National Survey of Substance Abuse
Treatment Services (N-SSATS): 2013

Data on Substance Abuse Treatment Facilities

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Table of Contents

Table of Contents

Acknowledgments

List of Tables

List of Figures

Highlights

Chapter 1. Description of the National Survey of Substance Abuse Treatment Services (N-SSATS)

Chapter 2. Trends in Facility Characteristics

Chapter 3. Trends in Client Characteristics

Chapter 4. Facility Characteristics and Services

Chapter 5. Client Characteristics

Chapter 6. State Data

Appendix A. N-SSATS Background

Appendix B. 2013 N-SSATS Questionnaire

Appendix C. Item Response and Imputation for N-SSATS 2013

List of Tables

Chapter 1

1.1 N-SSATS facilities, by status and mode of response: 2013

Chapter 2

2.1 Facility turnover: 2003-2013
Number and percent distribution

2.2 Facility operation: 2003-2013
Number and percent distribution

2.3 Facilities, by type of care offered, and facilities with Opioid Treatment Programs: 2003-2013
Number and percent

Chapter 3

3.1 Clients in treatment, by facility operation: 2003-2013
Number and percent distribution

3.2 Clients in treatment, by type of care received, and clients receiving methadone, buprenorphine, or Vivitrol^®: 2003-2013
Number and percent distribution

3.3 Clients in treatment, by substance abuse problem and diagnosed co-occurring mental and substance abuse disorders: 2003-2013
Number and percent distribution

3.4 Clients under age 18 in treatment, by type of care received, and clients under age 18 in treatment in facilities offering specifically tailored programs or groups for adolescents: 2003-2013
Number and percent distribution

Chapter 4

4.1 Type of care offered, by facility operation: 2013
Number and percent

4.2 Type of client substance abuse problem treated and treatment of clients with diagnosed co-occurring mental and substance abuse disorders, by facility operation: March 29, 2013
Number and percent

4.3 Facility size, according to type of care offered, by facility operation: March 29, 2013
Median number of clients

4.4 Facility size in terms of number of clients, by facility operation: March 29, 2013
Number and percent distribution

4.5 Facility outpatient operational capacity, by facility operation: March 29, 2013
Number and percent distribution

4.6 Facility capacity and utilization of residential (non-hospital) care, by facility operation: March 29, 2013
Number, utilization rate, and percent distribution

4.7 Facility capacity and utilization of hospital inpatient care, by facility operation: March 29, 2013
Number, utilization rate, and percent distribution

4.8 Services provided, by facility operation: 2013
Number and percent

4.9 Facilities using counseling as part of their substance abuse treatment program, by facility operation: 2013
Number

4.10 Clinical/therapeutic approaches, by frequency of use: 2013
Number and percent distribution

4.11 Facilities offering specifically tailored programs or groups, by facility operation and client type: 2013
Number and percent

4.12 Facilities offering services in sign language for the hearing impaired and in languages other than English, by facility operation: 2013
Number and percent

4.13 Facilities detoxifying clients, by substance and facility operation: 2013
Number and percent

4.14 Facilities with client outreach, by facility operation: 2013
Number and percent

4.15 Facility licensing, certification, or accreditation, by facility operation: 2013
Number and percent

4.16 Facility licensing, certification, or accreditation, by type of care offered: 2013
Number and percent

4.17 Facilities employing specific practices as part of their standard operating procedures, by facility operation: 2013
Number and percent

4.18 Types of client payments accepted by facility, by facility operation: 2013
Number and percent

4.19 Methods used to accomplish work at facility, by facility operation: 2013
Number and percent distribution

4.20 Facility funding, by facility operation: 2013
Number and percent

4.21 Facilities with Opioid Treatment Programs (OTPs) and clients receiving medication-assisted opioid therapy at OTPs and other facilities, by facility operation: March 29, 2013
Number and percent distribution

4.22 Type of care offered in facilities with Opioid Treatment Programs (OTPs), by facility operation: 2013
Number and percent

4.23 Facility licensing, certification, or accreditation of facilities with Opioid Treatment Programs (OTPs), by type of care offered: 2013
Number and percent

4.24 Facility smoking policy, by facility operation: 2013
Number and percent distribution

Chapter 5

5.1a Clients in treatment, according to type of care received, by facility operation: March 29, 2013
Number

5.1b Clients in treatment, according to type of care received, by facility operation: March 29, 2013
Row percent distribution

5.1c Clients in treatment, according to type of care received, by facility operation: March 29, 2013
Column percent distribution

5.2 Clients in treatment, according to substance abuse problem and diagnosed co-occurring mental and substance abuse disorders, by facility operation: March 29, 2013
Number and percent

5.3 Clients under age 18 in treatment, according to type of care received, by facility operation: March 29, 2013
Number and percent distribution

Chapter 6

6.1 N-SSATS facilities, by status, response rate, mode of response, and state or jurisdiction: 2013

6.2a Facilities and clients in treatment, by state or jurisdiction: 2003-2013
Number

6.2b Facilities and clients in treatment, by state or jurisdiction: 2003-2013
Percent distribution

6.3a Clients under age 18 in treatment, and clients under age 18 in facilities offering specifically tailored programs or groups for adolescents, by state or jurisdiction: 2003-2013
Number

6.3b Clients under age 18 in treatment, and clients under age 18 in facilities offering specifically tailored programs or groups for adolescents, by state or jurisdiction: 2003-2013
Percent

6.4a Facility operation, by state or jurisdiction: 2013
Number

6.4b Facility operation, by state or jurisdiction: 2013
Percent distribution

6.5a Type of care offered, by state or jurisdiction: 2013
Number

6.5b Type of care offered, by state or jurisdiction: 2013
Percent

6.6 Client substance abuse problem and diagnosed co-occurring mental and substance abuse disorders, by state or jurisdiction: March 29, 2013
Number and percent

6.7 Facility size, according to type of care offered, by state or jurisdiction: March 29, 2013
Median number of clients

6.8 Facility size in terms of number of clients, by state or jurisdiction: March 29, 2013
Number and percent distribution

6.9 Facility capacity and utilization of residential (non-hospital) and hospital inpatient care, by state or jurisdiction: March 29, 2013
Number and utilization rate

6.10 Type of counseling used, by state or jurisdiction: 2013
Number and percent

6.11a Clinical/therapeutic approaches used always or often or sometimes, by state or jurisdiction: 2013
Number

6.11b Clinical/therapeutic approaches used always or often or sometimes, by state or jurisdiction: 2013
Percent

6.12a Facilities offering specifically tailored programs or groups for specific client types, by state or jurisdiction: 2013
Number and percent

6.12b Facilities offering specifically tailored programs or groups for specific client types, by state or jurisdiction: 2013
Number and percent

6.12c Facilities offering specifically tailored programs or groups for specific client types, by state or jurisdiction: 2013
Number and percent

6.13a Facilities offering services in sign language for the hearing impaired and in languages other than English, by state or jurisdiction: 2013
Number

6.13b Facilities offering services in sign language for the hearing impaired and in languages other than English, by state or jurisdiction: 2013
Percent

6.14 Facilities detoxifying clients, by substance and state or jurisdiction: 2013
Number and percent

6.15 Facilities with client outreach, by state or jurisdiction: 2013
Number and percent

6.16a Facility licensing, certification, or accreditation, by state or jurisdiction: 2013
Number

6.16b Facility licensing, certification, or accreditation, by state or jurisdiction: 2013
Percent

6.17a Facilities employing specific practices as part of their standard operating procedures, by state or jurisdiction: 2013
Number

6.17b Facilities employing specific practices as part of their standard operating procedures, by state or jurisdiction: 2013
Percent

6.18a Types of client payments accepted by facility, by state or jurisdiction: 2013
Number

6.18b Types of client payments accepted by facility, by state or jurisdiction: 2013
Percent

6.19 Facility funding, by state or jurisdiction: 2013
Number and percent

6.20 Facilities with Opioid Treatment Programs (OTPs) and clients receiving medication-assisted opioid therapy at OTPs and other facilities, by state or jurisdiction: March 29, 2013
Number and percent distribution

6.21a Type of care offered in facilities with Opioid Treatment Programs (OTPs), by state or jurisdiction: 2013
Number

6.21b Type of care offered in facilities with Opioid Treatment Programs (OTPs), by state or jurisdiction: 2013
Percent

6.22a Facility licensing, certification, or accreditation of facilities with Opioid Treatment Programs (OTPs), by state or jurisdiction: 2013
Number

6.22b Facility licensing, certification, or accreditation of facilities with Opioid Treatment Programs (OTPs), by state or jurisdiction: 2013
Percent

6.23 Facility smoking policy, by state or jurisdiction: 2013
Number and percent distribution

6.24a Clients in treatment, according to facility operation, by state or jurisdiction: March 29, 2013
Number

6.24b Clients in treatment, according to facility operation, by state or jurisdiction: March 29, 2013
Percent distribution

6.25a Clients in treatment, according to type of care received, by state or jurisdiction: March 29, 2013
Number

6.25b Clients in treatment, according to type of care received, by state or jurisdiction: March 29, 2013
Percent distribution

6.26 Clients in treatment, according to substance abuse problem and diagnosed co-occurring mental and substance abuse disorders, by state or jurisdiction: March 29, 2013
Number and percent distribution

6.27 Clients in treatment, according to counseling type, by state or jurisdiction: March 29, 2013
Number and percent

6.28a Clients under age 18 in treatment, according to facility operation, by state or jurisdiction: March 29, 2013
Number

6.28b Clients under age 18 in treatment, according to facility operation, by state or jurisdiction: March 29, 2013
Percent distribution

6.29 Clients under age 18 in treatment, according to type of care received, by state or jurisdiction: March 29, 2013
Number and percent distribution

6.30 Clients in treatment aged 18 and over, according to substance abuse problem, by state or jurisdiction: March 29, 2013
Number and clients per 100,000 population aged 18 and over

6.31 Clients in treatment, according to opioid treatment, by state or jurisdiction: March 29, 2013
Number and clients per 100,000 population

Appendix A

A.1 Survey contents: 1996-2013

Appendix C

C.1 N-SSATS item percentage response rates: 2013

List of Figures

Chapter 1

Figure 1 Survey Response Mode: 2003-2013

Chapter 2

Figure 2 Facility Operation: 2003-2013

Figure 3 Type of Care Offered and Facilities with Opioid Treatment Programs: 2003-2013

Chapter 3

Figure 4 Clients in Treatment, by Facility Operation: 2003-2013

Figure 5 Clients in Treatment, by Type of Care Received: 2003-2013

Chapter 4

Figure 6 Residential (Non-hospital) and Hospital Inpatient Utilization Rates: March 29, 2013

Chapter 6

Figure 7 Clients in Treatment per 100,000 Population Aged 18 and Over: March 29, 2013

Highlights

This report presents results from the 2013 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual census of facilities providing substance abuse treatment. Conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), N-SSATS is designed to collect data on the location, characteristics, and use of alcohol and drug abuse treatment facilities and services throughout the 50 states, the District of Columbia, and other U.S. jurisdictions.¹ It is important to note that values in charts, narrative lists, and percentage distributions are calculated using actual raw numbers and rounded for presentation in this report; calculations using rounded values may produce different results.

• The N-SSATS facility response rate in 2013 was 94 percent. Thirty-four states or jurisdictions had response rates that equaled or surpassed the overall rate [Tables 1.1 and 6.1].
  
• A total of 14,630 facilities completed the survey. The 14,148 facilities eligible for this report had a one-day census of 1,249,629 clients enrolled in substance abuse treatment on March 29, 2013 [Tables 1.1 and 3.1].
  
• In the United States, there were 481 clients in treatment per 100,000 population aged 18 and older on March 29, 2013. The rate was highest for persons with both alcohol and drug problems (203 per 100,000 population aged 18 and older), followed by drug problems only (194 per 100,000), and alcohol problems only (84 per 100,000) [Table 6.30].
  

Trends in Facility and Client Characteristics 2003-2013

• Both the total numbers of substance abuse treatment facilities and clients in treatment increased slightly between 2003 and 2013. The number of eligible facilities responding to the 2013 survey increased by 4 percent, from 13,623 facilities in 2003 to 14,148 facilities in 2013 [Table 2.1]. The number of clients in treatment on the survey reference date increased by 14 percent, from 1,092,546 in 2003 to 1,249,629 in 2013 [Table 3.1].
  
• The operational structure of the substance abuse treatment system (i.e., the type of entity responsible for operating the facility: private non-profit, private for-profit, or government—local, state, federal,² or tribal) changed little between 2003 and 2013 [Table 2.2 and Figure 2].
  
• The major types of care—outpatient, residential (non-hospital), and hospital inpatient—changed little from 2003 to 2013 in terms of the proportion of facilities offering each type of care or the proportion of clients in treatment in each type of care [Tables 2.3 and 3.2 and Figures 3 and 5].
• Opioid Treatment Programs certified by SAMHSA for the provision of medication-assisted therapy with methadone and/or buprenorphine were provided by 8 to 9 percent of all facilities between 2003 and 2013 [Table 2.3 and Figure 3].
  
• The proportion of all clients receiving methadone ranged from 21 percent to 27 percent in the period 2003 to 2013 [Table 3.2].
  
• The proportion of all clients receiving buprenorphine ranged from less than 1 percent to 4 percent in the period 2003 to 2013 [Table 3.2].
  
• The proportion of clients in treatment for the three broad categories of substance abuse problems—both alcohol and drug abuse, drug abuse only, and alcohol abuse only—experienced only minor variation between 2003 and 2013. Clients in treatment for both drug and alcohol abuse made up 43 to 47 percent of all clients. Clients in treatment for drug abuse only made up 33 to 39 percent, and clients in treatment for alcohol abuse made up 17 to 20 percent of all clients [Table 3.3].
  
• Clients under age 18 made up 6 to 8 percent of all clients in treatment between 2003 and 2013. The proportion of clients under age 18 in treatment in each type of care (outpatient, residential [non-hospital], or hospital inpatient) differed little from the proportion of adults, and was stable between 2003 and 2013 [Tables 3.1 and 3.4].
  

Facility Operation—March 29, 2013

• Private non-profit organizations operated 55 percent of all facilities and were treating 51 percent of all clients.
• Private for-profit organizations operated 32 percent of all facilities and were treating 34 percent of all clients.
• Local governments operated 5 percent of all facilities and were treating 6 percent of all clients.
• State governments operated 2 percent of all facilities and were treating 2 percent of all clients.
• The federal government operated 4 percent of all facilities and was treating 4 percent of all clients.
• Tribal governments operated 1 percent of all facilities and were treating 1 percent of all clients [Tables 4.1 and 5.1c].

Primary Focus of Activity—March 29, 2013

• Private non-profit organizations operated 55 percent of all facilities and were treating 51 percent of all clients.
  
• Private for-profit organizations operated 32 percent of all facilities and were treating 34 percent of all clients.
  
• Local governments operated 5 percent of all facilities and were treating 6 percent of all clients.
  
• State governments operated 2 percent of all facilities and were treating 3 percent of all clients.
  
• The federal government operated 3 percent of all facilities and was treating 4 percent of all clients.
  
• Tribal governments operated 2 percent of all facilities and were treating 1 percent of all clients [Tables 4.1 and 5.1c].
  

Type of Care—March 29, 2013³

• Outpatient treatment was offered by 82 percent of all facilities and was received by 90 percent of all clients in treatment.
  
• Residential (non-hospital) treatment was offered by 24 percent of all facilities and was received by 9 percent of all clients in treatment.
  
• Hospital inpatient treatment was offered by 5 percent of all facilities and was received by 1 percent of all clients in treatment [Tables 4.1 and 5.1b].

Client Substance Abuse Problem and Diagnosed Co-occurring Mental and Substance Abuse Disorders—March 29, 2013

• Clients in treatment for both alcohol and drug abuse made up 43 percent of all clients.
  
• Clients in treatment for drug abuse only made up 40 percent of all clients.
  
• Clients in treatment for abuse of alcohol only made up 17 percent of all clients.
  
• Forty-eight percent of clients in treatment had a diagnosed co-occurring mental and substance abuse disorder [Table 5.2].
  

Facility Size and Utilization Rates—March 29, 2013

• The median number of clients at substance abuse treatment facilities was 40 clients. Outpatient facilities had a median of 46 clients, while residential (non-hospital) facilities had a median of 18 clients and hospital inpatient facilities had a median of 10 clients [Table 4.3].
  
• Ninety-seven percent each of all residential (non-hospital) beds and all hospital inpatient beds designated for substance abuse treatment were in use [Tables 4.6 and 4.7].
  

Medication-Assisted Opioid Therapy—March 29, 2013

• Clients receiving methadone, buprenorphine, or Vivitrol^® in Opioid Treatment Programs (OTPs) accounted for 27 percent of all clients in treatment, although OTPs were available in only 1,282 (9 percent) of all substance abuse treatment facilities [Tables 2.3, 3.1, and 4.21].
  
• Private for-profit organizations operated 55 percent of OTPs compared with 32 percent of all substance abuse treatment facilities [Tables 4.1 and 4.21].
  
• Of the 343,180 clients receiving medication-assisted opioid therapy in OTPs, 96 percent (330,308) received methadone [Table 4.21].
  
• Of the 48,148 clients receiving buprenorphine, 74 percent received it in facilities that were not OTPs [Table 4.21].
  
• Of the 3,781 clients receiving Vivitrol^®, 91 percent received it in facilities that were not OTPs [Table 4.21].
  
• More than half (57 percent) of clients receiving methadone were in private for-profit facilities compared with 48 percent of clients receiving buprenorphine. Clients receiving buprenorphine were more likely than those receiving methadone to be in private non-profit facilities (37 percent vs. 34 percent) [Table 4.21].

Table of Contents

Chapter 1

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

Data Collection Procedures for the 2013 N-SSATS
Facility Selection for the 2013 N-SSATS Report
Survey Response Mode
Data Considerations and Limitations
Organization of the Report
Terminology

The 2013 National Survey of Substance Abuse Treatment Services (N-SSATS) was conducted between March and November 2013, with a reference date of March 29, 2013. It is the 36th in a series of national surveys begun in the 1970s. The surveys were designed to collect data on the location, characteristics, and use of alcohol and drug abuse treatment facilities and services throughout the 50 states, the District of Columbia, and other U.S. jurisdictions.⁴ The Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, plans and directs N-SSATS. This report presents tabular information and highlights from the 2013 N-SSATS. It is important to note that percentages in charts, narrative lists, and percentage distributions in tables may not add to 100 percent due to rounding.

N-SSATS is designed to collect information from all facilities⁵ 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 A.)

N-SSATS provides the mechanism for quantifying the dynamic character and composition of the U.S. substance abuse treatment delivery system. N-SSATS collects 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 substance abuse treatment facilities and in forecasting substance abuse treatment resource requirements;
• Update SAMHSA’s Inventory of Behavioral Health Services (I-BHS), formerly called the Inventory of Substance Abuse Treatment Services (I-SATS), and which includes all known drug and alcohol abuse treatment facilities (see Appendix A);
• Analyze substance abuse 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 Behavioral Health Treatment Services Locator, which includes 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 2013 N-SSATS

Field period and reference date

The survey reference date for the 2013 N-SSATS was March 29, 2013. The field period was from March 29, 2013, through November 18, 2013.

Survey universe

The 2013 N-SSATS facility universe totaled 18,048 facilities, including all 17,777 active treatment facilities on SAMHSA’s I-BHS at a point 6 weeks before the survey reference date and 271 facilities that were added by state substance abuse agencies or otherwise discovered during the first 3 months of the survey.

Content

The 2013 N-SSATS questionnaire was a 16-page document with 41 numbered questions (see Appendix B). Topics included:

• Facility identification information
  
• Operating entity
  
• Type of care provided
  
  • Outpatient treatment services (regular outpatient treatment, intensive outpatient treatment, day treatment or partial hospitalization, detoxification, methadone/buprenorphine maintenance or Vivitrol^® treatment)
    
  • Residential (non-hospital) treatment services (long-term—more than 30 days, short-term—30 days or fewer, detoxification)
    
  • Hospital treatment services (inpatient treatment, inpatient detoxification)
• Services offered (assessment and pre-treatment services, counseling, pharmacotherapies, testing, transitional services, ancillary services)
  
• Clinical/therapeutic approaches
  
• Specifically tailored programs or groups provided for specific client types
  
• Provision of services in sign language and/or in languages other than English
  
• Detoxification from alcohol, benzodiazepines, opioids, cocaine, methamphetamines, or other drugs, and routine use of medication during detoxification
  
• Client outreach (outreach to persons in the community who may need treatment, provision of a facility website)
  
• Licensure, certification, or accreditation agencies or organizations
  
• Standard operating procedures
  
• Payment options accepted, including use of a sliding fee scale and/or treatment at no charge
• Work activity methods
  
• Receipt of government funding
  
• Smoking policy
  
• Operation of an Opioid Treatment Program (OTP) certified by SAMHSA and offering maintenance and/or detoxification with opioid drugs such as methadone
  
• Number of clients in treatment on March 29, 2013 (total, clients under age 18, clients receiving methadone, clients receiving buprenorphine, clients receiving Vivitrol^®)
  
• Percentage of clients in treatment on March 29, 2013, for abuse of both alcohol and drugs, alcohol abuse only, and drug abuse only
  
• Percentage of clients in treatment on March 29, 2013, with diagnosed co-occurring mental and substance abuse disorders
  
• Number of beds designated for residential (non-hospital) and hospital inpatient substance abuse treatment on March 29, 2013
  

Data collection

Three data collection modes were employed: a secure web-based questionnaire, a paper questionnaire sent by mail, and a telephone interview. Five weeks before the survey reference date of March 29, 2013, letters were mailed to all facilities to announce the survey. The letters also served to update records with new address information received from the U.S. Postal Service. During the last week of March 2013, a data collection packet (including the SAMHSA cover letter, state-specific letter of endorsement, state profile, information on completing the survey on the web, and a sheet of Frequently Asked Questions) was mailed to each facility. Initially, respondents could also request a paper questionnaire be sent to them. During the data collection phase, contract personnel were available to answer facilities’ questions concerning the survey. Web-based support for facilities completing the questionnaire on the web was also available. Three weeks after the initial data collection packet mailing, thank you/reminder letters were sent to all facilities. Approximately 8 weeks after the initial packet mailing, non-responding facilities that had completed a hard-copy questionnaire in either of the past two years (2012 or 2011) were mailed a second packet that included a hard-copy questionnaire along with the rest of first packet mailing materials. Eleven weeks after the second packet mailing, all the facilities that had not responded to previous mailings were mailed a hard-copy questionnaire along with the first and second packet mailing materials. About 2 weeks after the questionnaire mailing, nonrespondents received a reminder telephone call. Those facilities that had not responded within 3 to 4 weeks of the reminder call were telephoned and asked to complete the survey by computer-assisted telephone interview (CATI).

Facility status and response rate

Table 1.1 presents a summary of response rate information. There were 18,048 facilities in the survey universe. Of these facilities, 14 percent were found to be ineligible for the survey because they had closed or did not provide substance abuse treatment or detoxification. Of the remaining 15,496 facilities, 14,630 facilities (94 percent) completed the survey and 14,148 (91 percent of the respondents) were eligible for this report.

Quality assurance

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

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

Item non-response was minimized through careful editing and extensive follow-up. The item response rate for the 2013 N-SSATS averaged 97 percent across 242 separate items. Appendix C details item response rates and imputation procedures.

Facility Selection for the 2013 N-SSATS Report

Table 1.1. The N-SSATS questionnaire is deliberately sent to some facilities that are excluded from this report, as explained below. For this cycle, 313 of the 14,630 questionnaire respondents provided information but were deemed out of the scope of this report and excluded from the analyses presented here. The excluded facilities and reasons for exclusion fell into three categories:

• 208 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 the Locator.
• 74 facilities were solo practitioners. I-BHS and N-SSATS are designed to include facilities rather than individuals. Solo practitioners are listed and surveyed only if a state substance abuse agency explicitly requests that they be included in the survey. The excluded solo practitioners had not been identified for inclusion by a state substance abuse agency.
• 31 facilities were jails, prisons, or other organizations that treated incarcerated clients exclusively.

An additional 169 facilities whose client counts were included in or “rolled into” other facilities’ counts and whose facility characteristics were not reported separately were excluded from facility counts in this report. However, their client counts are included.

After the exclusion of 313 out-of-scope facilities and 169 rolled-up facilities, 14,148 eligible respondent facilities remained to be included in the 2013 N-SSATS report.

Number of respondents reporting facility and client data

There were 14,148 eligible respondents to the 2013 N-SSATS. The breakdown of facility data and client counts reported by these respondents is summarized below.

• 13,006 facilities reported facility data and client counts for themselves only.
  
• 401 facilities reported facility characteristics for themselves and provided client counts for their own facility and for 910 other facilities.⁶
  
• 741 facilities reported facility characteristics only. Their client counts were reported by another facility.
  

Survey Response Mode

Figure 1. The proportion of facilities using the web survey to respond to N-SSATS has increased steadily since introduction of the option in 2002. The percentage of facilities responding via the web increased from 27 percent in 2003 to 87 percent in 2013. Mail response declined from 49 percent in 2003 to 2 percent in 2013. Telephone response, which represents follow-up of facilities that had not responded by mail or web, also declined, from 23 percent in 2003 to 10 percent in 2013.

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 2013 N-SSATS. Some general issues are listed below; other considerations are detailed in Appendix A. 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 was no adjustment for the 7 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 specifically tailored 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 the following chapters.

• Chapter 2 presents trends in facility characteristics for 2003 to 2013.
  
• Chapter 3 presents trends in client characteristics for 2003 to 2013.
  
• Chapter 4 describes key characteristics of facilities and the programs and services they provided in 2013.
  
• Chapter 5 describes key characteristics of clients in substance abuse treatment on March 29, 2013.
  
• Chapter 6 presents state-level detail for most of the tables presented in Chapters 4 and 5.
  
• Appendix A provides additional information on N-SSATS, its history, and changes in the survey and survey universe over time.
  
• Appendix B contains the 2013 N-SSATS mail survey questionnaire.
  
• Appendix C contains information on item response and imputation.
  

Terminology

The majority of tables in the report are organized by facility operation and by the type(s) of care offered by the facility. 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
  • Government­
    • Local, county, or community
    • State
    • Federal (Dept. of Veterans Affairs, Dept. of Defense, Indian Health Service, other)
    • Tribal
• Type of care indicates the services the facility offers:
  
  • Outpatient
    
    • Regular
      
    • Intensive
      
    • Outpatient day treatment or partial hospitalization
      
    • Outpatient detoxification
      
    • Outpatient methadone/buprenorphine maintenance or Vivitrol^® treatment
      
  • Residential (non-hospital)
    
    • Short-term (30 days or less)
      
    • Long-term (more than 30 days)
      
    • Detoxification
      
  • Hospital inpatient
    
    • Inpatient detoxification
      
    • Inpatient treatment
      
• Clients in treatment were defined as:
  
  • Hospital inpatient and residential (non-hospital) clients receiving substance abuse treatment services at the facility on March 29, 2013
    and
    
  • Outpatient clients who were seen at the facility for a substance abuse treatment or detoxification service at least once during the month of March 2013, and who were still enrolled in treatment on March 29, 2013

To Chapter 1 Table

Table of Contents

Chapter 2

Trends in Facility Characteristics

Number of Facilities
Facility Operation
Type of Care Offered
Facilities with Opioid Treatment Programs

This chapter presents trends in facility characteristics for 2003 to 2013.

Number of Facilities

Table 2.1. The total number of substance abuse treatment facilities increased slightly between 2003 and 2013. There was considerable turnover from year to year in the individual facilities responding to the survey: every year, although between 86 and 90 percent of the facilities responding to a given survey had also responded to the previous year’s survey, some 10 to 15 percent of the facilities had closed, no longer provided substance abuse treatment, or didn’t respond to the previous year’s survey but were replaced by fairly similar numbers of new facilities.

There was a net decrease of 163 facilities between 2012 and 2013, to 14,148 facilities. Of the facilities responding to the 2013 survey, 90 percent had also responded to the 2012 survey and 10 percent were new to the 2013 survey. Eleven percent of the facilities that responded in 2012 had closed, no longer provided substance abuse treatment, or did not respond to the survey in 2013.

Despite the year-to-year changes in the facilities reporting, several core structural characteristics of the substance abuse treatment system remained stable from 2003 to 2013.

Facility Operation

Table 2.2 and Figure 2. The operational structure of the substance abuse treatment system (i.e., the type of entity responsible for operating the facility) changed slightly between 2003 and 2013.

• Private non-profit organizations operated 61 percent of all facilities in 2003 compared with 55 percent in 2013.
  
• Private for-profit organizations operated 25 percent of facilities in 2003, increasing slightly but steadily to 32 percent of facilities in 2013.
  
• Local, county, or community governments operated 7 percent of facilities in 2003, decreasing slightly but steadily to 5 percent in 2013.
  
• State governments operated about 3 percent of facilities each year.
  
• The federal government operated 2 to 3 percent of facilities each year.⁷
  
• Tribal governments operated 1 to 2 percent of facilities each year.
  

Type of Care Offered

Table 2.3 and Figure 3. The proportions of facilities offering the major types of care—outpatient, residential (non-hospital), and hospital inpatient—changed little between 2003 and 2013.

• Outpatient treatment was provided by 80 to 82 percent of facilities.
  
• Residential (non-hospital) treatment was provided by 24 to 28 percent of facilities.
  
• Hospital inpatient treatment was provided by 5 to 7 percent of facilities.

Facilities with Opioid Treatment Programs

Table 2.3 and Figure 3. Opioid Treatment Programs (OTPs), certified by SAMHSA, provide medication-assisted therapy with methadone, buprenorphine, and Vivitrol^®, the only three opioid medications approved for the treatment of opioid addiction. Facilities with OTPs can be associated with any type of care. They were provided by 8 to 9 percent of all facilities between 2003 and 2013.

• Outpatient treatment was provided by 90 to 93 percent of OTP facilities.
  
• Residential (non-hospital) treatment was provided by 8 to 10 percent of OTP facilities.
  
• Hospital inpatient treatment was provided by 8 to 12 percent of OTP facilities.
  
  

To Chapter 2 Tables

Table of Contents

Chapter 3

Trends in Client Characteristics

Facility Operation
Type of Care Received
Clients Receiving Methadone, Buprenorphine, or Vivitrol^®
Substance Abuse Problem Treated
Clients under Age 18 in Treatment

This chapter presents trends in client characteristics for 2003 to 2013.

Table 3.1. The number of clients in treatment on the survey reference date increased by 14 percent from 2003 to 2013, from 1,092,546 in 2003 to 1,249,629 in 2013.

Facility Operation

Table 3.1 and Figure 4. In almost all categories of facility operation, the proportions of clients in treatment changed little between 2003 and 2013.

• Private non-profit facilities treated 56 percent of clients in 2003, decreasing steadily to 51 percent in 2013. (The number of clients in private non-profit facilities increased by 4 percent, from 615,410 in 2003 to 638,858 in 2013.)
  
• Private for-profit facilities treated 26 percent of clients in 2003, increasing to 34 percent in 2013. (The number of clients in private for-profit facilities increased by 53 percent, from 282,161 in 2003 to 430,362 in 2013.)
• Local government-operated facilities treated 9 percent of clients in 2003, decreasing to 6 percent in 2013. (The number of clients in local government-operated facilities decreased by 28 percent, from 101,826 in 2003 to 72,949 in 2013.)
  
• State government-operated facilities treated 4 percent of clients in 2003 and 3 percent in 2013. (The number of clients in state government-operated facilities decreased by 22 percent, from 45,649 in 2003 to 35,812 in 2013.)
  
• Federal government-operated facilities treated 3 percent of clients in 2003 and 4 percent in 2013. (The number of clients in federal government-operated facilities increased by 45 percent, from 37,155 in 2003 to 53,695 in 2013.)⁸
  
• Tribal government-operated facilities treated 1 percent of clients in 2003, increasing to 2 percent of clients in 2011 and then decreasing to 1 percent in 2013. (The number of clients in tribal government-operated facilities increased by 74 percent, from 10,345 in 2003 to 17,953 in 2013.)
  

Type of Care Received

Table 3.2 and Figure 5. The proportions of clients in treatment for the major types of care—outpatient, residential (non-hospital), and hospital inpatient—were stable between 2003 and 2013.

• Clients in outpatient treatment increased from 89 percent (968,719 clients) of all clients in 2003 to 90 percent (1,127,235 clients) of all clients in 2013.
  
• Clients in residential (non-hospital) treatment decreased from 10 percent (108,592 clients) of all clients in 2003 to 9 percent (107,727 clients) of all clients in 2013.
  
• Clients in hospital inpatient treatment made up 1 percent of all clients in each year.

Clients Receiving Methadone, Buprenorphine, or Vivitrol^®

Table 3.2 and Figure 5. Clients receiving methadone, buprenorphine, or Vivitrol^® could be in any type of care—outpatient, residential (non-hospital), or hospital inpatient. Clients could receive methadone only in SAMHSA-certified Opioid Treatment Programs (OTPs). However, clients could receive buprenorphine or Vivitrol^® in any type of facility.⁹

• The proportion of all clients receiving methadone in OTP facilities was 21 to 26 percent (a range of 227,003 to 330,308 clients) between 2003 and 2013.
  
• The proportion of clients receiving buprenorphine was less than 1 percent (5,099 clients) in 2005¹⁰ but increased to 2 percent (24,173 clients) in 2009, to 3 percent (32,676 clients) in 2011, and to 4 percent (48,148 clients) in 2013.
  
• The proportion of clients receiving Vivitrol^® was less than 1 percent (3,781 clients) in 2013 (the question about Vivitrol^® clients was introduced in the 2013 survey).

Substance Abuse Problem Treated

Table 3.3. The proportion of clients in treatment for the three broad categories of substance abuse problems—both alcohol and drug abuse, drug abuse only, and alcohol abuse only—changed little between 2003 and 2013. Clients in treatment for both drug and alcohol abuse made up 43 to 47 percent of all clients from 2003 to 2013. Clients in treatment for drug abuse only ranged from 33 to 39 percent of all clients from 2003 through 2013. The proportion of clients treated for alcohol abuse only ranged from 17 to 20 percent between 2003 and 2013. Clients in treatment for diagnosed co-occurring mental and substance abuse disorders made up 37 to 45 percent of all clients from 2007 through 2013. (The co-occurring mental and substance abuse disorders question was introduced in the survey in 2007.)

Clients under Age 18 in Treatment

Tables 3.1 and 3.4. The proportion of clients under age 18 decreased from 8 percent (92,251 clients) of all clients in 2003 to 6 percent (78,156 clients) of all clients in 2013.

• The proportion of types of care received by clients under age 18 were stable between 2003 and 2013.
  
  • 87 to 89 percent of all clients under age 18 were in outpatient treatment.
    
  • 10 to 12 percent of all clients under age 18 were in residential (non-hospital) treatment.
    
  • 1 percent of all clients under age 18 were in hospital inpatient treatment.
    
• The proportion of clients under age 18 in treatment facilities with specifically tailored programs or groups for adolescents ranged from 80 to 85 percent between 2003 and 2013.

To Chapter 3 Tables

Table of Contents

Chapter 4

Facility Characteristics and Services

Facility Operation
Type of Care Offered
Client Substance Abuse Problem and Diagnosed Co-occurring Mental Disorders
Facility Size
Facility Capacity and Utilization Rates
Services Provided
Counseling Services Offered by Facilities
Clinical/Therapeutic Approaches
Specifically Tailored Programs or Groups
Services in Sign Language for the Hearing Impaired and in Languages Other than English
Detoxification Services
Client Outreach
Facility Licensing, Certification, or Accreditation
Facility Standard Operating Procedures
Payment Options
Work Activity Methods
Facility Funding
Facilities with Opioid Treatment Programs
Facility Smoking Policy

This chapter outlines key characteristics of facilities and programs in 2013.

Facility Operation

Table 4.1. Facilities were asked to designate the type of entity responsible for the operation of the facility.

Type of Care Offered

Table 4.1. Type of care offered was made up of three broad categories (outpatient, residential [non-hospital], and hospital inpatient), each with several subcategories. A facility could offer more than one type of care. The proportions of all facilities offering the different types of care were:¹²

Almost three quarters (74 percent) of private non-profit facilities provided outpatient care and one third (33 percent) provided residential (non-hospital) care. In contrast, 92 percent of private for-profit facilities provided outpatient care and 11 percent provided residential (non-hospital) care.

Client Substance Abuse Problem and Diagnosed Co-occurring Mental Disorders

Table 4.2. Facilities were asked to estimate the proportions of clients in treatment for both alcohol and drug abuse, for alcohol abuse only, and for drug abuse only. They were also asked to estimate the proportion of clients with diagnosed co-occurring mental and substance abuse disorders.

• Almost all facilities (94 percent) had clients in treatment for both alcohol and drug abuse on March 29, 2013. Eighty-five percent had clients in treatment for drug abuse only, and 81 percent had clients in treatment for alcohol abuse only.
  
• Most facilities (90 percent) also had clients in treatment with diagnosed co-occurring mental and substance abuse disorders on March 29, 2013.
  

Facility Size

Table 4.3. Facility size is defined by the number of clients in substance abuse treatment. The median number of clients in substance abuse treatment at a facility on March 29, 2013, was 40 clients.

Table 4.4. Facilities were sorted into five size groups based on the total number of clients in treatment on March 29, 2013. These five groups were treating fewer that 15 clients, 15-29 clients, 30-59 clients, 60-119 clients, and 120 or more clients, respectively.

• Facilities operated by the federal government were generally larger than facilities operated by other entities—32 percent had 120 clients or more in treatment on March 29, 2013, compared with 21 percent of all facilities.
  

Facility Capacity and Utilization Rates

Facilities were asked to report the number of residential (non-hospital) and hospital inpatient beds designated for substance abuse treatment. Utilization rates were calculated by dividing the number of residential (non-hospital) or hospital inpatient clients by the number of residential (non-hospital) or hospital inpatient designated beds. Because substance abuse treatment clients may also occupy non-designated beds, utilization rates could be more than 100 percent.

• Table 4.5. Some 2,517 facilities (24 percent) reported outpatient operational capacity under 80 percent, 3,798 facilities (36 percent) reported outpatient operational capacity between 80 and 94 percent, 3,616 facilities (34 percent) reported outpatient operational capacity between 95 and 105 percent, and 656 facilities (6 percent) reported operational capacity above 105 percent.
  
• Table 4.6. Some 3,272 facilities reported having 103,776 residential (non-hospital) beds designated for substance abuse treatment on March 29, 2013. The overall utilization rate¹⁴ was 97 percent, and ranged from 86 percent in facilities operated by local governments to 128 percent in facilities operated by tribal governments.
  
• Table 4.7. Some 728 facilities reported having 12,282 hospital inpatient beds designated for substance abuse treatment on March 29, 2013. The overall utilization rate¹⁵ was 97 percent, and ranged from 82 percent in facilities operated by private non-profit organizations to 431 percent in facilities operated by tribal governments.
  
• Tables 4.6 and 4.7 and Figure 6 show the distribution of facility-level utilization rates for residential (non-hospital) beds and for hospital inpatient beds. Facilities with residential (non-hospital) beds had generally higher utilization rates than facilities with hospital inpatient beds. Forty-eight percent of facilities with residential (non-hospital) beds had utilization rates of 91 to 100 percent while 9 percent had utilization rates above 100 percent. Twenty-seven percent of facilities with hospital inpatient beds had utilization rates of 91 to 100 percent and 18 percent had utilization rates above 100 percent.
  

Services Provided

Table 4.8. Facilities were asked about the types of services they provided. Services were grouped into the five broad categories shown below.

• Assessment and pre-treatment services were offered by 99 percent of all facilities.
  • Screening for substance abuse was provided by 95 percent of all facilities.
    
  • Comprehensive substance abuse assessment or diagnosis was provided by 92 percent of all facilities.
  • Screening for mental disorders was provided by 71 percent of all facilities.
    
  • Screening for tobacco use was provided by 60 percent of all facilities.
    
  • Outreach to persons in the community who may need treatment was provided by 60 percent of all facilities, but by 84 percent of tribal government-operated facilities.
    
  • Comprehensive mental health assessment or diagnosis was provided by 49 percent of all facilities.
    
  • Interim services for clients when immediate admission was not possible were provided by 47 percent of all facilities, but by 76 percent of federal government facilities.
• Testing services were provided by 89 percent of all facilities.
  • Drug or alcohol urine screening was provided by 85 percent of all facilities.
    
  • Breathalyzer or other blood alcohol testing was provided by 63 percent of all facilities, but by 81 percent of federal government-operated facilities.
    
  • Testing for TB, HIV, hepatitis B and C, and STDs was provided by between 21 and 37 percent of all facilities, but by 68 to 72 percent of facilities operated by federal government.
• Transitional services were provided by 99 percent of all facilities.
  • Discharge planning was provided by 96 percent of all facilities.
    
  • Aftercare/continuing care was provided by 85 percent of all facilities.
• Pharmacotherapies were provided by 54 percent of all facilities; rates were higher in federal government-operated facilities (85 percent), in state government-operated facilities (77 percent), and in local government-operated facilities (63 percent).
  • Medications for psychiatric disorders were the most frequently available pharmacotherapies—in 40 percent of all facilities and in 79 percent of federal government-operated facilities.
• Ancillary services were provided by 99 percent of all facilities.
  • Substance abuse education was provided by 97 percent of all facilities.
    
  • Case management services were provided by 81 percent of all facilities.
    
  • Mental health services were provided by 64 percent of all facilities.
• Other services were provided by 30 percent of all facilities.
  • Treatment for other addiction disorders was provided by 22 percent of all facilities.
  • Treatment for gambling disorders was provided by 19 percent of all facilities.
  • Treatment for Internet use disorders was provided by 9 percent of all facilities.
    

Counseling Services Offered by Facilities

• Table 4.9. Individual counseling was the most frequently reported form of counseling, by 98 percent of facilities, and marital/couples counseling was reported least frequently, by 59 percent of facilities.
  

Clinical/Therapeutic Approaches

Table 4.10. Facilities were asked to indicate whether they used any of 13 specific clinical/therapeutic approaches.

• Two approaches were each used always or often by nearly all facilities:
  • Substance abuse counseling was used always or often by 94 percent of facilities.
    
  • Relapse prevention was used always or often by 84 percent of facilities.
• A number of approaches were used at least sometimes (always, often, or sometimes) by more than half of facilities:
  • Cognitive-behavioral therapy was used at least sometimes by 92 percent of facilities.
    
  • Motivational interviewing was used at least sometimes by 88 percent of facilities.
    
  • Anger management was used at least sometimes by 81 percent of facilities.
    
  • Brief intervention was used at least sometimes by 79 percent of facilities.
    
  • 12-step facilitation was used at least sometimes by 74 percent of facilities.
    
  • Trauma-related counseling was used at least sometimes by 71 percent of facilities.
    
  • Contingency management/motivational incentives were used at least sometimes by 56 percent of facilities.
    
• Some approaches were used rarely or never, or were unfamiliar to the respondent, for more than half of all facilities:
  • Computerized substance abuse treatment was used rarely or never by 84 percent of facilities, and it was unfamiliar to an additional 5 percent of facilities.
    
  • Community reinforcement plus vouchers were used rarely or never by 79 percent of facilities, and it was unfamiliar to an additional 9 percent of facilities.
    
  • Rational emotive behavioral therapy was used rarely or never by 51 percent of facilities, and it was unfamiliar to an additional 4 percent of facilities.
    
  • The matrix model was used rarely or never by 48 percent of facilities, and it was unfamiliar to an additional 13 percent of facilities.
    

Specifically Tailored Programs or Groups

Table 4.11. Facilities were asked about the provision of treatment programs or groups specifically tailored for specific client types. Overall, 86 percent of facilities offered at least one such program or group to serve a specific client type.

¹⁶ Facilities treating incarcerated persons only were excluded from this report; see Chapter 1.
¹⁷ Persons who have experienced sexual abuse, persons who have experienced domestic violence, and young adults categories appeared for the first time in the 2013 questionnaire.

Services in Sign Language for the Hearing Impaired and in Languages Other than English

Table 4.12. Facilities were asked about the provision of substance abuse treatment services in sign language for the hearing impaired. They were also asked if treatment was provided in languages other than English, if this treatment was provided by a staff counselor or by an on-call interpreter, and in what languages staff counselors provided treatment.

• Substance abuse treatment services in sign language for the hearing impaired were offered in 28 percent of all facilities. Facilities operated by local and state governments were most likely to offer these services (53 and 44 percent, respectively).
  
• Substance abuse treatment services in languages other than English were provided in 41 percent of all facilities, ranging from 18 percent of federal government-operated facilities to 59 percent of local government-operated facilities.
  
• Forty percent of facilities providing services in languages other than English used only staff counselors who spoke other languages; another 26 percent of facilities used both staff counselors and on-call interpreters.
• In facilities where staff counselors provided services in languages other than English, Spanish was the most frequently spoken language (at 92 percent of those facilities). Services in American Indian/Alaska Native languages were provided by 3 percent of all facilities where staff counselors provided services in languages other than English. Most tribal government-operated and Indian Health Services-operated facilities where staff counselors provided services in languages other than English offered services in American Indian/Alaska Native languages (85 and 92 percent, respectively).
  

Detoxification Services

Table 4.13. Facilities that provided detoxification services were asked to indicate whether or not they detoxified clients from specified substances, and whether or not medication was routinely used during detoxification. The number of facilities providing any type of substance detoxification services was 2,581 (18 percent) out of a total of 14,148 facilities.

Client Outreach

Table 4.14. Facilities were asked whether or not they had a website providing information about their substance abuse treatment programs.

• Information about a facility’s substance abuse treatment programs was provided through websites by 81 percent of all facilities. Website availability ranged from 44 percent among facilities operated by tribal governments and 56 percent among facilities operated by the federal government to 87 percent among private non-profit facilities.
  
• Outreach to persons in the community who may need treatment was provided by 60 percent of all facilities, but by 84 percent of tribal government-operated facilities.
  

Facility Licensing, Certification, or Accreditation

Facilities were asked to report licensure, certification, or accreditation by specified agencies or organizations. These included the state substance abuse agency, state mental health department, state department of health, hospital licensing authority, the Joint Commission, CARF, NCQA, COA, and other state or local agency or organization.¹⁸

Table 4.15. Overall, 94 percent of all facilities reported that they were licensed, certified, or accredited by one or more agencies or organizations.

Table 4.16. Facility licensing, certification, or accreditation was associated with the type of care offered.

• State substance abuse agencies licensed, certified, or accredited 82 percent each of facilities offering outpatient treatment and residential (non-hospital) treatment but only 57 percent of facilities offering hospital inpatient treatment.
  
• State mental health departments licensed, certified, or accredited 42 percent of hospital inpatient facilities but only 41 percent of outpatient facilities and 30 percent of residential (non-hospital) facilities.
  
• Facilities offering hospital inpatient treatment were more likely than facilities offering other types of care to report licensure, certification, or accreditation by the following:

Facility Standard Operating Procedures

Table 4.17. Facilities were asked to indicate whether or not they followed specified practices as part of their standard operating procedures. All the standard practices listed were used by two thirds or more of all facilities.

Payment Options

Table 4.18. Facilities were asked to indicate whether or not they accepted specified types of payment or insurance for substance abuse treatment. They were also asked about the use of a sliding fee scale and if they offered treatment at no charge to clients who could not pay.

• Facilities operated by either federal or tribal governments were least likely to accept cash or self-payment (40 percent each). Private for-profit facilities were less likely to accept Medicare than were facilities operated by private non-profits (22 and 38 percent, respectively). Federal government-operated facilities were less likely to accept state-financed health insurance than were facilities operated by state and local governments (19, 53, and 54 percent, respectively).
  
• Use of a sliding fee scale was reported by 62 percent of all facilities, ranging from 17 percent of facilities operated by the federal government to 83 percent of facilities operated by local governments.
  
• Facilities operated by tribal governments were most likely to accept IHS/638¹⁹ contract care funds (74 percent).
  
• Treatment at no charge for persons who cannot afford to pay was offered by 48 percent of all facilities, ranging from 20 percent of private for-profit facilities to 81 percent of facilities operated by tribal governments.
  
• Acceptance of Access to Recovery vouchers was reported in 34 states or jurisdictions. In states with ATR grants, the proportion of facilities accepting Access to Recovery vouchers ranged from 4 percent in New York to 76 percent in Idaho [Table 6.18b].²⁰

¹⁹ Through a contract, tribes can receive the money that the Indian Health Service (IHS) would have used to provide direct health services for tribal members. Tribes can use these funds to provide directly, or through another entity, a broad range of health services. This option was part of P.L. 93-638 and is commonly known as “638 contracting.”
²⁰ Access to Recovery vouchers were available only in AK, AR, AZ, CA, CO, CT, DC, FL, HI, IA, ID, IL, IN, LA, MA, MD, MI, MO, MT, NH, NJ, NM, NY, OH, OK, OR, PA, RI, SD, TN, TX, UT, WA, WI, and WY. See table 6.18b for number of facilities accepting ATRs by state.

Work Activity Methods

Table 4.19. Facilities were asked to indicate what methods they used to accomplish their work.

• 60 percent of all facilities used both electronic and paper resources to accomplish intake activity.
• 56 percent of all facilities used both electronic and paper resources to accomplish referral activity, and 28 percent of all facilities used only paper resources to accomplish the same.
• 31 percent of all facilities used only electronic resources to accomplish billing activity.

Facility Funding

Table 4.20. Facilities were asked if they received federal, state, or local government funds or grants to support their substance abuse treatment programs.

• Overall, 57 percent of facilities reported receiving government funds to support substance abuse treatment programs. The proportions were highest in facilities operated by local or state governments (89 and 82 percent, respectively). Seventy-three percent of programs operated by private non-profit organizations reported receiving public funds whereas 19 percent of facilities operated by private for-profit organizations reported receiving public funds.  
  

Facilities with Opioid Treatment Programs

Table 3.2. Opioid Treatment Programs (OTPs) are certified by SAMHSA to provide medication-assisted therapy in the treatment of opioid addiction. Currently, methadone and buprenorphine are the only opioid medications approved for the treatment of opioid addiction.

• Tables 2.3, 3.1, and 4.21. Clients receiving methadone, buprenorphine, or Vivitrol^® in OTPs accounted for 27 percent of all clients in treatment on March 29, 2013, although OTPs were available in only 1,282 (9 percent) of all substance abuse treatment facilities.
  
• Tables 4.1 and 4.21. Private for-profit organizations operated 55 percent of OTPs but only 32 percent of all substance abuse treatment facilities.
  
• Table 4.21. Of the 343,180 clients receiving medication-assisted opioid therapy in OTPs, 96 percent (330,308) received methadone, 4 percent (12,513 clients) received buprenorphine, and less than 1 percent (359) received Vivitrol^®. (There were also 35,635 clients that received buprenorphine and 3,422 clients that received Vivitrol^® as part of their treatment in non-OTP facilities.)²¹
  
  • More than half (57 percent) of clients receiving methadone were in private for-profit facilities with OTPs.
    
  • Clients receiving buprenorphine in OTPs were more likely than clients receiving methadone to be in federal government-operated facilities (12 vs. 1 percent).
    
• Table 4.22. Most facilities with OTPs offered outpatient treatment (92 percent). Eighty-seven percent offered outpatient methadone/buprenorphine maintenance or Vivitrol^® treatment, and 48 percent offered detoxification.
  
• Tables 4.16 and 4.23. Facilities with OTPs were more likely than all facilities combined to be licensed, certified, or accredited by a state department of health (62 vs. 43 percent), the Joint Commission (27 vs. 18 percent), CARF (66 vs. 24 percent), or state substance abuse agencies (90 vs. 81 percent).
  

Facility Smoking Policy

• Table 4.24. Forty-eight percent of facilities permitted smoking outdoors only whereas 37 percent of facilities did not allow smoking on the property or within any building.

To Chapter 4 Tables

Table of Contents

Chapter 5

Client Characteristics

Facility Operation
Type of Care
Substance Abuse Problem and Diagnosed Co-occurring Mental Disorders
Clients under Age 18 in Treatment

This chapter describes key characteristics of the 1,249,629 clients in substance abuse treatment on March 29, 2013. Clients in treatment were defined as: 1) hospital inpatient and residential (non-hospital) clients receiving substance abuse treatment services on March 29, 2013, and 2) outpatient clients who were seen at the facility for a substance abuse treatment or detoxification service at least once during the month of March 2013, and who were still enrolled in treatment on March 29, 2013.

Facility Operation

Table 5.1a and 5.1c. Facilities were asked to designate the type of entity responsible for the operation of the facility.

Type of Care

Tables 5.1a, 5.1b, and 5.1c. Facilities were asked how many clients in treatment on March 29, 2013, received specified subcategories of type of care within three broad categories.

• As shown previously [Table 5.1c], the majority of clients (51 percent) were in facilities operated by private non-profit organizations. The largest proportion of clients in each of the three types of care (outpatient, residential [non-hospital], and hospital inpatient) were in private non-profit facilities. However, the majority of clients in outpatient methadone/buprenorphine maintenance or Vivitrol^® treatment (57 percent) and in outpatient detoxification (51 percent) were in facilities operated by private for-profit organizations.
  
• About three quarters (74 percent) of clients in residential (non-hospital) treatment were in facilities operated by private non-profit organizations.
  

Substance Abuse Problem and Diagnosed Co-occurring Mental Disorders

Table 5.2. Facilities were asked to estimate the proportions of clients in treatment on March 29, 2013, by substance abuse problem treated (alcohol abuse only, drug abuse only, or both alcohol and drug abuse).

• On March 29, 2013, 43 percent of clients were in treatment for both alcohol and drug abuse, 40 percent were in treatment for drug abuse only, and 17 percent were in treatment for alcohol abuse only.
  
  • Federal and tribal government-operated facilities had the highest proportions of clients in treatment for abuse of both alcohol and drugs (52 and 51 percent, respectively) and for abuse of alcohol only (31 and 28 percent, respectively). Private for-profit facilities had the highest proportion of clients in treatment for drug abuse only (52 percent).

Facilities were asked to estimate the proportion of clients in treatment with diagnosed co-occurring mental and substance abuse disorders.

• On March 29, 2013, 45 percent of clients who were in treatment had a diagnosed co-occurring mental and substance abuse disorder.
  
  • Federal government-operated facilities had the highest proportion of clients with co-occurring mental and substance abuse disorders (63 percent).

Clients under Age 18 in Treatment

Table 5.3. Facilities were asked how many clients in treatment on March 29, 2013, were under age 18.

• There were 78,156 clients under age 18 in substance abuse treatment on March 29, 2013, about 6 percent of the total 1,249,629 clients in treatment on that date.
  
• Clients under age 18 in substance abuse treatment on March 29, 2013, were more likely to be in private non-profit facilities than the general client population (64 vs. 51 percent, respectively) but less likely to be in private for-profit facilities (23 vs. 34 percent, respectively) [Table 5.1c].
  
• The proportion of clients under age 18 receiving each type of care was similar to the total treatment population [Table 5.1b]. Most (89 percent) were in outpatient treatment, 10 percent were in residential (non-hospital) treatment, and 1 percent were in hospital inpatient treatment.
  

To Chapter 5 Tables

Table of Contents

Chapter 6

State Data

Survey Response
Trends
Clients in Treatment per 100,000 Population Aged 18 and Older
Clients in Opioid Treatment per 100,000 Population

This chapter breaks down data presented in earlier chapters by state and jurisdiction. The Chapter 6 tables correspond to most of the tables presented in Chapters 4 and 5. Note that facilities operated by federal agencies are included in the states in which the facilities are located, although these facilities may have clients from other states.

Table 6.1 details the 2013 N-SSATS response rate.

Tables 6.2 to 6.3 present data on treatment facility and client trends for 2003 to 2013.

Tables 6.4 to 6.23 present facility data for 2013.

Tables 6.24a to 6.29 present client data for 2013.

Table 6.30 presents the number of clients in treatment per 100,000 population aged 18 and over, according to substance abuse problem treated, by state or jurisdiction.

Table 6.31 presents the number of clients in treatment per 100,000 population, according to opioid treatment, by state or jurisdiction.

Survey Response

Table 6.1. The overall response rate for the survey was 94 percent. Thirty-four states or jurisdictions had response rates that equaled or surpassed the overall rate.

Trends

Tables 6.2a-b. California and New York had the largest numbers of both facilities and clients in treatment in every year from 2003 through 2013. On March 29, 2013, California had 11 percent of all facilities and 9 percent of all clients. New York had 6 percent of all facilities and 9 percent of all clients.

Four other states were in the top 10 for both total numbers of facilities and clients in the 6 years shown in Tables 6.2a-b: Florida, Illinois, Michigan, and Pennsylvania. Texas and Colorado were in the top 10 for total number of facilities each year and Massachusetts, Maryland, and Washington were in the top 10 for number of clients in 5 out of the 6 years shown in the tables.

Clients in Treatment per 100,000 Population Aged 18 and Older

Table 6.30. For the 50 states, the District of Columbia, and Puerto Rico, there were 481 clients in treatment per 100,000 population aged 18 and over on March 29, 2013. The rate was highest for persons with both alcohol and drug abuse (203 per 100,000 population), followed by drug abuse only (194 per 100,000 population) and alcohol abuse only (84 per 100,000 population).

Clients in Opioid Treatment per 100,000 Population

Table 6.31. For the 50 states, the District of Columbia, and Puerto Rico, there were 121 clients in opioid treatment per 100,000 population on March 29, 2013. The rate was highest for persons receiving methadone (105 per 100,000 population), followed by buprenorphine (15 per 100,000 population) and Vivitrol^® (1 per 100,000 population).

To Chapter 6 Tables

Table of Contents

Appendix A

N-SSATS Background

Survey History
N-SSATS in the Context of the Behavioral Health Services Information System (BHSIS)
Survey Coverage
Changes in Survey Content

Survey History

N-SSATS has evolved from national survey efforts begun in the 1970s by the National Institute on Drug Abuse (NIDA) to measure the scope and use of drug abuse treatment services in the United States. The sixth of these surveys, conducted in 1976, introduced the data elements and format that have formed the core of subsequent surveys. These include organizational focus, service orientation, services available, clients in treatment by type of care, and hospital inpatient/residential capacity. The 1976 survey, called the National Drug Abuse Treatment Utilization Survey, was repeated in 1977 and 1978.

In 1979, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) became a cosponsor of the survey, alcoholism treatment facilities were added, and the study was renamed the National Drug and Alcoholism Treatment Utilization Survey. This survey was repeated in 1980 and 1982. In 1984, a one-page version called the National Alcoholism and Drug Abuse Program Inventory was used. In 1987, the full version of the survey was reinstated and renamed the National Drug and Alcoholism Treatment Unit Survey (NDATUS). NDATUS was conducted annually from 1989 to 1993.

In 1992, with the creation of SAMHSA, responsibility for conducting the survey shifted to SAMHSA’s Office of Applied Studies (now the Center for Behavioral Health Statistics and Quality). The survey was redesigned, and it was conducted annually as the Uniform Facility Data Set (UFDS) survey from 1995 to 1998. During these years, the survey was conducted by mail with telephone follow-up of non-respondents. The 1999 survey year was a transition year during which the survey was redesigned and an abbreviated telephone survey of treatment facilities was conducted. In 2000, a redesigned full mail survey was reinstated with telephone follow-up; it was renamed the National Survey of Substance Abuse Treatment Services (N‑SSATS). The reference date for the annual survey had always been the end of September or beginning of October. After the 2000 survey, the reference date was changed to the end of March, and no survey was conducted during 2001.

In 2000, the use of an Internet-based questionnaire was tested; beginning in 2002, all facilities were offered the opportunity to respond via the Internet.

N-SSATS in the Context of the Behavioral Health Services Information System (BHSIS)

N-SSATS is one of the three components of SAMHSA’s Behavioral Health Services Information System (BHSIS—formerly the Drug and Alcohol Services Information System, or DASIS) that contain information on substance abuse treatment.²² The core of BHSIS includes the Inventory of Behavioral Health Services (I-BHS), until recently called the Inventory of Substance Abuse Treatment Services (I-SATS). I-BHS includes a continuously updated, comprehensive listing of all known substance abuse treatment facilities. The other substance abuse component of BHSIS is the Treatment Episode Data Set (TEDS), a client-level database of admissions to and discharges from substance abuse treatment. Together, the components provide national- and state-level information on the numbers and characteristics of individuals admitted to alcohol and drug treatment programs and describe the facilities that deliver care to those individuals.

I-BHS is the list frame for N-SSATS. Facilities in I-BHS fall into two general categories and are distinguished by the relationship of the facility to its state substance abuse agency. These categories are described below.

Treatment facilities approved by state substance abuse agencies

The largest group of facilities (11,496 in 2013) includes facilities that are licensed, certified, or otherwise approved by the state substance abuse agency to provide substance abuse treatment. State BHSIS representatives maintain this segment of I-BHS by reporting new facilities, closures, and address changes to SAMHSA. Some facilities are not licensed, certified, or otherwise approved by the state agency. Some private for-profit facilities fall into this category. The approved facility group also includes programs operated by federal agencies—the Department of Veterans Affairs (VA), the Department of Defense, the Indian Health Service—and Opioid Treatment Programs certified by SAMHSA. I-BHS records for federally-operated facilities are updated annually through lists provided by these agencies.

Treatment facilities not approved by state substance abuse agencies

This group of facilities (2,652 in 2013) represents the SAMHSA effort since the mid-1990s to make I-BHS as comprehensive as possible by including treatment facilities that state substance abuse agencies, for a variety of reasons, do not fund, license, or certify. Many of these facilities are private for-profit, small group practices, or hospital-based programs. Most of them are identified through periodic screening of alternative source databases. (See Special efforts to improve survey coverage below.) State substance abuse agencies are given the opportunity to review these facilities and to add them to the state agency-approved list, if appropriate.

Survey Coverage

The use of I-BHS as the list frame for N-SSATS imposes certain constraints related to the unit of response and the scope of facilities included. In addition, the expansion of I-BHS in recent years to provide a more complete enumeration of substance abuse treatment facilities means that year-to-year comparisons of the numbers of facilities reporting to N-SSATS must be interpreted with caution.

Unit of response

N-SSATS is designed to collect data from each physical location where treatment services are provided. Accordingly, SAMHSA requests that state substance abuse agencies use the point of delivery of service (i.e., physical location) as the defining factor for a facility. Because of the different state administrative systems, however, there are some inconsistencies in implementation. For example, in some states, multiple treatment programs (e.g., detoxification, residential, and outpatient) at the same address and under the same management have separate state licenses. These are treated as separate by the state substance abuse agency, and are given separate I-BHS ID numbers. In other states, multiple sites are included as a single entity under a parent or administrative unit. In many of these cases, individual sites can report services data in N-SSATS, but client data are available only at a higher administrative level. Beginning in 1995, efforts have been made to identify facility networks and to eliminate duplicate reporting by networks. For most facilities, reporting level remains consistent from year to year. However, beginning in 1998, an emphasis was placed on collecting minimum information from all physical locations, and this has resulted in an increase in the number of ­facilities.

Special efforts to improve survey coverage

The great majority of treatment facilities in I-BHS are administratively monitored by state substance abuse agencies. Therefore, the scope of facilities included in I-BHS is affected by differences in state systems of licensure, certification, accreditation, and the disbursement of public funds. For example, some state substance abuse agencies regulate private facilities and individual practi­tioners while others do not. In some states, hospital-based substance abuse treatment facilities are not licensed through the state substance abuse agency.

To address these differences, SAMHSA conducted a large-scale effort during 1995 and 1996 to identify substance abuse treatment facilities that, for a variety of reasons, were not on the inventory. Some 15 source lists were examined, and facilities not on the inventory were contacted to ascertain whether they provided substance abuse treatment. As expected, this yielded a number of hospital-based and small private facilities that were not on the inventory. (These facilities were surveyed in 1995 and 1996, but they were not included in the published results of the survey until 1997.) Analysis of the results of this effort led to similar but more targeted updates before subsequent surveys. Potential new facilities are identified using data from the American Business Index and the annual American Hospital Association survey, and SAMHSA’s National Mental Health Services Survey (which was then called the Inventory of Mental Health Organizations), the source lists that yielded the most new facilities in 1995 and 1996. Survey participants, who are asked to report all of the treatment facilities in their administrative networks, also identify additional facilities during the survey itself. All newly identified facilities are initially included as not approved by the state substance abuse agency. State substance abuse agencies are given the opportunity to review these facilities and to add them to the state agency-approved list, if appropriate.

Expansion of survey coverage to include all sites within networks at which treatment was provided yielded a net increase of about 2,600 facilities between 1997 and 1998. These additions were not necessarily new facilities, but were facilities not previously included in the survey as separate sites. The number of facilities reporting continued to increase in 1999, but at a slower pace, a net increase of 1,800 facilities. The increase between 1998 and 1999 was in large part because of the improved survey response rate (95 percent in 1999 vs. 90 percent in 1998). Between 2003 and 2013, the number of facilities eligible for inclusion in this report increased steadily, from 13,623 to 14,148. The total number is deceptive, however. There was significant turnover as facilities closed and others opened. (See Table 2.1.)

Data collection

Until 1996, state substance abuse agencies distributed and collected the facility survey forms. Beginning in 1996, data collection was centralized; and SAMHSA began mailing survey forms directly to and collected forms directly from the facilities and conducting follow-up telephone interviews with the facility director or his/her designee. In 2000, SAMHSA introduced an on-line trial web version of the questionnaire for a few facilities in addition to the hard-copy questionnaire. The web version of the questionnaire was fully implemented in 2002. The proportion of facilities using the web survey to respond to N-SSATS has increased steadily since its full inception in 2002. Beginning with the 2011 N-SSATS, a questionnaire is only mailed to respondents by request.

Non-response

Beginning in 1992, SAMHSA expanded efforts to obtain information from non-responding facilities. A representative sample of non-respondents was contacted and administered an abbreviated version of the survey instrument via telephone. In 1993 and later years, this effort was extended to all non-responding facilities. In 1997, a series of measures was introduced to enhance the survey response rate. These included advance notification and improved methods for updating address and contact information. Between 2004 and 2012, use of these methods and intensive telephone follow-up resulted in an annual follow-up rate (i.e., facilities in the sample either completed the survey or were determined to be closed or otherwise ineligible) of 92 to 96 percent. In 2013, the final response rate was 95.2 percent.

Exclusions

In 1997, facilities offering only DUI/DWI programs were excluded; these facilities were reinstated in 1998.

Facilities operated by the Bureau of Prisons (BOP) were excluded from the 1997 survey and subsequent surveys because SAMHSA conducted a separate survey of correctional facilities.²³ During that survey, it was discovered that jails, prisons, and other organizations treating incarcerated persons only were poorly enumerated on the inventory. Beginning in 1999, these facilities were identified during the survey and excluded from analyses and public-use data files.

I-BHS and N-SSATS are designed to include specialty substance abuse treatment facilities rather than individuals. Solo practitioners are listed on I-BHS and surveyed in N-SSATS only if the state substance abuse agency explicitly requests that they be included.

Beginning in 2000, halfway houses that did not provide substance abuse treatment were included on I-BHS and in N-SSATS so that they could be listed in the National Directory of Drug and Alcohol Abuse Treatment Programs and on the Treatment Facility Locator (http://findtreatment.samhsa.gov). These facilities are excluded from analyses and public-use data files.

Changes in Survey Content

Table A.1 shows the major content areas for the survey from 1996 to 2013. Since 1992, SAMHSA has made adjustments each year to the survey design, both to minimize non-response and to include areas of emerging interest. For example, questions on the number of clients in treatment receiving specific medication-assisted opioid therapies have changed over the years: LAAM was replaced by buprenorphine in 2004 and Vivitrol^® was added in 2013. Questions about clinical/therapeutic methods, standard practices, and Access to Recovery grants were added in 2007. Questions about facility smoking policy were added in 2011; questions about outpatient facility operating capacity and Vivitrol^® as a pharmacotherapy were added in 2012; and questions about work activity and means to accomplish them as well as the Vivitrol^® client count question were added in 2013.

There have also been changes within content areas. For example, in response to concerns about over-reporting of programs or groups for specific client types, the survey question was revised in 2003 to distinguish between those facilities that accepted specific client types and those facilities that offered specially designed programs or groups for that client type. As a result, the number and proportion of facilities offering programs or groups for each of the specified client types decreased. Surveys from 2003 and later are believed to more accurately represent the number and proportions of facilities providing programs or groups for the specified client types. In addition, over time more categories have been added to the specific client types (e.g., persons who have experienced trauma, active duty military, and members of military families in 2012 and special programs for young adults, persons who have experienced sexual abuse, and persons who have experienced intimate partner violence, domestic violence were added in 2013). Because of the increase of programs for specific client types, and the corresponding question of those types of clients being accepted into treatment, the question was again revised in 2013 to clarify and reduce respondent burden. Moreover, the programs are now described as “specifically tailored” for specific client types.

To Table A.1

Appendix B

2013 N-SSATS Questionnaire

This Appendix contains the hard copy version of the 2013 N-SSATS questionnaire. Facilities also had the option of responding to the questionnaire on the Internet. For those facil­ities that had not completed the survey after extensive follow-up efforts (see Chapter 1), the questionnaire was administered by computer-assisted telephone interview (CATI).

Of the responding eligible treatment facilities included in this report, 87 percent completed the questionnaire on the Internet, 2 percent completed it by mail, and about 10 percent completed it by CATI [Table 1.1 and Figure 1].

Text versions of the Internet and CATI surveys are not included here because they are computer programs that contain complex skip patterns, are difficult to read, and are extremely long in text format.

To Sample 2013 N-SSATS Questionnaire PDF

Appendix C

Item Response and Imputation for 2013 N-SSATS

This Appendix contains Table C.1, a list of item response rates for questions from the N-SSATS 2013 questionnaire. Item non-response was minimized through careful editing and extensive follow-up.

The item response rate for the 2013 N-SSATS averaged 97 percent across 242 separate response categories.

Item non-response was 10 percent or more for only 18 of 242 separate response categories.

When available, client values and admissions values from up to five previous surveys were used to impute the missing counts. If historical data were not available, 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. Missing client counts were imputed for each type of service (i.e., hospital inpatient detoxification, hospital inpatient treatment, residential [non-hospital] detoxification, etc.) and summed to the larger service type totals (total hospital inpatient clients, total residential [non-hospital] clients, and total outpatient clients), and finally to total clients. There is no imputation for 2013 N-SSATS data.

Several facilities report client counts for themselves (parent) as well as for other facilities (children) within their family of substance abuse treatment facilities. Instead of reporting only the aggregate client count, we attempted to disaggregate and redistribute or unroll the parent facilities’ total client count wherever possible to reflect the number of clients served by each facility within the family of facilities. Our procedure was to first calculate the mean client count per type of care received (hospital inpatient, outpatient, and residential) for the facilities in N-SSATS that reported only for themselves. We then used these means to determine how to distribute the clients reported by a parent facility to its children facilities based on the type of facilities and the types of clients indicated by the family of facilities. Therefore, numbers reported may be an actual number reported by the facility itself or they may be an unrolled estimate based on the unrolling procedures. All totals sum to the actual reported numbers.

At Synectics, Parth Thakore, Hongwei Zhang, and Doren H. Walker were responsible for the content, analysis, and writing of the report.

To Table C.1