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Civil Justice Research Highlights   |    No. 3    |    October 2019

In our third Just Research newsletter, we profile data and studies that show how legal assistance helps those affected by the opioid crisis. This topic complements NLADA’s fall webinar series on how legal aid is an essential partner in addressing the opioid crisis, focusing on research and funding (Oct. 1 at 1:30pm ET), data collection and screening (Oct. 24 at 3pm ET), and partnerships and service delivery (Nov. 21 at 1:30pm ET).

The American Psychiatric Association reports that 31 percent of Americans know someone who is addicted to opioids, or has an opioid use disorder (OUD), compared to 27 percent in 2017.  Every day, it is estimated that more than 130 die from opioid-related overdoses. In November 2017, the White House reported the total economic cost to be $504 billion. Legal aid is already helping the many affected: In a 2018 survey of Legal Services Corporation (LSC) grantees, more than 95 percent reported that they provided services to individuals with OUD.

People with OUD report needs around health (they report eight times the healthcare costs compared to those without an OUD), family (drug use can limit how nurturing and safe the environment is for children), employment (workers with OUD miss an extra 18.5 days of work and have higher turnover than those without), and housing (early homeless experiences have been shown to predict drug misuse and behavior). Although those with OUD may not recognize these issues as being legal, studies show civil legal interventions can often be a key part of the solution to these problems.

The research directly linking improved outcomes and stability for those affected by opioids and civil legal aid is still young. As a result, this newsletter will focus on two topics – health and family – and show how legal aid can improve outcomes for individuals with OUD. 

 

Register for the NLADA's webinar series here.



 

RESEARCH SPOTLIGHT


The Opioid Crisis in America & the Role Medical-Legal Partnership Can Play in Recovery by Jay Chaudhary, Kate Marple, and Jillian Bajema at the National Center for Medical-Legal Partnership (2018). Read the brief here.

This brief presents four case studies of medical-legal partnerships (MLPs) with projects dedicated to assisting those with opioid use or substance use disorder in Cincinnati, Indianapolis, Portsmouth (Ohio) and Reno.
  • Case study #1: HOPE Program at Good Samaritan Hospital Faculty Medical Center (Cincinnati) connects with more than 500 pregnant women with OUD and substance use disorder (SUD) annually. The legal partner is the Legal Aid Society of Greater Cincinnati. “Dr. Michael Marcotte, Medical Director for the HOPE program, says that these women have two main goals: sobriety and parenting, and that these goals are intertwined. He said that their legal needs can directly and indirectly interfere with the stability and support needed to pursue both goals.” (p. 6)
  • Case study #2: Eskenazi Health Midtown Community Mental Health (Indianapolis) has two addiction programs that serve both urban and rural populations. The legal partner is Indiana Legal Services. “Since 2014, approximately 25 referrals for patients with SUDs were made for assistance with expunging criminal records, housing, and assistance with custody and other family law issues.” (p. 6)
  • Casey study #3: The Counseling Center (Portsmouth, OH). The legal partner is Southeastern Ohio State Legal Services Association. “During the partnership’s first year, case managers made 119 referrals for MLP services; seventy of those referrals were related to custody or divorce issues. Other referrals were for help reinstating driver’s licenses, sealing criminal records, and preventing housing evictions.” (p. 7)
  • Casey study #4: The MLP at Northern Nevada Hopes (Reno) focuses solely on patients with SUDs. The legal partner is Washoe Legal Services. “During the first month of the MLP’s SUD focus, providers referred 20 patients for assistance with criminal record expungement and resulting housing and employment issues. Additionally, since the program’s inception, 10 patients who are also receiving care through the MAT program were referred for legal services. The MLP regularly hosts Legal Education Clinics that help patients understand potential legal issues related to their recovery, such as criminal record sealing, so that they are better able to find a job and be stably employed” (p. 7)

More research: Health

  • People with OUD report eight times the healthcare costs when compared to those who do not have an OUD and are often high-utilizing patients. It’s not isolated to just those with OUD – children may accidentally take their family members’ opioids. Between 2004 and 2015, the rate of opioid-related hospitalizations of children requiring intensive care doubled.
  • In June 2019, researchers from The Kaiser Family Foundation found that approximately 18 percent of nonelderly adults with OUD were uninsured between 2016 and 2017. They also found that nearly three quarters of these individuals reported needing drug treatment in the preceding year but did not receive it. The researchers state lack of health insurance may hinder individuals’ access to health care services given the high rates of disability, chronic conditions, and mental illness in this population.
  • A Census report released in September 2019 found that 27.5 million Americans (8.5 percent of the US population) did not have health insurance in 2018, compared to 25.6 million (7.9 percent) in 2017. The number people with public health coverage decreased by .4 percent, and the number of insured children under the age of 19 decreased by .6 percent between 2017 and 2018.
  • Many barriers can prevent people with OUD from receiving medical-assisted treatment. For example, individuals with OUD who are transitioning back into the community after being incarcerated are less likely to receive medical-assisted treatment, despite its association with lower rates of relapse and recidivism.
Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership by Jeffrey Martin, Audrey Martin, Catherine Schultz, and Megan Sandel (2015) found that when underlying civil legal needs were addressed, inpatient and emergency department use of high-utilizing patients dropped 50 percent and health care costs decreased 45 percent. Read the article here.

The researchers, who are affiliated with Lancaster Hospital’s medical-legal partnership or Boston University Schools of Medicine and Public health, studied Lancaster General Health’s pilot “super-utilizer project” that offered services from social workers, psychologists, pharmacists, and civil legal aid lawyers. During the pilot year, 55 patients participated in the project.
Highlights from this study include:
  • Lawyers support the case management team. “Many of the civil legal problems identified through the pilot were able to be treated with this kind of indirect legal care where the lawyer relayed legal information and resources to social workers and medical staff. […] A little more than 16 percent of disability-related civil legal problems required direct legal care, while almost 84 percent could be addressed by a lawyer supporting the case management team.”
  • The MLP improves health outcomes. “[T]his pilot shows that medical-legal partnership can build on the intent of a super-utilizer program, which is to embed efficiencies within the health care system, reduce costs, and improve health outcomes among the most vulnerable patients.”

More research: Family

  • Children often have a detailed awareness of their parents’ drug use but rarely discuss it with anybody, leading to increased feelings of fear, isolation, and behavioral changes. One study found that among 100 children who had parents with SUD, the majority presented with developmental problems: 69 percent had cognitive limitations, 68 percent had speech and language impairments, 16 percent had emotional or behavioral problems, and 83 percent had medical problems.
  • The association between OUD and domestic violence (DV) is complex: DV is both a consequence and predictor of OUD. Opioid-dependent fathers are more likely than non-addicted fathers to report exerting physical and sexual aggression toward their partner. 27 percent of women in substance use recovery report being coerced into using substances by an abusive partner.
Civil legal aid can work to stop this cycle of family violence and substance abuse by helping partners escape turbulent and abusive relationships:

A study funded by the U.S. Department of Justice found that that when survivors of domestic violence have better access to civil legal aid attorneys, they are granted greater protections in child custody cases. Read Final Report of the “Impact of Legal Representation on Child Custody Decisions among Families with a History of Intimate Partner Violence Study” by Mary Kernic, a professor at University of Washington (2015). Read the report here. Highlights from this study include:
  • Legal aid attorneys are effective. “[C]ases in which the IPV [intimate partner violence] victim parent received legal aid attorney representation were 85% more likely to have visitation denied to the IPV abusing parent, 77% more likely to have restrictions or conditions placed on the IPV abusing parent's child visitation among the subset of cases in which the IPV abusing parent was awarded visitation, 47% more likely to have treatment or program completion ordered for the IPV abusing parent” (p. ii).
  • In comparison, “[c]ases in which the IPV victim parent received private attorney representation were 63% more likely to have supervision of the IPV-abusing parent's child visitation ordered by the court … and 36% more likely to have treatment or program completion ordered by the court” (p. 43).

Want even more research?

 
  • National Center for Medical-Legal Partnership at George Washington University’s website is a central source for information on the need for and impact of MLPs, as well as resources on how to establish them. Their issue brief on the opioid crisis details the role medical-legal partnerships can play in recovery.
  • LSC released their Opioid Task Force Report in June 2019. The Task Force was created in April 2018. Over the course of 11 months, the Task Force held meetings with subject matter experts to investigate and understand the intersection between the opioid epidemic and civil legal aid. The report makes 10 recommendations for strengthening the role of civil legal aid in the response to the opioid epidemic.
  • JGP and NLADA published a fact sheet on how civil legal aid helps those affected by the opioid crisis.
  • The JGP Toolkit presents the evidence base for using civil legal aid to further policy and program goals, identifies federal pass-through funds that states can use to support legal aid, and highlights examples of successful state partnerships with legal aid. Read the curated research on common co-occurring issues, such as health, domestic violence, and employment in Module 1.
  • NLADA’s LegalAidResearch.org. This research database provides free access to research reports and other documents about evidence-based practices and research results on civil legal aid. Find research related to substance use here.

Find data

Looking for funding?


For information about direct discretionary federal grants administered by federal agencies that could support legal aid for individuals with OUD and others affected, go to NLADA’s database of non-LSC federal resources, LegalAidResources.org.

For information about federal pass-through funds administered at the state level, go to JGP’s Toolkit Module 2 for FAQs about legal aid and certain pass-through funds that can be used for legal aid for individuals with OUD and others affected — see, e.g., VOCA, SOR, SABG/MHBG, AmeriCorps.

JGP and NLADA co-created a Grants Forecasting Guide to help individuals find forecasted federal grants and related information about prospective postings, identifying prior grantees, and strategies for using the information to prepare for possible applications.

JGP’s new Funding-By-Issue Cheat Sheet provides a birds-eye view of the populations served and issues commonly addressed by legal aid, including people with opioid use disorder, and the applicable state-administered federal funds that can support this work.

Advocacy in action


On August 26, Judge Thad Balkman ruled that Johnson & Johnson had helped initiate the opioid crisis in the state of Oklahoma by deceptively marketing painkillers. Judge Balkman ordered Johnson & Johnson to pay $572 million to the state of Oklahoma. The ruling was the first in the U.S. to hold a pharmaceutical company responsible for the drug crisis.

On September 3, The American Medical Association Opioid Task Force released their latest National Roadmap on State-Level Efforts to End the Opioid Epidemic. The report includes six recommendations on how states can best direct their federal funding and highlights lessons. One recommendations is: “Support reforms in the civil and criminal justice system that help ensure access to high quality, evidence-based care for opioid use disorder, including medication-assisted treatment.”

The ACLU of Kansas recently filed a complaint on behalf of Leaman Crews against the U.S. Federal Bureau of Prisons for denying him buprenorphine to treat opioid use disorder. Leaman Crews became addicted to opioids after injuries from a car crash left him with back pain, and entered the U.S. Penitentiary in Leavenworth on September 4 for a 36-month sentence. The majority of people with a substance use disorder entering or exiting correctional facilities do not receive medication-assisted treatment (MAT). The ACLU claimed that withholding medication from Crews was in violation of the Eighth Amendment’s prohibition of cruel and unusual punishment, the Rehabilitation Act, and the Administrative Procedures Act. On September 11, ACLU of Kansas and the Federal Bureau of Prisons reached a settlement that allows Crews to receive MAT. ACLU affiliates have since filed a similar case on behalf of Melissa Godsey of Washington state. 

On September 4, HHS announced $1.8 billion in new grants from the Substance Abuse and Mental Health Services (SAMHSA) to help states fight the opioid crisis. This includes approximately $932 million to all 50 states, DC, and the territories for the State Opioid Response grants, flexible funding to state governments to support prevention, treatment, and recovery services.

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Just Research is a monthly legal aid newsletter that compiles recently published research, resources, and tools for organizations, practitioners, and policymakers. It is co-produced by The Justice in Government Project (JGP) at American University and National Legal Aid & Defender Association (NLADA).

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