Police in East Liverpool, Ohio, last fall wanted to show the graphic toll of opioid overdoses, so they made the decision to post some photos to Facebook. The shocking images, which an officer had taken during a traffic stop, were graphic and heart-wrenchingly poignant. A man and a woman sit unconscious in the front seat of an SUV, slumped at impossible angles, mouths agape. Meanwhile, a 4-year-old blond child -- the woman’s grandson -- stares from the back seat.
The controversial photos went viral, and have now been seen by millions. Some people praised the police for drawing attention to the problem of opioid abuse; others lambasted the city for sensationalizing the crisis and attempting to publicly shame drug addicts. “We feel we need to be a voice for the children caught up in this horrible mess,” the city wrote in the post accompanying the images. “This child can’t speak for himself, but we are hopeful his story can convince another user to think twice about injecting this poison while having a child in their custody.”
What happened in East Liverpool was only one of the latest in a string of incidents where parents and guardians overdosed while their children watched. As a growing number of people have become addicted to prescription opioids and heroin, many child protection agencies are seeing a surge in abuse and neglect cases. After a six-year decline in the number of children being removed from their parents’ care, the annual figures climbed back up from 2012 to 2015. The most consistent reason given for a child’s removal is parental alcohol abuse or other drug use, and the percentage of cases where that’s the reason has increased nationally from 18.5 percent in 2000 to 34.4 percent in 2015.
While the problem is more pronounced in the Northeast and Midwest, Western states like Oregon and Southern states like North Carolina and Tennessee have all documented the same alarming connection between opioid abuse and child welfare caseloads. “I move all around the country,” says Susan Dreyfus, the president and CEO of the Alliance for Strong Families and Communities, a national association of nonprofit providers in social services, “and I cannot think of a single state where this is not becoming a growing issue in their child welfare system.”
Opioids pose special challenges for child welfare agencies. Compared with addiction to cocaine or methamphetamine, the recovery period is longer and the chance of relapse is higher. Sobriety is often a requisite for placing children back with parents. But federal law mandates a short window --less than two years -- for parents to undergo treatment and demonstrate that they’re sober enough to regain custody of their child. In many parts of the country, though, opioid treatment isn’t readily available, and waiting lists for treatment can stretch for months or years. The end result is an almost inevitable termination of parental rights.
Loss of custody isn’t even the worst possible outcome. Addiction to opioids is killing parents. In 2015, the most recent year where data are available, more than 33,000 people died of opioid overdoses, representing a 200 percent increase over 15 years, according to the Centers for Disease Control and Prevention. That’s unprecedented, says Tina Willauer, who has spent her 27-year career working with addicted parents in child welfare programs, first in Ohio and now in Kentucky. “I’ve never seen anything like this.”
Opioid addiction creates a variety of stresses on the child welfare system. Last year in Ohio, parental drug use was a factor in the removal of more than half of children taken into custody. In a recent report, the Public Human Services Association of Ohio detailed the ripple effects of those removals: The annual number of children taken into custody has climbed 11 percent in five years. Because parents are in treatment for more time, children stay with foster families for longer, reducing the supply of caregivers for other children who need a temporary home. If children can’t be reunited with their parents, they’re often placed with grandparents or other relatives, and since 2010, the number of Ohio children in “kinship care” has increased 62 percent. The association also credits the opioid crisis, at least in part, for an estimated 1 in 7 caseworkers in Ohio leaving their positions because of burnout. “Caseworkers become frustrated with the lack of progress on cases, the long hours and the secondary trauma of telling children that their parents have overdosed,” the report says.
(Source: American Public Human Services Association)
The opioid crisis took child welfare systems by surprise, but there are signs that leaders at the state and national level now at least understand the severity of the problem. Last year, a committee on aging in the U.S. Senate held a hearing specifically devoted to the subject of grandparents taking custody of grandchildren whose parents are struggling with opioid addiction. In May, Congress allocated $262 million to combat opioid addiction, some of which will go to helping children and families. National associations representing governors, legislatures and state courts have convened a working group from eight states to study child safety, including the harmful impacts of parental addiction to opioids. Some states, such as Ohio, are increasing funding for family drug courts and other interventions thought to be effective at keeping children safe and at home with their biological parents.
That’s all a positive start, even if the epidemic continues to overwhelm the child welfare system, says Joel Potts, the executive director of the Ohio Job and Family Services Directors’ Association. “We’ve been ringing the alarm bell for years. Now people at least are listening.”
Eleven years ago, Kentucky was looking for a better way to help families whose infants had experienced prenatal exposure to crack cocaine. Officials in the state’s Department for Community Based Services decided to borrow a promising model from Ohio and recruit someone from there to run the program. That’s how the Sobriety Treatment and Recovery Team (START) program and its director, Tina Willauer, came to Kentucky.
At the time, parents with a substance abuse disorder faced a system that almost guaranteed permanent loss of custody. Because Kentucky didn’t use Medicaid to pay for substance abuse treatment, and other state funding hadn’t kept up with inflation, those services were unavailable in most of the state. When child protection workers encountered parents who were abusing alcohol or drugs, they still referred them to treatment even though they knew the parents probably couldn’t access it. When Willauer joined the department, about 450 mothers were on waitlists of four months or more to receive treatment.
A fast response is critical for helping families struggling with addiction, Willauer says. In parts of the state where START doesn’t operate, child protection receives hotline calls about potential cases of child abuse and neglect. An investigator then visits the home, conducts an assessment and determines whether the child should be removed from the home. That process can take up to 45 days to complete. “What we found is with families that have substance abuse disorders, that’s a long time to wait,” Willauer says. Under START, parents get assessed for and can begin treatment within five days of an initial incident report to Child Protective Services. “We want to maximize that window of opportunity where the crisis is happening,” Willauer says. “We think the parents might be more likely at that point in time to be agreeable to go to treatment if they think that there might be a chance that they could keep their child.”
START may have begun as a response to crack cocaine addictions, but the program has proved to be an effective approach for addressing the opioid epidemic as well. While the model didn’t originate in Kentucky, it has expanded and gained credibility there because that’s where it has undergone regular independent evaluation. Studies published in peer-reviewed academic journals have found that mothers in the program have almost double the sobriety rates of mothers with similar profiles who didn’t participate in START (66 percent versus 37 percent). Children in START are half as likely to be removed from their home and placed in foster care (21 percent versus 42 percent). The state also looked at recurrence rates for child abuse and neglect within six months of an intervention: Compared to a similar group, children in START were nearly three times less likely to have another incident within six months of intervention.
Beyond quick access to treatment, Willauer and her team attribute the relative success of START to its use of medication-assisted treatment. That’s the combination of traditional counseling with prescriptions of certain drugs, such as methadone, that can reduce opioid craving during the early stages of recovery. Though the World Health Organization has identified medication-assisted treatment as the most effective treatment for opioid disorders, it remains an unpopular approach in many parts of the country. One national study found that roughly 1.3 million Americans with opioid use disorders could benefit from the treatment, but don’t receive it. A survey of drug courts across the country found that nearly half had policies in place that prohibit the use of medication-assisted treatment.
In a recent presentation to human services officials, a California researcher on opioids and child welfare, Nancy Young, explained that part of the reason courts are reluctant to condone the medication-assisted treatment is that they don’t want to harm unborn children. A disproportionate share of the child welfare cases involving opioid abuse are pregnant moms who give birth while the drugs are still in their bloodstream. That can result in neonatal abstinence syndrome, which can mean that infants experience withdrawal symptoms. “That is sometimes controversial,” Young said in her presentation.
Still, medication-assisted treatment prevents the mother from relapsing. If a mother abruptly halts her use of opioids or safer substitutes, “she’s likely to overdose,” Young said. “We know that from all the people who have some period of abstinence. They get out, they return to use and then they overdose.” Also, infants’ withdrawal symptoms are temporary and treatable; unlike alcohol, prenatal exposure to opioids does not permanently change the child’s brain chemistry.
As START has rolled out to five of nine regions in Kentucky, program administrators have encountered resistance, from both treatment providers and judges, to the idea of a state-sponsored recovery plan that includes prescribing more drugs. “Sometimes there’s a bias against the medication,” says Lynn Posze, who works in Kentucky’s Division of Mental Health and Substance Abuse and helps run START. Treatment providers and judges are more familiar with addictions to other substances, such as cocaine, where medication-assisted treatment isn’t considered a best practice. “We’ve really had to work on training our child welfare staff and addiction professionals and our courts,” Posze says.
Part of that training involves educating people about the improved outcomes associated with medication-assisted treatment. An evaluation of Kentucky START published last year found that medication-assisted treatment increased the odds that parents would retain custody of their children. Comparing families where parents received the treatment versus parents who didn’t, the families that did had a 71 percent retention rate; the parents that did not had a 52 percent retention rate.
There’s another component of START that Willauer and Posze believe is critical to the program’s success, despite the fact that it hasn’t undergone the same rigorous testing as other elements of the model: the use of family mentors. These are parents who have been in sustained recovery for at least three years and whose past experiences are related to child welfare, including the loss of child custody at some point. They are full-time employees who get paired with social services workers. Mentors take clients to treatment and community recovery support group meetings. “The mentor,” Willauer says, “is there to say, ‘I’ve been there, I’m in recovery and I’m going to help you navigate this.’”
Since Kentucky adopted the model, municipalities in Indiana, Georgia, New York and North Carolina have piloted their own versions of START. In Ohio, Attorney General Mike DeWine has set aside $3.5 million to expand his state’s START program to an additional 14 counties on a trial basis for two-and-a-half years. But even with the improvements under START, Kentucky continues to see an alarming number of overdoses, which affects caseworker morale. “This is a hard time to be a caseworker,” Willauer says. “Our teams are having parent fatalities. Once you go through that, it’s hard to have the same spirit and drive.”
Other potential solutions around opioids and child welfare are emerging across the country. Ohio, for example, has expanded family drug courts to connect parents with treatment in less time. Connecticut is using private pay-for-success financing to support the upfront costs of expanding its Family-Based Recovery program, which sends a team of clinicians and a family support specialist on weekly home visits for up to five months. The team follows a “two-generation” approach to human services, treating parental addiction while promoting healthy child development. The program’s decade of administrative data already suggests that parents see a dramatic improvement in their sobriety over the treatment period, but the new $11.2 million pay-for-success project includes a randomized control trial to further evaluate its impacts.
These and other efforts are promising, but they are still being outpaced by the opioid epidemic. Even the officials running successful initiatives on parental substance abuse say their programs are the exception to the rule. “We have a lot of the right ingredients,” says Kristina Stevens, an administrator who helps run the Family-Based Recovery program in Connecticut. But, she says, “I don’t think we’re at a place where we have enough of what we need.” Effective interventions haven’t been scaled up across the state, and she doesn’t expect large new investments for expansion anytime soon.
A program like START requires a dramatic shift in how the behavioral health, child welfare and court systems interact. It requires greater upfront investment that will result in cost savings down the road. That kind of radical departure is easier to launch as a limited pilot that could be replicated and scaled up over time. “It’s a great program for families,” says Willauer, “but it’s not a curriculum that you train and implement tomorrow.”
As good as some programs have become at responding to a family crisis involving opioid abuse, they’re still part of a national child welfare system that is too reactive, waiting for child abuse and neglect to occur, says Dreyfus of the Alliance for Strong Families and Communities. “Our system is funded for the deep end, for the removal of children. It’s not funded for prevention and earlier intervention,” she says.
Last year, Dreyfus sat on a federal commission that recommended Congress allocate $1 billion a year in child welfare for prevention services, which might identify families at risk of a crisis and connect them with services ahead of time. “We’ve got to get underneath the true causes of [opioid addiction], which are really steeped in people’s lack of coping skills, their own health, well-being and sense of hopefulness in their lives,” Dreyfus says. “I think people are self-medicating with opioids and we’ve got to understand why. If we think we’re going to solve the opioid epidemic by simply increasing access to treatment, we will be forever perplexed by the dilemma.”