Introduction
In February 2022, the Camden Coalition Medical-Legal Partnership launched a partnership with Cooper University Health Care’s “Center for Healing” addiction medicine program. This novel medical-legal partnership (MLP) model provides both civil and criminal legal support at no cost to Center for Healing patients who are seeking treatment for opioid use disorder (OUD) and other substance use disorders (SUD). In its first year, the Camden Coalition MLP received 183 Center for Healing patient referrals for legal advice and representation in a wide range of issues.
The objectives of this partnership are twofold: first, to enhance the wellbeing of Camden-area SUD patients and improve their ability to achieve and maintain stability; and second, to generate evidence and momentum for the establishment of legal services as a “standard of care” intervention for SUD treatment. We are attempting to achieve both objectives by providing high-volume, high-quality legal services, while concurrently capturing data to enable evaluation of this work.
This paper provides an overview of the first year of this “MLP for SUD” program. We begin by documenting the role and efficacy of medical-legal partnerships, while considering the benefits of this approach in enhancing treatment for SUD patients. We next provide background on this particular program, discussing the Camden Coalition MLP and Center for Healing operations, MLP referral processes, and our approach to client-centered legal representation for individuals struggling with addiction. We then discuss the legal services provided during this first year to provide insight into the range of legal issues faced by SUD patients. We focus especially on the program’s provision of criminal-legal representation, which is uncommon among MLPs. We next provide information about the participants served in this first year, including their history of involvement with the criminal legal system. Finally, we provide a preliminary assessment of this first year of work, based in part on feedback from clients whose input we have sought to ensure that we are providing effective assistance.
This paper provides an overview of the first year of this “MLP for SUD” program. We begin by documenting the role and efficacy of medical-legal partnerships, while considering the benefits of this approach in enhancing treatment for SUD patients. We next provide background on this particular program, discussing the Camden Coalition MLP and Center for Healing operations, MLP referral processes, and our approach to client-centered legal representation for individuals struggling with addiction.
1. Background
A Role for Medical-Legal Partnership Support of Substance Use Disorder Patients
Social determinants of health (SDOH) play a significant role in the development and exacerbation of substance use disorders.Reference Galea and Vlahov1 Included among these determinants are civil and criminal legal issues.Reference Rotter and Compton2 It follows that an intervention to address the legal needs of SUD patients will enhance treatment outcomes and patient wellbeing.
The medical-legal partnership model represents an intervention to address these legal needs. MLPs “bring legal services into health care settings to address patients’ unmet legal need.”Reference Ryan3 Researchers have demonstrated that MLP interventions can help patients improve overall health and wellbeing,Reference Klein4 decrease levels of stress and improve mental health,Reference Valverde5 and achieve more stable housing.Reference Tsai6 MLPs have traditionally provided free legal services for civil legal issues only, leaving criminal issues to court-appointed criminal defense attorneys.Reference Sandel7
The Camden Coalition/Rutgers Law MLP
The Camden Coalition and Rutgers Law School launched a medical-legal partnership in late 2017. From the outset, this MLP sought to address a broad array of legal issues facing Camden-area residents with complex health and social needs. The MLP served Coalition patients enrolled in the Camden Core Model care management program, many of whom had multiple chronic health conditions and regularly used the emergency department for primary care.8 The objectives of the program were twofold: first, to remove legal barriers to patient recovery and stability, and second, to demonstrate the efficacy of legal services as a tool in complex care management.
Consistent with the Camden Coalition’s approach to complex care, MLP attorneys received training on how to provide trauma-informed support, as well as on the Coalition’s COACH model, a framework designed to help care “build authentic healing relationships with individuals that empower them to take control of their health.”9 MLP lawyers also benefitted from the Coalition’s emphasis on data-driven care, and receive access to robust patient data, including through the Camden Health Information Exchange (HIE).10
In addition, to establish the MLP as a component of complex care and to enhance the legal services provided, the MLP emphasized the true integration of attorneys into the care team setting. Historically, this has meant that MLP attorneys work closely with Coalition nurses, social workers, and community health workers to ensure that relationships with referred patients begin from a place of trust and confidence. In the case of the Center for Healing partnership, as described below, this integration went a step further, with an MLP attorney co-locating with the Center and remaining in frequent contact with Center team members.
As with traditional MLPs, the Coalition/Rutgers MLP initially limited representation to civil matters, predominantly focusing on issues like housing conditions and eviction, government benefit appeals, and employee benefit disputes. The MLP quickly recognized that many patients in the complex care management program — who frequently had very limited incomes — faced court fines and fees stemming from prior engagement with municipal courts and low-level criminal justice matters. These fines and fees, and related warrants for arrest, affected patient wellbeing and prevented some patients from obtaining driving licenses and employment.Reference Noonan11 Accordingly, the MLP began helping patients address court fines and fees — seeking forgiveness or reduction of those penalties, institution of minimal payment plans, or, in some cases, substitution of community service time for financial obligations.
The MLP initially did not provide representation on open criminal matters, such as drug possession or theft charges — instead electing to support patients and their court-appointed counsel. However, over time, the MLP changed course, transitioning from passive support to active representation on criminal legal issues: That current work is the subject of this article.
Cooper University Health Care’s Center for Healing
Cooper University Health Care opened its Addiction Medicine Program in 2015, housed within its Urban Health Institute.12 The purpose of the Program was to provide evidence-based addiction treatment for the region’s most vulnerable patients.13 The Program grew into the Cooper Center for Healing, which offers an innovative, interdisciplinary approach to care for patients with SUD and psychiatric disorders that focuses on offering a range of evidence-based care options in a variety of care settings that aim to address all of a patient’s needs at once.
The Center’s medical specialists include experts in addiction medicine and toxicology; emergency, internal, and family medicine; palliative care and pain management; geriatrics; and psychiatry.14 These clinical specialists provide care in a variety of settings, ranging from community-based care settings to traditional hospital care, and across all levels of care, ranging from ambulatory specialty care to acute care in both the emergency department (ED) and urgent care clinics. The Center also employs a “robust interdisciplinary clinical team of behavioral health clinicians, nurses, and navigator specialists who offer wraparound services to patients in a biopsychosocial model” to address SDOH and care management needs alongside purely clinical care.15 Across its array of services and care settings, the Center focuses on aligning treatment with trauma-informed and evidence-based practices, driven by the philosophy that patients don’t fail treatment, treatment fails patients: this approach acknowledges that “[w]hile abstinence from substances is a goal for some, for others the overarching goal is to lessen or manage substance use, mitigate risks of substance use, and meet personal life goals.”16
The Center places strong emphasis on delivering care that accords with the latest scientific advancements in effective SUD treatment, and has created programs to ensure that patients who may have been traditionally excluded from access to the latest advancements in addiction medicine can benefit too: For example, the Center has worked to increase adoption of medication for opioid use disorder (MOUD) in county correctional facilities; created medical group visit opportunities for SUD patients with chronic pain, sedative dependence, and identities that may complicate their SUD recovery (e.g., older adults, current and soon-to-be mothers); and “expanded acute care networks from the ED to “bridge” to care for vulnerable populations.”17
The Camden Coalition/Center for Healing Partnership
In early 2022, the Camden Coalition MLP entered into a memorandum of understanding (MOU) with the Center for Healing to take direct referrals for patients with legal needs. The MOU provides that the MLP will engage with all patients referred by the Center for Healing. In turn, the Center for Healing committed to collaborate with the MLP team, provide space within their clinic for confidential MLP client meetings, and offer financial support for the legal work.
The MLP designated one attorney to handle all Center for Healing referrals. To maximize the benefit of this partnership, and in furtherance of the MLP’s emphasis on integrating legal services within the care team, the MLP attorney spends time at the Center for Healing each day. This enables the attorney to engage frequently with the Center navigators who make the greatest number of referrals and establishes the attorney as a familiar figure for patients and staff alike. The MLP is located in the same building as the Center, which ensures prompt access at all times.
The MLP attorney provides both formal and informal training to Center for Healing staff regarding legal referrals. All staff are encouraged to refer possible legal issues to the MLP for evaluation. Center for Healing team members inquire with patients about potential legal issues and also identify issues through conversation. Center staff then ask patients if they are interested in receiving legal help. The Center makes referrals in-person when an MLP attorney is present, and through email if they are not.
The regular presence of an MLP attorney in the clinical space, as well as communication between patients about successful legal outcomes, has increased patients’ comfort level with disclosing legal issues for referral. Patients frequently share their appreciation of the legal services during group therapy sessions, which provides comfort for other patients considering a legal referral. In addition, the harm reduction approach of the Center team encourages patients to seek support for issues, such as legal matters, that may seem uncomfortable in a more traditional medical setting.
Representation of Patients in Criminal Matters
Shortly after commencing this partnership, the MLP decided to undertake direct representation of clients for active criminal and municipal matters. This established the Camden Coalition MLP as one of the few MLPs providing criminal defense representation.Reference Vanjani18 The MLP chose to take on those matters because we could not provide comprehensive legal support to patients overcoming substance use disorder without addressing criminal legal involvement. In other words, for the MLP, the chance of improving the patient’s health was greater if the MLP attorney could address both pressing civil and criminal issues.
Multiple factors guided the MLP toward offering criminal representation. First, there is a high rate of justice involvement among SUD patients. By carving out criminal representation from the suite of legal services offered, the MLP would be unable to address the principal legal issue facing many of the patients being treated at Cooper: In the first year, over 40% of MLP referrals concerned criminal matters. Second, the MLP emphasizes legal representation that is integrated with, and supportive of, the medical treatment provided by the clinical team. MLP representation is different from a traditional, basic, pro bono referral: The MLP’s whole-person approach is particularly valuable in the context of SUD treatment, where stigma and unconscious bias may impact the legal representation and lawyer-patient relationship.Reference Weise19 Additionally, we have observed a positive impact where our MLP brought resources and expertise in support of patients represented by public defenders.20 This provided confidence that our model — and positive outcomes — would translate to direct criminal representation.
Our objective in taking on criminal defense matters is to supplement the work of local public defenders by addressing charges frequently associated with SUD. We principally take on drug-related charges and criminal or municipal matters stemming from active addiction (e.g., shoplifting, nuisance, etc.). In the rare situation where a patient faces charges for a violent crime or other charge requiring more substantial defense resources, the MLP encourages that individual to retain the public defender.
2. Year One MLP Referrals
The MLP began taking direct referrals from the Center for Healing in February 2022. From February 2022 through January 2023, the MLP received 183 referrals from the Center. Each referred patient received at minimum a meeting or phone call, nearly all within 24 hours of referral. The level of engagement required from the MLP attorney varied across these referrals. Approximately 25% of referrals required substantive engagement over a period of weeks or months. Another 25% of referred patients needed attorney phone calls or letters to third parties to resolve their legal issues. Around 35% required “brief advice” that could be accomplished through limited in-person or telephonic engagement. The remaining referrals either elected not to pursue MLP assistance, had other counsel, or did not engage for some other reason.
Below we provide data and analysis from the first year of this partnership with respect to patient/client legal issues, as well as history of justice involvement and overdose.21
Legal Issues
SUD patients face a variety of health-harming legal needs. To maximize the benefit of our partnership for Center patients, we seek to limit or remove these obstacles to patient wellbeing.
As reflected in Exhibit 1, over 40% of Center for Healing referrals principally concerned criminal or municipal charges. These cases primarily involved low-level charges related to poverty and drug use, including drug possession and shoplifting. In addition, MLP attorneys pursued records expungements and addressed court fines and fees.
Legal Issues Referred to Camden Coalition MLP at Center for Healing - Feb. 1, 2022 to Jan. 31, 2023
Notes:
1. The MLP received a total of 189 issue referrals for 183 individual patients.
2. The Criminal/Municipal category includes open criminal matters in Superior and Municipal Courts, municipal ordinance and traffic cases, open warrants, probation/parole issues, and court fine/fee matters.
In criminal defense matters, the MLP has achieved favorable outcomes for Center for Healing participants. We attribute this to several factors, including attorneys’ insight into clients’ medical conditions, treatment, and recovery. Particularly valuable is the MLP collaboration with the Center for Healing team, both to understand medical matters and to bring evidence into court relating to clients’ recovery. An emphasis on MLP clients’ hard work and progress in their recovery, especially with the backing of treating professionals, provides for powerful advocacy.
The next largest category of Center for Healing referrals concerned housing, primarily eviction defense, which accounted for approximately 25% of matters. This area of representation began to trend higher in 2023 as pandemic-era rental assistance programs concluded and housing court backlogs receded.
The MLP has also achieved positive outcomes in many eviction matters. In some cases, the Center for Healing legal referral has eliminated the threat of eviction entirely. In other cases, MLP legal support has provided patients with additional time and the ability to negotiate their departure, avoiding a potentially catastrophic eviction.
Another 15% of referrals concerned family law or domestic violence matters, including custody, visitation, and child support issues, as well as obtaining restraining orders in cases of domestic violence. A similar percentage concerned government benefits, employment issues, and other income-related matters. In these matters, the availability of an attorney with legal experience and an understanding of patient wellbeing has proven effective in providing client-centered counsel leading to optimal outcomes.
Patient/Client Background
Available data on first-year Center for Healing MLP referrals provides insight into the background of addiction medicine patients pursuing a legal referral.
Data concerning incarceration and criminal/municipal charges underscore the importance of legal support in those areas for addiction medicine patients. Over 40% of patients referred to the MLP have been incarcerated in Camden County, New Jersey at some point. Exhibit 2 identifies 652 New Jersey charges associated with prior incarcerations by MLP-referred patients. Of those charges, the vast majority — approximately 83% — concern drug charges, disorderly persons (misdemeanor) charges, traffic offenses, theft, or probation/parole violations. If left unaddressed, these charges — many of which stem from periods of active addiction — can undermine a patient’s recovery and undo months or years of hard work.Reference Csete22
Historical Frequency of Offenses Associated with Incarceration of Center for Healing Patients Referred to MLP - Jan. 2010 to October 2022
Notes:
1. Data reflects historical charges recorded in the Camden County, New Jersey jail system for those 133 Center for Healing patients referred to the MLP from Feb. 1, 2022 to Oct. 31, 2022.
2. “Other Municipal Offenses” include other disorderly persons (misdemeanor) charges adjudicated at the Municipal Court level (e.g., loitering).
These data should encourage MLPs that are considering commencement of criminal legal representation but are wary of taking on cases involving violence. An MLP can address the vast majority of SUD patients’ legal needs by offering criminal defense representation limited to those lesser charges most closely tied to periods of active addiction.
Exhibit 3 documents the history of incarceration and overdose for patients referred to the MLP. These data indicate that incarceration and overdose levels remain consistent in the period immediately preceding referral. This is consistent with MLP experience reflecting a substantial immediate need for criminal defense representation as well as a need for counsel to address legal fallout from recent periods of substance use. The rate of incarceration among SUD patients also demonstrates the need for evidence-based addiction treatment in jails and prisons, as well as following release.Reference Finger, DeDecker and Griffin23
Historical Overdose and Jail Bookings Data for Center for Healing Patients Referred to MLP – Jan. 2016 to Jan. 2023
Notes:
1.Data is for 183 patients referred during Feb. 2022 - Jan. 2023 period.
2. Overdose data comprises cases documented in the Camden Coalition Health Information Exchange.
3. Year One Analysis
The high rate of patient referrals, complexity of referred matters, and impact of legal cases on patients’ wellbeing reinforce the need for appropriately trained and integrated legal assistance for patients around the country seeking treatment for substance use disorder. Too often, patients are expected to move forward in their recovery without assistance to address the trail of charges and legal matters resulting from years of active addiction. Similarly, patients are sometimes prevented from engaging meaningfully with their children, or are unable to escape a problematic personal relationship, even as they make great progress in their treatment. One year of this partnership has demonstrated to our team the positive impact an integrated legal partnership can have on the lives of SUD patients.
The Camden Coalition MLP and Center for Healing are commencing a formal evaluation of this work, conducted by an academic research partner, to document the impact of integrated legal services within a high-volume, high-quality addiction medicine clinic. The first step will be a rigorous, interview-based, qualitative assessment of this work, with a focus on the impact on patient wellbeing achieved through the MLP intervention. A quantitative analysis of the intervention will follow.
The medical-legal partnership model is a promising approach for addressing health-harming legal needs facing substance use disorder patients. With the Camden Coalition MLP at Cooper Health Care’s Center for Healing, we have established a model that we believe maximizes the value of these legal services. We encourage addiction medicine providers, legal services groups, and funders to make this intervention standard of care for SUD patients.
In the meantime, preliminary lessons about this partnership can be gleaned from Center for Healing staff observation and preliminary quality improvement (QI) interviews conducted with MLP clients. A Camden Coalition interviewer recorded and transcribed interviews with six MLP participants at the conclusion of their legal engagement. Three themes stand out from this early analysis: first, that MLP legal assistance increases patient independence and stability; second, that MLP engagement reduces patient anxiety; and third, that MLP engagement uplifts patients in a way not commonly associated with legal assistance.
MLP Engagement Facilitates Patient Independence
Referred patients explained that engagement with an MLP attorney enabled them to progress toward goals. One client explained:
I started calling him from jail and let him know like situations and he handled it accordingly. And you know, gave me the next steps to take from there and yeah, slowly but surely you know, things begin to get better… I was on probation and I was able to get my probation terminated completely… that was like shocking that that happened. And a lot of a lot of court cases, like I said that I had, he was able to help me get dismissed. I was able to get my own place after I was like staying with a friend sleeping on his couch… I was able to get my own place, get a new job, and I’ve been doing good ever since.24
This testimonial illustrates how legal supports can fill the void in treatment and recovery identified by the Center for Healing team. Addiction medicine patients often face legal consequences from long periods of active addiction. Supplementing medical care and wraparound support with legal assistance can help patients address these lingering issues and accelerate progress towards stability.
MLP Engagement Reduces Anxiety and Helplessness
Addiction medicine patients, like many adults, feel anxious or helpless when thinking about outstanding legal matters. Interviewed patients have expressed that MLP engagement helped to reduce anxiety and enable additional progress. For example, one client explained:
Having [counsel] help me was like the most beautiful thing in the world. It really lifted my spirits. I was able to function a little bit more… and I feel like everything was a little bit better for me after that.25
Another added:
I just wanted everybody to know like how helpful [the attorney] was and [that] these services are available to us. I don’t think many people know that. So even after addicts get clean, I think we still struggle to just like do everything ourselves because we feel like we have to.26
These words demonstrate how legal services can be an important tool for improving the mindset of addiction medicine patients. With legal barriers removed, some patients feel more confident or optimistic about their next steps.
MLP Lawyers Can Impact Clients Beyond Legal Outcomes
One key element of this partnership is the background and training of MLP attorneys. It is critical that counsel has an approach that is supportive of the patients and compatible with the referring clinical team. In some of the above comments, referred patients identify gains that go beyond legal outcomes and reflect a benefit from the approach of the attorney. This theme comes across most clearly from one client, who stated:
[Counsel] was always polite, and I would highly recommend him to anybody that I know because, for the first time in my life, I felt like somebody really cared about me and didn’t just look at me as addict or ex-addict… It makes me value not getting into trouble. You know what I mean? Like it’s a lot of work to you know, get a record expunged and everything that he did for me and I don’t take that for granted. The way he was so understanding and non-judgmental, it was just like he was talking to a person who got a speeding ticket, not like drug charges, you know. So, it just made me grateful.27
These comments capture the importance of having attorneys provide trauma-informed, client-centered lawyering. As we look to a future where addiction medicine clinics integrate legal services, those elements must take priority.
4. Conclusion
The medical-legal partnership model is a promising approach for addressing health-harming legal needs facing substance use disorder patients. With the Camden Coalition MLP at Cooper Health Care’s Center for Healing, we have established a model that we believe maximizes the value of these legal services. We encourage addiction medicine providers, legal services groups, and funders to make this intervention standard of care for SUD patients.
Given the experiences of patients seeking treatment for substance use disorders, MLPs should include criminal representation alongside traditional civil legal support in these interventions. The scope of criminal representation can be limited to ensure buy-in from partners and payers. In addition, counsel must be trained not only to handle all relevant legal matters, but to engage appropriately and effectively with referred patients and medical staff. Finally, our joint experience over the past year, and our MLP’s experience for the previous five years, counsels in favor of close integration between legal and medical partners to maximize the efficacy of any legal intervention.
Acknowledgements
The authors wish to thank Kelly Zimmerman for her research assistance.
