How Are Cities Designing These Programs?

The Six Design Decisions

Every city that builds an overdose response team must answer the same six questions, and the answers define what the program can do, who it can reach, how fast it operates, and whether it survives. The cities that have built these programs made different choices at each decision point, and those choices produced different capabilities, different tradeoffs, and different results.

This section walks through the six decisions in order, showing what cities chose, what happened, and what the documented tradeoffs are.

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Decision 1: How Is the Team Activated?

The activation mechanism determines who the team can reach. A program that only follows up after 911 calls will never contact the person who overdosed alone and was revived by a friend who did not call 911. A program that screens in the emergency department will catch people the EMS data system missed.

Four activation mechanisms are documented across operating programs, and most programs use more than one.¹

Post-911 Follow-Up is the activation method used by the majority of documented programs.¹ The team reviews EMS run reports from recent overdose calls and contacts survivors at their homes within 24 to 72 hours.

Colerain Township, Milwaukee, Huntington, Dallas, and South Shore (Massachusetts) all use this as their primary activation method.¹ The advantage is that EMS data provides a systematic source of referrals that does not depend on individual clinician judgment or dispatcher recognition. The disadvantage is that EMS reports often contain incomplete or incorrect contact information. Polachowski identified this as the core operational barrier: “Biggest barrier, honestly, is making contact.”² Ohio research found that many programs averaged six to eight weeks between contacts rather than the intended 72 hours, and the EMS data quality problem was the primary cause.³

Programs that invested in dedicated data analysts, real-time EMS data feeds, and hospital partnerships (where patient records contain better contact information than field reports) achieved faster contact, according to the 2022 Ohio study.³

911 Direct Dispatch sends the team to active overdose calls alongside or instead of traditional EMS. Portland’s Community Health Assess and Treat (CHAT) program responds to live overdose calls from Fire and Rescue Station 1.⁴ Crawfordsville, Indiana provides 24/7 direct response.¹

The team that reverses the overdose is the same team that returns for follow-up, creating continuity that the post-911 model does not provide. The tradeoff is operational: a team responding to active calls must be available and mobile at all times, which requires either dedicated dispatch integration or co-location with a fire station, as Portland chose.⁴

Portland’s CHAT operates Monday through Thursday, 8 a.m. to 6 p.m.⁴ Direct dispatch capability during those hours is paired with no coverage outside them.

ED Screening and Hospital Referral identifies candidates through emergency department screening rather than EMS data. Houston’s Emergency Opioid Engagement System (HEROES) program, operated through the University of Texas Health Science Center, screens ED patients for substance use disorder and then sends teams for field follow-up.

The advantage is data quality: hospital records contain verified contact information, clinical history, and insurance status that EMS field reports typically lack. The disadvantage is that this model only catches people who reach the emergency department. Overdoses reversed in the field by bystanders with naloxone, or by EMS crews who do not transport, never enter the ED screening system.

Houston’s model parallels the Hospital-Based Violence Intervention Program entry mechanism: both use the hospital encounter as the entry point for sustained community-based follow-up. The difference is the target population (overdose survivors vs. penetrating trauma victims) and the follow-up workforce (peer recovery specialists vs. credible messengers).

Data-Driven Proactive Outreach uses overdose data, community intelligence, or referral networks to identify and reach high-risk individuals before the next overdose occurs. Sacramento County’s program uses data systems to target outreach. Ohio’s statewide programs integrate EMS data at the state level.

This model extends the team’s reach beyond people who have already come to the system’s attention through a specific overdose event. It is the most resource-intensive activation mechanism and the most difficult to execute, because it requires both data infrastructure and community relationships that allow the team to locate and approach people who have not asked for help.

The design choice: The 2022 Ohio study found that most programs used post-911 follow-up as their primary activation method.^{1 3} Programs that added direct dispatch, ED screening, or proactive outreach expanded their reach but added operational complexity. No documented program relied solely on proactive outreach without a reactive component triggered by specific overdose events.¹

The Ohio study also documented the direct link between activation mechanism and response timing: programs dependent on paper-based EMS report review averaged six to eight weeks between contacts, while programs with real-time electronic data feeds and dedicated analysts achieved faster contact.³

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Decision 2: Who Is on the Team?

Team composition determines what the program can do on scene and who it can reach. Four staffing models are documented across operating programs.¹

Paramedic/EMT + Peer Recovery Specialist is the staffing model used by the majority of documented programs.¹ The paramedic provides medical capability: naloxone administration, vital signs, and in some programs field-based buprenorphine. The peer recovery specialist provides relational capability: rapport through lived experience with addiction and recovery.

Milwaukee’s Overdose Response Initiative (MORI), the Dallas Recovery Resource Council, and Houston’s HEROES all use this model.⁵ Polachowski described the partnership: “Our badge gets us in the door, and then the peer support takes over.”⁶ Gorman described the mechanism: peer specialists connect “in ways others cannot because they’ve been there.”⁷

The combination pairs medical credibility with relational trust. Polachowski noted the limitation on the workforce side: peer recovery specialists who relapse lose both their personal stability and their professional credibility, and the emotional toll of the work produces attrition.⁶

Paramedic + Social Worker/Counselor adds clinical assessment capability. Seattle uses two firefighters and a social worker.¹ Portland’s CHAT uses a fire department team with clinical support.⁴

Paramedic + Counselor + Law Enforcement + Faith Leader is Huntington’s four-member model. No other documented program includes clergy as formal team members.⁸ The Huntington Black Pastors Ministerial Association, led by Bishop Shaw, provides an on-call rotation of ministers from multiple denominations.⁸

Priddy described the spiritual component as integral: “The whole team agrees that the spiritual component is critical in helping persons get and stay clean.”⁸ Clergy reported that the work helps them “feel less helpless after burying so many people.” Pastors initially asked just to provide food and logistical support, then pushed for direct involvement: “I’m tired of doing funerals for young people. I want to change all that and help.”⁸

Huntington’s team reports strong outcomes (nearly 1,200 survivors contacted, approximately one-third entering treatment, CDC-documented community-level overdose declines, and a 2025 peer-reviewed evaluation), but Huntington’s social context is specific.^{8 12}

Multi-Agency Partnership describes models where each team member comes from a different organization. Colerain Township pairs a police officer (police department), a firefighter/paramedic (fire department), and an addiction counselor (Addiction Services Council of Greater Cincinnati).¹ Colerain’s model has functioned since July 2015 and serves as one of the DOJ’s eight national peer mentor sites.¹¹

The critical workforce distinction: The peer recovery specialist in overdose response teams is defined by lived experience with addiction and recovery specifically. This is different from the peer support specialist in mobile crisis (lived experience with mental health conditions or substance use, a broader category) and the credible messenger in community violence intervention (lived experience with violence or incarceration). These are three different peer workforces, drawing from three different labor pools, with three different skill sets. Using the word “peer” without specifying which type collapses a real distinction.

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Decision 3: Where Does the Program Live Institutionally?

The institutional home determines the program’s budget authority, dispatch integration, political accountability, and long-term durability.¹

Fire Department is the institutional home for the majority of documented programs.¹ Milwaukee, Portland, Seattle, Colerain Township, and Buncombe County all operate through or in partnership with fire departments.^{1 4 6} The fire department offers existing EMS infrastructure (dispatch, vehicles, shift scheduling), a non-enforcement institutional identity, and a workforce pipeline of paramedics who already handle overdose calls.

The fire department’s baseline budget covers dispatch, vehicles, facilities, HR, and supervision independently of the overdose response program. The program adds staff to existing infrastructure rather than building from scratch. Polachowski described this as a practical advantage: the program operates within the department’s existing shift scheduling, vehicle fleet, and dispatch system.⁶

The limitation is that fire departments are primarily organized around emergency response, not sustained case management. The follow-up component of overdose response, which may extend for weeks or months, does not fit neatly into the fire department’s operational tempo. Programs housed in fire departments often partner with community organizations or health departments for the sustained engagement component.

Health Department provides the epidemiological and public health infrastructure that drives program targeting. Milwaukee’s MORI operates as a partnership between the Health Department and the Fire Department.⁶ Sacramento County runs its program through the Department of Health Services.¹

Community-Based Organization houses some programs in nonprofits. The Addiction Services Council of Greater Cincinnati provides the counselor for Colerain’s team.¹ Coastal Horizons Center in North Carolina operates its own program.⁹

The risk of the community organization home is financial fragility. CAHOOTS (Crisis Assistance Helping Out On The Streets), a 36-year-old civilian crisis response program in Eugene, Oregon, shut down in April 2025 after its nonprofit operator’s financial failure.¹⁴

University Medical Center provides academic and clinical infrastructure. Houston’s HEROES operates through the University of Texas Health Science Center.⁵

Multi-Agency Partnership describes programs where multiple agencies contribute. Colerain’s police-fire-nonprofit model is the primary example.^{1 11}

State Coordination describes the model used in Ohio and West Virginia. Ohio’s Recovery Ohio initiative supports programs in over 80 counties.³ West Virginia’s Department of Health and Human Resources (DHHR) coordinates across 33 counties.⁸

The design choice: The institutional home determines who controls the budget, who hires the staff, who sets the protocols, and who is accountable when the program faces challenges.¹

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Decision 4: What Population Does the Team Serve?

The straightforward answer is: anyone who has experienced a drug overdose, regardless of substance, insurance status, treatment readiness, or number of prior overdoses. Every documented program operates on this universal eligibility principle. Services are free to the person receiving them, with no billing, copays, or insurance requirements. This mirrors the public safety model: fire departments do not check insurance before responding to a fire.

But within this universal frame, the population actually reached varies by program design.

Fentanyl has rewritten the demographics. Polachowski described fatal overdoses in Milwaukee County ranging from teenagers to an 83-year-old: “Combat veterans. High school seniors. Young mothers.”⁶ Priddy described the range in Huntington: “We could go into an area that somebody might be living in an abandoned house with a dirt floor, and then the next minute, we’re going into a million-dollar home.”⁸ Gorman reported that heroin is “almost nonexistent” in Milwaukee’s drug supply; fentanyl mixed into crack cocaine, methamphetamine, and marijuana has expanded the affected population to people who never used opioids intentionally.⁷

Co-occurring conditions shape what the team encounters. Hubbard described Buncombe County’s approach: “A core tenet of the program is that team members let people choose the level of help they get.”⁹ The team addresses whatever the person is willing to work on.

Families are a secondary population. Huntington’s clergy team reported that visits help families “feel less helpless after burying so many people, ranging from young to old, rich to poor and everyone in between.”⁸

The design choice: Universal eligibility is standard. The real population design questions are operational: Does the program have the data infrastructure to identify all overdose events in the jurisdiction, or only those that generate EMS reports? Does the program reach people who overdose in private settings where no 911 call is made? Does the team have the capacity and training to address co-occurring conditions, or is it focused narrowly on addiction and treatment connection? The answers to these questions determine who the program actually reaches, regardless of who it is designed to serve.

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Decision 5: What Does the Team Do on Scene?

The on-scene toolkit is where the program’s theory of change becomes operational. Ten documented capabilities span from acute medical intervention to sustained relational engagement.

Naloxone administration is the same capability traditional EMS provides. For overdose response teams responding to active calls (Portland CHAT, Crawfordsville), this is the entry point. For teams doing post-crisis follow-up, they carry naloxone to leave with the survivor and family members for future emergencies.

Field-based buprenorphine is the most consequential clinical addition to the model. Portland’s CHAT and Buncombe County have demonstrated that paramedics can initiate medication-assisted treatment in the field immediately after an overdose reversal.^{4 9} Dr. Richard Bruno of Multnomah County described the value: “Being able to provide life-saving medications for opioid use disorder at the time the paramedics respond versus waiting for patients to arrive in the emergency room or following up at a clinic is a promising method to reduce overdose deaths.”⁴

Buncombe County takes this further: the team can administer buprenorphine for up to five days in the field, bridging the person to formal outpatient treatment without an ER visit or inpatient stay.⁹ This collapses the gap between overdose reversal and treatment initiation from weeks (the time it typically takes to get a treatment appointment) to hours.

Field-based buprenorphine requires specific paramedic authorization and training, and it is not available in most programs. Programs without this capability rely on referral and warm handoff to treatment facilities, which introduces the delay and attrition that buprenorphine initiation is designed to eliminate.

Post-overdose follow-up visits within 24 to 72 hours are the defining capability. The team returns to the survivor’s home after the acute event. Molinski described the commitment: “There’s no limit on the amount of times we’ll go back if they want us to come back.”⁶ Carteret County, North Carolina has documented the most structured follow-up schedule: wellness checks at two days, one week, two weeks, one month, and three months after initial contact, “even if the individual does not request services.”¹⁹

Sustained engagement extends over days, weeks, or months. The Recovery Resource Council in Dallas described its approach: teams “follow the lead of the individual to guide the frequency, type, and amount of follow-up services provided.”¹⁰ Priddy described what even casual contact accomplishes: “Even if they’re not ready for treatment, they appreciate someone checking in, asking how they are, bringing them resources.”⁸

Field-based medication beyond initial reversal. Orange County, North Carolina’s POST-Overdose Response Team provides “medication on a daily basis for up to seven days,” after which the team finds a longer-term treatment facility.¹⁹ This seven-day bridge parallels Buncombe County’s five-day model, with both programs treating the immediate post-overdose period as a treatment initiation window rather than just a referral opportunity.

Treatment connection and warm handoff bridges the gap between engagement and formal treatment. Colerain reported that 80% of people they followed up with “gotten into recovery.”¹¹ Coastal Horizons connected 485 of 525 individuals to treatment.⁹ Huntington reported 30% treatment entry.¹² The variation in these numbers reflects definitional differences (what counts as “connected” or “in recovery”), population differences, and local treatment capacity, not just team effectiveness.

Harm reduction supply distribution is standard across programs. Milwaukee’s MORI distributes “HOPE Kits” containing naloxone and fentanyl test strips during follow-up visits.⁶

Wraparound service connection addresses co-occurring conditions. Hubbard described Buncombe County’s approach: team members help with housing applications, insurance enrollment, transportation to treatment, and connection to social services.⁹

Spending time is a capability that traditional emergency response cannot provide. Teams can sit with someone for hours. Molinski described the commitment: “There’s no limit on the amount of times we’ll go back.”⁶ Priddy described what sustained presence accomplishes: “Even if they’re not ready for treatment, they appreciate someone checking in.”⁸

Family support includes leaving naloxone and information with families when the survivor is unavailable.⁸

Spiritual support is unique to the Huntington model, where clergy provide “a spiritual safe haven, caring listener, and gentle encourager.”⁸

The design choice: Every program provides the core capabilities (follow-up visits, naloxone distribution, treatment connection). The differentiating capabilities are field-based buprenorphine (which requires paramedic authorization and training), 911 direct dispatch response (which requires dispatch integration), and sustained engagement extending beyond initial contact (which requires funding for ongoing caseload capacity). A program with all three is Portland CHAT plus Buncombe County’s buprenorphine bridge. Most programs start with the core and add capabilities as funding, authorization, and workforce allow.

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Decision 6: How Is the Program Funded and Sustained?

Funding determines not just whether the program can start but whether it can survive past its initial grant period. The landscape for overdose response teams is more diversified than for most alternative response models, primarily because opioid settlement funds provide a dedicated revenue stream that did not exist for earlier programs.

Opioid Settlement Funds are reshaping how this program type is funded. Wisconsin expects approximately $780 million through 2038 from combined opioid settlements, with state distributions accelerating from $8 million in fiscal year 2024 to $36 million in fiscal year 2025.¹⁵ Connecticut expects roughly $600 million total.¹⁶ Travis County allocated $860,000 from the Texas Opioid Abatement Fund Council.¹⁷

The advantage of settlement funds is duration and dedication: 18-year payment schedules provide planning horizons that annual grants cannot match. The limitation is that settlement funds are finite. Communities that build programs on settlement funds without developing additional revenue streams will face the same cliff that grant-dependent programs face, just on a longer timeline.

Federal Grants provide startup and operational funding. The CDC’s Overdose Data to Action (OD2A) program funds 49 state and 41 local health departments.¹⁸ SAMHSA distributes crisis response grants. The DOJ’s COSSUP funded Colerain Township, and BJA mentor site designations provide both funding and technical assistance.¹¹

The Trump Administration revoked roughly $11.4 billion in COVID-era funding for addiction and mental health grant programs in March 2025.¹⁴

State Investment is growing but uneven. Ohio invested $51 million in a statewide youth program.³ Connecticut’s DMHAS provides coordination.¹⁶ West Virginia’s DHHR supports 33 counties.⁸

Local Government provides the operational backbone. Milwaukee funds its program through city and county budget lines.⁶ Sacramento County runs its program through the Department of Health Services.¹ Travis County allocated $860,000 from opioid settlement funds.¹⁷

Private and Healthcare Funding is emerging. Portland’s CHAT received $389,577 from CareOregon, a Medicaid coordinated care organization, through June 2025.⁴ Insurance reimbursement for field-based buprenorphine and other medical services could provide a sustainable revenue stream, but the billing mechanisms remain underdeveloped. The insight articulated by Angela Kimball of Inseparable, a national mental health advocacy organization, applies: Medicaid reimburses for billable clinical encounters, but the unfunded gap includes training, supervision, travel time, community relationship-building, and staff availability time when the team is on shift but not actively on a contact.

Cost-effectiveness data provides context for the investment argument. The NACo Opioid Solutions Center reported per-contact costs across documented programs in the range of $200 to $500 per overdose survivor visit.⁹ Portland’s 68% field treatment rate, reported in November 2024, produced an estimated $9 million in healthcare system savings.¹³

Angela Kimball of Inseparable articulated the structural funding gap: no single funding source covers the full cost of readiness.⁴ Programs embedded in fire departments or health departments operate within existing institutional infrastructure funded through baseline budgets. Programs dependent on a single grant or encounter-based revenue are exposed to the pattern that collapsed CAHOOTS in Eugene after 36 years.¹⁴

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Three Design Patterns Across Documented Programs

Data infrastructure and contact speed. The 2022 Ohio study found that programs with dedicated data analysts and real-time EMS data feeds achieved faster contact, while programs relying on manual paper review averaged six to eight weeks between contacts.³

Field-based buprenorphine and clinical reach. Portland’s CHAT and Buncombe County have demonstrated that paramedics can initiate medication-assisted treatment at the point of contact.^{4 9} Dr. Richard Bruno described this as “a promising method to reduce overdose deaths.”⁴ Buncombe County’s five-day field buprenorphine bridge is the longest documented field-based treatment course.⁹

Institutional embedding and program survival. Programs housed in fire departments or health departments operate within existing infrastructure funded through baseline budgets.¹ The CAHOOTS collapse in April 2025 demonstrated what happens when organizational infrastructure depends on a funding mechanism that cannot sustain it.¹⁴

The mobile crisis overlap. Denver’s Support Team Assisted Response (STAR) vans carry naloxone and respond to active overdoses as part of a broader mobile crisis scope. Portland operates CHAT (overdose response) and Portland Street Response (mobile crisis) as separate units.⁴ The NACo Opioid Solutions Center drew the distinction between post-overdose response teams and general crisis response explicitly.⁹

The downstream dependency. Polachowski identified housing as “one of the biggest barriers that MORI encounters.”⁶ Molinski described the geographic dimension: “When you have an individual that lives on the North Side of Milwaukee and you’re asking them to travel to West Allis every single day” for methadone treatment, the distance becomes a barrier independent of motivation.⁶

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The Bottom Line: Six design decisions define every overdose response team: how it is activated (post-911 follow-up, direct dispatch, ED screening, or proactive outreach), who is on the team (paramedic + peer, paramedic + clinician, multi-agency, or Huntington’s four-member model), where it lives institutionally (fire department, health department, community organization, university, multi-agency partnership, or state coordination), who it serves (universal eligibility, but actual reach depends on data infrastructure), what it does on scene (from basic follow-up to field buprenorphine and sustained engagement), and how it is funded (opioid settlements, federal grants, state investment, local budgets, or emerging healthcare reimbursement). The cities with the strongest programs invested in data infrastructure before expanding field teams, pursued field buprenorphine authorization, embedded in existing departments for structural durability, and braided multiple funding streams rather than depending on any single source. No single program has optimized all six decisions. Every community will make tradeoffs based on its existing infrastructure, workforce, funding, and political context.