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Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Final Report

Publication Date

Ellen Bouchery

Mathematica Policy Research

December 5, 2017

Printer Friendly Version in PDF Format (101 PDF pages)


ABSTRACT

Federal policies implemented in the last decade, including the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act, have promoted insurance coverage for substance use disorders (SUDs). By providing funding for treatment services, these federal policies were intended to increase the proportion of individuals with SUDs who seek and receive evidence-based treatments. This report presents findings of a study to better understand how federal policies implemented in the past decade which promoted insurance coverage of substance use disorder treatment changed demand for treatment. In the same time period, the study looked at changes in capacity using national survey data, including new questions which were fielded with the National Survey of Substance Abuse Treatment Services on types of professionals in the field. A significant challenge still remains in increasing the demand for treatment among those with a substance use disorder or dependence, and in providing an adequate workforce.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization

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ACRONYMS

The following acronyms are mentioned in this report and/or appendices.

ACA Affordable Care Act
 
BLS Bureau of Labor Statistics
 
CL Confidence Limit
CMS HHS Centers for Medicare and Medicaid Services
 
DSM-IV-TR   Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision  
 
FP For-Profit
FTE Full-Time Equivalent
 
HHS U.S. Department of Health and Human Services
HIV Human Immunodeficiency Virus
 
IAP Innovation Accelerator Program
IC&RC International Certification and Reciprocity Consortium
 
MH Mental Health
MHPAEA Mental Health Parity and Addiction Equity Act
 
N-SSATS National Survey of Substance Abuse Treatment Services
NA Not Available
NAADAC National Association for Alcoholism and Drug Abuse Counselors
NP Non-Profit
NSDUH National Survey on Drug Use and Health
 
OES Occupation Employment Survey
OTP Opioid Treatment Program
 
SAMHSA HHS Substance Abuse and Mental Health Services Administration
SUD Substance Use Disorder
 
TEDS Treatment Episode Data Set

EXECUTIVE SUMMARY

Despite federal policies enacted within the last decade aimed at promoting insurance coverage for substance use disorders (SUDs), the existing SUD treatment workforce may be insufficient to accommodate the potential increase in demand for care and other factors may be contributing to stagnant treatment utilization rates. To address this concern, in September 2014, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation contracted with Mathematica Policy Research to conduct this project to assess current demand for SUD treatment and the state of provider capacity in the SUD treatment field. The key study findings on the demand for and supply of SUD treatment are summarized below.

Demand for SUD Treatment

Uninsured rate among individuals with SUD declined following ACA implementation.

The uninsured rate among individuals 12-64 with an SUD declined to 20 percent in 2014 from an average rate of 25 percent between 2009 and 2013. Most of this decline resulted from an increase in the rate of Medicaid enrollment, from 13 percent between 2009 and 2013 to 18 percent in 2014. This change added about 1 million individuals with SUDs to the Medicaid program.

Nevertheless, the rate of SUD treatment receipt did not increase substantially in the initial years following implementation of the ACA.

Despite the increase in insurance coverage among individuals with SUDs, evidence from multiple data sources indicates there has been no or only a small increase in treatment service use since the beginning of 2014.

Overall treatment use has remained constant, according to the National Survey on Drug Use and Health (NSDUH). According to aggregate estimates from the NSDUH, the number of individuals receiving any SUD treatment in the past year remained constant between 2004 and 2014, at about 4 million individuals (Figure ES.1). About 60 percent of these individuals (2.2-2.6 million individuals per year) received treatment in a specialty setting, which the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) defined as any of the following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers.1 Because of methodological changes in the NSDUH survey implemented in 2015, the survey's estimate of 3.7 million and 2.3 million individuals receiving any and specialty treatment, respectively, in 2015 are not comparable to estimates from earlier years. According to NSDUH, between 2015 and 2016 there was again no significant change in the number of individuals receiving any and specialty treatment in the past year.

FIGURE ES.1. Number of Individuals Who Received Any Treatment or Specialty Treatment, NSDUH 2004-2014
FIGURE ES.1, Line Chart: There are two series displayed. A dark blue line shows the number of individuals receiving any treatment for substance use disorders has remained relatively constant between 2004 and 2014 at about 4 million individuals. A light blue line indicates the number of Individuals receiving specialty treatment has also remained relatively constant between 2004 and 2014, varying slightly between 2.2 and 2.6 million individuals in a given year.
SOURCE: NSDUH 2004-2014.

National Survey of Substance Abuse Treatment Services (N-SSATS) counts of clients in treatment indicate a small increase in the number of clients in care. In contrast to the NSDUH, which measures whether a person had any treatment in the past year based on person-level responses, N-SSATS measures counts of clients in care at a point-in-time as reported by specialty SUD treatment facilities.2

N-SSATS client counts indicate a small increase in the number of clients in care between 2013 and 2015 (4.5 percent over two years), or about 56,000 individuals. About 40 percent of the growth was related to increases in inpatient hospital (which had a change of 65.6 percent) and residential care (which had a change of 11.3 percent) (Table ES.1). The increases in hospital use align with sharp increases in opioid overdoses (Rudd et al. 2016) and opioid-related admissions to intensive care units3 observed in this period. Because NSDUH excludes institutionalized individuals from its sample, N-SSATS is a more accurate source of trends in institutional service use.

The lack of change in the population with service use in the past year based on NSDUH suggests that the increase in point-in-time outpatient clients observed in N-SSATS stems from a longer duration of care. Overall, the estimated increase in SUD treatment use was minimal relative to the increases in insurance coverage and the level of unmet treatment needs.

TABLE ES.1. Number of Clients by Setting of Care, N-SSATS 2013 and 2015
Type of Care Within Setting 2013 2015 % Change
Total 1,249,629 1,305,647 4.5%
Outpatient 1,127,235 1,161,456 3.0%
Residential (non-hospital) 107,727 119,900 11.3%
Hospital inpatient 14,667 24,291 65.6%
SOURCE: N-SSATS 2013 and 2015.
NOTE: N-SSATS surveys the universe of specialty SUD treatment facilities. In 2013 and 2015, respectively, the survey had a 94% and 92% response rate. Estimates are not adjusted for facility or item non-response. For inpatient and residential services counts indicate the number of clients in treatment on the last working day in March of each survey year. For outpatient services counts indicate the number of clients receiving services during March who are still enrolled in treatment on the last working day in March.

Lack of perceived need for treatment presents challenges in providing treatment services to those with SUDs.

Increasing treatment use for individuals with SUDs has the potential to substantially improve their welfare and that of their families as well as reduce societal and economic losses associated with SUDs, such as criminal justice costs, productivity loss, and mortality and morbidity due to accidents. The increased insurance coverage provided through recent federal policy initiatives resulted in, at most, small increases in treatment use. An important reason insurance coverage did not result in a significant expansion in treatment use is that, according to the 2015 NSDUH (Lipari et al. 2016), 95.4 percent of individuals who met criteria for an SUD but who did not receive specialty treatment (19.3 million people) did not feel they needed treatment. Among the remaining small percentage (4.6 percent, or 880,000 people) who felt they needed treatment but did not get it, 64.4 percent (about 567,000 people) reported making no effort to get treatment. Thus, expanding treatment use will require a multifaceted approach including changing attitudes about alcohol misuse and illicit drug use, increasing public awareness of treatment effectiveness, reducing stigma associated with SUD treatment, addressing financial barriers, and increasing primary care physicians' role in screening, treatment and referral.

Supply of SUD Treatment

The SUD treatment workforce comprises counselors, medical professionals, and support staff.

The 2016 N-SSATS survey found 197,559 full-time equivalent (FTE)4 paid staff and 6,726 unpaid staff in specialty SUD treatment facilities in 2016.5 About two-fifths of the FTE paid staff were counseling staff (that is, no-degree or degreed counselors); the other three-fifths were about evenly divided between medical staff (that is, physicians, nurses, pharmacists, and mid-level professionals), other support staff (that is, peer support staff, care managers, care navigators, other recovery support staff, other clinical staff and interns, pharmacy assistants, contractors/per diem staff, and intake coordinators), and administrative staff. A substantial majority of counseling staff FTEs (57 percent) had a graduate degree, but most counseling staff members with a graduate education were not certified in addiction treatment (60 percent).

FIGURE ES.2. Hours of Care per 100 Outpatient Clients per Week, by Facility Characteristics, N-SSATS 2016
FIGURE ES.2, Bar Chart: Each bar represents the number of hours of care provided by non-administrative staff per 100 outpatient clients per week for a subgroup of facilities. There are three sets of bars. The first set shows the distinction between urban and rural facilities, with urban facilities administering 278 hours of care per 100 outpatient clients per week, and rural facilities administering 370 hours of care per 100 outpatient clients per week. The second set shows the distinction between facilities that provide recovery support services and those that do not, with facilities providing recovery support services administering 373 hours of care per 100 outpatient clients per week, and facilities that do not provide recovery support services administering 269 hours of care per 100 outpatient clients per week. The final set shows the distinction between facilities that focus on substance use disorder treatment, mental health treatment, or both. Facilities that focus on substance use disorder treatment administer 193 hours of care per 100 outpatient clients per week, facilities that focus on mental health treatment administer 1,000 hours of care per 100 outpatient clients per week, and facilities that focus on both administer 405 hours of care per 100 outpatient clients per week.
SOURCE: N-SSATS 2016.
NOTE: Hours of care include only non-administrative staff time.

Outpatient treatment intensity varies based on facility characteristics.

On average, non-administrative staff provided 292 hours of care per 100 clients in outpatient treatment per week. The intensity of treatment varied substantially based on facility characteristics and services offered (Figure ES.2). Statutes and regulations for SUD treatment facilities vary by state and commonly allow facilities substantial flexibility in the professional credentials and intensity of services provided by staff (National Association of State Alcohol and Drug Abuse Directors 2013). There is little research on how staffing affects care quality.

The availability of evidence-based pharmacotherapy has increased, but challenges to further expansion remain.

Pharmacotherapy has been demonstrated to be clinically effective and cost effective for alcohol and opioid disorders (Baser et al. 2011; Mann et al. 2015). Although strong evidence suggests that the use of pharmacotherapy in managing SUDs provides substantial cost savings, the approach has not been widely adopted. The proportion of facilities offering pharmacotherapy has expanded in recent years, but still only 43 percent of facilities offered any pharmacotherapies in 2016.

FIGURE ES.3. Staff Hours of Care per 100 Outpatient Clients per Week, by Whether Facility Provided Pharmacotherapy, N-SSATS 2016
FIGURE ES.3, Stacked Bar Charts: Providing Pharmacotherpy includes Recovery support and other (39), Counselors (147), Nurses (32), and Prescribers (24).  Not Providing Pharmacotherpy includes Recovery support and other (74), Counselors (284), Nurses (14), and Prescribers (22).
SOURCE: N-SSATS 2016.
NOTE: Hours of care include only non-administrative staff time. Counselors include no-degree and degreed counselors. Nurses include registered and licensed practice nurses. Prescribers include physicians and mid-level medical staff.

Many of the barriers to expansion of pharmacotherapy are related to the workforce. The number of medical staff qualified to provide pharmacotherapy services and the staff supporting them needs to increase for provision of pharmacotherapy to expand. Training primary care providers to provide pharmacotherapy in primary care or other integrated care settings such as HIV or mental health treatment settings can improve treatment access and abstinence at six months (NIDA 2017; Korthuis et al. 2017). Primary care providers can act independently or work collaboratively with SUD treatment specialist in these models. In addition to increasing the number of qualified providers, workforce attitudes preferring behavioral therapies may need to change to attain more widespread adoption. Consistent credentialing and licensure requirements across states and insurers for professionals providing pharmacotherapy services are also needed. The HHS Opioid Strategy announced in April 2017 aims to continue the department's efforts to improve access to "treatment, and recovery services, including the full range of medication-assisted treatments" (HHS 2017); also, despite the barriers, the ACA has resulted in expansions in the number of physicians waivered to prescribe buprenorphine (Knudsen et al. 2015).

There were substantial differences in staffing patterns for outpatient treatment based on whether facilities offered pharmacotherapy (Figure ES.3). Facilities that did not offer pharmacotherapy provided nearly twice as many counselor and recovery support staff hours and about half as many nursing staff hours per 100 outpatient clients. Facilities provided a similar number of prescriber hours (including physician and mid-level medical staff) regardless of whether they provided pharmacotherapy.

Residential and inpatient hospital capacity for SUD treatment is insufficient in many states.

Despite increases in designated beds for residential and inpatient hospital SUD treatment between 2013 and 2015, utilization rates rose in these care settings. Nationally, the utilization rate for residential beds increased from 97 percent to 106 percent; that for inpatient hospital beds increased from 97 percent to 109 percent.6 In 18 states, residential bed utilization rates across all facilities were over 100 percent in 2015; the same number of states had inpatient bed utilization rates of over 100 percent.

Treatment provision at publicly operated facilities declined while care at privately operated facilities increased.

Between 2013 and 2015 clients served in public facilities declined substantially for outpatient care (13.7 percent) and somewhat for residential care (4.3 percent). Meanwhile clients served in private for-profit and private non-profit facilities expanded in these settings. This shift may be related to increased rates of insurance coverage. Inpatient clients increased substantially for facilities of all operation types.

The number of clients served in rural areas declined substantially although the population in rural areas was constant.

The number of clients receiving treatment in rural areas declined substantially (31.8 percent) and increased in urban areas (15.6 percent) between 2013 and 2015, the latest period of data available. Meanwhile, the population living in rural areas was fairly constant in this period while the population living in urban areas increased modestly (U.S. Department of Agriculture 2016). Given the treatment access barriers for individuals living in rural areas that pre-date this period, the substantial declines in treatment use in rural areas warrant further investigation.

Low wages for SUD treatment providers present challenges in expanding the workforce.

Although most SUD counselors and social workers providing SUD treatment hold post-graduate degrees, analyses of data from the Bureau of Labor Statistics show that average hourly wages for SUD treatment professionals are substantially below the average wage across all occupations and the difference between the average wage for all occupations and that for counselors has widened over the last decade, from $1.56 per hour in 2006 to $2.63 per hour in 2016. Looking at two health care professions requiring similar or fewer years of education mean hourly wages for SUD counselors were $5 and $13 lower, respectively, than those for marriage and family therapists and registered nurses.

Currently, high turnover and difficulty in hiring qualified SUD treatment staff are attributed by facility administrators to low compensation (Hyde 2013; Ryan et al. 2012; Bukach et al. 2017). Efforts to increase the supply of individuals seeking work in the SUD treatment field by increasing training program output without an associated increase in reimbursement for services or increases in funding sources are likely to result in reduced wage levels and lower retention as individuals in the SUD treatment field recognize the potential to increase their earnings by shifting to other professions.

Discussion

Policymakers at all levels of government have targeted increasing SUD treatment to address escalating drug overdose deaths related to the opioid epidemic and improve societal welfare. Meanwhile, rates of SUD treatment use generally have been constant for more than a decade despite the substantial recent increase in insurance coverage for SUD treatment. Individuals with SUD treatment needs overwhelmingly indicate that they do not feel a need for treatment and, even among the small minority who believe that they might benefit from treatment, most make no effort to obtain it. Increasing treatment penetration will require a multifaceted approach to identify and refer individuals in need to treatment, reduce treatment access barriers, and reduce stigma and change attitudes about SUDs and treatment efficacy.

Overall, the role of Medicaid in funding SUD treatment services has expanded since the beginning of 2014. There is concern that low reimbursement rates and restrictive treatment coverage under Medicaid may be a barrier to expanding treatment in some states (Dickson 2015). State Medicaid programs have the potential to play an important role in transforming the SUD treatment system and the HHS Centers for Medicare and Medicaid Services (CMS) is taking an active role encouraging states to make reforms. CMS is conducting an Innovation Accelerator Program (IAP) to support state efforts to improve care quality and continuity, enhance performance monitoring capacity, identify beneficiaries in need of treatment, develop a continuum of care that addresses the variety treatment needs and the chronic nature of SUDs, and target reimbursement models to incentivize better outcomes (CMS 2017). In addition, CMS has been working with states to improve access to and quality of SUD treatment through Medicaid Section 1115 demonstrations (CMS 2017b).

The impact of a number of recent federal efforts to increase SUD treatment use and the quality of SUD treatment services is not fully captured in the data available for this study. The initiatives include the CMS IAP as well as several SAMHSA grant programs intended to expand access to SUD treatment (McCance-Katz et al. 2017). There are also a number of federally-funded efforts to expand access to SUD screening and treatment in primary care settings and rural areas. Future years of data should be monitored to assess the impact of these initiatives.

I. INTRODUCTION

A. Purpose of Report

Despite federal policies enacted within the last decade aimed at promoting insurance coverage for substance use disorders (SUDs), the exiting SUD treatment workforce may be insufficient to accommodate the potential increase in demand for care and other factors may be contributing to stagnant treatment utilization rates. The Affordable Care Act (ACA) specifically required subsidized marketplace insurance plans, individual and small group market plans, and Medicaid expansion programs to cover SUD treatment as an essential health benefit. Two years before passage of the ACA, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) began requiring private insurance plans that included behavioral health benefits and were offered through large group insurers to cover those services on a par with medical/surgical care (Humphreys and Frank 2014; Beronio et al. 2014).

Providing insurance coverage for SUD treatment is intended to reduce financial barriers to treatment use and thereby increase the proportion of individuals with SUD treatment needs who seek and receive evidence-based care. However, the existing SUD treatment workforce may be insufficient to accommodate an increase in demand for care and other factors may be limiting treatment utilization. To address this concern, in September 2014, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation contracted with Mathematica Policy Research to assess: (1) the current demand for SUD treatment; (2) how demand will change as more people obtain insurance coverage for this treatment; (3) the current state of capacity in the SUD treatment field; and (4) the degree to which treatment providers are prepared for integration into the broader health care system.

A previous report from this study (Bouchery et al. 2015) reviewed and analyzed the available literature and data on SUD prevalence, treatment, and workforce capacity, and incorporated information obtained through expert interviews. In the current report, we supplement the findings from the previous report with analyses of newly collected survey data on the size and characteristics of the workforce. We also reassess supply and demand trends described in the previous report, incorporating newly available data for the period following the insurance expansions that began in 2014. The following research questions guided our analyses:

1. Demand-Related Questions

  • How many people are receiving SUD treatment services, and what services are they receiving?

  • How does service receipt vary geographically?

  • What is the relationship between prevalence of SUDs and demand for care? How does this relationship vary geographically?

  • What evidence exists about how increases in Medicaid enrollment have impacted demand?

2. Supply-Related Questions

  • What are the professions and SUD treatment credentials of the current workforce?

  • What is the current capacity of service providers to supply SUD treatment services? How does provider capacity differ across geographic areas? What disparities in care access are evident (for example, by region or subpopulation)? How does provider capacity differ in relation to various services, such as inpatient, residential, intensive outpatient, outpatient, and pharmacotherapy?

  • What is the current capacity of SUD treatment organizations to participate in efforts to integrate SUD treatment within the broader health care system? To what degree are SUD treatment providers used to billing Medicaid?

  • How have wages for SUD treatment staff changed over the last decade?

B. Report Methods

We conducted the study in two phases:

  • In Phase 1, from October 2014 through December 2015, we: (1) assessed available data sources to answer the research questions and analyzed relevant data from these sources; (2) reviewed and summarized findings from the existing professional literature that addressed the questions; (3) interviewed selected experts; and (4) developed supplemental questions regarding the workforce to be fielded with an existing survey of SUD treatment facilities in 2016.

  • In Phase 2, from September 2015 through November 2017: (1) the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) fielded the SUD workforce survey questions we developed, and we analyzed the results; and (2) we updated the analyses we conducted in the first phase to include newly released data so as to identify more recent trends.

Below, we briefly summarize the methods we used in conducting the study.

1. Review and Analysis of Existing Data Sources

We reviewed pre-existing sources of data regarding SUD treatment supply and demand, and identified the strengths and limitations of each. Based on this analysis, we determined which data sources were most relevant for describing the current state of and relevant trends in the supply of and demand for SUD treatment services. We obtained these data, analyzed them, and presented the results in our previous report. For the current report, we extended the analyses of selected trends for which more recent data have since become available. Appendix A provides a brief overview of the data sources analyzed in this study.

2. Literature Review

Using a defined set of key words, we searched the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Scopus, and PubMed databases for literature published from 2005 through November 2014 on the following topic areas:

  • Current demand for SUD treatment services.

  • Trends and policies impacting demand over the next decade.

  • Previous efforts to estimate the size and composition of the SUD workforce.

  • Recruiting and developing the workforce.

We also used Google to search for important studies in the gray literature. We reviewed the publication information and abstracts retrieved for relevance to our study and strength of the methodology used. We then obtained the studies most likely to provide evidence related to the four topic areas of interest and extracted relevant information from each.

3. Expert Interviews

In May and June of 2015, we interviewed three SUD workforce experts. First, we interviewed the executive director of the International Certification and Reciprocity Consortium (IC&RC), which develops standards and examinations that its local boards across the country use for credentialing and licensing. The director responded to our interview questions orally and provided written responses to the questions in our interview guide from local board staff in Louisiana, Minnesota, North Carolina, and Ohio. Next, we interviewed the executive director of the National Association for Alcoholism and Drug Abuse Counselors (NAADAC), an association for professionals in the SUD treatment workforce that also develops examinations for certifications. We conducted the third interview with the senior vice president of public policy and practice improvement for the National Council for Behavioral Health, an association of behavioral health provider organizations.

The interviews with the IC&RC and NAADAC representatives addressed trends in addiction provider certification and training programs; state requirements for licensing and certification; and recent changes in the workforce, including those associated with the ACA and MHPAEA. The interview with the National Council for Behavioral Health representative addressed the following topics:

  • Providers' experiences related to implementation of the ACA and MHPAEA.

  • How providers have adapted to the availability of expanded Medicaid and private insurance coverage for SUD treatment.

  • Barriers providers have identified related to supporting patient treatment through insurance coverage.

  • The most pressing concerns for providers related to training programs for SUD treatment professionals, recruitment and hiring of qualified staff, and retention of existing staff.

  • Those state-level differences in licensing/credentialing policies or professional certification requirements that have an important impact on the availability of SUD treatment programs or program staffing patterns.

The experts did not have data available to support responses to most questions and thus could provide only anecdotal information. They also were not able to address all topics identified. IC&RC and NAADAC representatives indicated that state board representatives might have information to address particular questions, but this information typically is not passed on to the national organization.

4. National Survey of Substance Abuse Treatment Services (N-SSATS) 2016 Supplemental Workforce Questions

Because no data had been collected on the size and composition of the SUD workforce since the late 1990s, we developed supplemental questions about them that were added to the 2016 N-SSATS, which surveys all specialty SUD treatment facilities in the United States and its territories. The supplemental questions asked facilities to identify, by profession, the total number of staff, staff hours worked in a week, and the number of paid and non-paid staff certified in addiction treatment.7

II. DEMAND FOR SUBSTANCE USE DISORDER TREATMENT

In this section, we examine recent trends in receipt of SUD treatment services by service type and geography. Then we analyze the relationship between the prevalence of SUDs and use of treatment services by type of SUD and geographic area. Last, we look specifically at the relationship between Medicaid coverage expansion and receipt of SUD treatment.

A. How Many People are Receiving SUD Treatment Services and What Services are They Receiving?

Here we analyze information on the number of people receiving SUD treatment services and the type of services they receive as derived from multiple data sources. Based on the National Survey on Drug Use and Health (NSDUH), we begin by looking at whether individuals used any services in the past year and the type of services they used. Then we analyze the number of clients in care at a given point-in-time by service type, based on the N-SSATS. Finally, we assess trends in the distribution of admissions by primary substance.

FIGURE II.1. Number of Individuals Who Received Any Treatment or Specialty Treatment, NSDUH 2004-2014
FIGURE II.1, Line Chart: There are two series displayed. A dark blue line shows the number of individuals receiving any treatment for substance use disorders has remained relatively constant between 2004 and 2014 at about 4 million individuals. A light blue line indicates the number of Individuals receiving specialty treatment has also remained relatively constant between 2004 and 2014, varying slightly between 2.2 and 2.6 million individuals in a given year.
SOURCE: NSDUH 2004-2014.

1. Trends in Receipt of Any or Specialty SUD Treatment in Past Year

We use data from the NSDUH to analyze trends in SUD treatment use in the community-based population in the United States. According to the NSDUH, the number of individuals receiving any SUD treatment in the past year was relatively constant between 2004 and 2014, at about 4 million individuals (Figure II.1).

TABLE II.1. Number of Individuals Who Received Any Treatment or Specialty Treatment, NSDUH 2015-2016
Type of Treatment 2015 2016
Any treatment in past 12 months 3.7 3.8
Specialty treatment in past 12 months 2.3 2.2
SOURCE: NSDUH 2015 and 2016.

About 60 percent of the individuals who received any treatment (2.2-2.6 million individuals per year) received treatment in a specialty setting, defined by SAMHSA as any of the following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers.8

Because of changes in the methodology of the survey between 2014 and 2015 survey estimates from 2015 and later may not be comparable to earlier years. Thus, we present estimates for 2015 and later separately from those in the earlier period. In 2015 there were 3.7 million and 2.3 million individuals receiving any and specialty treatment according to the NSDUH (Table II.1). Between 2015 and 2016 there was no significant change in the number of individuals receiving any and specialty treatment in the past year.

TABLE II.2. Number of Individuals Receiving Any Specialty SUD Treatment by the Settings in Which They Received Care, NSDUH 2012-2014
Type of Care Number (in thousands) Percentage
2012 2013 2014 2012 2013 2014
Total 2,496 2,466 2,606 100 100 100
Specialty settings
   Hospital inpatient 861 879 921 34 36 35
   Rehabilitation facility--inpatient 1,010 1,042 1,076 40 42 41
   Rehabilitation facility--outpatient 1,505 1,753 1,731 60 71 66
   Mental health center--outpatient 1,000 1,176 1,157 40 48 44
Non-specialty setting
   Emergency room 557 574 499 22 23 19
   Private doctor's office 470 522 561 19 21 22
   Self-help group 1,461 1,505 1,554 59 61 60
   Prison or jaila 340 189 280 14 8 11
SOURCE: NSDUH 2012-2014.
NOTE: The counts only include individuals who received care in a specialty setting during the year; however, the counts indicate the number of these individuals receiving care in non-specialty settings. Counts do not sum to the total and percentages do not sum to 100% because individuals may receive care in multiple settings.
  1. NSDUH surveys individuals living in the community. Individuals living in an institutional setting are excluded. Therefore counts of individuals receiving treatment in a prison or jail only include individuals who have been released from those settings and are living in the community at the time of the survey.

The distribution of the number of people receiving treatment by treatment setting also remained relatively constant from 2012 to 2014 (Table II.2) and 2015 to 2016 (Table II.3). Outpatient rehabilitation and self-help groups were the most common settings of care. About one-third of individuals who received specialty treatment received some services in an inpatient hospital; about 20 percent received emergency room care.

TABLE II.3. Number of Individuals Receiving Any Specialty SUD Treatment by the Settings in Which They Received Care, NSDUH 2015-2016
Type of Care Number (in thousands) Percentage
2015 2016 2015 2016
Total 2,346 2,229 100 100
Specialty settings
   Hospital inpatient 702 732 30 33
   Rehabilitation facility--inpatient 974 918 42 41
   Rehabilitation facility--outpatient 1,524 1,446 65 65
   Mental health center--outpatient 1,093 1,054 47 47
Non-specialty setting
   Emergency room 429 489 18 22
   Private doctor's office 445 540 19 24
   Self-help group 1,389 1,183 59 53
   Prison or jaila 221 202 9 9
SOURCE: NSDUH 2015-2016.
NOTE: The counts only include individuals who received care in a specialty setting during the year; however, the counts indicate the number of these individuals receiving care in non-specialty settings. Counts do not sum to the total and percentages do not sum to 100% because individuals may receive care in multiple settings. The 2015 and 2016 estimates are not comparable to estimates from prior years due to methodological changes in the survey.
  1. NSDUH surveys individuals living in the community. Individuals living in an institutional setting are excluded. Therefore counts of individuals receiving treatment in a prison or jail only include individuals who have been released from those settings and are living in the community at the time of the survey.

2. Trends in Point-in-Time Clients in Care, by Care Setting

In contrast to the consistency of NSDUH findings, analysis of N-SSATS indicates notable shifts between 2013 and 2015 in client counts and the distribution of clients by service type (Table II.4).9 Overall, N-SSATS client counts indicate a small increase in clients in care between 2013 and 2015 (4.5 percent). This increase was driven by large increases in several service types: outpatient pharmacotherapy for opioid use disorders (14.8 percent), residential detoxification (34.2 percent) and short-term care (34.8 percent), and hospital inpatient detoxification (114.9 percent) and treatment (33.7 percent). There was little change in the number of clients in regular outpatient care.

The observed increases in clients receiving pharmacotherapy reflect national efforts to improve quality of care by increasing access to these evidence-based treatments. Pharmacotherapy use is associated with more consecutive weeks of abstinence from illicit opioids (Fiellin et al. 2014) and reduced mortality due to overdose (Brugal et al. 2005; Clark et al. 2011; Cousins et al. 2016; Degenhardt et al. 2009; Pierce et al. 2016) .

TABLE II.4. Services Provided by Setting of Care, N-SSATS 2013 and 2015
Type of Care Number of Clients Percentage of All Clients in Care
2013 2015 % Change 2013 2015 % Change
Total 1,249,629 1,305,647 4.5% 100.0 100.0 0.0%
Outpatient 1,127,235 1,161,456 3.0% 90.2 89.0 -1.4%
   Regular 603,315 604,819 0.2% 48.3 46.3 -4.1%
   Intensive 147,162 128,536 -12.7% 11.8 9.8 -16.4%
   Detoxification 13,839 14,457 4.5% 1.1 1.1 0.0%
   Day treatment/partial hospitalization 22,828 23,138 1.4% 1.8 1.8 -3.0%
   Methadone/buprenorphine maintenance or injectable naltrexone 340,091 390,506 14.8% 27.2 29.9 9.9%
Residential (non-hospital) 107,727 119,900 11.3% 8.6 9.2 6.5%
   Detoxification 10,244 13,748 34.2% 0.8 1.1 28.4%
   Short-term 27,184 36,651 34.8% 2.2 2.8 29.0%
   Long-term 70,299 69,501 -1.1% 5.6 5.3 -5.4%
Hospital inpatient 14,667 24,291 65.6% 1.2 1.9 58.5%
   Detoxification 5,768 12,394 114.9% 0.5 0.9 105.7%
   Treatment 8,899 11,897 33.7% 0.7 0.9 28.0%
Clients receiving methadone, buprenorphine, or injectable naltrexone treatment 382,237 439,602 15.0% 30.6 33.7 10.1%
   Clients receiving methadone 330,308 356,843 8.0% 26.4 27.3 3.4%
   Clients receiving buprenorphine 48,148 75,724 57.3% 3.9 5.8 50.5%
   Clients receiving injectable naltrexone 3,781 7,035 86.1% 0.3 0.5 78.1%
SOURCE: N-SSATS 2013 and 2015.
NOTE: N-SSATS surveys the universe of specialty SUD treatment facilities. In 2013 and 2015, respectively, the survey had a 94% and 92% response rate. Estimates are not adjusted for facility or item non-response. For inpatient and residential services counts indicate the number of clients in treatment on the last working day in March of each survey year. For outpatient services counts indicate the number of clients receiving services during March who are still enrolled in treatment on the last working day in March. Care categories defined to align with the American Society of Addiction Medicine levels of care.

Discrepancies between trends in the N-SSATS and NSDUH are expected due to differences in the scope of the surveys and measures of service use (Batts et al. 2014). Although both NSDUH and N-SSATS collect information on the number of individuals in care at specialty SUD treatment facilities, they differ in how they measure this population. The NSDUH measures the number of individuals reporting any receipt of treatment in the past year in a specialty setting, whereas for N-SSATS specialty facilities report the number of clients in treatment on a single day in each year (the last working day in March of each survey year). Outpatient client counts in N-SSATS include individuals receiving services during March who are still enrolled in treatment on the last working day in March. If individuals experience a longer duration of care or repeat admissions to the same type of care, NSDUH will show no change in the number of individuals with service use; N-SSATS client counts, on the other hand, will increase under these circumstances. The lack of change in the population with service use in the past year in NSDUH, paired with the increases in client counts observed in the N-SSATS, suggests that the increase in outpatient clients observed in N-SSATS stems from a longer duration of care or repeated admissions rather an increase in the total number of individuals receiving treatment in the course of a year. Analysis of the distribution of length of stay in the Treatment Episode Data Set (TEDS) Discharge file in 2012 relative to 2014 (Table II.5) supports a small 2 percentage point decline in the number of discharges with length of stay 30 days or less and corresponding 2 percentage point increase stays greater than 180 days.

TABLE II.5. Distribution of Discharges by Length of Stay, TEDS 2012 and 2014
Length of Stay 2012 2014
1 to 30 days 47.8 45.9
31 to 45 days 6.8 6.7
46 to 60 days 5.3 5.3
61 to 90 days 9.0 9.0
91 to 120 days 7.4 7.5
121 to 180 days 8.9 9.2
181 to 365 days 9.8 10.5
More than a year 4.9 6.0
SOURCE: TEDS 2012 and 2014 (CBHSQ 2017a and 2017b).
NOTE: Individual states report discharges to SUD treatment facilities within their state to TEDS. The scope of SUD treatment providers included in each state's data may vary over time and based on differences across states in state licensure, certification, accreditation, and disbursement of public funds. At a minimum, facilities receiving federal substance abuse treatment block grant funds are included. The following states did not report usable data for the year 2012: Kansas, Mississippi, and New Mexico. The following states did not report usable data for the year 2014: Mississippi, Florida, Georgia, Kansas, West Virginia, and New Mexico.

Differences in the scope of the two surveys can explain why the N-SSATS reports show increases in residential and hospital inpatient care, whereas the NSDUH results show constant use of these services. NSDUH surveys residents in households with a fixed address and individuals in non-institutional group quarters. It excludes individuals who are institutionalized or homeless and not in a shelter from its respondent pool. Thus, the NSDUH will not accurately assess the number of individuals receiving institutional services. Specifically, NSDUH will not count hospital services provided to individuals who enter a hospital but who do not re-enter the community due to drug overdose death. Thus, N-SSATS is a more accurate source of trends in institutional service use.

3. Trends in the Primary Substance for Treatment Admission

According to the data collected in TEDS, over the last decade the primary substance for which individuals receive SUD treatment has shifted. Alcohol use disorders as a primary substance accounted for the highest proportion of clients in care in 2004 (40 percent) and 2014 (36 percent), but the proportion represented by these admissions has declined (Table II.6). The proportion of admissions for a disorder related to cocaine as a primary substance also has declined, from 14 percent to 5 percent. In contrast, the proportion of admissions for heroin and non-heroin opiates and synthetics as a primary substance rose from 18 percent to 30 percent.

TABLE II.6. Number and Percentage of Specialty SUD Treatment Admissions by Primary Substance, TEDS 2004 and 2014
  Number Percentage
2004 2014 2004 2014
Total 1,808,469 1,614,358 100 100
Alcohol 729,366 585,024 40 36
Marijuana 285,193 247,461 16 15
Heroin 262,518 357,293 15 22
Cocaine 248,492 87,510 14 5
Methamphetamine/amphetamine 142,510 143,659 8 9
Non-heroin opiates/synthetic 62,895 134,401 3 8
Other or not reported 77,495 59,010 4 4
SOURCE: TEDS 2004 and 2014 (SAMHSA 2016).
NOTE: Individual states report admissions to SUD treatment facilities within their state to TEDS. The scope of SUD treatment providers included in each state's data may vary over time and based on differences across states in state licensure, certification, accreditation, and disbursement of public funds. At a minimum, facilities receiving federal substance abuse treatment block grant funds are included. Alaska, Arkansas, and District of Columbia reported either no data, or less than a full calendar year of data for 2004. South Carolina did not report usable data for the year 2014.

B. How Does Service Receipt Vary Geographically, by Level of Urbanicity and by Facility Operation?

Geographically. SUD prevalence and treatment use varies based on geography. Geographic variation results from cultural and environmental influences on disorder prevalence as well as differences in jurisdictional policies, treatment funding and availability, and availability of other social services. Below, we discuss the geographic variations in service receipt, reflected in Table B.1 through Table B.4.b of Appendix B.

National and regional average changes in clients by type of care between 2013 and 2015 mask substantial variation by state. Across all regions, there was a substantial increase in clients in inpatient care (65.6 percent). We also observed substantial increases for each of the four regions (Table B.1), but the increase in the Midwest was much lower than for the other regions (16.8 percent). Within each region, however, changes in inpatient care varied substantially by state (Table B.2). Residential clients increased by 11.3 percent nationally but, as was true for inpatient care, results varied by region. At the extremes, the number of residential clients in the Midwest declined by 9.6 percent, whereas the number in the South increased by 28.5 percent. Outpatient client counts increased modestly in each region.

Use of pharmacotherapies targeted to alcohol and opioid dependence substantially increased in all regions (Table B.3.a and Table B.3.b). Buprenorphine and injectable naltrexone had higher percentage increases, but these medications were less commonly used in 2013 than methadone. Rates of change varied dramatically across states, with some states seeing declines in pharmacotherapy use (particularly for methadone), whereas others saw a surge in use (Table B.4.a and Table B.4.b).

Urbanicity. Variation in treatment use based on the level of urbanicity may be expected due to access barriers for individuals in more rural areas. Jackson and Shannon (2012) reviewed the literature on barriers to treatment access for rural residents and found: (1) rural residents are less likely to have access to health insurance; (2) there is a shortage of providers in rural areas; and (3) people in need of treatment in rural areas must travel longer distances to facilities. Cummings and colleagues (2014) used the 2009 N-SSATS and the Area Resource File to look at access to outpatient SUD treatment for Medicaid enrollees. This study found that rural counties are less likely than urban counties to have at least one outpatient SUD facility that accepts Medicaid. Lenardson and Gale (2007) compared SUD treatment offered in rural and urban counties using variables in the 2004 N-SSATS. Comparing the number of facilities and treatment beds to population size revealed that rural areas actually had a larger number of treatment facilities, but the facilities had fewer inpatients beds available per population. In addition, few facilities in rural counties not adjacent to a metropolitan area provided detoxification, transitional housing services, or intensive outpatient care. Nearly all opioid treatment programs (OTPs) were located in urban areas.

FIGURE II.2. Number of Clients by Urbanicity, N-SSATS 2013 and 2015
FIGURE II.2, Bar Chart: Each bar shows the number of clients (in thousand) who received treatment in specialty substance use disorder treatment facilities. The first bar displays that in 2013 facilities in urban areas served 305 thousand clients receiving pharmacotherapy and 650 thousand clients receiving other services. The second bar displays that in 2015 facilities in urban areas served 404 thousand clients receiving pharmacotherapy and 700 thousand clients receiving other services. The third bar displays that in 2013 facilities in rural areas served 69 thousand clients receiving pharmacotherapy and 211 thousand clients receiving other services. The fourth bar displays that in 2015 facilities in rural areas served 31 thousand clients receiving pharmacotherapy and 160 thousand clients receiving other services.
SOURCE: N-SSATS 2013 and 2015.
NOTE: Pharmacotherapy is limited to methadone, buprenorphine or injectable naltrexone. Urbanicity is assigned based on the HHS National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural client counts are only reported for facilities with known urbanicity.

The number of clients in each care setting declined substantially in rural areas and increased in urban areas between 2013 and 2015 (Figure II.2). The number of clients receiving pharmacotherapy also declined substantially in rural areas and increased in urban areas with the exception of clients receiving buprenorphine which stayed fairly constant in rural areas (Table B.3.a). According to the U.S. Department of Agriculture (2016) the population living in rural areas was fairly constant in this period while the population living in urban areas has increased steadily at approximately 1 percent annually. Given the treatment access barriers for individuals living in rural areas that pre-date this period and the consistent size of the population in these areas the substantial declines in treatment use in rural areas warrant further investigation.

Facility operation. Facility operation may affect the characteristics of clients served and types of services offered as facilities that are publicly owned or non-profits may have distinct missions to provide charitable care or act as the provider of last resort. Between 2013 and 2015 clients served in public facilities (Table B.1) declined substantially for outpatient care (13.7 percent) and somewhat for residential care (4.3 percent). Meanwhile clients served in private for-profit and private non-profit facilities expanded in these settings. This shift may be related to increased rates of insurance coverage. Inpatient clients increased substantially for facilities of all operation types.

C. What is the Relationship between the Prevalence of SUDs and Demand for Care? How Does the Relationship Vary Geographically?

According to NSDUH, the number of individuals with SUDs was relatively constant between 2004 and 2014 (Figure II.3). The aggregate estimates, however, mask substantial shifts in the substances with which the disorders are associated (Table B.5). Cocaine/crack-related, hallucinogen-related, inhalant-related, and alcohol-related disorders have declined over the last decade, whereas heroin, non-medical use of psychotherapeutics, and use of pain relievers have increased.

The direction of trends in the percent of the population with use disorders was similar across age groups (Table II.7). Between 2002 and 2015, the proportion of the population with an SUD declined for all age groups for alcohol and cocaine and increased for heroin. In contrast, the proportion of the population with marijuana use disorders remained constant among individuals 26 and older, but declined for individuals 12-17 and 18-25. Due to the survey sample size and prevalence of disorders, it is difficult to detect trends in disorder prevalence among more detailed subgroups within the 26 and older group with a single year of NSDUH data. Han et al. (2017) pooled two years of NSDUH data to compare the proportion of individuals 50 and older with alcohol use disorders in 2005-2006 to 2013-2014. In contrast to the results for the 26 or older group, they found the proportion of individuals 50 and older with an alcohol use disorder increased from 3.0 percent to 3.7 percent (a 23.3 percent increase). There is concern that SUD prevalence may increase among older age groups over time as the baby boomers age given their higher rates of substance use relative to previous generations (Elinson 2015).

FIGURE II.3. Number of Individuals Age 12 and Older with Abuse of or Dependence on Alcohol or Illicit Drugs in the Past Year, NSDUH 202-2014
FIGURE II.3, Line Chart: Three series are displayed. Each series is displayed as a line in a different shade of blue indicating the number of individuals, in thousands, with a substance use disorder of the indicated type in the past year. The series never intersect. The lowest line is in dark blue. It indicates that between 2002 and 2014 the number of individuals with an illicit drug disorder remained relatively constant at about 7 million. The middle line is in a medium shade of blue. It indicates that between 2002 and 2010 the number of individuals with an alcohol disorder disorder remained relatively constant at about 18 million. The number of individuals with an alcohol disorder declined between 2010 and 2014. In 2014 the figure individuals about 16 million individuals with an alcohol disorder. The highest line in light blue indicates that between 2002 and 2014 the number of individuals with an illicit drug disorder or an alcohol remained relatively constant at about 22 million.
SOURCE: NSDUH 2002-2014.

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition ("DSM-IV-TR" 2017), which was used to develop the diagnostic criteria in the NSDUH for having an SUD an individual must have serious negative consequences to qualify as having a disorder. For substance use dependence an individual must have three or more symptoms of dependence such as withdrawal symptoms, increased tolerance, repeated unsuccessful attempts to quit, having given up social, occupational or recreational activities or using the substance in larger amounts and for longer periods of time than intended. For abuse the individual must continue use despite having at least one negative consequence due to use including failure to fulfill a major work, school or home role, recurrent use in hazardous situations, recurrent legal issues, or social and interpersonal problems caused by use. Individuals meeting criteria for a disorder continue substance use despite serious negative consequences in their personal lives.

TABLE II.7. Percentage of Population with an SUD by Type of Substance and Age Group, NSDUH 2002 and 2015
  Age 12-17 Age 18-25 Age 26 or Older
2002 2015 2002 2015 2002 2015
Alcohol use 5.9* 2.5 17.7* 10.9 6.2* 5.4
Marijuana use 4.3* 2.6 6.0* 5.1 0.8 0.8
Cocaine use 0.4* 0.1 1.2* 0.7 0.6* 0.3
Heroin use 0.1 0.0 0.2* 0.4 0.1* 0.2
SOURCE: NSDUH 2002 and 2015 (CBHSQ 2016b).
* Estimate is significantly different from 2015 estimate at the 0.5% level.

Based on the NSDUH survey, there is a substantial gap between the number of people with an SUD and the number of individuals who receive specialty treatment in a given year. In 2014, an estimated 20.3 million United States residents aged 12-64 met criteria for an SUD in the past year. Among this group, less than 10 percent of individuals abusing or dependent on alcohol only received specialty SUD treatment in the past year (Figure II.4). The treatment rate was higher (about 20 percent) among individuals abusing or dependent on illicit drugs only. About 15 percent of those abusing or dependent on both illicit drugs and alcohol received treatment. Differences between the 2013 and 2014 rates are not statistically significant. According to a review by Foster (2014), treatment rates among individuals with SUDs are substantially lower than those for common health conditions, such as hypertension (77 percent), diabetes (73 percent), and major depression (71 percent). However, an individual's need for professional support to address an SUD may depend on several factors, such as the severity of the disorder, comorbid health conditions, personal coping skills, the individual's environment, and available sources of informal specialty support (Mechanic 2003). Treatment rates vary little across states (Table B.6).

FIGURE II.4. Percentage of Individuals Age 12-64 with Abuse or Dependence Who Received Specialty SUD Treatment, 2013-2014
FIGURE II.4, Bar Chart: The chart demonstrates the percentage of individuals with substance abuse or dependence disorders who received specialty SUD treatment. There are 3 groups of blue bars and each group represents a disorder type. The darker bar in each group represents the year 2013. The lighter bar in each group represents the year 2014. 6% of individuals with abuse or dependence on alcohol received treatment in 2013 and 8% received treatment in 2014. 20% of individuals with abuse or dependence on illicit drugs only received treatment in 2013 and 21% received treatment in 2014. 13% of individuals with abuse or dependence on both illicit drugs and alcohol received treatment in 2013 and 17% received treatment in 2014.
SOURCE: Mathematica analysis of NSDUH 2013 and 2014 public use files.

Individuals who meet the criteria for an SUD but do not receive treatment fall into three groups: (1) those who do not feel they need treatment; (2) those who feel they need treatment but do not seek it; and (3) those who feel they need and seek treatment but do not receive it. Based on the 2015 NSDUH, Lipari et al. (2016) found that 95.4 percent of people who met the criteria for an SUD but did not receive specialty treatment did not feel they needed treatment (19.3 million people). Among the remaining small percentage (4.6 percent, or 880,000 people) who felt they needed treatment but did not get it, 64.4 percent (about 567,000 people) reported making no effort to get treatment, whereas 35.6 percent (about 313,000 people) reported they did make such efforts. Figure II.5 displays trends in the number of individuals who received specialty SUD treatment, felt they needed treatment but did not seek it, and felt they needed treatment and sought it but did not receive it. These numbers were relatively constant from 2004 through 2014.

FIGURE II.5. Number of Individuals Who Received Specialty SUD Treatment or Felt They Needed but Did Not Receive Treatment, NSDUH, 2004-2014
FIGURE II.5, Wave Chart: The chart demonstrates the number of individuals who received specialty SUD treatment or felt that they needed it between 2004 and 2014. There are 3 waves, each a varying shade of blue. The darkest blue wave represents individuals who received treatment. The number of individuals receiving treatment stayed constant between 2004 and 2014 at about 2.5 million individuals. The wave that is medium blue is relatively constant from 2004 to 2014 at about 300,000 individuals who perceived a need for treatment and sought treatment, but did not receive treatment. The top wave that is light blue is relatively constant from 2004 to 2014 at about 700,000 individuals who perceived a need for treatment, but made no effort to obtain and did not receive treatment.
SOURCE: NSDUH 2004-2014.
NOTE: The figure depicts treatment receipt within the past 12 months.

D. What Evidence Exists about How Increases in Medicaid Enrollment Have Impacted Demand?

In Phase 1 of this project we reviewed the literature on the relationship between Medicaid insurance coverage and SUD treatment use. We found only a few studies in the literature that have explicitly examined how health insurance coverage impacts demand for SUD treatment services; furthermore, many of these studies did not employ experimental designs, so the findings may be confounded by other factors. Although a rigorous study with experimental design found that insurance coverage has a positive effect on the use of general health services (Newhouse and the Insurance Experiment Group 1993), findings for SUD treatment could differ for several reasons. First, SUD treatment is typically provided outside of the general health sector, and insurance coverage for these services may be less comprehensive, have a limited network of providers, and require greater out-of-pocket costs for the client, thereby deterring treatment use. The social stigma attached to SUDs and SUD treatment may also limit treatment seeking despite insurance coverage. In addition, states and the Federal Government (through block grants) fund SUD treatment directly, particularly for those who are uninsured. Thus, although other types of care may be more affordable for those who are insured, the availability of publicly funded SUD treatment for individuals without insurance may mean that access to Medicaid coverage has less impact on SUD treatment use than use of other types of health care services.

The findings from the limited studies we identified on the relationship between Medicaid coverage and SUD treatment use indicate that individuals with Medicaid coverage are more likely to use SUD treatment than those with private insurance or who are uninsured (Bouchery et al. 2012; Epstein et al. 2004; Larson et al. 2005). This finding may be due to out-of-pocket expenses being lower under Medicaid. It may also be due to differences in the care management and benefit packages provided through Medicaid and private insurance plans. Since these studies did not use an experimental design the findings may be due to characteristics of the Medicaid population that were not controlled for in the models. In particular, individuals who are eligible for Medicaid may be enrolled in Medicaid by a treatment provider.

For Phase 2 of this study data from the NSDUH on Medicaid enrollment and treatment use prior to (2009-2013) and following ACA implementation (2014) was available for analysis. We used these data to estimate how increased rates of Medicaid enrollment influenced SUD treatment use. First, among individuals with SUDs we estimated changes in Medicaid enrollment rates and the number of individuals with SUD who gained Medicaid coverage as a result of increased enrollment rates. Then we estimated treatment use rates among those with SUDs and assessed how access to Medicaid coverage likely affected treatment use among individuals who gained Medicaid coverage.

According to our analysis of the NSDUH, the proportion of individuals ages 12-64 with SUDs who were enrolled in Medicaid rose from 13.4 percent in the five years from 2009 to 2013 to 18.1 percent in 2014--a statistically significant change (Table II.8). There was a corresponding decline in the percentage uninsured from 24.8 percent in 2009-2013 to 20.0 percent in 2014. This change may be related to expansion of Medicaid eligibility under the ACA. The opioid epidemic and efforts to increase treatment use for individuals affected may also have contributed to increased Medicaid enrollment among individuals with SUDs.

Because of the higher Medicaid enrollment rate observed in 2014, we estimate that approximately 944,000 more individuals with SUDs were enrolled in Medicaid in 2014 than would have been expected, given the Medicaid enrollment rates observed between 2009 and 2013 (Table II.9). This represents a 34 percent increase in the size of the Medicaid population with SUDs. We estimate this by projecting what Medicaid enrollment would have been among individuals with SUDs given the average enrollment rate in 2009-2013 compared to the observed enrollment rate in 2014. The steps of this calculation are presented in Table II.9. The first step was to determine the actual number of individuals enrolled in Medicaid with SUDs in 2014. Then we calculated the ratio of the observed average Medicaid enrollment rate in 2009-2013 relative to that for 2014 based on the estimates in Table II.8. We multiplied these ratios by the actual number of Medicaid enrollees with an SUD in each diagnostic category in 2014 to calculate projected Medicaid enrollment for 2014 given the average enrollment rate between 2009 and 2013. We then subtracted the projected enrollment levels for 2009-2013 from the actual enrollment levels in 2014 to estimate the increase in the number of enrollees.

TABLE II.8. Percentage of Individuals Ages 12-64 with SUDs Who Were Enrolled in Medicaid or Uninsured in 2009-2013 versus 2014, by SUD Type
Type of Substance 2009-2013 2014
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Medicaid Enrolled
   Total 13.4 12.8 14.1 18.1 16.7 19.6
   Alcohol dependence 11.1 9.9 12.3 16.6 14.0 19.2
   Other alcohol and marijuana disorders 11.7 11.0 12.5 14.9 13.4 16.4
   Other drug abuse or dependence disorders 23.1 21.4 24.7 30.9 27.3 34.5
Uninsured
   Total 24.8 23.7 25.9 20.0 18.3 21.7
   Alcohol dependence 25.4 23.9 26.8 23.6 20.2 27.0
   Other alcohol and marijuana disorders 22.7 21.4 24.0 17.0 14.9 19.1
   Other drug abuse or dependence disorders 30.4 28.1 32.8 22.5 18.5 26.6
SOURCE: NSDUH 2009-2014.
TABLE II.9. Estimated Increase in Medicaid Enrollment Associated with Medicaid Expansion for Individuals Ages 12-64 with an SUD, by SUD Type
Type of Substance 2014 Medicaid Enrollmenta 2009-2013 Medicaid Enrollment
Rate as a Percentage
of 2014 Rateb
Projected 2014 Medicaid
Enrollment Based on
2009-2013 Enrollment Ratesc
Estimated Increase in
Medicaid Enrollment Associated
with Medicaid Expansiond
Total 3,684,517 74 2,740,333 944,184
Alcohol dependence 1,042,102 67 699,424 342,678
Other alcohol and marijuana disorders 1,571,584 79 1,241,446 330,138
Other drug abuse or dependence disorders 1,070,831 75 799,463 271,368
SOURCE: Mathematica analysis of NSDUH 2009-2014 public use files.
  1. These counts are estimated based on the NSDUH survey sample.
  2. This is the mean percentage of individuals ages 12-64 with an SUD enrolled in Medicaid in 2009-2013 divided by that for 2014. Means for these periods are those presented in Table II.4.
  3. This number is the 2014 Medicaid enrollment times the 2009-2013 Medicaid enrollment rate as a percentage of the 2014 rate.
  4. This number is the difference between 2014 Medicaid enrollment and the projected Medicaid enrollment based on 2009-2013 enrollment rates. The estimated increase in Medicaid enrollment may result from Medicaid eligibility expansion under the ACA, or other changes such as new policies implemented to address the opioid epidemic.

According to the NSDUH, in 2014 most Medicaid-enrolled individuals with an SUD, 85 percent, did not receive any specialty treatment. Assuming their treatment use rates are similar to those of the Medicaid population overall, most of the individuals whose enrollment is associated with Medicaid expansion (about 798,000, or 85 percent of the 944,000) did not receive any specialty SUD treatment in 2014 (Figure II.6). Individuals who are uninsured access treatment at a lower rate than those on Medicaid; a logit model predicting specialty treatment use for the NSDUH using data from 2009 to 2014 indicated that the likelihood of specialty SUD treatment for someone who was uninsured was 60 percent of that for an individual who was Medicaid insured. Thus, we would expect 60 percent of those whose enrollment in Medicaid was associated with Medicaid expansion who received SUD treatment in 2014 would have received specialty SUD treatment even if they were uninsured. The remaining approximately 59,000 (40 percent) would not have received specialty treatment in the absence of Medicaid enrollment.10

FIGURE II.6. Estimated Rate of Treatment Receipt among Medicaid Expansion Population Ages 12-64 with an SUD, 2014
FIGURE II.6, Pie Chart: The chart demonstrates the estimated rate of treatment receipt among the Medicaid expansion population with an SUD in the year 2014. 84.5% of the population received no treatment, represented by the darkest blue sector of the pie chart. 9.3% of the population, represented by the sector of the pie chart that is medium blue, received treatment and would have been expected to receive treatment if they were uninsured. 6.2% of the population, represented by the sector of the pie chart that is light blue, received treatment and would not have been expected to receive treatment if they were uninsured.
SOURCE: Mathematica analysis of NSDUH 2009-2014 public use files.
NOTE: We estimated the percentage receiving any specialty treatment (15.5%) based on the observed rate of specialty SUD treatment receipt in the NSDUH 2009-2014 for Medicaid-enrolled individuals ages 12-64 with an SUD. We estimated the share of individuals who would have received treatment without Medicaid expansion based on findings from a logit model using NSDUH 2009-2014 data, which indicated the likelihood of specialty treatment use for uninsured individuals was 60% of that for Medicaid-enrolled individuals.

A limitation to this analysis is that we assume that the SUD treatment use rate for the Medicaid expansion population with SUDs is the same as that for other Medicaid enrollees with SUDs. To assess the importance of this limitation, we compared treatment use rates by disorder type in 2014 to the average for 2009-2013. Despite the 34 percent increase in the number of individuals enrolled in Medicaid with SUDs specialty treatment use rates were unchanged between the two periods suggesting that the expansion population had similar rates of treatment use.

TABLE II.10. Percentage of Individuals Ages 12-64 with SUDs Who Were Enrolled in Medicaid Who Used Specialty Treatment in 2009-2013 versus 2014, by SUD Type
Type of Substance 2009-2013 2014
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Total 14.5 12.7 16.3 15.5 11.8 19.2
Alcohol dependence 10.7 7.3 14.0 11.1 5.5 16.8
Other alcohol and marijuana disorders 8.3 6.3 10.3 9.6 4.4 14.9
Other drug abuse or dependence disorders 28.2 24.2 32.2 28.2 20.1 36.4
SOURCE: Mathematica analysis of NSDUH 2009-2014 public use files.

Another limitation of this analysis is that it included only individuals with SUDs as identified by responses to questions in the NSDUH survey. Some individuals receive treatment for substance use, but do not meet criteria for an SUD in the past year. These may be individuals who previously met criteria for a disorder and are continuing to receive treatment to reduce the likelihood of relapse. According to the NSDUH, on average between 2009-2013 and in 2014, respectively, about 292,000 and 261,000 individuals enrolled in Medicaid who did not meet criteria for an SUD in the past year received specialty treatment (Table II.11). The difference between these estimates is not statistically significant suggesting the Medicaid expansion did not substantially change the number of individuals in this population receiving specialty treatment.

TABLE II.11. Number of Individuals Ages 12-64 Not Meeting Criteria for an SUD Who Received Specialty SUD Treatment in 2009-2013 versus 2014, by Medicaid Enrollment
Type of Substance 2009-2013 2014
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Mean Lower Bound
for 95% CL
Upper Bound
for 95% CL
Medicaid enrolled 291,898 243,132 340,664 261,103 179,849 342,356
Not Medicaid enrolled 672,861 588,171 757,551 728,473 540,615 916,332
SOURCE: Mathematica analysis of NSDUH 2009-2014 public use files.

III. SUPPLY OF SUBSTANCE USE DISORDER TREATMENT

In this section, we present our findings on the supply of SUD treatment services. The primary data source for these analyses is the information collected on the workforce questions added to the 2016 N-SSATS. These data are supplemented with information from the N-SSATS on trends in facility acceptance of insurance and utilization rates in beds designated for SUD treatment as well as data from Bureau of Labor Statistics (BLS) on trends in hourly wages.

A. What are the Professions and SUD Treatment Credentials of the Current Workforce?

Provision of SUD treatment requires a mix of counselors, medical professionals, and support staff. The level and type of staff needed vary across care types and settings, based on the needs of the clients in care. In this section, we present findings from recent N-SSATS 2016 survey data that characterize this multifaceted workforce, providing information on its overall size, composition, education, and training.

1. What is the Size of the SUD Treatment Workforce?

According to the N-SSATS survey, 256,449 paid staff members (representing 197,559 full-time equivalent [FTE] positions) and 14,458 unpaid staff members (representing 6,726 FTE positions) worked in specialty SUD treatment facilities in 2016 (Table B.7 and Table B.8). We define an FTE as 40 working hours per week. About two-fifths of the paid FTEs were degreed and no-degree counseling staff (Figure III.1). The other three-fifths of the paid FTEs were about evenly divided between medical staff (that is, physicians, pharmacists, nurses, and mid-level professionals), other support staff (that is, peer support staff, care managers, patient navigators, other recovery support staff, other clinical staff and interns, pharmacy assistants, contractors/per diem staff, and intake coordinators), and administrative staff.

FIGURE III.1. Distribution of Paid FTEs by Staff Type, 2016
FIGURE III.1, Pie Chart: The chart demonstrates distribution of paid full-time equivalent staff by staff type within the SUD treatment workforce. There are four sectors of the pie chart. 42% are classified as counseling staff. 19% are classified as medical staff. 18% are classified as administrative staff. 21% are classified as other support staff.
SOURCE: N-SSATS 2016.
NOTE: FTE is based on 40 working hours per week.

2. What is the Education Level of Medical and Counseling Staff?

The training and educational attainment of staff in specialty SUD treatment facilities varied. There are few standards for such staffing. State and federal regulations allow SUD treatment facilities substantial flexibility in selecting the number and types of professionals they employ. Thus, facilities can align their staff with the needs of their client population and the services they offer. In this section, we provide an overview of SUD specialty facility staffing nationally, based on Table B.7. More detailed information by state and facility characteristics is provided in Appendix B (Table B.9.a, Table B.10.a, and Table B.11.a).

Physicians and other prescribers are particularly important in expanding the use of pharmacotherapy. The SAMHSA-HRSA Center for Integrated Health Solutions (2014) identified lack of available prescribers as a barrier to expanding pharmacotherapy use. Physicians accounted for 20 percent (7,576 FTEs) of the medical staff at specialty SUD treatment facilities (Figure III.2). These physicians are supplemented by 4,043 FTEs for mid-level medical personnel (including nurse practitioners, physician assistants, and advanced practice nurses) who can also prescribe. Although they make up a small share of all medical staff (3 percent), pharmacists, who accounted for 1,110 FTEs, are also important in supporting opioid treatment facilities. Nurses are the most common type of medical staff in specialty SUD treatment facilities. About two-thirds of nursing staff are registered nurses (16,515 FTEs) and one-third are licensed practical nurses (8,073 FTEs).

FIGURE III.2. Distribution of FTE Medical Staff, by Training
FIGURE III.2, Pie Chart: The chart demonstrates the distribution of full-time equivalent medical staff within the substance use disorder treatment workforce by training. There are five sections of the pie chart. 44% of the medical staff are registered nurses. 22% are licensed practical nurses. 20% are physicians. 11% are midlevel providers. 3% are pharmacists.
SOURCE: N-SSATS 2016.
NOTE: FTE is based on 40 working hours per week.

Counseling staff in SUD treatment facilities have high rates of post-graduate education. A substantial majority (57 percent) of counselors (including degreed and no-degree counseling staff) in these facilities have a graduate degree (Figure III.3). Only 17 percent of counselors have less than a bachelor's degree.

FIGURE III.3. Distribution of FTE Counseling Staff, by Education Level
FIGURE III.3, Pie chart. The chart demonstrates distribution of full-time equivalent counseling staff within the SUD treatment workforce by education level. There are 4 sections of the pie chart. 5% of the counseling staff hold doctoral-level degrees. 52% hold master’s-level degrees. 26% hold bachelor’s degrees. 17% hold associate’s degrees or no degrees.
SOURCE: N-SSATS 2016.
NOTE: FTE is based on 40 working hours per week.

3. What Percentage of Specialty SUD Treatment Staff are Certified in Addiction Treatment?

Although counseling staff in SUD treatment facilities have high rates of post-graduate education, this advanced education may not translate into greater knowledge specific to SUD treatment, as many graduate programs in social work and psychology do not provide specialized training in SUDs. Community colleges provide much of the specialized academic training in SUDs (McCarty 2002; Institute of Medicine 2006). Addiction counselors can demonstrate their competency by obtaining certification through organizations such as IC&RC and NAADAC. Certification is available for different levels of staff and requires education/training, work experience, and an exam focused on SUDs and addiction. Certification in addiction treatment was more common among counselors with less educational attainment. In fact, as shown in Figure III.4, only 40 percent and 34 percent of master's-level and doctoral-level counselors, respectively, are certified in addiction treatment in contrast to 49 percent and 59 percent, respectively, for bachelor's degree and associate's degree or no-degree counselors. Overall, 31 percent of non-administrative staff in specialty SUD treatment facilities are certified in addiction treatment.

This section provides an overview of staff certification in addiction at SUD specialty facilities nationally. More detailed information on certification by state and facility characteristics is provided in Appendix B (Table B.9.b, Table B.10.b, and Table B.11.b).

FIGURE III.4. Percentage of Specialty SUD Treatment Staff Certified in Addiction Treatment, by Type of Staff
FIGURE III.4, Bar Chart: The chart displays the percentage of specialty SUD treatment staff certified in addiction treatment, by type of staff. Addiction treatment certification is held by 42% of physicians, 20% of mid-level providers, 8% of registered nurses, 10% of licensed practical nurses, 23% of pharmacists, 34% of doctoral-level counselors, 40% of master’s-level counselors, 49% of bachelor’s-degree counselors, 59% of associate’s-degree or no-degree counselors and 17% of non-administrative support staff.
SOURCE: N-SSATS 2016.
NOTE: Non-administrative support staff includes pharmacy assistants, peer support staff, care managers, patient navigators, other recovery support workers, interns, contractors, per diem staff, intake coordinators, and other clinical staff not included in other groups.

B. What is the Current Capacity of Service Providers to Supply SUD Treatment Services? How Does Provider Capacity Differ Across Geographic Areas? What Disparities in Care Access are Evident? How Does Provider Capacity Differ in Relation to Various Services, such as Inpatient, Residential, Intensive Outpatient, Outpatient, and Pharmacotherapy?

There are limited data available to assess treatment system capacity despite its importance and relevance in further policymaking. In this section, we provide information on the number of staff hours utilized per week for every 100 outpatient clients and the variation in this metric based on facility characteristics. We also provide data on access to pharmacotherapy and utilization rates for designated residential and inpatient care beds.

1. For Every 100 Clients in Outpatient Care, How Many Hours of Care are provided per Week by Type of Staff? How Does the Level of Hours provided Vary by State, Types of Services Offered, and Other Facility Characteristics?

In this section, we report staff hours per week for every 100 clients in care by type of staff and facility characteristics. We limit this analysis to facilities that provide only outpatient treatment. The level and distribution of staff hours provided differs substantially based on whether pharmacotherapies are offered at the facility. Overall, on average, for every 100 clients in care, outpatient facility staff provide 292 hours of services per week (Table III.1). Fewer staff hours were used per 100 clients in facilities providing pharmacotherapies (242 hours per week) than in those not providing pharmacotherapies (393 hours per week). In both groups, the bulk of hours were provided by counseling staff (66 percent across all facilities); however, medical staff accounted for a greater share of hours in facilities providing pharmacotherapy (25 percent) than those that did not (10 percent). Facilities providing no pharmacotherapy used substantially more counseling and recovery support staff hours than those providing pharmacotherapy. Detailed information on the level and distribution of staff hours per client per week by state are listed in Table B.12.a, Table B.12.b, and Table B.12.c.

TABLE III.1. Staff Hours per 100 Outpatient Clients per Week, by Type of Staff and Availability of Pharmacotherapy, 2016
Type of Staff Number Percentage
All Facilities Facilities Providing an
Pharmaco-therapies
Facilities Providing
No Pharmaco-therapy
All Facilities Facilities Providing an
Pharmaco-therapies
Facilities Providing
No Pharmaco-therapy
Total 292 242 393 100 100 100
Medical staff 52 60 38 18 25 10
   Physician 15 15 14 5 6 4
   Pharmacy staff 3 3 2 1 1 1
   Mid-level medical personnel 9 9 8 3 4 2
   Registered nurse 14 15 10 5 6 2
   Licensed practical nurse 13 17 4 4 7 1
Counselors 192 147 284 66 61 72
   Post-graduate level 113 87 167 39 36 42
   Bachelor's degree 51 39 75 17 16 19
   Associate's or no-degree 27 20 42 9 8 11
Recovery support staff 47 36 72 16 15 18
SOURCE: N-SSATS 2016.
FIGURE III.5. Staff Hours per 100 Outpatient Clients per Week, by Facility Services Offered, 2016
FIGURE III.5, Bar Chart: Each bar represents the number of hours of care provided by non-administrative staff per 100 outpatient clients per week for a subgroup of facilities in 2016. There are three sets of bars. The first set shows the distinction between facilities providing or not providing outreach with facilities providing outreach providing 316 hours of care per 100 outpatient clients per week, and facilities not providing outreach providing 248. The second set shows the distinction between facilities that provide recovery support services and those that do not, with facilities providing recovery support services administering 373 hours of care per 100 outpatient clients per week, and facilities that do not provide recovery support services administering 269. The final set shows the distinction between facilities that focus on substance use disorder treatment, mental health treatment, or both. Facilities that focus on substance use disorder treatment administer 193 hours of care per 100 outpatient clients per week, facilities that focus on mental health treatment administer 1,000, and facilities that focus on both administer 405.
SOURCE: N-SSATS 2016.
NOTE: We identified facilities as providing outreach if they said they offered outreach to persons who may need treatment (SRVC91 = 1). We identified facilities as providing recovery support services if they provided social skills development, mentoring/peer support, assistance in obtaining social services, employment counseling or training, or assistance in locating housing (SRVC96 = 1, SRVC97 = 1, SRVC36 = 1, SRVC39 = 1, and SRVC38 = 1). We determined facility focus based on responses to Question 6.

Unsurprisingly, when we examined disparities across facilities in staff hours per 100 clients per week based on differences in services offered (Table B.13), facilities that reported providing supplemental services such as outreach to individuals in the community who may need treatment and recovery support services averaged higher staff hours per 100 clients per week (Figure III.5). Most striking were the differences based on facility primary focus. Those that reported a dual focus on mental health and substance abuse treatment (405 hours per 100 clients per week) or primarily mental health treatment (1,000 hours per 100 clients per week) reported substantially higher staff hours per 100 clients per week relative to those whose focus was primarily SUD treatment (193 hours per 100 clients per week).

FIGURE III.6. Staff Hours per 100 Outpatient Clients per Week, by Urbanicity, Operation, and Size, 2016
FIGURE III.6, Bar Chart: Represented by blue bars are the mean staff hours per 100 outpatient clients per week by facility subgroup. The first subgroup of bars shows the distinction between urban and rural facilities. On average, urban facilities allocate 278 staff hours per 100 outpatient clients per week and rural facilities allocate 370 staff hours per 100 outpatient clients per week. The second group of bars shows the distinction by facility operation. On average, private, non-profit facilities allocate 339 staff hours per 100 outpatient clients per week, private, for-profit facilities allocate 206 staff hours per 100 outpatient clients per week, and public facilities allocate 432 staff hours per 100 outpatient clients per week. The final group of bars shows the distinction by facility size. On average, small facilities allocate 1606 staff hours per 100 outpatient clients per week, medium-sized facilities allocate 506 staff hours per 100 outpatient clients per week, and large facilities allocate 171 staff hours per 100 outpatient clients per week.
SOURCE: N-SSATS 2016.
NOTE: We assigned urbanicity based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core of at least 10,000 but less than 50,000 population, as well as those in non-core areas. Facilities in a central or fringe urban core of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural estimates are reported only for facilities with known urbanicity. Facility operation was self-designated in N-SSATS Question 7. We determined facility size based on the number of outpatient clients in care. We identified facilities below the 25th and above the 75th percentiles for client count as small and large, respectively. We designated the remaining facilities as medium.

There were also substantial differences in staff hours per 100 clients per week based on facility characteristics such as urbanicity and size (Table B.14). Some of these differences may result from economies of scale achieved in larger facilities. For example, rural facilities and those with fewer clients used substantially more staff hours per 100 clients (Figure III.6). There were also substantial differences based on facility operation. These differences may be related to differences in facility mission that align with operation. Public facilities often serve as the providers of last resort and serve clients with comorbid conditions and limited social and economic supports. Thus, it is not surprising that public facilities reported the highest numbers of hours per 100 clients (432 hours per 100 clients per week) followed by non-profit facilities (339 hours per 100 clients per week).

2. What Proportion of Facilities Provide Pharmacotherapy?

Pharmacotherapy has been demonstrated to be both clinically and cost effective for alcohol and opioid disorders (Mann et al. 2014; Baser et al. 2011). Although there is strong evidence that use of pharmacotherapy in managing SUDs provides substantial cost savings, this approach is not widespread. The proportion of facilities offering any pharmacotherapy, including those related to opioid use, has expanded in recent years as efforts to improve the quality of SUD treatment have focused on promoting its use. Overall, in urban and rural areas and across all facility operation types, the percentage of facilities offering any pharmacotherapies and specifically, opioid-related pharmacotherapies, has increased modestly from 2013 to 2016 (Figure III.7 and Figure III.8). Overall, however, only 43 percent of facilities offered any pharmacotherapies in 2016.

FIGURE III.7. Percentage of Facilities Offering Any Pharmacotherapies, 2013 and 2016
FIGURE III.7, Bar Chart: Each bar displays the percentage of facilities that offer any pharmacotherapy. Blue bars represent data from 2013 and red bars represent data from 2016. The first two bars represent all facilities. 37% of all facilities offered any pharmacotherapy in 2013 and 43% in 2016. The second group of bars show these percentages for urban and rural facilities. 40% of urban facilities and 32% of rural facilities offered any pharmacotherapy in 2013, and 46% and 33%, respectively, did in 2016. The third group of bars shows these percentages by facility operation. 34% of private, non-profit facilities, 40% of private, for-profit facilities, and 46% of public facilities offered any pharmacotherapy in 2013, and 40%, 45%, and 50% did in 2016, respectively.
SOURCE: N-SSATS 2016.
NOTE: We assigned urbanicity assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core of at least 10,000 but less than 50,000 population, as well as those in non-core areas. Facilities in a central or fringe urban core of 50,000 or more are considered urban. Facility operation was self-designated in N-SSATS Question 7.

Facility primary focus is associated with the availability of pharmacotherapies. Facilities indicating their primary focus was mental health treatment were substantially less likely to offer any pharmacotherapies (35 percent) than their counterparts focusing on SUDs (44 percent) or SUDs and mental health treatment (42 percent) (Figure III.9). This difference was more substantial when we assessed provision of pharmacotherapies for opioid-related disorders. Only 24 percent of facilities focusing on mental health treatment offered pharmacotherapy for opioid disorders. In contrast, 41 percent and 34 percent of facilities focusing on SUD treatment and SUD and mental health treatment, respectively, provided opioid-related pharmacotherapies.

FIGURE III.8. Percentage of Facilities Offering Opioid-Related Pharmacotherapies, 2013 and 2016
FIGURE III.8, Bar Chart: Each bar displays the percentage of facilities that offer opioid-related pharmacotherapy. Blue bars represent data from 2013 and red bars represent data from 2016. The first 2 bars represent all facilities. 30% of all facilities offered opioid-related pharmacotherapy in 2013 and 37% in 2016. The second group of bars show these percentages for urban and rural facilities. 33% of urban facilities and 23% of rural facilities offered opioid-related pharmacotherapy in 2013, and 41% and 26%, respectively, did in 2016. The third group of bars shows these percentages by facility operation. 27% of private, non-profit facilities, 35% of private, for-profit facilities, and 32% of public facilities offered any pharmacotherapy in 2013, and 35%, 41%, and 38% did in 2016, respectively.
SOURCE: N-SSATS 2016.
NOTE: We assigned urbanicity based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core of at least 10,000 but less than 50,000 population, as well as those in non-core areas. Facilities in a central or fringe urban core of 50,000 or more are considered urban. Facility operation was self-designated in N-SSATS Question 7.
FIGURE III.9. Percentage of Facilities Offering Opioid-Related and Any Pharmacotherapies, 2016
FIGURE III.9, Bar Chart: The chart displays the percentage of facilities offering opioid-related and any pharmacotherapies in 2016 by the facility’s primary focus. Data for facilities that offer opioid-related pharmacotherapies are displayed with blue bars and data for facilities that offer any pharmacotherapies are demonstrated with red bars. There are 4 group of bars, each representing a different facility focus. Among facilities focused on substance use disorder treatment, 41% offered opioid-related pharmacotherapies and 44% offered any pharmacotherapies. Among facilities focus on mental health treatment, 24% offered opioid-related pharmacotherapies and 35% offered any pharmacotherapies. Among facilities focused on both substance use disorder and mental health treatment, 34% offered opioid-related pharmacotherapies and 42% offered any pharmacotherapies. Among facilities focused on other services, 43% offered opioid-related pharmacotherapies and 50% offered any pharmacotherapies.
SOURCE: N-SSATS 2016.
NOTE: Facility focus was determined based on responses to Question 6.

According to the SAMHSA-HRSA Center for Integrated Health Solutions (2014), several barriers limit the use of pharmacotherapy. These barriers include lack of available prescribers, agency regulatory policies that restrict or forbid pharmacotherapy use, provider workforce attitudes, insurer limits on dosages prescribed (that is, annual or lifetime medication limits), insurer authorization requirements, requirements that behavioral therapies be tried first, lack of support staff for providers administering pharmacotherapy, and inconsistent credentialing or licensure requirements for counseling staff to be reimbursed for pharmacotherapy-related services. Cunningham et al. (2009) identified somewhat different obstacles to widespread adoption of pharmacotherapy, including regulatory restrictions, lack of access to medical personnel trained in delivering such treatment, and physician reluctance. Friedman et al. (2012) identified lack of qualified medical staff as a reason for lack of pharmacotherapy in the criminal justice system. Roman et al. (2011) asserted that limited knowledge about SUD treatment medications among the public hinders its use. Mass media advertising of prescription medications for other health conditions has accelerated use of those medications; broader public knowledge of the benefits of pharmacotherapy for SUDs could encourage its more widespread use.

Mark et al. (2015) demonstrated how Medicaid coverage restrictions can be a substantial barrier to provision of pharmacotherapy. They analyzed data from 2013 Medicaid pharmacy documents, 2011 and 2012 Medicaid state drug utilization records, and a 2013 American Society of Addiction Medicine survey. Only 13 state Medicaid programs included all medications approved for alcohol and opioid dependence on their preferred drug lists. The most commonly excluded were extended-release naltrexone (19 programs), acamprosate (19 programs), and methadone (20 programs). Almost all Medicaid programs required prior authorization for combined buprenorphine-naloxone and had lifetime limits.

Many of the barriers to expansion of pharmacotherapy are related to the workforce. The number of medical staff qualified to provide pharmacotherapy services and the staff supporting them needs to increase for pharmacotherapy provision to expand. Training primary care providers to provide pharmacotherapy in primary care or other integrated care settings such as HIV or mental health clinics can improve treatment access and abstinence at six months (NIDA 2017; Korthuis et al. 2017). Primary care providers can act independently or work collaboratively with SUD treatment specialist in these models. In addition to increasing the number of qualified providers workforce attitudes toward pharmacotherapy, such as requiring behavioral therapies be tried first, need to change to attain widespread adoption. Last, consistent credentialing and licensure requirements are needed across states and insurers for professionals providing pharmacotherapy services. The HHS Opioid Strategy announced in April 2017 aims to continue the department's efforts to improve access to "treatment, and recovery services, including the full range of medication-assisted treatments" (HHS 2017); also, despite the barriers, the ACA has resulted in expansions in the number of physicians waivered to prescribe buprenorphine (Knudsen et al. 2015).

3. What is the Utilization Rate for Residential and Inpatient Beds Designated for SUD Treatment?

The N-SSATS reports the number of beds designated for SUD treatment in residential and inpatient hospital specialty treatment settings. Capacity in these care settings can be assessed by estimating a utilization rate based on the number of clients in care relative to the number of designated beds. Facilities providing outpatient care generally do not have a consistent definition of available capacity. Thus, we were not able to assess utilization rates in outpatient settings.

Despite increases in designated beds, treatment capacity in the residential and inpatient hospital settings appears insufficient to meet demand in 2015 (Table B.17). Nationally, there was a 4 percent increase in designated residential beds and a 26 percent increase in inpatient hospital beds between 2013 and 2015. Despite these increases, the utilization rate for residential beds increased from 97 percent to 106 percent and that for inpatient hospital beds from 97 percent to 109 percent.11 In 18 states, residential bed utilization rates across all facilities were over 100 percent in 2015; the same number of states had inpatient bed utilization rates over 100 percent.

C. What is the Current Capacity of SUD Treatment Organizations to Participate in Efforts to Integrate SUD Treatment within the Broader Health Care System? To What Degree are SUD Treatment Providers Used to Billing Medicaid?

Many SUD treatment providers have traditionally relied on grant funding. As potential clients obtain insurance coverage as a result of insurance coverage expansions, there is concern that providers are not prepared to accept Medicaid and private insurance. The N-SSATS annually asks specialty SUD treatment facilities what forms of payment they accept for services. The facilities represented in the N-SSATS are a census of public and private facilities with SUD treatment programs, including hospital, residential, and outpatient treatment providers. These facilities account for the majority of SUD treatment spending in the United States. Table III.2 identifies the percentage of these facilities that reported accepting private health insurance and Medicaid coverage in 2013 and 2016. Between 2013 and 2016, there was a small increase in the percentage of facilities accepting private health insurance (66 percent in 2013 versus 70 percent in 2016) and Medicaid insurance (60 percent in 2013 versus 63 percent in 2016). Small proportional increases in insurance acceptance occurred in all regions and across all facility types except "any inpatient setting." It is notable that there was no change in Medicaid acceptance in states that had less than a 10 percent increase in Medicaid enrollment or in "any inpatient setting."

TABLE III.2. Percentage of Facilities Accepting Indicated Insurance Type
Facility Type Proportion Accepting Private Health Insurance Proportion Accepting Medicaid
2013 2016 % Change 2013 2016 % Change
Total 66 70 4 60 63 5
Urbanicity
   Urban 64 67 4 56 59 4
   Rural 71 76 8 67 74 11
Region
   Northeast 70 73 4 77 78 1
   Midwest 76 78 2 64 67 5
   South 61 63 4 56 58 3
   West 60 64 8 47 51 9
States in which Medicaid enrollment increased more than 10% between January 2014 and January 2015
   Yes 63 66 5 53 59 10
   No 69 71 4 65 65 0
Operation
   Private NP 66 68 2 69 71 4
   Private FP 64 69 8 41 45 10
   Public 65 67 3 62 67 8
Facility Setting
   Outpatient only 67 70 4 63 66 5
   Residential only 46 50 9 40 41 4
   Residential and outpatient 71 74 5 51 54 7
   Any inpatient hospital 93 92 -1 86 86 0
SOURCE: N-SSATS, 2013 (Question 25) and 2016 (Question 27).
NOTE: We calculated the percentage of facilities accepting private insurance and Medicaid by dividing the number of facilities reporting that they accept the indicated insurance type by the total number of facilities in the various categories. We excluded United States territories from the "Region" and "States in which Medicaid enrollment increased more than 10% between January 2014 and January 2015." We assigned urbanicity based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core of at least 10,000 but less than 50,000 population, as well as those in non-core areas. Facilities in a central or fringe urban core of 50,000 or more are considered urban. Facility operation was self-designated in N-SSATS Question 4 in 2013 and Question 7 in 2016.

D. How Have Wages for SUD Treatment Staff Changed Over the Last Decade?

Although most SUD counselors and social workers hold post-graduate degrees, average hourly wages for SUD treatment professionals are substantially lower than the average wage for all occupations. BLS collects hourly wage data in its Occupation Employment Survey (OES), including the following two occupational categories that include SUD counselors and social workers: (1) substance abuse and behavioral disorder counselors; and (2) mental health and substance abuse social workers. Wages for these two occupations have been below the average for all occupations for the last decade (Figure III.10). Trends in wage growth over the last decade resulted in expansion of these wage gaps for SUD treatment professionals, particularly substance abuse counselors:

  • 2006 to 2009. Wages increased substantially for all occupations (3.5 percent annually) and for the occupations including SUD counselors (4.0 percent annually) and social workers (2.8 percent annually).

  • 2009 to 2012. Wages of substance abuse counselors lost ground relative to other occupations, as there was little wage growth for the occupation category including them (0.4 percent annually). Wage growth continued for other occupations (1.7 percent annually), including substance abuse social workers (1.6 percent annually), albeit at a slower rate than in previous years. The lack of growth in this period was likely due to the economic recession and associated reductions in state revenue.

  • 2012 and 2016. Slow wage growth continued for all occupations and those including SUD counselor and social worker occupation categories (about 1.8 percent annually). Wage growth for substance abuse counselors increased at the same rate as other occupations but did not make up for losses in wages relative to other occupations that occurred during the recession.

FIGURE III.10. Trends in Wage Gaps for SUD Treatment Staff, BLS OES 2006-2016
FIGURE II.10, Line Chart: It displays the trends in wages for 2 substance use disorder treatment occupations and all occupations between 2006 and 20016. There are three trendlines. One highest line is light blue and never intersects with the other lines. It represents the average hourly wage across all occupations. It starts at $18.84 in 2006 and rises to $23.86 in 2016. The second trendline is in medium blue. It represents mean hourly wages for mental health and substance abuse social workers. It starts at $18.26 in 2006 and rises to $23.02 in 2016. The last trendline is in dark blue. It represents mean hourly wages for substance abuse and behavioral disorder counselors. It starts at $17.28 in 2006 and rises to $21.23 in 2016. In 2008, two trendlines appear to intersect when mental health and substance abuse social workers have a mean hourly wage of $19.05 and substance abuse and behavioral disorder counselors have a mean hourly wage of $19.07. Except at this point the trendline for mental health and substance abuse social workers is always higher than that for substance abuse and behavioral disorder counselors.
SOURCE: BLS OES 2006-2016.
NOTE: The OES is a semiannual survey measuring occupational employment and wage rates for wage and salary workers in non-farm establishments in the United States. The OES survey draws its sample from state unemployment insurance files.

Over the last decade, these wage growth trends resulted in an expansion of the gap between the mean wage for all occupations and that for the occupation including SUD treatment counselors (from $1.56 to $2.63 per hour). The wage gap for social workers relative to other occupations has fluctuated over the years (from about $0.54 in 2015 to about $1.27 in 2008) (Figure III.11).

To provide specific example of wages for alternative career paths, we selected two health care professions requiring similar or fewer years of education. In 2016, the mean hourly wages for SUD counselors were $5 and $13 lower, respectively, than those for marriage and family therapists and registered nurses.

FIGURE III.11. Gap Between Mean Hourly Wage for All Occupations and Occupations with SUD Treatment Staff, BLS OES 2006*2016
FIGURE III.11, Bar Chart: The bars descend from $0 at the top of the chart to indicate negative dollar amounts. There is a red and a blue bar for each year from 2006 through 2016. The blue bars represent the difference between the mean wage for all occupations and that for substance abuse and behavioral disorder counselors. The red bars represent the difference between the mean wage for all occupations and that for mental health and substance abuse social workers. In 2006, substance abuse and behavioral disorder counselors earned on average $1.56 less per hour than the average for all occupations and mental health and substance abuse social workers earned $0.58 less per hour than the average for all occupations. In 2016, substance abuse and behavioral disorder counselors earned $2.63 less per hour than the average for all occupations and mental health and substance abuse social workers earned $0.84 less per hour than the average for all occupations.
SOURCE: BLS OES, 2006-2016.
NOTE: The OES is a semiannual survey measuring occupational employment and wage rates for wage and salary workers in non-farm establishments in the United States. The OES survey draws its sample from state unemployment insurance files.

The SUD treatment field's current high turnover rate is commonly attributed to inadequate compensation. Compensation for behavioral health professionals is significantly lower than for other health and non-health professions requiring similar levels of training (Hyde 2013; Bukach 2017). The clinical directors interviewed as part of the national Vital Signs survey of specialty SUD treatment facilities noted that low compensation makes hiring and retaining qualified staff a challenge (Ryan et al. 2012). Efforts to increase the labor supply in the SUD treatment field through training programs without an associated increase in reimbursement for services through insurance or other funding sources are likely to result in reduced wage levels and even lower retention as individuals in the SUD treatment field recognize the potential to increase their earnings by shifting to other professions.

IV. DISCUSSION

Policymakers at all levels of government have targeted increasing SUD treatment use to address escalating drug overdose deaths related to the opioid epidemic and improve societal welfare. Meanwhile, rates of SUD treatment use generally have been constant for more than a decade despite the substantial recent increase in insurance coverage for SUD treatment. Individuals with SUD treatment needs overwhelmingly indicate that they do not feel a need for treatment and, even among the small minority who believe that they might benefit from treatment, most make no effort to obtain it. Thus, expanding treatment use will require a multifaceted approach including increasing public awareness of treatment effectiveness, reducing stigma associated with SUD treatment, addressing financial barriers, and increasing primary care physicians' role in screening, treatment and referral.

On the supply side, low wage rates for SUD treatment professionals are associated with high turnover and difficulty in hiring qualified staff. Individuals trained to provide SUD treatment quickly move on to other professions that offer better working conditions, wages, and benefits (Hyde 2013; Ryan et al. 2012; Bukach 2017). There is also concern that low treatment reimbursement rates and restrictions on SUD treatment coverage under Medicaid may be a barrier to expanding treatment in some states (Dickson 2015).

Overall, the role of Medicaid in funding SUD treatment services has expanded since 2014 although many of the individuals who gained Medicaid coverage would have received SUD treatment through another funding source such as state and local funding or federal block grants. In parallel to this shift in funding source there has been a shift from care provision in publicly operated facilities to increased use of privately operated facilities. There is an opportunity for policymakers to redirect the public funding and resources to activities encouraging expanded treatment use and providing a continuum of care that addresses the chronic nature of SUDs. Likewise state Medicaid programs have the potential to play an important role in transforming the SUD treatment system and HHS Centers for Medicare and Medicaid Services (CMS) is taking an active role encouraging states to make reforms. CMS is conducting an Innovation Accelerator Program (IAP) to support state efforts to expand SUD treatment under Medicaid. The IAP supports efforts to improve care quality and continuity, enhance performance monitoring capacity, identify beneficiaries in need of treatment, develop a continuum of care that addresses the variety treatment needs and the chronic nature of SUDs, and target reimbursement models to incentivize better outcomes (CMS 2017). In addition, CMS has been working with states to improve access to and quality of SUD treatment through Medicaid Section 1115 demonstrations (CMS 2017b).

The impact of a number of recent federal efforts to increase SUD treatment use and the quality of SUD treatment services is not fully captured in the data available for this study. The initiatives include the CMS IAP program as well as several SAMHSA grant programs intended to expand access to SUD treatment (McCance-Katz et al. 2017). The Opioid State Targeted Response grants provided $485 million to states and United States territories in fiscal year 2017 primarily to expand treatment, recovery support and prevention activities. The Medication-Assisted Treatment for Prescription Drug and Opioid Addiction program expands pharmacotherapy access by providing grants to states with the highest rates of treatment admissions for opioid addiction. There are also a number of federally-funded efforts to expand access to SUD screening and treatment in primary care settings and rural areas including integrating SUD treatment into community mental health centers, use of telemedicine, efforts to educate primary care providers on addiction risks and treatment, partnerships between primary care and specialty providers, and expansion of buprenorphine waivered primary care providers and the number of patients that can be treated under each waiver. Future years of data should be monitored to assess the impact of these initiatives.

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NOTES

  1. SAMHSA did not count positive responses to NSDUH questions regarding treatment at an emergency room, private doctor's office, self-help group, prison or jail, or hospital as an outpatient as specialty treatment.

  2. For the NSDUH SAMHSA defines specialty treatment based on the setting of care as described above. The N-SSATS universe is limited to specialty treatment facilities. These facilities have units or programs focused on provision of SUD treatment. Thus, facilities may not be defined as "specialty" in both surveys. For example, a general hospital or mental health center would not be included in the N-SSATS universe unless they have a treatment program or unit designated for SUD treatment. These settings are, however, consider specialty treatment for NSDUH.

  3. Stevens et al. (2017) found a 34 percent increase in opioid overdose-related admissions to hospital intensive care units between January 2009 and September 2015 in a study of 162 hospitals in 44 states.

  4. We define an FTE as 40 working hours per week.

  5. N-SSATS surveys the universe of specialty SUD treatment facilities. In 2016 the survey had a 91 percent response rate. Estimates are not adjusted for facility or item non-response.

  6. Utilization rate is calculated by dividing the number of clients in care by the total number of designated beds. The utilization rate will exceed 100 percent when clients are placed in beds not specifically designated for substance use treatment.

  7. The survey instrument is available at https://wwwdasis.samhsa.gov/dasis2/nssats/nssats_2016_q.pdf.

  8. SAMHSA did not include emergency room, private doctor's office, self-help group, prison or jail, or hospital as an outpatient in the definition of specialty settings.

  9. For the NSDUH SAMHSA defines specialty treatment based on the setting of care as listed above. The N-SSATS universe is limited to specialty treatment facilities. These facilities have units or programs focused on provision of SUD treatment. Thus, facilities may not be defined as "specialty" in both surveys. For example, a general hospital or mental health center would not be included in the N-SSATS universe unless they have a treatment program or unit designated for SUD treatment. These settings are, however, consider specialty treatment for NSDUH.

  10. We conducted a logistic regression using data from the 2009-2014 NSDUH to estimate the increase in the likelihood of receiving treatment that was associated with being enrolled in Medicaid relative to being uninsured. The regression controlled for age, gender, race/ethnicity, education level, household income, marital status, age of first alcohol/illicit drug use, cigarette use, criminal activity, health status, population density, work status, SUD type, and year. Holding all other characteristics constant at the average for the population, the regression analysis indicated that, at the margin, the likelihood of specialty SUD treatment for someone who was uninsured was 60 percent of that for an individual who was Medicaid insured.

  11. Utilization rate is calculated by dividing the number of clients in care by the total number of designated beds. The utilization rate will exceed 100 percent when clients are placed in beds not specifically designated for substance use treatment.

APPENDIX A: DATA SOURCES

In this appendix, we provide a brief description of the three data sources we used to develop the analyses in this report.

A. National Survey of Substance Abuse Treatment Services (N-SSATS)

The N-SSATS is an ideal source for analyzing trends in clients who are receiving specialty SUD treatment as well as trends in SUD treatment facility characteristics. It is an annual survey of the universe of specialty SUD treatment facilities. Counts of clients in care (on the last working day in March of each survey year) were collected annually through 2013 and biannually thereafter. Key strengths of the survey include its comprehensiveness in terms of the inclusion of facilities and the types of information collected. The N-SSATS, which includes all known specialty SUD treatment facilities in the United States, consistently achieves response rates greater than 90 percent. This allows for detailed analysis of small states or subgroups.

The N-SSATS data, however, are limited in several ways. Specifically, N-SSATS excludes non-specialty providers, solo practitioners, and facilities serving only criminal justice populations. The exclusion of solo practitioners might be particularly important to analysis of programs such as those implementing Hub and Spoke models, which seek to increase treatment access at non-specialty providers. The exclusion of facilities that target only criminal justice populations might limit the potential for analyzing programs that target people exiting criminal justice institutions; however, many of these people might be served by facilities included in N-SSATS. N-SSATS does include information on whether facilities have programs that focus on criminal justice clients (excluding programs for those convicted of driving under the influence/driving while intoxicated).

The N-SSATS estimates presented in this report were directly extracted from N-SSATS reports and special tabulations. We summarize the data presented in those reports or present tabulations produced by the SAMHSA from the workforce questions and other questions included in the N-SSATS 2016 survey. For example, Mathematica assigned states to a category identifying "States in which Medicaid enrollment increased more than 10 percent between January 2014 and January 2015" or not based on Medicaid enrollment reports. Then client counts from the N-SSATS reports were summarized for the states in each group to produce the estimates for these categories reported in Appendix B.

B. National Survey on Drug Use and Health (NSDUH)

The NSDUH is designed to track the prevalence of SUDs in the United States by type of substance. The NSDUH is an annual survey of the civilian, non-institutionalized population ages 12 and older in the United States. As a population survey, it provides the most comprehensive information about the number of people who meet diagnostic criteria for an SUD, who misuse prescription opioids, and who have accessed any SUD treatment service in the past year. The NSDUH includes a sufficient sample of respondents to develop state-level estimates when two years of survey data are combined; however, standard errors for estimates are often quite large for smaller states, making it impossible to identify small changes in disorder prevalence or treatment use.

There are a number of limitations to the NSDUH survey data. NSDUH provides limited information on the type of substance use treatment services received and no information on the intensity of services that respondents received. The survey excludes people who are homeless and not in a shelter, as well as those who are institutionalized, including those residing in hospitals, residential treatment settings, jails, or prisons. NSDUH does include individuals who have been released from prison or institutional care. Overall, estimates of the prevalence of alcohol and illicit drug use disorders based on the NSDUH reflect the household population only, and thus, are likely to understate national prevalence since groups with high prevalence are excluded. In addition to the exclusion of the subpopulations that have higher prevalence of SUDs (Office of Applied Studies 2002), the self-reported nature of the data collection likely results in some underreporting (Harrell 1997).

SAMHSA redesigned the NSDUH between the 2014 and 2015 surveys. Due to methodological changes associated with the redesign estimates from 2015 and later years are not comparable to earlier years. Updates to the prescription drug questions were a key component of the redesign (Center for Behavioral Health Statistics and Quality 2015):

  • Beginning in 2015, prescription drug questions were restructured to collect more information on use and misuse of specific prescription drugs. The definition of misuse was also changed with respondents being given more specific examples of misuse. In particular, prior to 2015 the definition of misuse did not include overuse of prescribed medication.

  • Methamphetamine was included as a prescription stimulant prior to 2015. However, most methamphetamine that is used in the United States is manufactured illegally, not prescribed. Therefore, beginning in 2015, a new methamphetamine module was added to address both prescription and non-prescribed use.

  • To help respondents categorize substances, the term "Molly" was added to questions about Ecstasy use in the hallucinogens module and use of felt tip pens and computer keyboard cleaner were added to the inhalants module.

The redesign also affected the abuse and dependence modules in the following key ways:

  • The logic for routing individuals to the substance abuse and dependence modules was updated.

  • Sedative withdrawal was updated to require two or more symptoms of withdrawal instead of one or more.

  • Dependence and abuse questions were added for methamphetamine.

The NSDUH estimates presented in this report were directly extracted from NSDUH reports prepared by SAMHSA or summarize data presented in those reports, with the exception of the analysis of Medicaid coverage in Section II.D.

C. Treatment Episode Data Set (TEDS)

Relative to the N-SSATS and the NSDUH, the TEDS provides more detailed information on treatment services and the characteristics of clients at admission and discharge. The TEDS aggregates admissions data collected in individual state administrative data systems. States collect these data to monitor their SUD treatment systems. Reporting requirements can vary substantially by state. Generally, facilities that receive public funds or that are licensed or certified by a state substance abuse agency are included in the state administrative systems. The universe of their admissions is reported to TEDS. The scope of facilities reporting in a given state may change over time.

REFERENCES

Center for Behavioral Health Statistics and Quality. "National Survey on Drug Use and Health: 2014 and 2015 Redesign Changes." Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.

Harrell, A.V. "The Validity of Self-Reported Drug Use Data: The Accuracy of Responses on Confidential Self-Administered Answer Sheets." In The Validity of Self-Reported Drug Use: Improving the Accuracy of Survey Estimates, edited by L. Harrison and A. Hughes. NIH Publication No. 97-4147, NIDA Research Monograph 167. Rockville, MD: National Institute on Drug Abuse, 1997, pp. 37-58.

Office of Applied Studies. "Results from the 2001 National Household Survey on Drug Abuse: Volume I; Summary of National Findings." NHSDA Series H-17, DHHS Publication No. SMA. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2002.

APPENDIX B: DETAILED TABLES

TABLE B.1. Distribution of Specialty Treatment Receipt by Geographic Location and Type of Service, 2013 and 2015
Geographic Area Total Outpatient Residential Inpatient
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 1,249,629 1,305,647 4.5 1,127,235 1,161,456 3.0 107,727 119,900 11.3 14,667 24,291 65.6
States in which Medicaid enrollment increased more than 10% between January 2014 and January 2015
   Yes 595,725 632,949 6.2 541,402 570,134 5.3 48,288 51,953 7.6 6,035 10,862 80.0
   No 638,421 661,025 3.5 573,454 583,257 1.7 56,877 64,933 14.2 8,090 12,835 58.7
Region
   Northeast 320,089 333,922 4.3 290,975 298,862 2.7 24,956 26,535 6.3 4,158 8,525 105.0
   Midwest 257,983 262,161 1.6 234,244 240,128 2.5 21,603 19,539 -9.6 2,136 2,494 16.8
   South 345,446 377,894 9.4 308,139 328,054 6.5 31,593 40,582 28.5 5,714 9,258 62.0
   West 310,628 319,997 3.0 281,498 286,347 1.7 27,013 30,230 11.9 2,117 3,420 61.5
Urbanicity
   Urban 954,890 1,103,406 15.6 860,436 979,226 13.8 83,150 102,633 23.4 11,304 21,547 90.6
   Rural 279,167 190,478 -31.8 254,331 174,075 -31.6 22,015 14,253 -35.3 2,821 2,150 -23.8
Operation
   Private, NP 638,858 670,593 5.0 553,157 570,450 3.1 79,714 88,260 10.7 5,987 11,883 98.5
   Private, FP 430,362 475,531 10.5 407,562 447,302 9.8 17,292 21,375 23.6 5,508 6,854 24.4
   Public 180,409 159,523 -11.6 166,516 143,704 -13.7 10,721 10,265 -4.3 3,172 5,554 75.1
SOURCE: N-SSATS 2013 and 2015.
NOTE: Inpatient and residential client counts represent the number of clients receiving services on March 31 of the indicated year (see Questions 28a and 29a in N-SSATS 2013 and Questions 29a and 30a in N-SSATS 2015). Outpatient client counts represent the number of clients who received outpatient services in March of the indicated year and who were still enrolled in care at the facility where they received those services on March 31 (see Question 30a in N-SSATS 2013 and Question 31a in N-SSATS 2015). Total clients is the sum of inpatient, residential, and outpatient clients. United States territories are excluded from the categories for: (1) region; and (2) states in which Medicaid enrollment increased more than 10% between January 2014 and January 2015. The percent increase in Medicaid enrollment for each state was determined based on Medicaid enrollment reports. Therefore, the totals for these categories are lower than the reported total in the first line of the table. Urbanicity is assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural client counts are only reported for facilities with known urbanicity. Facility operation was self-designated in N-SSATS Question 4 in 2013 and Question 7 in 2015.
TABLE B.2. Distribution of Specialty Treatment Receipt by State and Type of Service, 2013 and 2015
State % Change in Medicaid Enrollment
(Jan 2014 to Jan 2015)a
Total Outpatient Residential Inpatient
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 14.1 1,249,629 1,305,647 4.5 1,127,235 1,161,456 3.0 107,727 119,900 11.3 14,667 24,291 65.6
Alabama 8.9 15,089 14,548 -3.6 13,632 13,125 -3.7 1,205 1,391 15.4 252 32 -87.3
Alaska 7.0 3,900 3,363 -13.8 3,531 2,932 -17.0 359 431 20.1 10 NA NA
Arizona 22.8 31,832 33,978 6.7 29,449 30,671 4.1 2,016 2,845 41.1 367 462 25.9
Arkansas 9.7 5,927 7,154 20.7 5,124 4,704 -8.2 715 2,415 237.8 88 35 -60.2
California 24.0 117,159 111,961 -4.4 101,899 95,834 -6.0 14,300 14,156 -1.0 960 1,971 105.3
Colorado 26.5 42,256 34,793 -17.7 40,306 33,452 -17.0 1,804 1,186 -34.3 146 155 6.2
Connecticut 4.1 33,267 37,817 13.7 31,148 35,970 15.5 1,823 1,540 -15.5 296 307 3.7
Delaware 3.4 5,278 10,327 95.7 4,969 6,495 30.7 170 3,800 2135.3 139 32 -77.0
District of Columbia 9.1 3,833 2,824 -26.3 3,324 2,392 -28.0 468 431 -7.9 41 1 -97.6
Florida 9.1 53,641 63,287 18.0 45,069 51,823 15.0 7,786 8,531 9.6 786 2,933 273.2
Georgia 1.3 24,003 25,379 5.7 21,630 22,845 5.6 2,062 1,987 -3.6 311 547 75.9
Hawaii 2.5 5,205 5,768 10.8 4,820 5,113 6.1 385 611 58.7 NA 44 NA
Idaho 2.3 6,619 6,287 -5.0 6,467 6,125 -5.3 137 148 8.0 15 14 -6.7
Illinois 14.5 42,945 44,616 3.9 39,856 41,234 3.5 2,876 3,176 10.4 213 206 -3.3
Indiana 7.0 28,288 25,465 -10.0 27,466 23,861 -13.1 531 930 75.1 291 674 131.6
Iowa 4.0 9,731 8,975 -7.8 8,946 8,180 -8.6 738 747 1.2 47 48 2.1
Kansas -1.5 10,863 11,471 5.6 9,916 10,603 6.9 935 834 -10.8 12 34 183.3
Kentucky 16.5 24,071 23,565 -2.1 21,175 20,697 -2.3 2,509 2,347 -6.5 387 521 34.6
Louisiana 4.8 9,903 12,011 21.3 8,241 9,930 20.5 1,464 1,765 20.6 198 316 59.6
Maine -5.4 11,373 10,849 -4.6 10,865 10,483 -3.5 362 289 -20.2 146 77 -47.3
Maryland 14.0 42,128 46,913 11.4 39,992 44,659 11.7 1,704 1,989 16.7 432 265 -38.7
Massachusetts 12.8 44,133 45,438 3.0 40,227 40,734 1.3 3,171 3,602 13.6 735 1,102 49.9
Michigan 23.0 47,749 46,781 -2.0 42,045 43,577 3.6 5,241 3,043 -41.9 463 161 -65.2
Minnesota 7.0 18,034 19,235 6.7 14,223 15,676 10.2 3,753 3,487 -7.1 58 72 24.1
Mississippi 0.6 6,726 4,699 -30.1 5,360 3,547 -33.8 994 841 -15.4 372 311 -16.4
Missouri -17.1 23,028 25,015 8.6 21,600 22,590 4.6 1,279 2,223 73.8 149 202 35.6
Montana 17.9 4,429 5,064 14.3 3,809 4,785 25.6 488 187 -61.7 132 92 -30.3
Nebraska 1.6 6,374 5,735 -10.0 5,690 4,909 -13.7 684 824 20.5 NA 2 NA
Nevada 42.0 7,048 6,930 -1.7 6,403 6,179 -3.5 492 487 -1.0 153 264 72.5
New Hampshire 30.1 6,702 8,164 21.8 6,326 7,766 22.8 367 394 7.4 9 4 -55.6
New Jersey 26.1 36,605 36,708 0.3 33,068 32,578 -1.5 2,813 3,404 21.0 724 726 0.3
New Mexico 15.7 12,868 15,062 17.1 10,949 14,499 32.4 1,808 449 -75.2 111 114 2.7
New York 9.7 114,660 113,713 -0.8 103,167 101,982 -1.1 9,839 9,986 1.5 1,654 1,745 5.5
North Carolina 3.2 40,575 42,026 3.6 37,394 38,374 2.6 2,481 3,196 28.8 700 456 -34.9
North Dakota 9.0 1,785 2,404 34.7 1,222 1,949 59.5 510 396 -22.4 53 59 11.3
Ohio 25.2 37,262 45,129 21.1 34,397 42,006 22.1 2,365 2,406 1.7 500 717 43.4
Oklahoma 0.6 16,700 16,783 0.5 15,356 15,512 1.0 1,204 1,171 -2.7 140 100 -28.6
Oregon 25.0 21,898 30,401 38.8 20,537 29,047 41.4 1,299 1,258 -3.2 62 96 54.8
Pennsylvania 4.1 57,715 59,584 3.2 52,011 53,822 3.5 5,245 5,433 3.6 459 329 -28.3
Puerto Rico NA 15,169 11,358 -25.1 12,119 7,817 -35.5 2,511 2,971 18.3 539 570 5.8
Rhode Island 23.2 10,404 14,269 37.1 10,039 9,005 -10.3 323 1,723 433.4 42 3,541 8,331.0
South Carolina -2.8 15,824 18,236 15.2 14,906 16,473 10.5 552 614 11.2 366 1,149 213.9
South Dakota 2.5 3,267 2,964 -9.3 2,569 2,308 -10.2 623 585 -6.1 75 71 -5.3
Tennessee 13.4 14,149 22,445 58.6 11,698 20,187 72.6 2,010 1,994 -0.8 441 264 -40.1
Texas 6.3 34,704 35,293 1.7 28,843 26,984 -6.4 5,065 6,391 26.2 796 1,918 141.0
Utah 0.5 12,586 12,496 -0.7 11,183 11,070 -1.0 1,389 1,379 -0.7 14 47 235.7
Vermont 8.2 5,230 7,380 41.1 4,124 6,522 58.1 1,013 164 -83.8 93 694 646.2
Virginia -6.8 22,838 22,305 -2.3 21,879 20,807 -4.9 712 1,174 64.9 247 324 31.2
Washington 24.2 42,030 50,633 20.5 39,680 43,724 10.2 2,210 6,762 206.0 140 147 5.0
West Virginia 14.8 10,057 10,099 0.4 9,547 9,500 -0.5 492 545 10.8 18 54 200.0
Wisconsin -10.4 28,657 24,371 -15.0 26,314 23,235 -11.7 2,068 888 -57.1 275 248 -9.8
Wyoming -2.6 2,798 3,261 16.5 2,465 2,916 18.3 326 331 1.5 7 14 100.0
U.S. territories NA 314 315 0.3 260 248 -4.6 51 43 -15.7 3 24 700.0
SOURCE: N-SSATS 2013 and 2015.
NOTE: Inpatient and residential client counts represent the number of clients receiving services on March 31 of the indicated year (see Questions 28a and 29a in N-SSATS 2013 and Questions 29a and 30a in N-SSATS 2015). Outpatient client counts represent the number of clients who received outpatient services in March of the indicated year and who were still enrolled in care at the facility where they received those services on March 31 (see Question 30a in N-SSATS 2013 and Question 31a in N-SSATS 2015). Total clients is the sum of inpatient, residential, and outpatient clients.
  1. The percent increase in Medicaid enrollment for each state was determined based on Medicaid enrollment reports.
TABLE B.3.a. Number of Clients Receiving Medications by Geographic Location and Facility Characteristics, 2013 and 2015
  Total Receiving Methadone Receiving Buprenorphine Receiving Injectable Naltrexone
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 382,237 439,602 15 330,308 356,843 8 48,148 75,724 57 3,781 7,035 86
States in which Medicaid enrollment increased more than 10% between January 2014 and January 2015
   Yes 166,201 206,158 24 140,659 166,890 19 24,043 35,575 48 1,499 3,693 146
   No 208,168 228,187 10 182,208 185,422 2 23,711 39,436 66 2,249 3,329 48
Region
   Northeast 128,212 138,585 8 112,198 114,087 1 15,093 22,620 50 921 1,878 104
   Midwest 57,894 71,447 23 48,286 53,687 11 8,539 15,579 82 1,069 2,181 104
   South 121,655 145,753 20 103,161 116,555 13 17,441 27,649 59 1,053 1,549 47
   West 65,682 78,560 19 58,296 67,983 16 6,681 9,163 37 705 1,414 101
Urbanicity
   Urban 304,932 403,601 32 265,239 332,937 26 36,896 64,372 74 2,797 6,292 125
   Rural 68,511 30,744 -55 56,702 19,375 -66 10,858 10,639 -2 951 730 -23
Facility focus
   SUD treatment NA 376,265 NA NA 327,936 NA NA 44,616 NA NA 3,713 NA
   MH treatment NA 4,233 NA NA 1,416 NA NA 2,568 NA NA 249 NA
   SUD and MH treatment NA 45,718 NA NA 18,244 NA NA 24,671 NA NA 2,803 NA
   Other NA 13,386 NA NA 9,247 NA NA 3,869 NA NA 270 NA
Operation
   Private, NP 130,181 153,994 18 111,313 121,499 9 17,610 29,149 66 1,258 3,346 166
   Private, FP 214,533 252,423 18 189,264 213,421 13 23,152 36,286 57 2,117 2,716 28
   Public 37,523 33,185 -12 29,731 21,923 -26 7,386 10,289 39 406 973 140
SOURCE: N-SSATS 2013 and 2015.
NOTE: The number of clients receiving methadone, buprenorphine, or injectable naltrexone is based on counts of clients receiving these services as reported in Questions 28c, 29c, and 30c in N-SSATS 2013 and Questions 29c, 30c, and 31c in N-SSATS 2015. Total clients is the sum of methadone, buprenorphine, or injectable naltrexone clients. United States territories are excluded from the categories for: (1) region; and (2) states in which Medicaid enrollment increased more than 10% between January 2014 and January 2015. The percent increase in Medicaid enrollment for each state was determined based on Medicaid enrollment reports. Therefore, the totals for these categories are lower than the reported total in the first line of the table. Urbanicity is assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural client counts are only reported for facilities with known urbanicity. Facility operation was self-designated in N-SSATS Question 4 in 2013 and Question 7 in 2015. Facility focus was not asked on the N-SSATS 2013 survey.
TABLE B.3.b. Proportion of Clients Receiving Medications by Geographic Location, 2013 and 2015
  Total Receiving Methadone Receiving Buprenorphine Receiving Injectable Naltrexone
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 31 34 10 26 27 3 4 6 51 0 1 78
States in which Medicaid enrollment increased more than 10% between January 2014 and January 2015
   Yes 28 33 17 24 26 12 4 6 39 0 1 132
   No 33 35 6 29 28 -2 4 6 61 0 1 43
Region
   Northeast 40 42 4 35 34 -3 5 7 44 0 1 95
   Midwest 22 27 21 19 20 9 3 6 80 0 1 101
   South 35 39 10 30 31 3 5 7 45 0 0 34
   West 21 25 16 19 21 13 2 3 33 0 0 95
Urbanicity
   Urban 32 37 15 28 30 9 4 6 51 0 1 95
   Rural 25 16 -34 20 10 -50 4 6 44 0 0 13
Operation
   Private, NP 20 23 13 17 18 4 3 4 58 0 0 153
   Private, FP 50 53 6 44 45 2 5 8 42 0 1 16
   Public 21 21 0 16 14 -17 4 6 58 0 1 171
SOURCE: N-SSATS 2013 and 2015.
NOTE: The percentage of clients receiving methadone, buprenorphine, or injectable naltrexone is based on counts of clients receiving these services (as reported in Table B.3.a) divided by the total number of clients (indicated in Table B.1). United States territories are excluded from the categories for: (1) region; and (2) states in which Medicaid enrollment increased more than 10% between January 2014 and January 2015. The percent increase in Medicaid enrollment for each state was determined based on Medicaid enrollment reports. Urbanicity is assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural estimates are only reported for facilities with known urbanicity. Facility operation was self-designated in N-SSATS Question 4 in 2013 and Question 7 in 2015.
TABLE B.4.a. Number of Clients Receiving Medications by State, 2013 and 2015
  Total Receiving Methadone Receiving Buprenorphine Receiving Injectable Naltrexone
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 383,130 439,602 15 331,215 356,843 8 48,134 75,724 57 3,781 7,035 86
Alabama 8,785 8,457 -4 7,738 7,639 -1 967 787 -19 80 31 -61
Alaska 285 444 56 144 331 130 137 91 -34 4 22 450
Arizona 7,585 8,291 9 6,425 7,107 11 1,040 987 -5 120 197 64
Arkansas 992 1,484 50 831 1,095 32 161 389 142 NA NA NA
California 33,301 38,607 16 30,899 35,231 14 2,154 2,922 36 248 454 83
Colorado 2,561 2,290 -11 2,084 1,934 -7 379 256 -32 98 100 2
Connecticut 16,540 14,658 -11 15,531 14,072 -9 980 544 -44 29 42 45
Delaware 2,826 5,834 106 2,422 3,266 35 380 2,425 538 24 143 496
District of Columbia 1,856 1,428 -23 1,760 1,315 -25 93 104 12 3 9 200
Florida 16,471 20,978 27 14,441 17,670 22 1,700 2,922 72 330 386 17
Georgia 10,542 11,990 14 10,194 11,212 10 297 659 122 51 119 133
Hawaii 700 745 6 612 623 2 87 121 39 1 1 0
Idaho 147 678 361 NA 312 NA 137 353 158 10 13 30
Illinois 13,230 15,053 14 11,922 13,559 14 1,199 1,303 9 109 191 75
Indiana 10,037 8,393 -16 9,265 7,073 -24 744 1,178 58 28 142 407
Iowa 692 889 28 623 783 26 69 106 54 NA NA NA
Kansas 2,284 2,585 13 2,077 2,313 11 207 261 26 NA 11 NA
Kentucky 4,719 5,136 9 1,626 2,955 82 3,079 2,158 -30 14 23 64
Louisiana 2,193 4,731 116 1,907 3,502 84 271 1,153 325 15 76 407
Maine 4,503 5,304 18 3,658 3,751 3 838 1,529 82 7 24 243
Maryland 22,278 26,692 20 19,564 22,927 17 2,622 3,533 35 92 232 152
Massachusetts 19,626 22,146 13 15,479 17,633 14 3,861 4,113 7 286 400 40
Michigan 9,116 12,064 32 7,851 9,806 25 1,187 1,900 60 78 358 359
Minnesota 5,048 6,258 24 4,533 5,530 22 483 667 38 32 61 91
Mississippi 257 274 7 183 176 -4 70 97 39 4 1 -75
Missouri 3,817 4,764 25 2,704 3,083 14 738 1,155 57 375 526 40
Montana 382 773 102 174 489 181 190 284 49 18 NA NA
Nebraska 954 688 -28 553 619 12 78 52 -33 323 17 -95
Nevada 1,572 1,847 17 1,493 1,555 4 75 261 248 4 31 675
New Hampshire 2,656 4,754 79 2,340 2,748 17 311 1,991 540 5 15 200
New Jersey 12,818 14,506 13 11,704 13,103 12 1,036 1,166 13 78 237 204
New Mexico 2,752 5,029 83 2,407 4,088 70 332 890 168 13 51 292
New York 43,740 41,502 -5 38,873 34,535 -11 4,540 6,394 41 327 573 75
North Carolina 14,930 19,382 30 11,499 13,665 19 3,369 5,637 67 62 80 29
North Dakota 9 109 1,111 NA NA NA 9 84 833 NA 25 NA
Ohio 7,580 14,092 86 4,908 6,147 25 2,618 7,347 181 54 598 1,007
Oklahoma 3,279 3,760 15 3,091 3,500 13 188 227 21 NA 33 NA
Oregon 4,348 5,322 22 4,045 4,663 15 288 601 109 15 58 287
Pennsylvania 23,096 24,262 5 20,623 20,408 -1 2,308 3,530 53 165 324 96
Puerto Rico 8,761 5,230 -40 8,348 4,515 -46 380 702 85 33 13 -61
Rhode Island 4,243 7,552 78 3,517 6,213 77 715 1,078 51 11 261 2,273
South Carolina 5,020 5,334 6 4,323 4,524 5 671 799 19 26 11 -58
South Dakota 83 10 -88 82 5 -94 1 5 400 NA NA NA
Tennessee 2,974 5,721 92 2,427 4,421 82 488 1,179 142 59 121 105
Texas 12,497 12,126 -3 11,662 9,833 -16 673 2,189 225 162 104 -36
Utah 3,028 3,489 15 2,635 2,459 -7 345 790 129 48 240 400
Vermont 1,435 3,901 172 918 1,624 77 504 2,275 351 13 2 -85
Virginia 6,655 7,096 7 5,323 5,735 8 1,278 1,319 3 54 42 -22
Washington 8,950 10,953 22 7,495 9,191 23 1,335 1,534 15 120 228 90
West Virginia 5,510 5,330 -3 4,299 3,120 -27 1,134 2,072 83 77 138 79
Wisconsin 5,279 6,542 24 4,003 4,769 19 1,206 1,521 26 70 252 260
Wyoming 188 92 -51 NA NA NA 182 73 -60 6 19 217
SOURCE: N-SSATS 2013 and 2015.
NOTE: The number of clients receiving methadone, buprenorphine, or injectable naltrexone is based on counts of clients receiving these services, as reported in Questions 28c, 29c, and 30c in N-SSATS 2013 and Questions 29c, 30c, and 31c in N-SSATS 2015. Total clients is the sum of methadone, buprenorphine, or injectable naltrexone clients.
TABLE B.4.b. Proportion of Clients Receiving Medications by State, 2013 and 2015
  Total Receiving Methadone Receiving Buprenorphine Receiving Injectable Naltrexone
2013 2015 % Change 2013 2015 % Change 2013 2015 % Change 2013 2015 % Change
Total 31 34 10 27 27 3 4 6 51 0 1 78
Alabama 58 58 0 51 53 2 6 5 -16 1 0 -60
Alaska 7 13 81 4 10 167 4 3 -23 0 1 538
Arizona 24 24 2 20 21 4 3 3 -11 0 1 54
Arkansas 17 21 24 14 15 9 3 5 100 0 0 NA
California 28 34 21 26 31 19 2 3 42 0 0 92
Colorado 6 7 9 5 6 13 1 1 -18 0 0 24
Connecticut 50 39 -22 47 37 -20 3 1 -51 0 0 27
Delaware 54 56 6 46 32 -31 7 23 226 0 1 205
District of Columbia 48 51 4 46 47 1 2 4 52 0 0 307
Florida 31 33 8 27 28 4 3 5 46 1 1 -1
Georgia 44 47 8 42 44 4 1 3 110 0 0 121
Hawaii 13 13 -4 12 11 -8 2 2 26 0 0 -10
Idaho 2 11 386 NA 5 NA 2 6 171 0 0 37
Illinois 31 34 10 28 30 9 3 3 5 0 0 69
Indiana 35 33 -7 33 28 -15 3 5 76 0 1 463
Iowa 7 10 39 6 9 36 1 1 67 NA NA NA
Kansas 21 23 7 19 20 5 2 2 19 NA 0 NA
Kentucky 20 22 11 7 13 86 13 9 -28 0 0 68
Louisiana 22 39 78 19 29 51 3 10 251 0 1 318
Maine 40 49 23 32 35 7 7 14 91 0 0 259
Maryland 53 57 8 46 49 5 6 8 21 0 0 126
Massachusetts 44 49 10 35 39 11 9 9 3 1 1 36
Michigan 19 26 35 16 21 27 2 4 63 0 1 368
Minnesota 28 33 16 25 29 14 3 3 29 0 0 79
Mississippi 4 6 53 3 4 38 1 2 98 0 0 -64
Missouri 17 19 15 12 12 5 3 5 44 2 2 29
Montana 9 15 77 4 10 146 4 6 31 0 NA NA
Nebraska 15 12 -20 9 11 24 1 1 -26 5 0 -94
Nevada 22 27 19 21 22 6 1 4 254 0 0 688
New Hampshire 40 58 47 35 34 -4 5 24 426 0 0 146
New Jersey 35 40 13 32 36 12 3 3 12 0 1 203
New Mexico 21 33 56 19 27 45 3 6 129 0 0 235
New York 38 36 -4 34 30 -10 4 6 42 0 1 77
North Carolina 37 46 25 28 33 15 8 13 62 0 0 25
North Dakota 1 5 799 NA NA NA 1 3 593 NA 1 NA
Ohio 20 31 54 13 14 3 7 16 132 0 1 814
Oklahoma 20 22 14 19 21 13 1 1 20 NA 0 NA
Oregon 20 18 -12 18 15 -17 1 2 50 0 0 179
Pennsylvania 40 41 2 36 34 -4 4 6 48 0 1 90
Puerto Rico 58 46 -20 55 40 -28 3 6 147 0 0 -47
Rhode Island 41 53 30 34 44 29 7 8 10 0 2 1,630
South Carolina 32 29 -8 27 25 -9 4 4 3 0 0 -63
South Dakota 3 0 -87 3 0 -93 0 0 451 NA NA NA
Tennessee 21 25 21 17 20 15 3 5 52 0 1 29
Texas 36 34 -5 34 28 -17 2 6 220 0 0 -37
Utah 24 28 16 21 20 -6 3 6 131 0 2 404
Vermont 27 53 93 18 22 25 10 31 220 0 0 -89
Virginia 29 32 9 23 26 10 6 6 6 0 0 -20
Washington 21 22 2 18 18 2 3 3 -5 0 0 58
West Virginia 55 53 -4 43 31 -28 11 21 82 1 1 78
Wisconsin 18 27 46 14 20 40 4 6 48 0 1 323
Wyoming 7 3 -58 NA NA NA 7 2 -66 0 1 172
SOURCE: N-SSATS 2013 and 2015.
NOTE: The percentage of clients receiving methadone, buprenorphine, or injectable naltrexone is based on counts of clients receiving these services (as reported in Table B.2) relative to the total number of clients (indicated in Table B.4.a).
TABLE B.5. Substance Dependence or Abuse for Specific Substances in the Past Year Among Persons Age 12 or Older, 2002-2015
Past Year Dependence or Abuse 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Illicit drugsa 7,116 6,835 7,298 6,833 7,024 6,866 7,012 7,114 7,144 6,531 7,312 6,852 7,077 7,737n
   Marijuana and hashish 4,294 4,198 4,469 4,090 4,184 3,941 4,228 4,322 4,505 4,165 4,304 4,206 4,176 4,007
   Cocaine 1,488** 1,515** 1,571** 1,549** 1,665** 1,604** 1,412** 1,108 1,012 821 1,119 855 913 896
   Heroin 214** 189** 270** 227** 324** 214** 283** 369* 361** 426 467 517 586 591
   Hallucinogens 426** 321 449** 371* 380* 369* 362* 373* 402** 342 331 277 246 267n
   Inhalants 180* 169* 233** 221** 176* 164* 175* 164* 169* 141 164 132 96 121n
   Non-medical use of psychotherapeuticsb,c 2,018* 1,923** 2,048* 1,959** 2,036* 2,167 2,177 2,297 2,378 2,139 2,597 2,281 2,417 2,742n
   Pain relievers 1,509* 1,424** 1,388** 1,546* 1,636 1,715 1,715 1,878 1,923 1,768 2,056 1,879 1,918 2,038n
   Tranquilizers 509 435 573 419 403 443 453 476 522 400 629 423 472 688n
   Stimulantsb 436 378 470 409 388 405 351 380 358 329* 535 469 476 426n
   Sedatives 154 158 128 97 121 154 127 147 162 78 135 99 143 154n
Alcohol 18,100* 17,805 18,654** 18,658** 18,852** 18,687** 18,478** 18,763** 17,967 16,672 17,714 17,298 16,994 15,736
   Both illicit drugs and alcohola 3,210** 3,054* 3,445** 3,273** 3,215** 3,184** 3,102** 3,243** 2,889 2,598 2,840 2,589 2,592 2,663n
   Illicit drugs or alcohola 22,006 21,586 22,506 22,218 22,661* 22,369 22,388 22,634 22,221 20,605 22,187 21,561 21,480 20,810n
SOURCE: Results for 2002 to 2014 are extracted from Table 7.50A in Center for Behavioral Health Statistics and Quality 2015. Results for 2015 are extracted from Table 7.40A in the Center for Behavioral Health Statistics and Quality 2016.
NOTE: Dependence or abuse is based on definitions found in the fourth edition of the DSM.

a. Illicit drugs include marijuana and hashish, cocaine (including crack), heroin, hallucinogens, inhalants, and prescription psychotherapeutics used non-medically including data from original NSDUH questions regarding methamphetamines but not new items added in 2005 and 2006 NSDUH.
b. Estimates in these designated rows do not include data from new methamphetamine items added in 2005 and 2006.
c. Non-medical use of prescription psychotherapeutics includes the non-medical use of pain relievers, tranquilizers, stimulants, or sedatives and does not include over-the-counter drugs.
n. Estimates are not comparable to prior years due to changes in the survey methodology.
*The difference between this estimate and the 2014 estimate is statistically significant at the 0.05 level.
**The difference between this estimate and the 2014 estimate is statistically significant at the 0.01 level.
TABLE B.6. Proportion of Individuals 12 or Older Reporting Symptoms of SUD but Not Receiving Any Treatment, by State, 2013-2014
  Drug Use Disorders Alcohol Use Disorders
With a Disorder
(thousands)
With a Disorder but
Not Receiving Treatment
With a Disorder
(thousands)
With a Disorder but
Not Receiving Treatment
Number
(thousands)
Percentage Number
(thousands)
Percentage
Total 6,964 6,202 89 17,147 16,351 95
Alabama 107 98 92 233 225 97
Alaska 19 16 84 39 37 95
Arizona 177 157 89 418 383 92
Arkansas 58 53 91 128 126 98
California 876 791 90 2,127 2,030 95
Colorado 128 113 88 329 304 92
Connecticut 88 75 85 206 199 97
Delaware 27 20 74 48 46 96
District of Columbia 20 18 90 55 52 95
Florida 410 369 90 1,008 976 97
Georgia 238 208 87 506 482 95
Hawaii 26 25 96 78 73 94
Idaho 31 28 90 88 83 94
Illinois 267 246 92 661 636 96
Indiana 155 132 85 364 347 95
Iowa 56 52 93 160 154 96
Kansas 55 49 89 174 166 95
Kentucky 96 82 85 202 200 99
Louisiana 112 96 86 228 222 97
Maine 30 26 87 65 64 98
Maryland 140 123 88 331 311 94
Massachusetts 173 156 90 383 361 94
Michigan 205 181 88 510 497 97
Minnesota 107 97 91 286 274 96
Mississippi 65 59 91 141 138 98
Missouri 129 112 87 320 310 97
Montana 18 17 94 65 59 91
Nebraska 37 33 89 115 110 96
Nevada 62 55 89 158 150 95
New Hampshire 32 27 84 87 83 95
New Jersey 178 160 90 486 459 94
New Mexico 51 44 86 118 113 96
New York 483 420 87 1,101 1,014 92
North Carolina 229 201 88 501 476 95
North Dakota 14 12 86 47 44 94
Ohio 267 229 86 646 619 96
Oklahoma 74 64 86 200 183 92
Oregon 99 89 90 233 217 93
Pennsylvania 297 253 85 717 684 95
Rhode Island 30 26 87 69 64 93
South Carolina 102 89 87 235 229 97
South Dakota 15 13 87 53 47 89
Tennessee 125 116 93 293 290 99
Texas 464 441 95 1,396 1,358 97
Utah 61 55 90 124 118 95
Vermont 17 14 82 39 36 92
Virginia 171 154 90 484 464 96
Washington 159 141 89 383 355 93
West Virginia 46 42 91 100 92 92
Wisconsin 126 112 89 376 356 95
Wyoming 11 9 82 36 35 97
SOURCE: Data were extracted from "2013-2014 National Surveys on Drug Use and Health: Model-Based Estimated Totals" (CBHSQ 2015) as follows: number of individuals with illicit drug disorder in past year from Table 18, number of individuals with alcohol use disorder from Table 16, number with an illicit drug use disorder not receiving treatment from Table 21, and number with an alcohol use disorder not receiving treatment from Table 22. The authors calculated the percentage not receiving treatment by dividing the number of individuals with a disorder not receiving treatment by the total number of individuals with a disorder.
TABLE B.7. Total Paid Staff Working in Specialty SUD Treatment Facilities in the United States, by Profession, 2016
Profession Total Staff Members Total FTEsa Percentage Certified in
Addiction Treatment
Number Percentage Number Percentage
Total 256,449 100 197,559 100 27
Medical staff 55,665 22 37,317 19 19
   Physician 14,811 6 7,576 4 42
   Pharmacist 2,016 1 1,110 1 23
   Registered nurse 22,238 9 16,515 8 8
   Licensed practical nurse 10,316 4 8,073 4 10
   Mid-level medical personnel 6,284 2 4,043 2 20
Counseling staff 104,742 41 83,776 42 45
   Doctoral-level counselor 5,534 2 3,944 2 34
   Master's-level counselor 54,629 21 43,267 22 40
   Bachelor's degree counselor 26,447 10 22,038 11 49
   Associate's degree or no-degree counselor 18,132 7 14,527 7 59
Non-administrative support staff 54,988 21 41,009 21 17
   Pharmacy assistant 834 <1 684 <1 6
   Peer support staff 11,523 4 8,877 4 21
   Care manager or patient navigator 10,741 4 9,318 5 18
   Other recovery support worker 18,236 7 14,233 7 12
   Interns, contractors or per diem staff, and intake coordinators 11,504 4 6,402 3 20
   Other clinical staff 2,150 1 1,495 1 32
Administrative support staff 41,054 16 35,457 18 7
SOURCE: N-SSATS 2016, Question 22.
  1. One FTE is 40 working hours per week.
TABLE B.8. Total Unpaid Staff Working in Specialty SUD Treatment Facilities in the United States, by Profession, 2016
Profession Total Staff Members Total FTEsa Percentage Certified in
Addiction Treatment
Number Percentage Number Percentage
Total (all types of professions) 14,458 100 6,726 100 21
Doctoral-level medical staff 1,114 8 408 6 35
Nursing staff or mid-level provider 1,316 9 818 12 13
Post-graduate level counselor 2,228 15 1,134 17 25
Bachelor's degree counselor 1,349 9 659 10 33
Associate's degree or no-degree counselor 869 6 442 7 48
Pharmacy assistant 63 <1 32 <1 13
Peer support staff 1,026 7 337 5 18
Care manager or patient navigator 188 1 93 1 29
Other recovery support worker 759 5 238 4 14
Administrative staff 1,032 7 618 9 18
Interns, contractors or per diem staff, and intake coordinators 4,418 31 1,914 28 11
Other clinical staff 97 1 32 <1 31
SOURCE: N-SSATS 2016, Question 23.
  1. One FTE is 40 working hours per week.
TABLE B.9.a. Number and FTEs for Paid Medical Staff by Profession and State, 2016
State Number of Staff Number of FTEa
Total Physician Pharmacist Registered Nurse Licensed
Practical Nurse
Mid-Level
Medical Personnel
Total Physician Pharmacist Registered Nurse Licensed
Practical Nurse
Mid-Level
Medical Personnel
Total 55,665 14,811 2,016 22,238 10,316 6,284 37,318 7,576 1,110 16,515 8,073 4,043
Alabama 493 119 48 153 132 41 295 52 19 103 96 26
Alaska 146 61 4 35 21 25 98 32 4 28 16 18
Arizona 1,232 267 21 583 143 218 868 153 14 443 115 143
Arkansas 271 75 18 69 60 49 185 37 10 59 48 30
California 4,120 1,595 362 938 767 458 2,358 705 55 705 605 287
Colorado 655 208 24 211 71 141 398 113 22 140 41 83
Connecticut 1,129 302 39 379 213 196 654 150 13 244 140 108
Delaware 212 49 9 78 45 31 147 23 9 70 29 15
District of Columbia 112 38 5 33 15 21 63 18 3 17 10 15
Florida 3,680 972 135 1,170 965 438 2,797 653 77 961 799 308
Georgia 1,686 323 109 731 382 141 1,165 160 47 598 276 84
Hawaii 121 61 0 44 6 10 51 24 0 19 2 6
Idaho 198 38 11 63 32 54 102 15 3 42 18 24
Illinois 1,898 732 49 710 263 144 1,028 291 38 426 190 82
Indiana 1,224 251 24 622 199 128 889 169 17 472 148 82
Iowa 336 82 5 151 43 55 215 37 5 112 29 32
Kansas 582 130 20 200 133 99 475 87 13 180 120 75
Kentucky 840 195 19 415 109 102 511 92 15 300 54 50
Louisiana 742 213 24 208 255 42 476 100 15 148 192 21
Maine 488 113 21 264 26 64 295 57 8 167 20 44
Maryland 1,211 385 10 302 342 172 796 198 7 215 274 103
Massachusetts 1,953 516 34 818 355 230 1,278 251 20 629 238 140
Michigan 2,504 877 101 985 330 211 1,608 469 83 630 267 159
Minnesota 1,049 142 45 466 301 95 632 56 21 266 227 62
Mississippi 534 91 16 293 83 51 399 60 13 242 49 36
Missouri 933 210 14 443 209 57 752 127 12 406 166 41
Montana 580 113 51 291 76 49 517 106 40 257 72 42
Nebraska 375 108 32 117 41 77 240 71 24 79 34 33
Nevada 522 69 15 340 66 32 410 35 13 289 51 22
New Hampshire 331 144 6 51 40 90 258 104 1 47 34 72
New Jersey 1,360 423 30 586 189 132 772 184 12 400 112 64
New Mexico 492 158 41 162 57 74 309 70 18 124 42 54
New York 3,927 1,094 63 1,679 639 451 2,328 454 42 1,137 458 239
North Carolina 2,350 615 58 1,113 301 263 1,700 400 47 832 251 170
North Dakota 276 38 9 165 33 31 215 30 8 133 25 19
Ohio 2,109 593 57 812 433 214 1,413 284 38 627 333 131
Oklahoma 550 139 49 153 154 55 421 81 47 116 138 39
Oregon 517 140 25 153 114 85 350 65 23 113 101 48
Pennsylvania 2,904 729 79 1,088 804 204 2,039 304 67 824 718 126
Puerto Rico 615 219 13 317 57 9 409 111 12 237 42 8
Rhode Island 283 65 11 130 34 43 200 30 3 115 28 25
South Carolina 695 126 50 396 72 51 494 74 33 289 53 44
South Dakota 190 30 12 78 28 42 99 7 2 42 22 25
Tennessee 1,270 222 26 527 284 211 883 108 17 361 245 152
Texas 2,373 334 43 1,374 508 114 1,950 201 33 1,140 486 90
Utah 722 210 38 235 87 152 381 73 11 168 48 81
Vermont 224 61 10 80 38 35 150 42 3 60 21 25
Virginia 1,344 293 56 610 304 81 897 145 25 438 232 56
Washington 757 227 20 238 118 154 482 114 8 154 95 111
West Virginia 702 144 16 265 197 80 542 79 9 241 153 60
Wisconsin 1,541 438 35 858 110 100 1,072 257 28 641 84 63
Wyoming 101 27 2 48 4 20 52 13 1 28 2 8
Other U.S. Territories 207 7 2 8 28 162 203 5 2 6 28 162
SOURCE: N-SSATS 2016, Question 22.
  1. One FTE is 40 working hours per week.
TABLE B.9.b. Percentage of Medical Staff Certified in Addiction Treatment by Profession and State, 2016
  Total Physician Pharmacist Registered Nurse Licensed
Practical Nurse
Mid-Level
Medical Personnel
Total 19 42 23 8 10 20
Alabama 21 39 21 9 17 32
Alaska 17 28 0 9 14 8
Arizona 14 30 14 8 5 17
Arkansas 13 28 6 7 8 6
California 40 59 85 12 18 34
Colorado 19 39 0 9 3 14
Connecticut 24 47 28 8 18 26
Delaware 21 57 0 8 7 23
District of Columbia 39 45 40 36 60 19
Florida 21 36 22 12 16 26
Georgia 14 43 9 4 8 20
Hawaii 30 43 NA 11 0 40
Idaho 14 45 9 5 6 7
Illinois 27 48 8 13 16 14
Indiana 7 21 0 2 4 13
Iowa 7 18 0 1 5 11
Kansas 8 22 5 0 4 13
Kentucky 11 33 0 3 2 16
Louisiana 15 43 0 5 2 12
Maine 16 49 5 5 15 9
Maryland 26 50 10 13 11 27
Massachusetts 20 44 3 8 12 21
Michigan 12 23 1 7 7 9
Minnesota 17 45 16 10 11 25
Mississippi 6 26 0 1 1 12
Missouri 12 35 0 3 5 25
Montana 7 12 6 7 3 6
Nebraska 15 23 3 11 12 17
Nevada 16 42 0 9 9 9
New Hampshire 21 42 17 2 2 6
New Jersey 25 48 13 11 14 33
New Mexico 18 30 15 9 12 16
New York 26 57 10 15 9 20
North Carolina 15 37 5 4 5 21
North Dakota 5 5 0 1 0 39
Ohio 19 38 4 10 13 13
Oklahoma 11 29 2 4 5 7
Oregon 17 40 0 12 1 13
Pennsylvania 12 36 3 2 5 14
Puerto Rico 33 47 23 23 32 33
Rhode Island 27 54 27 15 15 30
South Carolina 9 33 6 1 14 8
South Dakota 5 13 0 3 4 5
Tennessee 13 44 8 2 9 11
Texas 12 48 7 4 9 20
Utah 36 57 8 19 25 45
Vermont 18 38 40 5 11 17
Virginia 11 30 7 6 2 15
Washington 32 55 35 13 13 43
West Virginia 9 35 0 2 1 9
Wisconsin 13 35 9 3 1 18
Wyoming 16 33 0 8 0 15
Other U.S. Territories 7 43 0 25 7 5
SOURCE: N-SSATS 2016, Question 22.
NOTE: The percentages of staff who are certified in addiction treatment are calculated by dividing the number of staff certified in addiction treatment by the total number of staff in facilities that reported information on staff certification. Nearly all (99.8%) of the reported staff worked in facilities that reported counts of certified staff.
TABLE B.10.a. Number of FTEs for Paid Counseling and Support Staff by Profession and State, 2016
State Number of Staff Number of FTEa Staff
Total Counselors Support Staff Total Counselors Support Staff
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Non-Administrative Administrative Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Non-Administrative Administrative
Total 200,784 60,163 26,447 18,132 54,988 41,054 160,241 47,210 22,038 14,527 41,008 35,457
Alabama 1,450 637 130 41 320 322 1,112 482 118 26 214 272
Alaska 1,083 284 143 133 299 224 1,035 278 135 121 279 223
Arizona 6,442 1,590 668 368 2,639 1,178 5,320 1,255 533 296 2,199 1,038
Arkansas 1,188 356 177 154 232 269 907 252 149 123 159 223
California 19,155 3,871 1,865 4,331 5,591 3,498 14,907 2,918 1,500 3,348 4,036 3,105
Colorado 3,935 1,435 643 337 754 766 3,042 1,140 508 238 526 629
Connecticut 3,576 1,363 383 221 976 633 2,820 1,093 318 175 676 558
Delaware 520 167 95 46 87 125 427 137 74 41 65 112
District of Columbia 400 128 53 42 99 78 298 91 44 37 67 60
Florida 12,359 3,215 1,238 648 5,096 2,163 9,938 2,560 1,027 524 3,896 1,932
Georgia 5,153 1,702 770 506 1,214 961 3,616 1,085 489 412 784 846
Hawaii 1,953 603 309 218 532 291 1,082 340 233 180 207 123
Idaho 1,438 587 173 84 305 289 976 376 121 61 168 250
Illinois 7,193 2,263 1,345 612 1,378 1,595 5,410 1,702 1,053 476 938 1,241
Indiana 4,853 1,590 1,079 335 893 956 4,157 1,335 972 285 709 855
Iowa 1,662 496 446 119 277 324 1,395 423 360 115 212 285
Kansas 2,366 748 255 129 711 523 2,019 646 218 123 564 468
Kentucky 4,482 1,322 628 389 1,275 868 3,248 1,011 401 73 1,043 720
Louisiana 1,694 466 176 91 573 388 1,386 373 138 74 466 334
Maine 1,608 510 222 109 430 338 1,244 372 182 98 315 278
Maryland 4,338 1,296 644 475 939 984 3,414 999 524 387 650 853
Massachusetts 6,239 2,314 634 459 1,679 1,153 4,807 1,778 535 329 1,197 968
Michigan 7,790 3,167 601 287 1,932 1,803 6,340 2,418 515 235 1,590 1,582
Minnesota 4,460 912 1,057 333 1,286 872 3,639 748 928 284 933 745
Mississippi 1,474 545 172 61 454 242 1,203 455 148 52 325 222
Missouri 4,269 908 366 206 1,966 822 3,421 760 303 163 1,438 758
Montana 979 151 118 59 350 301 870 137 110 46 317 259
Nebraska 1,515 551 124 51 459 330 1,232 420 111 47 355 298
Nevada 1,253 247 173 59 460 314 992 200 127 54 339 273
New Hampshire 1,633 662 156 58 275 482 1,435 558 153 52 205 467
New Jersey 4,383 1,531 580 384 956 932 3,418 1,153 491 350 638 787
New Mexico 1,993 720 135 111 464 563 1,630 555 113 83 372 506
New York 11,661 3,487 1,705 1,737 2,143 2,589 8,820 2,667 1,422 1,376 1,279 2,076
North Carolina 6,723 2,391 964 417 1,465 1,487 5,445 1,913 799 370 1,121 1,242
North Dakota 1,204 269 203 72 436 224 997 225 172 51 354 194
Ohio 8,738 2,601 1,269 807 2,170 1,891 7,276 2,237 1,135 686 1,562 1,656
Oklahoma 3,080 1,174 379 93 764 670 2,520 883 307 87 626 617
Oregon 3,212 932 539 434 615 693 2,730 767 487 396 466 614
Pennsylvania 7,585 2,470 1,286 246 1,950 1,634 6,136 1,973 1,109 199 1,457 1,398
Puerto Rico 1,210 257 124 32 447 350 893 194 96 22 317 263
Rhode Island 982 250 181 69 263 219 815 214 172 64 200 164
South Carolina 1,715 684 167 30 412 422 1,405 554 151 28 316 357
South Dakota 936 180 166 106 306 178 822 165 153 100 240 165
Tennessee 4,314 1,128 603 148 1,503 932 3,577 913 532 132 1,156 845
Texas 6,039 1,344 652 648 2,227 1,168 5,051 1,068 558 539 1,818 1,067
Utah 3,828 1,081 295 241 1,607 604 2,947 793 247 189 1,199 519
Vermont 888 366 117 82 159 164 724 309 101 71 103 141
Virginia 4,514 1,718 704 243 1,060 789 3,918 1,505 620 220 880 694
Washington 5,408 1,195 929 991 1,229 1,063 4,680 1,029 832 863 1,002 953
West Virginia 1,409 430 236 71 354 318 1,195 358 206 63 282 286
Wisconsin 3,683 1,571 324 183 706 899 2,857 1,138 269 142 519 790
Wyoming 683 279 33 16 208 147 571 240 27 13 171 120
Other U.S. Territories 138 21 15 10 64 28 123 15 15 9 57 27
SOURCE: N-SSATS 2016, Question 22.
  1. One FTE is 40 working hours per week.
TABLE B.10.b. Percentages of Counseling and Other Support Staff Certified in Addiction Treatment by Profession and State, 2016
State Total Counselors Support Staff
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Non-Administrative Administrative
Total 30 40 49 59 17 7
Alabama 39 53 62 44 29 10
Alaska 26 45 42 38 9 8
Arizona 13 30 15 17 7 2
Arkansas 24 24 40 45 18 5
California 44 39 65 76 34 14
Colorado 37 47 53 68 21 9
Connecticut 23 32 37 39 13 7
Delaware 32 43 68 37 15 2
District of Columbia 40 51 75 90 10 8
Florida 20 36 32 33 11 8
Georgia 20 25 32 24 17 3
Hawaii 33 66 20 34 18 5
Idaho 38 50 61 73 20 7
Illinois 41 49 53 68 36 15
Indiana 17 30 19 12 8 2
Iowa 34 43 59 30 15 2
Kansas 34 55 92 53 10 7
Kentucky 26 32 43 86 9 3
Louisiana 23 33 64 69 8 5
Maine 36 56 67 50 16 7
Maryland 45 56 84 71 25 10
Massachusetts 17 21 31 31 11 4
Michigan 29 45 42 51 19 4
Minnesota 43 53 87 67 16 10
Mississippi 11 17 10 20 8 2
Missouri 26 53 71 71 11 4
Montana 29 71 85 78 6 5
Nebraska 28 55 41 63 6 4
Nevada 32 63 64 80 15 7
New Hampshire 17 17 29 47 22 7
New Jersey 30 51 40 37 12 6
New Mexico 29 38 61 76 22 6
New York 38 42 65 60 29 9
North Carolina 32 51 41 44 19 5
North Dakota 19 32 59 8 3 0
Ohio 33 40 54 64 25 6
Oklahoma 30 50 34 29 19 4
Oregon 36 38 60 71 23 6
Pennsylvania 18 26 29 25 10 3
Puerto Rico 35 49 55 78 34 15
Rhode Island 26 45 39 49 12 5
South Carolina 32 52 60 60 13 4
South Dakota 36 66 66 60 12 6
Tennessee 14 16 11 29 13 12
Texas 33 38 75 79 16 9
Utah 21 41 41 27 9 6
Vermont 31 55 38 13 9 1
Virginia 15 22 18 38 7 2
Washington 45 45 69 74 30 13
West Virginia 10 22 6 13 7 1
Wisconsin 33 45 58 87 19 3
Wyoming 22 33 55 75 13 2
Other U.S. Territories 16 43 60 40 0 0
SOURCE: N-SSATS 2016, Question 22.
NOTE: The percentages of staff who are certified in addiction treatment are calculated by dividing the number of staff certified in addiction treatment by the total number of staff in facilities that reported information on staff certification. Nearly all (99.6%) of the reported staff worked in facilities that reported counts of certified staff.
TABLE B.11.a. FTE Medical Staff and Percentage Certified in Addiction Treatment by Profession and Facility Characteristic, 2016
Facility Type FTEa Staff Percentage Certified in Addiction Treatment
Total Physician Pharmacist Registered Nurse Licensed
Practical Nurse
Mid-Level
Medical Personnel
Total Physician Pharmacist Registered Nurse Licensed
Practical Nurse
Mid-Level
Medical Personnel
Total 37,318 7,576 1,110 16,515 8,073 4,043 19 42 23 8 10 20
Facility focus
   SUD treatment 14,184 2,619 264 5,301 4,645 1,355 30 61 40 15 13 31
   MH treatment 5,381 922 157 3,239 636 428 5 15 4 2 1 6
   SUD and MH treatment 13,782 3,110 432 6,448 2,205 1,586 15 34 10 5 7 18
   Other 3,971 926 258 1,527 586 674 4 11 2 1 2 5
Operation
   Private NP 15,569 3,315 361 6,888 2,986 2,019 21 40 42 9 13 19
   Private FP 12,889 2,315 248 5,781 3,498 1,048 22 53 14 7 10 29
   Public 8,860 1,946 501 3,846 1,589 977 10 25 3 5 3 8
Federally certified OTP
   OTP 6,502 1,023 167 2,116 2,625 571 26 61 17 14 14 31
   Not OTP 30,815 6,552 943 14,399 5,448 3,473 18 38 24 6 8 18
Any pharmacotherapy
   Provide 30,509 5,661 951 13,922 6,980 2,994 19 45 24 8 10 19
   Do not provide 6,809 1,915 159 2,593 1,093 1,049 20 33 6 8 10 23
Any pharmacotherapy for opioid disorders
   Provide 27,801 5,089 863 12,574 6,589 2,686 20 47 26 8 10 20
   Do not provide 9,517 2,487 247 3,941 1,484 1,357 17 31 5 6 8 20
SOURCE: N-SSATS 2016, Question 22.
NOTE: The percentages of staff who are certified in addiction treatment are calculated by dividing the number of staff certified in addiction treatment by the total number of staff in facilities that reported information on staff certification. Nearly all (99.6%) of the reported staff worked in facilities that reported counts of certified staff. Facility operation was self-designated in N-SSATS Question 4 in 2013 and Question 7 in 2015.
  1. One FTE is 40 working hours per week.
TABLE B.11.b. FTE Counseling Staff and Percentage Certified in Addiction Treatment by Profession and Facility Characteristic, 2016
Facility Type FTEa Staff Percentage Certified in Addiction Treatment
Total Counselor Support Staff Total Counselor Staff Staff
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Non-Administrative Staff Administrative Staff Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Non-Administrative Staff Administrative Staff
Total 160,241 47,210 22,038 14,527 41,008 35,457 30 40 49 59 17 7
Facility focus
   SUD treatment 73,862 17,537 11,709 9,591 19,796 15,229 41 58 64 67 24 11
   MH treatment 18,518 6,503 2,401 785 4,786 4,044 9 16 10 14 4 2
   SUD and MH treatment 62,660 21,805 7,550 3,858 14,897 14,550 24 33 37 49 14 5
   Other 5,201 1,365 377 294 1,529 1,635 15 25 42 46 7 2
Operation
   Private NP 89,819 26,580 12,901 8,575 22,499 19,264 29 39 46 56 17 7
   Private FP 47,773 13,340 6,598 4,128 12,630 11,078 33 43 52 62 21 8
   Public 22,649 7,291 2,539 1,824 5,879 5,116 25 34 51 65 9 4
Federally certified OTP
   OTP 16,303 4,676 3,612 2,142 2,379 3,494 39 50 55 62 21 7
   Not OTP 143,935 42,533 18,426 12,385 38,629 31,963 29 39 48 58 17 7
Any pharmacotherapy
   Provide 92,710 27,152 12,481 7,759 24,264 21,055 28 39 48 56 16 6
   Do not provide 67,530 20,059 9,557 6,768 16,744 14,403 32 41 50 62 20 8
Any pharmacotherapy for opioid disorders
   Provide 81,070 23,334 11,249 6,884 21,245 18,359 29 40 48 57 17 6
   Do not provide 79,171 23,877 10,789 7,643 19,763 17,099 31 39 49 60 18 8
SOURCE: N-SSATS 2016, Question 22.
NOTE: The percentages of staff who are certified in addiction treatment are calculated by dividing the number of staff certified in addiction treatment by the total number of staff in facilities that reported information on staff certification. Nearly all (99.6%) of the reported staff worked in facilities that reported counts of certified staff. Facility operation was self-designated in N-SSATS Question 7.
  1. One FTE is 40 working hours per week.
TABLE B.12.a. Number of Staff Hours per 100 Outpatient Clients per Week in Specialty SUD Treatment Facilities Providing Only Outpatient Services by Type of Staff and State, 2016 (all facilities)
State Total Medical Staff Counselor Support Staff
Physician Pharmacist Mid-Level
Medical Personnel
Registered Nurse Licensed
Practical Nurse
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Total 292 15 3 9 14 13 113 51 27 47
Alabama 238 11 8 4 15 21 123 26 3 27
Alaska 537 32 15 16 9 8 213 66 74 104
Arizona 300 9 1 11 8 10 86 42 18 113
Arkansas 295 14 5 12 5 27 136 45 21 31
California 289 19 1 8 7 11 78 41 73 51
Colorado 237 9 3 10 8 3 110 39 16 38
Connecticut 197 10 0 9 8 12 86 26 8 39
Delaware 184 9 13 4 10 15 72 34 10 18
District of Columbia 329 26 4 22 22 10 110 48 54 32
Florida 368 29 3 8 12 22 131 54 13 95
Georgia 312 14 8 5 13 30 128 49 23 42
Hawaii 749 11 0 1 4 2 303 228 152 47
Idaho 384 3 0 13 4 5 193 67 34 65
Illinois 325 24 2 5 13 12 133 66 30 41
Indiana 384 11 2 7 15 12 129 133 39 37
Iowa 455 11 2 14 22 7 175 156 22 46
Kansas 550 20 8 25 34 20 200 64 40 140
Kentucky 247 10 0 6 4 5 112 43 6 61
Louisiana 258 20 7 3 12 21 102 34 19 40
Maine 284 11 4 6 22 7 107 49 18 60
Maryland 201 12 1 6 10 17 66 36 25 26
Massachusetts 187 9 1 8 11 7 112 12 3 25
Michigan 261 15 2 5 9 10 140 24 9 47
Minnesota 437 7 8 9 38 19 116 143 35 62
Mississippi 964 59 12 23 82 18 472 144 16 138
Missouri 275 13 0 6 12 11 84 46 23 80
Montana 473 40 18 24 57 48 99 77 43 68
Nebraska 524 53 18 25 20 15 251 47 26 70
Nevada 249 15 11 6 15 14 65 45 22 56
New Hampshire 107 8 0 6 5 14 35 20 7 11
New Jersey 300 17 2 5 20 8 131 54 34 29
New Mexico 260 13 9 12 17 8 106 24 19 52
New York 192 10 0 5 16 6 79 35 24 17
North Carolina 366 34 4 10 26 17 150 57 24 43
North Dakota 958 52 15 42 111 3 328 85 12 309
Ohio 442 18 5 10 24 17 172 78 33 85
Oklahoma 325 12 13 7 15 18 145 52 8 55
Oregon 327 10 7 8 11 15 125 62 54 36
Pennsylvania 223 10 1 3 6 15 101 54 6 26
Puerto Rico 167 22 1 3 32 7 47 30 2 23
Rhode Island 264 9 1 11 29 10 76 49 16 63
South Carolina 147 6 5 2 4 5 80 31 5 10
South Dakota 523 6 4 20 19 14 170 149 75 65
Tennessee 421 18 10 29 24 30 136 76 8 90
Texas 240 13 1 8 7 17 57 52 47 38
Utah 269 8 1 14 9 7 128 41 17 45
Vermont 376 18 0 10 13 13 210 72 13 28
Virginia 548 19 4 7 21 28 230 93 21 125
Washington 319 6 0 11 8 6 100 76 75 37
West Virginia 212 11 0 9 8 19 71 54 3 35
Wisconsin 330 22 4 9 22 8 173 36 19 37
Wyoming 350 7 2 7 12 2 192 30 13 85
SOURCE: N-SSATS 2016, Question 22.
TABLE B.12.b. Number of Staff Hours per 100 Outpatient Clients per Week in Specialty SUD Treatment Facilities Providing Only Outpatient Services by Type of Staff and State, 2016 (facilities providing any pharmacotherapy)
State Total Medical Staff Counselor Support Staff
Physician Pharmacist Mid-Level
Medical Personnel
Registered Nurse Licensed
Practical Nurse
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Total 242 15 3 9 15 17 87 39 20 36
Alabama 194 10 10 3 15 25 94 24 2 12
Alaska 412 28 26 28 11 15 142 26 16 118
Arizona 204 10 1 12 10 15 47 23 12 74
Arkansas 246 17 10 5 6 46 61 47 17 36
California 237 21 1 9 9 17 66 31 50 34
Colorado 268 11 5 13 12 5 123 41 18 40
Connecticut 162 9 0 9 8 13 69 15 7 31
Delaware 176 9 15 4 10 16 63 31 11 18
District of Columbia 219 24 5 20 20 13 37 30 50 20
Florida 308 25 4 9 14 33 83 37 13 89
Georgia 227 13 10 4 9 34 77 40 19 20
Hawaii 190 9 0 1 9 4 71 14 45 35
Idaho 457 7 0 38 5 11 257 53 24 62
Illinois 291 22 2 6 16 16 117 60 22 30
Indiana 342 9 0 7 15 17 99 134 41 21
Iowa 372 8 7 17 28 11 162 84 11 45
Kansas 736 35 15 39 57 31 245 42 55 216
Kentucky 194 10 0 6 8 10 94 37 5 24
Louisiana 212 17 8 4 13 26 83 22 10 30
Maine 207 17 6 9 27 10 52 40 23 22
Maryland 180 13 1 6 11 20 56 33 22 17
Massachusetts 162 10 1 7 14 9 90 9 3 19
Michigan 273 22 3 6 13 17 141 20 9 42
Minnesota 297 7 5 4 14 26 85 91 23 42
Mississippi 1126 188 41 34 167 69 464 54 28 83
Missouri 219 16 0 9 12 14 73 33 13 49
Montana 394 61 5 12 82 65 76 55 29 8
Nebraska 513 40 28 37 30 25 207 31 32 84
Nevada 241 20 13 7 21 19 46 34 18 63
New Hampshire 90 8 0 3 4 15 25 17 8 10
New Jersey 251 14 2 4 23 9 99 47 30 22
New Mexico 234 16 13 14 23 11 75 25 19 39
New York 185 10 0 6 17 6 75 35 20 15
North Carolina 264 31 5 8 28 21 101 28 14 28
North Dakota 1114 76 25 6 163 5 346 20 0 472
Ohio 404 20 6 10 29 22 127 71 27 94
Oklahoma 151 11 12 5 11 17 51 23 3 18
Oregon 307 12 11 11 16 27 80 60 52 37
Pennsylvania 221 11 1 4 6 21 96 51 6 25
Puerto Rico 151 22 1 2 32 8 39 26 0 21
Rhode Island 279 10 1 12 31 11 75 50 18 70
South Carolina 133 10 11 0 5 12 44 39 8 4
South Dakota 481 8 0 22 16 22 132 137 73 71
Tennessee 247 12 5 15 8 27 77 38 2 62
Texas 201 16 1 8 8 28 36 41 35 28
Utah 222 10 1 18 11 9 88 34 14 38
Vermont 373 19 0 13 17 16 204 62 15 26
Virginia 398 17 4 6 17 31 177 57 18 71
Washington 204 7 1 9 14 14 44 48 44 23
West Virginia 157 11 0 9 7 21 49 45 0 14
Wisconsin 362 26 6 10 28 12 174 48 20 39
Wyoming 388 15 4 9 19 4 210 35 11 80
SOURCE: N-SSATS 2016, Question 22.
TABLE B.12.c. Number of Staff Hours per 100 Outpatient Clients per Week in Specialty SUD Treatment Facilities Providing Only Outpatient Services by Type of Staff and State, 2016 (facilities providing no pharmacotherapy)
State Total Medical Staff Counselor Support Staff
Physician Pharmacist Mid-Level
Medical Personnel
Registered Nurse Licensed
Practical Nurse
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Total 393 14 2 8 10 4 167 75 42 72
Alabama 370 12 5 8 15 10 210 31 8 71
Alaska 668 36 3 3 7 0 287 107 133 90
Arizona 474 7 0 11 6 2 156 77 29 185
Arkansas 314 12 3 15 5 19 165 44 22 30
California 373 14 2 6 4 2 97 56 112 80
Colorado 186 5 0 5 2 0 89 37 15 33
Connecticut 490 13 0 8 4 0 227 116 16 106
Delaware 250 5 0 4 7 0 145 66 2 21
District of Columbia 720 35 0 31 28 0 370 111 69 76
Florida 459 36 1 6 10 6 204 80 13 103
Georgia 608 18 1 9 26 12 304 82 38 118
Hawaii 1261 12 0 1 0 0 516 424 250 58
Idaho 364 1 0 6 3 3 176 70 37 66
Illinois 374 28 1 3 8 6 156 75 42 56
Indiana 464 14 6 7 14 3 187 132 33 68
Iowa 497 12 0 12 20 4 182 192 27 47
Kansas 361 5 0 10 11 9 153 86 25 63
Kentucky 288 10 0 5 1 0 126 48 7 90
Louisiana 385 29 4 1 7 9 154 66 45 69
Maine 399 3 0 1 13 3 190 62 10 118
Maryland 318 11 1 4 4 2 124 54 42 76
Massachusetts 274 6 0 9 1 0 189 21 3 44
Michigan 249 8 0 3 5 3 139 28 10 52
Minnesota 603 6 12 15 67 10 152 205 48 87
Mississippi 916 21 3 20 57 3 474 170 13 155
Missouri 364 8 0 2 12 7 101 66 40 128
Montana 548 19 30 35 34 31 120 97 55 125
Nebraska 531 63 10 16 13 7 283 58 21 59
Nevada 267 6 7 4 3 3 103 69 30 42
New Hampshire 319 12 0 48 10 6 166 54 0 23
New Jersey 486 28 0 12 10 4 249 82 46 55
New Mexico 306 8 2 8 6 3 161 23 20 76
New York 241 11 0 3 10 0 106 36 45 30
North Carolina 764 44 2 19 19 4 339 172 64 102
North Dakota 731 18 0 94 37 0 302 179 30 71
Ohio 519 15 2 9 12 6 266 94 46 68
Oklahoma 572 14 15 11 20 21 276 94 16 106
Oregon 345 8 4 5 7 4 167 64 55 34
Pennsylvania 228 9 0 1 4 1 114 62 6 30
Puerto Rico 327 22 0 10 37 0 130 67 21 42
Rhode Island 149 5 0 6 8 0 80 41 0 8
South Carolina 158 3 0 3 3 0 107 26 2 14
South Dakota 564 5 7 18 21 7 207 161 78 60
Tennessee 750 31 18 54 54 37 247 147 20 141
Texas 296 9 1 8 6 1 86 67 64 53
Utah 394 5 0 5 2 1 235 61 24 63
Vermont 386 15 0 0 0 0 229 104 4 34
Virginia 991 24 4 11 33 22 385 198 30 285
Washington 404 6 0 12 3 1 140 96 98 48
West Virginia 464 11 0 10 14 13 172 96 19 128
Wisconsin 277 15 1 6 14 3 172 16 16 34
Wyoming 320 0 0 6 7 0 178 27 15 88
SOURCE: N-SSATS 2016, Question 22.
TABLE B.13. Number of Staff Hours per 100 Outpatient Clients per Week in Specialty SUD Treatment Facilities Providing Only Outpatient Services, by Type of Services Offered at Facility, 2016
Type of Facility Total Medical Staff Counselor Support Staff
Physician Pharmacist Mid-Level
Medical Personnel
Registered Nurse Licensed
Practical Nurse
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Total 292 15 3 9 14 13 113 51 27 47
Federally certified OTP
   OTP 135 7 2 4 10 21 35 31 17 8
   Not OTP 397 20 4 11 16 7 166 64 34 74
MH services
   MH treatment offered 322 17 3 10 15 12 131 53 26 55
   Screening only 180 8 1 5 12 14 48 42 32 19
   No MH services 154 5 1 3 5 16 35 42 31 14
Screening for conditions other than SUDs
   Yes 293 25 9 18 30 25 81 39 24 42
   No 291 12 1 6 10 10 121 54 28 49
Outreach to people who may need treatment
   Yes 316 16 3 9 14 13 118 56 30 56
   No 248 13 2 7 13 12 105 42 23 32
Recovery support services
   Yes 373 17 4 10 17 16 132 68 34 76
   No 269 14 3 8 13 12 108 46 25 40
Facility focus
   SUD treatment 193 9 1 4 9 13 63 41 28 25
   MH treatment 1000 37 5 23 45 13 443 201 35 198
   SUD and MH treatment 405 21 4 11 15 8 187 57 25 77
   Other 905 101 53 120 133 75 187 48 33 157
SOURCE: N-SSATS 2016, Question 22.
NOTE: Facilities were classified as a federally certified OTP if they indicated in Question 11 that they administer or dispense methadone, buprenorphine, or naltrexone (Vivitrol®) as a federally certified OTP. Facilities were classified as offering MH treatment if they said in response to Question 1a that they provided mental health services to substance abuse treatment clients (MHTXSA). Remaining facilities were classified as only screening if in Question 10 they indicated that they provided screening for mental health disorders (SRVC90) or provided comprehensive mental health assessment or diagnosis (SRVC2). Facilities not classified as offering MH treatment or screening only were classified as having no MH services. Facilities were identified as providing screening services for conditions other than SUDs if they indicated that they provide screening for hepatitis B, hepatitis C, HIV, sexually transmitted diseases, and tuberculosis (SRVC73 = 1, SRVC74 = 1, SRVC14 = 1, SRVC15 = 1, and SRVC16 = 1). Facilities were identified as providing recovery support services if they provide social skills development, mentoring or peer support, assistance obtaining social services, employment counseling or training, or assistance locating housing (SRVC96 = 1, SRVC97 = 1, SRVC36 = 1, SRVC39 = 1, and SRVC38 = 1). Facility focus was determined based on responses to Question 6.
TABLE B.14. Number of Staff Hours 100 Outpatient Clients per Week in Specialty SUD Treatment Facilities Providing Only Outpatient Services, by Facility Characteristics, 2016
Type of Facility Total Medical Staff Counselor Support Staff
Physician Pharmacist Mid-Level
Medical Personnel
Registered Nurse Licensed
Practical Nurse
Post-Graduate Level Bachelor's Degree Associate's Degree
or No-Degree
Total 292 15 3 9 14 13 113 51 27 47
Urbanicity
   Urban 278 15 3 7 13 13 110 48 26 44
   Rural 370 14 4 11 17 13 138 69 34 69
Operation
   Private NP 339 15 2 10 16 10 140 59 29 58
   Private FP 206 11 2 5 6 15 74 41 23 29
   Public 432 30 11 19 33 17 156 58 33 74
Located in or operated by a hospital
   Yes 291 14 3 8 12 13 113 52 28 49
   No 298 29 5 20 35 13 117 34 17 27
Facility size
   Small 1606 81 17 46 74 28 671 257 137 294
   Medium 506 27 5 16 20 11 205 81 44 97
   Large 171 8 2 5 9 13 62 33 18 21
Type of insurance accepted
   Medicaid 294 14 2 8 14 12 119 52 25 47
   Private insurance 316 17 3 9 15 11 131 51 26 53
SOURCE: N-SSATS 2016, Question 22.
NOTE: Urbanicity is assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural estimates are only reported for facilities with known urbanicity. Facility size was based on the number of outpatient clients in care. Facilities below the 25th percentile and above the 75th percentile for client count were identified as small and large, respectively. Remaining facilities were designated as medium size. Facility operation was self-designated in N-SSATS Question 7.
TABLE B.15. Number and Percentage of Facilities Providing Any Pharmacotherapy or Opioid-Related Pharmacotherapy, by Facility Characteristics, 2013 and 2016
  Number of Facilities Percentage of Facilities
Providing Pharmacotherapies
for Opioid Disorders
Providing Any
Pharmacotherapies
Providing Pharmacotherapies
for Opioid Disorders
Providing Any
Pharmacotherapies
2013 2016 Change 2013 2016 Change 2013 2016 Change 2013 2016 Change
Total 4,246 5,373 27 5,267 6,191 18 30 37 24 37 43 15
Urbanicity
   Urban 3,272 4,519 38 3,936 5,115 30 33 41 24 40 46 16
   Rural 933 814 -13 1,283 1,032 -20 23 26 12 32 33 3
Facility focus
   SUD treatment NA 3,253 NA NA 3,519 NA NA 41 NA NA 44 NA
   MH treatment NA 242 NA NA 347 NA NA 24 NA NA 35 NA
   SUD and MH treatment NA 1,707 NA NA 2,126 NA NA 34 NA NA 42 NA
   Other NA 171 NA NA 199 NA NA 43 NA NA 50 NA
Operation
   Private, NP 2,101 2,644 26 2,622 3,071 17 27 35 28 34 40 20
   Private, FP 1,582 2,101 33 1,838 2,296 25 35 41 19 40 45 12
   Public 563 628 12 807 824 2 32 38 20 46 50 9
SOURCE: N-SSATS 2013 and 2016.
NOTE: Urbanicity is assigned based on the National Center for Health Statistics urbanicity classification scheme. Facilities in rural areas include those in micropolitan areas with an urban core population of at least 10,000 but less than 50,000, as well as those in non-core areas. Facilities in a central or fringe urban core with a population of 50,000 or more are considered urban. Information on urbanicity was not available for all facilities; urban and rural data are only reported for facilities with known urbanicity. Facility operation was self-designated in N-SSATS Question 7. Facility focus was not asked on the N-SSATS 2013 survey.
TABLE B.16. Number and Percentage of Facilities Providing Any Pharmacotherapy or Opioid-Related Pharmacotherapy, by State, 2013 and 2016
  Number of Facilities Percentage of Facilities
Providing Pharmacotherapies
for Opioid Disorders
Providing Any
Pharmacotherapies
Providing Pharmacotherapies
for Opioid Disorders
Providing Any
Pharmacotherapies
2013 2016 Change 2013 2016 Change 2013 2016 Change 2013 2016 Change
Total 4,246 5,373 27 5,267 6,191 18 30 37 24 37 43 15
Alabama 49 52 6 53 57 8 32 38 20 34 42 22
Alaska 16 17 6 22 23 5 17 18 5 24 24 3
Arizona 113 143 27 134 165 23 36 40 11 43 46 8
Arkansas 15 17 13 23 20 -13 17 15 -11 26 18 -32
California 424 477 13 468 517 10 27 33 22 30 36 20
Colorado 104 113 9 251 216 -14 21 28 33 51 54 5
Connecticut 81 115 42 125 142 14 38 51 34 59 63 8
Delaware 18 28 56 18 29 61 43 60 39 43 62 44
District of Columbia 14 16 14 15 16 7 38 47 24 41 47 16
Florida 171 286 67 211 312 48 27 40 45 34 44 28
Georgia 89 115 29 133 142 7 25 37 48 37 45 22
Hawaii 13 16 23 16 19 19 11 9 -13 13 11 -16
Idaho 21 27 29 23 32 39 18 19 5 20 22 14
Illinois 165 189 15 198 208 5 25 28 10 30 31 1
Indiana 60 83 38 94 101 7 22 31 44 34 38 12
Iowa 24 34 42 33 48 45 17 21 25 23 29 28
Kansas 33 35 6 45 58 29 16 17 11 21 29 35
Kentucky 68 94 38 82 104 27 21 26 25 25 29 15
Louisiana 37 50 35 56 70 25 22 32 43 34 45 32
Maine 56 62 11 66 66 0 25 27 7 30 29 -3
Maryland 157 199 27 169 208 23 44 50 14 47 52 10
Massachusetts 155 220 42 181 246 36 49 62 26 57 69 21
Michigan 118 126 7 165 173 5 24 26 9 34 36 7
Minnesota 74 98 32 101 119 18 21 26 27 29 32 13
Mississippi 23 19 -17 30 26 -13 23 20 -12 30 27 -8
Missouri 110 129 17 115 138 20 43 45 6 45 48 8
Montana 19 18 -5 27 26 -4 26 28 7 38 41 8
Nebraska 21 27 29 28 37 32 18 20 8 25 27 11
Nevada 26 33 27 29 39 34 32 41 29 36 49 36
New Hampshire 17 38 124 20 40 100 31 59 92 36 63 72
New Jersey 131 158 21 147 184 25 35 43 21 40 50 26
New Mexico 32 44 38 43 61 42 23 29 24 31 40 28
New York 510 661 30 574 692 21 56 72 27 63 75 18
North Carolina 131 169 29 159 195 23 30 35 14 37 40 9
North Dakota 9 10 11 18 18 0 14 17 20 28 30 8
Ohio 114 184 61 142 202 42 30 45 50 38 50 32
Oklahoma 26 38 46 34 52 53 12 19 60 15 25 67
Oregon 42 61 45 56 71 27 17 27 60 23 32 40
Pennsylvania 194 262 35 236 283 20 36 50 38 44 54 22
Puerto Rico 39 37 -5 44 41 -7 24 26 8 27 29 6
Rhode Island 32 39 22 40 42 5 52 75 45 65 81 25
South Carolina 35 37 6 38 41 8 32 32 3 34 36 5
South Dakota 7 13 86 13 16 23 11 21 89 21 26 25
Tennessee 57 85 49 74 94 27 26 37 45 33 41 24
Texas 161 175 9 170 189 11 35 36 3 37 39 5
Utah 64 112 75 73 125 71 37 48 27 43 53 25
Vermont 24 32 33 27 34 26 55 70 28 61 74 20
Virginia 82 94 15 119 121 2 36 41 13 53 53 0
Washington 84 96 14 94 110 17 19 22 20 21 26 23
West Virginia 47 57 21 57 62 9 47 54 16 56 58 4
Wisconsin 113 106 -6 152 130 -14 36 38 7 48 46 -3
Wyoming 19 24 26 23 28 22 36 41 15 43 48 11
Other US Territories 2 3 50 3 3 0 22 30 35 33 30 -10
SOURCE: N-SSATS 2013 and 2016.
TABLE B.17. Number and Percentage Change in Residential and Inpatient-Designated Beds and Utilization Rate by State, 2013 and 2015
  Number of Designated Beds Utilization Rate
Residential Inpatient Hospital Residential Inpatient Hospital
2013 2015 Change 2013 2015 Change 2013 2015 Change 2013 2015 Change
Total 100,417 104,012 4 12,213 15,415 26 97 105 9 97 109 12
Alabama 1,212 1,031 -15 252 52 -79 92 95 3 96 54 -44
Alaska 383 347 -9 NA NA NA 89 109 23 NA 0- NA
Arizona 1,853 2,235 21 210 297 41 97 120 23 129 117 -9
Arkansas 798 686 -14 83 46 -45 86 350 308 94 63 -33
California 13,688 13,390 -2 750 477 -36 94 95 1 102 95 -7
Colorado 1,446 1,162 -20 172 184 7 97 93 -5 80 73 -9
Connecticut 1,766 1,491 -16 290 219 -24 100 101 0 98 111 13
Delaware 184 262 42 NA 30 NA 92 1450 1,470 NA 107 NA
District of Columbia 428 396 -7 NA 12 NA 98 109 11 NA 8 NA
Florida 6,020 6,363 6 641 843 32 120 101 -16 94 128 36
Georgia 1,934 1,933 0 284 413 45 98 83 -15 90 110 22
Hawaii 456 466 2 NA 48 NA 84 95 12 0 92 NA
Idaho 162 144 -11 NA 15 NA 70 97 39 NA 93 NA
Illinois 3,099 2,885 -7 328 253 -23 87 100 15 59 65 9
Indiana 541 618 14 237 552 133 82 130 59 75 92 24
Iowa 815 935 15 NA 30 NA 80 73 -9 NA 80 NA
Kansas 765 720 -6 NA 29 NA 85 96 12 NA 79 NA
Kentucky 1,798 2,264 26 291 329 13 102 94 -8 80 126 58
Louisiana 1,615 1,785 11 199 270 36 83 92 10 81 74 -8
Maine 296 257 -13 112 118 5 107 91 -15 108 39 -64
Maryland 2,074 2,063 -1 709 344 -51 70 86 22 57 75 32
Massachusetts 3,211 3,292 3 595 811 36 95 105 11 106 121 14
Michigan 2,985 2,996 0 180 173 -4 163 88 -46 186 45 -76
Minnesota 3,862 3,593 -7 63 95 51 96 93 -4 92 76 -18
Mississippi 1,133 968 -15 259 148 -43 71 69 -3 129 128 0
Missouri 1,107 1,215 10 55 73 33 88 175 99 195 77 -61
Montana 258 222 -14 24 78 225 177 84 -52 529 118 -78
Nebraska 812 748 -8 NA NA NA 82 98 20 0 0 0
Nevada 455 543 19 113 143 27 93 90 -4 131 133 1
New Hampshire 368 390 6 NA 15 NA 90 90 0 NA 27 NA
New Jersey 2,541 2,837 12 365 307 -16 105 118 12 95 131 37
New Mexico 481 483 0 137 125 -9 353 83 -77 72 90 25
New York 10,531 10,125 -4 2,067 1,741 -16 91 97 7 79 95 20
North Carolina 2,655 2,591 -2 429 368 -14 92 112 21 129 73 -44
North Dakota 378 440 16 94 83 -12 111 84 -25 56 71 26
Ohio 1,758 1,955 11 586 561 -4 99 102 3 84 88 4
Oklahoma 1,570 1,206 -23 131 113 -14 76 97 27 85 68 -20
Oregon 1,260 1,268 1 83 52 -37 85 97 15 75 185 147
Pennsylvania 5,756 5,570 -3 529 392 -26 91 95 4 83 62 -25
Puerto Rico 3,027 2,553 -16 178 198 11 75 109 44 251 178 -29
Rhode Island 348 1,721 395 NA 3,543 NA 93 100 8 NA 100 NA
South Carolina 471 692 47 301 209 -31 117 89 -24 116 537 364
South Dakota 543 623 15 87 98 13 115 93 -19 86 69 -19
Tennessee 1,848 1,913 4 142 129 -9 86 93 8 280 95 -66
Texas 5,448 4,809 -12 375 404 8 87 122 40 89 138 56
Utah 896 928 4 NA 49 NA 109 91 -17 NA 71 NA
Vermont 245 213 -13 112 116 4 404 77 -81 82 587 615
Virginia 801 1,060 32 109 277 154 72 95 32 152 113 -26
Washington 2,417 5,729 137 189 192 2 87 117 35 72 77 6
West Virginia 433 552 27 NA 74 NA 91 93 2 NA 55 NA
Wisconsin 1,114 904 -19 130 261 101 74 86 17 102 68 -33
Wyoming 316 388 23 NA 16 NA 103 83 -20 0 31 NA
US territories 56 52 -7 NA 10 NA 89 83 -7 0 240 NA
SOURCE: N-SSATS 2013 Questions 28d and 29d, and N-SSATS 2015, Questions 29d and 30d, indicate hospital-designated and residential-designated beds.
NOTE: Utilization rate is calculated by dividing the number of clients in care by the total number of designated beds.

PROJECT AND REPORT INFORMATION

Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System

This report was prepared under contract #HHSP23320100019WI between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Mathematica Policy Research. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officer, Judith Dey, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail addresses is: Judith.Dey@hhs.gov.