The

n e w e ng l a n d j o u r na l

We thank Noroski and Fuleihan for their comments on the hyper-IgM syndrome as a cause of
cryptosporidium-induced secondary sclerosing cho
langitis. However, to put that diagnosis in perspective, it is worth noting that only about 6% of patients with this rare syndrome (about 1 in 500,000
people) will have cryptosporidium infections that
may cause secondary sclerosing cholangitis.3
KonstantinosN. Lazaridis, M.D.
NicholasF. LaRusso, M.D.
Mayo Clinic College of Medicine
Rochester, MN
larusso.nicholas@mayo.edu

of

m e dic i n e

Since publication of their article, the authors report no further potential conflict of interest.
1. Arnelo U, von Seth E, Bergquist A. Prospective evaluation of
the clinical utility of single-operator peroral cholangioscopy in
patients with primary sclerosing cholangitis. Endoscopy 2015;
47:696-702.
2. Lhr JM, Lnnebro R, Stigliano S, et al. Outcome of probebased confocal laser endomicroscopy (pCLE) during endoscopic
retrograde cholangiopancreatography: a single-center prospective study in 45 patients. United European Gastroenterol J 2015;
3:551-60.
3. Leven EA, Maffucci P, Ochs HD, et al. Hyper IgM syndrome:
a report from the USIDNET Registry. J Clin Immunol 2016;36:
490-501.
DOI: 10.1056/NEJMc1613273

A Police-Led Addiction Treatment Referral Program

in Massachusetts
To the Editor: During the period from 2009
through 2013, only 21% of people with an opioiduse disorder in the United States received any type
of treatment.1 In response to increasing rates of
overdose deaths in the community, the Gloucester Police Department developed the Angel Program, a voluntary, no-arrest program that offers
direct referral for drug detoxification or rehabilitation treatment.2 Police officers collect demographic information and call treatment centers
to identify a facility for placement. The police
department ensures that participants have access
to immediate transportation to the treatment
center, which is provided with an ambulance, if
necessary. If the officer judges that the process
will take more than a few hours, participants are
assigned a volunteer Samaritan for emotional
support.
From June 2015 through May 2016 (the first
year of the program), 376 different persons presented for assistance a total of 429 times. The
demographic characteristics of the participants
are shown in Table 1 and are similar to those
reported by the Substance Abuse and Mental
Health Services Administration for persons who
are admitted to treatment programs for an opioiduse disorder in Massachusetts.3 Of the persons
who sought treatment through the program,
11.8% resided in Gloucester, 24.8% lived in the
surrounding county, 16.8% were homeless, 5.6%

were from states other than Massachusetts, and

the remainder came from elsewhere in Massachusetts. In 12 instances, the person was ineligible
for drug detoxification because immediate medical attention was required. In 94.5% of instances
in which a person presented for assistance and
was eligible (394 of 417), direct placement was
offered; in 5.5% (23 of 417), the person was not
placed or had missing placement information.
The reasons for failed placement were inadequate
insurance, out-of-state residency, or lack of a bed
at a treatment facility. On the basis of police
documentation, in 374 encounters (95% of those
in which placement was offered), participants entered their assigned program, and in 20 encounters placement was declined. Follow-up telephone
calls reached 57% of participants in the first
9months of the program; in 85% of responses,
participation in the police-reported treatment
program was confirmed.
Despite the many barriers, including previous
arrests, that may prevent persons with an opioiduse disorder from engaging with police, 376 people sought help in the first year of this program.
The high direct-referral rate of 94.5% exceeds
those reported for hospital-based initiatives that
are designed to provide immediate access to detoxification and treatment.4,5 Factors that enabled
referrals included the motivation of participants
to enter treatment, as evidenced by their coming

n engl j med 375;25nejm.org December 22, 2016

The New England Journal of Medicine

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Copyright 2016 Massachusetts Medical Society. All rights reserved.

Correspondence

Table 1. Sociodemographic and Substance-Use Characteristics of the 376 Angel

Program Participants.
Characteristic
Age yr

Value*
29.49.8

Male sex no./total no. (%)

261/373 (70.0)

Location no./total no. (%)

Essex County, including Gloucester

137/374 (36.6)

Other parts of Massachusetts

153/374 (40.9)

Out of state

21/374 (5.6)

Currently homeless

63/374 (16.8)

Has medical insurance no./total no. (%)

309/362 (85.4)

Graduated from high school no./total no. (%)

263/307 (85.7)

Has previous drug arrests no./total no. (%)

161/295 (54.6)

Age started using drugs yr

15.33.6

Age started using opioids yr

20.45.6

Last opioid use no./total no. (%)

Same day or previous day

272/326 (83.4)

2 to 4 days ago

33/326 (10.1)

>5 days ago

21/326 (6.4)

Heroin, injected

228/291 (78.4)

Heroin, snorted

58/291 (19.9)

Prescription opioids

73/291 (25.1)

Fentanyl

11/291 (3.8)
6/291 (2.1)

Buprenorphine

15/291 (5.2)

Previous detoxification treatment no./total no. (%)

Never

53/285 (18.6)

1 to 5 times

144/285 (50.5)

>6 times

88/285 (30.9)

Other types of treatment received for opioid-use

disorder no./total no. (%)
Methadone

58/202 (28.7)

Buprenorphine

95/202 (47.0)

Self-help group, such as Narcotics

Anonymous
Counseling

Davida M.Schiff,M.D.
Boston Medical Center
Boston, MA
davida.schiff@bmc.org

Mari-LynnDrainoni,Ph.D.

Current drug use no./total no. (%)

Methadone

to the police station; the additional support provided by volunteers; the fact that officers searched
for placements 24 hours a day; the relationship
the police established with a local treatment
center in which the majority of participants were
placed; the provision of transportation; and the
state-mandated insurance in Massachusetts, which
covers drug detoxification.
This model has been adopted by 153 other
police departments in 28 states. Research is
needed to understand the experience of participants after direct referral by police for an opioiduse disorder. The success of these programs may
depend on streamlined access and an expandedcapacity to provide addiction treatment on
demand.

165/202 (81.7)
57/202 (28.2)

Long-term outpatient treatment

15/202 (7.4)

Residential treatment

20/202 (9.9)

Sober house

15/202 (7.4)

* Plusminus values are means SD. Percentages may not sum to 100% because
of rounding.
Value is based on 374 responses.
Value is based on 281 responses.
Value is based on 287 responses.
Participants were asked to choose all options that applied, and therefore percentages do not sum to 100%.

Boston University School of Public Health

Boston, MA

MeganBair-Merritt,M.D., M.S.C.E.
ZoeWeinstein,M.D.
Boston Medical Center
Boston, MA

DavidRosenbloom,Ph.D.
Boston University School of Public Health
Boston, MA
Disclosure forms provided by the authors are available with
the full text of this letter at NEJM.org.
1. Saloner B, Karthikeyan S. Changes in substance abuse treat-

ment use among individuals with opioid use disorders in the

United States, 2004-2013. JAMA 2015;314:1515-7.
2. For addicts and their friends, families, and caregivers. Gloucester, MA:Gloucester Police Department (http://gloucesterpd.com/
addicts/).
3. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS) 2003-2013: state admissions to
substance abuse treatment services. Rockville, MD:Center for
Behavioral Health Statistics and Quality, 2015.
4. The BNI ART Institute. Project ASSERT: SBIRT in emergency
care. Boston, MA:Boston University School of Public Health
(http://www.bu.edu/bniart/sbirt-experience/sbirt-programs/sbirt
-project-assert/).
5. DOnofrio G, Degutis LC. Integrating Project ASSERT: a screening, intervention, and referral to treatment program for unhealthy
alcohol and drug use into an urban emergency department. Acad
Emerg Med 2010;17:903-11.
DOI: 10.1056/NEJMc1611640

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The New England Journal of Medicine

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