March 13, 2019

Cleveland Metropolitan Bar Journal: Fighting the opioid epidemic with civil legal aid

Jennifer Kinsley is an attorney at The Legal Aid Society of Cleveland and one of two attorneys who work full-time with St. Vincent Charity Medical Center in a medical legal partnership (MLP). She recently wrote about MLPs in the Cleveland Metropolitan Bar Journal and how the St. Vincent Charity/Legal Aid Society MLP provides free, on-site services to resolve civil legal issues that impact the overall health of patients. The full text of the article is below or available here.

Fighting the opioid epidemic with civil legal aid

By Jennifer Kinsley
Attorney, The Legal Aid Society of Cleveland

As the United States wages war on an opioid epidemic which has worsened each year for the last 11 years, those in the legal profession should consider how civil legal services can contribute to overall solutions. Ohio is among the top five states with the highest rates of opioid related death in the United States. In Cuyahoga County, overdose deaths increased from 370 total deaths in 2015 to 727 overdose deaths in 2017 according to the Cuyahoga County Opiate Task Force. In October of 2018, the Cuyahoga County Medical Examiner’s Office estimated there will be a slight decrease to approximately 719 overdose deaths reported in 2018. This decrease is likely attributed to Project Dawn, a community-based program which provides overdose education and naloxone distribution. As naloxone helps to lower fatality rates countywide, more residents are entering community-based rehabilitation programs and residential treatment facilities.

The decision to leave behind a substance of choice and seek treatment is one that signifies the start of a long and often repeated journey towards sobriety. The first step is often an assessment, which is followed by decisions about treatment options that may include relocation to sober living or residential treatment facilities. A common phrase in recovery draws the participant’s attention to the “people, places, and things” in their life that are triggers to substance use and learning to avoid them. This often results in social isolation for those in recovery until they are able to build a new support system of sponsors, home groups, and individuals with whom they attend treatment programs.

When the fog of addiction begins to clear, the patient in recovery is at some point forced to face the skeleton of their life that was likely shattered by substance use. This might mean bankruptcy following numerous ambulance rides and naloxone administrations, or a divorce following many years of mental and physical abuse by a partner, or fighting to regain custody of minor children. Given that this moment of clarity often happens shortly after relocation and disconnection from social supports, it can be an immensely challenging time for that individual. If stress is a motivator for substance use, it is instantly apparent why relapse is so common. This presents a glaring opportunity for civil legal services to intervene with legal check-ups, often in the collaborative environment of a medical legal partnership.

Medical legal partnerships exist between a medical institution and a civil legal service provider, often a legal aid agency or law school clinic. The original concept for medical legal partnerships was based upon a pediatric model wherein attorneys assisted pediatricians by addressing housing conditions contributing to chronic respiratory problems in patients. More recently, medical legal partnerships are popping up in the behavioral health realm to address the looming opioid epidemic. In September of 2017, there were four behavioral health medical legal partnerships in the United States.

In October of 2017, the Legal Aid Society of Cleveland partnered with St. Vincent Charity Medical Center to develop a medical legal partnership with the initial intention of serving the behavioral health population. While the medical legal partnership has since expanded, a large focus remains on addiction medicine and those clients involved with Rosary Hall, St. Vincent’s addiction treatment center.

Applying the same concept that worked well for pediatrics to addiction medicine, we find that any number of attempts at sobriety will likely be thwarted by a patient being forced to return to an unstable position in the community. The evaluation of this social stability is based upon an analysis of social determinants of health. The Secretary’s Advisory Committee on Health Promotion and Disease Prevention defines social determinants of health as the conditions in which people are born, grow, live, work, and age.

The purpose of a medical legal partnership is to address those social determinants of health with civil legal assistance. Outside of the environment in which those with substance use disorders live, a major factor working against those in recovery is social stigma. Civil legal services may be able to assist by enforcing the Americans with Disabilities Act (ADA) to protect these individuals.

Drug addiction becomes a disability under Section 504 of the Rehabilitation Act, the ADA, and Section 1557 of the Affordable Care Act when the addiction substantially limits a major life activity. This means that any individual with a substance use disorder or opiate use disorder that substantially limits any one or more of their major life activities is generally considered to be disabled under the ADA. Major life activities include working, eating, sleeping, speaking, concentrating, and communicating. Whether or not a major life activity is substantially limited by the addiction should be construed broadly in favor of expansive coverage by the Act. An individual currently engaging in the illegal use of drugs is not protected under the Act; however, this exclusion from protection does not apply to the use of a substance under the supervision of a licensed healthcare professional, or in accordance with uses authorized by Federal laws. This provision protects those participating in a medication-assisted treatment program. It also protects those individuals who have successfully completed or are currently participating in a supervised drug treatment program and are no longer using drugs illegally.

The provision of civil legal aid with the intention of restoring stability to those in recovery provides motivation for sobriety and encourages an end to the opioid crisis.

Jennifer Kinsley is an attorney at The Legal Aid Society of Cleveland and one of two attorneys who work full-time with St. Vincent Charity Medical Center in a medical-legal partnership. Medical providers work as a team with Ms. Kinsley to improve health outcomes and create stability in patient lives.

About the Medical Legal Partnership
St. Vincent Charity’s MLP provides free, on-site services to resolve civil legal issues that impact the overall health of patients. When it launched in 2017, the program was the first of its kind in Ohio to focus on the needs of those in treatment for behavioral health and addiction diseases.

Today, the MLP has been expanded to all patients who qualify. The program is generously supported through a two-year $260,000 grant from the Jones Day Foundation, $100,000 from The George Gund Foundation and $80,000 from the Mt. Sinai Health Care Foundation. St. Vincent Charity Medical Center is a ministry of the Sisters of Charity Health System.

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