Notes: Substance Use, the Opioid Epidemic, and the Child Welfare System — Key Findings (ASPE, 2018)
Introduction
Context: After more than a decade of declines, national foster care caseloads rose starting in 2012. Between 2012 and 2016, foster care caseloads nationally rose by 10 percent from 397,600 to 437,500. Over this period, 36 states experienced caseload increases; six states saw increases of more than 50 percent. The six states are: Alaska, Georgia, Minnesota, Indiana, Montana, and New Hampshire.
Common assumption: Parental substance use (prescription drugs, illicit drugs, alcohol), especially opioids, is a primary driver of increased foster care placements. Prior to this study, national-level empirical evidence was limited.
Study purpose and design: ASPE conducted a mixed-methods study combining quantitative analysis and qualitative data collection to understand how substance use interacts with the child welfare system. Mathematica Policy Research assisted in collecting/synthesizing most qualitative interviews.
Focus of the brief: Key takeaways from the mixed methods study on how substance use affects child welfare systems across the country.
Top-line findings (3 core themes):
Caseloads: Nationally, higher overdose death rates and higher drug-related hospitalizations are statistically related to higher child welfare caseloads (including reports, substantiations, and foster care placements). Counties with higher substance-use indicators tend to have higher caseloads and more complex/severe cases.
Availability and use of treatment: Major challenges include limited family-friendly treatment options and widespread misunderstandings about how treatment works, including medication-assisted treatment (MAT), and lack of guidelines for integrating treatment into child welfare practice.
System response: Agencies and partners struggle with inconsistent substance-use assessments, collaboration barriers with treatment providers, and shortages of foster homes and trained staff, undermining effective responses to families.
How to read the figures mentioned: The brief references Figures 1–3 that illustrate relationships between substance-use indicators and child welfare caseloads; the figures summarize nationwide trends and county-level variation.
How We Conducted the Study
Overall design: A mixed-methods study combining statistical modeling with qualitative data collection to answer: how does parental substance use currently affect child welfare systems?
Quantitative component:
Indicators of substance use: two measures used were
Overdose death rates (drug overdose deaths)
Drug hospitalizations (hospital stays and emergency department visits related to substances, excluding alcohol and tobacco)
Outcome measures: child welfare caseload rates, including reports of maltreatment, substantiated maltreatment, and foster care entry rates.
Modeling approach: used multi-year county data, controlling for a range of demographic, economic, and other confounders that could bias the relationship between substance use and child welfare caseloads.
Qualitative component:
Sites chosen for high opioid sales (volume of morphine equivalents) and high overdose deaths, with varying changes in foster care rates.
Data collection: interviews and focus groups with 188 respondents in total, including child welfare administrators and practitioners, substance-use treatment administrators and practitioners, judges and other legal professionals, law enforcement, and other service providers.
Sites: Clark, Floyd, and Jefferson Counties (IN); Bristol County (MA); Marion, Pearl River, Hancock, Harrison (MS); Guilford (NC); Santa Fe (NM); Wagoner, Tulsa, and Cherokee Nation (OK); Multnomah and Washington (OR); Hawkins, Sullivan, and Washington (TN); Salt Lake (UT); Rutland and Bennington (VT); Cabell, McDowell, and Raleigh (WV).
Note on generalizability: qualitative findings are not nationally generalizable; interviews reflect local experiences and perceptions.
Data limitations and scope:
A companion brief provides methodological details (substance-use indicators, modeling approach, etc.).
The brief emphasizes patterns and contextual themes rather than universal national-level conclusions.
Key methodological detail (sites and respondents): 25 sites; 188 respondents; data collected 2015–2017; emphasis on high-opioid-sales areas with diverse demographic and caseload trends.
Relationship Between Substance Use Indicators and Child Welfare Caseloads
General nationwide relationship:
Foster care entries and overdose deaths are related nationally, but show substantial within-country variation.
In 2012–2016, overdose deaths rose while foster care entries began to rise around 2012 onward, with overdose deaths climbing faster over time.
County-level variation and regional patterns:
Some counties show a stronger relationship between overdose deaths and foster care entries (see Figure 2 in the report). By 2016, Appalachia, parts of the Pacific Northwest, parts of the Southwest, Oklahoma, and New England exhibited a particularly strong positive relationship between overdose death rates and foster care entry rates.
Other regions did not show a strong relationship in 2016, indicating substantial heterogeneity across counties.
Confounding factors:
Poverty is a strong predictor of both child welfare involvement and substance use; not accounting for poverty could mask the true relationship.
The study used models that account for such confounders to better estimate the relationship between substance use indicators and caseloads.
Quantitative key findings (nationwide averages):
A 10% increase in overdose death rate → approximately a 4.4% increase in foster care entry rate. ext{If } rac{ ext{OD deaths}{ ext{new}}- ext{OD deaths}{ ext{old}}}{ ext{OD deaths}{ ext{old}}}=0.10 ightarrow rac{ ext{FC entries}{ ext{new}}- ext{FC entries}{ ext{old}}}{ ext{FC entries}{ ext{old}}}
oughly=0.044.A 10% increase in drug-related hospitalizations → approximately a 2.9% increase in foster care entry rate. 10\% ext{ increase in hospitalizations}
ightarrow 2.9\% \text{increase in FC entries}.
Relationship with maltreatment metrics (Figure 3 reference):
Higher overdose death rates predicted higher rates of maltreatment reports and substantiated maltreatment reports.
A 10% increase in overdose death rates is associated with a 1.8% increase in the proportion of maltreatment reports that are placed in foster care. ext{OD increase }10\\%
ightarrow ext{placement increase }=1.8\%.
Case severity patterns:
As cases move from report to substantiation to foster care placement, the relationship with substance use becomes stronger, indicating that higher substance-use indicators are associated with more severe child welfare outcomes.
Substance-type comparisons in hospitalizations:
Opioids, stimulants (including cocaine/methamphetamine), and hallucinogens all show comparable relationships with foster care entry rates when considering their hospitalization rates, despite varying prevalence.
In the average county, a 10% increase in hospitalizations due to any of these substance types corresponds to ~2% increase in foster care entry rates. This increase is smaller than the relationship for all drug-related hospitalizations as a category.
Alcohol-related hospitalizations, though more prevalent than opioid hospitalizations, had a slightly stronger relationship with foster care entry: a 10% increase in alcohol-related hospitalizations predicted a 2.7% increase in foster care entry rates. 10\% ext{ increase in alcohol-related hospitalizations}
ightarrow 2.7\% \text{increase in FC entries}.
Additional contextual findings:
The opioid epidemic appears to affect families across a broader range of demographic groups than previous drug epidemics. This is supported by trends showing increases in heroin use among demographic groups that historically had lower heroin-use rates (doubling among women; more than doubling among non-Hispanic whites; Jones et al., 2015; 2017).
The study notes that different substances have different prevalence but similar relationships with foster care entry in many counties, underscoring that any substance use heightens risk to children, not just opioids.
Treatment Needs and Challenges in the Child Welfare System
Scope of the problem (variation across sites):
While substance use is a serious issue in all sites, some sites faced broader drug epidemics beyond opioids (e.g., methamphetamine).
Polysubstance use (use of multiple substances) is common and complicates treatment and recovery.
Interrelated parent and family issues:
Parents presenting with substance use disorders often have co-occurring challenges: domestic violence, mental illness, and long histories of trauma.
Addressing substance use alone is unlikely to achieve desired child welfare outcomes; reunification requires addressing family-level risks and needs (e.g., family therapy, parenting skills, child development services, domestic violence interventions).
Perceptions of root causes:
Many communities view the opioid epidemic as rooted in diminished economic opportunities, unresolved emotional pain from adverse experiences, and hopelessness, which initially drives substance use as an escape.
Temporal trends and ground realities:
By 2017, informants reported that local conditions had deteriorated compared with 2015; some places that saw decreases in foster care through 2015 reported increases thereafter.
Treatment system challenges:
Timeliness: Substance-use assessments and treatment initiation often lag behind placement decisions; timeliness is a persistent concern.
Treatment matching: Referral to programs matched to the client’s needs was often not feasible due to shortages; clients received whatever services were available, which may not fit needs.
Repeated detoxification and lack of ongoing treatment; instances of self-help programs without clinical treatment.
Understanding MAT: Widespread misunderstandings and skepticism about Medication-Assisted Treatment (MAT) persist in child welfare and court settings.
MAT: evidence and misperceptions:
MAT combines medication (e.g., methadone, buprenorphine) with counseling and behavioral therapies; evidence shows MAT is more effective for opioid use disorder and reduces overdoses and infections (e.g., HIV, hepatitis C).
Despite evidence, some judges and caseworkers expect rapid tapering or view long-term MAT as incompatible with parenting; some providers limit MAT (e.g., providing buprenorphine without counseling) or favor non-MAT approaches.
Buprenorphine/diversion concerns: Buprenorphine is perceived as at risk of abuse/diversion; some cases involve diversion due to insurance gaps or stigma leading to self-medication on the black market.
Under some circumstances, clients may use MAT to satisfy case plans while continuing to misuse other substances (e.g., methamphetamine, benzodiazepines).
While views vary, a substantial portion of professionals see MAT as offering the best chance for reunification for parents with opioid-use disorders.
Substance-use assessment and family-friendly treatment:
Assessment practices are often inconsistent or inadequate to identify extent/type of substance use and its impact on safety.
Family-friendly treatment options (those that support parenting and family involvement) are limited and frequently residential; outpatient family-friendly programs are rare.
Co-located, in-house substance-use specialists within child welfare agencies were used in some communities to shorten assessment timelines and align treatment with child welfare goals.
Some communities bypass traditional treatment systems by insourcing assessment/treatment within child welfare agencies or partnering with local public behavioral health agencies; these arrangements improved timeliness and alignment with child safety concerns.
Financing and access to treatment:
In some sites, child welfare agencies pay for or arrange treatment due to limited publicly funded options.
Medicaid expansion in some places improved access to treatment, and child welfare staff helped clients obtain Medicaid-funded services; however, there is concern that scaling back Medicaid expansion or making treatment optional could harm access.
MAT access is often hindered by Medicaid payer acceptance (some physicians do not accept Medicaid for MAT services).
Child Welfare Response: Practice and Resource Issues
Scope of the problem for agencies and caseworkers:
Agencies and caseworkers are overwhelmed by caseload volume, limited treatment resources, and the magnitude of the problem.
High stress, burnout, turnover; concerns about safety and violence against staff; reports of safety emergencies requiring police intervention in some sites.
Exposure to hazardous substances (e.g., methamphetamine production) heightens worker safety concerns.
Foster-home shortages and placement challenges:
Worsening shortages of foster homes; caseloads lead to longer stays in care, making it harder to accept new placements.
Children are often placed far from parents; large sibling groups are hard to place together; multigenerational substance use complicates kinship placements.
Caseworker and agency perspectives on outcomes and timelines:
Pessimism about family success: many staff believe serious substance misuse cases require removal and are likely to end in termination of parental rights, especially for substance-exposed newborns.
Marijuana-related concerns: with marijuana legalization and increased medical marijuana use, agencies face more cases where substance-use concerns are central but policy applications vary; some systems see differential response as inappropriate for significant substance-use cases due to recovery unpredictability and severity.
Adoption and Safe Families Act (ASFA) timelines: generally supported, with some discretion by judges to extend timelines when progress is being made; timeliness of reunification remains a challenge when parental recovery is slow.
Permanency decisions: agencies may petition to terminate parental rights after 15 of the previous 22 months in foster care, with some flexibility observed when families are making progress toward recovery.
Collaboration challenges:
Barriers to cross-system data sharing (confidentiality rules), misaligned missions/priorities, and tensions between engaging clients in treatment and clients’ mistrust of child protective services.
Cross-state issues complicate cases near state borders (foster care placements across state lines, access to prescription drug monitoring, Medicaid payment for out-of-state treatment).
Conclusion
Key takeaways:
Increased levels of substance use (not limited to opioids) have devastated many American families and affected the child welfare system. National foster care caseloads rose 10% from 2012 to 2016; nine of 25 counties saw increases of more than 50% from 2012 to 2015.
There is substantial variation across states and counties; the study focuses on areas hardest hit by substance use and opioid sales.
A positive note is that professionals recognize substance-use disorders as chronic diseases, not moral failures, and seek better treatment options. Family treatment drug courts and other justice-system interventions have engaged judges and court personnel to support treatment, recovery, and reunification.
Cautions:
Findings are not necessarily representative of the nation as a whole; the study highlights patterns in communities severely affected by substance use.
The current crisis extends beyond opioids and involves broader social and economic determinants of health.
Real-world relevance and implications:
Emphasizes the need for timely, integrated treatment and child welfare practice that addresses co-occurring issues (domestic violence, mental health, trauma).
Highlights policy considerations around Medicaid expansion, MAT implementation, and cross-system collaboration to improve outcomes for families involved with child welfare.
Final note on policy context:
The brief situates its findings within the broader literature on opioid use, MAT effectiveness, and child welfare strategies, citing key sources (e.g., Connery 2015; Jones 2015, 2017; Lofwall & Walsh 2014; Tsui et al. 2014) to support treatment approaches and outcomes.
References and Acknowledgements (summary)
Acknowledges field participants and Mathematica Policy Research for data collection.
References include work on MAT efficacy, demographic trends among heroin users, buprenorphine diversion, NAS trends, and infection risk reductions with MAT.
Core cited works (selected):
Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence. Harvard Review of Psychiatry.
Jones, C. M. (2017). The paradox of decreasing nonmedical opioid analgesic use and increasing abuse or dependence. Addictive Behaviors.
Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015). Vital signs: Demographic and substance use trends among heroin users. MMWR.
Lofwall, M. R., & Walsh, S. L. (2014). Buprenorphine diversion and misuse. Journal of Addiction Medicine.
Lynch, S., Sherman, L., Snyder, S., & Mattson, M. (2018). NAS trends. Children & Youth Services Review.
Tsui, J. I., et al. (2014). MAT and reduced hepatitis C infection risk. JAMA Internal Medicine.
Introduction
Context: After more than a decade of declines, national foster care caseloads rose starting in 2012. Between 2012 and 2016, foster care caseloads nationally rose by 10 percent from 397,600 to 437,500. Over this period, 36 states experienced caseload increases; six states saw increases of more than 50 percent. The six states are: Alaska, Georgia, Minnesota, Indiana, Montana, and New Hampshire.
Common assumption: Parental substance use (prescription drugs, illicit drugs, alcohol), especially opioids, is a primary driver of increased foster care placements. Prior to this study, national-level empirical evidence was limited.
Study purpose and design: ASPE conducted a mixed-methods study combining quantitative analysis and qualitative data collection to understand how substance use interacts with the child welfare system. Mathematica Policy Research assisted in collecting/synthesizing most qualitative interviews.
Focus of the brief: Key takeaways from the mixed methods study on how substance use affects child welfare systems across the country.
Top-line findings (3 core themes):
Caseloads: Nationally, higher overdose death rates and higher drug-related hospitalizations are statistically related to higher child welfare caseloads (including reports, substantiations, and foster care placements). Counties with higher substance-use indicators tend to have higher caseloads and more complex/severe cases.
Availability and use of treatment: Major challenges include limited family-friendly treatment options and widespread misunderstandings about how treatment works, including medication-assisted treatment (MAT), and lack of guidelines for integrating treatment into child welfare practice.
System response: Agencies and partners struggle with inconsistent substance-use assessments, collaboration barriers with treatment providers, and shortages of foster homes and trained staff, undermining effective responses to families.
How to read the figures mentioned: The brief references Figures 1–3 that illustrate relationships between substance-use indicators and child welfare caseloads; the figures summarize nationwide trends and county-level variation.
How We Conducted the Study
Overall design: A mixed-methods study combining statistical modeling with qualitative data collection to answer: how does parental substance use currently affect child welfare systems?
Quantitative component:
Indicators of substance use: two measures used were
Overdose death rates (drug overdose deaths)
Drug hospitalizations (hospital stays and emergency department visits related to substances, excluding alcohol and tobacco)
Outcome measures: child welfare caseload rates, including reports of maltreatment, substantiated maltreatment, and foster care entry rates.
Modeling approach: used multi-year county data, controlling for a range of demographic, economic, and other confounders that could bias the relationship between substance use and child welfare caseloads.
Qualitative component:
Sites chosen for high opioid sales (volume of morphine equivalents) and high overdose deaths, with varying changes in foster care rates.
Data collection: interviews and focus groups with 188 respondents in total, including child welfare administrators and practitioners, substance-use treatment administrators and practitioners, judges and other legal professionals, law enforcement, and other service providers.
Sites: Clark, Floyd, and Jefferson Counties (IN); Bristol County (MA); Marion, Pearl River, Hancock, Harrison (MS); Guilford (NC); Santa Fe (NM); Wagoner, Tulsa, and Cherokee Nation (OK); Multnomah and Washington (OR); Hawkins, Sullivan, and Washington (TN); Salt Lake (UT); Rutland and Bennington (VT); Cabell, McDowell, and Raleigh (WV).
Note on generalizability: qualitative findings are not nationally generalizable; interviews reflect local experiences and perceptions.
Data limitations and scope:
A companion brief provides methodological details (substance-use indicators, modeling approach, etc.).
The brief emphasizes patterns and contextual themes rather than universal national-level conclusions.
Key methodological detail (sites and respondents): 25 sites; 188 respondents; data collected 2015–2017; emphasis on high-opioid-sales areas with diverse demographic and caseload trends.
Relationship Between Substance Use Indicators and Child Welfare Caseloads
General nationwide relationship:
Foster care entries and overdose deaths are related nationally, but show substantial within-country variation.
In 2012–2016, overdose deaths rose while foster care entries began to rise around 2012 onward, with overdose deaths climbing faster over time.
County-level variation and regional patterns:
Some counties show a stronger relationship between overdose deaths and foster care entries (see Figure 2 in the report). By 2016, Appalachia, parts of the Pacific Northwest, parts of the Southwest, Oklahoma, and New England exhibited a particularly strong positive relationship between overdose death rates and foster care entry rates.
Other regions did not show a strong relationship in 2016, indicating substantial heterogeneity across counties.
Confounding factors:
Poverty is a strong predictor of both child welfare involvement and substance use; not accounting for poverty could mask the true relationship.
The study used models that account for such confounders to better estimate the relationship between substance use indicators and caseloads.
Quantitative key findings (nationwide averages):
A 10% increase in overdose death rate → approximately a 4.4% increase in foster care entry rate. \text{If } \frac{\text{OD deaths}{\text{new}}- \text{OD deaths}{\text{old}}}{\text{OD deaths}{\text{old}}}=0.10 \Rightarrow \frac{\text{FC entries}{\text{new}}- \text{FC entries}{\text{old}}}{\text{FC entries}{\text{old}}} \approx 0.044.
A 10% increase in drug-related hospitalizations → approximately a 2.9% increase in foster care entry rate. 10\% \text{ increase in hospitalizations} \Rightarrow 2.9\% \text{ increase in FC entries}.
Relationship with maltreatment metrics (Figure 3 reference):
Higher overdose death rates predicted higher rates of maltreatment reports and substantiated maltreatment reports.
A 10% increase in overdose death rates is associated with a 1.8% increase in the proportion of maltreatment reports that are placed in foster care. \text{OD increase } 10\% \Rightarrow \text{placement increase } = 1.8\%.
Case severity patterns:
As cases move from report to substantiation to foster care placement, the relationship with substance use becomes stronger, indicating that higher substance-use indicators are associated with more severe child welfare outcomes.
Substance-type comparisons in hospitalizations:
Opioids, stimulants (including cocaine/methamphetamine), and hallucinogens all show comparable relationships with foster care entry rates when considering their hospitalization rates, despite varying prevalence.
In the average county, a 10% increase in hospitalizations due to any of these substance types corresponds to ~2% increase in foster care entry rates. This increase is smaller than the relationship for all drug-related hospitalizations as a category.
Alcohol-related hospitalizations, though more prevalent than opioid hospitalizations, had a slightly stronger relationship with foster care entry: a 10% increase in alcohol-related hospitalizations predicted a 2.7% increase in foster care entry rates. 10\% \text{ increase in alcohol-related hospitalizations} \Rightarrow 2.7\% \text{ increase in FC entries}.
Additional contextual findings:
The opioid epidemic appears to affect families across a broader range of demographic groups than previous drug epidemics. This is supported by trends showing increases in heroin use among demographic groups that historically had lower heroin-use rates (doubling among women; more than doubling among non-Hispanic whites; Jones et al., 2015; 2017).
The study notes that different substances have different prevalence but similar relationships with foster care entry in many counties, underscoring that any substance use heightens risk to children, not just opioids.
Treatment Needs and Challenges in the Child Welfare System
Scope of the problem (variation across sites):
While substance use is a serious issue in all sites, some sites faced broader drug epidemics beyond opioids (e.g., methamphetamine).
Polysubstance use (use of multiple substances) is common and complicates treatment and recovery.
Interrelated parent and family issues:
Parents presenting with substance use disorders often have co-occurring challenges: domestic violence, mental illness, and long histories of trauma.
Addressing substance use alone is unlikely to achieve desired child welfare outcomes; reunification requires addressing family-level risks and needs (e.g., family therapy, parenting skills, child development services, domestic violence interventions).
Perceptions of root causes:
Many communities view the opioid epidemic as rooted in diminished economic opportunities, unresolved emotional pain from adverse experiences, and hopelessness, which initially drives substance use as an escape.
Temporal trends and ground realities:
By 2017, informants reported that local conditions had deteriorated compared with 2015; some places that saw decreases in foster care through 2015 reported increases thereafter.
Treatment system challenges:
Timeliness: Substance-use assessments and treatment initiation often lag behind placement decisions; timeliness is a persistent concern.
Treatment matching: Referral to programs matched to the client’s needs was often not feasible due to shortages; clients received whatever services were available, which may not fit needs.
Repeated detoxification and lack of ongoing treatment; instances of self-help programs without clinical treatment.
Understanding MAT: Widespread misunderstandings and skepticism about Medication-Assisted Treatment (MAT) persist in child welfare and court settings.
MAT: evidence and misperceptions:
MAT combines medication (e.g., methadone, buprenorphine) with counseling and behavioral therapies; evidence shows MAT is more effective for opioid use disorder and reduces overdoses and infections (e.g., HIV, hepatitis C).
Despite evidence, some judges and caseworkers expect rapid tapering or view long-term MAT as incompatible with parenting; some providers limit MAT (e.g., providing buprenorphine without counseling) or favor non-MAT approaches.
Buprenorphine/diversion concerns: Buprenorphine is perceived as at risk of abuse/diversion; some cases involve diversion due to insurance gaps or stigma leading to self-medication on the black market.
Under some circumstances, clients may use MAT to satisfy case plans while continuing to misuse other substances (e.g., methamphetamine, benzodiazepines).
While views vary, a substantial portion of professionals see MAT as offering the best chance for reunification for parents with opioid-use disorders.
Substance-use assessment and family-friendly treatment:
Assessment practices are often inconsistent or inadequate to identify extent/type of substance use and its impact on safety.
Family-friendly treatment options (those that support parenting and family involvement) are limited and frequently residential; outpatient family-friendly programs are rare.
Co-located, in-house substance-use specialists within child welfare agencies were used in some communities to shorten assessment timelines and align treatment with child welfare goals.
Some communities bypass traditional treatment systems by insourcing assessment/treatment within child welfare agencies or partnering with local public behavioral health agencies; these arrangements improved timeliness and alignment with child safety concerns.
Financing and access to treatment:
In some sites, child welfare agencies pay for or arrange treatment due to limited publicly funded options.
Medicaid expansion in some places improved access to treatment, and child welfare staff helped clients obtain Medicaid-funded services; however, there is concern that scaling back Medicaid expansion or making treatment optional could harm access.
MAT access is often hindered by Medicaid payer acceptance (some physicians do not accept Medicaid for MAT services).
Child Welfare Response: Practice and Resource Issues
Scope of the problem for agencies and caseworkers:
Agencies and caseworkers are overwhelmed by caseload volume, limited treatment resources, and the magnitude of the problem.
High stress, burnout, turnover; concerns about safety and violence against staff; reports of safety emergencies requiring police intervention in some sites.
Exposure to hazardous substances (e.g., methamphetamine production) heightens worker safety concerns.
Foster-home shortages and placement challenges:
Worsening shortages of foster homes; caseloads lead to longer stays in care, making it harder to accept new placements.
Children are often placed far from parents; large sibling groups are hard to place together; multigenerational substance use complicates kinship placements.
Caseworker and agency perspectives on outcomes and timelines:
Pessimism about family success: many staff believe serious substance misuse cases require removal and are likely to end in termination of parental rights, especially for substance-exposed newborns.
Marijuana-related concerns: with marijuana legalization and increased medical marijuana use, agencies face more cases where substance-use concerns are central but policy applications vary; some systems see differential response as inappropriate for significant substance-use cases due to recovery unpredictability and severity.
Adoption and Safe Families Act (ASFA) timelines: generally supported, with some discretion by judges to extend timelines when progress is being made; timeliness of reunification remains a challenge when parental recovery is slow.
Permanency decisions: agencies may petition to terminate parental rights after 15 of the previous 22 months in foster care, with some flexibility observed when families are making progress toward recovery.
Collaboration challenges:
Barriers to cross-system data sharing (confidentiality rules), misaligned missions/priorities, and tensions between engaging clients in treatment and clients’ mistrust of child protective services.
Cross-state issues complicate cases near state borders (foster care placements across state lines, access to prescription drug monitoring, Medicaid payment for out-of-state treatment).
Conclusion
Key takeaways:
Increased levels of substance use (not limited to opioids) have devastated many American families and affected the child welfare system. National foster care caseloads rose 10% from 2012 to 2016; nine of 25 counties saw increases of more than 50% from 2012 to 2015.
There is substantial variation across states and counties; the study focuses on areas hardest hit by substance use and opioid sales.
A positive note is that professionals recognize substance-use disorders as chronic diseases, not moral failures, and seek better treatment options. Family treatment drug courts and other justice-system interventions have engaged judges and court personnel to support treatment, recovery, and reunification.
Cautions:
Findings are not necessarily representative of the nation as a whole; the study highlights patterns in communities severely affected by substance use.
The current crisis extends beyond opioids and involves broader social and economic determinants of health.
Real-world relevance and implications:
Emphasizes the need for timely, integrated treatment and child welfare practice that addresses co-occurring issues (domestic violence, mental health, trauma).
Highlights policy considerations around Medicaid expansion, MAT implementation, and cross-system collaboration to improve outcomes for families involved with child welfare.
Final note on policy context:
The brief situates its findings within the broader literature on opioid use, MAT effectiveness, and child welfare strategies, citing key sources (e.g., Connery 2015; Jones 2015, 2017; Lofwall & Walsh 2014; Tsui et al. 2014) to support treatment approaches and outcomes.
References and Acknowledgements (summary)
Acknowledges field participants and Mathematica Policy Research for data collection.
References include work on MAT efficacy, demographic trends among heroin users, buprenorphine diversion, NAS trends, and infection risk reductions with MAT.
Core cited works (selected):
Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence. Harvard Review of Psychiatry.
Jones, C. M. (2017). The paradox of decreasing nonmedical opioid analgesic use and increasing abuse or dependence. Addictive Behaviors.
Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015). Vital signs: Demographic and substance use trends among heroin users. MMWR.
Lofwall, M. R., & Walsh, S. L. (2014). Buprenorphine diversion and misuse. Journal of Addiction Medicine.
Lynch, S., Sherman, L., Snyder, S., & Mattson, M. (2018). NAS trends. Children & Youth Services Review.
Tsui, J. I., et al. (2014). MAT and reduced hepatitis C infection risk. JAMA Internal Medicine.