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Challenges in Providing Substance Use Disorder Treatment to Child Welfare Clients in Rural Communities

Elizabeth Clary, Christina Ribar, and Elizabeth Weigensberg and Project Officers: Laura Radel and Emily Madden – 2020

• Rural communities often lack the resources to provide services to parents struggling with substance use issues. Rural economics, transportation and technological limitations exacerbate these challenges.
• Child welfare agencies and substance use disorder treatment providers face particular challenges to collaboration with one another in rural communities. Stigma, lack of anonymity and misinformation compound these issues.
• Strategies specifically tailored to rural communities are needed to improve service access, develop workforce capacity and improve collaboration.
Parental substance use is a risk factor for involvement with the child welfare system (Belanger et al. 2007). In 2018, parental drug use was a factor in 36 percent of cases that led to removing children from the home and parental alcohol use was a factor in five percent of such cases (Children’s Bureau 2019). Illicit substance use1 is associated with child maltreatment, and child welfare cases involving substance use tend to be complex, the maltreatment tends to be more severe, and foster care placements are more likely than they are in non-using populations (Radel et al. 2018b). Rural communities have been particularly hard-hit by substance use. Their per capita opioid overdose rate is 45 percent higher than the rate in urban areas (Weintraub et al. 2018). But opioids are not the only concern; while some rural communities have high rates of opioid use, others have high rates of methamphetamine use (Admon et al. 2019; Dombrowski et al. 2016; MacMaster 2013). Polysubstance use—using more than one illicit substance, Throughout this brief, substance use refers exclusively to illicit substances, including non-medical use of prescriptions, such as opioids or stimulants. or using a substance in combination with alcohol—is also common, complicating the treatment of substance use disorders everywhere, particularly in rural communities where adequate treatment capacity is a challenge (Radel et al. 2018b). Poverty is widespread and severe in many rural areas, which also may suffer from high unemployment rates. Unemployment and poverty are positively correlated with indicators of substance use (Ghertner and Groves 2018), and
are also risk factors for child maltreatment. In fact, in families where parents are unemployed, the child maltreatment rate is two to three times greater than that of families with employed parents (Children’s Bureau 2018), which, along with substance use, could partially explain the higher rates of maltreatment in rural areas (Sedlak et al. 2010). The rates of substance use issues in rural areas, and their association with child welfare involvement, have become a federal priority. In response to this urgent problem, the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica to identify key issues rural communities face in addressing parental substance use and its effect on children, and to recommend possible solutions. This brief summarizes the challenges involved in serving rural child welfare involved families with substance use issues. We highlight differences between rural and non-rural areas and discuss strategies that could help alleviate difficulties in addressing child welfare cases in rural communities. In a future brief, we will describe promising models for rural communities that could address the needs of parents who use substances and are involved with the child welfare system. For this project, Mathematica conducted a targeted literature search and interviewed subject matter experts from relevant fields (as described in Box 1). The literature reviewed represented a range of definitions of the term “rural,” which were not always consistent. For this brief, we used a broad definition of “rural” that encompasses all non-urban and non-suburban areas. However, each rural community is unique and not every rural community faces the same challenges. Additionally, while we are confident that our literature review and environmental scan encompassed the range of available literature, by focusing on published literature, our findings may not fully reflect current practice in rural areas which have not yet been studied. Recent federal investments have targeted treatment options in rural areas and the impact of these investments may not be fully reflected in this brief. For example, the Health Resources and Service Administration (HRSA) recently invested over $111 million to enhance rural substance use disorder treatment options. Research does indicate that in some respects, the availability of opioid use disorder (OUD) treatment options in rural areas has improved relative to non-rural areas (Ghertner 2019).