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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: J Ethn Subst Abuse. 2023 Jan 30;23(4):1039–1061. doi: 10.1080/15332640.2023.2172758

Holyoke Early Access to Recovery and Treatment (HEART): A Case Study of a Court-Based Intervention to Reduce Opioid Overdose

Amelia Bailey 1, Elizabeth A Evans 1
PMCID: PMC10387124  NIHMSID: NIHMS1896657  PMID: 36715087

Abstract

The District Court in Holyoke, Massachusetts, is among the first courts nationwide to provide access to medications for opioid use disorder (MOUD) and other evidence-based treatment during court appearances and afterwards. Known as the HEART program, it uses an innovative multisectoral approach to serve a primarily Latinx population living in communities of concentrated poverty with high opioid overdose rates. We document the origins of HEART, key programming elements during the first year of implementation, and the current status of program operations, including the use of on-site peer recovery specialists and robust data collection efforts. From August 16, 2021, to February 28, 2022, of the 1040 individuals who entered the court for an arraignment, 47.9% (n=498) were eligible for HEART program participation. Of those 498 individuals, 54.2% (n=270) spoke with a recovery specialist. Many self-identified as Latinx (53.0%) and male (69.3%). Over one-fourth (27.0%) were connected to a long-term peer recovery specialist and 11.5% were directly connected to a MOUD provider. Semistructured interviews with key implementers and participants revealed a shared appreciation for the life-saving efforts of the program. We conclude with practical and theoretical considerations required for systems-level change to offer linkage to MOUD in court-based contexts. Establishment of a MOUD-in-court program involves significant organizational change and detailed planning. Future efforts will assess participant outcomes to determine whether HEART is an effective and feasible intervention that can be adopted by other court-based settings.

Keywords: criminal justice system, opioid use disorder, court-based health interventions, case study, public health, health equity

Introduction

Over the past decade, opioid use in the United States has been characterized as an epidemic (Lyden & Binswanger, 2019) with particular consideration for hot spots where rates of opioid use disorder (OUD), nonfatal and fatal overdose, and premature avoidable death have significantly impacted the economic, political, and social terrain (Hagemeier, 2018). In Massachusetts, opioid overdoses increased by 5% from 2019 to 2020, continuing a decades long worsening trend (Massachusetts Department of Public Health, 2021a), with marked increases in overdoses among the Latinx population (Massachusetts Department of Public Health, 2021b).

Holyoke, a city in Western Massachusetts with a large Latinx population, has been especially impacted by the opioid epidemic. In 2015, an estimated 4.5% (n= 1,831) of Holyoke residents had OUD (Smeltzer et al., 2020). From 2018 to 2019, the rate of fatal opioid overdose among Holyoke residents increased 12.5%, from 34.7 to 39.6/100,000 residents (Smeltzer et al., 2020). Notably, this increase in the overdose death rate was mostly attributable to deaths occurring among Holyoke’s Latinx residents. For the Latinx group, the opioid overdose death rate increased 63.6%, from 19.4 deaths/100,000 residents in 2018 to 53.3 deaths/100,000 residents in 2019 (Smeltzer et al., 2020). In contrast, opioid overdose death rates decreased during the same time-period for other racial and ethnic groups in Holyoke (Smeltzer et al., 2020).

Many individuals with OUD are involved with the criminal justice system (Hollingsworth, Ruhm, & Simon, 2017; Webster, 2017). Justice-involved individuals have a significantly higher risk of overdose and other adverse health outcomes compared to the general population (Krask et al., 2020; National Institute on Drug Abuse, 2020; Pizzicato et al., 2018). In Massachusetts, individuals involved with the criminal justice system have 120 times greater overdose death risk than individuals not involved with the criminal justice system (Massachusetts Department of Public Health, 2017). A critical problem is that few criminal justice involved people with OUD are treated or engage with treatment long enough to sustain its beneficial effects, a treatment-need gap that places individuals at greater risk for a return to opioid and other substance use (Evans & Hser, 2019).

A key strategy to address the opioid overdose epidemic among criminal justice involved populations is increased access to all FDA-approved medications to treat OUD (MOUD, i.e., buprenorphine, methadone, naltrexone) (Brinkley-Rubinstein et al., 2018; Malta et al., 2019). Early efforts have focused on creating capacity for jails and prisons to offer MOUD (Evans et al., 2022), with Massachusetts on the forefront of these activities (Evans et al., 2019; Evans et al., 2021, Donelan et al., 2021). Courts are another key domain of the criminal justice system that offer the potential to link individuals with OUD to needed health and social services (Van Nostrand et al., 2021).

A few court-based interventions have been implemented by various judicial leaders to address the opioid epidemic within their communities. Referred to as “opioid intervention courts,” these programs have found success enrolling court-involved persons with MOUD and other substance use treatment services within 24-hours after arrest (Buffalo Opioid Intervention Court, 2017; County of Cumberland Pennsylvania, 2018). An independent evaluation of the opioid intervention court in Buffalo, NY, found higher rate of OUD treatment engagement among participants, most significantly among those receiving MOUD, compared to a control sample (Carey et al., 2021). Studies are necessary to establish peer-reviewed evidence regarding participant health service utilization, treatment outcomes, and community impacts. Another innovative strategy to address OUD is the use of peer recovery specialists (PRS). PRS are individuals with lived experience and knowledge about recovery that help others with OUD initiate and continue treatment (Bassuk et al., 2016). Of the few studies of PRS interventions in criminal justice settings, findings include reduced criminal justice involvement (Belenko et al., 2021) and increased social service utilization (Ja et al., 2009). Findings illustrate few but promising results for the use of PRS in criminal justice settings. Other models to connect court-involved individuals with voluntary treatment services are being developed and piloted in the US, illustrating the timeliness and poorly understood nature of non-coercive court-based interventions to address OUD (Commonwealth of Massachusetts, 2022).

In Massachusetts, the Holyoke Early Access to Recovery Treatment (HEART) program was launched in January 2021 with the goal to provide same-day access to medications and other treatment for OUD for individuals who appear before the Holyoke District Court. HEART uses on-site PRS to communicate with court-involved individuals regarding local treatment services and to support treatment initiation and retention. HEART collaborated with the University of Massachusetts Amherst (UMass) to assist with the design and implementation of HEART and to document and evaluate the program (Bailey et al., 2020; Bailey et al., 2021). In this paper, we present the key elements of HEART that were implemented during the first year of operation. We also describe program workflow, highlight the current status of program operations, and discuss future practical and theoretical adaptations of HEART. As multidisciplinary programs to address OUD are being implemented in criminal justice settings, findings can be used to provide guidance for future implementers of innovative court-based programs within their own communities.

Methods

Data were collected September 2020 to February 2022 from multiple sources. These included:

Planning Observations

From September 2020 to December 2020, UMass researchers attended and participated in key partner meetings (e.g., among presiding judge, court staff, behavioral health staff, police officers) to observe the planning and implementation of HEART. During these meetings, research staff took detailed notes and collected program documents. We then met as a group to identify salient topics from the meeting notes. Based on the identified themes and observations, we developed a question guide for individual semistructured interviews with the implementers. The interviews were held over virtual conferencing software, lasted approximately 30 minutes in duration, and were audio-recorded and transcribed. The interviews were completed November 2020 to December 2020 (n=15). Using an inductive analytic process (Ryan & Bernard, 2003), three researchers met as a group to review the transcriptions and develop a codebook. Members coded data individually and then met as a team to identify repeated and divergent themes (Saldana, 2016).

Implementation Observations

After implementation began, three UMass student interns worked in the Holyoke District Court each week. From January 2021 to May 2021, interns observed regular court proceedings, spoke with prospective HEART participants, and facilitated virtual connection of participants to treatment options (i.e., connected participants with video conferencing to communicate with a PRS and/or a clinician in a private space). After May 2021, UMass interns no longer facilitated virtual connection to treatment options, but they still worked at the courthouse weekly to observe court proceedings and HEART operations. The HEART interns collected materials produced from the Holyoke District Court regarding HEART (e.g., flyers, mailers). From their interactions with court staff and HEART program participants, the UMass interns took notes of facilitators and challenges to HEART operations at the court to provide program improvement feedback. These areas of feedback were then discussed among interns for agreement and distilled into areas of process improvement for the HEART design team.

Participant Flow

On August 16, 2021, HEART staff began daily data collection on participant flow (i.e., individuals eligible for HEART, individuals who spoke with a HEART staff) and participant sociodemographic characteristics. The research team analyzed deidentified data on n=270 individuals who were eligible for HEART from August 16, 2021, to February 28, 2022.

Participant Interviews

UMass has a written agreement with the Holyoke District Court to collect participant information in the courthouse. From November 2021 to March 2022, we conducted semi-structured interviews with program participants (n=12). We developed an interview guide with the goal of assessing participants’ perception of the court in general, their perception of service provision at the court, and future directions to reduce barriers to service receipt at the court. While in the courthouse, participants were approached by UMass interns to engage in a brief, semi-structured interview. The interviews were conducted in a private space in the courthouse, lasted approximately 20 minutes in duration, and were transcribed with both short-hand notes and full quotations. To protect the privacy of participants, the interviews were not audio recorded. All collected research materials were stored in a secure online repository. We used an inductive analytic process. After reading over interview notes and quotes, three researchers met as a group to summarize interviews, discuss salient perspectives, pull repeated themes, and select illustrative quotes (Saldana, 2016).

Preliminary results and findings were shared with the HEART team in annual reports (Bailey et al., 2020; Bailey et al., 2021) to elicit feedback and check the credibility of information prior to broader dissemination. We collected this data initially for program planning and evaluation purposes. As such, the data collection procedures in this publication did not undergo Institutional Review Board (IRB) review. We provide the data collection procedures in this publication to guide future programs’ planning and evaluation processes.

Results

HEART Mission and Goals

The HEART program is designed to provide same-day access to medications and other treatment for OUD for individuals who appear before the Holyoke District Court, and thereby reduce nonfatal and fatal opioid overdose events. The HEART Logic Model shows a graphic depiction, or “road-map,” of relationships among the resources, activities, outputs, and outcomes/impacts of a program between a program’s activities and its intended effects, in implicit ‘if-then’ relationships (Figure 1). A logic model helps clarify the boundary between “what” the program is doing and “so what”—the changes that are intended to result from strong implementation of the “what.”

Figure 1.

Figure 1

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HEART Program Logic Model

Note:

We created a Logic Model to portray the planned inputs and activities that are needed to operate HEART. Initial inputs to the program, as listed: multisectoral collaborative of local organizations, funding, telehealth connection, and partner buy-in. From these inputs, the following activities will occur: addiction advisory meetings, program fliers, local media marketing, offer participation in program (to eligible persons), connect participants with clinician for screening, and connect participants with OUD treatment. From the relationships and latter impacts of these activities, we are intending that the following outputs and outcomes will occur.

The program goals are illustrated in four steps that occur over time. First, outputs are intended to happen as the program occurs. The initial outputs will be evident: number of participants screened for OUD, number of participants enrolled in OUD treatment, number of participants connected with a PRS, and the rate of short-term participant retention. After successful program completion, intended outcomes will positively benefit the participants in the program, over a significant period. Initially, we hope the outcomes will be: increase in knowledge about OUD treatment process among participants, increase in participant access to naloxone, increase in the number of persons in OUD treatment, and increase in community awareness of program goals. It is important to note, these outcomes are intended for the community of Holyoke, where the intervention will occur. Overtime, we are expecting intermediate outcomes, listed as: increase in number of persons in OUD recovery and increase in participant retention rate between follow-up.

Lastly, the end goals for this program are illustrated in the long-term impacts. The long-term impacts are more systemic, large-scale changes that the program anticipates seeing after individual and community success due to HEART. Our intended long-term impacts, listed as: decrease in opioid use, decrease in opioid-related deaths, decrease in recidivism, and decrease in community stigma surrounding OUD.

Leadership and Partner Engagement

The Holyoke District Court is leading the HEART program with input from key collaborators. During the program planning and early implementation periods, topics were discussed at weekly advisory committee meetings guided by an agenda. The agenda items included discussion of factors that facilitate and impede program implementation and relevant action items. Since implementation of HEART ramped up in summer 2021, the advisory committee has met less frequently. The Holyoke District Court Community Advisory Committee is convened on a quarterly basis to invite input, disseminate information, and cultivate buy-in and collaboration.

Partners who represent a diverse set of institutions and roles are involved in the planning and implementation of the HEART program. Key partners include:

  • Holyoke District Court, the location of HEART

  • Statewide healthcare organization with HCS grant contract, provides funding for PRS position

  • Mental health services center, Gandara Center, provides trained, bilingual (Spanish and English) PRS both in-person at the court for the program and options for participants to connect to long-term peer support

  • Healthcare organizations provide MOUD and other forms of healthcare to program participants

  • Sheriff’s department provides clinicians to conduct telehealth screening for program participants

  • Police department arrests and summons individuals who appear before the court (i.e., people who are eligible to participate in the program)

  • University, UMass, provides student interns and faculty support for program evaluation

Funding and Impacts of COVID-19

The HEART program was founded by Presiding Justice William P. Hadley in 2019. To develop the program without funding and staff, Judge Hadley brought together a consortium of key implementers from the local community, including court staff, attorneys, opioid treatment providers, behavioral health clinicians, police officers, and social service providers. Soon after it was founded in March 2020, the HEART program was paused due to the COVID-19 pandemic. In the subsequent months, key partners worked together to re-design the HEART program to incorporate telemedicine and other COVID-19 mitigation policies, with the goal of re-launching the program in January 2021.

The HEART program received funds from the HEALing Communities Study (HCS) in Massachusetts, funded by the National Institutes of Health and led by Boston Medical Center (NIH HEAL Initiative, 2022), to support the development of telemedicine capacity. From January to May 2021, funds were used to support UMass student interns while they worked on-site at the court to connect participants with information about the HEART program and use technology to establish a virtual connection with recovery coaches, clinicians, and treatment providers. In the summer of 2021, additional HCS funds were allocated to the Gandara Center, an agency providing bilingual mental health and substance use support services, to support the daily presence of PRS on-site at the court. As COVID-19 receded in 2022, the court began to return to usual flow and operation. Currently, the HEART design team is considering state and federal funding sources to sustain HEART.

Eligibility

Adults (age 18 or older) with an evaluated or self-reported opioid problem who interact with the Holyoke District Court, including both pretrial and trial populations, are eligible to participate in the HEART program. Participants typically come before the court through these four routes: (1) arrested for a charge and brought into court for an arraignment, (2) summons from the police for a scheduled arraignment, (3) show-cause hearing where it is deemed beneficial for the person to enter OUD treatment, (4) screened for Involuntary Civil Commitment to treatment (i.e., individual is clinically evaluated to have a substance use disorder and to be of potential harm to themselves or others under Section 35 of “Chapter 123”) but deemed ineligible for commitment. Additionally, anyone seeking information for their family or loved one can speak with a PRS at the court and be provided with local treatment options and support services.

Size

The Holyoke District Court typically handles minor criminal offenses, all violations of city and town ordinances and bylaws, and felonies punishable by a sentence of no more than five years (Allen, 2017; Commonwealth of Massachusetts, 2020). Prior to the onset of the COVID-19 pandemic, the HEART program was expected to serve about 50 people per week, comprised mostly of people with non-violent offenses, “community quality of life” cases, and individuals with OUD and mental health conditions. The COVID-19 pandemic reportedly resulted in an influx of more serious felony offense cases into the court and a decrease in the number of minor offense cases. This meant that the court was operating at 60% capacity for more than a year starting in March 2020. By December 2021, the court returned to pre-pandemic capacity, meaning approximately 50 to 60 individuals who enter the court each month are eligible for HEART program participation.

Outreach

Prospective participants are informed of the HEART program through several outreach efforts, with the intent to provide several opportunities to consider participation. Communications are designed with an understanding of the value of participant empowerment and autonomy when making healthcare decisions (Cimino, Mendoza, Nochajski, & Farrell, 2017). At first contact, the court mails a one-page letter about HEART to all prospective participants prior to their court appearance. The mailer specifies the potential benefits and risks of participation, while making it clear that participation is voluntary and that the decision to participate or not participate in the HEART program will not affect the initiation or revocation of any order staying their criminal proceedings. Additionally, prospective participants who have been charged with a violation of a municipal ordinance or bylaw, or a misdemeanor offense, are notified that the successful completion of an assigned addiction treatment program may result in a dismissal of criminal charges (MGL “Chapter 111E” and “Chapter 276A”). When in court, prospective participants are told about the program verbally by the judge, their attorney, court staff, and PRS. Program fliers are also posted in the areas of the court (e.g., lobby waiting area) visible by prospective program participants. All materials are written in both Spanish and English (e.g., double-sided fliers) and all materials contain a link and QR code to access a promotional program video. The promotional video includes insight from two PRS and information on PRS access at the court (HEART Program Video, 2022). The video was disseminated to several community locations with the intent of increasing HEART program awareness to future participants and other community members. A few community locations include social media pages of the HCS, local opioid taskforce, local recovery center, and other neighborhood associations.

Engagement

The HEART program operates live and in-person at the Holyoke District Court on a weekly schedule, 9am to 1pm, every weekday the court is in session. During the court appearance, eligible individuals are approached by a PRS and told about HEART. Those who are not interested in engaging with HEART are provided with PRS contact information for future outreach. Those who are interested in learning more details about HEART immediately meet with a PRS in a space that is designed to permit a private and safe conversation about treatment options. Employed by the Gandara Center, PRS staff have completed Certified Addictions Recovery Coach (CARC) certification. The CARC certification requires standardized completion of clinical hours and training courses (Massachusetts Board of Substance Abuse Counselor Certification, 2017). The PRS are in recovery from OUD, are from a local Latinx community, and speak Spanish and English. As part of their role with HEART, the PRS are knowledgeable about harm reduction, MOUD, and other social services in the Holyoke community. The PRS discuss treatment options and social service supports and identify next steps for participants.

If the participant agrees to a clinical assessment, the PRS uses a computer to connect the participant via Zoom to a behavioral health clinician who is trained to conduct assessments for opioid and other substance use disorders. These clinicians are available on-call from the local sheriff’s department. While the clinicians are employed within the sheriff’s office, any information shared with a clinician is confidential and will not be used for criminal justice proceedings. The clinician conducts a screening and brief assessment for OUD and develops a treatment plan. Prospective participants are provided with headphones to be able to have a private conversation with the clinician. Depending on the preferences of the individual, the PRS will be invited to join this conversation to provide peer support. If the clinician determines that the participant does not have OUD, the participant will speak further with the PRS about social service support and be provided with resources for obtaining naloxone within a 5-minute walk from the court. If the clinician determines that the participant does have OUD, the clinician will discuss treatment options and next steps.

A goal is to achieve same day access to treatment by working with each individual’s level of motivation for treatment and by providing a warm hand-off to treatment. For individuals who express interest in treatment, the PRS connects the participant to the identified treatment provider. Based on participant preference, this connection is done by either walking the participant over to the provider, arranging transportation for the participant to the provider, or supplying provider contact information to the participant. For individuals who are not interested in treatment, the PRS will work with the individual to inform them of local treatment resources. The PRS ensures that before participants leave court, they have a written set of next steps for recovery, including PRS contact information, treatment program contact information, and directions to treatment with transportation options. To access local or distant treatment appointments, HEART participants are eligible to receive no-cost transportation services through Gandara Center’s “Highway to Hope” program. This service is also funded through the HCS.

Planning Challenges and Facilitators

During the program planning phase, key partners focused on resolving the expected challenges of implementing new processes in the court to conduct synchronous screenings, treatment assessments, and linkages to community based MOUD and other services. Topics included: defining new collaborative roles and responsibilities, scheduling and work flow, physical space, security, and COVID-19 mitigation protocols; coordination and information exchange between the court and treatment providers; technical infrastructure and identifying which telemedicine services are reimbursable and can be provided virtually; processes to assess participant flow and program success while abiding by participant privacy and data confidentiality regulations; and engagement of disproportionately affected populations with varying levels of treatment readiness, distrust of public institutions, Spanish language preferences, and unaddressed social determinants of health.

Partners also shared that program planning was facilitated by the ability of court staff to act as program champions and achieve common understanding of program goals, cross sector buy-in regarding the need for innovative solutions to address the opioid epidemic, and regular communication among key partners. Anticipated HEART program benefits, as identified by partners, included increased access to and use of MOUD and other needed healthcare; fewer overdose events and avoidable premature deaths; and strengthened collaboration between the criminal justice system, healthcare, and community-based agencies.

Since the program planning period, adaptations have been made to reduce challenges. To reduce the challenge of establishing physical space and telemedicine connection to PRS at the courthouse, in-person PRS have been implemented in the courthouse. In-person PRS are also utilized to increase participant engagement by provision of person-centered communication and knowledge sharing about recovery resources for people with OUD (Bassuk et al., 2016). Additionally, provision of PRS from diverse backgrounds who are bilingual (Spanish and English speaking) is a health equity-minded feature of HEART program operations (Substance Abuse and Mental Health Services Administration, 2020). Currently, other measures to improve participant engagement include creation of an informational video to disseminate to participants virtually, revision of paper materials to provide contact information for PRS, and further communication with other court staff (e.g., defense attorneys, administrative staff) to establish greater understanding how to refer participants to the program.

Characteristics and Experiences of Program Participants

From August 16, 2021, to February 28, 2022, 1040 people entered the court for an arraignment. Of those individuals, 47.9% (n=498) were eligible for HEART program participation. Of those 498 individuals, 54.2% (n=270) spoke with a PRS. Of the 270 participants who spoke with PRS staff about the HEART program (Figure 2), more participants identify as male than female (69.3% vs. 30.7%); many identify as Latinx (53.0%), followed by White (34.8%), and fewer identify as Black (12.2%).

Figure 2.

Figure 2

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HEART Participant Pipeline

MOUD = medications for opioid use disorder

Services Provided to Participants

The PRS collected data on which services the participants were connected to because of the HEART program (Figure 2). Services included: establishing long-term PRS, direct referral to MOUD provider (i.e., walked over to the facility), and direct referral to a detoxification facility (i.e., walked over or transported to the facility). PRS also discussed other local treatment options and social services with participants but did not collect data on these interactions. Of the 270 participants who spoke with a PRS at the court, over one-fourth established a long-term PRS support with Gandara Center (27.0%), around one-tenth were directly connected with same-day MOUD (11.5%), and fewer participants were directly connected to a same-day detoxification facility (7.0%).

Perspectives from Participants

UMass interns conducted 12 interviews with HEART participants from November 2021 to February 28, 2022, to understand participant knowledge and perception of HEART, along with their previous recovery experiences and barriers to service receipt at the court. We share a few themes, along with illustrative quotes.

Individuals were generally appreciative of the courts’ efforts to provide help for OUD:

“Even if you can help just one person, it’s a great start.”

“The drug problem in Holyoke, it’s bad… I’m glad you guys are trying to do something.”

A few interviewees noted that the court was doing as much as possible for individuals with OUD.

“Any more would be too much… you can’t force help onto people.”

“The court does enough… they’re not responsible for it.”

Several individuals lacked knowledge of HEART program’s existence, despite efforts to make the program known at the court.

Of those who spoke with a PRS at the court, individuals shared positive feedback on their conversations:

“I’ve been so depressed lately, I don’t know anyone here… talking to [PRS name], s/he made me feel better, s/he listened, s/he knows what I’m dealing with, I cried.”

“[PRS name] seemed so alive and happy, and s/he had a positive attitude. [PRS name] chased me down to talk to me, which showed that s/he cared.”

“I liked that I didn’t have to seek [the PRS] out and that I was approached instead.”

One participant shared the PRS was “very knowledgeable” and “could be useful for someone who is ready for [recovery]” but felt they personally were “not ready for [recovery].”

Participants also shared their thoughts about maintaining a PRS relationship. Participants indicated that they have spoken to various PRCs but felt that they needed a strong personal connection to continue contact with a PRS. Participants were seeking a variety of services from PRS support, including continuing education, employment, social security, and food stamps.

Participants also openly shared information about their past and present with substance use and recovery. One participant shared how serious their substance use was, as evidenced by their experience of multiple overdoses in the past. Another participant shared how ingrained substance use was in their community, as family members used drugs and brought drugs into their house. Several participants had made previous attempts of recovery, usually using many different approaches, including MOUD, counseling, and PRS. Participants shared their desire to achieve recovery goals with the support of a PRS.

“I am more willing to speak to a recovery coach because I am sure about getting clean. I’m realizing that this is my last chance.”

These insights from participants contribute to our growing understanding of the community of Holyoke, and characteristics and needs of individuals who comprise our target population. Participants shared an understanding of PRS and the importance of connecting to services for recovery support, although most participants were unaware of services offered through the court.

Discussion

HEART entails organizational and systems-level changes that are aimed at achieving better health and health equity for a population of underserved residents in Holyoke, MA. When leaders first conceptualized HEART, the purpose of the program was to decrease fatal opioid overdose in the community. To achieve this goal, experts were brought together from different sectors and institutions to provide guidance and funding was sought to support capacity. Throughout planning and implementation, HEART leaders have implemented adaptations to better tailor this intervention to the target population. There was no pre-defined protocol for this innovation, therefore, HEART has relied on key partner advised trial and error. HEART program adaptations have produced knowledge and guidance for future court-based OUD interventions to benefit from. In this section we identify potential next steps for HEART program development.

Public Health and Health Equity

About half of the participants who enter the court on an arraignment are eligible to participate in HEART (i.e., arrested on a drug-related charge). This proportion of individuals is higher than the general population, where an estimated 14.5% of the population has a substance use disorder (1.0% OUD) (Substance Abuse and Mental Health Services Administration, 2021). Due to this high concentration of individuals with substance use issues, who often lack healthcare utilization (Saloner et al., 2018), courts are a suitable place to situate an OUD intervention. However, of those who are eligible to participate in HEART, only half spoke with a PRS and fewer engage in long-term support (i.e., long-term recovery support, MOUD). There is a continued need for improved participant engagement with the HEART program.

Historically, opioid intervention programs for criminal justice involved individuals have neglected to consider cultural identity and other social determinants of health when designing program practices (Sugarman et al., 2020). In contrast, HEART implemented the use of multisectoral community partners, Spanish-language advertisement, and recovery coaches from diverse backgrounds to better engage Latinx populations with OUD (Sorrell, 2020). Future directions to better serve the Latinx population could include partnership with faith-based organizations (Substance Abuse and Mental Health Services Administration, 2020). Another culturally centered strategy to increase program engagement is to foster trust and treatment support among social networks (including trusted community elders) of prospective HEART participants. For example, have HEART PRS speak at town hall meetings and disseminate online resources within the Holyoke community (e.g., HEART video) (Castro et al., 2017). Going forward, health equity frameworks (Woodward et al., 2021; Eslava-Schmalbach et al., 2019) offer useful guiding principles for the refinement of HEART and the development of other similar court-based programs.

Peer Recovery Specialist Adaptations

At the Holyoke District Court, the implementation of PRS introduced a new programmatic workflow and created changes in organizational workflow. A potential avenue to reduce this issue is robust training for new staff (Goodman, French, & Battaglio, 2015; Hilliard & Boulton, 2012). For example, innovative healthcare programs have used process mapping to create a shared sense of understanding about program goals and staff roles (Lu et al. 2021). Process mapping includes documentation of staff workflow in reference to participant movement through a program. To streamline HEART program operations, a written, standardized workflow will be developed for each staff position.

One avenue to expand data collection efforts is to train on-site staff (e.g., PRS) to collect data (Rasmussen & Goodman, 2019). Some useful measures to be collected include - Of adults seen by the Holyoke District Court: % received PRS intervention; % connected to same-day MOUD; % referred to other treatment services.

Sociodemographic characteristics will be collected to support understanding of which populations are and are not accessing HEART. Outcomes will be assessed 90 days after initial referral. The primary outcome of interest is engagement with MOUD. Secondary outcomes of interest include: opioid use; nonfatal overdose events; mortality; recidivism (e.g., arrests); mental health; and social functioning. The collection and analysis of this data will help describe participant health and social outcomes after the intervention, improve HEART’s ability to meet target population’s needs, and assess whether HEART is a feasible innovation to be implemented in other communities.

Systems-Level Collaboration and Implementation Science

The HEART program can be conceptualized as the adaptation and implementation of an innovation. Concepts provided by the diffusion of innovations in health service delivery and organization (Greenhalgh et al., 2004) can help to identify behaviors and routines that determine how information generated from the PHD warehouse can be used for innovations, such as the HEART program, to improve health outcomes (Damschroder et al., 2009). HEART can be conceptualized as a process, rather than a fixed state. A critical implication is that as HEART moves through the different stages of adoption and implementation, it requires different resources and skills to operate, it is characterized by different strengths and limitations, and there is variation in its outcomes. The success of HEART is dynamic, dependent on its stage of implementation and the ways in which several factors operating at different levels. HEART is made up of three general components: (1) the HEART program, (2) the intended adopters (e.g., participants, key partners), and (3) the context of Holyoke. These components, and the concepts included within them, interact at different levels of influence to determine the extent to which HEART is successful.

More broadly, the HEART program may also be understood as an innovation that depends on multiple systems (i.e., criminal justice, health, policy) that together function as an “open system.” The HEART program is open to environmental influences rather than being isolated (Katz & Kahn, 1966; von Bertalanffy, 1956, 1968). The HEART program will continually strive to adapt to changes within the external environment, because it draws on the environment for inputs (i.e., funding, partner support, data). These inputs are “transformed” through the creation and maintenance of the program. The HEART program will also create outputs (i.e., outcome data) that affect the larger environment. Changes and stresses in parts of the external environment (i.e., COVID-19, fentanyl flooding the illicit drug market (Springer et al., 2019)), may create demands that affect the program’s processes. Similarly, the outputs from HEART may have significant effects for the external environment that cause it to react in ways that again affect HEART (feedback loops).

The provision of MOUD and other addiction treatment is known to pose specific challenges when implemented in criminal justice settings (Friedmann et al., 2015; Mitchell et al., 2016; Taxman & Belenko, 2012). The effectiveness of the HEART program is likely to depend on the organizational capacity and culture of the systems to implement and sustain it. For example, transformative leadership, community partnerships, and funding have been identified as key contextual influencers of MOUD implementation and sustainment in criminal justice settings (Evans & Hser, 2019; Ferguson et al., 2019; Guerrero et al., 2018). The current project offers the opportunity to understand contextual factors that facilitate and impede delivery of a court-based program to connect individuals to MOUD and other healthcare and best practice strategies that optimize the program outcomes.

Limitations and Strengths

The article has limitations and strengths. Due to time of publication, the HEART program considered COVID-19 mitigation (e.g., hybrid telemedicine approach) and related constraints when planning, implementing, and adapting the program. While some of these topics may be less relevant in the future, other programs can learn from the rapid, effective public health adaptations that were made to sustain this program through the pandemic waves. Another limitation to the article is the lack of quantitative data collected and, therefore, the lack of inferences to be made regarding participant outcomes. As for strengths, the current article assesses a unique program which is poised at the intersection of criminal justice, public health, addiction science, and health equity. We have detailed and synthesized the program’s planning, implementation, and current operations using mixed methods study design. As more criminal justice-based health interventions are generated to meet the needs of the growing opioid crisis, this article will provide insightful, timely guidance.

Conclusion

The HEART program is among the first nationwide to provide court-involved populations with same-day access to MOUD and other evidence-based treatment during court appearances and afterwards. HEART uses an interdisciplinary approach to primarily serve a Latinx population living in communities of concentrated poverty. Soon after it was founded in March 2020, the HEART program was adapted to utilize telemedicine and COVID-19 mitigation policies. Key partner interviews and routine meetings were conducted to explore and prepare for implementation. During the first year of program implementation, activities were conducted to inform workflow adaptations, including observation of program operations and participant interviews. A few health equity-focused adaptations to engage the target population included implementation of on-site bilingual PRS to engage participants with treatment and other services and dissemination of bilingual promotional materials (i.e., video, flyers) within the surrounding community. Next steps for program evaluation include assessment of participant outcomes to inform implementation of court-based programs in other contexts. Implementation of an innovative court-based program which serves people with OUD requires multisectoral collaboration and systems-level change.

Acknowledgements

The authors would like to acknowledge the UMass HEART interns; Holyoke District Court staff; Gandara Center peer recovery coaches; and the NIH HEALing Communities Study in Holyoke, MA.

Biographies

Amelia Bailey is a research fellow at the University of Massachusetts Amherst. She evaluates innovative substance use disorder treatment interventions that are implemented in carceral systems and in the community. Her background is in health education and drug overdose prevention.

Elizabeth A. Evans is an Associate Professor of Public Health at the University of Massachusetts Amherst. She researches how health care systems and public policies can better promote health and wellness among vulnerable and underserved populations, particularly for individuals at risk for opioid and other substance use disorders. Her current research focuses on how the criminal justice system can impact health outcomes.

Footnotes

Declaration of Conflicting Interest

The authors report no conflicts of interest.

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