Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Final Report. III. SUPPLY OF SUBSTANCE USE DISORDER TREATMENT

12/05/2017

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.