Addressing Substance Abuse To Improve Well-Being in Child Welfare Systems Current Trends, Continuing Challenges Three Branch Institute on Child Well-Being July 1, 2014 Sid Gardner, MPA
Drugs of the Decades
Crack Cocaine
Trying to Incarcerate Ourselves Out of the Drug Problem $1 trillion spent since 1971 U.S. has the largest prison population in the world
Methamphetamine
Ten states contributed to more than 90% of the decline in foster care population 7
PERCENT 50 40 PARENTAL AOD AS REASON FOR REMOVAL IN USA 1998-2012 30 20 13.9 15.8 18.5 19.6 21.6 22.7 23.4 24.9 26.1 26.3 25.8 26.1 28.4 29.3 30.5 10 Source: AFCARS Data Files 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Percentage of child removals Parental AOD as Reason for Removal 2012 70 60 50 40 30 20 10 0 Source: AFCARS, 2012 5
The Call for Effective Public Policy The ineffectiveness and harm of public policy based on slogans of fear, stigma, presumption, and prejudice Need for public policy that based on science, focuses on treatment and strengthens families
Addiction Here s What We Know 1.Addiction is a brain disease 2.Addiction can be managed successfully; treatment helps regain areas of life function 3.Timely access to effective treatment helps many but not all parents reunify with their children 4.Outcomes to prove treatment works and saves money
Child-well-being occurs in the context of family relationships 90% of children in substantiated abuse and neglect cases either stay home or go home Impact of substance use combined with added trauma of separation due to outhome custody = severe disruption of relationships Child Well-Being and Family Relationships
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Substance use and child maltreatment are often multi-generational problems that can only be addressed through a coordinated approach across multiple systems to address needs of both parents and children. Cross-System Collaboration Here s What We Know 14
How Collaborative Policy and Practice Impacts Recovery 5Rs Remain at home Reunification Recidivism Re-entry
Opiate and Prescription Drug Abuse: Current Trends, Future Opportunities 16
The Opportunities Demystifying myths is an important start stigma as a real barrier. Allow science to guide policy and practice the science of MAT Cross-system collaboration is critical Multiple intervention points exist
Number of ED Visits 600000 Trends in Emergency Department Visits Involving the Nonmedical Use of Opioid Pain Relievers: 2004-2011 500000 400000 300000 200000 100000 ED visits involving the misuse or abuse of opioid pain relievers rose 183% from 2004 to 2011 0 2004 2005 2006 2007 2008 2009 2010 2011 Source: 2011 SAMHSA Drug Abuse Warning Network (DAWN) 18
Overall Female Treatment Admissions for Other Opiates* as Primary Substance of Abuse 16 14 13.7% 12 11.9% 10 8 8.4% 6 4 2 1.9% 0 1998 2008 2011 2012 Retrieved 09/05/13 from http://wwwdasis.samhsa.gov/webt/newmapv1.htm *Other opiates includes non-prescription use of methadone, codeine, morphine, oxycodone, hydromorphone, meperidine, opium, and other drugs with morphine-like effects. 19
Why the Closed Doors? Stigma Four Factors 1. Misconception as a moral weakness or willful choice 2. Separation from rest of health care 3. Language mirrors and perpetuates stigma 4. Criminal justice system and medical/ treatment systems disagree on treatment approaches Source Olsen and Shafstein, JAMA, 2014
Opiates During Pregnancy 8
PSYCHOLOGICAL EFFECTS Counseling targets the cortex PHYSICAL EFFECTS Medication affects the limbic system http://www.vivitrol.com/opioidrecovery/howvivitrolworks
Different Populations of Women Can Give Birth to an Infant with NAS Symptoms* 1. Women with chronic pain or other medical condition maintained on medicines 2. Women actively abusing or dependent on opioids (e.g., untreated substance use disorder) Includes heroin users Misuse own prescribed narcotics for acute or chronic pain Misuse of non-prescribed opioids diverted from legitimate sources from friend of family member Misuse of opioids obtained through illicit means (purchased, theft) *Groups may overlap, adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy 15
Different Populations of Women Can Give Birth to an Infant with NAS Symptoms* (Cont d) 3. Women in recovery from opioid addiction maintained on methadone through OPT or buprenorphine through office based prescribing *Groups may overlap, adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy 16
Neonate Withdrawal Neonatal Abstinence Syndrome (NAS) In chronically opioid exposed newborns, norepinephrine rebound produces symptoms of gastrointestinal and motoric hyper-arousal after birth as opioids are no longer being administered through the umbilical connection to the mother and are metabolized 40-60% of exposed babies have NAS symptoms Research cannot predict which babies will experience NAS 17
Opiate and Prescription Drug Abuse: Implications for Child Welfare 26
Child Abuse Prevention and Treatment Act (CAPTA) Since 1974, CAPTA has been part of the federal government s effort to help states improve their practices in preventing and responding to child abuse and neglect. CAPTA provides grants to states to support innovations in state child protective services (CPS) and communitybased preventive services, as well as research, training, data collection, and program evaluation. 22
CAPTA Focuses on Four Elements of Substance Exposed Infants Identifying infants affected by illegal substance use or withdrawal symptoms or FASD Implementing the requirement that health care providers involved in the delivery or care of such identified infants notify the child protective services system of such conditions Developing a plan of safe care Addressing the needs of these infants 23
For the child: A five-point framework that addresses screening, assessment, referral and engagement across all stages of development For the mother: The whole perinatal picture - before, during, after pregnancy Multiple Intervention Points Prepregnancy Promote awareness Prenatal Birth Neo-natal Screening and referrals for services CAPTA, 2010 Testing for substance exposure Immediate postnatal services for newborn and families Childhood, Adolescence Ongoing services for children and families
Multiple Intervention Points 1. Objective 2. Policy Implications 3. Key Questions to Ask Please see Handout 30
MAT/NAS Policy and Practice Considerations Consistent screening and assessment of opiate addiction and other substance use during pregnancy for Medicaid-covered births Engaging pregnant women with opiate addiction in treatment services and/or prenatal care Availability of substance abuse treatment programs for opioid addiction Availability of specialized programs that serve both mother and infant together and enable them to remain together Using levers of Medicaid to ensure availability of medication-assisted treatment 31
2014 We can no longer say We don t know what to do. 37
5 Questions for State Governments 1. What is the scale of parental substance abuse and how does its prevalence affect children and state spending? 2. How effective are current state efforts to reduce parental substance abuse and its impact on children? 3. How can the most successful responses to parental substance abuse be scaled up to achieve larger effects on child and family well-being? 4. How can cost savings be captured when they take time to achieve and often benefit agencies that do not fund those programs? 5. How can the barriers that prevent collaborative efforts among state agencies be overcome to achieve results that no single agency can achieve by itself with its own resources? Please see Handout 38
Another Opportunity Availability of in-depth technical assistance focused on substanceexposed infants Six states Applications available: August 2014 Contact National Center on Substance Abuse and Child Welfare for more information 39
Q & A and Discussion 32
Contact Info Sid Gardner, MPA President, Children and Family Futures sgardner@cffutures.org (714) 505-3525 www.cffutures.org