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| September 11, 2014 |
Recovery Services Provided by Substance Abuse Treatment Facilities in the United States
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In 2012, 2.5 million people in the United States received substance abuse treatment at a specialty facility.1 For many individuals entering substance abuse treatment, substance abuse is not an isolated problem. Drug- and alcohol-abusing populations have higher rates of mental health issues than the general population,2 and many suffer from direct and indirect physical health conditions caused or exacerbated by their substance abuse.3 Because substance use often impacts multiple aspects of an individual's life, clients often enter treatment with housing issues, employment problems, and damaged family or social relationships.4
Treatment outcomes have been shown to improve when clients receive tailored services that match and address their specific needs.5,6,7 The Substance Abuse and Mental Health Services Administration (SAMHSA) defines the term "recovery" as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.8 SAMHSA has identified four dimensions of recovery from substance abuse8:
- Health: overcoming or managing one's disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and nonprescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional well-being;
- Home: having a stable and safe place to live;
- Purpose: participating in meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and having the independence, income, and resources to participate in society; and
- Community: engaging in relationships and social networks that provide support, friendship, love, and hope.
This report uses data from the 2012 National Survey of Substance Abuse Treatment Services (N-SSATS) to examine the extent to which substance abuse treatment facilities were providing recovery support services across each of the four dimensions of recovery. N-SSATS is an annual, national survey of all known substance abuse treatment facilities, both public and private, that collects data on a wide range of services commonly offered by facilities. This report includes the data reported by 14,311 substance abuse treatment facilities.
Recovery Dimension 1: Health
Because recovery pathways reflect the distinct needs and goals of individual treatment clients,5 the Health dimension of recovery encompasses a wide range of services. As the largest category, Health-related services include assessment and pre-treatment services, testing services, use of pharmacotherapies, and supportive ancillary services.
Assessment and Pre-Treatment Services
The most common assessment and pre-treatment services provided by facilities were screening for substance abuse (95 percent) and comprehensive substance abuse assessment or diagnosis (91 percent) (Figure 1). A majority of facilities also provided screening for mental health disorders (68 percent). Over half of facilities provided screening for tobacco use (56 percent). Less than half of facilities provided comprehensive mental health assessment or diagnosis (47 percent) or interim services for clients when immediate admission was not possible (45 percent).
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| Services | Percent of Facilities |
|---|---|
| Screening for substance abuse | 95% |
| Comprehensive substance abuse assessment or diagnosis | 91% |
| Screening for mental health disorders | 68% |
| Screening for tobacco use | 56% |
| Comprehensive mental health assessment or diagnosis | 47% |
| Interim services | 45% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Testing Services
The majority of facilities offered drug or alcohol urine screening (84 percent) or breathalyzer or other blood alcohol testing (61 percent) (Figure 2). Communicable disease testing was provided by substantially smaller proportions of facilities. Specifically, 36 percent of facilities provided tuberculosis (TB) screening, 28 percent provided testing for HIV, 24 percent screened for hepatitis C, 22 percent screened for hepatitis B, and 21 percent tested for sexually transmitted diseases.
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| Services | Percent of Facilities |
|---|---|
| Drug/alcohol urine screening | 84% |
| Breathalyzer/other blood alcohol testing | 61% |
| TB screening | 36% |
| HIV testing | 28% |
| Screening for hepatitis C | 24% |
| Screening for hepatitis B | 22% |
| Sexually transmitted disease testing | 21% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Pharmacotherapy Services
Medications for the treatment of psychiatric disorders were the most commonly provided pharmacotherapy (38 percent) (Table 1). About one-fifth of facilities provided nicotine replacement pharmacotherapy (22 percent) and 16 percent provided non-nicotine tobacco cessation medications. Less than 1 in 5 facilities offered pharmacotherapies used for alcohol and other substance abuse treatment, including oral naltrexone (18 percent), Antabuse® (17 percent), Campral® (17 percent), and Vivitrol® (injectable naltrexone; 10 percent). One in five or fewer facilities offered medications, such as buprenorphine with naloxone (Suboxone®; 20 percent), buprenorphine without naloxone (11 percent), or methadone (11 percent), which treat addiction to opioids such as heroin or prescription pain relievers like oxycodone.9
| Pharmacotherapies | Percent |
|---|---|
| Medications for psychiatric disorders | 38% |
| Nicotine replacement | 22% |
| Buprenorphine with naloxone (Suboxone®) | 20% |
| Naltrexone (oral) | 18% |
| Campral® | 17% |
| Antabuse® | 17% |
| Non-nicotine smoking/tobacco cessation medications | 16% |
| Buprenorphine without naloxone | 11% |
| Methadone | 11% |
| Vivitrol® (injectable naltrexone) | 10% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Ancillary Services
The vast majority of facilities (96 percent) offered substance abuse education (Figure 3). Over half of facilities provided mental health services (62 percent); HIV or AIDS education, counseling, or support services (58 percent); and health education other than HIV/AIDS or hepatitis (53 percent). About 2 in 5 facilities offered smoking cessation counseling (39 percent), and over 1 in 4 facilities (27 percent) provided early intervention for HIV.
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| Services | Percent of Facilities |
|---|---|
| Substance abuse education | 96% |
| Mental health services | 62% |
| HIV or AIDS education, counseling, or support | 58% |
| Health education other than HIV/AIDS or hepatitis | 53% |
| Hepatitis education, counseling, or support | 46% |
| Smoking cessation counseling | 39% |
| Early intervention for HIV | 27% |
| Acupuncture | 4% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Recovery Dimension 2: Home
The second dimension of recovery is having a stable and safe place to live. Home-related services provided in 2012 primarily included supportive ancillary services as well as services that helped clients transition out of treatment.
Ancillary Services
The majority of facilities offered discharge planning (94 percent) and aftercare or continuing care services (84 percent). Moreover, outcome follow-up after discharge was part of the standard operating procedures across 69 percent of facilities.
Transitional and Follow-up Services
Four in five facilities offered case management services (80 percent), and over half offered assistance with obtaining social services, such as Medicaid; Women, Infants, and Children; Supplemental Security Income; and Social Security Disability Income (57 percent) (Table 2). Nearly half of facilities (49 percent) provided assistance in locating housing for substance abuse treatment clients. Similar proportions of facilities offered transportation assistance to treatment (41 percent) and domestic violence services (40 percent).
| Service | Percent |
|---|---|
| Ancillary services | |
| Case management services | 80% |
| Assistance with obtaining social services | 57% |
| Assistance in locating housing for clients | 49% |
| Transportation assistance to treatment | 41% |
| Domestic violence—family or partner violence services | 40% |
| Transitional and follow-up services | |
| Discharge planning | 94% |
| Aftercare/continuing care | 84% |
| Outcome follow-up after discharge | 69% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Recovery Dimension 3: Purpose
Participating in society through meaningful daily activities such as a job, school, or family caretaking is central to the Purpose dimension of recovery. Purpose-related services offered by facilities primarily included ancillary services. Since having the resources to participate in meaningful activities is also part of the Purpose dimension, services that assisted clients with paying for their treatment are also included.
Ancillary Services
In 2012, nearly three-quarters (74 percent) of facilities provided services in support of social skills development. Employment counseling or training for clients was offered by 37 percent of facilities (data not shown). Only 7 percent provided child care services (data not shown).
Payment Services
Over half of facilities (62 percent) used a sliding-fee scale to determine an appropriate charge for services based on their clients' economic situations (data not shown); 9 in 10 facilities (90 percent) accepted self-payment for substance abuse treatment (Figure 4). Nearly two-thirds (65 percent) of facilities accepted private health insurance, and over half (58 percent) accepted Medicaid. A third of facilities (33 percent) accepted Medicare or federal military insurance such as TRICARE or CHAMPVA.
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| Types of Payment | Percent of Services |
|---|---|
| Self-payment | 90% |
| Private health insurance | 65% |
| Medicaid/federal military insurance | 58% |
| State-financed insurance | 40% |
| Federal military insurance | 33% |
| Medicare | 33% |
| Access to Recovery (ATR) vouchers | 13% |
| IHS/638 contract care funds | 5% |
| No payment accepted | 3% |
| Other | 5% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Recovery Dimension 4: Community
The role of Community in recovery refers to relationships and social networks that provide support, friendship, love, and hope. One way that treatment programs facilitate therapeutic networking, foster healthy relationships, and provide targeted services is to offer specially designed substance abuse treatment programs or groups for specified types of clients. In addition, Community-related services also included counseling, ancillary, and pre-treatment services.
Specially Designed Programs or Groups
Over a third (37 percent) of facilities offered a specially designed program or group for clients with co-occurring mental and substance abuse disorders (Figure 5). Over a quarter of facilities offered a special program or group for adult women (31 percent) or for adolescents (28 percent), and a quarter of facilities (25 percent) offered a special program or group for adult men. Nearly a quarter of facilities (23 percent) offered a specially designed program or group for criminal justice clients (other than DUI/DWI). Twelve percent of facilities offered a specially designed program or group for pregnant or postpartum women. Less than 1 in 10 facilities offered a specially designed program or group for persons with HIV or AIDS (8 percent); for veterans and seniors or older adults (both 7 percent); for lesbian, gay, bisexual, transgender, or questioning clients (6 percent); and for members of military families or active duty military (4 percent each).
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| Programs | Percent of Facilities |
|---|---|
| Clients with co-occurring disorders | 37% |
| Adult women | 31% |
| Adolescents | 28% |
| Adult men | 25% |
| Criminal justice clients (non-DUI/DWI) | 23% |
| Persons who have experienced trauma | 22% |
| Pregnant or postpartum | 12% |
| Persons with HIV/AIDS | 8% |
| Seniors or older adults | 7% |
| Veterans | 7% |
| Lesbian, gay, bisexual, transgender, or questioning | 6% |
| Member of military families | 4% |
| Active duty military | 4% |
| Other | 14% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Counseling Services
Counseling services can help clients in treatment with their addiction, as well as address interpersonal problems they are having with spouses, children, friends, and others in their social network. Virtually all facilities provided individual counseling (98 percent), and the majority provided group counseling or family counseling (93 and 82 percent, respectively) (Figure 6). Marital/couples counseling was provided by over half (59 percent) of all facilities.
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| Types of Counseling | Percent of Facilities |
|---|---|
| Individual | 98% |
| Group | 93% |
| Family | 82% |
| Marital | 59% |
| Source: 2012 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Other Services
In 2012, over half of facilities provided outreach to persons in the community who may have needed treatment (57 percent; data not shown). Mentoring or peer support was provided by over half (52 percent) of facilities. Self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, and SMART Recovery) were offered by nearly half (47 percent) of facilities (data not shown).
Discussion
Findings from this report indicate that the nation's substance abuse treatment facilities offered a range of services that reflect SAMHSA's four key recovery dimensions: Health, Home, Purpose, and Community. The Health recovery dimension was addressed primarily through substance abuse screening and comprehensive substance abuse assessment or diagnosis, substance abuse education, and drug or alcohol urine screening. However, communicable disease testing, comprehensive mental health assessments or diagnoses, and the provision of mental disorder medications were less commonly offered. These may be areas in need of increased resources given the high rates of these problems in substance abuse treatment populations and research showing improved treatment outcomes when the needed medical and mental health services are received.5,6,10
Several notable findings support the Home and Purpose recovery dimensions. Specifically, about half of facilities offered clients assistance with obtaining social services and locating housing, and most facilities provided transitional services such as discharge planning and aftercare or continuing care services. These services are critical as the provision of housing assistance and services that address aftercare needs have been shown to improve treatment outcomes.11,12,13 Because services that address access barriers have been associated with reductions in post treatment substance use,13 it is notable that most facilities used a sliding-fee scale and accepted Medicaid. However, less than two-fifths of facilities offered employment counseling; given that employment has been shown to be an important component of treatment success and post-treatment recovery, this may be one area that treatment administrators may consider expanding.11,12 Finally, the Community recovery dimension was primarily addressed through counseling, community outreach efforts, and mentoring or peer support.
Because individuals in treatment often face substantial challenges in addition to their substance abuse, it is important that facilities are equipped to address all four of the recovery dimensions to support enduring positive outcomes for their clients. Additional information on substance abuse recovery is available at the SAMHSA's Recovery Support Web site (https://www.samhsa.gov/recovery/). Individuals in need of substance abuse treatment can use SAMHSA's Behavioral Health Treatment Services Locator, which may be accessed at http://findtreatment.samhsa.gov/. Users can search the Locator for facilities by location and by specific characteristics, such as the types of services offered including payment assistance options, special programs/groups offered, and type of care.
End Notes
1 Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA 13–4795, NSDUH Series H–46). Rockville, MD: Substance Abuse and Mental Health Services Administration.
2 Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Mental health findings (HHS Publication No. SMA 13–4805, NSDUH Series H–47). Rockville, MD: Substance Abuse and Mental Health Services Administration.
3 Sullivan, L. E., & O'Connor, P. G. (2004). Medical disorders in substance abuse patients. In H. R. Kranzler & J. A. Tinsley (Eds.), Dual diagnosis and psychiatric treatment: Substance abuse and comorbid disorders (2nd ed., pp. 425–457). New York, NY: Marcel Dekker, Inc.
4 Substance Abuse and Mental Health Services Administration. (2012). Comprehensive case management for substance abuse treatment. (HHS Publication No. SMA 12–4215, Treatment Improvement Protocol [TIP] Series No. 27). Rockville, MD: Author.
5 Friedmann, P. D., Hendrickson, J. C., Gerstein, D. R., & Zhang, Z. (2004). The effect of matching comprehensive services to patients' needs on drug use improvement in addiction treatment. Addiction, 99(8), 962–972.
6 Institute of Medicine, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. (2006). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: National Academies Press.
7 National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.; NIH Publication No. 12–4180). Bethesda, MD: Author.
8 Substance Abuse and Mental Health Services Administration. (2012). SAMHSA's Working definition of recovery. Retrieved from https://store.samhsa.gov/shin/content/PEP12-RECDEF/PEP12-RECDEF.pdf
9 Two opioid medications are approved for the effective treatment of opioid addiction: methadone and buprenorphine. Methadone may be dispensed only in opioid treatment programs (OTPs), which are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment protocols require that a client take the medication at the clinic where it is dispensed daily; take-home dosages are allowed only for clients who have been in treatment for an extended period of time and meet additional requirements. Conversely, buprenorphine may be prescribed by physicians who obtain specialized training. Thus, it is possible for buprenorphine-trained physicians to operate out of private practices and through substance abuse treatment facilities or programs. The buprenorphine services indicated in this report include only those who operate in conjunction with a substance abuse treatment facility; it does not include the private practice physicians.
Although 11 percent of substance abuse treatment facilities offered methadone, only 8 percent of facilities were classified as OTPs. The reason for the difference is that some facilities, such as hospitals, can prescribe methadone for purposes other than treatment of opioid addiction, such as for pain relief, or can use methadone in emergency situations without being a SAMHSA-certified OTP.
10 Grella, C. E., & Stein, J. A. (2006). Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders. Psychiatric Services, 57(7), 1007–1015.
11 Marsh, J. C., Cao, D., & D'Aunno, T. (2004). Gender differences in the impact of comprehensive services in substance abuse treatment. Journal of Substance Abuse Treatment, 27(4), 289–300.
12 McLellan, A. T., Hagan, T. A., Levine, M., Gould, F., Meyers, K., Bencivengo, M., & Durell, J. (1998). Supplemental social services improve outcomes in public addiction treatment. Addiction, 93(10),1489–1499.
13 Krupski, A., Campbell, K., Joesch, J. M., Lucenko, B. A., & Roy-Byrne, P. (2009). Impact of Access to Recovery (ATR) services on alcohol/drug treatment outcomes. Journal of Substance Abuse Treatment, 37(4), 435–442.
Suggested Citation
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 11, 2014). The N-SSATS Report: Recovery Services Provided by Substance Abuse Treatment Facilities in the United States. Rockville, MD.
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The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey designed to collect information from all facilities in the United States, both public and private, that provide substance abuse treatment. 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 and in forecasting treatment resource requirements, to update SAMHSA's Inventory of Behavioral Health Services (I-BHS), to analyze general treatment services trends, and to generate the Behavioral Health Treatment Services Locator (http://findtreatment.samhsa.gov/). N-SSATS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA. N-SSATS collects three types of information from facilities: (1) characteristics of individual facilities such as services offered and types of treatment provided, primary focus of the facility, and payment options; (2) client count information such as counts of clients served by service type and number of beds designated for treatment; and (3) general information such as licensure, certification, or accreditation and facility Web site availability. In 2012, N-SSATS collected information from 14,311 facilities from all 50 states, the District of Columbia, Puerto Rico, the Federated States of Micronesia, Guam, Palau, and the Virgin Islands. Information and data for this report are based on data reported to N-SSATS for the survey reference date March 30, 2012. The N-SSATS Report is prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; Synectics for Management Decisions, Inc., Arlington, VA; and RTI International, Research Triangle Park, NC. Latest N-SSATS reports: https://www.samhsa.gov/data/DASIS.aspx#N-SSATS Latest N-SSATS public use files and variable definitions: http://datafiles.samhsa.gov Other substance abuse reports: https://www.samhsa.gov/data |
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