Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Initial Findings Report. III. Supply of Substance Use Disorder Treatment Providers

09/30/2015

This section discusses current and future trends in workforce supply. Appendix B provides a more detailed overview of past research assessing the size and composition of the SUD treatment workforce.

A. Current Supply of Substance Use Disorder Treatment

Provision of SUD treatment requires a mix of counselors, medical professionals and support staff. The level and type of staff needed varies across care types and settings. Intensive and standard outpatient treatment requires a variety of workers, such as nurses, counselors, physicians, psychologists, therapists, and social workers. A partial hospitalization program provides outpatient individual and group counseling in an environment with medical services and requires nurses and physicians for medical care. Inpatient treatment requires a physician, or possibly a physician assistant or nurse practitioner, to see patients on a daily basis; other workers, such as social workers and occupational therapists, are also typically present. Residential treatment has constant supervision, but does not require as high a level of staffing as inpatient treatment; counseling is provided and physicians see patients on an intermittent basis. This section attempts to characterize this multifaceted workforce based on limited available information. First we address the overall size and composition of the workforce. Then, we discuss training and certification requirements and the pipeline for entering the workforce. Finally, we discuss observed disparities in care access.

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

Describing the size and composition of the SUD workforce is complicated. The SOC system that is used by the BLS to categorize workers for the purpose of collecting data on employment does not capture SUD treatment providers as a category separate from other types of providers. A variety of professionals provide SUD treatment, including certified addiction specialists, medical and primary care providers, and support staff such as case managers and peer specialists. These professionals are identified in numerous occupational categories and these categories are not specific to SUD treatment professionals. Although the size of the SUD workforce is not systematically tracked, some studies have examined specific segments of the SUD workforce.

  • Workforce in Specialty Treatment Facilities. The most recent data available on the size of the SUD workforce is from the Information Services Survey (ISS), which collected data on the workforce at specialty SUD treatment facilities in 1999 (Lewin and NORC 2000). The data collected in this survey identified 67,400 workers directly involved in psychosocial treatment services, an additional 80,000-90,000 medical and administrative staff, and 17,000 other behavioral health professionals within specialty SUD treatment facilities, for a total of about 170,000 staff members (Dilonardo 2011). The sample of facilities upon which these estimates are based was small. The Alcohol and Drug Services Study (ADSS) collected data on the SUD treatment workforce about three years before the ISS, in 1996. These data indicated about 88,000 counselors, almost 50,000 medical professionals, and 65,000 other staff, for a total of about 200,000 staff members, constituted the workforce at the time of the study (SAMHSA 2003). Although these two studies arrived at somewhat similar conclusions, it is difficult to directly compare them, given differences in how staff were defined. Both studies are also quite dated, but we could not identify a more recent source.

  • Size of the Broader SUD Workforce. The Institute of Medicine (IOM) took a broader view to measure the SUD workforce in 1997. The IOM estimated over 3 million professionals who may provide SUD treatment across a range of medical and social service settings. These professionals included primary care physicians, nurses, physician assistants, and marriage/family counselors, but the IOM noted that only about 40,000 of them (1 percent) were certified in addiction treatment.

2. What are the Characteristics of the Workforce?

The Vital Signs survey is the most recent nationally representative survey collecting information on the composition of the direct care SUD workforce. The survey was conducted for SAMHSA by the Addiction Technology and Transfer Center (ATTC) Network (Ryan et al. 2012). It was fielded between November 2011 and May 2012. It surveyed a nationally representative sample of clinical directors at specialty SUD treatment facilities and identified characteristics of clinical directors and direct care staff:

  • Gender. The majority of clinical directors and direct care staff were female (59 percent and 64 percent, respectively).

  • Age. The majority of clinical directors were age 50 or older (60 percent). In contrast, the majority of direct care workers were younger than age 45 (56 percent).

  • Race. Most clinical directors and direct care staff were White (86 percent and 64 percent, respectively).

  • Educational Attainment. Eighty-one percent of clinical directors had a bachelor's degree or higher and a majority of direct care staff had a bachelor's degree or higher (63 percent).

  • Licensure. Fifty-five percent of clinical directors were licensed clinical supervisors. A majority of direct care staff are currently licensed (54 percent).

Results for the Vital Signs survey were not available at the state level. Given the variation in workforce requirements by state, there may be considerable variation in these characteristics at that level.

3. What Training and Certification is Required of the SUD Workforce, and How Does it Vary by State?

The three experts interviewed for this report all cited variation across states in SUD workforce policies as an obstacle to characterizing the workforce and associated trends and concerns at the national level. Experts have recommended that career paths for the treatment and recovery workforce and core competency standards for professions be adopted at a national level (Whittier et al. 2006). Following this recommendation in 2011, SAMHSA issued a report defining a national standard for the scope of practice and career ladder for SUD counselors. The establishment of a standard career ladder is intended to increase employee retention, create performance incentives, and give workers a career development plan (SAMHSA 2011b). Under this standardized classification scheme, there are five levels of counseling staff:

  • Substance Abuse Technician. Typically requires a high school diploma or a general equivalency diploma (GED), and practices under the supervision of a Category 3 or 4 counselor.

  • Category 1 Counselor: Associate SUD Counselor. Typically requires an associate's degree and practices under the supervision of a Category 3 or 4 counselor.

  • Category 2 Counselor: SUD Counselor. Typically requires a bachelor's degree and practices under the supervision of a Category 3 or 4 counselor.

  • Category 3 Counselor: Clinical SUD Counselor. Typically has a master's or other post-graduate degree but works under the supervision of a Category 4 counselor.

  • Category 4 Counselor: Independent SUD Counselor. Typically has a master's or other post-graduate degree and is licensed to practice independently.

The National Association of State Alcohol and Drug Abuse Directors (NASADAD 2013) used this scheme to compare licensing and credentialing requirements for the SUD workforce across the states in 2011.18 They found all states and the District of Columbia regulated the licensing or certification of individuals who provided SUD treatment. A majority of states (25) had an agency or bureau responsible for licensing or credentialing multiple types of health care providers including SUD treatment professionals. Other states (20) aligned with a national credentialing body, either the IC&RC or the National Certification Commission for Addiction Professionals. The remaining states gave this responsibility to the agency responsible for administering SAMHSA's substance abuse prevention and treatment block grant funding, commonly referred to as the single state agency (SSA).

When the licensing or credentialing requirements of these state entities were reviewed, only four (Alabama, Alaska, Louisiana, and Pennsylvania) had counselors certified at all five levels included in the SAMHSA career ladder. All states and the District of Columbia had an equivalent certification for Category 3; 28 states had a Category 4 certification; 31 states had a Category 2 certification; and 23 states had a Category 1 certification. Twelve states had an equivalent certification to SAMHSA's substance abuse technician.

Certain credentialing requirements were consistently found across all states. All state credentials require a minimum level of education, supervised work experience, and a standardized test (NASADAD 2013).19 Although all states require supervised hours prior to independent practice, the number of hours varies (IOM 2006).

The recent literature regarding state licensing and credentialing we identified included limited detail on the state specific requirements. We did not find any literature analyzing the relationship between state licensing and credentialing policies and the size and composition of the SUD workforce. The discussion in this section focuses on counselors who represent only part of the SUD treatment workforce. Medical professional and other support staff are also an important part of the workforce. Literature on career paths, training, and certification requirements for these professionals specific to SUD treatment provision was not identified during the literature review for this study.

4. What is the Pipeline for a Qualified Workforce? How do People Become Qualified?

Traditionally, experience rather than formal education has been a large part of the training process for SUD treatment providers. SUD counselor training has primarily followed an apprentice model. Those states that offer counselor certification generally required more hours of supervised work experience and less formal education for SUD counselors relative to mental health counselors (Dilonardo 2011; Kerwin et al. 2006). Recently, there is a trend toward more formal education for the workforce (Whitter et al. 2006).

These higher rates of educational attainment may not correspond to greater knowledge in the SUD treatment field, 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, with many counselors with master's and doctoral degrees indicating their SUD-specific training came from associate's degrees or two-year certification programs (McCarty 2002; IOM 2006). A lack of specialized graduate training continues to limit the professional development of the field (McCarty 2002).

The experts who were interviewed for this study from NAADAC and IC&RC noted the trend toward a more highly educated workforce and professional licensure; however the experts indicated that these trends may not be associated with improvements in the quality of SUD care. The increases in education and licensure are associated with insurer reimbursement and state licensure requirements. SUD treatment professionals may pursue graduate-level training because it helps them obtain mental health credentialing and provides better opportunities for employment and insurance reimbursement. Such advances in education and the opportunity it affords may result in exit from the SUD treatment field. The experts also expressed concern that more highly educated workers, most of whom graduate from programs that are not specifically focused on addiction, may not have adequate addiction-specific training.

Many SUD clinical directors and direct care staff are recruited from the recovery community with about one-third of both clinical directors and direct care staffing reporting being persons in recovery (Ryan et al. 2012). There has been a large effort to develop training for peer specialists (Hyde 2013). According to a 2010 national survey by the National Association of State Mental Health Program Directors, out of 22 responses from states that had Medicaid reimbursement for peer services, seven states required a certification or licensing process, nine required passing an exam or other certification, 11 required completing a training curriculum, ten required a high school diploma or GED, and seven required that the peer specialist use mental health services (Daniels et al. 2011).

Overall, the path to becoming an SUD treatment professional is multifaceted. Individuals may enter the field with varying levels of educational attainment in fields such as social work and psychology. Much of the specialized addiction training occurs through apprenticeship or in associate's or two-year certification programs.

5. Observed Variation in Provider Capacity

National estimates of capacity can mask substantial variation by urbanicity of residence or facility financing.

Level of Urbanicity. Jackson and Shannon (2011) 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.

Facility Financing. Two recent studies identified differences in the care delivered by both publicly and privately-funded treatment facilities. Abraham and colleagues (2013) found that publicly funded centers were less likely to have a physician on staff and prescribed fewer medications. Another study found that staffing levels significantly differed between private for-profit, private non-profit, and public treatment programs, with public programs offering fewer hours per client and having larger caseloads (Lemak and Alexander 2005).

Overall, the available research has identified substantial variation in treatment supply by urbanicity of residence and facility financing.

B. Trends and Policies Affecting Future Supply of Care

This section first looks at the available evidence for assessing future supply trends and funding sources. Then it looks at the potential to increase supply through care integration, innovative care models or other approaches. Lastly, the section addresses efforts to expand MAT.

1. Trends in the Size of the Workforce

The BLS, which develops employment statistics that include projections for employment by occupation, provides no specific category just for SUD treatment professionals. However, two categories encompass a substantial proportion of the SUD treatment workforce: (1) substance abuse and behavioral disorder counselors; and (2) mental health and substance abuse social workers. The share of these categories represented by SUD treatment versus mental health professionals is unknown. BLS project employment in these categories to grow at a faster rate than the average for all occupations (BLS 2015a, 2015b) because addiction and mental health counseling services will be increasingly covered by insurance policies, and health insurance coverage expansion will increase demand for health care services in general (BLS 2015a). BLS also notes that drug offenders are increasingly being sent to treatment rather than jail, thereby increasing treatment program use (BLS 2015a, 2015b).

These BLS projected growth rates diverge from past employment trends in these occupations. Nationally, employment of substance abuse and behavioral disorder counselors declined 3 percent between 2008 and 2011. However, in the most recent two years observed, 2011 to 2013, employment growth ranged from 4 percent to 5 percent per year. Likewise, employment of mental health and substance abuse social workers declined 16 percent between 2008 and 2012. Then, between 2012 and 2013, employment of these professionals grew by 1 percent (BLS 2015c).

Expert interview respondents from NAADAC and IC&RC had no available data on trends in training program output. The NAADAC representative reported anecdotally that availability of training programs has increased over the past ten years, with a small increase in addiction-specific programs. One IC&RC state board representative reported that their state started a counselor training program in 2006 as a result of a desperate need for training programs in the state. Since inception, the program has had over 200 graduates; however the number of individuals completing training annually has decreased recently from approximately 50 to around 36. Another state board representative noted that there has been an increase in training programs over the past few years, particularly programs at the graduate level. Finally, another state board representative indicated a recent increase in individuals with online degrees. Overall, the available evidence for assessing change in the size of the workforce is limited, but suggests, at most, a modest increase in training.

2. Trends in Funding Sources

Many SUD treatment providers have traditionally relied on grant funding. There is concern that providers are not prepared to accept the Medicaid and private insurance coverage that potential clients may obtain as a result of ACA insurance expansions. The N-SSATS (SAMHSA 2014a) 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.1 identifies the percentage of these facilities that reported accepting private health insurance and Medicaid coverage in 2013. Over one-third of facilities did not accept private insurance, and a larger percentage (41 percent) did not accept Medicaid. For-profit and federal facilities were the least likely to accept Medicaid.

General health care settings and solo practitioners are generally not represented in the N-SSATS. A recent study by Decker (2013) looked at acceptance of new Medicaid patients by community health centers and office-based providers in 2011-2012. Community health centers were the most likely to have accepted new Medicaid patients (94 percent). Most primary care physicians (67 percent) accepted new Medicaid patients. In contrast acceptance of new Medicaid patients among psychiatrists was low (44 percent).

TABLE III.1. Percentage of Facilities Accepting Indicated Insurance Type, N-SSATS 2013
  Number of Facilities
(%)
Proportion Accepting
Private Health Insurance
Proportion Accepting
Medicaid
Total 14,148 (100) 65.4 58.9
Private non-profit 7,820 (55) 66.2 68.8
Private for-profit 4,575 (32) 64.3 40.7
Local, county, or community government 739 (5) 67.0 76.9
Ownership
   State government ownership 351 (2) 66.7 71.8
   Federal Government ownership 370 (3) 63.8 23.5
   Tribal government ownership 293 (2) 57.0 63.8
SOURCE: Estimates obtained from SAMHSA 2014a.

Research on acceptance of Medicaid by physicians has identified several reasons physicians chose not to accept Medicaid (Ubel 2015). Most significantly Medicaid payment rates tend to be substantially lower than payment rates offered by private insurance and Medicare for the same services. Second, providers complain of slow reimbursement by some state Medicaid programs and substantial administrative burdens. Finally, providers note that Medicaid patients tend to require more time and attention than the average patient. Some SUD treatment providers may choose not to accept Medicaid based on these issues.

However, other providers who might be interested in accepting Medicaid may face barriers to accepting Medicaid and private insurance. First, they must meet the credentialing requirements established by these insurer and the requirements will vary across insuring organizations. This may not be straightforward as many SUD treatment providers do not hold the professional degrees or medical licenses needed for insurer-approved reimbursement (Andrews et al. 2015a). In 2012, only 54 percent of direct care staff were currently licensed and 63 percent held a bachelor's degree or higher (Ryan et al. 2012). A second potential barrier for providers is the need to contract with, meet contractual obligations (for example, utilization review and quality monitoring requirements) and accept risk from multiple insurers. This may place a significant burden on smaller organizations. Finally, lack of sophisticated information technology systems may act as a barrier to accepting payment from Medicaid and private insurers. Information systems are needed to bill multiple payment sources and comply with standards for electronic health records. A 2012 survey found that the majority of addiction treatment providers did not have sufficient information technology systems needed to contract with insurers under post-ACA implementation (Andrews et al. 2015a).

3. Potential for Expanding Supply Through Care Integration

Historically, SUD treatment services have been provided in specialty treatment facilities, and the level of integration with physical and mental health treatment services has been limited (Pringle et al. 2006; Ducharme et al. 2007; IOM 2006). The ACA promotes integrating SUD treatment with other types of care (Croft and Parish 2013). The ability of consumers to receive SUD treatment in non-specialty settings has the potential to increase the number of people receiving care by improving accessibility and reducing stigma (Buck 2011). Although the ACA offers incentives to integrate SUD treatment into other health care settings, a number of barriers to integration remain (Padwa et al. 2012; Brunette et al. 2008; Sterling et al. 2010; Croft and Parish 2013) with lack of professionals with adequate training to provide SUD treatment being one of the most significant obstacles.

A number of ACA provisions address the service delivery system and payment structure in an attempt to integrate SUD treatment into mainstream medical care:

  • Creating Care Coordination Entities. The ACA facilitates the creation of Medicaid health homes, coordinated care entities for dual Medicare-Medicaid beneficiaries, accountable care organizations, and patient-centered medical homes (Humphreys and Frank 2014). Under the ACA, care management, health promotion, transition care, referrals to support services, and technology used to link together services will be reimbursed by Medicaid at a 90 percent federal matching rate for the first two years after a health home is created (Barry and Huskamp 2011).

  • Provision of Funding for Integration. The ACA added $50 million in grants to an existing SAMHSA program for coordinated and integrated services through the co-location of primary and specialty care in community-based behavioral health sites (Druss and Mauer 2010). The program targets people with serious mental illnesses who have or are at risk of co-occurring physical health care challenges, but funds may also be used for screening and treatment of co-occurring SUDs (SAMHSA 2012).

  • Increased SUD Treatment at Health Centers. States that cover health centers in their Medicaid plans must reimburse centers at cost for SUD treatment, removing restrictions that states may have considered previously in determining health centers' involvement with SUD treatment (Buck 2011).

Although there are incentives to increase integration, significant obstacles are likely to slow progress toward integrated care:

Developing Integrated Care Models. Care integration for SUDs is not as advanced as care integration for depression and other common mental disorders. Because there is limited experience with care integration for SUDs, providers and policymakers are in the process of developing and evaluating potential approaches. SUD treatment integration approaches might build on recent experience integrating screening and treatment for mid-level anxiety and depression into the primary care setting (Padwa et al. 2012). U.S. Department of Veterans Affairs, known for leading in integrating SUD services with other care, may also have experience to share (Humphreys and McLellan 2010).

Financial Barriers. Much of the funding for the SUD treatment system comes from state, local, and federal sources that are distinct from the funding sources for general health care treatment. Integration of services will require coordination of SUD and general health funding. It will also require SUD treatment organizations to develop relationships with entities representing new funding sources. Many specialty SUD treatment facilities do not accept Medicaid, Medicare, or private insurance. In addition, despite parity legislation and the ACA, these insurance programs provide limited coverage of some community-based services, and the MHPAEA does not require that insurers cover all types of SUD treatment services (Dilonardo 2011). State policies that provide separate agencies focused on behavioral health or that contract with distinct entities to provide physical and behavioral health services may also be a barrier to integration. Some states have made efforts to address these potential barriers (Commonwealth Fund 2015).

Lack of Trained Professionals. The majority of primary care, mental health, and SUD treatment professionals are not trained in care integration (Dilonardo 2011). Effective techniques for training workers are still in development (Marshall et al. 2012; Madras et al. 2009; Bonham 2009). Only a small number of physicians, psychologists, and other health care workers have received extensive training in dealing with SUDs (Humphreys and McLellan 2010). Likewise, integrated health care providers will need to hire or contract with SUD treatment professionals to provide specialized care that cannot be incorporated into general practice. This is expected to increase demand for SUD professionals outside the specialty SUD treatment sector.

Although the ACA offers incentives to integrate SUD treatment into other health care settings, a number of barriers to integration remain. Lack of professionals with adequate training related to integration and provision of SUD treatment generally is likely the most significant obstacle.

4. Potential for Increasing Supply Through Innovative Care Models

Treatment professionals provide a range of SUD treatment modes (for example, regular outpatient, intensive day treatment, MAT) in various care settings (outpatient, residential, and inpatient). Client needs and the range of services offered vary substantially across facilities. This variation has important implications for the number and type of professionals each facility will demand in the labor market to fulfill its staffing needs. Although states have limited requirements for facility staffing, the type of staff available at a facility has important implications for the services a facility can provide. Thus, facilities may restrict the services they provide based on the availability of professional staff. The number and type of staff used to provide services at a given facility also has implications for the efficiency of service provision. There may be potential to employ the current workforce more effectively to increase supply of services.

SUD Staffing Requirements. There are limited standards for SUD treatment facility staffing. A study of 37 states (NASADAD 2013) found that only 19 states have standards for program directors. More often, in 80 percent of states, there are requirements for a medical director. The medical director typically does not need to be a medical doctor unless the facility is an OTP or a hospital. Only six states require that a prescribing professional be on site at least weekly in facilities other than OTPs, detoxification facilities, or hospital-based programs. Twenty-nine of the 37 states responding to the survey required a counseling staff supervisor. In addition, about half of the 37 states had standards for the ratio of counselors to clients. Thus, SUD treatment facilities have substantial flexibility to select the number and types of professionals they employ.

Broad Variety of Professionals Employed. Staffing for SUD treatment depends on the types of services a center offers, but, typically, core staff include a program director or clinical supervisor, SUD counselors, and therapists. These individuals are responsible for intake, screening, assessment, case management, SUD treatment, providing specialized education, planning continuing care, keeping records, and writing reports. Additional staff may include psychiatrists, psychologists, pediatricians, adolescent medicine specialists, internal medicine specialists, family practitioners, and nurses. Staffing may also include recreational therapists, occupational therapists, disability specialists, outreach workers, home intervention workers, continuing care workers, cultural advisors/spiritual leaders, students/interns/fellows, vocational specialists, and case managers (Center for Substance Abuse Treatment 1999). There is some overlap in the scope of practice for different levels of counseling staff, indicating some flexibility in terms of who does which task (SAMHSA 2011b). There may be opportunity to expand the capacity of the workforce by more efficiently using different levels of staff within facilities (Whitter et al. 2006).

Staffing Norms by Facility Characteristics. The type of professional present at a facility depends on the type of care offered (Johns Hopkins Medicine 2014). Lemak and Alexander (2005) identified factors that influence staffing levels. They found that managed care activity influenced the number of active cases managed by each full-time treatment staff member but not number of treatment hours per client. Programs accredited by the Joint Commission, which accredits and certifies more than 20,500 health care organizations and programs in the United States, offered more treatment hours per client.

Use of Peer Staff. Peer recovery support services have become more common and accepted in SUD treatment in recent years. A review of studies done on the effectiveness of peer staff indicated that peers worked with patients in both individual and group settings (Reif et al. 2014). The use of peer staff is now so widespread that it is often a requirement in state and federal grant applications (Ashcraft and Anthony 2012). One study found that 41 percent of clinical directors in addiction agencies had attempted to recruit and employ peer workers in the past year (Ryan et al. 2012). As of July 2014, 32 states and the District of Columbia, allow peer support to be a Medicaid-billable service (Miller 2014), and there is a push to get more peer staff trained to provide support services in behavioral health.

State and federal regulations allow facilities substantial flexibility in staffing. SUD treatment facilities use a range of professionals to deliver services to patients. Each type of professional has a limited scope of practice. If SUD treatment facilities have difficulty hiring certain types of professionals, they can continue operating, but may be forced to correspondingly limit the types of services they can offer clients. Overall, the available information is too limited to assess how alternative staffing models could be used to expand capacity.

5. Other Approaches to Increase Supply

We identified three recent studies that reported on methods to increase the supply of SUD treatment workers. These reports addressed recruiting new workers into the field and retaining current workers.

The Annapolis Coalition with funding from SAMHSA undertook a multiyear effort consulting numerous experts and stakeholders to develop approaches to strengthen the behavioral health workforce (Hoge et al. 2013). They identified best practices in recruiting and retention. These include early exposure to career opportunities in this field and the special populations served, mentoring by behavioral health specialists, training stipends, minority fellowships, loan repayment programs, and developing career ladders. Paying wages commensurate with the education, experience, and the level of responsibility of the position was identified as a key factor for recruiting and retention.

An earlier report (Whitter et al. 2006) aimed at strengthening the addiction treatment and recovery support workforce recommended similar strategies, including training and loan repayment programs; developing a national credentialing standard and career ladder; recruiting students at educational institutions; streamlining administrative burdens through information technology; improving the marketing strategies used for recruiting; and reducing stigma associated with working in the field.

The Vital Signs survey, a nationally representative survey, had SUD treatment program clinical directors identify retention strategies they thought were most successful (Ryan et al 2012). These included provision of health care benefits, implementation of a supportive culture, and access to ongoing training. They also reported strategies to improve recruiting, such as recruiting students at educational institutions and from the recovery community.

Although the literature includes many suggested approaches for increasing the supply of SUD professionals, there was no information documenting the potential impact of implementing the suggested strategies.

6. Efforts to Expand the Use of Medication-Assisted Treatment

MAT combines the use of evidenced-based behavioral therapies with the prescription of HHS Food and Drug Administration approved medications. MAT has been demonstrated to be clinically effective and cost effective (Mann et al. 2015; Baser et al. 2011). While there is strong evidence that use of MAT in managing SUDs provides substantial cost savings there has not been widespread adoption of this approach. Knudsen et al. (2011) analyzed data for privately-funded facilities in 2007-2008 and found that less than a third had adopted MAT. Even when the sample was limited to facilities that had access to a physician less than 42 percent had adopted any given form of MAT. Within the set of facilities that had adopted MAT only a limited percentage of patient used this treatment approach.

There are a number of barriers that limit the use of MAT according to SAMHSA-HRSA Center for Integrated Health Solutions (2014). These barriers include lack of available prescribers, agency regulatory policy that restricts or forbids MAT use, workforce attitudes, insurer limits on dosages prescribed (i.e., annual or lifetime medication limits), insurer authorization requirement, requirements that behavioral therapies be tried first, lack of support staff for providers administering MAT, and inconsistent credentialing or licensure requirements for counseling staff to be reimbursed for MAT related services. Cunningham et al. (2009) identified somewhat different obstacles to widespread adoption of MAT. These barriers include regulatory restrictions, lack of access to medical personnel trained in delivering such treatment, and physician reluctance. In a study focused on the criminal justice system Friedman et al. (2012) identified lack of qualified medical staff was a reason for lack of MAT in the criminal justice system (Friedman et al. 2012). Roman et al. (2011) asserts that limited knowledge about SUD treatment medications among the public hinders use. Mass media advertising of prescription medications for other health conditions has accelerated use of those medications. Broader public knowledge of the benefits of MAT for SUDs could encourage more widespread use.

Mark et al. (2015b) demonstrated how insurance coverage restrictions can be a substantial barrier to provision of MAT to Medicaid insured individuals. 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 MAT are related to the workforce. The number of medical staff qualified to provide MAT services and the staff supporting them needs to increase for provision of MAT to expand. In addition, workforce attitudes toward MAT need to change to attain widespread adoption. Lastly, consistent credentialing and licensure requirements across states and insurers for professionals providing MAT services are needed. The HHS Opioid Initiative aims to improve access and address some of these issues, and despite all of these obstacles, the ACA has resulted in expansions in the number of physicians waivered to prescribe Buprenorphine (Knudsen, Lofwall, Havens and Walsh 2015).

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