Texas Child Protection Law Bench Book

Updated September 2025

Substance Use Disorders

A. Statewide Overview of Substance Use

The impact of a Substance Use Disorder (SUD) on the family and individual family members merits attention, as each family and each family member is uniquely affected by the person using substances. Impacts of substance use on the family may include financial challenges, legal problems, and emotional distress.[151]According to the National Center on Substance Abuse and Child Welfare parental substance use was a condition associated with removal in 76.7% of children under the age of one and 62.6% of children over the age of one in Texas in 2021.[152]

1. Relevant Trends

According to the Department of State Health Services, in 2023 there were over 4,900 deaths due to Unintentional Drug Poisoning in Texas.[153] Additionally, data from the 2023 Treatment Episode Data Set showed the top six primary substances among admissions to treatment services in Texas included Alcohol, followed by Methamphetamines, Heroin, Other Opiates/Synthetics, Marijuana/Hashish, and Cocaine.[154] Texas Health and Human Services Commission (HHSC) funds an array of substance use services to help individuals and families address substance use and misuse. For more information, please visit HHSC Substance Use Disorder Services webpage.

For information about drug-related deaths and trends in Texas, please visit the Department of State Health Services Texas Health Data Dashboard.[155]

2. Useful Definitions:

•   Substance Use: The use—even one time—of any substance.[156]

•   Substance Misuse: The use of any substance in a manner, situation, amount, or frequency that can cause harm to users or to those around them. For some substances or individuals, any use would constitute misuse (e.g., under-age drinking, injection drug use).[157]

•   Substance Use Disorder (SUD): A medical illness caused by repeated misuse of a substance or substances. According to the DSM-5, substance use disorders are characterized by clinically significant impairments in health, social function, and impaired control over substance use and are diagnosed through assessing cognitive, behavioral, and psychological symptoms.[158]

•   Recovery: a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. The process of recovery is highly personal and occurs via many pathways. It may include clinical treatment, medications, faith-based approaches, peer support, family support, self-care, and other approaches. Recovery is characterized by continual growth and improvement in one's health and wellness and managing setbacks. Because setbacks are a natural part of substance use, resilience becomes a key component of recovery.[159]

Every public health region in Texas has an Outreach, Screening, Assessment and Referral (OSAR) program which can assist any Texas resident with finding appropriate treatment and community resources. To find local resources and additional assistance, please visit the HHSC OSAR webpage.[160] Individuals can also locate substance use services in their area by visiting the Health and Human Services - Substance Use Service Locations map.[161]

B. Pregnant Women and Relapse Prevention and Safety Plans

1. Pregnant Women and Substance Use

Neonatal abstinence syndrome (NAS) is a treatable condition that newborns may experience as a result of prenatal exposure to certain substances, most often opioids. Neonatal Opioid Withdrawal Syndrome (NOWS) is a related term that refers to the symptoms that infants may experience as a result of exposure to opioids.[162] Pregnant women using opioids should not discontinue opioid use due to the risk of maternal return to use, overdose, withdrawals, and fetal demise. The American College of Obstetricians and Gynecologists (ACOG) and SAMHSA recommend Medications for Opioid Use Disorder (MOUD), previously referred to as Medication Assisted Treatment or MAT, as a best practice in managing an opioid use disorder in pregnancy.[163] Research also indicates women with substance use disorder should continue their opioid agonist pharmacotherapy (MOUD) postpartum. The postpartum period represents a time of increased vulnerabilities, and women with opioid use disorder experience recurrence far more often in the postpartum period compared with during pregnancy.[164]

Since 1994, SAMHSA has designated pregnant women as a federal priority population in SUD treatment services. To better meet the needs of this priority population HHSC has a variety of substance use treatment services specifically designed to treat pregnant women and women with dependent children including withdrawal management, residential and outpatient treatment, and Medications for Opioid Use Disorder.

Special Issue: “Medication for Opioid Use Disorder” (MOUD) is the recommended term to replace MAT. “Return to use” is the recommended term to avoid shame and stigma associated with the term “relapse,” however “relapse” and “relapse prevention” are still commonly used terms.

2. Recurrence/Return to Use Prevention

According to the National Center on Substance Abuse and Child Welfare, research shows medications used in MOUD, when provided at the proper dose, have no adverse effects on a person's intelligence, mental capability, physical functioning, or employability. Medications for Opioid Use Disorder, along with a range of clinical and supportive services, can help people achieve stability while focusing on other aspects of their recovery, such as finding work, housing, or enhancing their parenting skills.[165]

At this time, there are no standardized resources statewide for the Department of Family and Protective Services (DFPS). Department of Family and Protective Services accesses state-funded and community resources that offer individualized treatment approaches to meet the needs of parents and families. Relevant DFPS policy states the following regarding recurrence (relapse) prevention planning:

•   Relapse is a return to a pattern of substance use after a period of non-use.

•   In the relapse safety plan, the person, along with a trusted support system, plans to ensure the safety of the child or children in case relapse becomes an issue.

•   Court orders supersede any actions that the person requests in the relapse safety plan.

•   A relapse safety plan can be developed at any stage of service.”

Please see Developing a Safety Plan in Case a Client Relapses CPS Policy Handbook § 1982.2 for more information.[166]

C. DFPS Response to Substance Use Disorders

The Child Abuse Prevention and Treatment Act (CAPTA) (P.L. 93-247) was originally enacted in 1974, was last reauthorized in 2010, and amended most recently in 2019; additionally, certain provisions were amended by the Comprehensive Addiction and Recovery Act (CARA) of 2016 and the Victims of Child Abuse Act Reauthorization Act of 2018 (P.L. 115-424).[167]

Under these federal laws, states are required to have plans of safe care for infants born and identified as being affected by substance use or withdrawal symptoms of both legal and illegal substances. The plans of safe care are required to “ensure the safety and well-being of such infant following [the infant's] release from the care of healthcare providers” to be achieved through “addressing the health and substance use disorder treatment needs of the infant and affected family or caregiver.” 42 U.S.C.S. § 5106a(b)(1)-(2).

To avoid confusion, DFPS does not utilize the unique federal term “plan of safe care” as set forth in CARA, as there are a number of DFPS tools and policies that reference “plans.” Statewide Intake protocols, safety and risk assessment tools, and the service planning process used in different stages of service, collectively mean that the state meets the requirements under the CARA plans of safe care.

Examples of types of plans that do not include removal include: use of Parental Child Safety Placements (PCSP) to assure safety as the parent initiates or becomes engaged in services; use of residential substance use disorder treatment programs that allow a mother (or father in a few programs) to live in a treatment setting with the child, when appropriate; use of Medication-Assisted Treatment in combination with behavioral therapies; and the guidance of specialized drug courts in some areas. While access to treatment can be challenging, families referred by DFPS are considered a state priority population for state-funded substance use intervention and treatment services. In Texas, a client who is not pregnant and is referred to an HHSC-funded substance use intervention or treatment service by DFPS must be admitted to services within 72 hours or 3 business days, depending on the program or services.

Doctors and nurses are required by mandatory reporting laws to report suspected child abuse and neglect if they have reasonable cause to believe the child has been abused as defined by statute. Tex. Fam. Code § 261.101(b). Definitions of child abuse in Texas law include the current use of controlled substances by an adult in a manner or to the extent that the use results in physical, mental, or emotional injury to a child. Tex. Fam. Code § 261.001(1)(I).

DFPS Statewide Intake advances any reports of substance-exposed infants to the field for an investigation. During the investigation, multiple steps occur including: a child assessment, parental assessment, holistic family assessment, safety planning, and the development of initial services. In some cases, the parent has sufficient support and is protective and/or engaged in treatment services, thereby eliminating the need for further DFPS involvement beyond investigation. Other parents may be assisted in development of a plan and access to services during the investigation stage of services, or a Family-Based Safety Services (FBSS) stage may be opened to provide ongoing services without removal. Where safety cannot be assured, DFPS will seek removal of the infant.

Special Issue: The birth of a substance-exposed infant does not result in an automatic removal of that child, nor even an automatic disposition of child abuse or neglect. Each family's specific circumstance is assessed. DFPS works closely with Health and Human Services agency partners who provide substance use intervention or treatment services to strengthen the State's response to parents who engage in substance use or misuse.

1. Behavioral Health Division at DFPS

DFPS has a Behavioral Health Services Division within CPS, with Behavioral Health and Substance Use Disorder Specialists spread throughout the state. The division is part of a broader CPS Medical Services Division that supports staff meeting medical, behavioral health, and dental needs for children in DFPS conservatorship. The Behavioral Health Division also provides support and subject matter expertise to staff in Family-Based Safety Services, where children are not in DFPS conservatorship. The combined Medical and Behavioral Health teams assist legacy and SSCC direct delivery staff with access to Medicaid services (STAR Health) and other public behavioral health services available to children and families. The broader team includes Well-Being Specialists, Nurse Consultants, CANS Program Specialist, and supporting staff. These positions complement two additional Substance Use Program Specialists and two Mental Health Program Specialists who report to Child Protective Investigations. The combined team works together to overcome barriers to services, and provide support, resources, and technical assistance to direct delivery staff in their work with families and youth through every stage of service.

D. Resources

•   American Addiction Centers' Information on Addiction Signs, Symptoms, Effects, and Treatment[168] and Addiction Cravings: Symptoms, Treatment and Relapse Prevention[169]

•   Children and Family Futures[170]

•   Child Welfare Information Gateway Information on Family Treatment Drug Court[171]

•   National Center on Substance Abuse and Child Welfare (NCSACW)[172]

•   National Council of Juvenile and Family Court Judges Substance Use and the Courts (NCJFCJ)[173]

•   National Institute on Drug Abuse[174]

•   Substance Abuse and Mental Health Services Administration (SAMHSA)[175]

•   Texas Health and Human Services Mental Health and Substance Use