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.
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.