Introduction to the Medical-Legal Partnership Symposium Issue

Since the first medical-legal partnership (MLP) opened in 1993 at the Boston Medical Center, MLPs have increasingly become integrated into community health centers around the United States. And MLPs are in the business of growth: more than 300 MLPs are currently operating in the United States, and 59 percent of those are fewer than five years old. MLPs are collaborations between physicians and civil attorneys in which the attorneys are integrated into the health care team, and work with the patient to address civil legal needs that impact the social determinants of a patient\u27s health

Severe Brain Injury, Disability, and the Law: Achieving Justice for a Marginalized Population

Thousands of persons with severe brain injury who are minimally conscious or locked in are wrongly treated as if they are unconscious. Such individuals are unable to advocate for themselves and are typically segregated from society in hospitals or nursing homes. As a result, they constitute a class of persons who often lack access to adequate medical care, rehabilitation, and assistive devices that could aid them in communication and recovery. While this problem is often approached from a medical or scientific point of view, here we frame it as a legal issue amenable to legal remedies. This Article comprehensively explores and analyzes sources of federal, state, and international human rights law that can be leveraged- both in traditional and novel ways-to improve the lives and protect the rights of persons with severe brain injury. We argue that state laws may be the most promising basis for legal action to ameliorate the clinical marginalization and societal neglect faced by persons with severe brain injury, and to promote their recovery and reintegration into their communities

Cue-induced craving in patients with cocaine use disorder predicts cognitive control deficits toward cocaine cues

INTRODUCTION: Cue-induced craving is a clinically important aspect of cocaine addiction influencing ongoing use and sobriety. However, little is known about the relationship between cue-induced craving and cognitive control toward cocaine cues. While studies suggest that cocaine users have an attentional bias toward cocaine cues, the present study extends this research by testing if cocaine use disorder patients (CDPs) can control their eye movements toward cocaine cues and whether their response varied by cue-induced craving intensity. METHODS: Thirty CDPs underwent a cue exposure procedure to dichotomize them into high and low craving groups followed by a modified antisaccade task in which subjects were asked to control their eye movements toward either a cocaine or neutral drug cue by looking away from the suddenly presented cue. The relationship between breakdowns in cognitive control (as measured by eye errors) and cue-induced craving (changes in self-reported craving following cocaine cue exposure) was investigated. RESULTS: CDPs overall made significantly more errors toward cocaine cues compared to neutral cues, with higher cravers making significantly more errors than lower cravers even though they did not differ significantly in addiction severity, impulsivity, anxiety, or depression levels. Cue-induced craving was the only specific and significant predictor of subsequent errors toward cocaine cues. CONCLUSION: Cue-induced craving directly and specifically relates to breakdowns of cognitive control toward cocaine cues in CDPs, with higher cravers being more susceptible. Hence, it may be useful identifying high cravers and target treatment toward curbing craving to decrease the likelihood of a subsequent breakdown in control

Severe Brain Injury, Disability, and the Law: Achieving Justice for a Marginalized Population

Thousands of persons with severe brain injury who are minimally conscious or locked in are wrongly treated as if they are unconscious. Such individuals are unable to advocate for themselves and are typically segregated from society in hospitals or nursing homes. As a result, they constitute a class of persons who often lack access to adequate medical care, rehabilitation, and assistive devices that could aid them in communication and recovery. While this problem is often approached from a medical or scientific point of view, here we frame it as a legal issue amenable to legal remedies. This Article comprehensively explores and analyzes sources of federal, state, and international human rights law that can be leveraged- both in traditional and novel ways-to improve the lives and protect the rights of persons with severe brain injury. We argue that state laws may be the most promising basis for legal action to ameliorate the clinical marginalization and societal neglect faced by persons with severe brain injury, and to promote their recovery and reintegration into their communities

Integrating Permanent Supportive Housing and Co-Occurring Disorders Treatment for Individuals Who Are Homeless

OBJECTIVES: While permanent housing, addictions, and mental health treatment are often critical needs to achieve housing stability and community reintegration, few studies have systematically integrated them into a single comprehensive approach for people experiencing chronic homelessness. This pilot study examined the feasibility and preliminary outcomes of systematically integrating permanent supportive housing and an evidence-based co-occurring disorders intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION). METHODS: This single-group open pilot enrolled 107 people with co-occurring disorders experiencing chronic homelessness from two Massachusetts inner-city and rural areas. Enrolled subjects were interested in receiving permanent supportive housing along with 1 year of MISSION services. Data were collected through baseline and 6- and 12-month follow-up assessments. RESULTS: Participants (Mage = 49.52 years, SD = 10.61) were mostly male (76.6%), Caucasian (52.3%), and unemployed (86.0%), with an average of 8.34 years (SD = 8.01) of homelessness. Self-reported lifetime problems with anxiety (75.7%) and depression (76.6%) were common, as was use of alcohol (30.8%), cannabis (31.8%), and cocaine (15.9%). Almost all participants (95.3%) were placed into permanent housing, which took on average 42.6 days from enrollment (SD = 50.09). Among those placed, nearly 80% of the clients were able to retain housing through the end of the study. Overall retention was high, with 86.0% remaining in MISSION treatment until the end of the study. While there were no significant changes in rehospitalization, service utilization, or substance use, there were modest significant mental health symptom improvements from baseline to program completion. CONCLUSIONS: This pilot study suggests that co-occurring disorder interventions like MISSION are feasible to integrate with permanent supportive housing despite the somewhat differing philosophies, and preliminary data suggested substantial improvements in housing and modest improvements in mental health symptoms. While caution is warranted given the lack of a comparison group, these findings are consistent with other rigorous studies using MISSION among homeless individuals who did not receive permanent supportive housing

Increased Depression and Anxiety Symptoms are Associated with More Breakdowns in Cognitive Control to Cocaine Cues in Veterans with Cocaine Use Disorder

OBJECTIVE: Cue-elicited craving is a clinically important aspect of cocaine addiction directly linked to cognitive control breakdowns and relapse to cocaine-taking behavior. However, whether craving drives breakdowns in cognitive control toward cocaine cues in veterans, who experience significantly more co-occurring mood disorders, is unknown. The present study tests whether veterans have breakdowns in cognitive control because of cue-elicited craving or current anxiety or depression symptoms. METHODS: Twenty-four veterans with cocaine use disorder were cue-exposed, then tested on an antisaccade task in which participants were asked to control their eye movements toward cocaine or neutral cues by looking away from the cue. The relationship among cognitive control breakdowns (as measured by eye errors), cue-induced craving (changes in self-reported craving following cocaine cue exposure), and mood measures (depression and anxiety) was investigated. RESULTS: Veterans made significantly more errors toward cocaine cues than neutral cues. Depression and anxiety scores, but not cue-elicited craving, were significantly associated with increased subsequent errors toward cocaine cues for veterans. CONCLUSIONS: Increased depression and anxiety are specifically related to more cognitive control breakdowns toward cocaine cues in veterans. Depression and anxiety must be considered further in the etiology and treatment of cocaine use disorder in veterans. Furthermore, treating depression and anxiety as well, rather than solely alleviating craving levels, may prove a more effective combined treatment option in veterans with cocaine use disorder