CREDENTIALING, LICENSING, AND REIMBURSEMENT OF THE SUD WORKFORCE: A REVIEW OF POLICIES AND PRACTICES ACROSS THE NATION. STATE APPROACHES TO LICENSING AND CREDENTIALING SUBSTANCE USE DISORDER TREATMENT PROVIDERS

12/01/2019

Career Ladder for the Substance Use Disorder Treatment Workforce

In 2010, SAMHSA convened a stakeholder group to develop a career ladder and model SOPs for the SUD counseling workforce (SAMHSA, 2011). Exhibit 2 shows the five categories defined by the stakeholder group and a brief description of the educational attainment and supervision requirements envisioned for each.

EXHIBIT 2. SAMHSA's Model Career Ladder and SOPs for the SUD Treatment Workforce
SAMHSA Category SAMHSA Category Title Brief Description
Category 4 Independent Clinical SUD Treatment Counselor/Supervisor Typically has a master's degree and is licensed to practice independently
Category 3 Clinical SUD Counselor Typically has a master's degree and either has not yet attained a license or the license is restricted to practice under supervision
Category 2 SUD Counselor Has a bachelor's degree and provides services under clinical supervision
Category 1 Associate SUD Counselor Has an associate degree and can provide services under supervision
SUD Technician SUD Technician Has a high school diploma or equivalent and works under supervision

We categorized the findings from our review of states' licensing and credentialing requirements into this framework, adding a sixth category for "peer recovery specialist." We separated credentials for supervision (e.g., Certified Clinical Supervisor or CCS) into their own category because their requirements (focused mostly on supervision skills) are typically overlays to the requirements for another underlying credential. We also classified Prevention Specialists into their own category because SAMHSA's career ladder is focused on SUD treatment.

Exhibit 3 shows the number of states with at least one credential for each of SAMHSA's five categories, plus peer recovery specialist.

EXHIBIT 3. Number of States with at Least 1 SUD Treatment Credential, by Category
(SAMHSA's 5 categories plus peer recovery)
EXHIBIT 3, Bar Chart. This exhibit shows the number and percentage of states (including D.C.) with at least 1 SUD treatment credential by category for the 5 categories in SAMHSA’s model career ladder plus peer recovery specialist. The numbers are: Category 4: 37 states (73%); Category 3: 40 states (78%); Category 2: 46 states (90%); Category 1: 31 states (61%); SUD Technician: 22 states (43%); Peer Recovery Specialist: 47 states (92%). Nine states (18%) have at least 1 credential in each of the 6 categories.

In all, 37 states (73%) have a credential equivalent to SAMHSA's Category 4 that allows for independent practice without supervision. We included a non-licensed, certified credential in this category if it was the terminal (highest) available SUD credential in the state and came with an authorization to practice independently without supervision.[3] A total of 40 states (78%) have a credential in Category 3 and 46 (90%) have a credential equivalent to SAMHSA's Category 2.

Credentials at the lower rungs of SAMHSA's career ladder were less frequent, identified in 31 states (61%) for Category 1 and 22 states (43%) for entry-level SUD technician. A greater number of states (47, or 92%) have a credential for peer recovery specialist. Nine states (18%) have at least one credential in each of the six categories.

Exhibit 4 on the following page summarizes the number of SUD treatment credentials we identified for each category by state. The number of available credentials ranged from three to 16 per state. On one hand, a greater number of credentials can signify more entry points into the field for individuals with varying levels of education and experience; on the other hand, numerous and often overlapping credentials can create confusion and burden to those seeking to enter the field and those pursuing advancement within it.

The title of every credential by category and by state is in Exhibit A1. Requirements for each credential (discussed in a later subsection on state variations) are also provided as detailed tables in Appendix A.

EXHIBIT 4. Number of SUD Treatment Credentials by SAMHSA Category and Total SUD Treatment Credentials, by State
State Cat 4 Cat 3 Cat 2 Cat 1 Tech Peer Superv Total
Alabama   1 1 4 1 1 1 9
Alaska 1 2 2   2   1 8
Arizona 1 1 2 1 1 1 1 8
Arkansas 1 1 2   1 1 1 7
California   2 1 2 1 1 3 10
Colorado 1   1 1 1 1   5
Connecticut 1 1 1 1   1 1 6
Delaware 1 1 1     1 1 5
D.C.   2 2     1 1 6
Florida   1 1 1 1 1   5
Georgia 1 2 2 1 2 1 1 10
Hawaii   1       1 1 3
Idaho   1 1   1 1 1 5
Illinois   2 1 1 1 1 1 7
Indiana 1 3 4 3 2 2 1 16
Iowa 1 1 2   1 1 1 7
Kansas 1 1 1     1   4
Kentucky 1 1 1     1   4
Louisiana 1 1 1 1 1 1 1 7
Maine   1 1   1   1 4
Maryland 1 1 3 1   1 1 8
Massachusetts 2 1 1 1 1 1 1 8
Michigan   1 1     1 1 4
Minnesota 1 1 1 1   2 2 8
Mississippi 2 2 1 1 1 1 1 9
Missouri 1 3 3 2   1   10
Montana 1     1   1   3
Nebraska 1   1     1   3
Nevada 1 1 1 1 1 1   6
New Hampshire 1 1       1 1 4
New Jersey 1   1 1   1 1 5
New Mexico 1 1   1   1 1 5
New York   1 2 1 1 2   7
North Carolina 1   1     1 1 4
North Dakota 1 1 1       1 4
Ohio 1 1 1 1 1 1 1 7
Oklahoma 1   1     1   3
Oregon 1   1 1   1   4
Pennsylvania 1 1 1 1 2 1 1 8
Rhode Island 1 3 1 1   1 1 8
South Carolina   1 1     1 1 4
South Dakota 1   1 1       3
Tennessee 1   1     1 1 4
Texas 2 1 1   1 1 1 7
Utah   2 2 3 1 1 1 10
Vermont 1   1 1   1   4
Virginia 1 1 2 2   1 1 8
Washington   1   1   1   3
West Virginia 1   1     1 1 4
Wisconsin   1 1 1   1 1 5
Wyoming 1 1 1 1   1   5

Licensure vs. Certification

A license is a state's grant of legal authority to practice within a designated scope of practice (IC&RC, 2018). Certification is similar in that it represents achievement of professional competency for a defined SOP, but it can be overseen by a non-governmental board and is considered weaker than licensure in terms of title protection. "Title protection" is statutory language mandating that only individuals with the credential can use the title; it is a formal, legal acknowledgement of professional qualification. The SOP for a credential can be identical whether it is licensed or certified, but licensure typically establishes a legal title and practice protection whereas certification does not. For example, a 2016 review of SOPs for addiction counselors found that title protection was included in 84% of the licensed addiction counselor (LAC) SOPs but only 19% of the certified alcohol and drug counselor (CADC) SOPs (Page et al., 2017).

As of November 2018, 31 states (61%) offer licensure for SUD counseling and 20 states (39%) offer certification only. The states offering licensure for SUD counseling are shown in Exhibit 5. Many states with licensure also offer certification. The ways in which licensure and certification relate to each other varies by state. For example, in some states, certification is a required step on the path to licensure. In some others, there are separate tracks for licensure and certification, where certification is typically pursued by professionals already licensed in another counseling field who wish to include SUD counseling in their practice--such as professional counselors or clinical social workers.

EXHIBIT 5. States Offering Licensure for SUD Counseling
EXHIBIT 5, State Map. This exhibit is a map of the United States with the 31 states that offer licensure for SUD counseling shaded dark blue and the 20 states (including D.C.) that do not offer licensure shaded light gray. The 20 states without licensure are: Alabama, Alaska, California, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Iowa, Michigan, Mississippi, Missouri, New York, Oregon, Pennsylvania, South Carolina, Washington, West Virginia, and Wisconsin.

State and National Credentialing Bodies

There are multiple credentialing bodies for the SUD profession, both at the national level and within individual states. As shown in Exhibit 6, 19 states (37%) have a single board that oversees licensure and/or certification for all SUD credentials (treatment and prevention) within the state; the rest have multiple boards offering credentials at different levels, often with no state-level standards for minimum requirements.

EXHIBIT 6. Variation across States in the Number of Credentialing Boards
EXHIBIT 6, Bar Chart. This exhibit shows the number and percentage of states (including D.C.) by the states’ number of credentialing boards. The numbers are: Single Board: 19 states (37%); Two Boards: 28 states (55%); Three Boards: 4 states (8%).

The main national credentialing bodies for the SUD profession are the International Certification and Reciprocity Consortium (IC&RC) and the Association for Addiction Professionals (NAADAC, formerly known as the National Association for Alcoholism and Drug Abuse Counselors). Both IC&RC and NAADAC define competencies required for practice and have standard tests for measuring competencies required at various levels of practice. NAADAC standards are national whereas IC&RC standards vary by state. On the other hand, professionals are required to meet the standards set forth by their state in order to apply for NAADAC certification, which infuses NAADAC certification with a level of variability by state as well. Although the standard credentials of the two national organizations (listed in Exhibit 7) have some overlap, they are by no means identical in scope or in minimum requirements.

EXHIBIT 7. Credentials Offered by the 2 National Certification Bodies
IC&RC NAADAC
  • Alcohol and Drug Counselor (ADC)
  • Advanced Alcohol and Drug Counselor (AADC)
  • Clinical Supervisor (CS)
  • Prevention Specialist
  • Certified Criminal Justice Addictions Professional (CCJP)
  • Peer Recovery
  • National Certified Addiction Counselor I (NACA I)
  • National Certified Addiction Counselor II (NACA II)
  • Master Addiction Counselor (MAC)
  • Nicotine Dependence Specialist
  • National Certified Adolescent Addictions Counselor
  • National Peer Recovery Support Specialist
  • National Endorsed Student Assistance Professional
  • National Clinical Supervision Endorsement (NCSE)
  • National Endorsed Co-Occurring Disorders Professional

Most SUD credentials available in a state are adapted from those issued by one of the two national organizations, and credentials that require a qualifying examination typically recognize standard tests developed by one of these two national organizations. Exhibit 8 shows variation across states in their affiliation with the two national credentialing bodies. In 30 states (59%), an IC&RC test is used for all credentials that are contingent on passing an examination; in 11 states (22%), only NAADAC tests are used. In the remaining ten states (20%), some credentials are linked to IC&RC and some to NAADAC tests. As mentioned earlier, both national bodies make room for state-level modifications to their credentialing requirements. Thus, a credential affiliated with the same national body in two different states does not necessarily have identical requirements, although reciprocity or endorsement between the two states is more likely than if they were affiliated with different credentialing organizations.

EXHIBIT 8. Variation across States in Affiliation with National Credentialing Bodies
EXHIBIT 8, State Map. This exhibit distinguishing states' affiliations with 2 national credentialing bodies: NAADAC and IC&RC. Alaska, Colorado, Kansas, Montana, North Dakota, Oregon, South Carolina, Tennessee, Washington, Wisconsin, and Wyoming are affiliated with NAADAC. Alabama, Arizona, District of Columbia, Georgia, Indiana, Maryland, Minnesota, New Mexico, Utah, and Virginia are affiliated with both NAADAC and IC&RC. The remaining states are affiliated with IC&RC.

State Variation in Licensing/Credentialing Requirements

We reviewed and extracted data on licensing and certification requirements for over 400 SUD practitioner credentials across the 50 states and D.C. These data are presented in Appendix A, organized by the five categories in SAMHSA's career ladder with additional categories for clinical supervisor, peer recovery specialist, and prevention specialist.

The data show wide variability across states' respective career ladders for SUD professionals and across educational and practice requirements for these credentials. This variation is especially informative as it applies to the highest level in each state's SUD career ladder (the state's "terminal" credential), because this level is the most impacted by reimbursement policies. Exhibit 9 and Exhibit 10 on the following page show the variation across states in the minimum degree and minimum practice hours required to attain the state's terminal SUD counseling credential.

EXHIBIT 9. Minimum Degree Required to Attain the Highest Level of the SUD Counseling Career Ladder
EXHIBIT 9, State Map. This exhibit is a map of the United States that shows the minimum degree required to attain the highest SUD counseling credential in each state. Alaska has no minimum degree requirement. Three states (Hawaii, Maine, Nebraska) require a high school diploma or equivalent. Four states (Montana, New Mexico, Washington, Wisconsin) require an associate degree. Six states (Arizona, California, District of Columbia, South Carolina, Tennessee, Utah) require a bachelor’s degree. The remaining 37 states require a master’s degree.

Thirty-seven states (73%) require a master's degree to attain the highest SUD counseling credential in the state; six states including D.C. (12%) require a bachelor's degree, four states (8%) require an associate degree, and three states (6%) require only a high school diploma or equivalent. One state, Alaska, currently has no minimum degree requirement but reduces the number of required practice hours for individuals who hold a degree. Similarly, in other states, higher education can often be substituted for some practice requirements.

EXHIBIT 10. Minimum Practice Hours Required to Attain the Highest Level of the SUD Counseling Career Ladder
EXHIBIT 10, State Map. This exhibit is a map of the United States that shows the minimum practice duration required to attain the highest SUD counseling credential in each state. No information about minimum required practice duration was available in the District of Columbia. Montana requires less than 1 year of practice and Alaska requires more than 5 years. A minimum of 3-4 years of practice are required in 10 states (Arkansas, Connecticut, Hawaii, Massachusetts, Nebraska, New York, Oregon, South Carolina, West Virginia, Wisconsin). The remaining 38 states require 1-2 years.

The minimum number of practice hours required to attain the highest SUD counseling credential within each state (Exhibit 10) ranged from 1,000 (equivalent to half a year) to 12,000 (6 years). Most states (38 states, 76%) require between 2,000 and 4,000 hours (1-2 years). Comparing the two maps on the following page (Exhibit 9 and Exhibit 10), we find that states with lower minimum degree requirements often require more practice hours. The substitution of practice experience for education hours is often referred to as the "apprentice model," in contrast to the "professional model" for credentialing typical of most other clinical practices. In most states that require less than a master's degree, a portion of the required practice hours can be substituted by a higher degree. This is the case in Alaska, where an individual with no degree is required to have 12,000 practice hours (6 years) to attain the highest credential, but the requirement is reduced to 10,000 hours (5 years) if the applicant has a degree.

Discussion of Credentialing Policies: Barriers and Facilitators

Based on the environmental scan, state review, and case studies, we identified two key credentialing-related barriers to entering the SUD counseling field:

  1. Lack of standard credentials and inaccessibility of qualification information.

  2. Low and non-standard training and educational requirements for practice.

The rest of this chapter is organized into separate sections discussing each of these two barriers. Examples of efforts and initiatives to address each barrier, as identified through the environmental scan and case studies, are also included in the relevant sections under subsection headings labeled as "facilitators."

Barrier 1: Lack of Standard Credentials and Difficulty Obtaining Information on Practice Requirements

As the preceding discussion demonstrates, the SUD treatment workforce is regulated by a wide range of credentials, credentialing bodies, and minimum requirements. The high degree of variation within and across states in credentialing requirements poses a serious barrier to professionals considering careers in this area. All but 19 states have multiple credentialing boards offering different but in many instances overlapping credentials with differing requirements. This creates a complex environment to navigate for students and early-career professionals interested in an SUD treatment specialty. For example, as part of a 2016 study of assets and gaps in New Hampshire's SUD service continuum, researchers surveyed and interviewed stakeholders throughout the state and found that "complex, unclear, and cumbersome" licensing procedures were the most frequently cited barrier to addressing the state's SUD workforce shortages (NHBDAS, 2016). This view was reiterated by most of our key informants when commenting on nationwide SUD workforce barriers. Other studies focusing on these barriers also reached similar conclusions (Alagoz, Hartje, & Fitsgerald, 2017). In addition to the lack of clarity in and complexity of the credentialing process, variation across states in certification and licensure regulations limits the portability of SUD credentials, constituting a barrier to career mobility; this is an additional disincentive to entering the field.

There was consensus among the experts interviewed for this study that uniform standards for competency requirements and credentialing of SUD counselors is a high national priority; this position is backed up by the published literature (Miller et al., 2010). An Institute of Medicine (IOM) report on the quality of behavioral health care (IOM, 2006) noted the differences between states in credentialing and licensing standards for mental health and SUD providers and recommended measures to reduce, and ideally, eliminate these differences, guided by core competencies included in education programs nationwide. This call for uniform standards was reiterated in a more recent report (IOM, 2011) within the broader context of the nation's public health policies: "national accreditation holds promise as a conduit in aiding governmental public health agencies to demonstrate minimum structural and quality process capabilities" (p. 6). This is especially relevant for SUD counseling, one of the least standardized clinical practices in the nation and a crucial one in addressing the current opioid crisis. Establishing uniform credentials, however, poses many challenges and requires collaboration among multiple stakeholders, such as the federal and state health agencies, credentialing boards, and advocacy groups representing behavioral health and counseling professionals. There are, however, initiatives to establish consensus and/or facilitate collaboration among these stakeholders and to otherwise reduce the barriers associated with licensing and certification.

Facilitator 1.1: Efforts to Establish National Credentials

In 2005, SAMHSA issued a mandate calling for the two main credentialing entities--NAADAC and IC&RC--to work together to find common standards for credentialing the SUD workforce. In accordance with the mandate, the two bodies met on and off for several years to explore alternatives for a joint set of credentials, without concrete results. There was another wave of joint action in 2013 with a "softer" approach to collaboration than all-out merger, involving a joint workgroup to coordinate unified efforts in areas such as workforce advocacy, reimbursement, licensure, and certification. However, we learned from a key informant who was intimately familiar with these efforts that the collaboration effort gradually lost momentum; currently there are no active efforts in place that we are aware of. Resuming this or a similar initiative would be a step toward national standardization, given our finding that almost all the credentials we reviewed nationwide were to some degree aligned with the credentials defined by one of these two national organizations.

Facilitator 1.2: Within-State Consolidation of Certification Boards

As mentioned earlier, 19 states have a single certification board for the SUD profession. This reduces the variability within states in the career pathways available to SUD practitioners and the requirements for obtaining credentials (Morgen, Miller, & Stretch, 2012). As our North Carolina case study revealed, consolidation of multiple boards into a single board with a shared mission, values, and practice standards greatly facilitates SUD practitioners' entry into the state's SUD workforce, both in the case of new graduates and established professionals seeking endorsement for credentials received from other states. The consolidation process, however, is usually challenging; it involves moving against the inertia of established practices and professional identities.

Case in point
North Carolina Substance Abuse Professional Practice Board (NCSAPPB) is the state's sole certification board for addiction counselors. It is also the sole accreditation entity for education programs that provide training for SUD counselors. A member of the Board interviewed for this study described it as "a quasi-state agency that operates independently." The board director reports directly to the legislature, the governor's office, and the state auditor. Although the Board operates autonomously from the North Carolina Department of Health and Human Services (DHHS), it closely collaborates with that agency. One of the strengths of the Board is the degree of autonomy it allows its staff, resulting in quicker decisions than would be the case in a government agency. NCSAPPB was established in the 1980s through the merger of two boards that separately CADCs. The merger was a contentious process with both groups of professionals initially resisting a single practice definition comprising both. With time, however, it has become the valuable resource incentivizing the SUD workforce that it is today.

Facilitator 1.3: Centralized Information Dissemination and Technical Assistance to Providers

One of the negative consequences of multiple credentials and credentialing boards is the difficulty that students and early-career professionals face in obtaining detailed and unambiguous information about the SUD counseling career ladder and qualifications for practice in their state. Some states have addressed this barrier by establishing centralized training and technical assistance resources for the SUD workforce to help them navigate this complex information environment.

Case in point
New York's Office of Alcoholism and Substance Abuse Services (OASAS) partners with the Community Technical Assistance Center (CTAC) and Managed Care Technical Assistance Center (MCTAC) to maintain a "one-stop shop" to meet behavioral health providers' need for practice information. In addition to providing in-person and online training and technical assistance to providers, CTAC/MCTAC maintains a portal with information on credentialing, within-state variation on regulations, establishing and maintaining a practice in the changing environment of system redesign, working with the regional managed care organizations (MCOs), and best clinical practices. An important resource developed through a partnership between OASAS and CTAC is the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool, a web-based application that guides providers in determining the most appropriate levels of care for a given SUD. The state strongly encourages all insurers and providers to use the tool in determining the appropriate level of care for their enrollees and clients, and Medicaid MCOs are required to use it. CTAC/MCTAC also maintains an email helpline to respond to questions from individuals and agencies. Over 5,000 messages arrive daily and receive responses within 24 hours, on average. These services are all offered free of charge and funded by the state. Close communication with OASAS keeps CTAC/MCTAC informed of new and upcoming policy developments and provides OASAS with timely feedback from the field to aid in policy decisions.

Barrier 2: Low and Non-Standard Educational Requirements

Although this study focuses on the portion of the counseling workforce with SUD-related credentials, it is useful to consider the entire SUD counseling workforce in discussing training requirements. A survey of specialty SUD treatment facilities across the nation found that 42% of the staff working in these facilities were counselors, and 19% were medical staff (e.g., physicians, pharmacists, nurses, mid-level professionals). The rest were evenly divided among administrative staff and patient support staff (e.g., peer support specialists, care managers, patient navigators). Less than a third of the non-administration staff were certified in addiction treatment and certification was inversely correlated with education level: 59% of the counselors with an associate degree were certified in addiction compared with 40% of those with a master's and 34% of those with a doctoral degree (Bouchery, 2017). These figures suggest hat even though the majority of the counseling staff in SUD specialty facilities had at least a master's degree (57%), their advanced education does not necessarily translate into enhanced knowledge of addiction treatment (Bouchery & Dey, 2018). These findings give us a rough snapshot of workforce composition.

The following comment by Kirk Bowden, made at a time when he was NAADAC's president, is very telling with respect to low and uneven education requirements for SUD counseling:

I hold two behavioral health licenses in my state. Both of my licenses grant me the authority to independently practice psychotherapy with clients whose primary diagnosis is an addiction and/or substance use disorder. Neither license required me to complete a single hour of course work in addiction counseling. (Bowden, 2015)

Education requirements for SUD-specific credentials are also lower than those of other counseling professions. For example, a 50-state review of training requirements for counselors found that requirements for mental health counselors were generally structured around formal education whereas addiction counselors' qualifications were typically structured around hours of supervised work (Kerwin, Walker-Smith, & Kirby, 2006). The majority of content experts and state officials interviewed for this study reiterated that unless education and training in addiction treatment is made a requirement for providing SUD services, professionals interested in practicing in this area will prefer to specialize in behavioral health fields with better career advancement prospects, income, and clearer credentialing requirements, such as clinical social work or mental health counseling.

To a large extent, low educational requirements have their roots in the historical development of addiction treatment as an area of knowledge best acquired through lived experience and on-the-job training, in contrast to other clinical specialties where skill acquisition is tightly linked to nationally accredited academic programs. This apprenticeship model of training may be effective in trades with high levels of predictability and a narrowly defined set of tasks, but it might not be as suitable for professions with rapid knowledge development, rigorous research on best practices, and an ever-changing landscape of risk and protective factors. Training of the latter type of professionals typically involves standard curricula that are frequently updated to address new knowledge and practice models, and a standard credentialing system linked to education and professional development in order to bridge the gap between research and practice (Lamb, Greenlick, & McCarty, 1998; Bowden, 2015). There is increasing emphasis on research-based practices in the SUD treatment field that requires the rapid diffusion of new research findings within the profession. Low and varying education requirements in the field will likely delay the adoption of best practices and the discontinuation of discredited treatment models in response to new research findings (Glasner-Edwards & Rawson, 2010).

Our review of minimum education and practice hour requirements (Exhibit 9 and Exhibit 10) revealed that in some states, SUD treatment can be provided without an academic degree or with a minimum of a high school education whereas no state has a minimum practice requirement under 1,000 hours. This suggests that the apprenticeship model still has a hold in parts of the nation, reinforcing the perception that addiction treatment is more a trade than a profession. This is further disincentive to selecting this field as an academic specialty (Morgen et al., 2012). As one of our key informants put it, "Why waste education hours and money if it is not required?" The perception that addiction treatment does not require as much academic training as other behavioral health professions, although no longer an accurate representation of the field, also plays into lower salaries and reimbursement rates for SUD treatment providers; this barrier is discussed in detail later in this report (the section on billing eligibility and reimbursement).

Facilitator 2.1: State Licensure Statutes and Title/Practice Protections

States can address this barrier by regulating the SUD treatment profession: imposing minimum educational requirements for certification and licensure and making it illegal to use an SUD counseling title without certification (title protection) and ultimately, legally requiring clearly defined credentials in order to provide SUD services (practice protection). Legislative actions in this direction are lengthy processes requiring a carefully forged collaboration and consensus among multiple stakeholders in the state, such as state health officials, legislators, professional associations representing the entire range of behavioral health professionals, institutions of higher education, practicing behavioral health providers, individuals with lived experience, and the public at large. Drafting of the legislation is typically preceded by a comprehensive review of the profession, often called a "sunrise review," that specifies clearly demarcated professional boundaries, a career ladder, SOPs, and competency requirements. These factors are all subject to opposition from multiple stakeholders potentially affected by changes to the status quo, underscoring the importance of consensus building in preparation for bringing the statutes to the state's legislature. Two common reasons for such legislation to fail are: (1) opposition from counseling professionals with established practices to newly imposed professional boundaries and competency requirements; and (2) the absence of a corresponding academic career ladder in the state's higher education system.

Case in point
After several failed attempts, the Indiana Addiction Counselor Licensure bill was signed into law in 2009. The law includes both title and practice protection for addiction counselors. The successful effort had several factors based on lessons learned from previous failures: A professional mediator with legal and legislative experience assisted in establishing consensus among stakeholders previously opposed to the legislation; the SOP was clearly defined, with collaboration from state and national professional associations in counseling professions; an academic career ladder in line with qualifications required for practice was established through collaboration with the state's community college system and a private university; and grandfathering options were included in the legislation to offer "soft" transition options for practicing providers. This legislative effort has come to be referred to as the "Indiana Model," and is cited as a roadmap for other states (Turner-Bull, 2011; Osborn, 2015).

There are guidelines and roadmaps for establishing clearly defined professional titles and credentials for the SUD profession. SAMHSA's (2011) model career ladder and SOPs, used in the present study to classify the over 300 credentials we found across the nation into categories comparable across states, is one such guideline that states can use to set up and regulate a multi-tiered career ladder. Another example is NAADAC's (2011) model legislative language to regulate the profession.

Facilitator 2.2: Efforts to Establish Standardized Core Competencies and Link SUD Credentials to Academic Programs

Establishing and enforcing standard training requirements for addiction counselor credentials will require standard educational curricula, which, in turn, depends on consensus among multiple national state and local stakeholders around a set of core competencies (Bowden, 2015). An early effort to identify and define core competencies for the profession was funded by the National Institute on Alcohol Abuse and Alcoholism in 1984 (Birch & Davis Associates, 1984). This work laid the foundations for subsequent work in this area. Currently, the most commonly recognized professional standards are those developed by the Center for Substance Abuse Treatment in 2006 (CSAT, 2006); these have been regularly updated since their first publication. Commonly referred to as TAP 21, the CSAT standards facilitate the development and accreditation of degree programs for addiction counseling.

The Council for Accreditation of Counseling and Related Educational Programs (CACREP) that accredits educational programs in counseling has established standards for addiction counseling (CACREP, 2016). While these standards provide guidelines for counseling programs that choose to offer addiction as a specialization, they do not necessarily correspond to the credentialing requirements of the SUD field, which developed separately from the professional counseling field. A move toward state licensing/credentialing requirements that link to degree programs with uniform accreditation standards will, therefore, involve a reconsideration of the entire counseling field (Morgen et al., 2012), requiring collaboration among multiple credentialing and accreditation bodies.

Our study also identified some state-level efforts to link educational and credentialing standards for the profession.

Case in point
North Carolina's Substance Abuse Professional Practice Board (NCSAPPB), the state's single certification body for addiction counselors, also provides accreditation for educational programs in the state (and a few other states) with curricula that align with their certification requirements. The NCSAPPB website maintains a list of these accredited programs as a resource for SUD professionals, and members of the board pay visits to colleges with accredited programs to provide the students with information about the field. These visits also function as efforts to raise interest in the profession and to encourage new students to specialize in this area.

One training gap mentioned by multiple expert informants and state officials is the lack of cross-training between addiction and other behavioral health fields. Given the co-occurring nature of these disorders, this training gap has created a competency gap in the behavioral health workforce. Coordination between state certification bodies and institutions of higher education would be needed to develop training resources required for qualification.

Case in point
A senior member of the California County Behavioral Health Directors Association interviewed for this study observed that any qualified counselor can provide SUD treatment, regardless of their background in addiction-specific education and practice. The SUD-specific credentials that require addiction training and practice hours, while obtainable from either of the two certification boards in the state, are voluntary. Thus, there is no incentive for a licensed counselor to further specialize in SUD treatment that requires additional education and practice hours beyond what they have already completed to obtain their professional counseling license. On the other hand, the state is in the process of transforming its SUD services, moving toward an integrated delivery system with strict quality controls. One of the requirements for an SUD treatment program to receive funding from the state--through the state's Medicaid waiver demonstration--is to have a licensed counselor on staff. In the absence of state-level practice protections banning the provision of SUD counseling without demonstrating core competencies needed for the practice, the presence of a licensed counselor in an SUD treatment facility will fall short of ensuring service quality. Addressing this issue will require the collaboration of multiple professional associations, the state, and institutions of higher education in an effort establish minimum addiction-specific educational standards for the entire SUD workforce and provide the training resources needed to meet those standards. A step in the right direction was taken when a bill was introduced during the 2017-2018 session of the State Assembly (AS-2804) to develop the state's SUD treatment workforce. The bill combined mandates for certifying organizations to formalize a career ladder for addiction professionals and requires that the California State University system, the University of California, and the California Community College system develop goals and plans to provide the necessary training resources. The bill also included appropriations for scholarships, grants, and loan forgiveness programs for completing SUD-related courses. Although the bill failed during the last session, a member of the California Consortium of Addiction Programs and Professionals (CCAPP) indicated that a similar SUD licensure bill is being drafted for submission to the Assembly in January 2019

In line with the increasing need for integrated mental health and SUD treatment, there are ongoing efforts to develop cross-training curricula with positive outcomes (Wendler & Murdock, 2006). Programs that incorporate addiction-related material into a broader range of clinical disciplines would help ensure that the entire SUD workforce--Licensed Clinical Social Workers (LCSWs), licensed professional counselors (LPCs), clinical psychologists, and other addiction service providers as well as practitioners with SUD-specific credentials--has the skills and knowledge to implement best practices. In fact, a fully-integrated health care delivery system can best be supported with broader interdisciplinary cross-training, including professions that do not routinely treat SUDs but encounter these symptoms in their practice, such as primary care providers, psychiatrists, pediatricians, and obstetricians (Broyles, Conley, & Harding, 2013; Das & Roberts, 2016).

Facilitator 2.3: Student Loan Repayment Programs

Student loan repayment is an effective strategy for attracting new professionals into a specialty field, and it is widely used across the nation to address workforce shortages. These programs partially or fully repay the student loans of qualified individuals, either as a grant or a one-time payment, in return for a commitment to work for a specified period of time in a specialty field and/or geographic area that is experiencing workforce shortages. In addition to addressing workforce shortages, these programs incentivize professionals to further their education in the specified field. Until recently, these funding opportunities were not available to addiction counselors, perhaps because the field was perceived as depending more on supervised practice than on formal education. Some states now include SUD practitioners among their eligibility criteria for loan repayment programs. For example, Texas passed a law in 2018 to provide loan repayment of up to $10,000 for Licensed Chemical Dependency Counselors (LCDC) willing to work in underserved areas or with underserved populations.

The opioid crisis has also sparked interest in loan forgiveness and other career support programs at the federal level. In March 2018, the U.S. Department of Labor announced up to $21 million out of its National Health Emergency demonstration grant projects to provide career support (including training and education support) for new entrants or incumbent workers in the SUD treatment workforce in areas impacted by opioid use, addiction, and overdose. This was followed by the signing into law of the SUPPORT for Patients and Communities Act in 2019. Section 7071 of the act provides forgiveness for student loans of up to $250,000 in federal funds for SUD treatment professionals. The law requires the recipient to work in a full-time substance use treatment position for up to 6 years in a geographical area with a workforce shortage.

Loan repayment programs, grants, and scholarships are powerful incentives to pursue degrees in SUD treatment. It is important, however, to ensure that such programs do not reinforce existing assumptions about the low educational requirements of the profession. An example of such an assumption is the Texas program, where the repayment scale for LCDCs stops at an associate degree whereas LCSWs, professional counselors, and MFTs are eligible for loan repayments of up to $40,000--and up to $80,000 if they earn a doctorate.

One factor that may limit the effectiveness of loan repayment and scholarship programs in addressing the SUD workforce shortage are the large practice hour requirements that graduates need to fulfill to get certified or licensed in SUD counseling. This period increases the time between graduation and the onset of independent practice by several years in some states. Morgen et al. (2012) point out that in many states, the long practice hour requirements are a carryover from an earlier era when most SUD counselors had no more than a high school diploma. The authors suggest that as the profession transitions from the early "apprenticeship model" to the newly emerging professional model with advanced degree requirements, practice hour requirements need to be recalibrated accordingly. In addition to streamlining SUD-specific credentialing requirements, they point out, such a recalibration will facilitate entry into the profession from individuals already qualified in other counseling professions.