E

The Substance Abuse Treatment System: What Does It Look Like and Whom Does It Serve? Preliminary Findings from the Alcohol and Drug Services Study

Constance M. Horgan and Helen J. Levine

Institute for Health Policy, Heller Graduate School, Brandeis University

INTRODUCTION

The substance abuse treatment system is a complex mixture of different types of providers, serving a diverse array of clients with varying treatment needs. The system continues to evolve in response to changes in the external environment, including the financing of treatment with its increasing emphasis on managed care, and the multiple needs of its clients which are frequently nonmedical in nature. Despite these changes, the substance abuse treatment system remains one that is essentially community based with substantial funding from the public sector. It is in the context of this diversity of providers and clients that one examines the interface between research and community-based treatment.

The purpose of this paper is to describe what the substance abuse treatment system looked like in late 1996 as background for the IOM report on the effective transfer of information between research and community-based drug treatment. The paper is structured by answering a series

The Alcohol and Drug Services Study is supported by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Administration (SAMHSA), U.S. Department of Health and Human Services. It is being conducted under contract by Brandeis University in collaboration with Westat, Inc. We thank Grant Ritter and Paula Wolk for their programming assistance, Margaret Lee and Sharon Reif for their research assistance, and Lisa Andersen for manuscript preparation. We are also grateful for comments received from other colleagues, including Daniel Ames, Sara Lamb, Carla Maffeo, Mary Ellen Marsden, and Dennis McCarty and the advice we received from SAMHSA/OAS in the preparation of the paper.



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E The Substance Abuse Treatment System: What Does It Look Like and Whom Does It Serve? Preliminary Findings from the Alcohol and Drug Services Study Constance M. Horgan and Helen J. Levine Institute for Health Policy, Heller Graduate School, Brandeis University INTRODUCTION The substance abuse treatment system is a complex mixture of different types of providers, serving a diverse array of clients with varying treatment needs. The system continues to evolve in response to changes in the external environment, including the financing of treatment with its increasing emphasis on managed care, and the multiple needs of its clients which are frequently nonmedical in nature. Despite these changes, the substance abuse treatment system remains one that is essentially community based with substantial funding from the public sector. It is in the context of this diversity of providers and clients that one examines the interface between research and community-based treatment. The purpose of this paper is to describe what the substance abuse treatment system looked like in late 1996 as background for the IOM report on the effective transfer of information between research and community-based drug treatment. The paper is structured by answering a series The Alcohol and Drug Services Study is supported by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Administration (SAMHSA), U.S. Department of Health and Human Services. It is being conducted under contract by Brandeis University in collaboration with Westat, Inc. We thank Grant Ritter and Paula Wolk for their programming assistance, Margaret Lee and Sharon Reif for their research assistance, and Lisa Andersen for manuscript preparation. We are also grateful for comments received from other colleagues, including Daniel Ames, Sara Lamb, Carla Maffeo, Mary Ellen Marsden, and Dennis McCarty and the advice we received from SAMHSA/OAS in the preparation of the paper.

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of questions about the organization and financing of alcohol and drug treatment facilities, and the characteristics of the clients that these facilities serve. This paper relies on data from the 1997 Alcohol and Drug Services Study (ADSS), which includes as one of its components a nationally representative sample survey of all types of alcohol and drug abuse treatment facilities in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA) contracted with Brandeis University to direct and analyze ADSS. The subcontractor for conducting the field data collection was Westat, Inc. METHODOLOGY ADSS encompasses a three-phase research design and is based on a complex national sample of alcohol and drug abuse treatment facilities in the United States. Phase I consisted of a mail questionnaire collected by telephone interview of a stratified random sample of 2,400 noncorrectional alcohol and drug treatment facilities. Phase II consists of two components: (1) an administrator interview which collects more detailed cost information and other facility level data from a subset of approximately 300 facilities, and (2) record abstraction of over 6,000 clients. Phase III consists of up to six in-person follow-up interviews with Phase II clients, accompanied by urine testing to be conducted at six-month intervals. Data are being collected on treatment history, characteristics at admission to the index treatment, characteristics at follow-up including alcohol and drug use, employment, mental and physical health status indicators, illegal activities, and readmission to treatment. Facility level data collected in Phases I and II, combined with client level data collected in Phases II and III will allow for cost-effectiveness analyses, as well as other measures of treatment outcome. This paper relies entirely on preliminary data from Phase I. The sampling frame was SAMHSA's 1995 National Master Facility Inventory augmented to encompass the universe of substance abuse treatment facilities. Phase I was conducted during early 1997 with data collected for the point-prevalence date of October 1, 1996 and for the most recent twelve-month reporting period of the facility. Data were collected which described facility characteristics as well as aggregate information on clients in the sampled facilities. Facility directors or administrators completed the questionnaire. The Phase I response rate was 92 percent. The Phase I sampling design incorporates a stratified random probability sample that allows for estimates of parameters at the national level. The strata were selected to reflect the different modalities of care within the substance abuse treatment system. Since ADSS is based on sample data, weights have been developed to produce national estimates of facilities and characteristics of clients in treatment. The sampling weights adjust for

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facility nonresponse, as well as differential response rates within strata. The data presented in this report are weighted, but do not contain imputation for any missing values. Sampling errors are calculated using WESVAR, a procedure for complex survey data employing replicated estimates of variance, developed by Westat, Inc. Calculations for these sampling errors are available from the authors upon request. The data in this paper should be considered preliminary until final weights for Phase I are produced after adjustments are made based on Phase II data. HOW IS THE SYSTEM ORGANIZED? Each facility in the survey answered a series of questions about its ownership and location (Table E-1). The majority of substance abuse treatment facilities (63 percent) are owned by private not-for-profit entities and another 14 percent are publicly owned by either federal, state, or local governments. Almost one-quarter of facilities are organized as private for-profit entities (23 percent). This is reflective of the increasing shift to for-profit ownership in health care more generally. These sampled facilities reflect the fact that substance abuse treatment takes place in many types of treatment settings. A sizable minority of facilities reported that they were located in hospitals (10 percent in general hospitals and 4 percent in psychiatric or other specialized hospitals). Almost one in five reported being in some type of free-standing residential setting. Only seven percent of all facilities are therapeutic communities and 6 percent are half-way houses. Many facilities reported a link to the mental health system and described themselves as being located in a community mental health center (19 percent). More than two-fifths were in other types of outpatient treatment settings. Other organizational questions were asked, including the types of care offered, the facility's relationship with other entities, and other services provided (Table E-2). The majority of sampled substance abuse treatment facilities provide some type of outpatient treatment. Over 61 percent of facilities offered only outpatient nonmethadone services and another 5 percent delivered outpatient methadone treatment either alone or in combination with outpatient nonmethadone services. About 3 percent offered only inpatient treatment, 17 percent offered only residential, and 14 percent offered inpatient or residential care combined with outpatient treatment. Many treatment facilities were engaged in providing not only substance abuse services, but also mental health treatment (55 percent) and medical treatment (27 percent). Most treatment facilities are connected to some other organization, with 62 percent reporting that they were legally part of another organization. About 56 percent of facilities that were part of another organization

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TABLE E-1 Organizational Characteristics of Substance Abuse Treatment Facilities, October 1, 1996: Percentage of Facilities by Ownership and Treatment Setting Ownership   Private for-profit 23.4% Private nonprofit 62.3% Public 14.2% Totala 100.0% Treatment Settingb   General hospital 10.3% VA hospital 1.3% Psychiatric or specialized hospital 4.1% Nonhospital residential 19.2% Therapeutic community 6.9% Halfway house 5.6% Community mental health center 18.7% Solo practice 2.3% Group practice 5.1% School 1.4% Outpatient, other than above 44.2% Other 6.1% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. a Does not total to 100% because of rounding. b Does not total to 100% because facilities could respond to as many categories as applied. reported that this parent organization was an administrative office. The parent organization for 30 percent of facilities was a substance abuse treatment facility and for 20 percent was a hospital. ADSS does not have any direct measures of a facility's capacity to conduct and/or participate in research. It does however have information on the existence of an operational computerized information system. While such systems serve administrative functions, sometimes data in these systems are used for research purposes. Table E-3 shows that the majority of facilities have an operational computerized information system, but its existence varies along a number of dimensions. For example, using the point prevalence client count as a measure of facility size, we see the existence of a computerized system is directly related to size. Almost 80 percent of facilities with a client census of greater than 100 active clients have comput-

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TABLE E-2 Organizational Characteristics of Substance Abuse Treatment Facilities, October 1, 1996: Percentage Distribution of Facilities by Type of Care, and Percentage of Facilities by Relationship with Other Organization, Mental Health, or Medical Treatment Provider Type of Care   Inpatient only 3.0% Residential only 17.4% Outpatient methadonea 5.0% Outpatient nonmethadone only 61.1% Combination inpatient and/or residential with outpatient nonmethadone 13.6% Totalb 100.0% Legally Part of Other Organization 61.9% Types of Other Organizationc,d   Administrative office 55.5% Substance abuse treatment facility 29.8% Hospital 19.7% Government agency 11.9% Other organization 27.0% Provision of Other Servicesa   Mental health treatment 54.3% Medical treatment 27.0% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. a Twenty-six percent of outpatient methadone treatment facilities also provide outpatient nonmethadone treatment. b Does not total to 100% because of rounding. c Does not total to 100% because facilities could respond to as many categories as applied. d Distribution is for facilities indicating that they are legally part of another organization. erized systems compared with about 60% for small facilities. Residential programs are the least likely to use a computerized information system with 54 percent having a computerized system. Interestingly, facilities that rely more heavily on public dollars are more likely to report having a computerized system. Whether this is related to the mandated reporting requirements for facilities receiving public dollars, or other factors, is unknown.

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TABLE E-3 Characteristics of Facilities with an Operational Computerized Information System: Percentage of Facilities with System by Organizational and Financial Characteristics Facility Characteristics Percentage with a Computerized Information System Type of Care   Inpatient only 72.4% Residential only 54.3% Outpatient methadone* 77.4% Outpatient nonmethadone only 69.2% Combination inpatient and/or residential with outpatient nonmethadone 70.3% Size   Small (W16) 58.9% Medium (17-40) 64.0% Large (41-100) 68.9% Extra large (>100) 78.1% Ownership   Private for-profit 61.1% Private nonprofit 67.1% Public 77.0% Percentage of Revenue from Public Sources   0-50% 64.3% 50-90% 67.1% 90-100% 71.0% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. * Twenty-six percent of outpatient methadone treatment facilities also provide outpatient nonmethadone treatment. Table E-4 demonstrates the substantial role played by others in getting clients into treatment. Of all clients in treatment on October 1, 1996, only 21 percent were classified by facilities as being self-referred. The criminal justice system was the largest source of referrals, accounting for over one-third of referrals. Other substance abuse treatment facilities referred 12 percent and health or mental health providers accounted for 9 percent of referrals. Over 7 percent were referred by welfare or other social service

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TABLE E-4 Referral to Substance Abuse Treatment Facilities, October 1, 1996: Percentage Distribution of Clients by Referral Sources Percentage of Clients from:   Criminal justice system 34.0% Self-referred/voluntary 21.3% Other treatment facility 11.6% Health or mental health provider 9.1% Welfare or social service agency 7.2% Family 5.1% Employer 4.5% Friend 2.3% Other 4.8% Total* 100.0% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. * Does not total to 100% because of rounding. agencies. Family and employers each accounted for about 5 percent of the referrals. The vast majority of clients in treatment on October 1, 1996 were being treated on an outpatient basis (89 percent) as shown in Table E-5, with most clients being served in outpatient nonmethadone programs (75 percent) and the remainder in outpatient methadone programs (14 percent). Almost one in ten clients were receiving treatment in a residential setting, with 8 percent in residential rehabilitation and 2 percent in residential detoxification programs. The numbers of patients served in hospital inpatient settings continues to dwindle, accounting for just over 1 percent of all clients in treatment on the ADSS point prevalence date. The mean number of clients per facility in treatment on October 1, 1996 varied by type of setting. Outpatient methadone programs were the largest with 216 mean number of active clients in treatment, followed by other outpatient programs with a mean number of 82 active clients. The mean number of active clients in treatment was 27 in both residential rehabilitation and residential detoxification programs. The mean number of clients in hospital inpatient settings was 12. WHO ARE THE CLIENTS? A typical client treated in the substance abuse treatment system is a white, young adult male whose primary drug of abuse is alcohol. The

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TABLE E-5 Type of Care of Active Clients in Substance Abuse Treatment Facilities, October 1, 1996: Percentage Distribution and Mean Number of Clients in Treatment   Percentage Distribution Mean Number of Clients in Treatment Total Hospital Inpatient 1.4%   Hospital detoxification 0.7% 7.0 Hospital rehabilitation 0.7% 11.3 Total Residential 9.4%   Residential detoxification 1.8% 26.9 Residential rehabilitation 7.6% 27.3 Total Outpatient 89.2%   Outpatient methadone 13.9% 215.6 Outpatient nonmethadone 75.3% 82.2 Total 100.0% 82.8   SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. diversity of clients is shown in Table E-6 which summarizes selected demographic characteristics of clients in treatment on October 1, 1996. Over two-thirds of those in treatment were male (68 percent). The majority of clients were white of non-Hispanic origin (57 percent); however, a substantial number of clients were of minority origin (24 percent black, nonHispanic; 12 percent Hispanic, and 3 percent Native American). The age distribution of clients in treatment shows a distinctly youthful population. More than one in five clients are less than 25 years old. Well over one-half of clients are less than 35 and 80 percent of clients are under 45 years of age. Alcohol remains the primary drug of abuse for the largest number of clients in treatment (43 percent). As expected, the use of heroin, cocaine, and marijuana, as primary drugs of abuse, is significant. The number of heroin clients has been increasing relative to other illicit drugs, consistent with trends of drug abuse in this country. WHAT SERVICES ARE OFFERED? A variety of services are offered in conjunction with substance abuse treatment reflecting the diverse needs of the treatment population. Table E-7

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TABLE E-6 Aggregate Client Characteristics of Substance Abuse Treatment Facilities, October 1, 1996: Percentage Distribution of Active Clients by Selected Demographic Characteristics Gender   Male 68.1% Female 30.4% Unknown 1.6% Total* 100.0% Race/Ethnicity   White, not Hispanic 57.1% Black, not Hispanic 23.7% Hispanic 11.8% Asian or Pacific Islander 0.8% American Indian/Alaskan Native 3.0% Unknown 3.7% Total* 100.0% Age at Admission   Under 18 8.4% 18-24 13.0% 25-34 30.8% 35-44 27.5% D45 14.3% Unknown 6.1% Total* 100.0% Primary Drug of Use   Alcohol 43.4% Heroin/other opiates 17.6% Cocaine 15.1% Marijuana 9.7% Amphetamines 2.9% Benzodiazepines 1.0% PCP/LSD 0.8% Barbiturates 0.5% Other (not alcohol) 3.1% Unknown 5.8% Total* 100.0% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. * Does not total to 100% because of rounding.

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summarizes the types of services offered in treatment facilities during the course of their most recent 12-month reporting period. It should be noted that ADSS determined only if the services were offered at the facility during the twelve-month reporting period. The data do not indicate how frequently the services were available and whether they were available to all clients, targeted subpopulations, or on an ad hoc basis. Well over 90 percent of facilities offered comprehensive assessment and diagnosis, individual therapy, and group therapy. More than 75 percent provided family counseling, HIV/AIDS counseling, relapse prevention, and aftercare (after the cessation of routine treatment) services. Far fewer facilities were likely to offer services of a nonmedical nature. Employment counseling/training was offered in 41 percent of facilities; academic education/GED classes in 17 percent; and child care in 13 percent. TABLE E-7 Percentage of Facilities Offering Selected Services in Substance Abuse Treatment Facilities (over 12-month reporting period) Facilities Offering:*   Individual therapy 96.6% Comprehensive assessment/diagnosis 93.7% Group therapy (not including relapse prevention) 91.7% Family counseling 85.6% Aftercare 82.3% Relapse prevention groups 78.4% HIV/AIDS counseling 75.5% Self-help or mutual-help groups 71.3% Outcome follow-up 66.8% Combined substance abuse and mental health 66.5% Transportation 48.6% TB screening 42.1% Employment counseling/training 40.7% Detoxification 25.6% Smoking cessation 24.4% Academic education/GED classes 17.2% Child care 12.9% Prenatal care 11.7% Acupuncture 4.7% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. * Does not total to 100% because facilities indicated as many services as they offered.

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WHO PAYS FOR TREATMENT? The substance abuse treatment system in this country has always been largely publicly supported and continues to be so as shown in Table E-8, albeit to a diminishing extent. The majority of funding (65 percent) comes from public sources, with nearly half coming from public noninsurance mechanisms such as the federal, state, and local grants and contracts (47 percent). The remaining private revenue sources (30 percent) are divided between client fees (17 percent) and private insurance (13 percent). This differs substantially from the rest of the health care system where private and public insurance accounts for the majority of revenue. The relative importance of public funding in facilities varies depending on facility ownership. As expected, private for-profit facilities do not rely heavily on public dollars, with only 22 percent of revenues coming from public sources. Publicly owned facilities are heavily but not completely reliant on public dollars (84 percent). The majority of treatment facilities are private nonprofit organizations, and they too rely heavily on public sources with over 71 percent of funding coming from the public sector. CONCLUSION In summary, although the substance abuse treatment system is generally publicly funded and serves patients largely on an outpatient basis, there is still considerable diversity along a number of dimensions. It is unknown the degree to which substance abuse treatment facilities participate either actively or passively in research studies, or how quickly research findings disseminate into the delivery of services. The data suggest that given such a diverse substance abuse treatment system, there will be varying abilities and willingness to engage and benefit from research, particularly in a system that many view as underfunded.

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TABLE E-8 Revenue Type of Substance Abuse Treatment Facilities (over 12-month reporting period): Percentage Distribution by Sources of Revenue and Mean Percentage of Public Revenue by Ownership Sources of Revenue   Private 30.3% Client fees 16.9% Private insurance, fee for service 6.8% Private insurance, managed care 6.6% Public 64.9% Medicaid, unspecified 10.7% Medicaid, managed care 1.8% Medicare 2.3% Other federal funds (VA, CHAMPUS) 3.1% Other public funds (federal, state, and local block grants, contracts) 47.1% Other 4.7% Other (philanthropy, in-kind) 3.6% Unknown 1.1% Total* 100.0%   Mean Percentage of Revenue from Public Sources Ownership   Private for-profit 21.7% Private nonprofit 71.4% Public 83.7% Total 62.5% SOURCE: 1997 Alcohol and Drug Services Study—Phase I—Preliminary Data. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. * Does not total to 100% because of rounding.