Although parental substance use disorders have been a major reason for involvement with the child protection agency, the devastating nature of the opioid crisis has drawn national attention to the challenges that substance misuse and addiction pose for children, families, and communities. This document contextualizes the epidemic with statistical information, provides a selection of resources that underscore the key safety and permanency considerations in addressing substance abuse, highlights tools and frameworks that facilitate the collaborative action required for successful intervention, and describes some innovations and jurisdictional implementations.

Setting the stage and mapping the issue: Who is hurting?

• The United States has less than 5 percent of the world’s population yet consumes 80 percent of the global opioid supply. The number of prescriptions for opioids has increased from 76 million in 1991 to nearly 207 million in 2013.¹ 
• In 2016, 64,070 Americans died from drug overdoses, nearly double in a decade. From 2002 to 2015 there was a 2.8-fold increase in the total number of deaths from opioids.2
• Parental substance abuse is a key factor associated with children coming into foster care. AFCARS data from 2016 found that approximately 35 percent of children, or over 92,000, were removed due to parental substance abuse.³

As the National Conference of State Legislatures (2017) notes, parental substance abuse is not a new challenge for child welfare agencies, but the opioid epidemic is placing new demands on child welfare caseloads.⁴

A great deal of anecdotal information exists about the opioid epidemic and increasing foster care caseloads, but little or no data directly link the two. Here is what we do know:

• In Fiscal Year 2015, there were nearly 428,000 children in foster care in the U.S., the highest number since 2008. In the same year, nearly 270,000 children entered care, representing the highest number of children entering care since 2008.
• The number of children under the age of 1 entering foster care is increasing and has become the highest percentage, by age group, of children entering foster care, from 39,697 in 2011 to 49,234 in 2016.
• The number of children experiencing neonatal abstinence syndrome (NAS)⁵ is on the rise, from 3.4 per 1,000 hospital births in 2009 to 5.8 per 1,000 hospital births in 2012. Among infants covered by Medicaid, NAS incidence increased more than fivefold between 2004 and 2014, from 2.8 per 1000 births in 2004 to 14.4 per 1000 births in 2014.

The following three graphs⁶ represent statistics reflecting these recent trends:

Key considerations

Since the crack cocaine epidemic of the 1980s and 1990s, effective policy and practice have been advanced and reflect a new set of core themes and commitments when addressing substance abuse in the context of child welfare service delivery, including:

• Addiction is a progressive brain disease and should be addressed as such, loss of control of use is a characteristic marker of the disease.
• Relapse can be a regular step of the recovery process.
• Evidence-based treatments exist and can be adapted for jurisdictional implementation.
• Medication-Assisted Treatment has a strong evidence base and is an important part of an individual’s treatment plan, especially when combined with other evidence-based treatments.
• Whole family care that focuses on keeping children and parents together, and supports the family system instead of the individual parent or child in isolation, is essential.
• Addiction is a complex issue that requires a multifaceted, communitywide response.
• Prevention and early identification strategies are key elements of an effective service array.

The selection of resources below underscore these considerations:

Key considerations resources

Generations United, Raising the Children of the Opioid Epidemic: Solutions & Support for Grandfamilies (2016)
This report highlights key solutions and action steps to support grandfamilies raising their kin grandchildren as a result of the opioid epidemic.

National Advisory Committee on Rural Health and Human Services, Families in Crisis: The Human Service Implications of Rural Opioid Misuse (2016)
The Committee highlights the unique rural challenges related to opioid use disorder, the experiences of families in crisis, and the recommendations and promising approaches. One of the recommendations includes expanding the availability of Medication-Assisted Treatment for dealing with opioid misuse.

National Center on Substance Abuse & Child Welfare, Medication Assisted Treatment (MAT): A Component of Comprehensive Treatment for Substance Use Disorders (2013)
This PowerPoint provides an overview of substance use disorders and their impact on the brain, as well as principles of drug addiction treatment and an overview of Medication-Assisted Treatment. Considerations for child welfare policy and practice are included on slides 49-52.

Substance Abuse and Mental Health Services Administration, Drug Testing in Public Child Welfare: Practice and Policy Considerations (2010)
This guidance describes the practice and policy issues that policymakers must address to include drug testing in the comprehensive assessment and monitoring that child welfare agencies provide.

Substance Abuse and Mental Health Services Administration, State Policies in Brief: Substance Abuse During Pregnancy (2014)
This state policy scan provides information on whether states consider substance abuse during pregnancy a criminal act, child abuse, or grounds for civil commitment; whether states require testing or reporting when abuse is suspected; and what drug treatment is available.

Tools and frameworks for collaborative action

As the opioid epidemic has spread across the country, it has cut into every sector of the society, necessitating a comprehensive, multisystem approach. Partnerships between child welfare, law enforcement, public health, substance use disorder, mental health, schools, the courts, and more are not only necessary but critical to achieve better outcomes for vulnerable children and families. In addition, new opportunities for training and professional development are needed to support this approach.

Children and Family Futures, The Collaborative Practice Model For Family Recovery, Safety, and Stability (2011)
This document offers 10 system linkage elements that child welfare, substance abuse treatment, juvenile court dependency systems, and other agencies/providers should use to collaborate with one another. It provides examples of collaborative practice in each element, and can be used to guide other jurisdictional efforts.

Deloitte Center for Government Insights, Fighting the Opioid Crisis: An Ecosystem Approach to a Wicked Problem (2016)
This report uses the concept of an “ecosystem” as a metaphor for the type of collaboration needed to take on the opioid epidemic, and offers five common elements that all successful opioid collaborations should have.

National Center on Substance Abuse & Child Welfare, Online Tutorials (2015)

• A Guide for Substance Abuse Treatment Professionals

• A Guide for Child Welfare Professionals

• A Guide for Legal Professionals

  • These three free tutorials are designed to support and facilitate effective collaboration between the child welfare system, the substance abuse treatment system, and the courts.

National Governors Association, Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States (2016)
This tool is designed to help states respond to the growing crisis of opioid misuse and overdose, by assessing current capacity to address the problem, selecting evidence-based and promising strategies, such as Medication-Assisted Treatment, and evaluating their work and the effectiveness of those strategies.

National League of Cities & National Association of Counties, A Prescription for Action: Local Leadership in Ending the Opioid Crisis (2016)
This report provides recommendations for:

• leadership,
• education and prevention,
• treatment, including increasing the availability of Medication-Assisted Treatment, and
• public safety and law enforcement. Several of the recommendations are accompanied by existing local practices from cities and counties.

Substance Abuse and Mental Health Services Administration, A Collaborative Approach to the Treatment of Pregnant Women With Opioid Use Disorders: Practice and Policy Considerations for Child Welfare, Collaborating Medical, and Service Providers (2016)
This publication highlights the extent of opioid use by pregnant women and the effects on infants, evidence-based treatment approaches, including Medication-Assisted Treatment, an in-depth case study of adoption/adaptation by other jurisdictions, and a guide for collaborative planning that includes needs and gaps analysis tools.

U.S. Department of Health & Human Services, Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities (2017)
This toolkit, developed by the HHS Center for Faith-Based and Neighborhood Partnerships, contains practical steps organizations can take to help those suffering opioid abuse disorders.

Innovations and jurisdictional examples

Five recent compilations of state and local strategies address the opioid epidemic and its impact on children and families:

1. The National Center for Substance Abuse and Child Welfare has developed a pair of documents – In-Depth Technical Assistance (IDTA)⁷ to selected sites since 2007, and Substance Exposed Infants In-Depth Technical Assistance (SEI-IDTA) – ⁸ with all of the tools and resources that have been developed by selected sites for use and adaptation.
2. The Association of Maternal and Child Health Programs’ The Opioid Epidemic: Implications for MCH Populations (2017)⁹ provides an overview of the scope of the epidemic, national policy efforts to address it, and state and local strategies for opioid abuse prevention and treatment among maternal and child health populations.
3. The National Conference of State Legislatures’ Substance Abuse and Child Welfare Programs in States and Resources (2017)¹⁰ contains a list of various state policies and programs designed to address the intersection of substance use and child welfare.
4. The Hearing before the House Ways and Means Subcommittee on Human Resources, The Heroin Epidemic and Parental Substance Abuse: Using Evidence and Data to Protect Kids from Harm (2016),¹¹ highlights a range of efforts in jurisdictions across the country.

Additional examples

Below are additional examples of jurisdictional and community approaches to address substance abuse within the child welfare context:

Connecticut

Family Stability Pay for Success Project
The Connecticut Family Stability Pay for Success Project promotes family stability and reduces parental substance use for DCF-involved families. The initiative mobilizes $11.2 million to expand Family-Based Recovery’s services to an additional 500 Connecticut families.

Kentucky

Kentucky START
This California Evidence-Based Clearinghouse for Child Welfare (CEBC) page provides a description of the Kentucky START Program, including the essential program components, required provider qualifications, education and training resources, and considerations for implementation. It also summarizes current published research on Kentucky START.

Louisiana

Facing Addiction
As a Facing Addiction pilot community-driven project led by Capital Area Human Services (CAHS), Baton Rouge grassroots community groups, organizations, and activists will create a public response and action plan for addiction programming.

New Hampshire

The Opiate Public Health Crisis
This document describes NH’s comprehensive response to this crisis, including Medication-Assisted Treatment, additional efforts and next steps, and describes the Division for Children, Youth and Families’ related staffing enhancements and training.

Vermont

Vermont’s Child and Recovering Mothers (CHARM) Collaborative
Vermont’s CHARM collaborative is a multidisciplinary group of agencies across Vermont serving women with opiate addiction and their infants. A discussion of Medication-Assisted Treatment is included.

Wisconsin

Wisconsin’s Heroin Epidemic: Strategies and Solutions
This report includes recommendations organized into five pillars to provide comprehensive approaches at the community, municipality, organizational, county, tribal, and state levels, with a focus on mothers and children. Medication-Assisted Treatment is included as part of the Treatment Pillar.

 

1 Bingham, M.K., Cooper, T., & Hough, M.L. (2016). Fighting the Opioid Crisis: An Ecosystem Approach to a Wicked Problem. A report from the Deloitte Center for Government Insights. Retrieved from: https://www2.deloitte.com/content/dam/insights/us/articles/fighting-opioid-crisis-heroin-abuse-ecosystem-approach/DUP_3406_Opioid-ecosystem_MASTER_FINAL.pdf
2 Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
3 U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). The 2016 AFCARS Report. Retrieved from: https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport27.pdf
4 The National Conference of State Legislatures. (2017). Substance Abuse & Child Welfare Resources. Retrieved from http://www.ncsl.org/research/human-services/substance-abuse-and-child-welfare-resources.aspx
5 NAS is a constellation of problems that occur in newborns who were exposed to addictive illegal or prescription drugs while in the mother’s womb.
6 The National Center on Substance Abuse and Child Welfare. (2017). Child Welfare and Treatment Statistics. SAMHSA, US DHHS. Retrieved from https://ncsacw.samhsa.gov/topics/parental-substance-use-disorder.aspx
7 The National Center on Substance Abuse and Child Welfare. (2017). In-depth Technical Assistance. Retrieved from https://ncsacw.samhsa.gov/technical/idta.aspx
8 The National Center on Substance Abuse and Child Welfare. (2017). Substance Exposed Infants In-Depth Technical Assistance. SAMHSA, US DHHS. Retrieved from https://ncsacw.samhsa.gov/technical/idta.aspx
9 Association of Maternal & Child Health Programs. (2017). The Opioid Epidemic: Implications for MCH Populations. Washington, DC. Retrieved from https://amchp.org/?s=opioid+epidemic
10 The National Conference of State Legislatures. (2017). Substance Abuse and Child Welfare Programs in States and Resources. Retrieved from http://legislature.vermont.gov/assets/Documents/2018/WorkGroups/House%20Human%20Services/Agency%20of%20Human%20Services/DCF/Family%20Services%20Division/W~Meghan%20McCann~Substance%20Abuse%20and%20Child%20Welfare%20Programs%20in%20States%20and%20Resources~4-13-2017.pdf
11 The Committee on Ways and Means. (2017). Hearing on “The Heroin Epidemic and Parental Substance Abuse: Using Evidence and Data to Protect Kids from Harm.” Washington, DC. Retrieved from https://docs.house.gov/meetings/WM/WM03/20160907/105262/HHRG-114-WM03-Transcript-20160907.pdf