Chapter 1

Description of the National Survey of Substance Abuse
Treatment Services (N-SSATS)

This report presents tabular information and high-lights from the 2003 National Survey of Substance Abuse Treatment Services (N-SSATS), conducted between March and October 2003, with a reference date of March 31, 2003. It is the 26th in a series of national surveys begun in the 1970s designed to collect data on the location, characteristics, and utilization of alcohol and drug treatment facilities and services throughout the 50 States, the District of Columbia, and other U.S. jurisdictions.¹ The Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, plans and directs N-SSATS.

N-SSATS is designed to collect information from all facilities² in the United States, both public and private, that provide substance abuse treatment. (Additional information on N-SSATS, its history, and changes in the survey and survey universe over time is provided in Appendix C.)

N-SSATS provides the mechanism for quantifying the dynamic character and composition of the U.S. substance abuse treatment delivery system. The objectives of N-SSATS are to collect multipurpose data that can be used to—

• assist SAMHSA and State and local governments in assessing the nature and extent of services provided in State-supported and other treatment facilities and in forecasting treatment resource requirements;
   

• update SAMHSA’s Inventory of Substance Abuse Treatment Services (I-SATS), which includes all known drug and alcohol abuse treatment facilities (see Appendix C);
   

• analyze treatment services trends and conduct comparative analyses for the nation, regions, and States;
   

• generate the National Directory of Drug and Alcohol Abuse Treatment Programs, a compendium of facilities approved by State substance abuse agencies for the provision of substance abuse treatment; and
   

• update the information in SAMHSA’s Substance Abuse Treatment Facility Locator, a searchable database of facilities approved by State substance abuse agencies for the provision of substance abuse treatment. The Treatment Facility Locator is available on the Internet at:

http://findtreatment.samhsa.gov

Data Collection Procedures for the 2003 N-SSATS

Field period and reference date

The field period for the 2003 N-SSATS ran from March 2003 through October 2003, with a reference date of March 31, 2003.

The 2003 N-SSATS facility universe included all 17,787 active facilities on SAMHSA’s I-SATS at a point 6 weeks prior to the survey reference date. Facilities added by State substance abuse agencies or discovered during the first 8 weeks of the survey were also included in the survey.

The 2003 N-SSATS survey instrument was a 10-page document with 37 numbered questions. (See Appendix A.) Topics included:

• Facility identification information
   

• Facility focus (substance abuse treatment services, mental health services, mix of mental health and substance abuse treatment services, general health care, other)
   

• Facility operation (private for-profit; private non-profit; government—local, county, or community; State; Federal; tribal)
   

• Hotline operation
   

• Services offered (assessment services, substance abuse therapy and counseling, pharmacotherapies, testing, transitional services, other services)
   

• Operation of an Opioid Treatment Program (OTP) certified by the Center for Substance Abuse Treatment (CSAT), SAMHSA
   

• Services in sign language for the hearing impaired
   

• Services in languages other than English
   

• Types of clients accepted into treatment (adolescents, clients with co-occurring mental and substance abuse disorders, criminal justice clients, persons with HIV or AIDS, gays or lesbians, seniors or older adults, pregnant or postpartum women, women, men, DUI/DWI offenders, other)
   

• Special programs or groups offered for specific types of clients (adolescents, clients with co-occurring mental and substance abuse disorders, criminal justice clients, persons with HIV or AIDS, gays or lesbians, seniors or older adults, pregnant or postpartum women, women, men, DUI/DWI offenders, other)
   

• Types of treatment provided

• Hospital inpatient (detoxification, treatment)

• Non-hospital residential (detoxification; short-term, i.e., 30 days or less; long-term, i.e., more than 30 days)

• Outpatient (detoxification, methadone or LAAM maintenance, day treatment or partial hospitalization, intensive, regular)
 

• Payment options
  
  

• Receipt of public funding for substance abuse treatment programs
  
  

• Managed care participation
  
  

• Number of clients in treatment on March 31, 2003 (total, clients under age 18, clients receiving methadone or LAAM)
  
  

• Number of beds designated for non-hospital residential and hospital inpatient substance abuse treatment
  
  

• Client substance abuse problem treated
  
  

• Facility licensure, certification, or accreditation
  
  

• Facility Internet access and web site availability

Data collection

Six weeks before the survey, letters were mailed to all facilities to alert them to expect the survey. An additional benefit of the letters was to update records with new address information returned from the post office. On the survey reference date, data collection packets, including the questionnaire, SAMHSA cover letter, State-specific letter of endorsement, information on completing the survey on the Internet, and a sheet of Frequently Asked Questions, were mailed to each facility. During the data collection phase, contract personnel were available to answer facilities’ questions concerning the survey. Support in responding to questions for those facilities completing the questionnaire over the Internet was also available. Four to 5 weeks after the initial questionnaire mailing, thank you/reminder letters were sent to all facilities. Approximately 8 weeks after the initial questionnaire mailing, non-responding facilities were sent a second questionnaire mailing. About 4 to 5 weeks after the second questionnaire mailing, non-respondents received a reminder telephone call. Those facilities that had not responded within 2 to 3 weeks of the reminder call were telephoned and asked to complete the survey by telephone. The overall response rate was 96 percent.

Forms accounting and response rate

Summary response rate information is presented in Table 1.1. Questionnaires were mailed to a total of 17,787 facilities believed to offer substance abuse treatment services. Of these facilities, 15 percent were found to be ineligible for the survey because they had closed or did not provide substance abuse treatment or detoxification on March 31, 2003. Of the remaining 15,124 facilities, 96 percent completed the survey.

Exclusions

Of the 14,503 survey respondents, 398 facilities provided information but were deemed out of the scope of this report and were excluded from the analyses presented here. The excluded facilities fell into three categories:

• 148 excluded facilities were halfway houses that did not provide substance abuse treatment. These facilities were included in the survey so that they could be listed in the Directory and on the Treatment Facility Locator, but were excluded from the analyses in this report.
   

• 130 excluded facilities were jails, prisons, or other organizations that treated incarcerated clients exclusively.
   

• 120 excluded facilities were solo practitioners. I-SATS and N-SSATS are designed to include facilities rather than individuals. Solo practitioners are listed and surveyed only if the State substance abuse agency explicitly requests that they be included. The excluded solo practitioners had not been identified for inclusion by the State substance abuse agency.

An additional 482 facilities whose client counts were included in or "rolled into" other facilities’ counts and whose facility characteristics were not reported separately were also excluded from facility counts in this report. However, their client counts are included.

After allowing for the exclusion of 398 out-of-scope facilities and 482 rolled-up facilities, there were 13,623 eligible respondent facilities included in the 2003 N-SSATS report.

Number of respondents reporting facility and client data

Table 1.2. There were a total of 13,623 eligible respondents to the 2003 N-SSATS. The breakdown of these respondents with respect to their reporting of facility data and client counts is summarized below.

• 11,939 facilities reported both facility data and client counts for their own organizations.
   

• 676 facilities reported facility characteristics for their own facility and provided client counts for their own facility and for other facilities. These 676 facilities reported client counts for a total of 1,421 facilities, including themselves.
   

• 1,008 facilities reported facility characteristics only. Their client counts were reported by another facility.

Quality assurance

All mail questionnaires were reviewed manually for consistency and for missing data. After data entry, automated quality assurance reviews were conducted. These incorporated the rules used in manual editing, plus consistency checks and checks for data outliers not readily implemented by manual review. Calls were made to facilities to clarify questionable responses and to obtain missing data.

If facilities could not be reached during the edit callbacks, responses that were clearly in error were replaced by imputation.

The Internet questionnaire was programmed to be self-editing, that is, respondents were prompted to complete missing responses and to confirm or correct inconsistent responses.

Item non-response

Careful editing and extensive follow-up have minimized item non-response. (See Appendix B.) Although there were instances of non-response in most data items, item non-response was generally low, only 1 to 3 percent for most items. An exception was the question on payment types accepted by the facility, where non-response rates ranged from 1 to 12 percent for the various response categories.

Missing data for client count variables (e.g., the number of clients in hospital inpatient, non-hospital residential, and outpatient treatment) were imputed. For the remaining unimputed variables, facilities with missing values for a given variable were excluded from the tabulations using that variable. As a result, the number of treatment facilities on which tables are based may vary somewhat from table to table. The number of facilities actually reporting data is generally included on each table.

Methodology of Imputation of Missing Client Counts

A total of 114 facilities were missing one-day census client count values for one or more types of service (i.e., hospital inpatient detoxification, hospital inpatient treatment, non-hospital residential detoxification, etc.). A facility was given imputed values for a type of service if it reported that it provided the service but had not provided client counts for that service type. For example, if a facility reported that it provided hospital inpatient services and outpatient services, but not non-hospital residential services, client values were imputed for the hospital inpatient and outpatient variables only. Missing values for the number of clients under age 18 and the number of hospital inpatient beds and/or non-hospital residential beds were not imputed.

When available, client values from the 2002 N-SSATS were used to impute the missing client counts on the 2003 N-SSATS. In all other cases, the average client value, stratified by State and facility operation, was used to impute the missing client counts. If a facility were unique in its State and facility operation category, values were imputed using average values for the State only. Client counts were imputed for each type of service (i.e., hospital inpatient detoxification, hospital inpatient treatment, non-hospital residential detoxification, etc.) and summed to the larger service type totals (total hospital inpatient clients, total non-hospital residential clients, and total outpatient clients), and finally to total clients.

Further Data Considerations and Limitations

As with any data collection effort, certain procedural considerations and data limitations must be taken into account when interpreting data from the 2003 N-SSATS. Some general issues are listed below, and other considerations are detailed in Appendix C. Considerations and limitations of specific data items are discussed where the data are presented.

• N-SSATS attempts to obtain responses from all known treatment facilities, but it is a voluntary survey. There is no adjustment for the approximately 4 percent facility non-response.
   

• N-SSATS is a point-prevalence survey. It provides information on the substance abuse treatment system and its clients on the reference date. Client counts reported here do not represent annual totals. Rather, N-SSATS provides a "snapshot" of substance abuse treatment facilities and clients on an average day.
   

• Multiple responses were allowed for certain variables (e.g., services provided and specialized programs). Tabulations of these variables include the total number of facilities reporting each response.

Organization of the Report

The balance of this report is organized into five analytic sections. Chapter 2 presents broad trends in facility characteristics for 1997 to 2003. Chapter 3 presents broad trends in client characteristics for 1997 to 2003. Chapter 4 describes key characteristics of facilities and the programs and services they provide. Chapter 5 describes key characteristics of clients in substance abuse treatment on March 31, 2003. Finally, Chapter 6 presents State-level detail for most of the tables presented in Chapters 4 and 5.

Terminology

The majority of tables in the report are organized according to facility operation and the primary focus of the facility, and present data on the characteristics of facilities and clients in treatment at these facilities. Therefore, it is important to define these terms.

Facility operation indicates the type of entity responsible for the operation of the facility: private for-profit; private non-profit; or government—local, county, or community; State; Federal; or tribal.

Primary focus indicates the services the facility primarily provides: substance abuse treatment services; mental health services; a mix of mental health and substance abuse treatment services; general health care; or other.

Clients in treatment were defined as: 1) hospital inpatient and non-hospital residential clients receiving substance abuse services at the facility on March 31, 2003; and 2) outpatient clients who were seen at the facility for a substance abuse treatment or detox service at least once during the month of March 2003, and who were still enrolled in treatment as of March 31, 2003.