Nationally, rates of drug overdose deaths and drug-related hospitalizations have a statistical relationship with child welfare caseloads (that is, rates of child protective services reports, substantiated reports, and foster care placements). Generally, counties with higher overdose death and drug hospitalization rates have higher caseload rates. In addition, these substance use indicators correlate with rates of more complex and severe child welfare cases. Availability and use of substance use treatment: Several major challenges affect how child welfare agencies and families interact with substance use treatment options, including medication-assisted treatment for opioid use disorder. Family-friendly treatment options are limited, and caseworkers, courts, and other providers often misunderstand how treatment works and lack guidelines on how to incorporate it into child welfare practice. System response: Child welfare agencies and their community partners are struggling to meet families’ needs. Haphazard substance use assessment practices, barriers to collaboration with substance use treatment providers and other stakeholders, and shortages of foster homes and trained staff undermine the effectiveness of agencies’ responses to families.