure that there's more resources for you all to follow up on. But with that, we'll bring this episode to a close. Again, thanks to our guests, Dr. Aleksandra Zgierska from Penn State, captain Joe Balles, retired captain of the City of Madison, Wisconsin Police Department and the MPD MARI Project Coordinator since 2017.

[00:30:00] Michael Donovan: And Captain Diana Nachtigal, captain of community outreach with MPD. Thank you all so much for your time and the important work you do.