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Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
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Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs
Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
Opioid Misuse, Labor Market Outcomes, and Means-Tested Public Expenditures: A Conceptual Framework
Joel E. Segel, PhD; Yunfeng Shi, PhD; John R. Moran, PhD; and Dennis P. Scanlon, PhD
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Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
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Laura Fassbender, BPH; Gwendolyn B. Zander, Esq; and Rachel L. Levine, MD
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Alonzo L. Plough, PhD, MPH

Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs

Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
The negative impact of opioids on those who misuse them has been widely documented. Despite significant spillover effects in the form of elevated rates of child maltreatment and child welfare system (CWS) involvement for children affected by parental opioid misuse, the public costs of opioid misuse to the CWS remain largely undocumented. This work seeks to understand the value and limitations of public data in estimating the costs of the opioid epidemic on the CWS. National data from federal sources are combined with best estimates of the association between opioid misuse and child services system utilization. The limitations of this work are explored, and future research priorities are outlined. Ultimately, this work illustrates the need to (1) improve data quality related to parental opioid misuse and CWS linkages; (2) better estimate the number of children and families coming into contact with the CWS as a result of parental opioid misuse; (3) improve predictions of CWS trajectories, including investigation, service provision, and foster care entry among this population; and (4) better estimate the CWS costs associated with patterns of system involvement resulting from parental opioid misuse. This information is crucial to ensuring the production of high-quality system involvement and cost projections related to the opioid crisis.
Am J Manag Care. 2019;25:-S0
Introduction

The opioid epidemic has taken the lives of thousands of individuals and devastated the lives of many more.1 The highly addictive nature of opioids and increased access to both licit and illicit sources, high rates of environmental stress, and societal redefinitions of pain are among several factors that have created the perfect storm for a national epidemic.2-4 Although much of the initial focus in addressing this crisis was on those who misuse, and on health and criminal justice implications, the negative impact in several areas is now being recognized as well.5-8 Many individuals who misuse opioids are parents or child caregivers. The relationship between substance misuse and child maltreatment has been well established and has resulted in the expansion and creation of child welfare services aimed specifically at protecting the children of substance misusers.9-13 The widespread use of opioids among parents and the resulting impact on parental capacity raise major concerns regarding the well-being and safety of children.14

Despite the importance of this issue, little research has been conducted that demonstrates the relationship between parental opioid misuse and child welfare involvement, and fewer studies have considered the costs to the child welfare system (CWS) associated with such misuse. The present analyses use publicly available data to provide an initial national estimate of these costs via the use of empirically based estimates of system involvement and CWS costs. These estimates illustrate the potential value of existing data sources while highlighting the potential limitations of existing data and informing data-related needs to provide more accurate estimates that can guide policy and practice in the child welfare field.15 We begin by reviewing existing research on the relationship between opioid use and CWS involvement. We then present a conceptual model to guide estimates of CWS costs and use publicly available data to project the attributable cost to the CWS from parental opioid misuse. We conclude by discussing data-related needs to improve these estimates that are derived from public data.

Opioid Misuse and Child Welfare System Involvement

Each year, 7.5 million children are the focus of a child protective services (CPS) investigation for suspected maltreatment, resulting in some level of formal CWS involvement or contact.16 Although federal data on the specific association between opioid misuse and CWS involvement are limited, ample evidence highlights the role of parental substance misuse as a significant contributing factor to the increased rates of child abuse and neglect, as well as the high rates of foster care entry and poor foster care outcomes.8,17,18 National point-in-time estimates of youth in foster care show a decline of more than 20% from fiscal years 2006-2012; however, the subsequent 4-year period through 2016 began to reverse that trend, with a 10% upswing in foster care population numbers.16,19-21 More than 70% of states reported increased numbers of youth entering foster placement from 2014 to 2015.20 Although multiple factors may affect rates of CWS involvement (eg, efforts to improve that quality of data reporting), parental substance use is a significant contributing factor to this observed rise: From 2009 to 2016, the percentage of entries submitted to foster care, for which parental substance use was a contributing factor, rose from 26% to 34%, representing the largest percentage increase among reasons for home removal.21 State child welfare directors in various localities attributed a significant portion of the rise in foster placement rates to parental substance use, particularly the rise in opioid and methamphetamine use.21

Information on referrals for child protection associated with parental substance use are less widely available, in part because these data are not required for federal reporting through the National Child Abuse and Neglect Data System (NCANDS), a federally sponsored national data collection. Between 2015 and 2017, the presence of caregiver drug misuse was a documented risk factor for 27.1% to 30.8% of substantiated or indicated child maltreatment victims; 34 to 35 states provided information.16 In 2010, using data from the National Survey of Child and Adolescent Well-Being—a nationally representative study of children and youth involved in CPS reports with sample weights to replicate national estimates of system contact and outcomes—Berger and colleagues reported that caseworkers perceived substance use problems in a primary or secondary caregiver in 13% of investigated cases, with approximately 1% having experienced referrals for substance use treatment.22 Caseworker reports of substance use were correlated with significantly higher probabilities of perceived severe risk for harm to children compared with parents with no such indication (24% vs 5%, respectively), receipt of services arranged for or provided to the family (74% vs 43%, respectively), and substantiation (ie, an affirmative maltreatment finding [61% vs 27%, respectively]).22 Further, substance use within this sample was associated with more than twice the risk for out-of-home/foster care placement (38% vs 16%, respectively). These results support the observation that children in households marked by caregiver substance use are at risk for a more involved system response at 2 phases of investigation—that is, service provision and removal.22

One factor contributing to the increase in opioid misuse rates has been the access to prescription opioids, particularly among pregnant women and new parents. Prescription opioid use and misuse have increased dramatically among reproductive-age and pregnant women in the United States in recent years.23,24 In fact, between 2000 and 2007, overall, 21.6% of Medicaid-enrolled pregnant women filled a prescription for opioids, and 2.5% received opioid prescriptions for an extended period (ie, >30 days).25 Further, between 1992 and 2012, the proportion of pregnant women entering federally funded, facility-based substance use treatment with a history of prescription opioid misuse increased from 2% to 28%.26

The link between opioid use among pregnant women and child welfare reporting is affected by state policy. According to the Guttmacher Institute, statutes in 24 states and the District of Columbia classify substance use during pregnancy as reportable child abuse. A total of 23 states and the District of Columbia require healthcare professionals to report suspected prenatal drug use to child welfare authorities, with 7 states requiring testing for prenatal drug exposure if substance use is suspected. Among 40 states, substance exposure data on risk factors for child maltreatment victims <1 year of age were indicated for 9.8%; for infants <1 month of age, data were indicated for 18.2%; for infants 1 month of age, data were indicated for 3.2%; and for infants between 2 and 11 months of age, data were indicated for 1.5% to 1.9%.27

Neonatal abstinence syndrome (NAS), a related consequence of opioid use among pregnant women, is associated with a negative impact on the developing child across many functional domains. In parallel, with the increased rates of opioid use disorder (OUD), rates of NAS or neonatal withdrawal symptoms from opioids or other drugs have also increased across the United States—from 1.2 cases per 1000 hospital births in 2000 to 5.8 cases births per 1000 hospital births in 2012.28 This increase poses a considerable burden on states where prenatal substance exposure must be reported to CPS agencies and can incur significant costs when infants must be placed in special care settings. A recent 10-state study of trends in NAS from 2004 to 2014 revealed a substantial increase in the percentage of reports to CPS for NAS—from 4.72% in 2004 to 9.19% in 2014.29 An Australian study documented that NAS led to a 5.7 times greater likelihood of CPS reporting, an 8.0 times greater likelihood of substantiated child maltreatment, and a 10.5 times greater likelihood of out-of-home placement.30 Finally, a Massachusetts study revealed that, on average, opioid-related NAS resulted in >10,000 hours of additional caseworker activity per month across the statewide system.31

Limited data are available that reflect individual- and family-level associations between opioid misuse and CWS involvement. Several state- and community-level studies provide verification of this association. Wolf and coworkers used community-level hospital discharge data for the state of California to examine the association between prescription opioid overdose and rates of hospitalization for child maltreatment from 2001 to 2011.32 Results demonstrated a significant positive association (relative rate, 1.089; 95% credible interval, 1.004-1.165), indicating that a 1.0% increase in hospital discharges for prescription opioid overdose was associated with an 8.9% increase in hospitalization discharges for child maltreatment.32 Because such cases may represent the most high-risk situations (eg, hospitalization for overdose, hospitalization for maltreatment-related injury), more general population–level research on rates of opioid misuse and CPS referral or foster care placement is needed. In an effort to investigate this association, Quast and colleagues, in a Florida-based study, observed that community-level prescription opioid rates predicted higher rates of foster placements.33

Nationally, Ghertner and coworkers used county-level data from 2011 to 2016 to determine that rates of overdose-related deaths were related to those of CPS and child welfare involvement: A 10.0% increase in drug overdose deaths was associated with a 2.4% increase in reports of maltreatment to CPS, a 2.4% increase in substantiated reports, and a 4.4% increase in foster care entries.34 Drug-related hospitalizations generated a similar pattern: A 10.0% increase was associated with a 1.7% increase in reports of maltreatment to CPS, a 1.9% increase in substantiated reports, and a 3.0% increase in the foster care entries.34

Substance misuse is a significant contributing factor to increased rates of child abuse and neglect. Over recent decades, greater access to such addictive substances as opioids has increased the probability of long-term substance use and addiction problems and has increased the likelihood of child maltreatment on the part of parents across the country. As child maltreatment rates are affected, so, too, is the probability of formal involvement with the CWS. Next, we consider a conceptual framework for projecting national costs from increased CWS needs attributable to opioids.

Conceptual Framework

 
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