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Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
The Economic Burden of the Opioid Epidemic on States: The Case of Medicaid
Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
Estimated Costs to the Pennsylvania Criminal Justice System Resulting From the Opioid Crisis
Gary Zajac, PhD; Samaan Aveh Nur, BA; Derek A. Kreager, PhD; and Glenn Sterner, 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
Participating Faculty
Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers
Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
Beyond Rescue, Treatment, and Prevention: Understanding the Broader Impact of the Opioid Epidemic at the State Level
Laura Fassbender, BPH; Gwendolyn B. Zander, Esq; and Rachel L. Levine, MD
The Cost of the Opioid Epidemic, In Context
Sarah Kawasaki, MD; and Joshua M. Sharfstein, MD
The Opioid Epidemic: The Cost of Services Versus the Cost of Despair
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 evidence summarized above illustrates how rising rates of substance misuse among parents are linked to increases in problems related to child maltreatment, which require action from the CWS. To provide a conservative estimate of costs for child and family services, specifically those associated with opioid use, modeling the impact on system service utilization is required. Several pathways are followed once child maltreatment is suspected (ie, a referral is made because suspicions exist that a child is in danger). Different pathways are associated with different costs, which involve personnel time and other administrative resources. For the purpose of this initial work, we consider 3 service categories that are likely affected by increased access due to any form of opioid misuse: prescription opioids, heroin, and fentanyl.

Child Protective Services: CPS can involve intake, screening, family assessment or alternative response, and investigation services, as well as all associated administrative supports. Of these services, the 2 most costly types of CPS are screening and investigation.35 The screening process involves the receipt and processing of child maltreatment referrals, to determine whether a report meets the criteria for further investigation or assessment (“screened-in”) or is below this threshold (“screened-out”). Screened-in reports are then referred for an investigation or an alternative response (eg, family assessment). Investigation, which involves activities that are designed to determine the validity of the child maltreatment allegation, results in a case finding (ie, substantiated/indicated or unsubstantiated/unfounded), as well as the determination of a child’s safety or future risk for harm/maltreatment. Alternative response focuses less on investigating the occurrence of maltreatment but rather on assessing underlying factors that may affect child safety and family-level needs to reduce the likelihood of maltreatment.35

In-Home Services: In-home services are provided when a need is determined after an investigation or a family assessment. These can include the following services: support for parenting, including parental training, coaching, and/or skill building; individual and/or family therapy; referral for substance use treatment and skill building to enhance coping and/or replacement behaviors; referral for mental or behavioral health treatment; support for applying treatment gains to family management and child safety; information on and referral for job training; assistance with child care, transportation, budgeting, and other logistical planning; and concrete assistance, such as food, clothing, furniture, and/or housing.

Out-of-Home Services: The primary out-of-home service within the CWS involves placement. Children may be temporarily placed in state custody, which leads to placement in a traditional foster home (eg, nonrelative), with a relative (eg, kinship care or relative foster home), in a specialty foster home setting (eg, treatment foster care), or in congregate care settings (eg, shelter care, group home, or residential care facility).

Modeling Child Welfare System Service Utilization

Here, we build on previous works that have simulated the costs of the CWS and the effects of environmental or policy changes.36 We adopt an analogous conceptual framework to capture the major cost drivers, incorporating projections by the Washington State Institute for Public Policy and the RAND Corporation (Figure 1).34,36,37 A simulation approach for modeling has been used to demonstrate how changes in child maltreatment affect service utilization and consequent costs to the CWS.37

To conduct our analysis, we first obtained annual data on child maltreatment and CWS utilization rates from the NCANDS and the Adoption and Foster Care Analysis and Reporting System (AFCARS).16,20,21 The NCANDS is a voluntary data collection system that gathers information from all 50 states, the District of Columbia, and Puerto Rico on reports of child maltreatment. NCANDS was established in response to the Child Abuse Prevention and Treatment Act of 1988. The NCANDS child file includes information for each child involved in a completed CPS investigation during the fiscal reporting period. Elements include demographics of children and their perpetrators, types of maltreatment, case disposition, child and family risk factors, and postinvestigation services provided to the child and/or his/her family. The data are used to examine trends in child maltreatment across the country, with key findings published in our Child Welfare Outcomes Reports to Congress and annual Child Maltreatment reports. This includes children who receive protective and in-home services.

AFCARS collects case-level information from state and tribal title IV-E agencies on all children in foster care and those who have been adopted with title IV-E agency involvement. Examples of data reported in AFCARS include demographic information on the foster child, as well as the foster and adoptive parents; the number of removal episodes a child has experienced; the number of placements in the current removal episode; and the current placement setting. Title IV-E agencies are required to submit the AFCARS data twice a year based on two 6-month reporting periods.16,20,21

Importantly, neither NCANDS nor AFCARS includes direct information about the role of opioids in the CPS report or foster care entry, although each has indicators related to parental drug use more generally. NCANDS includes information on whether drug use was an identified caregiver risk factor, which is not submitted by all states, and AFCARS includes parental drug use as a reason for foster care placement. Our purpose in using NCANDS and AFCARS was to estimate national trends in CPS and CWS involvement that may be attributable to opioids based on prior research, as well as to estimate state child welfare costs.

Projecting National Child Welfare Service Utilization

Before estimating the portion of CWS utilization attributable to opioids, we first used annual national data to calculate the total levels and rates of CPS, in-home services, and foster care services provided between 2011 and 2016 (Figure 2).21,38 Both the total number of children with CPS involvement and those receiving in-home services were identified from NCANDS data.16,20,21 AFCARS collects information on the total number of children entering foster care each year.16,20,21 The costs associated with screening, investigation, and foster care were identified from published national estimates. For projections, we used a national per-case average cost in 2014—the most recent year available—of CPS utilization ($2447), in-home service utilization ($3680), and foster care ($33,210).35 All cost estimates were adjusted for inflation.21

With the goal of this work intended to highlight what publicly available data indicate the attributable CWS costs of the opioid epidemic to be, these estimates are expected to have key limitations that will serve to inform future research in this area. In particular, this work will be limited by the availability of data (eg, post 2016), as well as by limited information about the direct impact of opioids on rates of child maltreatment and formal CWS involvement. These factors limit precision of the range of the attributable impact of opioids. Additionally, given data limitations, our analysis does not value the downstream costs of child maltreatment attributable to opioids relative to the health and development of the maltreated child, although future work should seek to determine this additional burden for addressing such needs. Greater downstream costs to child and family services are likely to also result from misuse of opioids among pregnant mothers. In this context, estimates derived from public data are likely to be conservative estimates of the total CWS costs from opioid misuse.

Considering Attributable Impact of Opioid Misuse on the Child Welfare System

Limited information is available to determine the exact relationship between opioid availability and changes in child maltreatment, along with the consequent impact on CWS costs. To project the relationship between opioid misuse and CWS, we used the research from Ghertner and colleagues, which estimates the relationship between opioid-related hospitalizations and CWS utilization.34 Specifically, from 2011 to 2016, a 10.0% increase in opioid-specific hospitalizations corresponded with a 1.1% increase in reports of maltreatment, a 1.1% increase in substantiated maltreatment reports, and a 1.2% increase in foster care entry. These numbers represent the only national, peer-reviewed estimates of the relationship between opioid-related hospitalizations and child welfare outcomes. In this context, they represent the best estimates available. Opportunities to improve these estimates are described below. Using data from the Healthcare Cost and Utilization Project, we calculated the projected increase in child welfare reports, substantiations, and foster care entries attributable to opioid hospitalizations.39 The formula is reflected in Figure 3.39 From the projection of the attributable impact of opioid misuse on the CWS, utilization and costs can be estimated. Based on the standard errors for the association of opioid hospitalizations and child welfare utilization reported by Ghertner and colleagues, 95% confidence intervals were constructed to model uncertainty in these estimates.34 These models seek to capture the upper and lower bounds of these estimates.

Projected Child Welfare Resource Utilization and Costs Attributable to Opioid Misuse

The costs presented here represent high and low estimates based on the previously described assumption each year for the 3 key CWS categories. Although these estimates represent rough calculations, they are the best estimates given the currently available public data. Specifically, between 2011 and 2016, the CWS experienced more than $2.8 billion in costs attributable to opioid misuse, or about 2.1% of all child welfare costs during this time. This approach also demonstrated that in these 5 years, >200,000 reports of suspected child maltreatment, >80,000 victims of substantiated maltreatment, and >95,000 foster care entrants were attributable to opioid misuse.21,39 The projected costs attributable to each form of service grew across time (regardless of inflation; Figure 4).21,39 As expected, foster care services represent the largest driver of child welfare costs attributable to opioids.

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