A large portion of families receiving child welfare services are coping with parental substance misuse. The following conclusions have been retrieved from a publication by childwelfare.gov. A 2009 study showed that about 12% of children in the United States live with a parent who is dependent on or misuses alcohol or other drugs. About 10% of births occur with the infant having been exposed to substances prenatally which can have severe long-term impacts on the child.

“Maternal drug and alcohol use during pregnancy have been associated with premature birth, low birth weight, slowed growth, and a variety of physical, emotional, behavioral, and cognitive problems (AIA, 2012; National Institute on Drug Abuse [NIDA], 2011).”

There are unique challenges child welfare agencies face when addressing parental substance use disorders. Some obstacles include insufficient service availability to meet existing needs, inadequate funds for services or lack of client insurance coverage, difficulties engaging parents in treatment, knowledge gaps among child welfare workers, and lack of coordination between child welfare systems and other healthcare services.

Innovative approaches and treatments do exist, including early identification of at-risk families in treatment programs, shared family care programs that connect families with a host family mentor, family peer mentors, family treatment drug courts, gender-sensitive treatment, and family-centered treatment services that involve the whole family. There are also numerous grant programs funded by The Children’s Bureau to support children and families, such as the Regional Partnership Grants.

Individualized treatment and case plans are crucial to a person or family’s recovery. Collaborative strategies with health professionals, mentors, and specialists have proven to be most successful in achieving long-term and permanent success.

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Family Treatment Drug Courts (FTDC) have shown such promise in the US, that they are utilized at an international level.  In England, Family Drug and Alcohol Courts (FDAC) use an integrated approach similar to FTDCs in the US, where the same judge oversees both the care proceedings and the treatment intervention. In contrast to some American FTDCs, if parents don’t follow their FPAC plan, the case goes back to being public law care proceedings where authorities still must prove the child is at risk and the FDAC has no further involvement.

The London FDAC was evaluated for long-term outcomes before FDAC was implemented in other regions in England. All London FDAC cases from January 2008 to  August 2012 were tracked for up to five years after the intervention. The cohort was compared to cases that weren’t provided FDAC. Thirty-six percent of FDAC mothers had previously removed children,  37% had mental health problems, and 71% had experienced domestic violence. The majority of children (87%) of the cases were brought because of neglect, 25% had emotional and behavioral difficulties, and 41% had physical health problems.

Overall, FDAC mothers had better outcomes than comparison mothers. Forty-six percent of FDAC mothers stopped misusing substances, compared to only 30% of the comparison mothers ceased. Thirty-seven percent of FDAC families either continued to live together or were reunited vs. 25% of comparison familiesFifty-eight percent of FDAC mothers sustained the reunification compared to only 24% of the comparison mothers. However, there was no difference in the amount of time it took for the child to be permanently placed. The study also found that the first two years after the reunification was especially risky for mothers. However, about a fifth of all children (both FDAC and comparison) were estimated to change placements after they had received their permanent placement. This study shows evidence of positive, long-lasting effects from FDAC. Additional support for the first two years following FDAC may need to be offered, as this study showed that it is a vulnerable time for families.

Harwin J, Alrouh B, Broadhurst K, McQuarrie T, Golding L, Ryan M. 2018. Child and parent outcomes in the London Family Drug and Alcohol Court five years on: building on international evidence. International Journal of Law, Policy and the Family 32(2): 140–169. https://doi.org/10.1093/lawfam/eby006.

Individuals who have a criminal history have high rates of opioid dependence and mortality risk. The fatality risk from substances such as heroin, for example, is much higher in the weeks following release from prison. Despite this risk, Medications for Opioid Use Disorder (MOUD) are critically underused among inmates. The objective of this study was to examine the association between adherence to methadone maintenance treatment (MMT) and fatal overdoses among individuals with criminal histories.

This study analyzed 14,530 administrative records of individuals in British Columbia with conviction histories who filled a methadone prescription between January 1st, 1998 and March 31st, 2015. Participants were followed from the date methadone was first dispensed, until a death certificate was issued and registered, or until March 31st, 2015. The average age of participants was 34.5, and 71.4% were male. The median follow-up time was 6.9 years, and 1,275 individuals died during that time. The overall all-cause mortality rate was 11.2 per 1,000 Person-Years (or 11.2 deaths per 1000 persons observed for one year). Looking at non-MMT compared to MMT periods, the all-cause mortality rate was significantly higher at 15 per 1,000 person-years compared to 5.9 per 1,000 PYs during MMT periods.

Methadone use was associated with a lower mortality rate among individuals with a criminal history and opioid dependence. It is worth considering that individuals adhering to MMT exhibit lifestyle changes that influence mortality. Despite the known benefits of MOUD, such as methadone, they are not routinely offered in prisons. Barriers to providing treatment include stigma, lack of knowledge, concerns about medication diversion, and lack of linkages between providers and correctional facilities. Inmates and those recently released would benefit from ongoing treatment, following detox while incarcerated.

Russolillo, A., Moniruzzaman, A., & Somers, J. M. (January 01, 2018). Methadone maintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada. Plos Medicine, 15, 7.)

Previous studies have shown consistently that Medications for Opioid use Disorder (MOUD) formally known as Medication-Assisted Treatment], including methadone maintenance treatment (MMT), buprenorphine, and naltrexone are beneficial across outcomes. Findings are mixed when it comes to MOUD following an overdose. Because a major risk factor for fatal opioid overdose is prior to nonfatal overdoses, this study investigates whether MOUD after opioid overdoses decreases mortality rates – both related and unrelated to opioid use. This study used retrospective data from 17,568 adults in Massachusetts who survived an opioid overdose between 2012 and 2014. Individuals who died within 30 days of the nonfatal overdose were excluded from the study, as were individuals with evidence of cancer.

Sixty-two percent of participants were male and 69% were under the age of 45. In the previous  12 months before the nonfatal overdose, 26% received 1 or more kinds of MOUD, 41% received prescriptions for opioids, and 28% received prescriptions for benzodiazepines. See the chart below for the results of the study.

Approximately a third of the individuals in this sample received MOUD. MMT and Buprenorphine treatment were associated with reduced all-cause mortality and opioid-related mortality. Considering the greater mortality risk that the non-MOUD group face, this study supports engaging individuals in MOUD treatment following a non-fatal overdose.

Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., Bagley, S. M., … Walley, A. Y. (January 01, 2018). Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Annals of Internal Medicine, 169, 3, 137-145.

Poorly managed persistent pain is a risk factor for opioid use disorders (OUD). An estimated 62% of patients using medication-assisted treatment (MAT) have persistent pain. Individuals receiving MAT while coping with persistent pain face unique challenges such as heightened sensitivity to pain and high opioid tolerance. Complicating these barriers further, many MAT patients with persistent pain don’t have health insurance that covers other pain therapies such as acupuncture or cognitive behavioral therapy. Additionally, many OUD treatment providers don’t offer on-site support for pain management. This study piloted an online pain management program, Goalistics Chronic Pain Management Program (CPMP), among adults with persistent pain who receive MAT at an outpatient clinic in Washington State.

CPMP is a self-directed, Internet-based program for patients with persistent pain. CPMP is made up of modules to be completed over the course of eight weeks. The modules target four areas of pain management: cognitive, emotional, behavioral, and social. The program includes written information, interactive activities, homework exercises, and self-monitoring activities. The goal is to decrease pain symptoms, improve mood, and reduce opioid misuse.

A total of 31 individuals participated in CPMP, with 29 individuals in the control group. Sixty-five percent of CPMP participants engaged with the online program, by completing some or all of the modules. CPMP participants showed improvement of pain severity, pain interference, opioid misuse, and depressive symptoms, compared to the control group. The CPMP group did not show changes in self-efficacy, anxiety, or withdrawal symptoms after the course of the program. One possible explanation is that the chronic pain symptoms of the participants exacerbated their withdrawal and anxiety symptoms. These results are promising and show that online self-management programs may be effective among adults receiving MAT while coping with persistent pain in managing physical and emotional symptoms of pain. Going forward, treatment clinics should place more emphasis on the specialized needs of individuals with persistent pain.

Wilson, M., Finlay, M., Orr, M., Barbosa-Leiker, C., Sherazi, N., Roberts, M. L. A., Layton, M., … Roll, J. M. (November 01, 2018). Engagement in online pain self-management improves pain in adults on medication-assisted behavioral treatment for opioid use disorders. Addictive Behaviors, 86, 130-137.

Oxford Houses are self-run, abstinence-based recovery homes for individuals recovering from a substance use disorder (SUD). With over 2000 Oxford Houses in several different countries including the U.S., Australia, Canada, the UK, and Ghana, the Oxford House model is the largest network of abstinence-based recovery homes. The Houses rely on a democratic vote for resident matters like accepting prospective residents, establishing rules, and assigning chores. Any resident that is discovered repeatedly using substances is immediately evicted. The vast majority of residents attend 12-step groups, like Narcotics Anonymous, where an individual using Medication-Assisted Treatment (MAT) is not considered abstinent. The purpose of this study was to examine residents’ views on MAT.

The majority of the 87 participants were men. Fourteen percent of the residents reported they were receiving MAT and 32% stated they had previously been on MAT. The residents’ views on MAT often depended on their own drug of choice. None of the residents currently receiving MAT believed that someone who takes buprenorphine/naloxone was a “using addict”. However, 22% of current MAT patients believed that someone who takes methadone was still a “using addict”. Among non-MAT residents, nearly half (49%) reported that an individual who takes buprenorphine/naloxone was still a “using addict”, and 68% thought someone who takes methadone was also still an addict. None of the MAT group reported they would vote against a prospective resident for using buprenorphine/naloxone, but 50% would vote against someone taking methadone. Of the non-MAT residents, 38% stated that they would vote against a prospective resident taking buprenorphine/naloxone and 65% of this group reported they would vote against someone taking methadone. There were also gender differences in responses with 41% of men saying they would vote against a resident taking buprenorphine/naloxone, compared to only 13% of women. Interestingly, longer time in recovery was related to harsher attitudes towards MAT.

Findings suggest Oxford Houses may not be the best recovery model for individuals receiving MAT. However, residents of abstinence-based homes should be educated on the science and benefits of MAT, and the ways in which use of MAT differ from addiction. The results also show that further education is needed to address stigma associated with methadone use so individuals receiving MAT can stay in and benefit from supportive environments.

Majer, J. M., Beasley, C., Stecker, E., Bobak, T. J., Norris, J., Nguyen, H. M., Ogata, M., … Jason, L. A. (January 01, 2018). Oxford House Residents’ Attitudes Toward Medication Assisted Treatment Use in Fellow Residents. Community Mental Health Journal, 54, 5, 571-577.

In addition to their substance use disorders (SUD), women involved in Drug Treatment Court (DTC) face other obstacles that can influence their motivation and ultimately their success in DTC. These include isolation from family, inadequate physical and mental health care, lack of social support, and past trauma. To be successful, women must balance their own motivation against these obstacles. In this study, peer interventionists interviewed 15 women participating in the Women’s Initiative Supportive Health DTC program. The participants were asked about past trauma on the trauma they’d experienced, along with other family and social barriers that may affect success in the program.

The women ranged in age from 20-40+. Thirteen of the women had at least one child and 14 out of 15 participants had experienced incarceration. Nearly all of the women (14 out of the 15) had experienced past trauma, including homelessness, physical or emotional abuse, intimate partner violence, and sexual assault. The women also faced mental and physical health obstacles, as all of the 15 women had histories of chronic health conditions including Hepatitis and HIV. Participants reported their main motivation to maintain their sobriety and to become supportive parents was most influential in completing DTC despite additional obstacles. Accordingly, the women reported that their parenting skills were the most common changed behavior. Participants stated that the second motivation and a source of support to maintain their health and sobriety was their families. Families helped the women in their journey to recovery by encouraging their competence and supporting their autonomy. A third common motivating factor was related to overcoming past trauma.

What can be taken away from this study? First, one of the most important ways to assist women in DTC is to empower them to be autonomous and to support the decision they make in their recovery. Second, past trauma must be taken into account in SUD interventions and treatment. Almost all of the women interviewed had experienced trauma. Finally, family can be a powerful motivator for women to achieve recovery. A supportive family helps reduce SUD among women who are mentally ill and suffer from a SUD. Future interventions should incorporate family or family dynamics into the treatment of women with SUD.

Goldberg, Z. E., Chin, N. P., Alio, A., Williams, G., & Morse, D. S. (January 01, 2019). A Qualitative Analysis of Family Dynamics and Motivation in Sessions With 15 Women in Drug Treatment Court. Substance Abuse: Research and Treatment, 13.

Family Treatment Drug Court (FTDC) is one of the most promising interventions for families involved in the child welfare system because of parental substance abuse. However, there are mixed feelings on the efficacy of FTDC on child welfare outcomes. This 2019 examined seventeen FTDC interventions with a total of 3402 participants enrolled in FTDC and 3683 comparison participants.

Overall, the reunification rate of FTDC participants was nearly two times higher than non-FTDC participants. However, there was no difference between FTDC and non-FTDC participants when it came to the risk of foster care reentry or child maltreatment re-report. Additionally, reunification rates improved over time suggesting that FTDC programs have improved over time. Future studies should examine the risk of foster care reentry for FTDC participants. The child welfare system should also consider enhancing follow-up services for those who have graduated from FTDC to prevent reentry into foster care.

Zhang, S., Huang, H., Wu, Q., Li, Y., & Liu, M. (February 01, 2019). The impacts of family treatment drug court on child welfare core outcomes: A meta-analysis. Child Abuse & Neglect, 88, 1-14.

Substance Use Disorders (SUD) are increasing among older adults in the US. Compared to younger groups, older adults have an increased risk of overdose, falls, drug interactions, cognitive and psychomotor impairment, as well as an increased risk of mortality. Medication-Assisted Treatment (MAT) is an effective treatment for Opioid Use Disorders (OUD), but it is especially underused among older adults with an estimated 7.9-9.8% of older adults used MAT as part of their treatment.

It can be challenging treating older populations for OUD, as there can be physical limitations, comorbidities, and negative interactions with other medications. Methadone maintenance treatment requires counseling sessions, toxicology screens, and same-day screening which can be challenging for older adults with physical limitations and transportation issues. Methadone, in particular, may interact with other drugs that are common for older adults. Insurance coverage of MAT services is also a significant barrier for older adults, as Medicare does not cover methadone use for OUD. Primary care providers, and other physicians that treat older adults, should be trained on how to screen for OUD and refer them to treatment.

Joshi, P., Shah, N. K., & Kirane, H. D. (April 01, 2019). Medication-Assisted Treatment for Opioid Use Disorder in Older Adults: An Emerging Role for the Geriatric Psychiatrist. The American Journal of Geriatric Psychiatry, 27, 4, 455-457.