Clinicians face the prospect of mandated reporting when a patient reports, either during the intake appointment or during the course of addiction treatment, their risky substance use-related behavior around a child. Beyond legal considerations, many factors might influence a clinician’s decision whether or not to report the case to child protective services (CPS). Although there is literature regarding mandated reporting in the setting of pre- or perinatal substance use, there is limited literature regarding the mandated reporting obligation in the setting of postnatal substance use around children. We survey the relevant statutes and regulations in the 51 jurisdictions of the United States regarding postnatal mandated reporting for substance-related parental abuse and neglect. Drawing from these results, we identify areas of legal obligation, areas open to interpretation, and areas that remain unaddressed. We further propose a clinical framework for determining whether to make a CPS report in the course of addiction treatment. In the current state of significant variability in mandated reporting regulation, clinicians must consider the safety of the child, the well-being of the family, stigma toward individuals with substance use disorder, maintenance of the conditions necessary for the patient to engage with addiction treatment, and what the law requires.