Access to non-police crisis response for people who use drugs: lessons from community safety response programs in two U.S. cities

INTRODUCTION: Community Safety Response (CSR) programs increasingly provide non-police alternatives to behavioral health crises, but their role in addressing substance use calls remains poorly understood. This qualitative study examined how municipal stakeholders in Denver, Colorado and San Francisco, California perceive and operationalize CSR protocols for substance use-related emergencies. METHODS: Between 2021 and 2023, we conducted 82 semi-structured interviews and 32 field observations with 911 dispatchers, law enforcement, city officials, and alternative responders from Denver and San Francisco's respective CSR programs. Transcripts and field notes were analyzed using thematic analysis to identify attitudes toward substance use, decision-making processes for call deployment, and barriers and facilitators to routing of substance use related calls to alternative response. RESULTS: Although written protocols permitted non-police response to substance use calls absent violence or weapons, findings revealed a gap between policy and practice. Dispatcher and responder discretion played a central role in determining CSR deployment: while some stakeholders regularly sent alternative responders on substance use calls, others described any mention of drugs -particularly methamphetamines-as automatically triggering police involvement. Barriers to effective CSR response included limited referral options for people who use drugs, fragmented service systems, community tensions around visible drug use, and perceived safety concerns. Facilitators included CSR teams' unique engagement capacity and potential for peer specialist involvement. CONCLUSION: To promote effectiveness of CSR as a public health intervention to reduce morbidity and mortality, programs must address discretionary decision-making, enhance training on stigma and harm reduction principles, and coordinate with broader service systems to ensure equitable access to non-police responses for people who use drugs.