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Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
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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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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
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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
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Sarah Kawasaki, MD; and Joshua M. Sharfstein, 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
Importantly, we sought to explore uncertainty in these estimates. Specifically, this included modeling the uncertainty of the association between opioid misuse (ie, hospitalization) and increases in CWS service needs. Bearing this in mind, we constructed 95% confidence intervals around these estimates. This represented a total attributable cost range between $2.65 billion and $3.0 billion. Costs attributable to CPS were between $852 million and $900 million, costs attributable to in-home services ranged between $162 and $174 million, and costs attributable to foster care were between $1.6 and $1.9 billion.

Limitations and Priorities for Future Work

Through this work, we sought to highlight what is known about the attributable costs of opioid misuse to the CWS based on public data. This effort was intended to generate estimates of the costs to the CWS that are attributable to opioids. All assumptions and estimates were intentionally designed to provide an initial estimate of the potential CWS costs that reflected the limitations of the data. This work was limited by the scarcity of data, as well as by the limited information available on the direct impact of opioids on child maltreatment. This, in turn, limited the precision of all estimates of the attributable impact from opioids. Further, they reflect the estimates based on the work of the Administration for Children and Families and the research by Ghertner and coworkers.19,34 As described below, further efforts to develop convergent evidence from multiple studies will help to improve the precision and utility of these estimates. Child maltreatment is associated with substantial known costs to the healthcare system and the education system. Additionally, we do not include other potential cost drivers to the CWS that would increase projected cost estimates (eg, adoption services, federal overhead costs). Lacking the availability of better information on these linkages, we provide this initial estimate based on more direct costs.

Ultimately, these estimates require several kinds of data to improve precision and capture the full range of costs. This includes individual-level child welfare data, preferably with information that would allow for linkage to perpetrators’ medical records. For example, a linkage between Medicaid records and perpetrator records could allow a direct estimation of costs. Additionally, information on the availability of opioids within local geographic areas would allow for an improved understanding of how availability relates to changes in child maltreatment.

Understandably, most of the focus on family and child services affected by the opioid epidemic is related to the CWS. Service utilization for additional family needs, however, should be considered as well. Recent studies have noted trends for necessary treatment and programming to address personal and family dysfunction resulting from opioid addiction that is directly or indirectly related to opioid use.40 For example, OUD is associated with a greater risk for intimate partner violence (IPV). Although it is challenging to sort through the reciprocal relationships between OUD and IPV, studies have documented an increased likelihood for IPV following substance use.41 The family problems resulting from OUDs are likely to coincide with increased rates of IPV, thus requiring effective treatment that can serve collateral issues. Also occurring comorbidly with OUDs are mental health conditions that are exacerbated by long-term problems. Effective treatment for opioid misuse requires resources that address mental health needs concurrently, with some of the burden falling on state governments. The urgent need for adequate mental health support has led several states to seek joint support from the federal government. This is particularly true of children in foster care, whose healthcare costs are, on average, higher than those of children not in foster care.42

The opioid epidemic has led to efforts to implement and fund services that address family issues linked to substance misuse. These include services for treatment and prevention that may not have been required in the past. For example, the state of Wisconsin has developed Project Hope (Heroin, Opiate, Prevention, and Education) to serve families, including treatment and prevention programming, monitoring prescription drug patterns, and increasing the response time of public health officials to reported problems.43 This initiated $2 million per year to help support treatment and prevention efforts; $250,000 in additional funds per year through the Child Psychiatry Consultation Partnership was provided for mental health services, and an additional $5.4 million was allocated in the recent annual budget for the treatment of residential substance use.43 Substantial state costs are linked to personnel and other administrative costs for funding and planning programs to address the problems that arise from opioid misuse. These costs are not captured by estimates provided in publicly available data.

Ultimately, these limitations illustrate what can be accomplished with currently available public data and can underscore the opportunities for future work. Of particular concern is the fact that these data are likely what many policy makers and practitioners rely on to guide their efforts to address the current opioid epidemic. To improve estimates of the full costs of the opioid epidemic for children and families, a clear need exists for more research and strong available data in this area.44 From this effort, we identified 4 core priority domains and highlighted illustrative examples of what is needed to move the field forward (Table). Specifically, there is a need to (1) improve data quality, (2) better identify the causal relationship between opioid misuse and child maltreatment, (3) increase model sensitivity to heterogeneity, and (4) develop improved price information.

Data Quality: Key to improving our understanding in this area includes improving the quality of data to better reflect a number of key issues. This includes enhanced documentation of the type of opioid misuse tracked in healthcare databases (eg, prescription opioid, heroin, fentanyl), along with the need to link electronic medical records and claims data with CWS records—in particular, perpetrator data. Further, there is a need to enhance the quality of healthcare data from pediatric care providers who capture injury and illness data related to child maltreatment.

Mapping Opioid Misuse and Maltreatment Associations: To strengthen the quality of projection estimates, there is a need for investigators to prioritize our understanding of the specific pathways of opioid misuse that lead to child maltreatment. Our estimates focus on associations between opioid-related hospitalization rates and CPS or CWS involvement, but research also must address the direct link between caregiver misuse and CWS contact. These paths may include prenatal exposure and NAS, as well as the relationships between opioid misuse and the occurrence of child abuse or neglect. Similarly, pathways to foster care placement may be associated with caseworker estimates of increased risk among households affected by opioid misuse but may also include entry to foster care due to the death of a parent that is attributable to opioid misuse. Moreover, elucidating the differential relationships between opioid misuse and other forms of maltreatment (ie, neglect; physical, sexual, and psychological abuse) and placement trajectories (eg, length of stay, type of placement) is also important. Clearer indicators of the association between parental opioid misuse and the differential pathways of CWS involvement associated with misuse would reduce the uncertainty in estimates and provide more precise cost projections.

Understanding Heterogeneity: Increasing the utility of projection models requires improved understanding of the heterogeneity across geographic locales, as well as key demographic groups. This involves, in particular, more detailed estimates of variation in opioid misuse across gender and racial groups and whether there are subgroup differences in future engagement with the CWS. Further, understanding how contextual factors are related to misuse and maltreatment is also important. For example, regional variation in urbanicity and neighborhood socioeconomic variability are critical aspects to consider.

Improving Price Information: Ultimately, the success of cost projections requires accurate price estimates to minimize uncertainty.45 These data should account for local price information, such that the cost of services will enhance our understanding of how market prices fluctuate over time (eg, inflation). Finally, accurate price information should provide not only average costs of service provision but also marginal price estimates that reflect the costs for local markets (eg, scarcity of child welfare workers, limited foster care sites).


This work sought to understand how publicly available data can inform estimates of the attributable costs of CWS from opioid misuse. Preliminary estimates indicate a substantial burden of different child welfare services from opioid misuse but also illustrate a high degree of uncertainty in terms of magnitude. We identify a number of research priorities that provide a map for future research. In this context, we view these high costs to children and their families from this epidemic as key to motivating not only further inquiry but also strategic investment in evidence-based programs and policies.

Acknowledgment: This work was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development P50HD089922.
Author affiliations: The Pennsylvania State University (DMC, CMC, DJ, MWD).
Funding: This project was supported by the Commonwealth of Pennsylvania under the project “Estimation of Societal Costs to States Due to Opioid Epidemic,” as well as by a Strategic Planning Implementation Award from The Pennsylvania State University Office of the Provost, entitled “Integrated Data Systems Solutions for Health Equity.”
Authorship information: Concept and design (DMC, CMC, DJ, MWD); acquisition of data (DMC); analysis and interpretation of data (DMC, DJ, MWD); drafting of the manuscript (DMC, CMC, DJ, MWD); critical revision of the manuscript for important intellectual content (DMC, CMC, DJ); statistical analysis (DMC, DJ); administrative, technical, or logistic support (DMC, MWD).
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