Prescription Drug Monitoring and Child Maltreatment in the United States, 2004-2018

Published:October 19, 2021DOI:


      To test whether a policy approach aimed at decreasing prescription drug misuse, specifically, state monitoring of controlled substance prescriptions—prescription drug monitoring programs (PDMPs)—were associated with changes in Child Protective Services-reported maltreatment prevalence.

      Study design

      Using a difference-in-differences design and maltreatment data (2004-2018) from 50 states and the District of Columbia, we compared the prevalence of total maltreatment incidents and total victims, in states with and without PDMPs, before and after implementation. Exploratory analyses further examined models disaggregated by maltreatment type (neglect, physical abuse, sexual abuse, psychological abuse) and among different racial/ethnic groups. Quasi-Poisson models included state-level covariates, state- and year-fixed effects, and cluster-robust standard errors.


      Difference-in-differences models identified greater relative reductions in PDMP states relative to controls (total prevalence ratio, 0.87; 95% CI, 0.80, 0.940; victimization prevalence ratio, 0.92; 95% CI, 0.85-0.98) over the observation period. Decreases seemed to be driven by changes in neglect (prevalence ratio, 0.87; 95% CI, 0.80-0.93) and physical abuse (prevalence ratio, 0.78; 95% CI, 0.71-0.87) incidents, and may have been especially salient for American Indian/Alaskan Native children (prevalence ratio, 0.78; 95% CI, 0.65-0.94).


      We found evidence supporting an association between prescription drug monitoring and reduced maltreatment prevalence at the state level. Policies aimed at restricting the prescribing and dispensing of controlled substances may have indirect implications for child welfare.


      CAPTA (Child Abuse Prevention and Treatment Act), CPS (Child Protective Services), PDMP (Prescription drug monitoring program), SUD (Substance use disorder)
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        • Clemans-Cope L.
        • Lynch V.
        • Epstein M.
        • Kenney G.M.
        Opioid and substance use disorder and receipt of treatment among parents living with children in the United States, 2015-2017.
        Ann Fam Med. 2019; 17: 207-211
        • Lipari R.N.
        • Van Horn S.L.
        Children living with parents who have a substance use disorder. CBHSQ Report.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2013
        • Wildeman C.
        • Emanuel N.
        • Leventhal J.M.
        • Putnam-Hornstein E.
        • Waldfogel J.
        • Lee H.
        The prevalence of confirmed maltreatment among US children, 2004 to 2011.
        JAMA Pediatr. 2014; 168: 706-713
        • Finkelhor D.
        • Turner H.A.
        • Shattuck A.
        • Hamby S.L.
        Prevalence of childhood exposure to violence, crime, and abuse: results from the National Survey of Children’s Exposure to Violence.
        JAMA Pediatr. 2015; 169: 746-754
        • Petersen A.C.
        • Joseph J.
        • Feit M.
        New directions in child abuse and neglect research.
        The National Academies Press, Washington DC2014
        • Yi Y.
        • Edwards F.R.
        • Wildeman C.
        Cumulative prevalence of confirmed maltreatment and foster care placement for US children by race/ethnicity, 2011-2016.
        Am J Public Health. 2020; 110: 704-709
        • Hughes K.
        • Bellis M.A.
        • Hardcastle K.A.
        • Sethi D.
        • Butchart A.
        • Mikton C.
        • et al.
        The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.
        Lancet Public Health. 2017; 2: e356-e366
        • Brown D.S.
        • Fang X.
        • Florence C.S.
        Medical costs attributable to child maltreatment: a systematic review of short- and long-term effects.
        Am J Prev Med. 2011; 41: 627-635
        • Bunting L.
        • Davidson G.
        • McCartan C.
        • Hanratty J.
        • Bywaters P.
        • Mason W.
        • et al.
        The association between child maltreatment and adult poverty – a systematic review of longitudinal research.
        Child Abus Negl. 2018; 77: 121-133
        • Pinto Pereira S.M.
        • Li L.
        • Power C.
        Child maltreatment and adult living standards at 50 years.
        Pediatrics. 2017; 139: e20161595
        • Felitti V.J.
        • Anda R.F.
        • Nordenberg D.
        • Williamson D.F.
        • Spitz A.M.
        • Edwards V.
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study.
        Am J Prev Med. 1998; 14: 245-258
        • Radel L.
        • Baldwin M.
        • Crouse G.
        • Ghertner R.
        • Waters A.
        Substance use, the opioid epidemic, and the child welfare system: key findings from a mixed methods study.
        (ASPE Research Brief [updated 2018])
        • Freisthler B.
        • Kepple N.J.
        • Wolf J.P.
        • Curry S.R.
        • Gregoire T.
        Substance use behaviors by parents and the decision to substantiate child physical abuse and neglect by caseworkers.
        Child Youth Serv Rev. 2017; 79: 576-583
        • Price Wolf J.
        • Kepple N.J.
        • Freisthler B.
        Understanding the role of parental opiate or marijuana use in child welfare substantiation decisions.
        J Soc Work Pract Addict. 2019; 19: 238-261
        • Berger L.M.
        • Slack K.S.
        • Waldfogel J.
        • Bruch S.K.
        Caseworker-perceived caregiver substance abuse and child protective services outcomes.
        Child Maltreat. 2010; 15: 199-210
        • Morris M.C.
        • Marco M.
        • Bailey B.
        • Ruiz E.
        • Im W.
        • Goodin B.
        Opioid prescription rates and risk for substantiated child abuse and neglect: a Bayesian spatiotemporal analysis.
        Drug Alcohol Depend. 2019; 205: 107623
        • Ghertner R.
        • Waters A.
        • Radel L.
        • Crouse G.
        The role of substance use in child welfare caseloads.
        Child Youth Serv Rev. 2018; 90: 83-93
        • Wolf J.P.
        • Ponicki W.R.
        • Kepple N.J.
        • Gaidus A.
        Are community level prescription opioid overdoses associated with child harm? A spatial analysis of California zip codes, 2001-2011.
        Drug Alcohol Depend. 2016; 166: 202-208
        • Sumetsky N.
        • Burke J.G.
        • Mair C.
        Relationships between opioid-related hospitalizations and intimate partner violence and child maltreatment hospitalizations in Pennsylvania across space and time.
        J Interpers Violence. 2020 Aug 17; ([Epub ahead of print])
        • Quast T.
        • Bright M.A.
        • Delcher C.
        The relationship between foster care entries and high-dose opioid prescribing in California.
        Addict Behav. 2019; 93: 52-58
        • Quast T.
        • Storch E.A.
        • Yampolskaya S.
        Opioid prescription rates and child removals: evidence from Florida.
        Health Aff. 2018; 37: 134-139
        • Quast T.
        State-level variation in the relationship between child removals and opioid prescriptions.
        Child Abus Negl. 2018; 86: 306-313
        • Meinhofer A.
        • Angleró-Díaz Y.
        Trends in foster care entry among children removed from their homes because of parental drug use, 2000 to 2017.
        JAMA Pediatr. 2019; 173: 881-883
        • Berthelot N.
        • Lemieux R.
        • Maziade M.
        Shortfall of intervention research over correlational research in childhood maltreatment: an impasse to be overcome.
        JAMA Pediatr. 2019; 173: 1009-1010
        • Fink D.S.
        • Schleimer J.P.
        • Sarvet A.
        • Grover K.K.
        • Delcher C.
        • Castillo-Carniglia A.
        • et al.
        Association between prescription drug monitoring programs and nonfatal and fatal drug overdoses: a systematic review.
        Ann Intern Med. 2018; 168: 783-790
        • Strickler G.K.
        • Zhang K.
        • Halpin J.F.
        • Bohnert A.S.B.
        • Baldwin G.T.
        • Kreiner P.W.
        Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing.
        Drug Alcohol Depend. 2019; 199: 1-9
        • Mauri A.I.
        • Townsend T.N.
        • Haffajee R.L.
        The association of state opioid misuse prevention policies with patient- and provider-related outcomes: a scoping review.
        Milbank Q. 2020; 98: 57-105
        • Delcher C.
        • Pauly N.
        • Moyo P.
        Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019).
        Curr Opin Psychiatry. 2020; 33: 326-333
        • Puac-Polanco V.
        • Chihuri S.
        • Fink D.S.
        • Cerdá M.
        • Keyes K.M.
        • Li G.
        Prescription drug monitoring programs and prescription opioid-related outcomes in the United States.
        Epidemiol Rev. 2020; 42: 134-153
        • Schuler M.S.
        • Heins S.E.
        • Smart R.
        • Griffin B.A.
        • Powell D.
        • Stuart E.A.
        • et al.
        The state of the science in opioid policy research.
        Drug Alcohol Depend. 2020; 214: 108137
        • Martins S.S.
        • Ponicki W.
        • Smith N.
        • Rivera-Aguirre A.
        • Davis C.S.
        • Fink D.S.
        • et al.
        Prescription drug monitoring programs operational characteristics and fatal heroin poisoning.
        Int J Drug Policy. 2019; 74: 174-180
        • Delcher C.
        • Wang Y.
        • Wagenaar A.C.
        • Goldberger B.A.
        • Cook R.L.
        • Maldonado-Molina M.M.
        Prescription and Illicit opioid deaths and the prescription drug monitoring program in Florida.
        Am J Public Health. 2016; 106: e10-e11
        • Meinhofer A.
        Prescription drug monitoring programs: the role of asymmetric information on drug availability and abuse.
        Am J Heal Econ. 2018; 4: 504
        • Cerdá M.
        • Ponicki W.R.
        • Smith N.
        • Rivera-Aguirre A.
        • Davis C.S.
        • Marshall B.D.L.
        • et al.
        Measuring relationships between proactive reporting state-level prescription drug monitoring programs and county-level fatal prescription opioid overdoses.
        Epidemiology. 2020; 31: 32-42
        • U.S. Department of Health and Human Services Office of the Asssistant Secretary for Planning
        Opioid Abuse in the U.S. and HHS actions to address opioid-drug related overdoses and deaths.
        (ASPE Issue Brief)
        • Tipps R.
        • Buzzard G.
        • McDougall J.A.
        The opioid epidemic in Indian Country.
        J Law Med Ethics. 2018; 46: 422-436
        • United States Children’s Bureau
        Child Maltreatment 2018. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.
        Date: 2017
        Date accessed: September 10, 2021
        • Children’s Bureau
        NCANDS. Administration for Children and Families.
        • Horwitz J.R.
        • Davis C.
        • McClelland L.
        • Fordon R.
        • Meara E.
        The importance of data source in prescription drug monitoring program research.
        Health Serv Res. 2021; 56: 268-274
        • Wing C.
        • Simon K.
        • Bello-Gomez R.A.
        Designing difference in difference studies: best practices for public health policy research.
        Annu Rev Public Health. 2018; 39: 453-469
        • Colin Cameron A.
        • Miller D.L.
        A practitioner’s guide to cluster-robust inference.
        J Hum Resour. 2015; 50: 317-372
        • Hoef JM Ver
        • Boveng P.L.
        Quasi-Poisson vs. negative binomial regression: how should we model overdispered data.
        Ecology. 2007; 88: 2766-2772
      1. U.S. Department of Health and Human Services Administation on Children Youth and Families.
        (Child Maltreatment)
        • Jones L.
        • Finkelhor D.
        Updated trends in child maltreatment 2007. Crimes Against Children Research Center.
        • Zeileis A.
        Sandwich, Version 3.0-1. 2021 [cited 2021 Oct 8].
        • Kleiber C.
        • Zeileis A.
        AER: Applied Econometrics with R, Version 1.2-9. [cited 2021 Oct 8].
        • Griffin B.A.
        • Schuler M.S.
        • Stuart E.A.
        • Patrick S.
        • McNeer E.
        • Smart R.
        • et al.
        Moving beyond the classic difference-in-differences model: A simulation study comparing statistical methods for estimating effectiveness of state-level policies.
        ( 2020 Mar 26 [cited 2021 May 2])
        • Vestal C.
        In Cherokee Country, opioid crisis seen as existential threat. Pew Research Center.
        • Gihleb R.
        • Giuntella O.
        • Zhang N.
        The effect of mandatory access prescription drug monitoring programs on foster care admissions.
        J Hum Resour. 2019; 2019 (0918-9729R2)
        • Cunningham S.
        • Finlay K.
        Parental substance use and foster care: evidence from two methamphetamine supply shocks.
        Econ Inq. 2013; 51: 764-782
        • Quash-Mah S.
        • Stockard J.
        • Johnson-Shelton D.
        • Crowley R.
        Fulfilling the hope of ICWA: the role of community context.
        Child Youth Serv Rev. 2010; 32: 896-901
        • Hall M.T.
        • Wilfong J.
        • Huebner R.A.
        • Posze L.
        • Willauer T.
        Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system.
        J Subst Abuse Treat. 2016; 71: 63-67
        • Lundgren L.M.
        • Fitzgerald T.
        • Young N.
        • Amodeo M.
        • Schilling R.F.
        Medication assisted drug treatment and child well-being.
        Child Youth Serv Rev. 2007; 29: 1051-1069