“Jamie” was in recovery for almost a year when Indiana’s Department of Child Services (DCS) recommended she try to regain full custody of her daughter, who was placed in foster care since she was a newborn due to Jamie’s addiction.
The possibility of reuniting with her child was what motivated Jamie to get and stay in treatment for substance use disorder, so she was excited about the recommendation from DCS. But during what she thought was the final child custody hearing, a judge told Jamie to “wean off” her medication-assisted treatment (MAT), methadone, because she was “replacing one addiction with another.”
She didn’t heed the medical advice of the family court judge. Instead, she sought help from her provider at Eskenazi Health Midtown in Indianapolis, who then referred her to the health center’s on-site lawyer. An attorney from Indiana Legal Services (ILS) — who also works several hours a week at the treatment center — went with Jamie to her next court hearing. And together, they presented the judge a letter written by her doctor under the guidance of ILS, explaining MAT is the golden standard for addiction treatment. The judge ultimately changed her mind, and Jamie secured full, permanent custody of her now two-year old daughter.
This isn’t always the case. Sometimes people don’t have access to legal aid, as it isn’t customary to have lawyers embedded in medical settings, much less addiction treatment centers.
“We’ve heard stories of folks who were in fact pressured by family court or DCS to wean off their MAT, which is never a good outcome,” said the managing attorney at ILS, Jay Chaudhary.
It’s hard to say what could have happened if Jamie didn’t have a supportive attorney present. But there are plenty of personal testimonies and studies that show the benefit of embedding legal assistance in medical facilities — particularly in settings like addiction treatment, where patients have complicated legal histories. The idea is legal aid can address social circumstances that the medical community cannot — like custody issues, housing evictions, or workplace rights — but that influence health outcomes nevertheless.
Medical-legal partnerships, explained
ILS has partnered with Eskenazi Health since 2010. And in 2014, ILS began accepting referrals from health care providers in treatment programs specifically for patients with a substance use diagnosis (and many of whom are also dual diagnosed with mental illness). Now, one full-time lawyer spends several hours a week at three addiction treatment programs located at the mental health division of Eskenazi Health, the safety net hospital for Marion County. Referrals are left to the discretion of the doctor, and Midtown providers and ILS lawyers train one another on appropriate language and protocols. Both parties described it as a symbiotic partnership, and perhaps more importantly, seamless for patients.
This is just one example of a medical-legal partnership. Nationwide, there are over 300 health care organizations that operate medical-legal partnerships. Of that there are only four that focus on helping people with substance use disorder, as of September 2017.
Various stakeholders who spoke with ThinkProgress believe these types of set-ups can play an essential role in addressing the opioid crisis. Even so, federal and state lawmakers haven’t payed too much attention to them, at least not to date.
“Lawmakers may focus on very specific things like overdose-reversal drugs, medication-assisted treatment … all those things are important to battling disease. But sometimes we miss some very basic things that could go a long way to accessing treatment and maintaining recovery,” said Jon Ferguson, the program manager for addiction services at Eskenazi Health Midtown Community Mental Health. “We find often it is very difficult for our patients to engage in treatment if they don’t have housing, don’t have education, don’t have transportation, or have lots of legal barriers.”
“Lawmakers may focus on very specific things like overdose-reversal drugs, medication-assisted treatment … But sometimes we miss some very basic things.”
Although helpful to holistic recovery, medical-legal partnerships haven’t garnered much attention from Congress, which is currently working through various opioid-related bills. On Wednesday, both the House and Senate health committees are meeting to work on bills. Meanwhile, there will be a separate briefing in the House on medical-legal partnerships in the context of the opioid crisis.
“I have not heard any Member of Congress or staffer mention it over the past year of extensive contact (e.g., multiple hearing testimonies, lots of phone calls and emails),” Keith Humphreys, who served as a drug policy adviser under the Bush and Obama administrations, told ThinkProgress by email. “I don’t think that means they are against it, I suspect they haven’t heard of it.”
Humphreys’ own view is that “we have evidence going back 25 years that providing opioid-addicted people with services beyond drug use per se — legal and financial advice, mental health care, job training — makes it more likely that they will recover.”
These types of partnerships at, for example, Veterans Affairs medical centers demonstrated stronger housing and mental health outcomes for vulnerable vets as compared to those who receive fewer integrated services.
At Midtown, they also believe medical-legal partnerships address the crux of the opioid epidemic: stigma.
Legal aid often intervenes when addiction is viewed as a moral failing rather than a chronic disease. ILS has represented people who’ve nearly lost their jobs because their employer saw methadone as enabling addiction rather than treatment. Or helped someone maintain stable housing because the attorney advocated on their behalf for a bank loan. Currently, ILS is helping one father in recovery file a child custody modification. He owes child support even though he’s the primary caregiver to his kid, as his ex-partner is no longer in the picture. He’s certainly going to accrue debt, but ILS is still trying to help him because he shouldn’t be penalized indefinitely for forgetting to modify custody arrangements when he was trying to get sober.
“We’re clearly not the magic bullet or the panacea to the problem, but we are a real and important part of any sort of effort to address this,” said Chaudhary, who’s also director of medical-legal partnerships at ILS.
Competing for funds
When a Boston-based education non-profit recommended Mary Miff get her criminal record sealed, she thought this was a good way to officially put her past behind her. Her future employer wouldn’t know about the time she was charged with larceny (for using someone else’s information to pay her utility bills) or destruction of property (for bashing a neighbor’s car) — misdemeanor offenses Miff was charged with more than five years ago when she was struggling with addiction to prescription opioids and crack cocaine.
She called Greater Boston Legal Services (GBLS) but couldn’t get through by phone.
“I gave up for awhile,” Miff told ThinkProgress. It wasn’t until, by chance, she ran into a GBLS lawyer at a student event, where she pleaded her case in person. She finally got a call back, and in 2016, they helped her get her criminal record sealed.
“If we prevented eviction, we help this person stay in their house. If we get somebody on benefits, we give them benefits. You don’t have to stretch and strain to see how it impacts somebody’s life.”
It was a big moment for Miff, who will be four years sober in May. There was something empowering about going back to the court house on her own terms. “Because every time I’ve been to a court house, it was something I did based on drug usage,” she said. But that time, “good things were said about me.”
GBLS partners with nearby hospitals, but to train domestic violence advocates for referrals. Hannah Tanabe, who represented Miff in court, tried to create a medical-legal partnership with a community health center, which she expected would address the city-wide addiction problem, but couldn’t acquire the funding. It’s a shame we didn’t, Tanabe said, because GBLS helps with health-harming legal problems. For example, “Having a criminal record perpetuates the cycle of poverty and addiction,” she said.
The hard part is money.
ILS is currently bidding for an Indiana University grant. They didn’t win last year. And the medical legal partnership isn’t competitive enough yet to apply for state government administered grants, said Chaudhary. There are a lot of stakeholders competing for these funds, so it’s challenging for medical-legal partnerships.
But “our outcomes and results are really tangible,” said Chaudhary. “If we prevented eviction, we help this person stay in their house. If we get somebody on benefits, we give them benefits. You don’t have to stretch and strain to see how it impacts somebody’s life.”
Demand for their services don’t stop when funding runs out. In fact, ILS is already trying to collaborate with Indianapolis first responders to provide legal services as part of wrap-around services to people who are revived with the overdose-reversal drug naloxone. According to Project Point, of the 203 individuals revived from overdoses between January and March 2018 — and who were later screened — 70 spent two or more nights in jail last year, 43 worried about losing housing, and 12 reported being afraid of a partner or ex-within the last year.
“If you sort of get them in like a moment of lucidity maybe you can get them to where they can make some arrangements or plans because I think that the realistic view is that if they overdose once, there’s a good chance they do it again,” said Chaudhary. “I think it’s super sad to think about but, with this case, I think a lot of the problems are… people don’t want to focus on harm reduction.”
On the national front at least, law in the context of the opioid crisis has been reductive. The president views the epidemic as primarily a law enforcement problem and some administration officials and lawmakers have been blurring the legal lines between the drug user and dealer by proposing harsher fentanyl sentencing laws.
“In many ways it’s even more important for that work because the response around substance use is primarily legal and not health focused,” said Leo Beletsky, a professor of law and health sciences at Northeastern University, of medical-legal partnerships.
“People need legal adequate counsel,” he said, adding, “but advocates who are well-versed in substance use.”