Alcohol and Drug Services Study (ADSS)

The National Substance Abuse Treatment System:

Facilities, Clients, Services, and Staffing

NOTE

The Alcohol and Drug Services Study (ADSS) provides an opportunity for researchers to explore
and analyze a unique data base that can provide new insights into the relationships between
substance abuse treatment clients and facilities. Great care has been taken by staff of SAMHSA's
Office of Applied Studies (OAS) and its contractors to create ADSS public-use data sets that are
as complete as possible and consistent with the statutory requirements to maintain and safeguard
the confidentiality of individual and institutional records. These requirements have been balanced
against the important need to make the ADSS data files available in a timely fashion and to
facilitate electronic download and analysis by users. Accompanying these files is documentation
that has been compiled into a series of ADSS reports. Several of these ADSS reports are being
released as working documents to minimize delay. Every effort has been made to ensure the
accuracy of the working documents, but errors may still remain. We request that you bring any
errors to the attention of OAS staff.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration
Office of Applied Studies
 Acknowledgments

This publication was developed for the Substance Abuse and Mental Health Services Administration
(SAMHSA), Office of Applied Studies (OAS), by the Schneider Institute for Health Policy, Brandeis
University, under Contract No 283-92-8331. Constance M. Horgan was the Principal Investigator. Helen
J. Levine was Co-Principal Investigator and project director for the ADSS Phase I Facility Survey.
Westat, Inc., subcontractor on the project, conducted the data collection. Anita Gadzuk was the
SAMHSA Project Officer. Individual authors, all with Brandeis University, are cited below and at the
beginning of each chapter. The authors wish to thank Paula Wolk for her programming assistance. At
RTI under Contract No. 283-99-9018, the document was reviewed and edited by Carol Council, David
Belton, and Richard S. Straw in preparation for web publication.

Authors

Chapter 1: Helen J. Levine, Sharon Reif, Grant A. Ritter, Margaret T. Lee, Mary Ellen Marsden, and
Constance M. Horgan. Anita Gadzuk was the lead reviewer within OAS.
Chapter 2: Mary Ellen Marsden, Sharon Reif, Maria Pieroni, Helen J. Levine, Margaret T. Lee, Grant
A. Ritter, and Constance M. Horgan. Within OAS, the lead reviewer was Barbara Ray.
Chapter 3: Margaret T. Lee, Sharon Reif, Grant A. Ritter, Helen J. Levine, Mary Ellen Marsden, and
Constance M. Horgan. Within OAS, the lead reviewer was Charlene Lewis.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without
permission from the Substance Abuse and Mental Health Services Administration. However, this
publication may not be reproduced or distributed for a fee without specific, written authorization of the
Office of Communications, SAMHSA, U.S. Department of Health and Human Services. Citation of the
source is appreciated. Suggested citation:

Substance Abuse and Mental Health Services Administration. Alcohol and Drug Services Study
(ADSS): The National Substance Abuse Treatment System: Facilities, Clients, Services, and
Staffing. Office of Applied Studies. Rockville, MD, 2003.

Copies of the Report

To request hard copies of this web-only report, click on "Mail" on the banner of most pages on the OAS
website, then choose "OAS Mail Room" (http://www.samhsa.gov/oas/Mail/email.cfm). Copies also may
be obtained by calling OAS at 1-301-443-6239.

Electronic Access to Publication

http://www.SAMHSA.gov
http://www.DrugAbuseStatistics.SAMHSA.gov
http://www.samhsa.gov/oas/adss.htm

Originating Office

SAMHSA, Office of Applied Studies, 5600 Fishers Lane, Room 16-105, Rockville, MD 20857

July 2003

ii
 Table of Contents
Page

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

CHAPTER 1. Organizational Characteristics of Substance Abuse Treatment Facilities . . . . . . . 7

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.1 Treatment Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.2 Clients in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.3 Average Staff Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3.4 Public Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4 Organizational Characteristics of Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.1 Key Facility Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.3 Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.4.4 Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.5 Urbanicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.4.6 Facility Licensing, Approval, and Certification or Accreditation . . . . . . 20
1.4.7 Level of Facility Affiliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.4.8 Services Provided by Other Organizations . . . . . . . . . . . . . . . . . . . . . . . 21
1.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.6 References for Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

CHAPTER 2. Client Populations in Substance Abuse Treatment Facilities . . . . . . . . . . . . . . . . 39

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.1.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.1.2 Methodology Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.1.3 Organization of the Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.2 Findings on the Number of Clients in Treatment . . . . . . . . . . . . . . . . . . . . . . . . 42
2.2.1 Type of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.2.2 Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.2.3 Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.2.4 Percent Public Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.5 Urbanicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.6 Level of Affiliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.3 Findings on Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.3.1 Clients in Types of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.3.2 Clients in Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.3.3 Clients in Ownership Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.3.4 Treatment for Alcohol and Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . 47

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 Table of Contents (continued)
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2.4 Findings on Special Population Clients and Programs . . . . . . . . . . . . . . . . . . . . 47

2.4.1 Special Population Clients in Types of Facilities . . . . . . . . . . . . . . . . . . 48
2.4.2 Programs for Special Population Clients . . . . . . . . . . . . . . . . . . . . . . . . . 49
2.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
2.6 References for Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

CHAPTER 3. Treatment Services and Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.1.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.1.2 Methodology Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.1.3 Organization of the Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.2 Findings on Service Patterns in the Treatment System . . . . . . . . . . . . . . . . . . . . 69
3.2.1 Treatment Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.2.2 Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.2.3 Other Notable Service Variations by Facility Characteristics . . . . . . . . . 72
3.2.4 Facilities That Offer Varying Numbers of Services . . . . . . . . . . . . . . . . . 73
3.3 Findings on Staffing of the Substance Abuse Treatment System . . . . . . . . . . . . 75
3.3.1 Distribution of Staffing Categories Among Full-Time, Part-Time, and
Contract Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.3.2 FTE Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.3.3 Mean Ratios of Clients to Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.3.4 Percentage of Direct-Care Staff Certified in Substance Abuse
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.3.5 Mean Ratio of Clients to Staff Certified in Substance Abuse
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.4.1 Service Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.4.2 Staffing Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
3.5 References for Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Appendix

A ADSS Phase I Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

B Variable Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
C Standard Error Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

iv
 List of Tables
Page

Table 1.A Number and Percentage Distribution of Single and Multiple

Modality Substance Abuse Treatment Facilities: National
Estimates, ADSS Phase I Facility Survey, October 1, 1996 . . . . . . . . . . . . . . . . 11

Table 1.B Number and Percentage Distribution of Substance Abuse

Treatment Facilities, and the Percentage Distribution of the U.S.
Population, by Urbanicity Category: National Estimates, 1996 . . . . . . . . . . . . . 19

Table 1.1 Number of Substance Abuse Treatment Facilities, Average

Number of Direct-Care Staff per Facility, and Average Facility
Percentage of Public Revenue, by Facility Type of Care: National
Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Table 1.2 Number of Facilities and Number of Clients, and the Average
Number of Clients per Facility, by Client Type of Care: National
Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Table 1.3 Percentage Distribution of Substance Abuse Treatment Facilities,

by Selected Facility Characteristics and by Facility Type of Care:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Table 1.4 Percentage Distribution of Substance Abuse Treatment Facilities,

by Selected Facility Characteristics and by Facility Ownership:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table 1.5 Percentage Distribution of Substance Abuse Treatment Facilities,

by Selected Facility Characteristics and by Urbanicity: National
Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 1.6 Percentage Distribution of Substance Abuse Treatment Facilities,

by Selected Facility Characteristics and by Facility Certification:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Table 1.7 Percentage Distribution of Substance Abuse Treatment Facilities,

by Selected Facility Characteristics and by Level of Affiliation
with Other Facilities: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . 36

Table 1.8 Number and Percentage of Substance Abuse Treatment Facilities

with Affiliation with Other Organizations, and Service Provided by
Affiliated Organizations, by Facility Type of Care: National
Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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 List of Tables (continued)
Page

Table 2.1 Number of Substance Abuse Treatment Clients, by Selected

Facility Characteristics, Point-Prevalence Count, Annual
Admissions, and Annual Discharges: National Estimates, October
1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table 2.2 Percentage Distribution of Substance Abuse Treatment Clients, by

Selected Facility Characteristics and by Client Type of Care:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Table 2.3 Percentage Distribution of Substance Abuse Treatment Clients, by

Selected Facility Characteristics and by Treatment Settings:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Table 2.4 Percentage Distribution of Substance Abuse Treatment Clients, by

Selected Facility Characteristics and by Facility Ownership:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Table 2.5 Percentage of Clients Receiving Treatment for Alcohol Abuse

Only, Drug Abuse Only, or Both, by Selected Facility
Characteristics: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . 62

Table 2.6 Facilities Offering Programs for Special Populations and Number
of Special Population Clients Admitted in 12-Month Period:
National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Table 2.7 Percentage of Facilities That Admitted Special Client Types:

National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Table 2.8 Percentage of Facilities That Admitted Special Population Clients

and Have Special Programs for Them: National Estimates, October
1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Table 3.1 Percentage of Facilities in the Treatment System Offering

Treatment and Support Services: National Estimates . . . . . . . . . . . . . . . . . . . . . 85

Table 3.2a Percentage of Facilities Offering Treatment Services, by Selected

Facility Characteristics: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Table 3.2b Percentage of Facilities Offering Support Services, by Selected

Facility Characteristics: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Table 3.3 Percentage Distribution of Facilities Offering Varying Number of

Services, by Facility Characteristics: National Estimates . . . . . . . . . . . . . . . . . . 90

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 List of Tables (continued)
Page

Table 3.4 Percentage of Facilities, by Staffing Category and Mean Staff per
Facility: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Table 3.5a Number and Percentage Distribution of Full-Time, Part-Time, and

Contract Staff, by Staff Type: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . 93

Table 3.5b Number and Percentage Distribution of Staff Type, by "Time"

Category in the Treatment System: National Estimates . . . . . . . . . . . . . . . . . . . . 94

Table 3.5c Number and Percentage Distribution of FTE Staff, by Staffing

Categories: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Table 3.6 Mean Ratio of Clients to FTE Staff, by Facility Characteristics:

National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Table 3.7 Percentage of Staff Certified in Substance Abuse Treatment and

Mean Ratio of Clients to Staff Certified in Substance Abuse
Treatment, by Facility Characteristics: National Estimates . . . . . . . . . . . . . . . . . 98

Table A.1 Number of Facilities in the ADSS Phase I Survey Results . . . . . . . . . . . . . . . . 106

Table C.1.1 Standard Errors - Number of Substance Abuse Treatment

Facilities, Average Number of Direct-Care Staff per Facility, and
Average Facility Percentage of Public Revenue, by Facility Type of
Care: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Table C.1.2 Standard Errors - Number of Facilities and Number of Clients, and
the Average Number of Clients per Facility, by Client Type of
Care: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Table C.1.3 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Facilities, by Selected Facility Characteristics and by
Facility Type of Care: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . 122

Table C.1.4 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Facilities, by Selected Facility Characteristics and by
Facility Ownership: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . 124

Table C.1.5 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Facilities, by Selected Facility Characteristics and by
Urbanicity: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . 126

vii
 List of Tables (continued)
Page

Table C.1.6 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Facilities, by Selected Facility Characteristics and by
Facility Certification: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . 128

Table C.1.7 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Facilities, by Selected Facility Characteristics and by
Level of Affiliation with Other Facilities: National Estimates,
October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Table C.1.8 Standard Errors - Number and Percentage of Substance Abuse

Treatment Facilities with Affiliation with Other Organizations, and
Service Provided by Affiliated Organizations, by Facility Type of
Care: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Table C.2.1 Standard Errors - Number of Substance Abuse Treatment Clients,

by Selected Facility Characteristics, Point-Prevalence Count,
Annual Admissions, and Annual Discharges: National Estimates,
October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Table C.2.2 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Clients, by Selected Facility Characteristics and by
Client Type of Care: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . 134

Table C.2.3 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Clients, by Selected Facility Characteristics and by
Treatment Setting: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . 136

Table C.2.4 Standard Errors - Percentage Distribution of Substance Abuse

Treatment Clients, by Selected Facility Characteristics and by
Facility Ownership: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . 138

Table C.2.5 Standard Errors - Percentage of Clients Receiving Treatment for

Alcohol Abuse Only, Drug Abuse Only, or Both, by Selected
Facility Characteristics: National Estimates, October 1, 1996 . . . . . . . . . . . . . 140

Table C.2.6 Standard Errors - Facilities Offering Programs for Special

Populations and Number of Special Population Clients Admitted in
12-Month Period: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . 141

Table C.2.7 Standard Errors - Percentage of Facilities That Admitted Special

Client Types: National Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . 142

viii
 List of Tables (continued)
Page

Table C.2.8 Standard Errors - Percentage of Facilities That Admitted Special

Population Clients and Have Special Programs for Them: National
Estimates, October 1, 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

Table C.3.1 Standard Errors - Percentage of Facilities in the Treatment System

Offering Treatment and Support Services: National Estimates . . . . . . . . . . . . . 145

Table C.3.2a Standard Errors - Percentage of Facilities Offering Treatment

Services, by Selected Facility Characteristics: National Estimates . . . . . . . . . . 146

Table C.3.2b Standard Errors - Percentage of Facilities Offering Support

Services, by Selected Facility Characteristics: National Estimates . . . . . . . . . . 148

Table C.3.3 Standard Errors - Percentage Distribution of Facilities Offering

Varying Number of Services, by Facility Characteristics: National
Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Table C.3.4 Standard Errors - Percentage of Facilities, by Staffing Category and

Mean Staff per Facility: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Table C.3.5a Standard Errors - Percentage Distribution of Full-Time, Part-Time,

and Contract Staff, by Staff Type: National Estimates . . . . . . . . . . . . . . . . . . . 153

Table C.3.5b Standard Errors - Number and Percentage Distribution of Staff

Type, by "Time" Category in the Treatment System: National
Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Table C.3.5c Standard Errors - Number and Percentage Distribution of FTE

Staff, by Staffing Categories: National Estimates . . . . . . . . . . . . . . . . . . . . . . . 155

Table C.3.6 Standard Errors - Mean Ratio of Clients to FTE Staff, by Facility
Characteristics: National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Table C.3.7 Standard Errors - Percentage of Staff Certified in Substance Abuse

Treatment and Mean Ratio of Clients to Staff Certified in
Substance Abuse Treatment, by Facility Characteristics: National
Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

ix
x
 Highlights
This report presents findings on the organizational characteristics of the substance abuse
treatment system nationwide from Phase I of the Alcohol and Drug Services Study (ADSS). The
key components of the national treatment system presented in this report are the treatment
facilities (Chapter 1), the clients in treatment (Chapter 2), and the services and staffing resources
of the facilities (Chapter 3). ADSS Phase I, a mail/telephone survey of a nationally representative
sample of 2,395 treatment facilities, was conducted to study facility-level characteristics of
substance abuse treatment in the United States. Facility-level data reported here include facility
size, facility staffing patterns, facility certification, services offered, and revenue sources, all by
treatment type. Later phases of ADSS are the Phase II client record abstract study, which studied
the characteristics of the treatment population, including drugs of abuse, prior treatment, and
length of stay, and the Phase III client follow-up survey to assess post-treatment status. The
ADSS Cost Study is an in-depth report providing estimates of cost by type of care.

Highlights from this Phase I treatment system report follow:

Facilities (Chapter 1)

! An estimated 12,387 substance abuse treatment facilities were providing treatment on

October 1, 1996 (Tables 1.1 and 1.2).

! An estimated 85 percent of facilities in the facility universe are single-modality (i.e.,

providing only one type of care: hospital inpatient, non-hospital residential, outpatient
methadone, or outpatient non-methadone). Fifteen (15) percent of facilities provided a
combination of types of care (Table 1.1).

! There was a median of 6 full-time-equivalent (FTE) direct care staff per treatment
facility, ranging from a median of 5 FTEs in outpatient non-methadone facilities to 15
FTEs in facilities with more than one type of care (Table 1.1).

! The predominant type of care, outpatient non-methadone treatment, was provided at

about 76 percent of facilities, either alone or in combination with another type of care
(Table 1.2).

! The median number of clients in substance abuse treatment facilities was an estimated 40
clients per facility on October 1, 1996. Outpatient methadone facilities were the largest,
with a median of 177 methadone clients in treatment; however, outpatient methadone
treatment was provided at only about 6 percent of the facilities. Hospital inpatient
facilities had the fewest clients, with a median of about 6 clients in treatment (Table 1.2).

! Most substance abuse treatment facilities (86 percent) reported some public funding
among their sources of revenue (Table 1.3), with a mean of 62 percent of funding coming
from public sources (Table 1.1).

1
! Seventy (70) percent of treatment facilities reported an affiliation with another
organization, either as a parent facility of that other organization (21 percent) or some
other legal connection (49 percent) (Table 1.3).

Clients (Chapter 2)

! An estimated 1,091,328 clients were in substance abuse treatment on October 1, 1996

(Tables 1.2 and 2.1).

! Most clients were in outpatient, non-methadone care, an estimated 76 percent or 824,507

clients; an additional 14 percent (151,882 clients) were in outpatient methadone
treatment. About 9 percent of clients were in non-hospital residential care, and only about
1 percent were in hospital inpatient treatment (Tables 1.2 and 2.1).

! The majority of clients (60 percent) were treated in facilities owned by private non-profit
organizations. About 19 percent received care in private for-profit facilities and 21
percent in publicly owned facilities (Table 2.1).

! More than two thirds of clients received treatment in facilities that received half or more
of their revenue from public sources (Table 2.1).

! Half of all clients received care in facilities in large metropolitan areas (Table 2.1).

! Across all types of facilities, clients in substance abuse treatment programs were
predominantly male (67 percent) and predominantly white non-Hispanic (61 percent),
with alcohol as the principal substance of abuse (47 percent) (Table 2.2).

! For almost one half of all clients (47 percent), the primary expected source of payment
was public funds, either Medicaid, Medicare, or other public payment. About one in five
had private health insurance that was expected to pay for treatment, and almost one fourth
were described as self-pay (Table 2.3).

Services and Staffing (Chapter 3)

! With the exception of detoxification and acupuncture, all treatment services were offered
at 67 percent or more facilities. More than 90 percent of facilities offered treatment
services, such as individual therapy, comprehensive assessment and diagnosis, and group
therapy (Table 3.1).

! Individual therapy was the most frequently offered treatment service and was offered at
95 percent or more of facilities (Table 3.2a). It was offered least often in hospital
inpatient facilities.

! Aftercare treatment services and relapse prevention were offered at fewer facilities than
any of the counseling services (Table 3.2a).

2
! Support services were offered at less than 50 percent of facilities, with the exception of
HIV/AIDS education/counseling/support, which was offered at 77 percent of facilities
(Table 3.1).

! Support services such as transportation, employment counseling/training, and academic

education/GED classes were not routinely offered in the substance abuse treatment
system, but among the various types of care, they were offered more often in non-hospital
residential facilities (Table 3.2b).

! Facilities with no public revenue tended to offer fewer support services, such as
HIV/AIDS counseling, TB screening, and employment counseling (Table 3.2b).

! Facilities with high levels of support services were more likely to be non-hospital
residential or combination facilities. Facilities with low levels were more likely to be
outpatient non-methadone (Table 3.3).

! Facilities with low client-to-staff ratios offered more treatment and support services
(Table 3.3).

! In terms of direct care staff, the substance abuse treatment system was staffed primarily
with full-time M.A.- and B.A.-level counselors. Non-degreed counselors also played a
large role. Higher level and more costly staff, such as physicians or doctoral level
counselors, tended to be on staff as part-time or contract staff (Table 3.4).

! Low client-to-staff ratio was associated with facilities that offered high numbers of
treatment and support services, facilities with inpatient types of care, and facilities with
some public revenue (Table 3.6).

! The percentage of direct care staff certified in substance abuse tended to be low. In
general, the percentage of certified staff was less than 50 percent of the treatment staff.
The percentage of certified staff tended to be lower in methadone and hospital inpatient
types of care, publicly owned facilities, and those facilities using public funding for 90
percent or more of their revenue (Table 3.7).

! The mean ratio of clients to certified staff was highest in facilities offering methadone
type of care, larger facilities, public facilities, and facilities offering a low number of
treatment services (Table 3.7).

3
4
 Introduction
The Alcohol and Drug Services Study (ADSS) was designed to produce statistically
unbiased national estimates that are representative of substance abuse treatment facilities and
clients in treatment. Data reported here are based on reports of facility directors drawn from
Phase I: The Facility Survey of the ADSS study conducted from December 1996 to June 1997.
This study was conducted by mail/telephone interviews with facility directors at 2,395 facilities
that represent 12,387 substance abuse treatment facilities nationwide. Substance abuse treatment
facilities are those providing alcohol and/or drug treatment or recovery services using specified
personnel, designated space or resources, and a specified budget. Types of treatment facilities
excluded from the sample frame in this study are halfway houses without paid counselors, solo
practitioners, correctional facilities, Department of Defense (DoD) facilities, Indian Health
Service facilities, and facilities that are intake and referral only. This report presents national
estimates of the number of facilities, number and characteristics of clients in substance abuse
treatment facilities, as well as the staffing and services found in those facilities.

Methodology Overview

Phase I of ADSS consisted of a mail questionnaire collected by telephone interview with

facility directors at a national, stratified random sample of alcohol and drug treatment facilities.
The sample frame was the Substance Abuse and Mental Health Services Administration
(SAMHSA) 1995 national inventory of substance abuse treatment facilities known to SAMHSA,
supplemented with facilities identified from other sources, such as hospital listings, provider
associations, and business directories. Facilities in the frame were stratified by treatment type:
hospital inpatient, non-hospital residential, outpatient predominantly alcohol, outpatient
predominantly methadone, all other outpatient facilities, and facilities with combined treatment
types.

Phase I was conducted from December 1996 to June 1997, with data collected for a point
prevalence date of October 1, 1996, and for the most recent 12-month reporting period of the
facility. The Phase I response rate was 91.4 percent with 2,395 facilities responding. Because the
Phase I sampling design incorporated a stratified random probability sample, weights were
developed to produce national estimates of facilities. The sampling weights adjusted for facility
non-response and for differential response rates within strata. Further information about the data
collection methodology for the study is presented in Appendix A and in the ADSS Methodology
Report. A description of analytic variable construction appears in Appendix B, and standard error
tables are provided in Appendix C. Later phases of ADSS are the Phase II facility and client
record subsample and the Phase III client follow-up study.

Chapter 1. Organizational Characteristics of Substance Abuse Treatment Facilities

This chapter examines the organization of the national substance abuse treatment system
based on responses from substance abuse treatment facility directors in Phase I of the ADSS. It
describes key organizational elements of substance abuse treatment facilities and provides
national estimates of the size of the system as measured by the numbers of facilities and clients

5
and the characteristics of the system regarding ownership, urbanicity, facility licensing, and
facility affiliation with other organizations.

Chapter 2. Client Populations in Substance Abuse Treatment Facilities

This chapter presents national estimates of the number and characteristics of clients in
substance abuse treatment facilities in 1996 based on reports of facility directors. It examines the
demographic and other characteristics of clients receiving treatment in varied types of care and
treatment settings and in facilities owned publicly or by private for-profit and private non-profit
organizations. The number of special population clients, such as women and adolescents, and the
number of facilities providing special programs for those clients also are examined.

An estimated 1 million clients were receiving treatment in substance abuse treatment

facilities across the Nation on October 1, 1996. Some 4.3 million admissions to treatment and 3.7
million discharges were made within the year. Three fourths of clients received treatment in
outpatient non-methadone care, and almost 60 percent were treated in facilities owned by private
non-profit organizations.

Young adults, males, and non-Hispanic whites predominated in treatment. Alcohol was
the principal drug of abuse among treatment clients, although cocaine, heroin, and marijuana also
were important. More than half of the clients received care for alcohol and drug abuse problems
combined. Variations in the client populations of treatment facilities occurred by type of care,
treatment setting, and ownership of facility. These data demonstrate that facilities served a
variety of types of clients. Many clients in treatment were special populations, such as women
and adolescents, who required specialized services. But these clients were not treated in all
programs, nor did all programs provide special programs for them.

Chapter 3. Treatment Services and Staffing

This chapter documents the types of services offered to clients and the characteristics of
staff providing treatment services to clients in the national substance abuse treatment system. It
examines the relationship between facility characteristics and service patterns and staffing.
Comprehensive assessment/diagnosis, individual therapy, and group therapy made up the
cornerstone of the network of services. Services and staffing varied by facility characteristic,
such as type of care, ownership, facility size, percent dependence on public revenue, urbanicity,
level of affiliation, and facility setting. Generally, treatment services directly related to substance
abuse were offered at more facilities than were support services, such as transportation,
employment, and academic services. In addition, services offered after the client leaves
treatment, such as aftercare and outcome follow-up, were offered at fewer facilities than services
offered during treatment, such as counseling and comprehensive assessment and diagnosis.

Staffing in the substance abuse treatment system consisted primarily of master's and
bachelor's level counselors, with non-degreed counselors playing a large role. Higher level
professional staff, as measured by educational training, were less often on staff. High level and
more costly staff tended to be hired as contract or part-time staff. The ratio of clients to direct
care staff varied with facility characteristics.

6
 Chapter 1. Organizational Characteristics of Substance
Abuse Treatment Facilities
Helen J. Levine, Sharon Reif, Grant A. Ritter, Margaret T. Lee, Mary Ellen Marsden, and
Constance M. Horgan

1.1 Introduction
This chapter examines the organization of the national substance abuse treatment system
based on responses from substance abuse treatment facility directors in Phase I of the Alcohol
and Drug Services Study (ADSS). It describes key organizational elements of substance abuse
treatment facilities and provides national estimates of the size of the system as measured by the
numbers of facilities and clients and the characteristics of the system regarding ownership,
urbanicity, facility licensing, and facility affiliation with other organizations. ADSS Phase I,
which was a telephone survey of a nationally representative sample of 2,395 substance abuse
treatment facilities, collected data for October 1, 1996 and the facility's most recent 12-month
reporting period. This study builds upon the work of the 1990 Drug Services Research Survey
(DSRS) (Batten et al., 1993) with a more complete sampling frame, a larger facility sample, and
improved measures of financing and organization.1

1.2 Background
According to the Uniform Facility Data Set (UFDS), a periodic census survey sponsored
by the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of
clients in the substance abuse treatment system more than doubled from 488,903 in 1980
(SAMHSA, 1997) to 940,141 in 1996 (SAMHSA, 1999). UFDS reported 6,866 treatment
facilities in 1987 and 10,641 facilities in 1996 (SAMHSA, 1999). Prior research, reviewed
below, has examined the distribution of types of care in the substance abuse treatment system,
facility size, facility ownership, facility location relative to urban areas of the country, licensing
and accreditation of facilities, and facility affiliations. ADSS contributes to this research with its
extensive sample and detailed facility data.

Type of Care. Most clients receive outpatient substance abuse treatment (SAMHSA,
1999). In 1990, the DSRS showed that 87 percent of clients received care in outpatient facilities,
10 percent in residential care, and 3 percent in hospital inpatient facilities (Batten et al., 1993). In
1996, UFDS reported a similar distribution: 88 percent of clients in outpatient care, 10 percent in
residential care, and 2 percent in hospital inpatient care. ADSS examines the distribution of types
of care in the national substance abuse treatment system based on its enhanced sampling frame.

Facility Size. Most clients receive treatment in facilities with fewer than 100 clients
(SAMHSA, 1999). From 1990 through 1996, facilities with fewer than 30 clients had about 40

1
DSRS surveyed drug and alcohol/drug facilities and excluded alcohol-only facilities. ADSS Phase I
includes alcohol-only, drug-only, and combined alcohol/drug facilities.

7
percent of clients in treatment, and facilities with 30 to 99 clients had about a third of clients
(SAMHSA, 1999). Although larger facilities can take advantage of economies of scale, smaller
ones may have more flexibility to address the needs of individual clients. For example, a
Michigan survey (Mavis & Stoffelmayr, 1994) showed that larger outpatient programs were
positively correlated with staff size, budget, the number of medical full-time equivalent (FTE)
staff and staff role, and they were inversely related to the influence of Alcoholics Anonymous
(AA) on the program. Larger programs also were related to improvement in patients' problems
and patient satisfaction. Similarly, larger programs in residential facilities (Timko, 1995) were
associated with clearly documented policies, more health and treatment services, and greater
daily living assistance. However, larger residential programs offered less privacy to clients and
fewer choices in daily activities. In ADSS, detailed analyses of the impact of facility
organizational characteristics on treatment differences are presented.

Ownership. The majority of substance abuse treatment facilities in the United States are
private non-profit entities; however, a significant minority of facilities are either publicly owned
or are under for-profit auspices. From 1990 through 1996, between 61 and 64 percent of facilities
had private non-profit ownership, 17 to 19 percent had public ownership, and 17 to 22 percent
had private for-profit ownership (SAMHSA, 1999). The Drug Abuse Treatment System Survey
(DATSS), a panel study of 600 outpatient drug treatment facilities conducted in 1988, 1990, and
1995, showed the influence of ownership on treatment (Friedmann, Alexander, & D'Aunno,1999;
Price et al., 1991; Price & D'Aunno, 1992). DATSS data suggest that publicly owned or private
non-profit facilities provided greater access to care for poorer clients (Wheeler, Fadel, &
D'Aunno, 1992). Burke and Rafferty (1994) found that ownership influenced organizational
outlook on profit maximization, access to care, and patient outcomes. Furthermore, facilities
owned by private for-profit entities served a less impaired group of clients than facilities with
private non-profit ownership. McCaughrin & Howard (1996) found shorter waiting times for
treatment in facilities with a publicly funded client base. Data from the 1995 DATSS suggest that
public units continued to offer greater access to treatment services than private for-profit units
(Friedmann et al., 1999). ADSS contributes to the discussion of relationships between facility
ownership and substance abuse treatment, based on a large sample of nationally representative
public, private non-profit, and private for-profit facilities.

Urbanicity. The U.S. Bureau of the Census (1998) reported that about 80 percent of the
U.S. population lived in metropolitan statistical areas (MSAs) in 1996. Similar to the distribution
of the U.S. population, most substance abuse treatment is delivered in urban settings, and
especially in densely populated States (Institute of Medicine [IOM], 1997). Behavioral health
care facilities are more prevalent in urban or metropolitan areas, and they delivered more services
there than in rural or non-metropolitan areas (Goldsmith et al., 1994). Goldsmith et al. (1994)
also found that just over half of rural, non-metropolitan counties had behavioral health care
facilities, and inpatient facilities were rare in rural counties. Similarly, substance abuse treatment
facilities were rarely located in rural areas. D'Aunno, Folz, and Lin (1999) showed that almost no
methadone facilities were located in rural areas. The size of the ADSS sample allows further
investigation of the geographic spread of substance abuse treatment services and characteristics
associated with treatment in less urban areas.

8
 Licensing and Accreditation. Licensing is used by Federal, State, and local governments
to regulate the delivery of substance abuse treatment and to set standards for care (IOM, 1997;
McCarty, 1995). The Federal Government regulates methadone treatment, and State agencies
such as departments of drug and alcohol abuse, mental health, and public health typically oversee
State interests in regulating substance abuse treatment (IOM, 1995). State licensure is critical for
facilities to obtain third-party reimbursement (IOM, 1997). Accrediting agencies representing
medical establishments also regulate substance abuse treatment. The Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) accredits hospitals and has guidelines for
substance abuse facilities and community mental health programs (IOM, 1997). In 1995, 24
percent of outpatient facilities were JCAHO accredited, linking substance abuse services and
medical and mental health care (Friedmann et al., 1999). ADSS data provide a detailed
examination of the relationship of licensing and accreditation to the organizational characteristics
of substance abuse treatment facilities.

Affiliation. Historically, the treatment system was composed of small, freestanding

facilities that operated independently of one another, but recent analyses point to greater
integration among substance abuse treatment facilities and with other organizations (IOM, 1997).
In 1990, 62 percent of facilities reported legal connections to other organizations (DSRS
unpublished analyses, 1994). Integration can reduce costs and increase market flexibility
(Bazzoli, Shortell, Dubbs, Chan, & Kralovec, 1999). Changes in organizational integration may
lead to greater access to services for some clients, but gatekeeping mechanisms, used by some
managed care organizations, may provide a barrier to any care for poorer clients (Friedmann et
al., 1999). Questions in ADSS about facility affiliation with other organizations will extend this
analysis.

In summary, the substance abuse treatment system is large, diverse, and complex.
Freestanding community-based substance abuse treatment programs are facing stiff competition
from larger behavioral health care entities and other for-profit organizations that emphasize fiscal
accountability and professional accreditation (IOM, 1998). The era of managed care has
increased the complexities of the relationship between ownership and funding streams and their
potential impact on the delivery of services to clients (IOM, 1997). Because of its size and
nationally representative character, ADSS provides an opportunity to examine these issues in
greater depth and offers national estimates of the organizational attributes of the substance abuse
treatment system.

The remainder of this chapter is organized into two sections. The first section discusses
national estimates of substance abuse treatment facilities and clients for October 1, 1996, the
point-prevalence date for Phase I of ADSS, and gives a snapshot of clients, staffing, and public
funding for the major types of care within the system (Tables 1.1 and 1.2). The second section
describes in detail organizational variation within the system by type of care, ownership,
urbanicity, and certification and accrediting mechanisms (Tables 1.3 through 1.6), as well as
patterns of facility affiliation with other organizations (Tables 1.7 and 1.8).

9
1.3 National Estimates
1.3.1 Treatment Facilities

Based on the ADSS Phase I sample data, an estimated 12,387 facilities2 (Tables 1.A and
1.1) were providing substance abuse treatment to 1,091,328 clients (Table 1.2) on October 1,
1996. About 85 percent of the facilities provided only one type of care (i.e., either hospital
inpatient, non-hospital residential, outpatient methadone, or outpatient non-methadone care), and
an additional 15 percent provided more than one type of care, labeled "combination" facilities
(Tables 1.1 and 1.A).

The predominant modality of treatment nationwide is outpatient non-methadone

treatment. When the combination facilities are included in the counts of facilities providing each
type of care, and thereby counted in more than one category (Table 1.2), an estimated 76 percent,
or 9,384 of the total 12,387 facilities, were providing outpatient non-methadone care, either alone
or in combination with another type of care. Six (6) percent of facilities (688 facilities) were
providing outpatient methadone treatment, bringing the total proportion of facilities offering any
type of outpatient care to 81 percent, or 10,073 facilities. An estimated 26 percent of facilities
provided non-hospital residential care, and about 10 percent offered hospital inpatient care, either
alone or with other types of care.

1.3.2 Clients in Treatment

The largely outpatient substance abuse treatment system is also evident for clients in
treatment (Table 1.2), with an estimated 76 percent of clients in outpatient non-methadone
treatment (824,507 clients) and an additional 14 percent of clients (151,882 clients) in outpatient
methadone care, for a total of 90 percent of clients in some type of outpatient treatment. Only
about 10 percent of clients were in hospital inpatient (1 percent) or non-hospital residential (9
percent) care.

2
The number of facilities estimated from the ADSS sample (12,387 facilities) is somewhat higher than the
number of facilities reported in SAMHSA's Uniform Facility Data Set (UFDS) survey for 1996 (10,641 facilities) for
two reasons: (1) the ADSS Phase I sample survey adjusts for facility nonresponse, while UFDS reports for the
facilities responding to the census survey without adjustment for non-response; and (2), the ADSS facility universe
includes facilities identified through a search of provider and business listings for treatment facilities not on the main
facility listings, while the 1996 UFDS reporting did not include the additional set of facilities. A small part of this
increased ADSS coverage is offset by the exclusion of some facility types from ADSS that are not excluded from
UFDS (i.e., intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense, Indian Health Service, and Bureau of Prisons facilities). Overall, there are
relatively small differences of only 2 or 3 percentage points in facility characteristics estimated from ADSS for the
two facility universes—the full, expanded ADSS universe versus only the core universe covered in the 1996 UFDS
report. For example, there was an estimated 23 percent of facilities with private for-profit ownership for the larger
ADSS universe compared with about 20 percent for the core universe. There were no large differences for the
distributions of facility type of care, revenue source, urbanicity, or affiliation with other facilities (see Appendix A).

10
Table 1.A Number and Percentage Distribution of Single and Multiple Modality
Substance Abuse Treatment Facilities: National Estimates, ADSS Phase I
Facility Survey, October 1, 1996
Number of
Facilities Percent
Total, All Facilities 12,387 100.0
Single-Modality Facilities 10,501 84.8
Hospital inpatient only 378 3.1
Non-hospital residential only 2,135 17.2
Outpatient methadone only 464 3.8
Outpatient non-methadone only 7,524 60.7
Combination Facilities 1,886 15.2
Non-hospital residential/outpatient non-methadone 823 6.6
Hospital inpatient/outpatient non-methadone 663 5.4
Hospital inpatient/non-hospital residential/outpatient non-methadone 153 1.2
Hospital inpatient/non-hospital residential 23 0.2
Outpatient methadone and:
Outpatient non-methadone 167 1.3
Non-hospital residential / outpatient non-methadone 25 0.2
Hospital inpatient/outpatient non-methadone 22 0.2
Hospital inpatient/non-hospital residential/outpatient non-
methadone 7 0.1
Non-hospital residential 3 <0.0

1.3.3 Average Staff Size

Table 1.1 shows substance abuse treatment facilities by two descriptive facility-level
measures: the average number of full-time equivalent (FTE) direct-care staff per facility on
October 1, 1996, and the average facility proportion of revenue received from public sources.
The staffing data and sources of revenue were collected for the facility as a whole, and, therefore,
are provided at the facility level for combination facilities, rather than within their individual
treatment types.

The number of facility staff can be an indicator of facility resource intensity (Mavis &
Stoffelmayr, 1994). Both the mean and median numbers of FTE direct-care staff per facility are
presented in Table 1.1. Overall, substance abuse facilities had an average of 11.4 FTE direct-care
staff providing substance abuse treatment. Hospital inpatient facilities served the fewest clients
but had on average the most substance abuse staff (27.1 FTEs), more than double the overall
average. In contrast, outpatient non-methadone facilities had a mean of 7.2 FTEs.

The mean is presented to show average value. However, the median value, the point
above and below which half the facilities fall, provides another measure of central tendency and
may provide a clearer picture of staffing patterns. Across all types of care, there was an estimated

11
median of six direct-care staff members per facility. Broken down by facility type of care,
combination facilities and hospital inpatient-only facilities had the highest median staff size per
facility, 15 and 14 staff members per facility, respectively, followed by outpatient methadone-
only care, 10 staff members per facility. Non-hospital residential care and outpatient non-
methadone had a median of fewer than six staff members per facility.

Median comparisons suggest that the majority of hospital inpatient facilities had many
fewer FTEs (14 FTEs) than the mean indicates, but staffing differences remained. Median FTEs
(5 FTEs) for outpatient non-methadone facilities were a third of those for hospital inpatient
facilities (14 FTEs). Combination facilities, like hospital inpatient facilities, were staff intensive
with a mean of 25.9 FTEs and a median of 15 FTEs.

1.3.4 Public Revenue

Public revenue, including Medicaid, Medicare, other Federal Government funds, and
other public funds, is an important source of funding for substance abuse treatment. (See
Appendix B for a more detailed description of the public revenue category.) The mean proportion
of facility funding from public sources is presented in Table 1.1 along with the median
percentage. Overall, public funds are the predominant revenue source for treatment facilities,
with an estimated mean of two thirds to three quarters of substance abuse treatment facility
revenue coming from public sources. Non-hospital residential facilities received the largest
proportion of revenue from public sources, a mean facility proportion of 77 percent, and
outpatient non-methadone facilities received the lowest mean proportion from public sources (58
percent). Overall, the mean proportion of public revenue was 62 percent. Looked at by the
median percentage of public revenue, an estimated 76 percent of total treatment facility revenue
came from public sources (i.e., half the facilities had higher than 76 percent of revenue from
public sources and half had lower percentages), indicating that facilities with relatively high
proportions of public revenue outnumber facilities with lower proportions and that public
revenue may be more critical to facilities than the mean of 62 percent indicates.

1.4 Organizational Characteristics of Facilities

1.4.1 Key Facility Characteristics

Tables 1.3 through 1.7 present national estimates and percentage distributions of
treatment facilities for five key facility organizational characteristics, respectively: facility type of
care, facility ownership, facility urbanicity, facility certification or accreditation, and level of
affiliation with other facilities. Within the tables, these key characteristics are shown by an array
of other selected facility characteristics, including facility size, percent public revenue, number of
treatment services, number of support services, client-to-staff ratio, and facility setting.

1.4.2 Definitions

The following list provides a general description of the facility characteristics used in this
section; more detailed descriptions for the creation of the variables are provided in Appendix B.

12
! Facility type of care - Facilities were sampled and analyzed by the following broad types
of care: hospital inpatient; non-hospital residential; outpatient methadone-only; outpatient
non-methadone-only; and combination facilities.

! Ownership - Facilities were identified by their self-reported ownership type, collapsed

into three categories: private for profit; private non-profit; and public (government
ownership).

! Facility urbanicity - Facilities were classified by location with respect to metropolitan or

non-metropolitan county and by the size of the urban population in the county, based on a
modification of the rural-urban continuum codes (see Section 1.5 and Appendix B).

! Facility certification or accreditation - Facilities were identified by the organizational

certifications they held, including State alcohol and drug agencies, hospital licencing
authorities, drug and alcohol credentialing organizations, and the Joint Commission on
the Accreditation of Healthcare Organizations (JCAHO).

! Level of affiliation with other facilities - Facilities were classified by their relationships to
other facilities, either as a parent of other facilities, or as some other type of affiliate (e.g.,
legally part of a hospital or other institution).

! Facility size - Facilities were classified according to size based on their point-prevalence
client count on October 1, 1996. Four size categories, each representing approximately
one fourth of the treatment facilities, were created.

! Percent public revenue - Facilities were classified by their proportion of substance abuse
treatment revenue that came from public sources (e.g., Federal, State, or county funding,
Medicare, Medicaid).

! Number of treatment services - Facilities were classified by the types of selected

treatment services they provide to patients (e.g., individual therapy, group therapy, relapse
prevention). The number of services was grouped into low, medium, and high levels of
services.

! Treatment - Facilities also were categorized according to the level of selected treatment
and support services they offered. Facilities reported whether they offered each of 19
services to clients in the previous year. The 19 services were categorized as either
treatment services (11 services) or support services (8 services). The treatment services
include comprehensive assessment/diagnosis, self-help or mutual-help groups,
detoxification, individual therapy, group therapy other than relapse prevention, relapse
prevention groups, family counseling, combined substance abuse and mental health
treatment, acupuncture, aftercare, and outcome follow-up. Facilities were categorized into
three treatment intensity groups based on the level of treatment services they offered. An
estimated 12 percent of facilities offered a low level of treatment services (5 or fewer
services); 52 percent offered a medium level (6 to 8 services); and 36 percent offered a
high level (9 to 11 services) of treatment services.

13
! Number of support services - Facilities were classified by types of selected support
services they provide to patients (e.g., child care, transportation, employment
counseling/training). The number of services was grouped into low, medium, and high
levels.

! Support - The eight services classified for ADSS as support services included child care,
transportation, employment counseling/training, academic education/GED classes,
HIV/AIDS education/counseling/support, TB screening, prenatal care, and smoking
cessation. Facilities were categorized into four support service levels. Eleven (11) percent
of facilities offered no support services; 37 percent of facilities offered a low level of
support services (1 to 2 services); 35 percent offered a medium level (3 to 4 services); and
17 percent offered a high level of support services (5 to 8 services) (Table 1.4).3

! Client-to-staff ratio - Facilities were classified by their ratio of substance abuse clients to
direct-care substance abuse treatment staff. A client-to-staff ratio variable was created to
examine the distribution of caseloads in the substance abuse treatment system. The point-
prevalence client count was divided by the point-prevalence direct-care FTE staff count.
One third of facilities was categorized as having a low client-to-staff ratio (4 clients or
fewer per staff ); one third had a medium client-to-staff ratio (5 to 14 clients per staff);
and one third had a high client-to-staff ratio (more than 14 clients per staff).

! Facility setting - Facilities were classified by the setting of the substance abuse treatment
facility with respect to its location within a hospital organization or being freestanding
apart from hospital organizations, in community health centers, non-hospital residential
units, schools, or in outpatient organizations.

1.4.3 Type of Care

Facilities were sampled and analyzed by the following broad types of care: hospital
inpatient, non-hospital residential, outpatient methadone-only, outpatient non-methadone only,
and combination facilities. National estimates of the number of facilities by type of care (Tables
1.1 and 1.3) indicate that on October 1, 1996, the treatment system was largely composed of
outpatient non-methadone facilities. Of the estimated 12,387 facilities, 61 percent of facilities
provided outpatient non-methadone-only care, and 17 percent offered non-hospital residential-
only care. Less than 4 percent of facilities provided outpatient methadone-only care, and 3
percent of facilities offered hospital inpatient-only care. An additional 15 percent of facilities
provided more than one type of care in combination facilities. Organizational characteristics of
facilities differed by type of care. A detailed analysis of the facilities by type of care follows.

Hospital inpatient-only facilities were smallest. Seventy-two (72) percent had fewer than
17 clients on October 1, 1996. Nearly 60 percent of these hospital inpatient-only facilities were
owned by private non-profit organizations. More hospital inpatient facilities (22 percent) had

3
Chapter 3 examines treatment and support services in greater detail.

14
public ownership than any other type of care. Like other types of care, the majority of hospital
inpatient-only facilities were located in large or medium metropolitan areas (40 and 26 percent,
respectively, of hospital inpatient-only facilities). However, they had a higher proportion of
facilities (12 percent) in non-MSA urban areas compared with outpatient methadone-only (1
percent) and outpatient non-methadone-only facilities (7 percent). Hospital inpatient-only
facilities were more likely to be legally part of another organization, as an affiliate (62 percent),
than outpatient non-methadone-only facilities (48 percent) and combination facilities (44
percent). However, more than 20 percent of other types of facilities (except for outpatient
methadone-only) reported as a parent facility compared with only 10 percent of hospital
inpatient-only facilities.

Hospital inpatient-only facilities were categorized as offering the highest level of

treatment services: 56 percent were in the high treatment services group (9 to 11 services),
significantly more than all other types of care. Nearly all hospital inpatient-only facilities (97
percent) had client-to-staff ratios falling in the low (4 or less) category, considerably lower ratios
than in all other types of care. Hospital inpatient-only facilities had a mean of 3.2 types of
accreditation or license. Compared with other types of care, they were less likely to have
licensing by State alcohol and drug agencies (65 percent). They were more likely than
non-hospital residential and outpatient methadone to have licensing by State departments of
mental health (39 percent vs. 15 and 13 percent, respectively), more likely than all others to have
State hospital licensing authorities (62 percent) and JCAHO accreditation (85 percent).

Non-hospital residential-only facilities also were relatively small—50 percent had fewer
than 17 clients in treatment on a given day. More than 80 percent had private non-profit
ownership, the highest of any type of care. Eighty-four (84) percent received more than 50
percent of their funding from public revenue sources, also the highest proportion of any type of
care. Almost half (48 percent) of residential facilities were situated in large metropolitan areas
with populations over 1 million, significantly less frequently than outpatient methadone-only
facilities (70 percent) but significantly more frequently than outpatient non-methadone facilities
(40 percent). Fewer non-hospital residential-only facilities (53 percent) were affiliated with
another organization than hospital inpatient-only facilities (62 percent). Thirty-five (35) percent
of non-hospital residential facilities offered a high level of treatment services (9 to 11 treatment
services), exceeding the level of treatment services for outpatient facilities but below the level for
hospital inpatient-only facilities. Thirty-eight (38) percent reported a high level of support
services (5 to 8 support services), significantly higher than any other type of care, except for
combination facilities. Consistent with this, 60 percent of residential facilities had low
client-to-staff ratios, second only to hospital inpatient-only facilities. Compared with other types
of care, non-hospital residential-only facilities were least likely to have JCAHO accreditation (14
percent). However, they were considerably more likely to have licensing from State departments
of public health (36 percent) than outpatient non-methadone facilities (21 percent), most likely
because of the provision of housing and food services.

Outpatient methadone-only facilities differed from other types of care in many respects.
They were the largest facilities: 82 percent had more than 100 clients in treatment on the survey
point-prevalence date. They had the most private for-profit ownership (39 percent of facilities),
and a larger percentage was located in large metropolitan areas (70 percent of facilities) than

15
other types of facilities. They were less likely to be a parent facility (12 percent) than all other
types of care, except for hospital inpatient-only facilities (10 percent).

Outpatient methadone-only facilities reported lower levels of treatment services than any
other type of care (23 percent, 5 or fewer treatment services). Consistent with a lower level of
treatment services, client-to-staff ratios were higher among outpatient methadone-only facilities
than any other type of care: 87 percent reported high client-to-staff ratios. Nearly three quarters
of outpatient methadone-only facilities reported a medium or high level of support services,
significantly more than outpatient non-methadone facilities (33 percent) but significantly less
than non-hospital residential-only facilities (88 percent) or combination facilities (82 percent).
Outpatient methadone-only facilities were more likely to have licensing from State alcohol and
drug agencies (92 percent) and departments of public health (51 percent) than most other types of
care.

Three quarters of facilities (76 percent) provided outpatient non-methadone care, either
alone (60 percent of all facilities) or in combination with other types of care (an additional 15
percent). Outpatient non-methadone-only facilities had a great deal of organizational
heterogeneity. While 59 percent had private non-profit ownership, 27 percent had private
for-profit ownership, and 14 percent were publicly owned. Level of affiliation also varied among
outpatient non-methadone facilities: 22 percent reported as parent facilities, 48 percent as having
legal ties with other organizations, and 30 percent reported no affiliations. Outpatient non-
methadone-only facilities were more likely than other types of care to be in community mental
health centers (28 percent of outpatient non-methadone-only facilities).

Only about one quarter of outpatient non-methadone-only treatment facilities provided a

high level of treatment services (i.e., 9 to 11 types of treatment service), and only 7 percent
provided a high level of support services (i.e., 5 to 8 support services), a lower proportion than
any other type of care. Outpatient non-methadone-only facilities were second only to outpatient
methadone-only facilities in the proportion of facilities with high client-to-staff ratios. State
licensing by alcohol and drug agencies was prevalent in outpatient non-methadone facilities (83
percent of facilities), but relatively few had JCAHO accreditation (22 percent of facilities).

Combination facilities also showed organizational variation. Almost all combination

facilities included outpatient non-methadone treatment in combination with another type of care.
The most frequent combinations were facilities that offered both residential and outpatient
non-methadone care (7 percent of all facilities) and hospital inpatient and outpatient
non-methadone care (5 percent of all facilities). About 2 percent of all facilities offered
methadone treatment combined with some other type of care. When the number of
methadone-combined facilities is added to the number of outpatient methadone-only facilities,
the total estimated number of facilities that provide methadone to clients is 688 facilities.4

4
Estimates of the number of methadone treatment facilities and the number of clients they served are
examined in greater detail in the ADSS Phase I report on methadone treatment facilities.

16
 Combination facilities, almost all of which were outpatient facilities combined with other
types of care, were somewhat larger than other facilities. More than half (57 percent) had more
than 41 clients; only 15 percent reported fewer than 17 clients (Table 1.3). The rate of public
funding was higher in combination facilities, with virtually all reporting some public revenue (98
percent).

Nearly half of combination facilities (868 of the 1,886 combination facilities) included
hospital inpatient care, extrapolating from Table 1.A. Consistent with this finding, combination
facilities offered a high proportion of facilities offering a high level of treatment services (74
percent), higher than any other type of care and 32 percent offered a high number of support
services, significantly more than outpatient methadone-only (20 percent) and outpatient non-
methadone-only (7 percent). The majority of combination facilities (54 percent) reported client-
to-staff ratios of 4 or less, the lowest level, and half were located in hospital settings. They had
higher rates of State alcohol and drug licensing (77 percent) than hospital inpatient-only facilities
(65 percent) but lower rates than outpatient methadone-only facilities (92 percent).

1.4.4 Ownership

The substance abuse treatment system continued to be comprised largely of private

non-profit organizations, as shown in Tables 1.3 and 1.4. There were an estimated 7,847 facilities
with private non-profit ownership on October 1, 1996, or 63 percent of the total. Almost a
quarter of the treatment system, an estimated 2,814 facilities or 23 percent of the total, were
private for-profit organizations. Publicly owned facilities included 1,726 facilities, only 14
percent of all treatment facilities. This picture confirms the important role of private non-profit
organizations, described by earlier studies (Batten et al., 1993; Hubbard et al., 1989; IOM, 1990).

ADSS data suggest important distinctions among facilities by ownership. For example,
private for-profit facilities were less likely to provide non-hospital residential care (only 6 percent
of facilities) than were private non-profit (23 percent of facilities) and publicly owned facilities
(11 percent). A higher proportion of private for-profit organizations (71 percent) provided
outpatient non-methadone care than did private non-profit facilities (57 percent). More private
for-profit facilities (52 percent) were located in large metropolitan areas compared with private
non-profit (42 percent) and public facilities (33 percent), which were more geographically
dispersed. In keeping with their private status, more than 75 percent of private for-profit facilities
reported receiving 50 percent or less of their revenue from public sources.

Facilities with private for-profit ownership reported lower rates of affiliation than other
facilities. Only about half of private for-profit facilities were affiliated with another organization,
either as a parent or through another affiliation, compared with three fourths of private non-
profits and 80 percent of publicly owned facilities. The level of treatment services offered also
varied by ownership. Twenty (20) percent of private for-profit facilities reported a low level of
treatment services compared with 9 percent of private non-profit and 11 percent of publicly
owned facilities. Similarly, few private for-profit facilities (7 percent) provided as high a level of
support services as private non-profit and publicly owned facilities (20 percent of each provided
a high level of support services). These results are consistent with research by Burke and Rafferty
(1994), Friedmann et al. (1999), and Wheeler et al. (1992). Finally, a relatively low proportion of

17
private for-profit facilities were located in community mental health center settings (4 percent of
facilities) compared with private non-profit or publicly owned facilities (21 and 30 percent,
respectively).

As nearly two thirds of the treatment system was comprised of private non-profit
facilities, it is not surprising that they had greater heterogeneity than for-profit or public facilities.
Like the rest of the system, the majority of private non-profit facilities offered outpatient non-
methadone care. However, private non-profit facilities were more likely to provide non-hospital
residential care (23 percent of facilities) compared with private for-profit (6 percent) and public
facilities (11 percent). Although about three fourths (76 percent) of private non-profit facilities
were funded primarily from public revenue sources, nearly a quarter (22 percent) received up to
half of their funding from private sources.

Private non-profit facilities were considerably more likely than private for-profit facilities
to be affiliated with another organization, either as a parent facility (23 percent) or legally part of
another organization (52 percent). More than 90 percent of private non-profit facilities offered a
medium to high level of treatment services, and over half provided a medium to high level of
support services. They were less likely to be located in hospital settings (13 percent) than public
facilities (22 percent), but almost a third (31 percent) were in non-hospital residential settings,
significantly more than private for-profit facilities (10 percent) or public facilities (17 percent).

Like privately owned facilities, the majority of publicly owned facilities provided
outpatient non-methadone care. Publicly owned and private non-profit facilities shared several
characteristics. Both were largely publicly funded, and almost 90 percent provided a medium to
high level of treatment services. Also like private non-profit facilities, about a fifth of public
facilities provided a high level of support services.

However, publicly owned facilities differed from private for-profit and non-profit
facilities in that they were larger, with 38 percent of public facilities having over 100 clients in
treatment on the point-prevalence date compared with only about 20 percent of others having
over 100 clients. As expected, the majority of public facilities had more than 90 percent of their
funding from public sources. While about half were located in large or medium metropolitan
areas, publicly owned facilities were more likely than private for-profits or non-profit facilities to
be in small urban non-MSA areas, 24 percent of public facilities compared with 5 percent of
private for-profit and 12 percent of private non-profit facilities. Public facilities (80 percent) were
also more likely to be affiliated with another organization than either private non-profit (75
percent) or private for-profit facilities (52 percent).

1.4.5 Urbanicity

Table 1.5 shows that most substance abuse treatment facilities were in urban areas.5
Almost 80 percent of all facilities were located in MSAs, consistent with similar estimates of the

5
The urbanicity category used for ADSS is a modification of the Beale Rural-Urban Continuum Codes
(Economic Research Services, U.S. Department of Agriculture). (See Appendix B for a description of the urbanicity
category.)

18
U.S. population living in metropolitan areas in 1996 as shown in Table 1.B (U.S. Bureau of the
Census, 1998). More than 40 percent of facilities were in large metropolitan areas with
populations of 1 million or more; about a fourth were in medium metropolitan areas where the
population ranged from 250,000 to 1 million; and 12 percent were in small MSAs with
populations of fewer than 250,000. Of the remaining 21 percent of facilities in non-MSA
locations, most were in counties with urban populations between 2,500 and 19,999 individuals.
The remaining facilities were in non- metropolitan counties with populations of 20,000 or more
(7 percent of facilities) or were in non-MSA counties that were completely rural or had fewer
than 2,500 urban population. (See Appendix B for description of the urbanicity categories.) In
general, the distribution of facilities mirrored the distribution of the population by urbanicity
setting.

Table 1.B Number and Percentage Distribution of Substance Abuse Treatment

Facilities, and the Percentage Distribution of the U.S. Population, by
Urbanicity Category: National Estimates, 1996
Substance Abuse Treatment U.S. Population
Facilities Distribution, 1996
Cumula- Cumula-
Number of tive tive
Collapsed Beale Code Facilities Percent Percent Percent Percent
Large metro (1m+ pop) 5,359 43% 43% 49% 49%
Medium metro (250k to 1m pop) 2,981 24% 67% 22% 71%
Small metro (less than 250k) 1,418 12% 79% 8% 79%
Large urban, non-metro (20k+) 893 7% 86% 7% 86%
Small urban, non-metro (2.5k to 20k) 1,471 12% 98% 12% 98%
Rural, non-metro (less than 2.5k) 265 2% 100% 2% 100%
Total 12,387 100% 100%

More than 5,000 facilities (43 percent) were located in large MSAs. They were more
likely to offer outpatient methadone treatment (6 percent) than facilities in smaller or less urban
areas, facilities in medium MSAs, and those facilities in rural and small urban non-MSAs. Fewer
facilities in large MSAs (41 percent of facilities) offered no or low levels of support services than
facilities in medium MSAs (50 percent) and those facilities in rural and small urban non-MSAs
(72 and 61 percent, respectively). Nine (9) percent of facilities in small urban MSAs offered
non-hospital residential care compared with up to 20 percent of facilities in MSAs and urban
non-MSAs. Virtually no facilities in small urban or rural non-MSAs offered outpatient
methadone-only care. This finding is consistent with results reported by D'Aunno et al. (1999).

Similar to the U.S. population, facilities in non-MSA rural areas comprised only 2 percent
of the substance abuse treatment facilities. Like the facilities in small MSAs and urban
non-MSAs, facilities in rural areas tended to be small, with 71 percent of facilities having 40 or
fewer clients in treatment on October 1, 1996. A third were publicly owned. More than three
fourths (78 percent) received more than half their funding from public revenue sources, similar to

19
other non-MSA facilities (compared with less than two thirds of MSA facilities). The majority of
rural facilities offered a medium level of treatment services and a low level of support services.
Rural facilities were most often located in community mental health centers (53 percent), a larger
proportion than MSA facilities (9 to 21 percent of these facilities).

1.4.6 Facility Licensing, Approval, and Certification or Accreditation

Licensure or other facility certification or accreditation is influenced by differences in

State regulatory requirements and also is related to facility type of care, percent of public revenue
received, and services offered. Table 1.6 shows types of facility licensing, approval, and
certification or accreditation by facility organizational characteristics. Ninety-five (95) percent of
all facilities (11,732 facilities) reported being licensed, certified, or accredited by some
organization. Most facilities (82 percent) were licensed by State alcohol and drug abuse agencies.
More than a fourth reported licensing by a State mental health agency and over a quarter by State
public health agencies. About 29 percent had JCAHO accreditation, similar to findings of
Friedmann et al. (1999). Ten (10) percent of facilities were licensed by a hospital licensing
authority. Twenty-three (23) percent of facilities reported licensing by some other organization.
Most facilities had more than one type of licensing or accreditation (Table 1.3).

Two thirds of substance abuse treatment facilities licensed by State mental health
agencies (68 percent of these facilities) offered outpatient non-methadone care, more than 4 times
as frequently as those that offered combination care (17 percent). They were least likely to offer
outpatient methadone care (2 percent). These facilities were also most likely to have 50 to 90
percent of their funding from public sources (37 percent) than any other category of facilities
with or without public revenue.

Substance abuse treatment facilities with licensing from State public health departments
were more likely to provide outpatient non-methadone or non-hospital residential care (44 and 21
percent, respectively) than hospital inpatient care (4 percent) or outpatient methadone care (2
percent). More than a third (37 percent) had between 50 and 90 percent of public revenue, and 42
percent provided a high level of treatment services. In fact, very few, 8 percent, offered a low
level of treatment services. Twenty-six (26) percent of these facilities offered a high level of
support services, and no other facilities with different licensing or accreditation characteristics
offered this high a percentage. More commonly, however, facilities licensed by State public
health departments offered a medium level of support services (35 percent). In keeping with the
generous provision of treatment and support services, they were significantly more likely to offer
a low client-to-staff ratio (42 percent) than a high client-to-staff ratio (23 percent).

More than a third of facilities with hospital authority licensing (38 percent) had a low
level of public funding (less than half of their funding from public sources), a significantly
greater proportion than the 10 percent of facilities reporting the highest level of public funding
(more than 90 percent of public revenue). They had a high level of treatment services (78
percent), exceeding facilities in any other licensing or accreditation category. They were more
likely to provide a medium level of support services than a high level (48 vs. 20 percent,
respectively). A greater proportion of facilities with hospital authority licensing (70 percent) had
a low client-to-staff ratio than facilities with other types of licensing.

20
 Similar to facilities with hospital authority licensing, a third of facilities with JCAHO
accreditation received less than half their funding from public revenue sources. JCAHO-
accredited facilities were significantly more likely to receive limited public funding compared
with JCAHO-accredited facilities with more than 90 percent of public funding (23 percent).
More than half of JCAHO-accredited facilities provided a high level of treatment services (57
percent) and low client-to-staff ratios (53 percent).

1.4.7 Level of Facility Affiliation

Table 1.7 shows reported affiliation with other organizations among substance abuse
treatment facilities. More than two thirds of facilities (70 percent) reported having a legal
connection to another organization. Twenty-one (21) percent reported they were a parent
organization with one or more facilities that provided substance abuse treatment services. Nearly
half (49 percent of facilities) reported they were legally a part of another organization but were
not a parent organization. These facilities are designated in this report as affiliated organizations.
Thirty (30) percent of substance abuse treatment facilities reported no affiliation with another
organization.

Facilities reporting as parent organizations tended to be larger (63 percent had more than
40 clients vs. 44 percent of affiliated facilities and 50 percent with no affiliations). Affiliated
non-parent organizations were more likely than non-affiliated facilities to be small (30 vs. 22
percent of non-affiliated facilities) and to be publicly owned (18 vs. 9 percent of non-affiliated
facilities). Twenty-one (21) percent of affiliated organizations were situated in a hospital setting,
twice as many as parent organizations and also significantly more than non-affiliated
organizations (13 percent).

Non-affiliated organizations, those reporting being neither a parent nor a part of another
organization, differed from parent and affiliated organizations. More than a third were private
for-profit facilities (37 percent), and they were more likely than parent facilities to offer a low
level of treatment services (16 percent of non-affiliated facilities vs. 9 percent of parent
facilities).

1.4.8 Services Provided by Other Organizations

Table 1.8 shows facilities that were legally part of another facility and received services
from another organization. Facilities that reported being parent organizations but had no other
affiliations (about 7 percent of all facilities) are excluded from this table. Affiliated facilities in
this table include 63 percent of all facilities (7,748 facilities). Hospital inpatient-only facilities
received a higher proportion of services from another organization (72 percent of facilities) than
facilities that offered outpatient non-methadone or combination types of care (61 percent of each
of these). Because facilities could be linked to more than one type of organization, or the
organization could have multiple designations (i.e., administrative office and a government
agency), column distributions may add to greater than 100 percent.

Over half (55 percent of affiliated facilities) reported being connected to another
organization that is an administrative office. Thirty (30) percent were connected with another

21
substance abuse treatment facility, 20 percent with a hospital, and 27 percent with another type of
organization. Fewer than 12 percent were linked to a government agency. Not surprisingly,
hospital inpatient-only facilities (65 percent) were most likely to be connected to a hospital.
About two thirds of non-hospital residential-only and outpatient methadone-only facilities with
affiliations reported links to administrative offices. Non-hospital residential-only facilities (38
percent of facilities) also were significantly more likely than other types of care, except for
outpatient non-methadone facilities, to report an affiliation with another substance abuse
treatment facility.

Nearly all affiliated facilities (92 percent) received some type of administrative services
from an affiliated organization. More than 80 percent received financial services (88 percent) or
personnel services (82 percent). Two thirds of all affiliated facilities received pricing services.
Hospital inpatient-only facilities (79 percent) were more likely than other types of care, except
for combination facilities, to receive pricing services. Combination facilities (76 percent) were
more likely to receive pricing services than outpatient methadone-only and non-hospital
residential facilities (60 percent of each of these types of facilities).

The majority of affiliated facilities (54 percent) received treatment protocols from other
organizations. Outpatient methadone-only and outpatient non-methadone-only facilities (63 and
57 percent, respectively) received treatment protocols significantly more often than hospital
inpatient-only facilities (46 percent) and combination facilities (39 percent). Non-hospital
residential facilities (56 percent) also received treatment protocols more often than combination
facilities. Less than a third of affiliated facilities (30 percent) received client intake assessment
services. Hospital inpatient-only facilities were more likely to receive client intake assessment
services (40 percent) than outpatient methadone-only and combination facilities (22 and 23
percent, respectively).

1.5 Conclusion
Consistent with findings from earlier studies (Batten et al., 1993; Hubbard et al., 1989;
IOM, 1990; SAMHSA, 1999), ADSS confirms that outpatient and private non-profit facilities
remain most prevalent in the substance abuse treatment system. Also consistent with other
studies (Batten et al., 1993; Hubbard et al., 1989; IOM, 1990; Price & D'Aunno, 1992), ADSS
estimates indicate that two of three facilities (64 percent) delivered outpatient care and 63 percent
had private non-profit ownership. Two thirds received more than 50 percent of their revenue
from public sources. Ownership was associated with differences in service delivery, with private
for-profit facilities delivering a lower level of support services than public or non-profit facilities
(Friedmann et al., 1999; Hubbard et al., 1989; Wheeler et al., 1992). Consistent with the
distribution of the U.S. population, 79 percent of facilities were in MSAs, and urban locations
were associated with a higher level of support services (Goldsmith et al., 1994).

Earlier studies noted the importance of facility licensure or certification in service

delivery (IOM, 1998). ADSS data show substantial licensing or accreditation in the substance
abuse treatment system. Most facilities were licensed by State alcohol and drug abuse agencies.
Although private for-profit facilities tended to report less licensing by State agencies than other
facilities, JCAHO accreditation was more prevalent among this group, perhaps reflecting the fact

22
that they were more likely to be hospital-based or be methadone facilities. The dominant
licensing group included State alcohol and drug agencies, but mental health and medical
organizations also licensed or certified a quarter of all substance abuse treatment facilities.

The influence of the private sector also was evident. In contrast to earlier studies that
indicated methadone treatment was largely delivered by publicly owned facilities (Hubbard et al.,
1989; IOM, 1990), 39 percent of outpatient methadone facilities had private for-profit ownership,
the highest rate of private for-profit ownership among all types of care.

Outpatient non-methadone facilities that treat almost two thirds of all clients are more
diverse than other types of care. They were spread geographically in highly urban and less urban
areas, represented a mix of public and private funding, and a broad range in the numbers of
treatment and support services provided.

ADSS results also point to linkages between substance abuse treatment facilities and
other organizations. Seventy (70) percent of facilities reported some type of affiliation with other
organizations. For the majority of affiliated substance abuse treatment facilities, other
organizations provided administrative and other services, such as providing treatment protocols
or client intake and assessment services. Facilities affiliated with other organizations reported
more public dollars and more support services.

ADSS confirms the size, diversity, and complexity of the U.S. substance abuse treatment
system. More than 12,000 facilities treated more than a million clients on October 1, 1996. While
dominated by outpatient care in private non-profit settings, there also was a substantial presence
of private ownership and funding, particularly in outpatient methadone treatment. More than two
thirds of facilities were linked to other organizations, potentially extending their accessibility and
their range of services. Licensing or accreditation was prevalent across the system. The substance
abuse treatment system is diverse and complex as reflected in the heterogeneity of outpatient
non-methadone care, the mix of public and private ownership, as well as the relationship between
affiliation and level of services.

23
1.6 References for Chapter 1
Batten, H. L., Horgan, C. M., Prottas, J. M., Simon, L. J., Larson, M.J ., Elliott, E. A., Bowden,
M. L., & Lee, M. T. (1993). Drug Services Research Study, Phase I final report:
Non-correctional facilities (revised; submitted to the National Institute on Drug Abuse; available
at http://www.samhsa.gov/oas/dsrs.htm). Waltham, MA: Institute for Health Policy, Brandeis
University.

Bazzoli, G. J., Shortell, S. M., Dubbs, N., Chan, C., & Kralovec, P. (1999). A taxonomy of
health networks and systems: Bringing order out of chaos. Health Services Research, 33,
1683-1717.

Burke, A. C., & Rafferty, J. A. (1994). Ownership differences in the provision of outpatient
substance abuse services. Administration in Social Work, 18, 59-91.

D’Annuo, T., Folz-Murphy, N., & Lin, X. (1999). Changes in methadone treatment practices:
Results from a panel study, 1988-1995. American Journal of Drug and Alcohol Abuse, 25,
681-699.

Drug Services Research Survey (DSRS) unpublished analyses. (1994). Levine-Batten, H.,
Marsden, M. E., Simon, L., Horgan, C. M.

Friedmann, P. D., Alexander, J. A., & D’Aunno, T. A. (1999). Organizational correlates of access
to primary care and mental health services in drug abuse treatment units. Journal of Substance
Abuse Treatment, 16, 71-80.

Goldsmith, H. F., Wagenfeld, M. O., Manderscheid, R. W., Stiles, D. J., Windel, C., & Witkin,
M. J. (1994). The ecology of mental health facilities in metropolitan and nonmetropolitan
counties. In R. W. Manderscheid & M. A. Sonnenschein (Eds.), Mental health, United States,
1994 (DHHS Publication No. SMA 94-3000, pp. 126-134). Rockville, MD: Center for Mental
Health Services, Substance Abuse and Mental Health Services Administration.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg,
H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC:
University of North Carolina Press.

Institute of Medicine. (1990). Treating drug problems: Volume 1 (D. Gerstein & H. Harwood,
Eds.). Washington, DC: National Academy Press.

Institute of Medicine. (1995). Federal regulation of methadone treatment (R. A. Rettig & A.
Yarmolinsky, Eds.). Washington, DC: National Academy Press.

Institute of Medicine. (1997). Managing managed care: Quality improvement in behavioral

health (M. Edmunds, R. Frank, M. Hogan, D. McCarty, R. Robinson-Beale, & C. Weisner, Eds.).
Washington, DC: National Academy Press.

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Institute of Medicine. (1998). Bridging the gap between practice and research: Forging
partnerships with community-based drug and alcohol treatment (S. Lamb, M. R. Greenlick, & D.
McCarty, Eds.). Washington, DC: National Academy Press.

Mavis, B. E., & Stoffelmayr, B. E. (1994). Program factors influencing client satisfaction in
alcohol treatment. Journal of Substance Abuse, 6, 345-354.

McCarty, D. (1995). The effects of state and federal policies and practices on the cost and
utilization of services for alcohol abuse and alcohol dependency (Working Paper). Waltham,
MA: Institute for Health Policy.

McCaughrin, W. C., & Howard, D. L. (1996). Variation in access to outpatient substance abuse
treatment: Organizational factors and conceptual issues. Journal of Substance Abuse, 8, 403-415.

Price, R. H., Burke, A. C., D’Aunno, T. A., Klingel, D. M., McCaughrin, W. C., Rafferty, J. A.,
& Vaughn, T. E. (1991). Outpatient drug abuse treatment services, 1988: Results of a national
survey. In R. W. Pickens, C. G. Leukefeld, & C. R. Schuster (Eds.), Improving drug abuse
treatment (DHHS Publication No. ADM 91-1754, NIDA Research Monograph 106, pp. 63-92).
Rockville, MD: National Institute on Drug Abuse.

Price, R. H., & D’Aunno, T. A. (1992). The organization and impact of outpatient drug abuse
treatment services. In R. R. Watson (Ed.), Drug and alcohol abuse reviews, Volume 3: Treatment
of drug and alcohol abuse (pp. 1-22). Totowa, NJ: Humana Press, Inc.

Substance Abuse and Mental Health Services Administration. (1997). Uniform Facility Data Set
(UFDS): Data for 1996 and 1980-1996. Rockville, MD: Office of Applied Studies.

Substance Abuse and Mental Health Services Administration. (1999). Uniform Facility Data Set
(UFDS): 1997. Data on substance abuse treatment facilities (DHHS Publication No. SMA
99-3314, Drug and Alcohol Services Information System Series S-6; available as a PDF,
http://wwwdasis.samhsa.gov/97ufds/ufds1997report.pdf, from
http://www.samhsa.gov/oas/dasis.htm#nssats2). Rockville, MD: Office of Applied Studies.

Timko, C. (1995). Policies and services in residential substance abuse programs: Comparisons
with psychiatric programs. Journal of Substance Abuse, 7, 43-59.

U.S. Bureau of the Census. (1998). Statistical abstract of the United States 1998 (available on-
line as a PDF at http://www.census.gov/statab/www/). Washington, DC: U.S. Government
Printing Office, Superintendent of Documents. [See No. 40, Metropolitan and Nonmetropolitan
Area Population: 1970-1996, p. 39.]

Wheeler, J. C, Fadel, H., & D’Aunno, T. A. (1992). Ownership and performance of outpatient
substance abuse treatment centers. American Journal of Public Health, 82, 711-718.

25
 Table 1.1 Number of Substance Abuse Treatment Facilities, Average Number of Direct-Care Staff per Facility, and Average Facility
Percentage of Public Revenue, by Facility Type of Care: National Estimates
Average Number of
Unweighted Direct-Care Staff Average Percentage of
Number of National Estimates of Facilities (FTE) per Facility Facility Revenue from
Facilities on October 1, 1996 on October 1, 1996 Public Sourcesb

Sample Weighted
Facility Type of Carea n N (± SE) % Mean Median Mean Median
Total, All Facilities 2,395 12,387 267.4 100.0 11.4 6 62.3 76.1
Type of Care
Hospital Inpatient Only 203 378 25.0 3.1 27.1 14 64.1 70.4
Non-Hospital Residential Only 428 2,135 107.7 17.2 10.2 6 76.7 87.8
Outpatient Methadone Only 324 464 24.8 3.8 11.7 10 59.9 73.4
Outpatient Non-Methadone Only 1,083 7,524 236.3 60.7 7.2 5 57.9 73.0
Combination Facilities 357 1,886 113.7 15.2 25.9 15 63.8 69.9
26

a
Because Table 1.1 presents data on facility staffing and revenue available only at the overall facility level, rather than within each type of care, the facilities are categorized by
their overall type of care (i.e., facilities with only one type of care are counted by that type of care and facilities with more than one type of care are classified as
"combination" facilities, except methadone facilities, which are included in the outpatient methadone category if 70 percent or more of their clients are in methadone
treatment). Therefore, the counts of facilities offering a specific type of care in Table 1.1 generally include only the single-modality facilities and do not represent all facilities
with that type of care; those with a type of care in combination with another modality are counted in the "combination" category. For a count of all facilities providing a
particular type of care, whether alone or in combination with another type of care, see Table 1.2.
b
At least 97 percent of facilities provided source of revenue data for their most recent 12-month reporting period.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, and Department of
Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Table 1.2 Number of Facilities and Number of Clients, and the Average Number of Clients per Facility, by Client Type of Care:
National Estimates
National Estimates of
Clients in Treatment, by
Weighted Facilities with Facility Type, Number of Clients per
Unweighted
Each Type of Careb on October 1, 1996 Facility
Facility
Client Type of Carea Sample (n)b N % N % Mean Median
Total 2,395 12,387 100.0 1,091,328 100.0 88 40
Type of Care
Hospital Inpatient 343 1,247 10.1 14,649 1.3 12 6
Non-Hospital Residential 598 3,169 25.6 100,290 9.2 32 13
Outpatient Methadone 418 688 5.6 151,882 13.9 221 177
Outpatient Non-Methadone 1,435 9,385 75.8 824,507 75.6 88 29
a
Because clients in combination facilities can be counted by their specific treatment modality within the facility, there is no "combination" type of care category, as there is
for facility type of care in Table 1.1.
27

b
This table presents estimates of the number of facilities providing each type of care, whether provided alone or in combination with other types of care (i.e., facilities
providing more than one type of care are counted in more than one category). Therefore, the unweighted and weighted numbers of facilities providing each type of care add
to more than the total, and the percentages offering each type of care add to more than 100 percent.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, and Department of
Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services
Administration.
Table 1.3 Percentage Distribution of Substance Abuse Treatment Facilities, by Selected Facility
Characteristics and by Facility Type of Care: National Estimates, October 1, 1996
Facility Type of Care
Non- Outpatient
Hospital Hospital Outpatient Non-
Inpatient Residential Methadone Methadone Combination
Total Only Only Only Only Facilities
Number of Facilities (weighted estimate) 12,387 378 2,135 464 7,524 1,886
Percent of Facilities 100.0 3.1 17.2 3.8 60.7 15.2
Facility Sizea (on October 1, 1996)
Small (<17 clients) 25.7 72.0 49.8 0.9 20.7 15.3
Medium (17-40) 24.4 20.5 32.8 1.9 22.8 27.6
Large (41-100) 26.4 6.9 14.2 15.2 30.8 29.0
Very Large (>100) 23.5 0.7 3.3 82.0 25.7 28.1
a
Ownership
Private For-Profit 22.7 18.7 7.7 38.9 26.6 21.2
Private Non-Profit 63.4 59.1 83.2 48.7 59.0 62.8
Public 13.9 22.2 9.2 12.5 14.4 16.0
a
Percent Public Revenue
0% 13.6 6.6 7.4 18.1 18.5 1.6*
1 - 50% 18.8 26.6 7.0 17.4 18.4 32.6
51 - 90% 33.7 29.4 42.7 29.5 31.7 33.7
91 - 99% 18.6 18.3 27.2 30.7 15.0 20.3
100% 12.4 8.8 14.4 2.1 13.4 9.6
Unknown % 2.8 10.4 1.3* 2.2 3.1 2.2*
Urbanicitya
Metro: Large Metro (1 million+ pop) 43.3 40.4 48.3 69.5 39.8 45.6
Medium Metro (250,000 - 1
million pop) 24.1 25.9 22.3 24.6 24.0 25.8
Small Metro (< 250,000 pop) 11.5 8.3 13.6 4.5 10.8 13.9
Non-metro: Urban (20,000+ pop) 7.2 12.2 8.4 1.4 6.9 7.7
Small Urban (2,500 - 19,999
pop) 11.9 11.0 6.4 0.0 15.8 5.5
Rural (< 2,500 pop) 2.1 2.1* 1.0* 0.0 2.7 1.5*
a
Level of Affiliation
Parent Facility 21.4 10.4 21.3 11.8 21.8 24.8
Affiliate 49.0 62.2 53.4 55.5 47.9 44.2
Non-Affiliate 29.6 27.4 25.3 32.7 30.3 31.0
a
Number of Treatment Services
Low (0-5) 11.7 9.9 11.3 23.2 13.7 2.0*
Medium (6-8) 51.8 34.1 53.5 46.0 59.6 23.9
High (9-11) 36.4 55.9 35.3 30.9 26.7 74.1
See notes at end of table. (continued)

28
Table 1.3 (continued)
Facility Type of Care
Non- Outpatient
Hospital Hospital Outpatient Non-
Inpatient Residential Methadone Methadone Combination
Total Only Only Only Only Facilities
a
Number of Support Services
None 10.7 7.9 0.7* 0.2* 16.8 1.0*
Low (1-2) 36.9 21.9 11.7 28.0 50.3 17.0
Medium (3-4) 35.4 47.1 49.7 52.0 26.0 49.9
High (5-8) 17.1 23.2 37.9 19.8 6.9 32.1
Client-to-Staff Ratio (Direct-Care
FTEs)a
Low (4 or less) 32.9 97.2 59.5 2.9 18.9 53.8
Medium (>4 to 14) 33.9 2.5* 38.2 10.6 36.4 30.8
High (more than 14) 33.2 0.4 2.3 86.5 44.8 15.4
Facility Settinga,b
Hospital (inpatient or outpatient) 16.1 95.8 2.7 11.6 7.7 49.9
Non-Hospital Residential, Therapeutic
Community or Halfway House 24.2 2.9 96.1 0.9 1.7 42.3
Community Mental Health Center 18.5 2.3* 2.2* 5.0 28.2 4.7
Other Outpatient 45.5 1.2* 1.1* 83.0 60.3 36.3
Other 11.4 2.2 7.6 4.4 15.1 4.6
Certification Typea,b
State Alcohol or Drug Agency 82.4 65.3 86.0 92.1 82.8 77.3
State Dept. of Mental Health 28.8 39.1 15.3 12.7 32.1 32.7
State Dept. of Public Health 29.1 56.3 35.6 50.8 21.2 43.3
Hospital Licensing Authority 10.3 62.1 2.0* 6.2 4.6 33.4
JCAHO 28.7 85.4 14.3 27.7 21.9 61.0
Other 22.5 20.4 22.6 40.1 18.2 36.0
Mean Number of Licenses or
Accreditation 1.9 3.2 1.6 1.9 1.7 2.6
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with
caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and
Mental Health Services Administration.

29
Table 1.4 Percentage Distribution of Substance Abuse Treatment Facilities, by Selected Facility
Characteristics and by Facility Ownership: National Estimates, October 1, 1996
Facility Ownership
Private Private
Total For-Profit Non-Profit Public
Number of Facilities (weighted estimate) 12,387 2,814 7,847 1,726
Percent of Facilities 100.0 22.7 63.4 13.9
a
Facility Type of Care
Hospital Inpatient Only 3.1 2.5 2.9 4.9
Non-Hospital Residential Only 17.2 5.8 22.6 11.4
Outpatient Methadone Only 3.8 6.4 2.9 3.4
Outpatient Non-Methadone Only 60.7 71.1 56.6 62.9
Combination Facilities 15.2 14.2 15.1 17.5
a
Facility Size (on October 1, 1996)
Small (<17 clients) 25.7 28.9 25.8 20.2
Medium (17-40) 24.4 28.7 23.8 19.9
Large (41-100) 26.4 22.8 28.6 21.8
Very Large (>100) 23.5 19.7 21.7 38.1
a
Percent Public Revenue
0% 13.6 39.6 6.8 2.4*
1 - 50% 18.8 35.3 15.3 7.8
51 - 90% 33.7 14.3 40.7 33.7
91 - 99% 18.6 2.5 22.2 28.4
100% 12.4 1.4* 13.1 27.3
Unknown % 2.8 6.9 1.9 0.4
a
Urbanicity
Metro: Large Metro (1 million+ pop) 43.3 52.3 42.4 32.5
Medium Metro (250,000 - 1 million
pop) 24.1 27.0 24.6 16.6
Small Metro (< 250,000 pop) 11.5 11.5 11.2 12.6
Non-metro: Urban (20,000+ pop) 7.2 3.9* 8.0 8.9
Small Urban (2,500 - 19,999 pop) 11.9 5.0 11.6 24.4
Rural (< 2,500 pop) 2.1 0.3* 2.2 5.0*
a
Level of Affiliation
Parent Facility 21.4 17.9 23.1 19.6
Affiliate 49.0 33.9 51.7 61.3
Non-Affiliate 29.6 48.2 25.2 19.1
a
Number of Treatment Services
Low (0-5) 11.7 20.0 8.8 11.4
Medium (6-8) 51.8 38.1 57.1 50.2
High (9-11) 36.4 41.9 34.1 38.4
See notes at end of table. (continued)

30
Table 1.4 (continued)
Facility Ownership
Private Private
Total For-Profit Non-Profit Public
a
Number of Support Services
None 10.7 21.2 8.2 5.0
Low (1-2) 36.9 45.8 34.9 31.0
Medium (3-4) 35.4 26.2 37.1 42.6
High (5-8) 17.1 6.8 19.8 21.4
a
Client-to-Staff Ratio (Direct-Care FTEs)
Low (4 or less) 32.9 34.1 32.4 33.7
Medium (>4 to 14) 33.9 34.9 34.7 28.4
High (more than 14) 33.2 31.0 33.0 37.8
a,b
Facility Setting
Hospital (inpatient or outpatient) 16.1 21.2 13.0 21.8
Non-Hospital Residential, Therapeutic
Community or Halfway House 24.2 9.7 31.0 16.8
Community Mental Health Center 18.5 4.4 21.0 30.1
Other Outpatient 45.5 56.7 43.6 36.0
Other 11.4 26.8 6.8 7.2
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, half-way houses without paid counseling staff, solo
practices, correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

31
Table 1.5 Percentage Distribution of Substance Abuse Treatment Facilities, by Selected Facility
Characteristics and by Urbanicity: National Estimates, October 1, 1996
Urbanicitya
Metropolitan Non-Metropolitan
Medium
Metro Small Urban
Large Metro (250,000 - Small Metro Urban (2,500 - Rural
Total (1 million+) 1 million) (< 250,000) (20,000+) 19,999) (<2,500)
Number of Facilities (weighted
estimate) 12,387 5,359 2,981 1,418 893 1,471 265
Percent of Facilities 100.0 43.3 24.1 11.5 7.2 11.9 2.1
a
Facility Type of Care
Hospital Inpatient Only 3.1 2.9 3.3 2.2 5.2 2.8 3.0*
Non-Hospital Residential Only 17.2 19.2 16.0 20.4 20.1 9.3 8.3*
Outpatient Methadone Only 3.8 6.0 3.8 1.5 0.7 0.0 0.0
Outpatient Non-Methadone Only 60.7 55.9 60.6 57.4 57.8 80.8 77.9
Combination Facilities 15.2 16.1 16.3 18.5 16.2 7.0 10.9*
a
Facility Size (on October 1, 1996)
Small (<17 clients) 25.7 22.0 24.4 38.7 29.4 24.6 40.5
Medium (17-40) 24.4 25.7 24.7 13.3 26.2 27.5 30.4*
Large (41-100) 26.4 25.9 26.0 25.7 24.5 32.2 16.6*
Very Large (>100) 23.5 26.4 24.9 22.3 19.9 15.7 12.4*
a
Ownership
Private For-Profit 22.7 27.5 25.5 22.9 12.4* 9.5 2.8*
Private Non-Profit 63.4 62.1 64.9 61.8 70.5 61.9 64.3
Public 13.9 10.5 9.6 15.3 17.1 28.6 32.9
a
Percent Public Revenue
0% 13.6 16.4 14.4 10.5 10.2* 9.4 1.2*
1 - 50% 18.8 18.3 20.6 25.4 14.6 13.5 16.8*
51 - 90% 33.7 27.1 35.5 29.1 42.7 52.5 37.6
91 - 99% 18.6 20.8 16.6 18.9 18.0 15.4 15.9*
100% 12.4 13.4 11.4 13.6* 13.0* 7.3 24.1*
Unknown % 2.8 4.1 1.5 2.5* 1.5* 1.9* 4.4*
a
Level of Affiliation
Parent Facility 21.4 21.2 23.1 18.2 19.9 23.9 17.3*
Affiliate 49.0 46.3 50.1 51.2 56.2 50.9 44.1
Non-Affiliate 29.6 32.5 26.8 30.6 24.0 25.3 38.6
a
Number of Treatment Services
Low (0-5) 11.7 12.6 11.4 13.4 12.4 6.7* 14.7*
Medium (6-8) 51.8 49.1 49.1 56.9 51.4 61.8 57.3
High (9-11) 36.4 38.4 39.5 29.8 36.2 31.4 28.0*
See notes at end of table. (continued)

32
Table 1.5 (continued)
Urbanicitya
Metropolitan Non-Metropolitan
Medium
Metro Small Urban
Large Metro (250,000 - Small Metro Urban (2,500 - Rural
Total (1 million+) 1 million) (< 250,000) (20,000+) 19,999) (<2,500)
Number of Support Servicesa
None 10.7 7.7 8.7 12.0 12.0* 22.7 17.1*
Low (1-2) 36.9 33.6 40.8 39.8 31.5 38.2 54.4
Medium (3-4) 35.4 39.7 33.9 27.7 41.8 28.1 23.8*
High (5-8) 17.1 19.0 16.7 20.5 14.8 11.0 4.6*
Client-to-Staff Ratio (Direct-Care
FTEs)a
Low (4 or less) 32.9 30.8 34.7 39.3 37.2 29.1 29.9*
Medium (>4 to 14) 33.9 37.6 28.3 34.2 36.4 29.6 34.8
High (more than 14) 33.2 31.6 37.1 26.5 26.4 41.3 35.3
b
Facility Setting
Hospital (inpatient or outpatient) 16.1 16.2 17.9 14.3 18.9 14.0 5.8*
Non-Hospital Residential,
Therapeutic Community or
Halfway House 24.2 26.5 21.5 30.6 29.8 12.3 19.1*
Community Mental Health Center 18.5 9.1 16.3 21.3 28.5 42.2 52.6
Other Outpatient 45.5 51.9 49.0 33.4 36.3 35.5 29.6*
Other 11.4 11.6 11.9 17.4 4.2 8.9 6.4*
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service Facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

33
Table 1.6 Percentage Distribution of Substance Abuse Treatment Facilities, by Selected Facility
Characteristics and by Facility Certification: National Estimates, October 1, 1996
Type of Certificationa [Q-A7]
Facilities State Alcohol State Mental State Public Hospital
with Any or Drug Health Health Certification
Total Certification Abuse Agency Agency Facility Authority JCAHO Other
Number of Facilities (weighted
estimate) 12,387 11,732 10,177 3,527 3,573 1,255 3,523 2,739
Percent of Facilities 100.0 94.7 82.4 28.8 29.1 10.3 28.7 22.5
Percent of Facilities with
Certification Type 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Facility Type of Carea
Hospital Inpatient Only 3.1 3.2 2.4 4.1 5.9 18.6 9.2 2.8
Non-Hospital Residential Only 17.2 17.0 18.0 9.1 21.0 3.3* 8.5 17.3
Outpatient Methadone Only 3.8 3.9 4.2 1.6 6.5 2.2 3.5 6.7
Outpatient Non-Methadone Only 60.7 59.8 61.2 67.8 44.0 27.0 46.5 49.2
Combination Facilities 15.2 16.1 14.3 17.3 22.6 48.9 32.3 23.9
a
Facility Size (on October 1,
1996)
Small (<17 clients) 25.7 25.3 24.3 23.8 28.6 33.6 32.2 26.6
Medium (17-40) 24.4 24.0 22.4 32.1 26.9 34.9 27.7 26.4
Large (41-100) 26.4 26.5 27.9 23.3 23.0 18.9 19.5 22.7
Very Large (>100) 23.5 24.2 25.4 20.8 21.4 12.7 20.7 24.4
Ownershipa
Private For-Profit 22.7 21.8 20.2 21.2 21.1 31.9 29.4 22.2
Private Non-Profit 63.4 64.0 66.8 62.2 68.3 55.5 57.6 66.9
Public 13.9 14.2 13.0 16.5 10.6 12.6 12.9 10.9
Percent Public Revenuea
0% 13.6 12.6 12.6 8.5 9.7 9.1* 10.4 11.1
1 - 50% 18.8 19.2 18.5 21.9 19.1 37.8 32.8 16.6
51 - 90% 33.7 34.7 35.4 37.0 36.8 30.5 28.8 36.3
91 - 99% 18.6 19.4 20.6 20.6 23.7 6.4 11.4 19.9
100% 12.4 11.6 10.9 8.0 8.6 4.1 11.2 12.1
Unknown % 2.8 2.5 2.1 4.1 2.2* 12.1* 5.5* 3.93*
a
Urbanicity
Metro: Large Metro (1 million+
pop) 43.3 42.9 43.7 33.0 42.8 45.5 42.1 55.6
Medium Metro
(250,000 - 1 million pop) 24.1 23.8 22.5 23.8 26.7 26.9 29.6 17.6
Small Metro (< 250,000
pop) 11.5 11.5 11.9 11.3 10.0 6.7 9.9 10.9
Non-metro: Urban (20,000+
pop) 7.2 7.4 7.6 10.6 7.0 10.4 6.7 7.2
Small Urban (2,500 -
19,999 pop) 11.9 12.3 12.4 17.7 11.8 9.2* 10.2 8.1
Rural (< 2,500 pop) 2.1 2.1 1.9 3.6* 1.6* 1.2* 1.6* 0.6*
See notes at end of table. (continued)

34
Table 1.6 (continued)
Type of Certificationa [Q-A7]
Facilities State Alcohol State Mental State Public Hospital
with Any or Drug Health Health Certification
Total Certification Abuse Agency Agency Facility Authority JCAHO Other
a
Level of Affiliation
Parent Facility 21.4 21.9 22.9 19.8 23.0 15.5 18.6 20.2
Affiliate 49.0 50.0 49.2 53.9 51.0 62.1 60.0 50.4
Non-Affiliate 29.6 28.1 27.9 26.4 26.0 22.5 21.5 29.5
Number of Treatment Servicesa
Low (0-5) 11.7 11.0 11.1 8.6 7.5 2.3* 6.2 7.1
Medium (6-8) 51.8 51.6 54.4 48.9 44.9 19.4 36.4 47.7
High (9-11) 36.4 37.5 34.5 42.4 47.6 78.3 57.3 45.3
Number of Support Servicesa
None 10.7 10.4 10.2 11.7 9.3 2.8* 8.5 5.7
Low (1-2) 36.9 36.2 37.4 39.2 30.4 29.6 35.0 32.4
Medium (3-4) 35.4 35.8 34.3 33.9 34.8 47.6 36.9 29.5
High (5-8) 17.1 17.6 18.2 15.2 25.5 19.9 19.6 22.4
Client-to-Staff Ratio (Direct-
Care FTEs)a
Low (4 or less) 32.9 32.9 30.2 35.3 42.4 69.9 52.8 38.1
Medium (>4 to 14) 33.9 33.5 34.0 34.9 34.2 18.3 23.2 30.9
High (more than 14) 33.2 33.6 35.8 29.7 23.3 11.8 24.0 31.0
Facility Settinga,b
Hospital (inpatient or outpatient) 16.1 17.0 13.5 17.9 23.3 87.7 50.4 19.2
Non-Hospital Residential,
Therapeutic Community or
Halfway House 24.2 24.4 25.7 16.3 31.8 4.4 13.8 30.1
Community Mental Health Center 18.5 19.2 19.3 45.9 14.1 2.7* 15.8 14.0
Other Outpatient 45.5 44.8 47.9 27.5 40.4 12.7 28.0 46.8
Other 11.4 9.8 9.8 12.5 11.1 3.7* 3.6 10.1
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

35
Table 1.7 Percentage Distribution of Substance Abuse Treatment Facilities, by Selected Facility
Characteristics and by Level of Affiliation with Other Facilities: National Estimates,
October 1, 1996
Level of Affiliationa
Total Parent Affiliate None
Number of Facilities (weighted estimate) 12,387 2,657 6,067 3,661
Percent of Facilities 100.0 21.4 49.0 29.6
Percent of Facilities with Affiliation Type 100.0 100.0 100.0 100.0
a
Facility Type of Care
Hospital Inpatient Only 3.1 1.5 3.9 2.8
Non-Hospital Residential Only 17.2 17.1 18.8 14.8
Outpatient Methadone Only 3.8 2.1 4.3 4.1
Outpatient Non-Methadone Only 60.7 61.8 59.3 62.3
Combination Facilities 15.2 17.6 13.8 16.0
Facility Sizea (on October 1, 1996)
Small (<17 clients) 25.7 22.1 29.6 21.9
Medium (17-40) 24.4 15.1 26.1 28.4
Large (41-100) 26.4 35.9 22.9 25.2
Very Large (>100) 23.5 27.0 21.4 24.6
Ownershipa
Private For-Profit 22.7 19.0 15.7 37.1
Private Non-Profit 63.4 68.3 66.9 53.9
Public 13.9 12.7 17.5 9.0
Percent Public Revenuea
0% 13.6 12.5 10.2 20.2
1 - 50% 18.8 17.5 18.1 20.8
51 - 90% 33.7 38.9 33.1 31.1
91 - 99% 18.6 21.0 20.6 13.7
100% 12.4 8.4 15.5 10.3
Unknown % 2.8 1.8* 2.6 4.1*
a
Urbanicity
Metro: Large Metro (1 million+ pop) 43.3 42.8 40.9 47.5
Medium Metro (250,000 - 1 million pop) 24.1 25.9 24.6 21.8
Small Metro (< 250,000 pop) 11.5 9.7 12.0 11.9
Non-metro: Urban (20,000+ pop) 7.2 6.7 8.3 5.9
Small Urban (2,500 - 19,999 pop) 11.9 13.2 12.3 10.2
Rural (< 2,500 pop) 2.1 1.7* 1.9* 2.8
a
Number of Treatment Services
Low (0-5) 11.7 8.8 10.6 15.7
Medium (6-8) 51.8 51.3 51.7 29.9
High (9-11) 36.4 40.0 37.7 31.8
See notes at end of table. (continued)

36
Table 1.7 (continued)
Level of Affiliationa
Total Parent Affiliate None
a
Number of Support Services
None 10.7 10.3 9.4 13.2
Low (1-2) 36.9 35.8 36.1 38.9
Medium (3-4) 35.4 32.1 36.7 35.6
High (5-8) 17.1 21.8 17.8 12.4
Client-to-Staff Ratio (Direct-Care FTEs)a
Low (4 or less) 32.9 28.6 38.1 27.4
Medium (>4 to 14) 33.9 35.9 30.3 38.4
High (more than 14) 33.2 35.5 31.6 34.3
a,b
Facility Setting
Hospital (inpatient or outpatient) 16.1 10.0 20.7 12.8
Non-Hospital Residential, Therapeutic
Community or Halfway House 24.2 27.6 22.5 24.4
Community Mental Health Center 18.5 20.3 22.0 11.5
Other Outpatient 45.5 48.7 39.0 54.1
Other 11.4 10.8 6.4 20.0
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

37
 Table 1.8 Number and Percentage of Substance Abuse Treatment Facilities with Affiliation with Other Organizations, and Service
Provided by Affiliated Organizations, by Facility Type of Care: National Estimates, October 1, 1996
Facility Type of Care
Non- Outpatient
Hospital Hospital Non-
All Inpatient Residential Methadone Methadone Combination
Affiliations Facilities Only Only Only Only Facilities
Total Number of Facilities (national estimates) 12,387 378 2,134 464 7,524 1,886
Number of Facilities with Affiliationsa 7,748 271 1,460 294 4,570 1,153
Percent with Affiliations 62.6 71.7 68.4 63.3 60.7 61.1
a,b
Types of Organizations Affiliated with Percent of Affiliated Facilities
Hospital 20.0 65.2 6.6 22.0 16.9 38.7
Substance abuse treatment facility 29.7 10.4 38.0 28.2 30.1 22.0
Administrative office 55.3 40.7 65.6 65.4 52.9 52.0
Government agency 11.5 12.9 7.1 11.1 12.8 12.2
Other 27.1 12.6 21.7 13.6 33.5 14.5
38

a,b
Types of Services Provided by Other Organization
Financial 88.4 89.1 91.0 90.0 88.3 84.7
Personnel 82.4 84.1 82.5 90.9 82.5 79.5
Pricing 67.2 78.7 59.7 59.5 67.1 76.2
Treatment protocols 54.0 45.9 55.8 63.0 57.0 39.4
Client intake/assessment 29.7 39.8 27.8 22.2 32.0 22.9
a
Facilities with affiliations are those that indicated in ADSS Phase I question A11 that they were legally part of another organization.
b
Not mutually exclusive categories.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, and Department of
Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Chapter 2. Client Populations in Substance Abuse
Treatment Facilities
Mary Ellen Marsden, Sharon Reif, Maria Pieroni, Helen J. Levine, Margaret T. Lee, Grant A.
Ritter, and Constance M. Horgan

2.1 Introduction
This chapter presents national estimates of the number and characteristics of clients in
substance abuse treatment facilities in 1996 based on reports of facility directors. Substance
abuse treatment facilities are facilities providing alcohol or drug abuse treatment or recovery
services using specified personnel, designated space or resources, and a specified budget for such
services. Types of facilities excluded from this study are halfway houses without paid counselors,
solo practitioners, correctional facilities, Department of Defense (DoD) facilities, Indian Health
Service facilities, and facilities that are intake and referral only. This chapter examines the
demographic and other characteristics of clients receiving treatment in varied types of care and
treatment settings and in facilities that are owned publicly or by private for-profit and private
non-profit organizations. The number of special population clients, such as women and
adolescents, and the number of facilities providing special programs for those clients also are
examined. Data reported here are drawn from Phase I: The Facility Survey of the Alcohol and
Drug Services Study (ADSS). ADSS Phase I is a study of a nationally representative sample of
substance abuse facilities across the Nation, and it builds upon the work of the 1990 Drug
Services Research Survey (DSRS) (Batten et al., 1993) with a more complete sampling frame,
enhanced sampling design, and improved measures of financing and organization. ADSS uses
the same sample frame as that of the Uniform Facilities Data Set (UFDS) (Substance Abuse and
Mental Health Services Administration [SAMHSA], 1997b), augmented to yield the universe of
substance abuse treatment facilities in the United States. Facilities providing treatment for both
illicit drug and alcohol problems are included in the study, as are publicly and privately owned
facilities. ADSS was designed to produce statistically unbiased national estimates of substance
abuse treatment facilities and clients in treatment.

The data reported on here are based on reports from facility directors regarding their
client populations and are not aggregated from data about individual clients within those
facilities. In the tables appearing at the end of this chapter, the Phase I questionnaire numbers
from which the data were drawn are noted as Q-x. Information about the data collection
methodology of the ADSS Phase I study and about methadone facilities will be presented in
separate reports. Findings from Phase II on the cost of treatment and on detailed client-level
treatment record abstract data will be presented in subsequent reports.

2.1.1 Background

According to UFDS, almost 1 million people receive treatment in substance abuse

treatment facilities on a given day, and this number had grown over the prior decade. On October
1, 1996, 940,141 people were receiving treatment for substance abuse compared with 614,123 on
October 30, 1987 (Alcohol, Drug Abuse, and Mental Health Administration [ADAMHA], 1989;

39
SAMHSA, 1997b). Increases in the number of clients in treatment reflected dramatic increases in
public expenditures for treatment over the prior decade (Huber, Pope, & Dayhoff, 1994), as well
as the growth in private-sector facilities (Schmidt & Weisner, 1993). These increases in
expenditures marked an intensified Federal commitment to drug control activities, as well as an
attempt to increase the number of individuals receiving treatment. Part of the increase in the
numbers of clients in treatment may, however, be related to improved data collection procedures
in studies on which knowledge of treatment populations is based. Although the growth in the
private sector leveled off during the 1990s, the increase in private-sector clients coupled with
targeted treatment for women changed the character of the client population (Weisner,
Greenfield, & Room, 1995). The client population is aging and becoming more female, although
males constitute about 70 percent of the treatment population. The racial and ethnic composition
of the client population has, however, changed little in recent years (SAMHSA, 1997b).

The drugs of abuse of the treatment population also are changing. Although heroin
abusers were the largest group of drug abuse treatment clients during the 1970s and 1980s
(Hubbard et al., 1989), they were superseded by cocaine abusers during the 1990s (Craddock,
Rounds-Bryant, Flynn, & Hubbard, 1997). A doubling of heroin-related emergency room
episodes between 1990 and 1996 may foreshadow increases in heroin abusers among the
treatment population (SAMHSA, 1997c). Among clients in substance abuse treatment facilities,
according to the Treatment Episode Data Set (TEDS), treatment admissions are dominated by
four primary substances of abuse: alcohol, cocaine, heroin and other opiates, and marijuana.
Alcohol accounted for about half of all treatment admissions in 1996, according to TEDS
(SAMHSA, 1998a). Because TEDS includes predominantly publicly owned facilities, these
findings might differ somewhat if a broader representation of facilities were included. Substance
abuse treatment clients are, however, more likely to abuse both alcohol and drugs than either
alone, and the proportion who abuse both is increasing, according to UFDS data. In 1996, 28
percent of substance abuse treatment clients had abused alcohol only, 29 percent had abused
drugs only, and 43 percent had abused alcohol and drugs. The proportion of clients who abused
both alcohol and other drugs increased from 26 to 43 percent during the 1990s, while
corresponding decreases were found in the proportion who abused alcohol only (SAMHSA,
1997b). The proportion abusing drugs only was more stable.

The majority of clients receive care in outpatient facilities and in facilities that are largely
publicly funded (SAMHSA, 1997b). The characteristics of clients receiving care differ by type of
facility. The Institute of Medicine (IOM, 1990b), for example, documented the fact that public
clients were less likely to be employed and had lower levels of education, higher severity
substance abuse problems, and more involvement with the criminal justice system. Clients in
inpatient and residential settings also are more likely to have greater problem severity than clients
in outpatient settings (Hubbard et al., 1989). Facilities with private-only funding reported higher
proportions of men, white, and Hispanic clients (SAMHSA, 1997b, p. 29).

Many clients are thought to require special treatment services to remain in treatment and
for treatment to be effective. These "targeted population" clients include women, adolescents,
indigent clients, and racial/ethnic minorities, among others (IOM, 1990a). Women, for example,
reported more psychiatric symptoms and depression, were less likely to be employed, and were
less likely to have been arrested (Wallen, 1992). They may benefit from services such as child

40
care and transportation to remain in treatment (SAMHSA, 1994). The AIDS epidemic has had a
dramatic effect on the delivery of services in substance abuse treatment as the importance of drug
abuse treatment in reducing the spread of AIDS and the special treatment needs of AIDS clients
were recognized (Fletcher, Tims, & Brown, 1997). More emphasis is being placed on getting
substance abusers into treatment and not lapsing into risky behaviors (Sorensen & Miller, 1996).
Racial/ethnic groups may benefit from culturally appropriate treatment programs that take into
account their differential patterns of substance abuse (Arciniega, Arroyo, Miller, & Tonigan,
1996). Criminal justice clients may require close supervision in treatment, and their involuntary
stay may affect the treatment process, although they typically stay longer in treatment than other
clients (IOM, 1990b). Although adolescents constitute less than 10 percent of the treatment client
population according to most studies, they are often treated in separate programs and indeed may
not benefit from standard treatment approaches (Kaminer & Frances, 1991).

2.1.2 Methodology Overview

Phase I of ADSS consisted of a mail questionnaire collected by telephone interview with

facility directors at a random sample of 2,395 non-correctional alcohol and drug treatment
facilities representing 12,387 facilities nationwide, stratified by type of care within the substance
abuse treatment system. The sample frame was SAMHSA's 1995 National Master Facility
Inventory (NMFI), augmented to yield the universe of substance abuse treatment facilities known
to SAMHSA. As mentioned in the introduction, treatment facilities excluded from the sampling
frame were halfway houses without paid counselors, solo practitioners, correctional facilities,
DoD facilities, Indian Health Service facilities, and facilities that are intake and referral only.

Phase I: The Facility Survey was conducted from December 1996 to June 1997, with data
collected for a point-prevalence date of October 1, 1996, and for the most recent 12-month
reporting period of the facility. The point-prevalence date was chosen to be the same as the 1996
UFDS (SAMHSA, 1997a). The questionnaire was mailed out in advance so that the director had
a chance to gather information to fill out the questionnaire. The responses then were collected by
telephone. The Phase I response rate was 91.4 percent of 2,603 facilities eligible for ADSS.

Because the Phase I sampling design incorporates a stratified random probability sample,
weights have been developed to produce national estimates of facilities. The sampling weights
adjust for facility non-response and for differential response rates within strata. The data in this
report were imputed to account for missing values on several key variables. Overall, item
non-response was very low, about 3 percent for client counts and about 10 percent for cost and
revenue. Further information about the data collection methodology for the study is presented in
Appendix A. Variable definitions appear in Appendix B, and standard error tables are presented
in Appendix C. Information on imputation of missing data also is presented in the separate report
titled Sample Design, Selection and Estimation for Phase I of ADSS (Mohadjer, Yansaneh,
Krenzke, & Dohrmann, 2000, Chapter 5). In analyses presented here, only statistically significant
differences are discussed.1

1
All comparisons reported in this chapter are significant, except where noted otherwise, using the
Bonferroni correction to p = .05 based on the number of comparisons.

41
 2.1.3 Organization of the Chapter

First, the chapter presents national estimates of the number of clients in substance abuse
treatment, according to point-prevalence and annual admissions and discharge data gathered from
facility directors. These estimates are examined by selected facility characteristics, including type
of care, treatment setting, ownership of facility, percent public revenue, urbanicity, and level of
affiliation of the facility with other organizations. In these analyses, attention focuses on the size
of the client population in treatment facilities and the types of facilities in which clients receive
care. Second, demographic and other client characteristics are reviewed by type of care, treatment
setting, and ownership of the facility providing treatment. These analyses examine the extent to
which the client populations differ in types of facilities. Third, the number of special population
clients, such as women and adolescents, and the nature of facilities providing treatment to these
populations are discussed. Special population clients may require specialized treatment services
to aid in their recovery. The chapter ends by summarizing findings on the characteristics of
clients in substance abuse treatment facilities.

2.2 Findings on the Number of Clients in Treatment

On October 1, 1996, about 1 million individuals were receiving treatment in substance
abuse treatment programs across the Nation, according to reports of facility directors in ADSS.
Some 4.3 million admissions to treatment and about 3.7 million discharges were reported within
the recent year (see Table 2.1). Note, however, that the definition of a treatment admission or
discharge may vary across treatment facilities, affecting the reporting of the number of
admissions and discharges. There is particularly likely to be variation in reporting the number of
discharges in outpatient facilities; while some facilities may officially discharge a client who has
not received treatment within a month or other specified period of time, other facilities may keep
those clients as part of the active client population.

The estimate of 1,091,328 clients in treatment on October 1, 1996, derived from ADSS, is
slightly higher than the estimate provided by UFDS for the same date: 940,141 (SAMHSA,
1997b). The difference of about 150,000 between the two point-prevalence estimates from ADSS
and UFDS is related to how facility response was handled and to differences in sampling frames
(see footnote 2 in Chapter 1, Section 1.3.1). Although ADSS omits certain types of facilities that
are included in the UFDS study (halfway houses without paid counselors, solo practitioners,
correctional facilities, DoD facilities, Indian Health Service facilities, and facilities that are intake
and referral only), the ADSS frame augmentation process increased the number of facilities
surveyed and thereby the number of clients. Indeed, 12,387 facilities are represented in ADSS
and 10,641 facilities in UFDS for 1996. Further, the more intensive mail/telephone data
collection procedures utilized by ADSS may have affected the estimates of the size of the client
treatment population.

The number of annual admissions and discharges to treatment is generally several times
higher than the number of clients in a 1-day census. As shown in Table 2.1, facility directors
reported 4,295,815 admissions to treatment in substance abuse treatment facilities during the
most recent 12-month period and 3,680,566 discharges from those facilities in that year. Thus,

42
the number of admissions is 3.9 times higher and the number of discharges 3.4 times higher than
the 1-day census of clients in this study.

Note also that the numbers of admissions and discharges are not unduplicated counts of
clients. That is, individual clients could have been admitted or discharged more than once during
the year, contributing more than once to the total number of admissions or discharges during the
year. According to the ADSS Phase II client abstract data, for example, about 30 percent of
clients in substance abuse treatment had been in treatment during the 12 months prior to the
treatment episode in question (SAMHSA, unpublished data). The actual number of individual
clients admitted or discharged during the year is therefore smaller than the total number of
admissions or discharges.

Table 2.1 also presents information about the distribution of clients among types of
facilities, based on point-prevalence data from October 1, 1996, as well as data on annual
admissions and discharges. Only the findings from the point-prevalence data are discussed here.

2.2.1 Type of Care

Data from the client census on October 1, 1996, show that clients were in predominantly
outpatient types of care: 824,507 clients or 76 percent of the client population of about 1 million
were in outpatient non-methadone treatment and 14 percent were in outpatient methadone
treatment for a total of 90 percent of clients in outpatient care. Few clients were being treated in
hospital inpatient (1.3 percent) or in residential (9 percent) care. Data from the 1996 UFDS study
(SAMHSA, 1997b) similarly indicate that the majority of clients were in outpatient treatment.

2.2.2 Setting

Consistent with the distribution of clients by type of care, the majority of clients received
treatment in outpatient settings: 18 percent were receiving outpatient care in community mental
health centers and 60 percent were in treatment in other outpatient settings. Only 13 percent of
clients were receiving treatment in hospitals, and 15 percent were receiving treatment in other
residential settings, such as non-hospital residential, therapeutic communities, or halfway houses.
Most clients were thus receiving care in community-based non-hospital settings on an outpatient
basis. Note that these types of settings are not mutually exclusive and therefore do not add to 100
percent. Note also that the current treatment may not be the first or only treatment episode or
setting; substance abusers may have multiple treatment episodes during their lifetimes in varied
treatment settings (Anglin, Hser, & Grella, 1997).

2.2.3 Ownership

The majority of clients (60 percent) were being treated in facilities owned by private
non-profit organizations, as shown in Table 2.1. About 19 percent of clients received care in
private for-profit facilities and 21 percent in publicly owned facilities. The IOM (1990b)
documented the relative stability of the number of publicly owned facilities during the 1980s,
contrasted with the growth in the private tier of programs that includes private non-profit and
private for-profit programs.

43
 2.2.4 Percent Public Revenue

Consistent with the high proportion of clients who received treatment in private
non-profit facilities, the majority of clients were receiving treatment in facilities with largely
public funding. More than two thirds of clients (68 percent) received treatment in facilities that
received half or more of their revenue from public sources. Relatively few clients (14 percent)
received treatment in facilities that received none of their revenue from public sources.

2.2.5 Urbanicity2

Half of all clients (49 percent) were receiving care in facilities in large metropolitan areas
(metropolitan statistical areas [MSAs] with a population of 1 million or more), according to the
distribution of clients among categories of metropolitan and non-metropolitan areas defined by
the Beale index (Butler & Beale, 1994). Another one fourth (25 percent) received care in
medium-sized MSAs (counties with populations of 250,000 to 1 million). About 15 percent of
clients received care in facilities located in non-metropolitan areas—in rural, small urban, or
urban areas. Data from the National Household Survey on Drug Abuse (NHSDA) indicate that
about 48 percent of those who needed treatment lived in large metropolitan areas and about 55
percent of those who received treatment in the past year lived in large metropolitan areas
(SAMHSA, 1997a).

2.2.6 Level of Affiliation3

A higher proportion of clients were being treated in facilities that are affiliates of other
treatment organizations (44 percent) than in facilities that are parent organizations (26 percent) or
not affiliated with other facilities (31 percent). The level of services appears to be higher in
treatment facilities that are affiliated with other organizations. Lee et al., as seen in Chapter 3 of
this report, found that parent and affiliate facilities tend to offer more services; similarly,
Alexander, Anderson, and Lewis (1985) found that units that were owned or affiliated with
another entity offer more services.

2.3 Findings on Client Characteristics

Demographic characteristics, primary source of payment, referral source, and principal
drug of abuse reported by facility directors for clients in substance abuse treatment on October 1,
1996, are presented in Tables 2.2 to 2.4 by type of care (Table 2.2), treatment setting (Table 2.3),
and ownership of facility (Table 2.4). Additional information about whether clients are receiving
treatment for alcohol abuse, drug abuse, or both is presented in Table 2.5.

Across all types of facilities, as shown in Table 2.2, clients in substance abuse treatment
programs were predominantly males (67 percent), white non-Hispanic clients (61 percent), and

2
See Appendix B for the definition of "urbanicity."

3
See Appendix B for the definition of "facility level of affiliation."

44
primarily alcohol abusers (47 percent). About 1 in 5 were primarily cocaine abusers (19 percent),
about 1 in 10 were marijuana/hashish/THC abusers (12 percent), and 1 in 10 were heroin/other
opiate abusers (10 percent). Most clients were relatively young: More than half (58 percent) were
under the age of 35, and one fourth were under the age of 25 (26 percent), including 11 percent
under the age of 18. About one third (38 percent) were aged 35 or older (4 percent were of
unknown age). Table 2.2 also includes information on clients' primary expected source of
payment for treatment, as reported by facility directors. For almost one half of clients (47
percent), the primary expected source of payment for treatment reported by facility directors was
public funds, either Medicaid, Medicare, or other public payment. About one in five (19 percent)
had private health insurance that was expected to pay for treatment, while almost one fourth (23
percent) were described as self-pay. About one third (34 percent) were referred to treatment by
the criminal justice system, while more than one in four were referred by another treatment
program, health care organization, or social service agency. About one in five (21 percent) were
self-referred to treatment or came to treatment voluntarily.

Findings regarding the percentage distribution of clients by gender, race/ethnicity, and age
are highly similar to those reported in UFDS for 1996 (SAMHSA, 1997b) and TEDS for 1996
(SAMHSA, 1998). Because ADSS and UFDS facilities are based on generally the same universe
of facilities, their similarity is expected. ADSS and TEDS, however, are not directly comparable
because private facilities are underrepresented in TEDS, which primarily includes facilities that
receive public funding and report to State substance abuse agencies, not all of which report for
private for-profit facilities. Data from UFDS show that the proportion of women increased
between 1980 and 1996, while the treatment population aged overall and the racial/ethnic
composition was relatively stable.

These findings support those found in a number of studies about the predominance of
young adults, males, and non-Hispanic whites in substance abuse treatment, as well as the
importance of public funds in paying for treatment. Alcohol is the major problem substance,
although cocaine, heroin, and marijuana also are important. A large proportion of clients
continue to be referred to treatment by the criminal justice system. Note, however, that recent
changes in Federal legislation, which now disallows Supplemental Security Income and Social
Security Disability Insurance to those disabled by substance abuse only without a disabling
psychiatric or medical condition, may bring changes in the substance abuse treatment population
and funding for treatment (IOM, 1997).

2.3.1 Clients in Types of Care

The characteristics of clients by or within types of care are similar to those found for all
types of facilities, as shown in Table 2.2, with several exceptions. In each of the types of care
(hospital inpatient, residential, outpatient methadone, and outpatient non-methadone), about two
thirds of clients are male and half to two thirds are non-Hispanic whites. However, the client
populations of types of facilities differ as to age composition. Clients in outpatient methadone
facilities are on average older: 66 percent are aged 35 or older and only 5 percent are under age
25. Residential and outpatient non-methadone facilities have higher proportions of clients under
age 18 than other types of facilities. The older age of methadone clients is consistent with
findings from the Drug Abuse Treatment Outcome Study (DATOS) in which outpatient

45
methadone clients were older on average than clients in other modalities (mean age of 37 years
vs. an overall mean of 33 years) and the most likely to have had prior substance abuse treatment
(74 percent vs. less than 50 percent in other modalities) (Anglin et al., 1997).

Although the primary source of payment reported by facility directors for almost half of
clients in most types of care is public funds, for residential facilities, the proportion is almost two
thirds. Client self-payment is the primary source of payment for a relatively large proportion of
outpatient methadone clients (39 percent); relatively few clients in residential and outpatient
methadone facilities pay for treatment with private health insurance. In contrast to the one third
of clients across all types of facilities who are referred to treatment by the criminal justice
system, only 10 percent of hospital inpatient or outpatient methadone clients are so referred.
More than one in five residential clients are referred to treatment by other treatment programs.
The primary drug of abuse for clients in outpatient methadone facilities is as expected
overwhelmingly heroin and other opiates, while the proportion of clients who are cocaine abusers
is highest in residential facilities.

These differences in the client populations of types of facilities reflect variations in

funding, treatment needs, and the long-term nature of methadone treatment. It is possible that
different types of care may need to offer different types of services to meet the needs of their
client populations.

2.3.2 Clients in Treatment Settings

The characteristics of clients by treatment setting are similar to those found for all types
of facilities for gender, race/ethnicity, and age, as shown in Table 2.3. However, there are some
differences by treatment setting for other client characteristics. A higher proportion of clients in
hospital settings pay for treatment with private insurance (41 percent), while relatively few
clients in non-hospital residential or related facilities or in community mental health centers do
so. Almost two thirds of clients in non-hospital residential and related facilities pay for treatment
with public money, a much higher proportion than in other settings. More than 40 percent of
clients in community mental health centers and other outpatient settings are referred to treatment
by the criminal justice system compared with about one fourth of clients in residential facilities
and 14 percent in hospital settings. Clients in community mental health centers are more likely to
have alcohol as the primary drug of abuse, while cocaine abusers are more common in
non-hospital residential and related facilities than other types of facilities.

2.3.3 Clients in Ownership Types

There was relatively little variation in client characteristics by ownership of facility;

clients in private for-profit, private non-profit, and public facilities were similar on most
characteristics (Table 2.4). The major exception was source of payment as reported by facility
directors. Clients in private for-profit facilities were reported to be more likely to self-pay (32
percent) and to pay for treatment with private health insurance (41 percent) and less likely to
have treatment covered by public sources (22 percent) than were clients in other types of
facilities. Relatively few clients in private non-profit and public facilities paid for treatment with
private health insurance. Private for-profit facilities treated slightly higher proportions of males

46
and non-Hispanic whites, while private non-profit facilities treated higher proportions of
adolescents than other types of facilities. These findings suggest that the client populations of
ownership types of facilities are similar, at least on the characteristics considered here. However,
clients who are able to pay for their care themselves or with private insurance are more likely to
receive treatment in private for-profit facilities. Indeed, facilities are now likely to accept a range
of types of clients who pay with both public and private funds.

2.3.4 Treatment for Alcohol and Drug Abuse

More than half of clients in substance abuse treatment facilities on October 1, 1996 (51
percent) were receiving treatment for both alcohol and drug abuse (Table 2.5). Almost one third
(29 percent) were receiving treatment for alcohol abuse but not drug abuse, while about one in
five (19 percent) were receiving treatment for drug abuse but not alcohol abuse. Alcohol abusers
were more common in outpatient non-methadone facilities and community mental health centers;
in facilities with lower proportions of public revenue; and in facilities in rural and small urban
non-metropolitan areas. Drug-only abusers were more common in outpatient methadone facilities
and in facilities in large metropolitan areas. Combined alcohol and drug abusers were more
common in residential facilities and in non-hospital residential and therapeutic community
settings; in private non-profit facilities and facilities with larger proportions of public funding;
and in non-metropolitan urban and metropolitan areas. Combined alcohol and drug abusers
increased in treatment programs during the 1990s (SAMHSA, 1997b).

2.4 Findings on Special Population Clients and Programs

Many clients in treatment for substance abuse are members of special populations, such
as women and adolescents who bring to treatment special needs and may require specialized
services to meet those needs. As shown in Table 2.6, of the more than 4.2 million clients
admitted to treatment during the most recent 12-month period at the time of the survey, about 1.2
percent were pregnant women, 9 percent were receiving Supplementary Security Income (SSI) or
Social Security Disability Income (SSDI) payments, 0.2 percent had active tuberculosis, and 2.1
percent were HIV-positive. Although these special populations constitute relatively small
proportions of the client population of substance abuse treatment facilities, they may require
highly specialized services.

During the recent 12-month period, not all facilities admitted clients who fell into the
groups considered to be special populations. About two thirds of facilities reported that they
admitted SSI/SSDI clients, slightly more than one half admitted pregnant women, half admitted
HIV-positive clients, and one third admitted those diagnosed with AIDS. Fewer (15 percent)
admitted clients with active tuberculosis.

Less than half of all substance abuse treatment facilities reported that they provided
special programs for these types of clients, also shown in Table 2.6. About 40 percent provided
special programs for dual-diagnosis clients (those with combined substance abuse and mental
health problems), while about one third provided special programs for women, one third had
programs for adolescents, and one third had programs for clients driving while impaired or under
the influence (DWI/DUI). About one in five facilities provided special programs for clients with

47
HIV or AIDS, and one in five had programs for pregnant women. Thus, although facilities may
admit clients who fall into special populations, they do not necessarily provide special programs
for those clients.

2.4.1 Special Population Clients in Types of Facilities

Table 2.7 shows the characteristics of facilities that admit special population clients
during the 12 months before the survey or for which selected types of clients are included in their
treatment populations. As noted above, more than half of all facilities admitted SSI/SSDI clients,
pregnant women, or HIV-positive clients, while fewer admitted AIDS-diagnosed or active
tuberculosis clients. Women are included in the treatment populations of about 90 percent of all
facilities, while about 80 percent include dual-diagnosis clients. Adolescents received treatment
in about 40 percent of all facilities. The types of facilities admitting or having in their treatment
populations these types of clients varied:

! Pregnant women were more often admitted to hospital inpatient and outpatient programs
than other residential types of care, publicly owned facilities, facilities with largely public
funding, and parent facilities compared with affiliates or non-affiliates.

! SSI/SSDI clients were more often admitted to hospital inpatient and outpatient
methadone facilities, community mental health centers, publicly owned facilities, and
facilities with largely public funding.

! Clients with active tuberculosis were more often admitted to hospital inpatient facilities
or outpatient methadone facilities, facilities in hospital settings or non-hospital residential
facilities, and publicly owned facilities or facilities with a larger proportion of public
funding.

! Clients who are HIV-positive or AIDS-diagnosed are more often admitted to hospital
inpatient facilities or outpatient methadone facilities, hospital settings, publicly owned
facilities or facilities with a larger proportion of public funding, and facilities in large
metropolitan areas.

! Women are more often included in the client populations of outpatient (methadone and
non-methadone) facilities and settings other than non-hospital residential facilities.

! Adolescents are more often included in the client populations of outpatient

non-methadone facilities, community mental health centers, publicly owned facilities,
facilities in rural and small urban areas compared with medium and large metropolitan
areas and parent facilities compared with affiliates.

! Dual-diagnosis clients are more often included in the client populations of outpatient
methadone and outpatient non-methadone facilities, non-hospital residential and hospital
settings, and publicly owned facilities and facilities with a larger proportion of public
funding.

48
Overall, publicly owned and funded facilities are more likely to admit special population clients
and include them in their client populations, but these types of clients are not consistently related
to other facility characteristics. Women, adolescents, and dual-diagnosis clients are often treated
in outpatient settings, while clients with medical problems, such as active tuberculosis or
HIV/AIDS status, are more often included in inpatient facilities or outpatient methadone
facilities.

2.4.2 Programs for Special Population Clients

Not all facilities that admitted special population clients provide special programs for
them, as shown in Table 2.8. Comparing the findings presented in Tables 2.7 and 2.8, although
almost 40 percent of facilities reported that they accept adolescents, only about two thirds of
those facilities that include adolescents in their treatment population offer special programs for
them. Of the almost 80 percent of facilities that accept dual-diagnosis clients, about half of
facilities with dual-diagnosis clients reported that they provide special programs for them.
Although women are included in the client populations of about 90 percent of all facilities, only
about 40 percent of facilities with women clients offer special programs for women. Of the half
of all facilities that admitted pregnant women, only about one third of those who admitted them
offer special programs. Of the almost 54 percent of facilities that admitted HIV-positive clients
or almost 33 percent that admitted AIDS-diagnosed clients, about one third offer programs for
AIDS/HIV-positive clients.

The provision of special programs for special population clients is not consistently related
to facility characteristics. However, public and private non-profit facilities, publicly funded
facilities, facilities in metropolitan areas, and parent facilities are generally more likely to provide
specialized programs for special population clients. Provision of specialized programs in public
facilities is in part a reflection of block grant requirements and mandates for services for special
populations (IOM, 1998).

2.5 Conclusions
More than 1 million individuals were receiving treatment in substance abuse treatment
facilities on October 1, 1996. Almost 4.3 million admissions to treatment and about 3.7 million
discharges from treatment were made in the recent year. Three quarters of clients were receiving
treatment in outpatient non-methadone, and another 14 percent in outpatient methadone facilities,
for a total of about 89 percent being treated in outpatient facilities. Relatively few were in
hospital inpatient or residential treatment. The majority of clients received care in facilities
owned by private non-profit organizations and in facilities with largely public funding. Most
clients were treated in facilities in metropolitan areas. Across all types of facilities, clients were
largely males, white non-Hispanics, and more than half were under 34 years of age. Cocaine,
marijuana, and heroin were common drugs of abuse, and more than half of clients in substance
abuse treatment facilities were receiving care for both alcohol and drug abuse. The client
population of substance abuse treatment facilities varied by type of care, treatment settings, and
ownership of facilities. Clients with private insurance were more likely to receive care in
inpatient settings, while others were more likely to receive outpatient care. Residential and

49
inpatient facilities were more likely to admit clients with special medical problems, such as
tuberculosis, HIV, and AIDS.

Although many facilities admitted special population clients, such as women or

adolescents, not all offered special programs for those types of clients. Of the more than 4
million admissions to treatment during the most recent year, about 9 percent were receiving SSI
or SSDI payments, about 2.1 percent were HIV-positive, about 1.2 percent were pregnant
women, and 0.2 percent had active tuberculosis. Publicly owned and funded facilities were more
likely to admit special population clients as well as provide special programs for them. Some
public funding carries requirements that may include services for special populations.

Findings presented in this chapter illustrate the diversity of types of clients receiving care
in substance abuse treatment facilities. Clients in treatment are at varying stages of their overall
recovery process. For many, the treatment received in these facilities will not be their only
treatment episode, and they may be in treatment multiple times in response to their abuse of
alcohol or drugs or both.

50
2.6 References for Chapter 2
Alcohol, Drug Abuse, and Mental Health Administration. (1989). National Drug and Alcoholism
Treatment Unit Survey (NDATUS): 1987 final report (DHHS Publication No. ADM 89-1626).
Rockville, MD: U.S. Department of Health and Human Services.

Alexander, J. A., Anderson, J. G., & Lewis, B. L. (1985). Toward an empirical classification of
hospitals in multihospital systems. Medical Care, 23, 913-932.

Anglin, M. D., Hser, Y.-I., & Grella, C. E. (1997). Drug addiction and treatment careers among
clients in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive
Behaviors, 11, 308-323.

Arciniega, L., Arroyo, J., Miller, W., & Tonigan, J. S. (1996). Alcohol, drug use and
consequences among Hispanics seeking treatment for alcohol-related problems. Journal of
Studies on Alcohol, 57, 613-618.

Batten, H. L., Horgan, C. M., Prottas, J. M., Simon, L. J., Larson, M. J., Elliott, E. A., Bowden,
M. L., & Lee, M. (1993). Drug Services Research Survey. Phase I final report: Non-correctional
facilities (revised; submitted to National Institute on Drug Abuse; available at
http://www.samhsa.gov/oas/dsrs.htm). Waltham, MA: Institute for Health Policy, Brandeis
University.

Butler, M. A., & Beale, C. L. (1994). Rural-urban continuum codes for metropolitan and
nonmetropolitan counties, 1993 (Staff Report No. AGES 9425; codes also available at
http://www.ers.usda.gov:80/briefing/rural/data/code93.txt). Washington, DC: U.S. Department of
Agriculture, Economic Research Service.

Craddock, S. G., Rounds-Bryant, J. L., Flynn, P. M., & Hubbard, R. L. (1997). Characteristics
and pretreatment behaviors of clients entering drug abuse treatment: 1969 to 1993. American
Journal of Drug and Alcohol Abuse, 23, 43-59.

Fletcher, B. W., Tims, F. M., & Brown, B. S. (1997). Drug Abuse Treatment Outcome Study
(DATOS): Treatment evaluation research in the United States. Psychology of Addictive
Behaviors, 11, 216-229.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg,
H. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC: University
of North Carolina Press.

Huber, J. H., Pope, G. C., & Dayhoff, D. A. (1994). National and state spending on specialty
alcoholism treatment: 1979 and 1989. American Journal of Public Health, 84, 1662-1666.

Institute of Medicine. (1990a). The treatment of special populations: Overview and definitions.
In Institute of Medicine (Ed.), Broadening the base of treatment for alcohol problems (pp. 344-
355). Washington, DC: National Academy Press.

51
Institute of Medicine (D. Gerstein & H. Harwood, Eds.). (1990b). Treating drug problems.
Volume 1. Washington, DC: National Academy Press.

Institute of Medicine (M. Edmunds, R. Frank, M. Hogan, D. McCarty, R. Robinson-Beale, & C.

Weisner, Eds.). (1997). Managing managed care: Quality improvement in behavioral health.
Washington, DC: National Academy Press.

Institute of Medicine (S. Lamb, M. R. Greenlick, & D. McCarty, Eds.). (1998). Bridging the gap
between practice and research: Forging partnerships with community-based drug and alcohol
treatment. Washington, DC: National Academy Press.

Kaminer, K., & Frances, R. J. (1991). Inpatient treatment of adolescents with psychiatric and
substance abuse disorders. Hospital & Community Psychiatry, 42, 894-896.

Mohadjer, L., Yansaneh, I., Krenzke, T., & Dohrmann, S. (2000). Sample design, selection and
estimation for Phase I of ADSS: Final report (available as a PDF file at
http://www.samhsa.gov/oas/adss.htm). Rockville, MD: Substance Abuse and Mental Health
Services Administration, Office of Applied Studies.

Schmidt, L., & Weisner, C. (1993). Developments in alcoholism treatment. In M. Galanter (Ed.),
Recent developments in alcoholism, Volume II: Ten years of progress (pp. 369-396). New York:
Plenum Press.

Sorensen, J. L., & Miller, M. S. (1996). Impact of HIV risk and infection on delivery of
psychosocial treatment services in outpatient programs. Journal of Substance Abuse Treatment,
13, 387-395; discussion 439.

Substance Abuse and Mental Health Services Administration. (1994). Practical approaches in
the treatment of women who abuse alcohol and other drugs. Rockville, MD: Substance Abuse
and Mental Health Services Administration, Center for Substance Abuse Treatment.

Substance Abuse and Mental Health Services Administration (Gerstein, D. R., Foote, M. L., &
Ghadialy, R.). (1997a). The prevalence and correlates of treatment for drug problems (DHHS
Publication No. SMA 97-3135, NHSDA Series H-2). Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (1997b). Uniform Facility Data
Set (UFDS): Data for 1996 and 1980-1996. Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (1997c). Year-end preliminary
estimates from the 1996 Drug Abuse Warning Network (DHHS Publication No. SMA 98-3175,
DAWN Series D-3). Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (1998). National admissions to
substance abuse treatment services: The Treatment Episode Data Set (TEDS) 1992-1996 (DHHS
Publication No. SMA 98-3244, Drug and Alcohol Services Information System Series S-5).
Rockville, MD: Author.

52
Wallen, J. (1992). A comparison of male and female clients in substance abuse treatment.
Journal of Substance Abuse Treatment, 9, 243-248.

Weisner, C., Greenfield, T., & Room, R. (1995). Trends in treatment of alcohol problems in the
US general population, 1979 through 1990. American Journal of Public Health, 85, 55-60.

53
54
Table 2.1 Number of Substance Abuse Treatment Clients, by Selected Facility Characteristics, Point-
Prevalence Count, Annual Admissions, and Annual Discharges: National Estimates, October 1,
1996
Point Prevalence Annual Data
Clients in Treatment on
October 1, 1996 Admissions Discharges
[Q-B1] N % N % N %
Total Number of Clients 1,091,328 100.0 4,295,815 100.0 3,680,566 100.0
Client's Type of Care
Hospital Inpatient 14,649 1.3 603,311 14.0 614,005 16.7
Non-Hospital Residential 100,290 9.2 1,079,858 25.1 990,282 26.9
Outpatient Methadone 151,882 13.9 136,310 3.2 105,382 2.9
Outpatient Non-Methadone 824,507 75.6 2,476,336 57.7 1,970,897 53.5
Facility Settinga
Hospital (inpatient and outpatient) 140,371 12.9 1,156,078 27.0 1,044,061 28.5
Non-Hospital Residential, Therapeutic
Community or Halfway House 162,468 14.9 1,233,077 28.8 1,116,067 30.5
Community Mental Health Center 199,700 18.3 599,439 14.0 475,353 13.0
Other Outpatient 654,245 60.0 1,857,466 43.4 1,534,928 42.0
Other 123,690 11.3 433,492 10.1 363,022 9.9
Ownership
Private For-Profit 210,722 19.3 979,505 22.9 884,877 24.2
Private Non-Profit 652,593 59.8 2,562,028 59.8 2,172,782 59.4
Public 228,013 20.9 742,119 17.3 600,598 16.4
Percent Public Revenue
0% 151,727 13.9 381,687 8.9 307,102 8.4
1-50% 185,139 17.0 939,492 21.9 848,435 23.2
51-90% 403,473 37.0 1,576,796 36.8 1,357,101 37.1
91-99% 223,370 20.5 753,544 17.6 627,349 17.2
100% 108,641 10.0 473,915 11.1 366,382 10.0
Unknown % 18,978 1.7 158,217* 3.7* 151,886* 4.2*
Urbanicityb
Metro: Small Metro 124,238 11.4 511,544 11.9 458,086 12.5
Medium Metro 266,819 24.5 1,145,254 26.7 989,453 27.0
Large Metro 537,867 49.3 1,949,053 45.5 1,657,662 45.3
Non-metro: Rural 12,448 1.1 42,503* 1.0* 37,695* 1.0*
Small Urban 89,613 8.2 333,042 7.8 258,946 7.1
Urban 60,343 5.5 302,255 7.1 256,414 7.0
Level of Affiliationc
Parent Facility 278,323 25.5 1,086,081 25.4 925,674 25.3
Affiliate 475,899 43.6 1,895,799 44.3 1,649,997 45.1
Non-Affiliate 337,090 30.9 1,301,583 30.4 1,082,492 29.6
a
Not mutually exclusive.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities responded to affiliation.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

55
Table 2.2 Percentage Distribution of Substance Abuse Treatment Clients, by Selected Facility Characteristics
and by Client Type of Care: National Estimates, October 1, 1996
Client Type of Care
Hospital Non-Hospital Outpatient Outpatient
Totala Inpatient Residential Methadone Non-Methadone
Total Number of Clients 1,091,328 14,649 100,290 151,882 824,507
Percent of Clients 100.0 100.0 100.0 100.0 100.0
Gender [Q-B2a]
Male 67.2 69.8 63.7 60.5 68.1
Female 31.8 28.9 36.2 38.1 30.5
Unknown 1.1 1.3* 0.2* 1.5* 1.4
Race/Ethnicity [Q-B2b]
White, non-Hispanic 61.0 61.4 53.2 54.4 64.3
Black, non-Hispanic 23.1 23.9 30.4 23.1 20.9
Hispanic 9.8 8.5 9.7 18.2 8.8
Asian or Pacific Islander 0.9 0.1 0.5* 0.8 1.0
American Indian or Alaskan Native 2.5 1.1* 4.1 0.4 2.2
Unknown 2.8 5.1* 2.2* 3.1* 2.9
Age [Q-B2c]
Under 18 11.4 3.6 13.0 0.2* 12.1
18-24 14.1 14.1 15.3 5.0 14.2
25-34 32.1 31.7 37.2 24.3 31.3
35-44 26.4 28.5 25.2 42.0 25.6
45 and older 11.7 17.6 8.1 23.6 11.8
Unknown 4.3 4.5* 1.2 4.9 5.1
Primary Source of Payment [Q-B2d]
No payment 7.4 5.2 9.9 4.1 7.4
Client self-payment 23.1 6.0 15.3 38.6 24.6
Private health insurance (fee-for-service) 9.3 10.8 4.0 2.1* 11.6
Private health insurance (HMO, PPO, managed
care) 10.1 25.3 5.7 4.1 11.9
Medicaid 15.0 22.3 11.1 29.1 13.7
Medicare 3.7 15.3 1.2* 2.6 4.2
Other public payment 28.6 10.9 51.6 17.5 23.3
Unknown 3.0 4.3* 1.3 1.9* 3.4
Referral Sourceb [Q-B6]
Other treatment facility 11.6 10.8 22.6 8.2 7.8
Criminal justice system 33.8 9.6 26.5 10.0 38.4
Self-referred/voluntary 20.6 27.9 19.6 64.9 18.4
Family 5.2 8.4 5.1 2.7 5.5
Friend 2.3 3.0 1.9 5.4 2.2
Employer 4.6 8.9 2.8 0.7 5.5
Health care or mental health providers 9.3 20.5 8.8 3.5 9.4
Welfare offices or other social service agencies 7.4 4.5 9.7 3.3 7.2
Other 5.2 6.4 3.0 1.4 5.6
See notes at end of table. (continued)

56
Table 2.2 (continued)

Client Type of Care

Hospital Non-Hospital Outpatient Outpatient
Totala Inpatient Residential Methadone Non-Methadone
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 10.1 9.7 8.5 98.2 4.4
Cocaine (including crack) 19.1 20.1 30.9 0.4 17.2
Benzodiazepines 1.0 3.0 0.6 0.1* 1.3
Barbiturates 0.5 0.3 0.4 0.0* 0.5
Amphetamines 3.7 1.7 5.3 0.0 3.6
Marijuana/hashish/THC 11.6 3.3 10.4 0.0* 13.3
PCP/LSD 0.8 0.0 0.6 0.0* 0.9
Alcohol 46.8 55.1 38.0 0.0* 51.7
Other drugs (not alcohol) 2.6 2.1 2.7 0.1* 2.9
Unknown 3.7 4.8 2.6 1.2* 4.3
a
Total is not the sum of the four types of care because it is based on the overall client count variables instead of the sum of individual care
variables.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the referral source
information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

57
Table 2.3 Percentage Distribution of Substance Abuse Treatment Clients, by Selected Facility Characteristics
and by Treatment Settings: National Estimates, October 1, 1996
Clients in Treatment Settingsa
Non-Hospital
Inpatient or Residential, Community
Outpatient Therapeutic Mental
Hospital Community or Health Other
Total Setting Halfway House Center Outpatient Other
Total Number of Clients 1,091,328 140,371 162,468 199,700 654,245 123,690
Percent of Clients 100.0 100.0 100.0 100.0 100.0 100.0
Gender [Q-B2a]
Male 67.2 69.0 62.6 67.4 68.9 66.7
Female 31.8 29.6 37.0 31.4 30.0 32.3
Unknown 1.1 1.4* 0.3* 1.3* 1.2* 1.0*
Race/Ethnicity [Q-B2b]
White, non-Hispanic 61.0 65.0 53.4 70.0 59.1 65.3
Black, non-Hispanic 23.1 22.1 30.3 18.4 22.7 17.8
Hispanic 9.8 7.0 10.1 5.1 12.2 9.4
Asian or Pacific Islander 0.9 0.6* 0.5* 1.5* 1.3 1.7*
American Indian or Alaskan Native 2.5 1.3* 3.8 1.9 2.5 3.6*
Unknown 2.8 4.0 1.9 3.2 2.3 2.2
Age [Q-B2c]
Under 18 11.4 7.9* 12.9 12.9 11.7 16.2
18-24 14.1 10.7 16.1 14.8 14.3 14.0
25-34 32.1 31.0 37.0 31.1 31.1 30.6
35-44 26.4 30.7 24.1 25.2 25.5 25.4
45 and older 11.7 15.2 8.1 11.1 12.5 10.1
Unknown 4.3 4.6 1.9 4.9* 4.9 3.8
Primary Source of Payment [Q-B2d]
No payment 7.4 5.2 10.1 7.9 6.5 8.6
Client self-payment 23.1 8.2 17.2 25.6 29.4 26.6
Private health insurance (fee-for-service) 9.3 18.1 4.1 7.4 8.8 13.4
Private health insurance (HMO, PPO,
managed care) 10.1 23.3 4.1 6.0 9.4 13.6
Medicaid 15.0 16.9 11.5 16.9 15.3 14.1
Medicare 3.7 12.2 1.5* 2.7 2.5 2.0*
Other public payment 28.6 13.6 50.0 30.2 24.5 18.0
Unknown 3.0 2.5 1.6 3.3 3.6 3.7*
Referral Sourceb [Q-B6]
Other treatment facility 11.6 11.8 23.5 7.4 6.8 6.9
Criminal justice system 33.8 13.7 27.1 42.3 41.2 34.2
Self-referred/voluntary 20.6 24.6 18.7 18.2 21.0 22.8
Family 5.2 9.0 4.5 6.8 4.2 5.5
Friend 2.3 2.8 2.2 1.9 2.3 2.8
Employer 4.6 8.9 2.4 2.7 4.6 5.6*
Health care or mental health providers 9.3 17.2 7.7 8.4 7.4 11.1
Welfare offices or other social service
agencies 7.4 6.4 10.1 7.4 7.1 6.4
Other 5.2 5.6 3.8 4.9 5.4 4.7
See notes at end of table. (continued)

58
Table 2.3 (continued)

Clients in Treatment Settingsa

Non-Hospital
Inpatient or Residential, Community
Outpatient Therapeutic Mental
Hospital Community or Health Other
Total Setting Halfway House Center Outpatient Other
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 10.1 12.0 8.9 3.2 12.7 5.9
Cocaine (including crack) 19.1 20.6 29.5 14.4 16.3 16.2
Benzodiazepines 1.0 2.1 0.7 1.4 0.7 1.2
Barbiturates 0.5 0.2 0.5* 0.4 0.5 0.5
Amphetamines 3.7 2.6 5.5 2.3 3.6 6.0
Marijuana/hashish/THC 11.6 6.7 10.5 13.6 13.3 13.6
PCP/LSD 0.8 0.3 0.6 0.9* 1.0* 0.8*
Alcohol 46.8 47.9 38.7 55.4 46.2 51.1
Other drugs (not alcohol) 2.6 2.6 2.6 3.0 2.6 1.4
Unknown 3.7 5.1 2.5 5.4 3.0 3.2*
a
Not mutually exclusive.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the referral source
information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

59
Table 2.4 Percentage Distribution of Substance Abuse Treatment Clients, by Selected Facility
Characteristics and by Facility Ownership: National Estimates, October 1, 1996
Clients in Ownership Types
Private For- Private Non-
Totala Profit Profit Public
Total Number of Clients 1,091,328 210,722 652,593 228,013
Percent of Clients 100.0 100.0 100.0 100.0
Gender [Q-B2a]
Male 67.2 70.7 65.8 67.7
Female 31.8 27.5 33.3 31.6
Unknown 1.1 1.7* 0.9 0.8*
Race/Ethnicity [Q-B2b]
White, non-Hispanic 61.0 69.9 58.3 58.2
Black, non-Hispanic 23.1 16.0 25.6 23.8
Hispanic 9.8 8.5 10.8 6.8
Asian or Pacific Islander 0.9 0.6 0.9* 1.1
American Indian or Alaskan Native 2.5 0.9 2.0 7.7
Unknown 2.8 4.2 2.4 2.3
Age [Q-B2c]
Under 18 11.4 7.2 13.6 8.5
18-24 14.1 12.4 14.6 14.7
25-34 32.1 32.7 32.4 29.5
35-44 26.4 30.4 25.0 26.3
45 and older 11.7 12.0 10.7 15.9
Unknown 4.3 5.4 3.7 5.0
Primary Source of Payment [Q-B2d]
No payment 7.4 1.5 8.0 15.0
Client self-payment 23.1 32.4 19.4 23.7
Private health insurance (fee-for-service) 9.3 18.3 7.2 4.2
Private health insurance (HMO, PPO, managed care) 10.1 22.9 6.7 4.3
Medicaid 15.0 8.7 16.9 16.2
Medicare 3.7 7.1 2.7 2.6
Other public payment 28.6 6.1 36.5 29.9
Unknown 3.0 3.1 2.7 4.1
b
Referral Source [Q-B6]
Other treatment facility 11.6 8.5 13.0 10.0
Criminal justice system 33.8 31.4 35.0 32.7
Self-referred/voluntary 20.6 21.0 19.4 25.2
Family 5.2 6.4 4.8 5.0
Friend 2.3 3.7 1.9 1.5
Employer 4.6 10.2 3.0 2.6
Health care or mental health providers 9.3 10.8 8.6 10.1
Welfare offices or other social service agencies 7.4 3.8 8.6 8.1
Other 5.2 4.1 5.7 4.8
See notes at end of table. (continued)

60
Table 2.4 (continued)

Clients in Ownership Types

Private For- Private Non-
Totala Profit Profit Public
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 10.1 13.4 9.3 8.0
Cocaine (including crack) 19.1 16.0 20.6 17.4
Benzodiazepines 1.0 2.0 0.8 0.6
Barbiturates 0.5 0.5 0.5 0.4*
Amphetamines 3.7 2.9 3.9 4.2
Marijuana/hashish/THC 11.6 8.7 13.2 9.6
PCP/LSD 0.8 0.8* 0.8 0.6*
Alcohol 46.8 51.7 43.8 52.0
Other drugs (not alcohol) 2.6 1.5 3.0 2.9
Unknown 3.7 2.6 4.2 4.3
a
Total is not the sum of the four types of care because it is based on the overall client count variables instead of the sum of
individual care variables.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the
referral source information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

61
Table 2.5 Percentage of Clients Receiving Treatment for Alcohol Abuse Only, Drug Abuse Only,
or Both, by Selected Facility Characteristics: National Estimates, October 1, 1996
Percent of Clients
Both Alcohol
Alcohol Drug and Drug
[Q-B7] Total Abuse Only Abuse Only Abuse Unknown
Total 100.0 29.0 19.0 51.3 0.7
Type of Care
Hospital Inpatient Only 100.0 30.9 15.7 46.4 6.9
Non-Hospital Residential Only 100.0 14.7 14.7 69.8 0.8*
Outpatient Methadone Only 100.0 0.3* 85.5 14.2 0.0
Outpatient Non-Methadone Only 100.0 35.7 16.3 47.4 0.6*
Combination Facilities 100.0 24.6 19.2 56.1 0.1*
Facility Settinga
Hospital (inpatient and outpatient) 100.0 30.3 16.9 51.5 1.4
Non-Hospital Residential, Therapeutic
Community or Halfway House 100.0 16.1 15.3 67.7 0.9*
Community Mental Health Center 100.0 38.6 16.3 44.6 0.5*
Other Outpatient 100.0 29.6 23.0 47.0 0.5*
Other 100.0 32.2 16.7 50.4 0.7*
Ownership
Private For-Profit 100.0 35.1 18.6 46.3 -
Private Non-Profit 100.0 26.2 19.2 53.6 1.1
Public 100.0 31.7 19.2 48.8 0.4*
Percent Public Revenue
None 100.0 36.9 17.6 44.5 1.0*
1-50% 100.0 36.1 15.2 47.8 0.9*
51-90% 100.0 28.0 18.2 53.0 0.8*
91-99% 100.0 20.8 22.9 56.2 0.2*
100% 100.0 24.1 23.7 51.3 0.9*
Unknown % 100.0 29.5 15.3 55.2 -
Urbanicityb
Metro: Small Metro 100.0 30.3 13.0 55.7 1.1*
Medium Metro 100.0 29.5 17.6 52.4 0.5*
Large Metro 100.0 22.4 23.5 53.8 0.4*
Non-metro: Rural 100.0 51.4 15.0 28.1 5.5*
Small Urban 100.0 43.3 16.1 39.1 1.4*
Urban 100.0 34.1 12.5 52.8 0.6*
Level of Affiliationc
Parent 100.0 29.1 19.2 51.7 0.0*
Affiliate 100.0 28.0 20.0 50.9 1.1*
Non-Affiliate 100.0 30.4 17.3 51.6 0.7*
a
Not mutually exclusive.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities provided affiliation.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted
with caution.

Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

62
Table 2.6 Facilities Offering Programs for Special Populations and Number of Special
Population Clients Admitted in 12-Month Period: National Estimates, October 1, 1996
Facilities Clients
Number of Clients Percent of Clients
Admitted in 12- Admitted in 12-
N % Month Period Month Period
All Facilities 12,387 100.0 4,295,815 100.0
Admitted Specific Clients [Q-C4]
Pregnant women 6,528 52.7 51,557 1.2
SSI/SSDI 7,897 63.8 391,861 9.1
Active tuberculosis 1,716 14.6 9,350 0.2
HIV-positive 6,267 53.9 91,534 2.1
AIDS-diagnosed 3,795 32.8 42,606* 1.0*
Had Special Programs [Q-B10]
Women 4,631 37.4
Pregnant women 2,393 19.3
Adolescents 3,932 31.8
DWI/DUI 4,253 34.4
AIDS/HIV 2,697 21.8
Dual Diagnosis 4,988 40.4
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

63
Table 2.7 Percentage of Facilities That Admitted Special Client Types: National Estimates, October 1, 1996
Percentages of Facilities That Admitted Three Types Percentages of Facilities with
of Clientsa Clients in Treatment Populationb
Dual
Pregnant Active HIV AIDS Women Adolescents Diagnosis
Women SSI/SSDI TB Positive Diagnosed [Q-B2-pt [Q-B2-pt [Q-B9-pt
[Q-C4] [Q-C4] [Q-C4] [Q-C4] [Q-C4] prev] prev] prev]
Total 52.7 63.8 14.6 53.9 32.8 90.1 39.5 79.9
Facility Type of Care
Hospital Inpatient Only 60.0 72.1 32.9 74.6 59.4 75.0 8.2 73.1
Non-Hospital Residential Only 41.7 61.6 18.3 58.4 26.1 71.4 17.1 69.1
Outpatient Methadone Only 59.8 75.8 42.1 84.3 64.8 99.8 2.4* 87.9
Outpatient Non-Methadone Only 52.0 62.0 8.8 45.2 26.4 94.3 51.4 80.5
Combination Facilities 64.8 68.7 22.7 72.3 53.0 95.2 32.9 89.3
Facility Settingc
Hospital (inpatient and outpatient) 52.7 68.0 19.6 69.4 51.3 90.2 21.1 87.6
Non-Hospital Residential, Therapeutic
Community or Halfway House 47.7 62.5 18.0 58.2 30.4 78.2 25.5 73.5
Community Mental Health Center 57.9 78.4 11.4 44.4 27.0 93.9 61.2 93.3
Other Outpatient 54.0 59.1 13.3 51.8 32.0 95.6 45.5 76.5
Other 48.4 52.7 8.9 39.3 24.4 90.8 45.0 73.5
Ownership
Private For-Profit 45.7 50.0 10.2 50.4 31.8 92.4 32.5 78.4
Private Non-Profit 52.9 66.4 14.5 53.1 31.6 88.6 39.9 78.0
Public 63.4 74.3 22.5 63.8 40.1 93.5 49.1 91.4
Percent Public Revenue
0% 33.7 30.7 5.7 33.5 24.0 86.9 28.0 66.5
1-50% 53.5 61.5 12.7 53.3 33.4 93.1 38.7 83.2
51-90% 57.7 72.3 16.2 59.4 33.3 91.3 46.2 83.4
91-99% 62.3 71.6 19.8 59.1 38.7 90.1 40.6 83.2
100% 50.4 66.9 16.1 53.3 29.7 86.9 37.1 72.9
Unknown % 26.2* 70.4 11.7* 63.5 39.6* 86.7 23.5* 87.0
Urbanicityd
Metro: Small Metro 55.1 59.6 11.5 43.6 23.2 87.2 45.0 78.1
Medium Metro 55.5 64.1 11.0 52.0 34.4 90.0 38.2 80.6
Large Metro 51.2 61.1 18.2 65.6 40.6 89.9 30.8 78.6
Non-metro: Rural 56.6 78.6 13.5* 32.8* 8.4* 87.6 65.8 84.5
Small Urban 51.6 71.7 11.0 33.6 20.6 92.8 61.3 85.1
Urban 49.2 67.5 14.9 46.6 22.6 93.0 43.8 78.1
See notes at end of table. (continued)

64
Table 2.7 (continued)

Percentages of Facilities That Admitted Three Types Percentages of Facilities with

of Clientsa Clients in Treatment Populationb
Dual
Pregnant Active HIV AIDS Women Adolescents Diagnosis
Women SSI/SSDI TB Positive Diagnosed [Q-B2-pt [Q-B2-pt [Q-B9-pt
[Q-C4] [Q-C4] [Q-C4] [Q-C4] [Q-C4] prev] prev] prev]
Level of Affiliatione
Parent Facility 61.2 64.6 17.9 58.4 34.5 92.6 46.6 80.9
Affiliate 51.3 67.0 13.2 55.0 32.1 90.0 37.4 81.4
Non-Affiliate 48.9 57.8 14.5 49.1 32.7 88.5 38.0 76.6
a
95 percent of facilities responded to active TB question; 94 percent responded to HIV-positive question; and 93 percent responded to AIDS
question.
b
96 percent of facilities responded to dual-diagnosis question.
c
Not mutually exclusive.
d
Based on Beale code (Butler & Beale, 1994).
e
At least 99 percent of facilities responded to affiliation question.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

65
Table 2.8 Percentage of Facilities That Admitted Special Population Clients and Have Special
Programs for Them: National Estimates, October 1, 1996
AIDS or
HIV- Dual
Pregnant Positive Diagnosisb
[Q-B10] Womena Womena Adolescentsa Clientsa [Q-B9]
Total 40.2 32.0 65.8 32.5 49.8
Facility Type of Care
Hospital Inpatient Only 22.8 20.9 84.6 25.7 50.3
Non-Hospital Residential Only 58.3 46.9 66.1 44.6 47.2
Outpatient Methadone Only 42.9 50.5 0.0 61.4 41.2
Outpatient Non-Methadone Only 37.0 27.4 64.3 26.2 49.4
Combination Facilities 39.6 33.9 75.2 30.0 55.6
Facility Settingc
Hospital (inpatient and outpatient) 29.4 20.8 74.5 29.4 57.5
Non-Hospital Residential, Therapeutic
Community or Halfway House 56.2 44.6 70.6 41.9 50.5
Community Mental Health Center 35.5 34.1 61.6 26.0 65.9
Other Outpatient 40.1 30.9 66.3 32.2 41.0
Other 34.9 36.5 57.0 26.0 46.6
Ownership
Private For-Profit 30.7 10.9 59.2 21.2 46.8
Private Non-Profit 42.9 35.5 69.0 36.0 49.6
Public 43.9 43.5 61.1 34.8 55.1
Percent Public Revenue
0% 26.6 15.6 56.9 11.2 41.7
1-50% 30.0 13.7 66.8 19.6 44.6
51-90% 45.6 34.0 66.8 34.8 51.8
91-99% 49.4 41.0 64.3 44.0 56.5
100% 44.6 53.6 75.7 43.8 53.5
Unknown % 29.2* 12.0* 31.6* 27.9* 35.2*
Urbanicityd
Metro: Small Metro 42.6 45.9 70.6 30.9 52.4
Medium Metro 40.5 28.9 67.9 28.9 48.4
Large Metro 43.4 32.3 69.3 38.1 51.5
Non-metro: Rural 27.9* 41.1 57.5 27.6* 38.6
Small Urban 31.6 27.9 57.7 23.6 48.9
Urban 34.8 21.5 59.5 13.0 46.1
Level of Affiliatione
Parent Facility 48.1 33.5 67.9 37.7 50.1
Affiliate 37.0 34.4 63.9 31.1 49.9
Non-Affiliate 39.6 26.5 67.0 30.9 49.5
a
99 percent of facilities responded to special programs question.
b
96 percent of facilities responded to dual-diagnosis question.
c
Not mutually exclusive.
d
Based on Beale code (Butler & Beale, 1994).
e
99 percent of facilities responded to affiliation question.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted
with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, and Department of Defense and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

66
 Chapter 3. Treatment Services and Staffing
Margaret T. Lee, Sharon Reif, Grant A. Ritter, Helen J. Levine, Mary Ellen Marsden, and
Constance M. Horgan

3.1 Introduction
This chapter documents what services are offered to clients and what type of staff treat
clients in the national substance abuse treatment system. It examines the relationship between
facility characteristics and service patterns and staffing. Data reported here are drawn from Phase
I of the Alcohol and Drug Services Study (ADSS). ADSS is a nationally representative sample of
substance abuse facilities across the Nation, excluding halfway houses without paid counselors,
solo practitioners, correctional facilities, Department of Defense (DoD) facilities, Indian Health
Service facilities, and facilities that are intake and referral only. This study builds upon the work
of the 1990 Drug Services Research Survey (DSRS) (Batten et al., 1993) with a more complete
sampling frame, an enhanced sampling design, and improved measures of financing and
organization.

3.1.1 Background

The quality of care provided in the treatment system depends on the array of services
offered to clients and the quality of staff at treatment facilities. A third factor that affects the
quality of care is how well the services offered at the facility match the client's needs
(Schottenfeld, Pascale, & Sokolowski, 1992). This chapter looks at services offered in the current
treatment system and the staffing patterns. However, this chapter does not have data to shed light
on the issue of matching client needs to services. Chronic substance abusers suffer from a variety
of serious health problems, such as disease of the heart and blood vessels, cirrhosis, HIV
infection, and hepatitis (Harwood, Fountain, & Livermore, 1998; Institute for Health Policy,
1993). In addition, they suffer from social problems, including unemployment, poor family
relations, mental health problems, and legal problems. Consequently, various services provided
by qualified substance abuse treatment staff are needed, in addition to drug and alcohol education
and counseling, to foster recovery and rehabilitation.

There is accumulating evidence that the range and quality of services provided to clients
while they are in substance abuse treatment is related to treatment outcomes (Hoffman et al.,
1996; McLellan et al., 1993). Furthermore, the number of services received in the areas of
medical, employment, family, and psychiatric care is significantly and positively related to better
post-treatment social adjustment (McLellan et al., 1994). Despite the importance of the number
and intensity of services for positive treatment outcomes, substance abuse services declined from
the mid-1980s to the mid-1990s (D'Aunno & Vaughn, 1995; Etheridge, Craddock, Dunteman, &
Hubbard, 1995). Generally, wraparound services or support services, such as employment and
legal services, were not offered as often as such services as individual therapy, group therapy,
and alcohol and drug services (Burke & Rafferty, 1994; McLellan et al., 1993; Price et al., 1991).

67
 Factors other than clinical need may determine the amount of services provided by
programs. Facility-level characteristics, such as type of care, ownership, and level of affiliation,
have implications for service delivery. Level of affiliation, or whether a facility is an independent
entity or an integral part of a larger organization, has been shown to have an impact on service
delivery (Friedmann, Alexander, & D'Aunno, 1999; James, 1998). Facility ownership also has
been shown to have an impact on services offered. Private for-profit outpatient units have been
reported to be more likely than other ownership types to provide physical exams and medical
tests to their clients during the assessment process; however, they are less likely to provide
mental health assessment (Burke & Rafferty, 1994; Friedmann et al., 1999). In addition, private
for-profit units provide less tuberculosis treatment and HIV/AIDS treatment than public units
(Friedmann et al., 1999). Different client bases at private and public facilities also may be a
factor in determining services offered. Private facilities tend to treat clients who are more affluent
and less impaired than clients in public facilities (Price & D'Aunno, 1992; Wheeler, Fadel, &
D'Aunno, 1992). Differences in clients' economic resources have been associated with
differences in substance abuse severity and, therefore, differences in service needs. Historically,
the purpose of the publicly funded health care system has been to serve those clients who have
more problems and fewer resources (Humphreys, Hamilton, Moos, & Suchinsky, 1997). Public
facility clients may have more need for such services as HIV/AIDS counseling, tuberculosis
treatment, employment counseling, academic classes, and transportation; therefore, that is why
they offer these services more in public facilities than in private facilities.

In addition, staffing plays a key role in the quality of services and the type of services
delivered. Variations also occur in staffing by facility characteristics, such as type of care,
ownership, and setting. For example, staff at methadone facilities tend to have more medical
training than at other outpatient facilities (Calsyn, Saxon, Blaes, & Lee-Myer, 1990; Price &
D'Aunno, 1992). This reflects the fact that methadone facilities have more requirements or
regulations regarding medical staff than other types of care. Private for-profit units tend to
employ higher proportions of part-time staff and independent contractors or consultants than
private non-profit and public units (Burke & Rafferty, 1994). In the outpatient treatment system,
mental health centers tend to have the most highly educated staff with the most training. Non-
hospital residential treatment units (i.e., those that are not part of a hospital or mental health
center) tend to have staff with lower levels of education, and they tend to have more part-time
staff (Price & D'Aunno, 1992). A study of alcoholism and drug abuse treatment programs in
Massachusetts found that community mental health centers tended to have staff with higher
education levels, were least likely to have recovering counselors, and tended to stress education
and licensing more than substance abuse certification (Mulligan, McCarty, Potter, & Krakow,
1989).

Client-to-staff ratios also are important determinants of service quality. When treatment
staff have higher caseloads, this affects service delivery. A higher client-to-staff ratio has been
associated with fewer routine medical care services, less HIV/AIDS treatment, and less
tuberculosis screening (Friedman et al., 1999). Number of staff and ratio of client to treatment
staff also are related to percent of clients who continue to abuse alcohol or drugs after treatment
(McCaughrin & Price, 1992).

68
 3.1.2 Methodology Overview

Phase I of ADSS consisted of a telephone interview with facility directors at a stratified

random sample of 2,395 alcohol and drug treatment facilities across the Nation (representing
12,387 facilities nationwide). The questionnaire was mailed out in advance so that directors had a
chance to gather information to fill out the questionnaire. The responses then were collected by
telephone. Sample strata were selected to reflect the different types of care within the substance
abuse treatment system. The sample frame was SAMHSA's 1995 National Master Facility
Inventory (NMFI) augmented to yield the universe of treatment facilities known to SAMHSA.
The Phase I ADSS Facility Survey was conducted from December 1996 to June 1997, with data
collected for a point-prevalence date of October 1, 1996, and for the most recent 12-month
reporting period of the facility. The point-prevalence date was chosen to be the same as the 1996
Uniform Facility Data Set (UFDS) (SAMHSA, 1997) in order to allow comparison with UFDS.
The Phase I response rate was 91.4 percent of 2,621 facilities eligible for ADSS. Because the
Phase I sampling design incorporated a stratified random probability sample, weights were
developed to produce national estimates of facilities. The sampling weights adjusted for facility
non-response and for differential response rates within strata. The data in this chapter were
imputed to account for missing values. Overall, item non-response was generally well below 10
percent. Further information about the data collection methodology for the study is presented in
the Appendix A. A description of variable definitions appears in Appendix B, and standard error
tables are presented in Appendix C.

3.1.3 Organization of the Chapter

First, ADSS findings are presented on the percentage of facilities in the overall treatment
system offering each of the selected services. Second, types of treatment and support services
offered at facilities are examined by facility characteristics. This chapter explores such questions
as whether facility ownership is related to different services and staffing patterns or whether
variation also is related to the facility funding stream. ADSS examines ownership and degree of
dependence on public revenue as separate variables and explores the effect of each. This chapter
also looks at the degree of affiliation as it relates to services offered by examining whether a
facility that is affiliated with another organization offers more services than non-affiliated
facilities. Third, the characteristics of facilities that offer high, medium, and low numbers of
services are examined. Fourth, staffing percentages at facilities and mean number of staff per
facility based on several measures are examined. Fifth, national estimates of the number of staff
in the treatment system are presented. Sixth, variations in client-to-staff ratios by facility
characteristics are investigated. The last part of the findings for this chapter examine the
percentage of staff who are certified in substance abuse treatment and how the ratio of clients to
certified staff vary by facility variables. The chapter ends by drawing some conclusions about the
services and staffing in the treatment system. In the tables appearing at the end of this chapter,
the Phase I questionnaire numbers from which the data were drawn are noted as Q-x.

3.2 Findings on Service Patterns in the Treatment System

The selected services examined in this chapter are divided into two categories: treatment
services and support services (see Table 3.1). Treatment services include those that are directly

69
oriented toward treating alcohol and drug abuse (e.g., comprehensive assessment, individual
therapy, group therapy, family counseling and aftercare1), while support services include those
directed toward related problems or toward keeping the client in treatment (e.g., employment
counseling, academic education, transportation, and child care). Among the expectations for
positive treatment outcome are improvement in employment, psychological functioning, medical
health, and family and social relationships, as well as a decrease in substance use and criminal
activity. Various treatment and support services are offered during treatment to rehabilitate the
client in these areas.

Generally, facilities offered more treatment services than support services. Table 3.1
shows that all treatment services, except for detoxification and acupuncture, were offered at 67
percent or more of the facilities. More than 90 percent of facilities offered individual therapy,
comprehensive assessment/diagnosis, and group therapy. In contrast, support services were
offered at less than 50 percent of facilities with the exception of HIV/AIDS
education/counseling/support, which was offered at 77 percent of all facilities. Thus, services
directly treating alcohol and drug abuse appear to have a priority over support services. This
lends support to the findings of the Drug Abuse Treatment System Survey (DATSS), a national
study of the outpatient substance abuse system. Support services, such as employment, financial,
and legal counseling, were offered at less than 40 percent of DATSS facilities, while treatment
services, such as individual therapy, group therapy, and alcohol/drug education, were offered at
90 percent or more of the facilities (Price et al., 1991).

3.2.1 Treatment Services

Facilities varied in the type of services offered to clients. Tables 3.2a and 3.2b show
service variations by key facility characteristics (see Appendix B for a description of variable
definitions). Of all the various services offered by substance abuse treatment facilities, individual
therapy was offered the most frequently. It was offered by 95 percent or more of facilities
regardless of the type of care, except for hospital inpatient facilities where it was offered at 87
percent of the facilities. Significantly fewer hospital inpatient facilities offered individual therapy
as compared with each of the other types of care.2

Although group therapy was one of the treatment services more routinely offered, it was
offered less often than individual therapy. Group therapy was offered in fewer outpatient
methadone facilities than in any other type of care—in fewer small facilities than other size
facilities, in fewer private-for-profit facilities than other ownership facilities, and in fewer
non-affiliate facilities than affiliate or parent facilities (see Appendix B for a definition of facility
level of affiliation).

Non-hospital residential facilities, in particular therapeutic communities, have as their

goal rehabilitation and recovery through self-help/mutual support (De Leon, 1994; De Leon &

1
Services offered to clients after discharge.

2
All comparisons reported in this section are significant, except where noted otherwise, using the
Bonferroni correction to p = .05 based on the number of comparisons.

70
Ziegenfuss, 1986, pp. 9-10; Institute of Medicine [IOM], 1990, p. 171). Therefore, one would
expect more self-help services to be offered in non-hospital residential facilities than other types
of care. Table 3.2a partially supports this by indicating that self-help or mutual-help groups were
offered in more non-hospital residential facilities than outpatient methadone and outpatient
non-methadone facilities. However, there was no significant difference in self-help or
mutual-help groups offered in non-hospital residential, hospital inpatient, and combination
facilities. Another service important to rehabilitation is relapse prevention. Relapse prevention
was offered in 88 percent of non-hospital residential facilities, which was more than all other
types of care with the exception of combination facilities. This is consistent with the
rehabilitative nature of non-hospital residential facilities. It also should be noted that more
facilities that were in non-hospital residential settings compared with those that were not in
residential settings offered self-help/mutual support and relapse prevention services.

Aftercare treatment services provided after the client leaves treatment were offered at
fewer facilities than any of the counseling services. Aftercare and outcome follow-up were
offered more in combination facilities (94 and 85 percent, respectively) than other types of care.
Combination facilities are facilities that consist of more than one type of care and, therefore, are
more likely to offer a wider range of services in order to meet the needs of all their clients.
Generally, aftercare and outcome follow-up were offered least often in methadone facilities (64
and 44 percent, respectively). Comparisons of these two services in outpatient methadone
facilities with other types of care were significant with the exception of outpatient methadone
compared with hospital inpatient facilities for aftercare services. Information on aftercare
services reported in ADSS concur with past findings that aftercare is not routinely offered (IOM,
1990, p. 171). It is of importance to note the findings on aftercare because aftercare group
therapy has been found to decrease readmission significantly (Lash & Blosser, 1999).

Detoxification was offered mostly in hospital inpatient facilities followed by outpatient

methadone facilities and combination facilities. More hospital inpatient facilities offered
detoxification than any other type of care. There was no significant difference between
methadone and combination facilities; both offered detoxification more than residential and
outpatient non-methadone types of care.

3.2.2 Support Services

Generally, support services were offered by fewer facilities than treatment services (see
Table 3.2b). Among the support services, HIV/AIDS education/counseling/support was offered
at 77 percent of facilities, which was more than any other support service.

Transportation, employment counseling/training, and academic education/GED classes

were not routinely offered in the substance abuse treatment system. However, these support
services were offered in non-hospital residential type of care more than any other type of care
(Table 3.2b). This is in line with the rehabilitation treatment philosophy of residential facilities.
The principal goal of the therapeutic community is a "global change in lifestyle" that includes
abstinence from illicit substances, elimination of antisocial behavior, and positive changes in
lifestyle that include employability (De Leon & Ziegenfuss, 1986, p. 5). In addition, Table 3.2b
shows that HIV/AIDS education/counseling/support was offered at more residential than

71
outpatient non-methadone and hospital inpatient types of care. A similar percentage of
residential, methadone, and combination types of care offered this service. At the time of the
study, residential programs had begun to address the problems of treating HIV/AIDS clients and
to provide support and care to these clients (Tims, Jainchill, & De Leon, 1994). More facilities in
residential settings offered transportation, employment, academic, and HIV/AIDS services than
facilities not in residential settings.

3.2.3 Other Notable Service Variations by Facility Characteristics

Compared with the other types of care, a lower percentage of methadone facilities offered
the selected treatment and support services. Group therapy, family counseling, and outcome
follow-up were offered at a lower percentage of methadone facilities than any other type of care.
In addition, fewer methadone facilities offered relapse prevention than any other type of care
except outpatient non-methadone facilities. Relapse prevention was equally offered in outpatient
methadone and outpatient non-methadone types of care. Of the support services, smoking
cessation was offered at fewer methadone facilities than any other type of care. Transportation
was offered in fewer methadone facilities than all other types of care except for outpatient
non-methadone facilities. It should be noted, however, that HIV/AIDS
education/counseling/support and tuberculosis screening were support services offered at a high
percentage of methadone facilities (94 and 93 percent, respectively). Tuberculosis screening was
offered in methadone facilities more than other types of care. HIV/AIDS
education/counseling/support was offered more in methadone facilities than in hospital inpatient
and outpatient non-methadone facilities. In view of injection drug use and health problems
among methadone clients, these are much needed services for this population.

A high percentage of combination facilities offered comprehensive assessment/diagnosis,

individual therapy, group therapy, family counseling, relapse prevention, aftercare, and outcome
follow-up (Table 3.2a). Combination facilities, which provide more than one type of care, offer a
broader scope of services.

There was some tendency for fewer private-for-profit facilities to offer the selected
services than private non-profit and public (publicly owned) facilities. For support services in
Table 3.2b, fewer private for-profit facilities offered each of the services compared with public
facilities. The only exception was that there was no significant difference in the percentage of
private for-profit and public facilities that offered smoking cessation services. However, among
treatment services, only group therapy was offered at significantly fewer private for-profit
facilities than public facilities. Thus, it appears that public facilities offered a range of services to
include more support services compared with private for-profit facilities. This is not surprising
considering that the mission of many public facilities is to serve clients with a range of problems
and who have fewer resources available to them (Humphreys et al., 1997; Price & D'Aunno,
1992; Wheeler et al., 1992). DATSS data indicate that private-for-profit outpatient facilities
serve a different clientele than private non-profit and public facilities. A smaller percentage of
for-profit clients are under 20, unemployed, unable to pay for treatment, or have multiple drug
problems (Price & D'Aunno, 1992). Services in public facilities are driven by the client base and
because they have mandates to treat a different client base compared with private for-profit

72
facilities. Many public facilities receive public funding to serve special populations, such as
HIV/AIDS clients, tuberculosis clients, injection drug users, and pregnant women.

It is noted that private non-profit facilities were similar to publicly owned facilities in
terms of support services offered. More private non-profit facilities also offered each of the
support services in Table 3.2b than private for-profit facilities, with the exception of smoking
cessation. Thus, the for-profit status was the key distinguishing variable that differentiated
facilities along ownership lines. Burke and Rafferty (1994) also found that ownership differences
were between private for-profit versus private non-profit and public facilities. Private for-profit
facilities were more likely to receive private funds, such as client self-pay fees and private
insurance. At the same time, these facilities were less likely to receive clients through criminal
justice referrals and social service agency referrals; therefore, a different client base was in
treatment at private-for-profit facilities compared with other facilities.

As mentioned above, HIV education/counseling/support and tuberculosis screening were

offered in more publicly owned facilities and private non-profit facilities than private for-profit
facilities. In addition, HIV education/counseling/support was offered at fewer facilities that
received no public funds than any other percent public revenue category. Furthermore, fewer
facilities that received 50 percent or less public revenue offered HIV/AIDS services compared
with facilities that received public funds for more than 50 percent of their revenue. Tuberculosis
screening was offered in fewer facilities with no public revenue than facilities with some public
revenue. This concurs with other research findings (Friedmann et al., 1999), which attributed
these findings to facility ownership. ADSS data suggest that it is not simply ownership that is
important, but that facility sources of funding need to be considered. Facilities receiving greater
public revenue offered more support services than facilities receiving less public revenue.

ADSS estimates indicate that there was some support that being a parent or affiliate
facility was associated with more treatment services being offered than facilities that were not
affiliated with any other organization. Group therapy and self-help groups were offered at fewer
non-affiliate facilities than facilities that were parents or affiliates. In addition, relapse prevention
groups, aftercare, and outcome follow-up were offered at more parent facilities than affiliates and
non-affiliates. There did not seem to be much significant difference in the offering of support
services between parent, affiliate, and non-affiliate facilities. The only notable exception was that
child care and prenatal care were offered in more parent facilities than non-affiliate facilities, and
HIV/AIDS education/counseling/support was offered at more parent and affiliate facilities than at
non-affiliates. This supports research by Alexander, Anderson, and Lewis (1985) who found that
units owned or affiliated with another entity offered more services.

3.2.4 Facilities That Offer Varying Numbers of Services

Table 3.3 examines the question of whether facilities differed in the number of the
selected treatment and support services they offered. That is, which facilities offered low (5 or
fewer), medium (6 to 8), or high (9 to 11) different treatment services? Which facilities offered
no support services, low (1 or 2), medium (3 or 4), or high (5 to 8) different support services?

73
 The majority of facilities with combination type of care (74 percent) offered a high
number of treatment services. In fact, more combination facilities offered a high number of
treatment services than the other types of care. As mentioned earlier, combination facilities
offered more than one type of care and, generally, offered more types of services in order to serve
their various clients' needs. After combination facilities, hospital inpatient facilities were next in
offering a high number of treatment services. Equal proportions of residential, outpatient
non-methadone, and methadone type of care offered a high number of treatment services. As
noted earlier, methadone type of care offered a low number of treatment services compared with
other types of care.

Few facilities offered a high number of support services. Across the treatment system,
only 17 percent of facilities offered a high number of support services. More non-hospital
residential type of care (38 percent) offered support services than other types of care, although
the difference between non-hospital residential and combination facilities was not significant.
Combination facilities, similar to residential facilities, offered more support services than
outpatient types of care (methadone and non-methadone).

The percentage of facilities that offered a high number of treatment services did not vary
significantly by ownership. Roughly a little over a third of all facilities regardless of ownership
offered a high number (9-11) of treatment services. However, more private for-profit facilities
offered no support services or a low number of support services compared with private non-profit
and public facilities. These findings support reports from a national outpatient study that private
for-profit programs delivered fewer support services than public programs (Friedmann et al.,
1999).

More facilities with no public revenue offered a low number of treatment and low or no
support services compared with facilities receiving some public funding. The only pairwise
comparison that was not significant was zero percent public funding versus 1 to 50 percent
public funding for low support services. Facilities that received 50 percent or less public funding
offered low support services compared with facilities that received public funding for more than
50 percent of their funding. This again may be related to the purpose of public facilities to serve
the wide range of clients who depend on the public sector for health care.

Forty (40) percent of parent facilities offered a high number of treatment services
compared with 32 percent of non-affiliates. A similar trend was indicated for support services (22
vs. 12 percent). Therefore, more parent facilities offered a high number of treatment and support
services compared with non-affiliates. Integration of units allows for more resources to be made
available to the client as the resources that each of the units provides is shared throughout
(James, 1998). There is some evidence that hospitals owned by another organization tend to offer
more inpatient and outpatient services (Alexander et al., 1985). There are few findings specific to
the substance abuse field as to whether services differ in non-hospital residential substance abuse
treatment facilities compared with facilities that are affiliated with other organizations. However,
Friedmann et al. (1999) did find that substance abuse facilities affiliated with mental health
centers provided on-site mental health services to a greater degree than those not affiliated with a
mental health center.

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3.3 Findings on Staffing of the Substance Abuse Treatment System
The ratio of clients to staff is important to study because it is one of the factors that
affects the delivery of services. Table 3.3 examines the relationship between client-to-staff ratio
and number of services offered. The ratio of clients to staff can be viewed as caseload level.

Table 3.3 shows that 51 percent of facilities with a low client-to-staff ratio offered a high
number of treatment services. More facilities with a low client-to-staff ratio offered a high
number of treatment services than facilities with a medium client-to-staff ratio, and more
facilities with a medium client-to-staff ratio offered a high number of treatment services than
facilities with a high client-to-staff ratio. Thus, it appeared that the lighter the caseload for direct-
care staff, the more likely the facility offered a variety of treatment services. This pattern was
also true of support services. The lower the client-to-staff ratio, the more kinds of support
services the facility offered. These results are in line with the findings of a national outpatient
survey where higher client-to-staff ratios were associated with fewer services (D'Aunno &
Vaughn, 1995; Friedmann et al., 1999; Price et al., 1991).

Table 3.4 shows staffing percentages and means among facilities. The first column of the
table shows the percentage of facilities that have each of the staffing categories. More than three
fourths of facilities had graduate-degreed counseling staff, B.A. or non-degreed counseling staff,
and staff other than medical and counseling staff. The "all other staff" category in Table 3.4
refers to non-medical and non-counseling staff and includes administrators, administrative
assistants, clerical staff, and any other staff who did not provide medical or counseling services.
Most facilities (86 percent) had "all other staff." Seventy-seven (77) percent of facilities had
master's level counselors, and 68 percent had B.A.-level counselors. Therefore, in terms of
direct-care staff, the substance abuse treatment system had facilities primarily staffed by
counselors with M.A. and B.A. degrees. This finding supports the staffing patterns found in the
DATSS where master's and bachelor's level educational backgrounds dominated outpatient
treatment, in particular in outpatient non-methadone programs (Price et al., 1991; Price &
D'Aunno, 1992).

Columns 2-4 of Table 3.4 indicate that master's level counselors were on staff full time at
significantly more facilities (62 percent) than any other direct-care staff category, except for
bachelor's level counselors. Only 12 percent of facilities reported having a full-time doctoral
level counselor on staff, while a slightly higher but significant percentage (16 percent) reported
having one on contract. Although only 13 percent of facilities had at least one full-time physician
on staff, 21 percent of facilities reported having a part-time physician and 37 percent of facilities
reported having a contract physician on staff. Therefore, more highly educated and costly staff
may more likely be part time or contract.

Table 3.4 looks at the mean number of staff per facility based on several measures. Means
for "all facilities" included all facilities in the denominator regardless of whether they had the
staff category. Means for "facilities with staff category" were calculated by including in the
denominator only those facilities that had a member of the staff category for the row. "Mean
staff" counted full-time, part-time, and contract staff each as one. "Mean FTE staff" counted
full-time equivalent staff (see FTE calculation in Appendix B definition for client-to-staff ratio).

75
In general, the mean number of staff in any one category was low, ranging from one to six across
all facilities.

3.3.1 Distribution of Staffing Categories Among Full-Time, Part-Time, and Contract

Staff

Tables 3.5a and 3.5b are based on data from an estimated 11,782 facilities (about 95
percent of the universe) that could report their staff numbers by full-time, part-time, and contract
staff. Table 3.5a shows the percentage distribution of full-time, part-time, and contract staff by
staff category and provides national estimates of staff in these categories. Note that in this table
the columns total to 100 percent. In 1996-1997, there were an estimated 134,184 full-time staff in
the treatment system compared with an estimated 44,956 part-time staff and an estimated 22,283
contract staff. Medical staff and graduate-degreed counselors each accounted for about 17
percent of full-time staff. B.A. and non-degreed counselors made up 29 percent of the full-time
work force, while staff other than medical and counseling staff made up 37 percent of the
full-time staff. Among direct-care staff, more B.A. and non-degreed counselors were full time
than graduate-level counselors or medical staff. In contrast, medical staff made up 47 percent of
the system's contract staff while graduate-degreed counselors made up 32 percent, and B.A. and
non-degreed counselors made up only 11 percent. Therefore, direct-care staff who were more
highly trained, educated, and paid were more likely to be hired on contract. "All other staff"
made up only 10 percent of the contract staff, which was not significantly different from the
percentage of B.A. and non-degreed counselors on contract.

Table 3.5b shows the percentage distribution of staff type by "time" category. The
information is based on the same data as Table 3.5a but with the rows adding to 100 percent. The
findings reported in Table 3.5b parallel the findings in Table 3.4. That is to say, the more
educated and more costly staff members, such as physicians, were more often on contract (56
percent) than part-time (26 percent) and full-time (18 percent) staff. Doctoral-level counselors,
however, were mostly either full time or contract. Master's level, bachelor's level, and
non-degreed counselors were most often full time and least often on contract. The same was true
of "all other staff" (i.e., staff other than medical and counseling staff).

3.3.2 FTE Staff

Data for Table 3.5c is based on the same data as Tables 3.5a and 3.5b but also includes
data for an estimated 605 facilities that could only report their staff by numbers of FTEs. Table
3.5c shows the estimated number and percentage distribution of FTE staff in the treatment
system by staff category. The largest group of FTE staff were the "all other staff' (32 percent)
followed by master's level counselors (17 percent). The four subtotal rows (in bold) indicate that
there were more "all other staff" followed by "BA and non-degreed counselors," then "total
medical staff" and "total graduate degreed counseling staff." The difference between the
estimated number of "total medical staff" and "total graduate degreed counseling staff"was not
significant.

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 3.3.3 Mean Ratios of Clients to Staff

Because of the relationship between staff caseload and service delivery, Table 3.6
examines a number of different mean ratios of clients to FTE staff. They all tended to have a
similar pattern with the lowest client-to-staff ratio in hospital inpatient and non-hospital
residential types of care, and the highest ratio in outpatient types of care. This is to be expected
given that residential facilities must be staffed 24 hours a day. In hospital inpatient facilities,
there was on average one client to a direct-care staff; in non-hospital residential facilities, there
were on average five clients per direct-care staff. This ratio was highest in methadone care. On
average, there were 24 methadone clients per direct-care staff. The next highest ratio was in
outpatient non-methadone facilities, with 19 clients per staff. Therefore, direct-care staff in the
outpatient treatment system had to spread their time among many more clients than staff in the
inpatient treatment system.

Facilities with no public revenue had the highest client to direct-care staff ratio. These
facilities also tended to have the highest client to all staff ratios (includes direct-care and all other
staff). The difference between the 0 and 1 to 50 percent public revenue groups was not
significantly different for the client to all staff ratio, but the 0 percent group was significantly
different from all other percentage public revenue groups. Therefore, facilities that received no
public revenue tended to have higher client-to-staff ratios than facilities that received some
public funding.

Generally, the lower the ratio of clients to staff, the more treatment services offered at a
facility. The difference between high, medium, and low treatment service facilities were all
significant for the client to all staff and client to direct-care staff categories. For the client to all
other staff ratio, the comparison for high and low treatment services facilities was significant,
whereas the ratio for the medium treatment services facilities was not significantly different from
the high or low. A similar trend was found for support services as for treatment services for the
client to all staff and client to direct-care staff ratios. Lower ratios of clients to staff were found
in facilities that offered medium or high numbers of support services (three or more). Higher
ratios of clients to staff were found in facilities that offered low or no support services.

3.3.4 Percentage of Direct-Care Staff Certified in Substance Abuse Treatment

In addition to client-to-staff ratios, the percentage of direct-care staff certified in

substance abuse treatment and the ratio of clients to certified staff are two other staffing factors
that may be related to service delivery. Quality of services depends on adequate numbers of staff
who are certified and trained in substance abuse treatment.

Certification of addiction counselors began in the early 1970s in response to two

concerns. One was the lack of special training for counselors in the field of addiction medicine.
The other was the need to provide credentialing for non-degreed staff working in substance abuse
treatment. Organizations such as the National Association of Alcoholism and Drug Abuse
Counselors (NAADAC) have established requirements for certification that specify level of
education, years or hours of experience as an alcoholism and/or drug abuse counselor, and
passing score on a national certification exam (Beck, 1998).

77
 The debate surrounding certification versus licensing of counselors has continued over
the years. Certification specifies counselor experience in the field of substance abuse. Although
counselors with certification may have more experience with substance abuse treatment, some
managed care plans require counselors to have graduate training and master's degrees in order to
treat clients. Organizations such as NAADAC advocate certification requirements for degreed
and non-degreed counselors. The argument is that counselors should not only be academically
trained, but also be skilled and experienced in the treatment of substance abusers (IOM, 1997, pp.
58-59).

Table 3.7 shows the percentage of direct-care staff certified in substance abuse treatment.
Across all facilities, less than half of all direct-care staff were certified (45 percent). Similar
findings were reported in a national study of the outpatient system. Across all outpatient
facilities, about 40 percent of all staff were certified in substance abuse (Burke & Rafferty,
1994).

Outpatient non-methadone facilities had the highest percentage of certified direct-care

staff, although the difference between non-hospital residential and outpatient non-methadone
facilities was not significant. The percentage of certified direct-care staff was higher in
non-hospital residential type of care than in methadone and hospital inpatient types of care. The
percentage of direct-care staff certified in substance abuse treatment was lower in methadone
facilities than in all other types of care except for hospital inpatient care. This finding of fewer
certified staff in methadone facilities compared with outpatient non-methadone facilities was
consistent with past findings (Price et al., 1991; Price & D'Aunno, 1992). The treatment
orientation at facilities may influence the number of staff certified in substance abuse treatment.
Methadone facilities tend to have more of a medical orientation than a counseling orientation
(Friedmann et al., 1999; Price & D'Aunno, 1992). Therefore, they may emphasize credentials
other than certification in substance abuse treatment. In addition, Federal methadone regulations
required that a licensed physician be on staff to assume responsibility for setting methadone
dosages to be dispensed, and methadone could be dispensed only by a practitioner licensed under
the appropriate State and Federal regulations to order narcotic drugs for clients. By requirement,
the staff dispensing methadone was a pharmacist, registered nurse, a licensed practical nurse, or
another health care professional authorized by State or Federal law to dispense narcotic drugs.

Facilities with no public revenue compared with facilities with greater than 90 percent
public revenue had a higher percentage of direct-care staff certified in substance abuse treatment.
Similarly, private for-profit and private non-profit facilities had a higher percentage of certified
direct-care staff than publicly owned facilities. Therefore, private facilities and facilities with no
public funding had more certified direct-care staff. Public facilities use a network of service
agencies that specialize in providing services to the complex needs of the uninsured or publicly
insured. Counselors in the public sector can run the gamut from licensed to certified to
non-certified (IOM, 1997, p. 59).

Two other findings are noted in Table 3.7, column 1. Facilities that provide no support
services, compared with those that offer a medium or high number of support services, tended to
have a higher percentage of staff certified in substance abuse treatment. Therefore, facilities that
offered more support services did not necessarily have these services delivered by a staff member

78
who was certified in substance abuse treatment. Setting variations for the percentage of direct-
care staff certified in substance abuse treatment indicate that community mental health centers
had fewer certified staff than facilities that were not in community mental health centers. This
lends support to past findings that community mental health centers tend to stress credentials
other than certification in substance abuse treatment (Mulligan et al., 1989).

3.3.5 Mean Ratio of Clients to Staff Certified in Substance Abuse Treatment

The second column in Table 3.7 looks at the mean ratio of clients to staff certified in
substance abuse treatment. The ratio was highest in outpatient methadone care. On average, in
hospital inpatient facilities, there were five clients per staff certified in substance abuse treatment.
In contrast, methadone facilities had, on average, 106 clients per staff certified in substance abuse
treatment. The ratio of clients to certified staff was a function of size. The larger the facility, the
higher the ratio, and the client caseload for treatment staff became heavier. Over 80 percent of
methadone facilities were very large, as defined by client count, and therefore tended to have a
higher ratio of clients to certified staff. In addition, as mentioned above, the number of certified
staff tended to be low in methadone type of care. Setting variations, once again, showed a
similarity to type of care variations. Facilities in inpatient settings had lower ratios of clients to
certified staff than facilities not in inpatient settings.

In terms of facility ownership, private facilities (for-profit and non-profit) had lower
ratios of clients to staff certified in substance abuse treatment than public facilities. The pattern
was less clear regarding the percentage of public revenue. Facilities that had 50 percent or less
public revenue had a lower ratio of clients to certified staff than facilities with more than 50
percent public revenue.

3.4 Conclusions
3.4.1 Service Variations

There were variations in service patterns by facility level characteristics; overall,

however, most facilities in the treatment system offered treatment services, such as individual
therapy, comprehensive assessment and diagnosis, and group therapy. Services provided after the
client leaves treatment, such as aftercare and outcome follow-up, were not offered as often as the
various types of counseling. Furthermore, support services were not offered as often as treatment
services in the substance abuse treatment system.

Variations in services by facility characteristics included the following patterns.

Self-help/mutual support and relapse prevention services tended to be offered in non-hospital
residential type of care. Support services such as transportation, employment counseling/training,
and academic education/GED classes were not routinely offered in the substance abuse treatment
system, but among the various types of care they were offered more often in non-hospital
residential facilities. This was likely due to the rehabilitative nature of non-hospital residential
type of care. In terms of ownership, fewer private-for-profit facilities offered services compared
with public facilities. Group therapy and most support services were offered at fewer private
for-profit facilities. Facilities receiving no public revenue tended to offer fewer services, such as

79
HIV/AIDS and tuberculosis services. Thus, the funding stream is important to consider in
addition to facility ownership. Furthermore, facilities that were parent or affiliate facilities tended
to offer more services than non-affiliates. Combination facilities, those that offered more than
one type of care, offered a broader range of services.

Facilities varied in the number of services they offered clients. Combination facilities
offered a high number of treatment services while methadone facilities offered a low number of
treatment services. In contrast, high numbers of support services were offered in more
non-hospital residential and combination facilities and in fewer outpatient non-methadone
facilities. Public and private facilities did not differ in the number of treatment services offered,
but more public facilities offered support services to clients. Therefore, the difference between
services offered by ownership was in support services. In addition, findings on funding stream
also support that facilities with no public revenue offered low treatment and low or no support
services compared with facilities that received at least some public funding. Facilities with low
client-to-staff ratios offered more treatment and support services.

3.4.2 Staffing Variations

In terms of direct-care staff, the substance abuse treatment system was staffed primarily
with M.A.- and B.A.-level counselors. This result agrees with findings of a national outpatient
study of drug treatment facilities (Price et al., 1991; Price & D'Aunno, 1992). However,
non-medical and non-counseling staff, such as administrators and administrative support, were
most frequently on the payrolls of facilities. There were fewer Ph.D.-level professional staff at
substance abuse treatment facilities, and these and other costly staff, such as physicians, tended
to be on staff as part-time or contract staff.

The ratio of the number of clients to direct-care staff may affect the delivery of services.
The ratio of clients to direct-care staff in the treatment system varied by a number of facility
characteristics. Low client-to-staff ratio was associated with facilities that offered high numbers
of treatment and support services, facilities with inpatient types of care, and facilities that
received some public revenue.

The percentage of direct-care staff certified in substance abuse tended to be low. In

general, the percentage of certified staff was less than 50 percent of the treatment staff. The
percentage of certified staff tended to be lower in methadone and hospital inpatient types of care
(where other credentials are important), publicly owned facilities, and those facilities that
received public funding for 90 percent or more of their revenue.

The mean ratio of clients to certified staff was highest in facilities that were methadone
type of care, larger facilities, public facilities, and facilities that offered a low number of
treatment services.

The findings presented in this chapter illustrate variations in service patterns and staffing
in the substance abuse treatment system. Facility characteristics are important in determining
these variations. The substance abuse treatment system offers a range of services and has a range
of staff in order to serve the clients treated in the national treatment system.

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3.5 References for Chapter 3
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hospitals in multihospital systems. Medical Care, 23, 913-932.

Batten, H. L., Horgan, C. M., Prottas, J. M., Simon, L. J., Larson, M. J., Elliott, E. A., Bowden,
M. L., & Lee, M. T. (1993). Drug Services Research Study, Phase I final report:
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University.

Beck, D. (1998). Certified addiction counselors (CAC): Real world issues in managed care
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Burke, A. C., & Rafferty, J. A. (1994). Ownership differences in the provision of outpatient
substance abuse services. Administration in Social Work, 18(3), 59-91.

Calsyn, D. A., Saxon, A. J., Blaes, P., & Lee-Myer, S. (1990). Staffing patterns of American
methadone maintenance programs. Journal of Substance Abuse Treatment, 7, 255-259.

D’Aunno, T. & Vaughn, T. E. (1995). An organizational analysis of service patterns in outpatient

drug abuse treatment units. Journal of Substance Abuse, 7, 27-42.

De Leon, G. (1994). The therapeutic community: Toward a general theory and model. In F.M.
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De Leon, G., & Ziegenfuss, J. T. (Eds.). (1986). Therapeutic communities for addictions:
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Etheridge, R. M., Craddock, S. G., Dunteman, G. H., & Hubbard, R. L. (1995). Treatment
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Friedmann, P. D., Alexander, J. A., & D’Aunno, T. A. (1999). Organizational correlates of access
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Harwood, H., Fountain, D., & Livermore, G. (1998). The economic costs of alcohol and drug
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Hoffman, J. A., Caudill, B. D., Koman, J. J., 3rd, Luckey, J. W., Flynn, P. M., & Mayo, D. W.
(1996). Psychosocial treatments for cocaine abuse: 12-month treatment outcomes. Journal of
Substance Abuse Treatment, 13, 3-11.

Humphreys, K., Hamilton, E. G., Moos, R. H., & Suchinsky, R. T. (1997). Policy-relevant
program evaluation in a national substance abuse treatment system. Journal of Mental Health
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Institute for Health Policy, Brandeis University. (1993). Substance abuse: The nation’s number
one health problem (report prepared for the Robert Wood Johnson Foundation, Princeton, NJ).
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Weisner, Eds.). (1997). Managing managed care: Quality improvement in behavioral health.
Washington, DC: National Academy Press.

Institute of Medicine (D. Gerstein & H. Harwood, Eds.). (1990). Treating drug problems:
Volume 1. Washington, DC: National Academy Press.

James, D. M. (1998). An integrated model for inner-city health-care delivery: The Deaconess
Center. Journal of the National Medical Association, 90, 35-39.

Lash, S. J., & Blosser, S. L. (1999). Increasing adherence to substance abuse aftercare group
therapy. Journal of Substance Abuse Treatment, 16, 55-60.

McCaughrin, W. C., & Price, R. H. (1992). Effective outpatient drug treatment organizations:
Program features and selection effects. International Journal of the Addiction, 27, 1335-1358.

McLellan, A. T., Alterman, A. I., Metzger, D. S., Grissom, G. R., Woody, G. E., Luborsky, L. &
O’Brien, C. P. (1994). Similarity of outcome predictors across opiate, cocaine, and alcohol
treatments: Role of treatment services. Journal of Consulting and Clinical Psychology, 62,
1141-1158.

McLellan, A. T., Grissom, G. R., Brill, P., Durell, J., Metzger, D. S., & O’Brien, C. P. (1993).
Private substance abuse treatments: Are some programs more effective than others? Journal of
Substance Abuse Treatment, 10, 243-254.

Mulligan, D. H., McCarty, D., Potter, D., & Krakow, M. (1989). Counselors in public and private
alcoholism and drug abuse treatment programs. Alcoholism Treatment Quarterly, 6(3/4), 75-89.

Price, R. H., Burke, A. C., D’Aunno, T. A., Klingel, D. M., McCaughrin, W. C., Rafferty, J. A.,
& Vaughn, T. E. (1991). Outpatient drug abuse treatment services, 1988: Results of a national
survey. In R. W. Pickens, C. G. Leukefeld, & C. R. Schuster (Eds.), Improving drug abuse
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83
84
Table 3.1 Percentage of Facilities in the Treatment System Offering Treatment and Support
Services: National Estimates
Percent of Responding
Facilities Offering Servicea
Services [Q-C9]
Treatment Services
Individual therapy 96.9
Comprehensive assessment/diagnosis 93.8
Group therapy, not including relapse prevention 92.6
Family counseling 85.6
Aftercare 82.6
Relapse prevention groups 78.8
Self-help or mutual-help groups 71.4
Outcome follow-up 66.7
Combined substance abuse and mental health treatment 66.7
Detoxification 26.5
Acupuncture 4.8
Support Services
HIV/AIDS education/counseling/support 76.5
Transportation 49.6
TB screening 43.2
Employment counseling/training 40.2
Smoking cessation 24.2
Academic education/GED classes 17.1
Child care 13.3
Prenatal care 12.0
a
More than 99 percent of facilities responded to each service question.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies,
Substance Abuse and Mental Health Services Administration.

85
Table 3.2a Percentage of Facilities Offering Treatment Services, by Selected Facility Characteristics: National
Estimates

Combined Substance Abuse

Group Therapy, Not Incl.
Assessment/Diagnosis

Self-Help or Mutual-

Outcome Follow-Up

& Mental Health Tx

Relapse Prevention

Relapse Prevention
Individual Therapy

Family Counseling
Comprehensive

Detoxification

Acupuncture
Help Groups

Aftercare
Groups
Treatment Services
[All services from Q-C9]
All Facilitiesa 93.8 96.9 92.6 85.6 78.8 71.4 82.6 66.7 66.7 26.5 4.8
Facility Type of Care
Hospital Inpatient Only 96.1 87.0 86.9 80.4 77.6 85.9 68.0 60.3 74.9 88.5 4.4
Non-hospital Residential Only 84.7 95.5 95.0 78.6 88.0 92.3 76.4 74.4 53.9 24.6 7.2
Outpatient Methadone Only 87.2 96.3 76.5 66.6 66.0 62.7 64.4 43.8 55.9 74.7 14.9
Outpatient Non-methadone Only 95.8 97.2 91.4 86.9 72.6 61.0 83.1 61.4 67.8 9.3 3.7
Combination Facilities 97.1 98.9 99.1 94.0 95.9 87.9 94.4 85.0 77.4 71.7 4.0
Facility Size
Small (<17 clients) 91.8 94.5 85.8 81.1 72.9 73.9 78.9 70.2 61.9 24.3 2.3
Medium (17-40) 94.0 97.5 92.6 91.5 75.6 71.7 83.0 67.9 69.5 25.6 5.4
Large (41-100) 95.9 98.8 95.9 87.6 82.4 72.4 86.2 69.5 69.9 24.1 4.8
Very Large (>100) 93.2 96.3 95.8 82.0 84.2 66.9 81.6 58.1 65.3 31.7 7.0
Ownership
Private For-profit 93.2 94.4 86.9 84.1 73.8 62.9 79.6 59.4 70.1 29.0 5.9
Private Non-profit 93.9 97.7 94.1 86.7 79.6 75.0 84.0 69.5 63.5 24.2 4.3
Public 94.2 96.9 94.3 83.0 82.7 68.1 80.5 64.6 75.5 31.6 5.5
Percent Public Revenue
0% 91.2 91.4 85.4 77.0 68.5 59.7 75.9 54.2 56.9 13.4 2.8
1-50% 96.0 97.4 92.5 89.9 79.2 68.3 86.1 72.3 74.5 35.6 4.0
51-90% 92.5 97.5 94.4 86.1 78.4 72.9 88.1 69.3 65.0 27.9 5.4
91-99% 95.0 97.0 95.5 85.8 84.2 73.4 80.5 63.9 68.5 23.5 4.6
100% 93.7 99.3 91.9 84.0 82.6 81.6 73.0 68.5 62.2 19.9 8.0
Unknown % 97.2 98.0 86.2 97.4 74.8 69.0 77.8 65.5 88.6 53.9 0.9*
Urbanicityb
Metro: Small Metro 88.7 98.3 88.9 80.9 77.1 63.9 82.9 61.0 66.2 24.5 0.4*
Medium Metro 95.9 98.3 93.6 85.2 76.2 72.1 83.6 70.9 62.9 27.6 5.2
Large Metro 93.2 95.2 93.2 84.2 82.6 75.1 81.4 63.7 67.5 27.0 7.7
Non-metro: Rural 98.8 98.4 88.0 98.0 70.9 52.7 82.5 65.0 76.3 13.9* 0.0*
Small Urban 95.8 98.4 91.2 92.9 72.3 64.5 86.2 69.8 70.7 22.6 0.5*
Urban 92.9 95.9 93.1 87.0 79.3 74.4 78.3 73.1 65.4 30.6 1.5*
Level of Affiliationc
Parent Facility 94.8 97.5 94.6 86.5 84.6 74.7 87.5 73.8 67.0 23.2 6.4
Affiliate 94.5 97.2 93.9 85.0 78.6 73.4 81.6 63.9 69.4 28.8 4.5
Non-Affiliate 91.7 95.7 88.7 85.9 74.6 65.4 80.2 65.7 61.8 24.6 4.2
See notes at end of table. (continued)

86
Table 3.2a (continued)

Combined Substance Abuse

Group Therapy, Not Incl.
Assessment/Diagnosis

Self-Help or Mutual-

Outcome Follow-Up

& Mental Health Tx

Relapse Prevention

Relapse Prevention
Individual Therapy

Family Counseling
Comprehensive

Detoxification

Acupuncture
Help Groups

Aftercare
Groups
Treatment Services
[All services from Q-C9]
Facility Settingd
Hospital (inpatient and outpatient) 97.7 96.2 95.2 93.7 88.0 88.4 90.7 82.0 89.4 72.8 4.6
Non-Hospital Residential, Therapeutic
Community or Halfway House 88.1 97.3 96.9 82.4 91.5 90.3 81.7 77.8 56.6 29.5 5.9
Community Mental Health Center 97.9 98.1 87.1 95.4 67.3 53.6 82.1 60.3 88.4 13.0 1.2*
Other Outpatient 94.3 96.8 91.9 82.7 75.3 64.8 82.0 60.8 55.1 17.1 5.5
Other 90.2 95.2 84.4 83.2 67.2 62.9 78.4 63.7 71.0 13.6 6.1
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilties responded to affiliation.
d
Not mutually exclusive
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study, Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health
Services Administration.

87
Table 3.2b Percentage of Facilities Offering Support Services, by Selected Facility Characteristics: National
Estimates

HIV/AIDS Education/

Academic Education/
Counseling/Training
Counseling/Support

Smoking Cessation
Transportation

TB Screening

Prenatal Care
GED Classes
Employment

Child Care
Support Services
[All services from Q-C9]
All Facilitiesa 76.5 49.6 43.2 40.2 24.2 17.0 13.3 12.0
Facility Type of Care
Hospital Inpatient Only 75.8 54.3 85.1 23.3 40.8 13.7 0.9* 32.6
Non-Hospital Residential Only 90.2 86.2 62.4 65.5 30.5 41.4 15.4 19.1
Outpatient Methadone Only 93.8 28.9 92.9 57.5 12.8 19.8 7.8 19.0
Outpatient Non-Methadone Only 68.7 34.9 21.8 30.3 19.3 7.4 12.7 5.6
Combination Facilities 87.4 69.1 84.1 48.7 35.2 27.5 17.0 22.8
Facility Size
Small (<17 clients) 73.5 57.1 40.7 41.5 21.4 17.8 13.2 13.0
Medium (17-40) 73.5 49.9 42.5 41.0 28.1 16.7 7.6 11.0
Large (41-100) 79.2 43.1 39.0 39.5 23.9 17.3 12.3 11.4
Very Large (>100) 79.4 47.2 50.0 37.9 23.0 15.9 20.3 12.2
Ownership
Private For-Profit 67.3 29.3 32.2 26.0 21.8 6.6 4.2 6.9
Private Non-Profit 78.5 55.2 43.4 45.1 23.4 20.5 15.1 12.0
Public 81.8 55.4 58.1 39.6 30.8 17.6 19.5 19.5
Percent Public Revenue
0% 58.4 18.3 19.5 20.6 21.5 6.9* 5.5* 5.0
1-50% 70.6 32.4 41.9 30.7 23.2 9.4 7.1 10.4
51-90% 80.2 54.7 41.7 40.6 22.1 16.8 18.6 12.8
91-99% 83.3 68.9 58.3 54.1 26.6 28.6 15.9 16.6
100% 85.2 67.1 46.5 58.0 30.9 24.7 15.3 14.0
Unknown % 72.4 39.0* 58.7 15.9* 19.7* 6.2* 1.4* 4.1*
Urbanicityb
Metro: Small Metro 71.4 52.9 37.2 34.7 26.8 23.3 16.4 12.4
Medium Metro 79.6 43.9 43.9 40.4 24.2 14.4 11.3 10.8
Large Metro 81.7 52.2 48.5 44.7 24.4 20.0 13.5 14.2
Non-metro: Rural 70.7 47.0 27.9* 18.5* 10.7* 21.4* 4.2* 4.6*
Small Urban 57.9 42.8 28.8 31.7 24.9 8.4 13.4 8.1
Urban 73.9 56.0 42.9 38.8 20.0 9.8 15.8 9.8
Level of Affiliationc
Parent Facility 80.8 52.4 41.8 43.2 24.3 18.0 16.8 14.2
Affiliate 79.0 50.8 44.6 41.3 24.8 17.7 12.9 12.8
Non-Affiliate 68.9 44.6 40.8 35.5 22.6 15.0 11.2 8.8
See notes at end of table. (continued)

88
Table 3.2b (continued)

HIV/AIDS Education/

Academic Education/
Counseling/Training
Counseling/Support

Smoking Cessation
Transportation

TB Screening

Prenatal Care
GED Classes
Employment

Child Care
Support Services
[All services from Q-C9]
Facility Settingd
Hospital (inpatient and outpatient) 80.0 52.1 74.7 32.0 36.3 14.3 7.1 19.8
Non-Hospital Residential, Therapeutic
Community or Halfway House 90.4 83.9 64.2 64.1 32.0 40.4 16.7 19.5
Community Mental Health Center 70.0 47.3 22.4 29.0 16.9 7.2 13.9 5.0
Other Outpatient 75.5 37.2 33.6 37.0 18.4 11.6 13.9 9.4
Other 66.9 36.3 30.1 35.0 26.9 17.3 12.6 10.1
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilties responded to affiliation.
d
Not mutually exclusive.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

89
Table 3.3 Percentage Distribution of Facilities Offering Varying Number of Services, by Facility
Characteristics: National Estimates
Number of Treatment Services Number of Support Services
Low Medium High None Low Medium High
All Facilitiesa 11.7 51.8 36.4 10.7 36.9 35.4 17.1
Facility Type of Care
Hospital Inpatient Only 9.9 34.1 55.9 7.9 21.9 47.1 23.2
Non-Hospital Residential Only 11.3 53.5 35.3 0.7* 11.7 49.7 37.9
Outpatient Methadone Only 23.2 46.0 30.9 0.2* 28.0 52.0 19.8
Outpatient Non-Methadone Only 13.7 59.6 26.7 16.8 50.3 26.0 6.9
Combination Facilities 2.0* 23.9 74.1 1.0* 17.0 49.9 32.1
Facility Size
Small (<17 clients) 14.6 52.9 32.5 11.9 35.2 36.2 16.7
Medium (17-40) 11.1 52.1 36.8 12.3 32.3 38.8 16.6
Large (41-100) 8.8 52.6 38.6 9.7 41.1 33.8 15.4
Very Large (>100) 12.5 49.6 37.9 8.9 38.7 32.6 19.9
Ownership
Private For-Profit 20.0 38.1 41.9 21.2 45.8 26.2 6.8
Private Non-Profit 8.8 57.1 34.1 8.2 34.9 37.1 19.8
Public 11.4 50.2 38.4 5.0 31.0 42.6 21.4
Percent Public Revenue
0% 26.4 47.3 26.3 26.8 49.5 20.3 3.4*
1-50% 9.6 43.9 46.6 13.6 45.3 31.7 9.4
51-90% 9.1 54.7 36.2 9.9 34.0 37.3 18.9
91-99% 8.2 58.8 33.0 2.8* 31.1 37.4 28.8
100% 10.8 55.1 34.1 4.0* 24.5 47.5 24.0
Unknown % 13.9* 31.9 54.2 5.6* 46.9 42.5 5.0
Urbanicityb
Metro: Small Metro 13.4 56.9 29.8 12.0 39.8 27.7 20.5
Medium Metro 11.4 49.1 39.5 8.7 40.8 33.9 16.7
Large Metro 12.6 49.1 38.4 7.7 33.6 39.7 19.0
Non-metro: Rural 14.7* 57.3 28.0* 17.1* 54.4 23.8* 4.6*
Small Urban 6.7* 61.8 31.4 22.7 38.2 28.1 11.0
Urban 12.4 51.4 36.2 12.0* 31.5 41.8 14.8
Level of Affiliationc
Parent Facility 8.8 51.3 40.0 10.3 35.8 32.1 21.8
Affiliate 10.6 51.7 37.7 9.4 36.1 36.7 17.8
Non-Affiliate 15.7 52.5 31.8 13.2 38.9 35.6 12.4
Client/Staff Ratioc
Low (0-4) 8.8 40.1 51.2 4.9 30.2 40.5 24.5
Medium (>4-14) 11.8 54.9 33.3 12.0 33.3 37.6 17.2
High (>14) 14.2 60.1 25.8 14.2 47.8 28.1 9.9
See notes at end of table. (continued)

90
Table 3.3 (continued)

Number of Treatment Services Number of Support Services

Low Medium High None Low Medium High
d
Facility Setting
Hospital (inpatient and outpatient) 2.6 20.7 76.8 4.9 29.9 44.4 20.9
Non-Hospital Residential, Therapeutic 8.4 50.3 41.3 1.1* 11.6 50.8 36.5
Community or Halfway House
Community Mental Health Center 9.8 62.4 27.8 13.9 53.9 23.3 9.0
Other Outpatient 15.8 58.0 26.2 12.9 43.3 33.4 10.3
Other 21.9 41.6 36.6 20.5 39.4 21.6 18.6
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilties responded to affiliation and client/staff questions.
d
Not mutually exclusive.
Note: Each row adds to 100 percent within each section (treatment services or support services).
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

91
 Table 3.4 Percentage of Facilities, by Staffing Category and Mean Staff per Facility: National Estimates
Percent of Facilities with Staff in
Each "Time" Category (all
facilities) Mean Staff Per Facility
a
Mean Staff Mean FTE
Percent of per Facility Staffb per Mean FTE
Facilities with (for facilities Facility (for Mean Staffa Staffb per
Staff Part- with staff facilities with per Facility Facility (all
Category Full-Time Time Contract category) staff category) (all facilities) facilities)
c
Total Staff 99.8 93.1 72.3 54.9 18.4 17.2 18.3 17.2
Physicians 61.4 12.8 21.0 36.7 2.0 1.3 1.2 0.8
Registered Nurses 36.5 25.8 17.4 5.9 4.9 4.9 1.8 1.8
Other Medical Personnel 24.2 17.5 12.1 3.5 4.4 4.0 1.1 1.0
Any Medical Staff 65.8 34.0 32.8 39.1 6.2 5.4 4.1 3.5
Doctoral Level Counselors 32.7 12.0 8.8 16.1 1.6 1.5 0.5 0.5
Master's Level Counselors 76.5 61.9 24.7 15.4 3.5 3.7 2.7 2.8
Any Graduate-Degreed Counseling Staff 80.3 64.0 28.1 26.9 4.0 4.1 3.2 3.3
92

Other Degreed Counselors 68.1 58.5 19.2 6.4 3.2 3.4 2.2 2.3
Non-Degreed Counselors 57.7 50.3 17.4 4.7 3.6 3.8 2.1 2.2
Any BA or Non-Degreed Counseling Staff 85.0 75.3 30.0 9.7 5.0 5.3 4.3 4.5
All Other Staff 86.4 72.8 38.1 6.5 6.4 6.2 5.5 5.3
a
The mean was calculated by adding all full-time, part-time, and contract staff, and dividing by the total number of facilities to obtain a facility mean for each staffing category.
b
Part-time and contract staff were counted as .41 FTE, based on ADSS Phase II data.
c
Does not add to 100 percent because 0.2 percent of facilities reported no paid staff on October 1, 1996.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense facilities, and
Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Table 3.5a Number and Percentage Distribution of Full-Time, Part-Time, and Contract Staff, by Staff Type: National Estimatesa
Full-Time Part-Time Contract
N Percent N Percent N Percent
Total Staff 134,184 100% 44,956 100% 22,283 100%
Physicians 2,653 2.0 3,700 8.2 8,053 36.1
Registered Nurses 13,474 10.0 6,139 13.7 1,334 6.0
Other Medical Personnel 7,390 5.5 4,106 9.1 1,118* 5.0
Total Medical Staff 23,517 17.5 13,945 31.0 10,504 47.1
Doctoral Level Counselors 2,170 1.6 1,331 3.0 2,524 11.3
Master's Level Counselors 20,631 15.4 6,172 13.7 4,537 20.4
Total Graduate-Degreed Counseling Staff 22,801 17.0 7,504 16.7 7,061 31.7
Other Degreed Counselors 19,767 14.7 4,613 10.3 1,462 6.6
Non-Degreed Counselors 18,918 14.1 5,095 11.3 1,012 4.5
Total BA and Non-Degreed Counseling Staff 38,685 28.8 9,708 21.6 2,474 11.1
93

All Other Staff 49,181 36.7 13,800 30.7 2,244 10.1

a
This table is based on data from the estimated 11,782 facilities (about 95 percent of the universe) that reported their staff by full-time, part-time, and contract.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of
Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services
Administration.
 Table 3.5b Number and Percentage Distribution of Staff Type, by "Time" Category in the Treatment System: National Estimatesa
Total Full-Time Part-Time Contract
N Percent N Percent N Percent N Percent
Physicians 14,406 100.0 2,653 18.4 3,700 25.7 8,053 55.9
Registered Nurses 20,946 100.0 13,474 64.3 6,139 29.3 1,334 6.4
Other Medical Personnel 12,614 100.0 7,390 58.6 4,106 32.6 1,118* 8.9
Total Medical Staff 47,965 100.0 23,517 49.0 13,944 29.1 10,504 21.9
Doctoral Level Counselors 6,025 100.0 2,170 36.0 1,331 22.1 2,524 41.9
Master's Level Counselors 31,341 100.0 20,631 65.8 6,172 19.7 4,537 14.5
Total Graduate-Degreed Counseling Staff 37,366 100.0 22,801 61.0 7,504 20.1 7,061 18.9
Other Degreed Counselors 25,841 100.0 19,767 76.5 4,613 17.9 1,462 5.7
Non-Degreed Counselors 25,025 100.0 18,918 75.6 5,095 20.4 1,012 4.0
Total BA and Non-Degreed Counseling Staff 50,866 100.0 38,685 76.1 9,708 19.1 2,474 4.9
94

All Other Staff 65,225 100.0 49,181 75.4 13,800 21.2 2,244 3.4
a
This table is based on data from the estimated 11,782 facilities that reported their staff by full-time, part-time, and contract.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
Table 3.5c Number and Percentage Distribution of FTE Staff, by Staffing Categories: National
Estimatesa
FTE Staffb
N Percent
Total 206,852 100.0
Physicians 9,862 4.8
Registered Nurses 21,950 10.6
Other Medical Personnel 12,081 5.8
Total Medical Staff 43,894 21.2
Doctoral Level Counselors 5,977 2.9
Master's Level Counselors 35,086 17.0
Total Graduate-Degreed Counseling Staff 41,063 19.9
Other Degreed Counselors 29,028 14.0
Non-Degreed Counselors 26,847 13.0
Total BA and Non-Degreed Counseling Staff 55,875 27.0
All Other Staff 66,019 31.9
a
This table is based on data from an estimated 12,387 facilities, including 605 facilities that could not report their staff by
full-time, part-time, and contract. These 605 facilities could only report staff numbers in terms of full-time equivalents.
b
Part-time and contract staff were counted as .41 FTE, based on Phase II data.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service Facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies,
Substance Abuse and Mental Health Services Administration.

95
Table 3.6 Mean Ratio of Clients to FTE Staff,a by Facility Characteristics: National Estimates
Mean Ratios
Clients to Direct- Clients to All
Clients to All Care Staffb [Q- Other Staffc [Q-
Staffb [Q-A9a-h] A9a-g] A9h]
All Facilities 9.9 14.1 39.0
Facility Type of Care
Hospital Inpatient Only 0.8 1.0 6.1
Non-Hospital Residential Only 2.3 4.6 7.6
Outpatient Methadone Only 18.1 23.6 95.8
Outpatient Non-Methadone Only 13.3 18.5 50.0
Combination Facilities 4.8 7.3 26.6
Facility Size
Small (<17 clients) 2.6 3.8 6.4
Medium (17-40) 6.0 8.1 16.7
Large (41-100) 10.2 14.8 40.0
Very Large (>100) 21.5 30.3 89.4
Ownership
Private For-Profit 10.7 14.8 43.7
Private Non-Profit 9.2 13.4 35.8
Public 12.0 15.9 46.3
Percent Public Revenue
0% 13.2 19.1 51.1
1-50% 10.2 13.5 37.0
51-90% 10.2 14.5 40.7
91-99% 8.7 12.5 35.9
100% 8.1 11.7 31.7
Unknown % 5.7 9.4 27.6
Urbanicityd
Metro: Small Metro 8.7 12.8 32.0
Medium Metro 10.6 14.7 40.5
Large Metro 9.7 13.9 42.8
Non-metro: Rural 12.9* 17.5 27.4
Small Urban 11.3 15.4 39.1
Urban 7.9 11.9 26.1
Level of Affiliatione
Parent Facility 10.2 14.5 40.2
Affiliate 9.6 13.0 39.6
Non-Affiliate 10.3 15.6 37.1
Number of Treatment Services
Low (0-5) 13.6 19.0 50.6
Medium (6-8) 10.7 15.5 39.1
High (9-11) 7.6 10.5 35.4
See notes at end of table. (continued)

96
Table 3.6 (continued)

Mean Ratios
Clients to Direct- Clients to All
Clients to All Care Staffb [Q- Other Staffc [Q-
Staffb [Q-A9a-h] A9a-g] A9h]
Number of Support Services
None 13.4 18.8 44.3
Low (1-2) 12.4 17.5 48.7
Medium (3-4) 8.0 11.4 32.1
High (5-8) 6.4 9.4 29.9
Facility Settingf
Hospital (inpatient and outpatient) 4.5 5.7 27.1
Non-Hospital Residential, Therapeutic
Community or Halfway House 3.2 6.0 11.4
Community Mental Health Center 12.1 16.5 43.1
Other Outpatient 13.7 19.4 53.7
Other 10.5 15.0 38.1
a
Part-time and contract staff were counted as .41 FTE, based on Phase II data.
b
At least 99 percent of facilities responded to staffing questions.
c
At least 89 percent of facilities reported having "other staff."
d
Based on Beale code (Butler & Beale, 1994).
e
At least 99 percent of facilities responded to affiliation.
f
Not mutually exclusive.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

97
Table 3.7 Percentage of Staff Certified in Substance Abuse Treatment and Mean Ratio of Clients
to Staff Certified in Substance Abuse Treatment, by Facility Characteristics: National
Estimates
Mean Ratio of Clients to
Percent of Direct-Care Staff Staff Certified in
Certified in Substance Abuse Substance Abuse
[Q-A10] Treatmenta Treatmentb
All Facilities 44.7 30.3
Facility Type of Care
Hospital Inpatient Only 23.8 4.9
Non-Hospital Residential Only 41.9 10.3
Outpatient Methadone Only 26.0 105.6
Outpatient Non-Methadone Only 49.4 35.2
Combination Facilities 38.6 21.8
Facility Size
Small (<17 clients) 42.5 5.4
Medium (17-40) 40.8 12.8
Large (41-100) 47.7 27.1
Very Large (>100) 47.8 73.9
Ownership
Private For-Profit 47.8 25.5
Private Non-Profit 45.1 29.2
Public 37.8 45.1
Percent Public Revenue
0% 51.7 35.6
1-50% 47.0 22.3
51-90% 47.7 30.5
91-99% 38.2 35.0
100% 36.3 32.8
Unknown % 37.3 18.8
Urbanicityc
Metro: Small Metro 50.3 23.9
Medium Metro 46.4 33.5
Large Metro 42.9 31.8
Non-metro: Rural 32.4 28.6
Small Urban 45.8 26.6
Urban 43.3 26.7
Level of Affiliationd
Parent Facility 46.8 30.0
Affiliate 41.7 29.4
Non-Affiliate 48.0 32.0
Number of Treatment Services
Low (0-5) 43.7 38.6
Medium (6-8) 48.2 30.3
High (9-11) 40.3 28.1
See notes at end of table. (continued)

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Table 3.7 (continued)

Mean Ratio of Clients to

Percent of Direct-Care Staff Staff Certified in
Certified in Substance Abuse Substance Abuse
[Q-A10] Treatmenta Treatmentb
Number of Support Services
None 56.5 27.6
Low (1-2) 46.9 32.5
Medium (3-4) 40.7 29.5
High (5-8) 41.4 29.4
Facility Settinge
Hospital (inpatient and outpatient) 35.3 18.2
Non-Hospital Residential, Therapeutic Community
or Halfway House 42.9 13.8
Community Mental Health Center 36.5 40.9
Other Outpatient 51.3 39.2
Other 49.9 24.4
a
At least 88 percent of facilities provided number of direct-care staff (not FTEs).
b
At least 99 percent of facilities reported having staff certified in substance abuse treatment.
c
Based on Beale code (Butler & Beale, 1994).
d
At least 99 percent of facilities provided affiliation.
e
Not mutually exclusive.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

99
100
 Appendix A

ADSS Phase I Methodology

101
102
 Appendix A: ADSS Phase I Methodology
Phase I of the Alcohol and Drug Services Study (ADSS) consisted of a national
mail/telephone survey of substance abuse treatment facilities. Data collected were based on
reports of facility directors. The survey, conducted in 1996-1997, was based on a nationally
representative, stratified random sample of 2,395 alcohol and drug treatment facilities, sampled
from the Substance Abuse and Mental Health Services Administration's (SAMHSA's) national
inventory of substance abuse treatment facilities. This appendix provides a summary of the
methodology for Phase I of the ADSS. For more detailed information, see the ADSS
methodology report.1

Facility Sample Frame. The sample frame for ADSS Phase I was the enhanced 1996
National Master Facility Inventory (NMFI) created by SAMHSA. The ADSS sampling frame of
18,368 consisted of 13,787 substance abuse treatment facilities previously known to SAMHSA
and listed on the National Facility Register (NFR) and an additional 4,581 facilities identified
from other sources, such as hospital listings, provider associations, and business directories.
Types of facilities excluded from the ADSS sampling frame were intake/referral-only facilities,
halfway houses without paid counseling staff, solo practices, correctional facilities, Department
of Defense facilities, and Indian Health Service facilities.

Facility Stratification. The strata used to select the ADSS facility sample reflect the
types of care offered within the Nation's substance abuse treatment system: hospital inpatient,
non-hospital residential, outpatient-predominantly methadone, outpatient-non-methadone, and
combined. For the outpatient, non-methadone type of care, the sample was further stratified to
reflect whether or not facility clients were almost exclusively alcohol abusers. A seventh stratum
was included for facilities whose type of care could not be determined based on existing
information at the time of sampling.

Facility Sample Size. A total sample size of about 2,400 facilities was planned.
Approximately 300 facilities per stratum were considered minimal to provide estimates with the
necessary precision and stability. Stratified proportional samples are known to produce optimal
design effects. Based on needed minimums and design effect considerations, target strata sizes
for the ADSS Phase I sample were determined: 316 facilities each for the hospital inpatient,
non-hospital residential, outpatient-predominantly methadone, outpatient-almost exclusively
alcohol, and combined strata, and 560 facilities for the outpatient-other strata. The target for the
unknown stratum was set to zero as facilities would be reclassified based on their Phase I
responses.

Facility Sampling. Facility selection into the ADSS sample was based on a probability
proportional to size (PPS), with size calculated as the 0.7th power of the facility's most recent

1
Ritter, G.A., Levine, H.J., Mohadjer, L., Krenzke, T., Lee, M.T., Reif, S., & Horgan, C.M. (2003). Phase
I methodology—ADSS Facility Survey. In Office of Applied Studies (Ed.), Alcohol and Drug Services Study
(ADSS): Methodology report: Phases I, II, and III (Chapter 1; available at http://www.samhsa.gov/oas/adss.htm).
Rockville, MD: Substance Abuse and Mental Health Services Administration.

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point-prevalence client count from their response to SAMHSA's annual Uniform Facility Data
Set (UFDS) census of facilities. Facilities with no prior UFDS point-prevalence count were given
an estimated size based on other existing information from the NFR or UFDS. Factors used for
such estimates included the facility's stratum, location, capacity, annual admissions, annual
revenues, and whether the facility treated drug abusers only, alcohol abusers only, or both.

The ADSS Phase I sample was released in two waves to ensure the target number of
facilities per strata and in recognition of some incompleteness and misclassification of initial
strata groups. Information on response rate, reclassification of stratum designation, and the
distribution of facilities in the unknown stratum for the first wave of 2,447 facilities was used to
determine the distribution of facilities released in the second wave. In all, an oversample of 3,643
facilities was released as the ADSS Phase I sample, allowing for closed or otherwise ineligible or
out-of-scope facilities.

Comparison of the ADSS and UFDS Facility Universes. Because the ADSS facility
universe is an expansion of the original frame previously used for the annual UFDS survey,
comparison of national estimates from the two survey frames was undertaken to determine
whether the addition of facilities from the business listings and other sources in ADSS made any
important changes to the survey universe.

Looking at the facility organizational characteristics for the 12,387 facilities estimated in
ADSS Phase I versus the characteristics for only the original NFR portion of the ADSS estimate
(10,035 facilities or 81 percent of the ADSS estimate of facilities,) a few small differences are
noted.

For the full ADSS frame, there was a slightly lower proportion of non-hospital residential
facilities (17 percent residential) compared with the NFR portion of the frame (19 percent
residential). Conversely, for the full ADSS frame, there was a slightly higher proportion of
outpatient non-methadone facilities (61 percent outpatient non-methadone) compared with the
NFR portion of the frame (59 percent outpatient non-methadone).

There were other small differences of 2 to 3 percentage points between the full ADSS
frame and original NFR frame. In the full ADSS universe, there was a slightly larger
representation of private for-profit facilities (23 percent in the full ADSS universe vs. 20 percent
in the NFR universe) and correspondingly fewer non-profit facilities. There was a slightly higher
percentage of medium-sized facilities in the full universe (24 percent) compared with the NFR
universe (22 percent) and correspondingly fewer very large facilities in the complete ADSS
sample (23.5 percent) than the NFR (25.5 percent). There were no differences in percent public
revenue, urbanicity, or level of affiliation with other organizations. The small differences that
might exist between sample estimates are largely due to somewhat greater representation of
private for-profit, medium-sized, outpatient non-methadone facilities among the newly identified
facilities.

Instrument Development and Data Collection. The ADSS Phase I data collection
consisted of three steps: a telephone screener to confirm eligibility status and to update the
mailing address; a mailing of the ADSS Phase I facility questionnaire; and a telephone call to

104
collect the responses prepared by the facility's administrator. The last step often took a number of
follow-up telephone calls to complete, sometimes to more than one person at the facility.

Instrument development was the result of an extensive process of planning, development,

and review. The ADSS advisory group, formed to help in the development process, was
comprised of members of the research community, including representatives from SAMHSA and
members of other U.S. Department of Health and Human Services (DHHS) agencies,
representatives of the National Association of State Alcohol and Drug Abuse Directors
(NASADAD), provider organizations, and private treatment providers. Final instruments used in
ADSS were subject to both internal institutional review board (IRB) review and governmental
Office of Management and Budget (OMB) approval. Both the screener and the facility
questionnaire were revised based on pilot results. The revised screener was estimated to take
about 10 minutes to complete. The revised facility questionnaire was estimated to require about 3
hours of preparation and an additional 50 minutes of telephone time to provide the responses.

ADSS Screener. The screener was a telephone call to sampled ADSS facilities to verify
name and mailing address and to gather additional information regarding the facility's ADSS
eligibility, stratum classification, and size. Questions included the facility's types of care, setting,
ownership, managed care arrangements, and whether the facility provided treatment or only
performed intake and referral. This information was necessary to confirm that facilities still were
in business and to refine stratification assignment.

Of the 3,643 Phase I facilities for which screening was attempted, 221 were out of
business,18 refused, and 3,404 facilities responded to the screener. Ultimately, 2,771 of the 3,404
responding facilities were determined by the screener to be eligible to receive the ADSS Phase I
questionnaire. Screened facilities were designated ineligible for the ADSS survey because of
duplicate listings (n = 55), out-of-scope setting (n = 186), out-of-scope ownership (n = 14), or
lack of substance abuse treatment (n = 378). Further breakdown of the ineligible categories
follows. Facilities ineligible for ADSS based on out-of-scope setting included correctional
facilities (n = 103), halfway houses without paid counselors (n = 14), and solo practitioners (n =
69). Facilities ineligible for ADSS based on ownership included Department of Defense facilities
(n = 8) and Indian Health Service facilities (n = 6). Facilities ineligible for ADSS because of lack
of treatment included administrative-only units (n = 35), facilities with prevention services only
(n = 319), and facilities providing only intake and referral (n = 24). Overall, 2,771 eligible
facilities responded to the screener out of 2,789 eligible facilities (2,771 respondents and 18
refusals), for a screener response rate of 99.4 percent.

ADSS Facility Questionnaire. The ADSS Phase I Facility Survey was conducted from
December 1996 to June 1997, using the ADSS Facility Questionnaire. It was mailed to facilities
that met ADSS eligibility criteria on the basis of screener responses. The questionnaire collected
point-prevalence information for October 1, 1996, concerning the facility's organizational
structure, the number of clients served, and client characteristics. It also asked for the facility's
most recent 12-month data on admissions and discharges; special treatment programs; special
populations served; treatment services offered; managed care participation; and annual costs and
revenues. The questionnaire was organized in four sections: Section A involved facility
organization and staffing, Section B concerned point-prevalence client counts, Section C

105
concerned 12-month client counts and treatment services, and Section D involved financial data.
Questionnaires were mailed to facility directors to allow them time to assemble the detailed
information necessary for responses. Data were collected by telephone interviews beginning
approximately 2 weeks after the questionnaire was mailed.

ADSS Phase I Response Rate. Table A.1 shows each survey step and the resulting
response rate for the ADSS Phase I survey. Of the 2,771 facilities originally mailed Phase I
questionnaires, 168 were designated ineligible because they were out of business or did not
provide substance abuse treatment as of October 1, 1996. Of the remaining 2,603 eligible
facilities, 2,395 completed the interview and 208 refused, for a questionnaire response rate of 92
percent.

Table A.1 Number of Facilities in the ADSS Phase I Survey Results

Mailed Questionnaire 2,771
Out of Business/Closed/No Treatment 168
Eligible 2,603
Refusals/No Contact 208
Eligible Completers 2,395
Phase I Questionnaire Response Rate 92.0% (2,395 out of 2,603)

Phase I Cumulative Response Rate. The cumulative response rate for ADSS Phase I is
calculated as the product of the Phase I screener response rate (.994) and the Phase I
questionnaire response rate (.920) for a cumulative response rate of .914 or 91.4 percent.

Weighting. The Phase I sampling design incorporated a stratified random probability

sample. Weights were developed for the Phase I sample to facilitate overall and by-stratum
estimates of facility-level and client-level characteristics of the Nation's substance abuse
treatment system. Final Phase I weights were constructed in a multi-step process involving
calculation of initial base weights, trimming to guard against excessive influence by a few highly
weighted facilities, adjustment for facility non-response, and poststratification adjustment of the
facility estimates to initial frame counts.

Because the Phase I sample was selected using a complex multi-stage design, resampling
is the appropriate method of calculating the stability of computed statistics. Replicate weights
based on the stratified jackknife procedure (JKn) are included in the ADSS Phase I dataset for
the purpose of standard error (SE) calculation.

Imputation. In the Phase I data file, imputation was used to fill in missing values for key
responses concerning staffing, point-prevalence counts, characteristics of clients, admissions,
revenues, and costs. Variables for which missing responses were imputed generally had item
non-response of well under 10 percent, except for total revenue and total cost, which had 10 to
11 percent missing values across the full sample; missing values within hospital inpatient
facilities were higher. Phase I imputation involved a number of methods designed to approximate

106
the true missing value and at the same time maintain variability and preserve joint relationships
among responses. Listed in order of preference these methods include logical imputation,
substitution from an external source, and imputation by statistical method. The statistical
imputation methods used in ADSS Phase I were non-deterministic, based on random regression2
and random within class hot-decking.3

Imputation was performed to blocks of items at a time—staffing, point-prevalence counts,

admissions, revenues, and costs. Within each block, missing totals were imputed first, followed
by imputation of missing components in a manner to produce internally consistent responses.
Upon completion of a block, pre-imputation to post-imputation comparisons were done to ensure
that key statistics of the data remained invariant. Imputation error variances, measuring the
amount of error introduced, also were calculated to provide added assurance that the imputation
process did not compromise the quality of ADSS data. More detailed information about frame
construction, sample design, sampling method, the data collection process, weighting, and
imputation can be found in the ADSS methodology report.4

2
Montaquila, J., & Ponickowski, C. (1995). An evaluation of alternative imputation methods. In
Proceedings of the Section on Survey Research Methods. Alexandria, VA: American Statistical Association.

3
Kalton, G., & Kish, L. (1984). Some efficient random imputation methods. Communication in Statistics,
13, 1919-1939.

4
See footnote 1.

107
108
 Appendix B

Variable Definitions

109
110
 Appendix B: Variable Definitions
The variables used in this report were constructed from the Alcohol and Drug Services
Study (ADSS) Phase I Facility Questionnaire. See the ADSS methodology report for a copy of
the questionnaire.1 Data items included organization and staffing, point-prevalence client data,
12-month client data, and financial data. Constructed variables include type of care, facility size,
ownership, percent public revenue, urbanicity, level of affiliation, number of treatment services,
number of support services, setting, and client-to-staff ratio. Categories for each variable are
listed with a description of how they were constructed.

Facility Type of Care (ADSS Phase I Question B1). Facilities were asked whether they
offered specific types of substance abuse treatment on the point-prevalence date of October 1,
1996. The majority of facilities offered a single type of care and were categorized as such.
Although many combinations of the four types of care are represented in the combination
category, they were grouped together to create cell sizes large enough for analysis and so indicate
facilities offering multiple types of care. Facilities were classified as follows:

! hospital inpatient only—offered hospital inpatient (including hospital inpatient

detoxification or rehabilitation) and no other types of care.
! non-hospital residential only—offered residential care (including residential
detoxification or rehabilitation) and no other types of care.
! outpatient methadone only—offered outpatient methadone and no other types of care.
! outpatient non-methadone only—offered outpatient non-methadone care and no other
types of care.
! combination facilities—offered more than one of the types of care listed above. Any
combination is included in this category.

Facility Size (ADSS Phase I Question B1). Facilities were categorized by the total
number of clients in all types of care reported as in treatment on the point-prevalence date of
October 1, 1996. The categories represent quartiles of the weighted data, and they are used to
facilitate comparisons among facilities of similar size:

! small—16 or fewer clients.

! medium—17 to 40 clients.
! large—41 to 100 clients.
! very large—more than 100 clients

Ownership (ADSS Phase I Question A6). Facilities were asked to describe their
ownership on October 1, 1996:

! private for-profit.

1
Office of Applied Studies. (2003). Alcohol and Drug Services Study (ADSS): Methodology report:
Phases I, II, and III (available at http://www.samhsa.gov/oas/adss.htm). Rockville, MD: Substance Abuse and
Mental Health Services Administration.

111
! private non-profit.
! public—collapses categories for city or county government agency, State government
agency, Federal Government agency, or tribal government.

Mean Percent Public Revenue (ADSS Phase I Questions D7 and D8). Facilities were
asked to break down their annual revenue by 10 different sources. Of these 10 categories, 5 were
"public revenue" categories: Medicaid (not specified), Medicaid (managed care), Medicare, other
Federal Government funds (VA, CHAMPUS, etc.), and other public funds (block grants,
contracts, grants, etc.). The percentage of revenue from each of these five sources was summed
and calculated as a percentage of total revenue for each sample facility, creating a public revenue
variable. This public revenue percentage was categorized based, in part, on frequency
distributions. The frequency distribution of the public revenue variable was divided into thirds: 0
to 50 percent, 51 to 90 percent, and 91 to 99 percent. Based on further analyses, these thirds were
then modified to separate facilities with no public revenue and facilities with 100 percent public
revenue, as these were deemed to be inherently different types of facilities. Therefore, the public
revenue categories are as follows:

! none—facility reported no revenue from any of the five public revenue categories.
! 1 to 50 percent—public revenue was more than 0 percent, and up to and including 50
percent of the facilities' total revenue.
! 51 to 90 percent—more than 50 percent, and up to and including 90 percent of total
revenue.
! 91 to 99 percent—more than 90 percent, but less than 100 percent.
! 100 percent—all revenue reported came from the public revenue categories.

Urbanicity. Based on facility ZIP code, facilities were coded according to the Beale
Rural-Urban Continuum Codes developed by the U.S. Department of Agriculture to categorize
facilities by level of urbanicity.2 The Beale classification uses 10 county-based categories. For the
ADSS analysis, the 10 Beale categories were collapsed into 6 categories, combining several
categories as follows:

! large metro—central or fringe counties in metropolitan statistical areas (MSAs) with a

population of 1 million or more. Beale Code equals 0 (central counties) or 1 (fringe
counties).
! medium metro—counties in MSAs with population of 250,000 to 1 million. Beale Code
equals 2.
! small metro—counties in MSAs with population <250,000. Beale Code equals 3.
! non-metro, urban—urban population of 20,000 or more, in non-metropolitan counties.
Beale Code equals 4 (adjacent to a metro area) or 5 (not adjacent to a metro area).
! non-metro, small urban—urban population of 2,500 to 19,999, in non-metropolitan
counties. Beale Code equals 6 (adjacent to a metro area) or 7 (not adjacent to a metro
area).

2
Butler, M.A., & Beale, C.L. (1994). Rural-urban continuum codes for metropolitan and nonmetropolitan
counties, 1993 (Staff Report No. AGES 9425; http://www.ers.usda.gov:80/briefing/rural/data/code93.txt).
Washington, DC: U.S. Department of Agriculture, Economic Research Service.

112
! non-metro, rural—completely rural with <2,500 population, in non-metropolitan
counties. Beale Code equals 8 (adjacent to a metro area) or 9 (not adjacent to a metro
area).

Level of Affiliation (ADSS Phase I Questions A11 and A16). Level of affiliation refers
to whether a facility is an independent entity or an integral part of a larger organization. This
variable was created to capture organizational configurations in the substance abuse treatment
system. Facilities were asked if they were a parent organization to other substance abuse facilities
on October 1, 1996 (A16), and whether they were legally part of another organization on October
1, 1996 (A11). Using these questions, facilities were classified for this report as follows:

! parent—If the facility answered "yes" to being a parent, whether or not they were legally
part of another organization.
! affiliate—If the facility was not a parent to other substance abuse facilities, but was
legally part of another organization.
! non-affiliate—If the facility was not a parent to other substance abuse facilities and was
not legally part of another organization.

Number of Treatment Services (ADSS Phase I Question C9). Facilities were asked
whether they offered each of 19 selected services. For this report, the 19 services were classified
into two groups—treatment services and support services. The following 11 were classified as
treatment services: comprehensive assessment/diagnosis, self-help or mutual-help groups,
detoxification, individual therapy, group therapy (not including relapse prevention), relapse
prevention groups, family counseling, combined substance abuse and mental health treatment,
acupuncture, aftercare, and outcome follow-up. Facilities were categorized by the number of
these 11 treatment services they offered:

! low—offered 5 or fewer types of treatment services.

! medium—offered 6 to 8 types of treatment services.
! high—offered 9 to 11 types of treatment services.

Number of Support Services (ADSS Phase I Question C9). Facilities were asked
whether they offered each of 19 services. For this report, eight (8) of the services were classified
as support services: child care, transportation, employment counseling/training, academic
education/GED classes, HIV/AIDS education/counseling/ support, TB screening, prenatal care,
and smoking cessation. Facilities were categorized by the number of these eight support services
they offered:

! none—offered no support services.

! low—offered one or two types of support services.
! medium—offered three or four types of support services.
! high—offered five to eight types of support services.

Setting (ADSS Phase I Question A5). Facilities were asked to identify the settings or
locations (14 settings listed plus "other" category) that best applied as of October 1, 1996.
Because facilities checked all that applied, a facility may be represented in more than one of the

113
categories below. The settings were collapsed into the major types of settings represented as
follows:

! hospital (inpatient and outpatient)—general hospital, Veterans Affairs (VA) hospital, or

psychiatric/other specialized hospital. Inpatient and/or outpatient treatment at this setting.
! non-hospital residential—non-hospital residential facility, therapeutic community, or
halfway house.
! community mental health center—community mental health center.
! other outpatient—outpatient, other than above (i.e., excluding outpatient set at a hospital,
community mental health center, or group practice).
! other—reported settings other than hospital, residential, community mental health center,
or other outpatient. These include group practice, school, or other.

Client-to-Staff Ratio (ADSS Phase I Questions A9 and B1). A client-to-staff ratio

variable was created to examine the distribution of caseloads in the substance abuse treatment
system. The point-prevalence client count was divided by the point-prevalence direct-care full-
time equivalent (FTE) staff count to calculate a ratio at each facility. The direct-care staff
category was created to include physicians, nurses, other medical personnel, doctoral-level
counselors, master's level counselors, other degreed counselors (B.A., B.S.), and non-degreed
counselors. FTE estimates for part-time and contract staff were derived from Phase II data
because Phase I did not collect FTE data for those categories.3 The weighted frequency
distribution of facilities by this ratio was divided by thirds, and facilities were categorized as
follows:

! low—0 to 4 clients per staff.

! medium—more than 4 to 14 clients per staff.
! high—more than 14 clients per staff.

3
The average number of hours worked by a part-time and contract staff was 14.34 hours per week.
Full-time was defined in ADSS as 35 hours per week. Therefore, part-time and contract staff were counted as .41
FTE.

114
 Appendix C

Standard Error Tables

115
116
 Appendix C: Standard Error Tables

The Alcohol and Drug Services Study (ADSS) was designed to produce statistically
unbiased national estimates that are representative of substance abuse treatment facilities and
clients in treatment. Because ADSS is based on sample data, the statistics presented in this report
may differ from the figures that would have been obtained if the whole universe were surveyed.
The potential difference between sample statistics and statistics from a complete census is the
standard error (SE) of the estimate. The SEs are calculated using WesVar v.3.0, a software
program that employs replication to calculate statistics based on data from complex surveys.
WesVar v.3.0 was developed by Westat, Inc. This appendix presents SEs for tables appearing
earlier in this report.

117
118
 Table C.1.1 Standard Errors - Number of Substance Abuse Treatment Facilities, Average Number of Direct-Care Staff per
Facility, and Average Facility Percentage of Public Revenue, by Facility Type of Care: National Estimates
Average Number of
Unweighted Direct-Care Staff (FTE) Average Percentage of
Number of National Estimates of per Facility Facility Revenue from
Facilities Facilities on October 1, 1996 on October 1, 1996 Public Sourcesb

Sample Weighted
Facility Type of Carea n N (± SE) Percent Mean Median Mean Median
Total, All Facilities . 267.4 . . 0.45 0.2 1.16 1.35
Type of Care
Hospital Inpatient Only . 25.0 . 0.20 2.35 1.2 2.43 4.62
Non-Hospital Residential Only . 107.7 . 0.84 0.87 0.4 1.43 0.81
Outpatient Methadone Only . 24.8 . 0.21 0.39 0.5 2.10 1.88
Outpatient Non-Methadone Only . 236.3 . 1.05 0.41 0.2 1.78 2.13
Combination Facilities . 113.7 . 0.89 2.05 1.4 2.05 3.80
119

a
Because Table 1.1 presents data on facility staffing and revenue available only at the overall facility level, rather than within each type of care, the facilities are categorized by
their overall type of care (i.e., facilities with only one type of care are counted by that type of care and facilities with more than one type of care are classified as
"combination" facilities, except methadone facilities, which are included in the outpatient methadone category if 70 percent or more of their clients are in methadone
treatment). Therefore, the counts of facilities offering a specific type of care in Table 1.1 generally include only the single-modality facilities and do not represent all facilities
with that type of care; those with a type of care in combination with another modality are counted in the “combination” category. For a count of all facilities providing a
particular type of care, whether alone or in combination with another type of care, see Table 1.2.
b
At least 97 percent of facilities provided source of revenue data for their most recent 12-month reporting period.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Table C.1.2 Standard Errors - Number of Facilities and Number of Clients, and the Average Number of Clients per Facility,
by Client Type of Care: National Estimates
National Estimates of Clients
in Treatment, by Facility
Weighted Facilities with Type, Number of Clients per
Unweighted
Each Type of Careb on October 1, 1996 Facility
Facility Sample
Client Type of Carea (n)b N Percent N Percent Mean Median
Total . 267.4 . 42,787.2 . 2.98 1.8
Type of Care
Hospital Inpatient . 92.6 0.96 1,079.4 0.15 0.63 0.6
Non-Hospital Residential . 121.3 1.53 13,867.0 1.63 4.30 0.8
Outpatient Methadone . 36.9 0.42 9,453.5 1.41 9.24 12.8
Outpatient Non-Methadone . 254.3 3.69 38,487.7 6.49 3.44 3.0
a
Because clients in combination facilities can be counted by their specific treatment modality within the facility, there is no "combination" type of care category, as there is for
facility type of care in Table 1.1.
b
This table presents estimates of the number of facilities providing each type of care, whether provided alone or in combination with other types of care (i.e., facilities
120

providing more than one type of care are counted in more than one category). Therefore, the unweighted and weighted numbers of facilities providing each type of care add to
more than the total, and the percentages offering each type of care add to more than 100 percent.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
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121
Table C.1.3 Standard Errors - Percentage Distribution of Substance Abuse Treatment Facilities, by Selected
Facility Characteristics and by Facility Type of Care: National Estimates, October 1, 1996
Facility Type of Care
Hospital Non-Hospital Outpatient Outpatient Non-
Inpatient Residential Methadone Methadone Combination
Total Only Only Only Only Facilities
Number of Facilities (weighted estimate) 267.40 25.03 107.66 24.76 236.26 113.65
Percent of Facilities . 0.20 0.84 0.21 1.05 0.89
Facility Size (on October 1, 1996)
Small (<17 clients) 1.32 2.18 2.79 0.22 1.85 3.45
Medium (17-40) 1.17 1.58 2.33 0.32 1.62 4.14
Large (41-100) 1.12 1.17 1.33 2.23 1.69 3.92
Very Large (>100) 1.00 0.11 0.63 2.21 1.46 2.70
Ownershipa
Private For-Profit 1.44 2.89 1.42 2.58 2.06 3.26
Private Non-Profit 1.45 3.27 1.92 2.26 2.07 3.49
Public 0.80 1.83 1.54 1.51 1.25 1.91
Percent Public Revenuea
0% 1.07 1.41 1.16 2.56 1.73 0.54*
1-50% 1.17 3.80 1.35 2.40 1.56 3.51
51-90% 1.39 3.11 2.95 2.21 1.81 3.99
91-99% 1.17 2.93 2.17 2.22 1.67 2.79
100% 0.87 1.08 1.79 0.26 1.30 1.68
Unknown % 0.57 2.49 0.56* 0.36 0.87 1.26*
Urbanicitya
Metro: Large Metro (1 million+ pop) 1.21 3.14 2.55 3.04 1.65 3.53
Medium Metro (250,000 - 1
million pop) 1.07 3.56 1.95 2.99 1.49 3.29
Small Metro (< 250,000 pop) 1.04 1.38 2.26 1.22 1.56 2.40
Non-metro: Urban (20,000+ pop) 0.65 2.88 1.29 0.18 0.88 1.83
Small Urban (2,500 - 19,999
pop) 1.01 1.50 1.57 . 1.54 1.38
Rural (< 2,500 pop) 0.43 1.35* 0.49* . 0.64 1.08*
Level of Affiliationa
Parent Facility 1.10 1.53 2.08 1.59 1.51 2.97
Affiliate 1.24 3.05 2.57 2.65 1.81 3.08
Non-Affiliate 1.19 2.91 2.45 2.86 1.71 2.82
Number of Treatment Servicesa
Low (0-5) 0.92 1.80 1.79 2.36 1.40 0.65*
Medium (6-8) 1.56 3.38 2.73 2.57 2.31 2.81
High (9-11) 1.46 3.21 2.81 2.40 2.13 2.87
See notes at end of table. (continued)

122
Table C.1.3 (continued)

Facility Type of Care

Hospital Non-Hospital Outpatient Outpatient Non-
Inpatient Residential Methadone Methadone Combination
Total Only Only Only Only Facilities
Number of Support Servicesa
None 0.90 1.81 0.52* 0.14* 1.45 0.80*
Low (1-2) 1.42 3.22 1.53 2.63 2.09 2.79
Medium (3-4) 1.32 3.24 2.47 2.72 1.53 4.23
High (5-8) 0.89 2.75 2.67 2.46 0.83 3.46
Client-to-Staff Ratio (Direct-Care
FTEs)a
Low (4 or less) 1.38 0.83 2.63 0.45 1.94 3.90
Medium (>4 to 14) 1.39 0.82* 2.68 1.42 2.13 3.33
High (more than 14) 1.31 0.08 0.40 1.44 1.94 1.90
Facility Settinga,b
Hospital (inpatient or outpatient) 0.98 0.90 0.78 2.15 1.32 2.71
Non-Hospital Residential, Therapeutic
Community or Halfway House 0.92 0.78 0.98 0.17 0.44 2.57
Community Mental Health Center 1.19 0.98* 0.70* 1.13 1.83 1.46
Other Outpatient 1.43 0.68* 0.64* 2.35 1.87 3.81
Other 1.02 0.60 1.70 0.86 1.58 1.18
Certification Typea,b
State Alcohol or Drug Agency 1.22 3.29 1.75 0.83 1.62 3.61
State Dept. of Mental Health 1.47 3.48 2.30 1.27 2.10 3.88
State Dept. of Public Health 1.44 3.33 2.43 2.57 1.84 4.62
Hospital Licensing Authority 0.84 2.83 0.61* 0.58 0.98 3.41
JCAHO 1.32 2.53 2.03 2.43 1.91 2.74
Other 1.21 2.34 2.18 2.90 1.69 3.32
Mean Number of Licenses or Accreditation 0.08 0.05 0.04 0.04 0.13 0.03
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

123
Table C.1.4 Standard Errors - Percentage Distribution of Substance Abuse Treatment Facilities,
by Selected Facility Characteristics and by Facility Ownership: National Estimates,
October 1, 1996
Facility Ownership
Private Private
Total For-Profit Non-Profit Public
Number of Facilities (weighted estimate) 267.44 183.13 255.28 106.50
Percent of Facilities . 1.44 1.45 0.80
Facility Type of Carea
Hospital Inpatient Only 0.20 0.40 0.30 0.48
Non-Hospital Residential Only 0.84 1.07 1.24 1.89
Outpatient Methadone Only 0.21 0.76 0.20 0.45
Outpatient Non-Methadone Only 1.05 2.46 1.54 3.04
Combination Facilities 0.89 2.12 1.12 2.53
Facility Sizea (on October 1, 1996)
Small (<17 clients) 1.32 3.60 1.57 3.09
Medium (17-40) 1.17 3.09 1.44 3.26
Large (41-100) 1.12 2.73 1.52 2.87
Very Large (>100) 1.00 2.03 1.33 3.19
Percent Public Revenuea
0% 1.07 3.49 0.90 0.78*
1-50% 1.17 3.54 1.11 2.31
51-90% 1.39 2.25 1.68 3.30
91-99% 1.17 0.58 1.61 3.16
100% 0.87 0.49* 1.28 2.88
Unknown % 0.57 2.05 0.48 0.12
Urbanicitya
Metro: Large Metro (1 million+ pop) 1.21 3.93 1.54 3.35
Medium Metro (250,000 - 1 million pop) 1.07 3.18 1.47 2.26
Small Metro (< 250,000 pop) 1.04 2.50 1.26 2.92
Non-metro: Urban (20,000+ pop) 0.65 1.25* 0.91 1.59
Small Urban (2,500 - 19,999 pop) 1.01 1.17 1.28 3.76
Rural (< 2,500 pop) 0.43 0.26* 0.55 1.60*
Level of Affiliationa
Parent Facility 1.10 2.05 1.50 2.63
Affiliate 1.24 3.39 1.53 3.31
Non-Affiliate 1.19 3.25 1.52 2.47
Number of Treatment Servicesa
Low (0-5) 0.92 2.88 0.81 2.26
Medium (6-8) 1.56 3.90 1.85 3.49
High (9-11) 1.46 4.00 1.80 3.20
See notes at end of table. (continued)

124
Table C.1.4 (continued)

Facility Ownership
Private Private
Total For-Profit Non-Profit Public
Number of Support Servicesa
None 0.90 2.84 0.97 1.40
Low (1-2) 1.42 3.59 1.70 2.91
Medium (3-4) 1.32 3.15 1.50 3.60
High (5-8) 0.89 1.44 1.21 2.65
Client-to-Staff Ratio (Direct-Care FTEs)a
Low (4 or less) 1.38 3.78 1.70 3.24
Medium (>4 to 14) 1.39 3.98 1.70 3.12
High (more than 14) 1.31 2.75 1.71 3.07
Facility Settinga,b
Hospital (inpatient or outpatient) 0.98 3.53 1.15 2.49
Non-Hospital Residential, Therapeutic Community or
Halfway House 0.92 1.51 1.35 2.66
Community Mental Health Center 1.19 1.38 1.43 3.60
Other Outpatient 1.43 3.35 1.94 3.16
Other 1.02 3.50 1.01 1.33
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted
with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

125
Table C.1.5 Standard Errors - Percentage Distribution of Substance Abuse Treatment Facilities, by Selected
Facility Characteristics and by Urbanicity: National Estimates, October 1, 1996
Urbanicitya
Metropolitan Non-Metropolitan
Medium Small
Large Metro Urban
Metro (250,000 - Small Metro Urban (2,500 - Rural
Total (1 million+) 1 million) (< 250,000) (20,000+) 19,999) (<2,500)
Number of Facilities (weighted estimate) 267.40 171.83 148.37 133.74 84.90 130.22 53.70
Percent of Facilities . 0.43 1.01 0.65 1.04 1.07 1.21
Facility Type of Carea
Hospital Inpatient Only 0.20 0.28 0.52 0.42 1.29 0.46 2.02*
Non-Hospital Residential Only 0.84 1.18 1.55 3.83 3.11 2.41 4.10*
Outpatient Methadone Only 0.21 0.41 0.56 0.42 0.11 . .
Outpatient Non-Methadone Only 1.05 1.64 2.46 4.91 4.35 2.77 8.40
Combination Facilities 0.89 1.34 2.09 3.42 3.64 1.80 7.66*
Facility Sizea (on October 1, 1996)
Small (<17 clients) 1.32 1.75 3.29 5.48 4.84 3.82 9.65
Medium (17-40) 1.17 1.73 2.97 2.90 5.14 4.12 9.49*
Large (41-100) 1.12 1.37 2.56 4.80 4.15 3.84 8.32*
Very Large (>100) 1.00 1.48 2.20 3.23 3.60 2.65 6.05*
Ownershipa
Private For-Profit 1.44 2.41 3.07 4.57 3.81* 2.15 2.81*
Private Non-Profit 1.45 2.08 3.16 4.92 4.45 4.69 9.84
Public 0.80 1.15 1.37 3.43 2.96 4.55 9.50
Percent Public Revenuea
0% 1.07 2.00 2.86 2.91 3.21* 2.35 0.99*
1-50% 1.17 1.70 2.71 4.40 3.77 3.00 6.83*
51-90% 1.39 1.73 3.02 4.26 5.39 4.06 10.61
91-99% 1.17 1.70 2.46 4.46 2.89 3.00 8.08*
100% 0.87 1.47 1.70 4.45* 4.41* 1.72 7.65*
Unknown % 0.57 1.16 0.55 0.96* 1.05* 1.37* 4.24*
Level of Affiliationa
Parent Facility 1.10 1.26 2.87 3.21 3.21 3.73 9.35*
Affiliate 1.24 1.84 3.18 4.80 4.83 4.11 11.34
Non-Affiliate 1.19 1.74 2.44 4.98 3.66 3.49 10.55
Number of Treatment Servicesa
Low (0-5) 0.92 1.57 1.81 2.96 2.62 2.05* 9.44*
Medium (6-8) 1.56 2.42 2.83 5.27 4.85 3.45 10.60
High (9-11) 1.46 2.28 2.95 4.70 4.79 3.43 8.87*
See notes at end of table. (continued)

126
Table C.1.5 (continued)

Urbanicitya
Metropolitan Non-Metropolitan
Medium Small
Large Metro Urban
Metro (250,000 - Small Metro Urban (2,500 - Rural
Total (1 million+) 1 million) (< 250,000) (20,000+) 19,999) (<2,500)
Number of Support Servicesa
None 0.90 1.22 1.75 2.77 4.62* 3.66 9.50*
Low (1-2) 1.42 1.94 3.16 5.16 4.56 4.14 11.11
Medium (3-4) 1.32 1.96 2.88 4.14 4.60 3.77 8.80*
High (5-8) 0.89 1.28 1.87 3.62 3.37 2.07 3.10*
Client-to-Staff Ratio (Direct-Care FTEs)a
Low (4 or less) 1.38 1.90 3.19 5.21 4.94 3.84 9.38*
Medium (>4 to 14) 1.39 2.07 3.29 4.95 4.83 4.09 9.45
High (more than 14) 1.31 1.64 3.26 3.58 5.14 4.67 9.98
Facility Settinga,b
Hospital (inpatient or outpatient) 0.98 1.68 2.73 3.14 4.04 2.99 3.57*
Non-Hospital Residential, Therapeutic
Community or Halfway House 0.92 1.49 2.11 4.31 3.48 2.30 8.33*
Community Mental Health Center 1.19 1.27 2.32 5.19 4.95 4.13 11.11
Other Outpatient 1.43 2.13 3.32 4.23 4.36 3.91 11.04*
Other 1.10 1.52 1.95 4.57 1.38 2.57 4.36*
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

127
Table C.1.6 Standard Errors - Percentage Distribution of Substance Abuse Treatment Facilities, by Selected
Facility Characteristics and by Facility Certification: National Estimates, October 1, 1996
Type of Certificationa [Q-A7]
Facilities State State State Hospital
with Any Alcohol or Mental Public Certifica-
Certifica- Drug Abuse Health Health tion
Total tion Agency Agency Facility Authority JCAHO Other
Number of Facilities (weighted
estimates) 267.40 274.93 263.92 195.60 184.95 107.90 177.58 156.33
Percent of All Facilities . 0.73 1.22 1.47 1.44 0.84 1.32 1.21
Percent of Facilities with
Certification Type . . . . . . . .
Facility Type of Carea
Hospital Inpatient Only 0.20 0.22 0.20 0.46 0.50 2.08 0.83 0.36
Non-Hospital Residential Only 0.84 0.87 0.91 1.42 1.83 1.02* 1.31 1.63
Outpatient Methadone Only 0.21 0.23 0.27 0.17 0.54 0.24 0.43 0.61
Outpatient Non-Methadone Only 1.05 1.13 1.09 2.52 2.82 4.97 2.73 2.89
Combination Facilities 0.89 0.95 0.96 2.26 2.52 4.67 2.37 2.36
Facility Sizea (on October 1, 1996)
Small (<17 clients) 1.32 1.35 1.49 2.61 2.43 4.89 3.25 2.92
Medium (17-40) 1.17 1.21 1.29 2.75 2.49 5.55 2.86 2.71
Large (41-100) 1.12 1.17 1.30 2.08 2.12 3.94 2.00 2.31
Very Large (>100) 1.00 1.05 1.20 1.95 1.78 1.88 1.87 2.10
Ownershipa
Private For-Profit 1.44 1.33 1.36 2.83 2.66 5.44 3.34 3.12
Private Non-Profit 1.45 1.40 1.54 2.82 2.54 5.04 3.05 3.25
Public 0.80 0.80 0.92 1.97 1.44 2.13 1.40 1.67
Percent Public Revenuea
0% 1.07 1.04 1.03 1.62 2.05 3.20* 2.23 2.41
1-50% 1.17 1.29 1.38 2.56 2.41 4.87 2.82 2.38
51-90% 1.39 1.41 1.45 3.00 2.59 4.13 2.56 2.69
91-99% 1.17 1.23 1.28 2.77 2.91 1.13 1.60 1.99
100% 0.87 0.93 1.02 1.23 1.33 1.02 1.83 2.09
Unknown % 0.57 0.54 0.60 1.48 0.68* 4.44* 1.66* 1.82*
Urbanicitya
Metro: Large Metro (1 million+
pop) 1.21 1.25 1.46 2.70 2.12 5.00 2.87 3.35
Medium Metro (250,000 -
1 million pop) 1.07 1.14 1.25 2.52 2.33 4.70 2.71 2.36
Small Metro (< 250,000
pop) 1.04 1.04 1.13 2.27 1.87 1.69 1.87 1.77
Non-metro: Urban (20,000+ pop) 0.65 0.69 0.77 1.37 1.02 2.97 1.36 1.28
Small Urban (2,500 -
19,999 pop) 1.01 1.07 1.14 2.22 1.73 2.95* 1.75 1.65
Rural (< 2,500 pop) 0.43 0.45 0.47 1.09* 0.64* 0.72* 0.59* 0.36*
See notes at end of table. (continued)

128
Table C.1.6 (continued)

Type of Certificationa [Q-A7]

Facilities State State State Hospital
with Any Alcohol or Mental Public Certifica-
Certifica- Drug Abuse Health Health tion
Total tion Agency Agency Facility Authority JCAHO Other
a
Level of Affiliation
Parent Facility 1.10 1.15 1.27 1.85 2.48 3.83 2.21 2.17
Affiliate 1.24 1.26 1.43 2.73 2.73 5.17 2.88 2.92
Non-Affiliate 1.19 1.15 1.36 2.49 2.50 4.44 1.90 2.65
Number of Treatment Servicesa
Low (0-5) 0.92 0.83 0.90 1.43 1.27 0.77* 1.32 0.97
Medium (6-8) 1.56 1.57 1.56 3.09 3.00 2.98 2.85 2.93
High (9-11) 1.46 1.50 1.48 2.84 2.90 3.08 3.14 2.90
Number of Support Servicesa
None 0.90 0.93 0.99 1.88 2.03 0.96* 1.73 1.12
Low (1-2) 1.42 1.46 1.57 2.59 3.27 4.57 2.84 3.42
Medium (3-4) 1.32 1.32 1.35 2.66 2.47 4.80 2.84 3.69
High (5-8) 0.89 0.93 1.06 1.79 2.07 3.10 1.70 2.42
Client-to-Staff Ratio (Direct-Care
FTEs)a
Low (4 or less) 1.38 1.38 1.57 2.89 2.39 4.66 2.59 3.24
Medium (>4 to 14) 1.39 1.36 1.51 2.70 2.42 4.41 2.51 2.83
High (more than 14) 1.31 1.35 1.46 2.54 1.88 2.53 2.18 2.42
Facility Settinga,b
Hospital (inpatient or outpatient) 0.98 1.02 1.08 2.35 2.51 2.40 2.87 2.98
Non-Hospital Residential, Therapeutic
Community or Halfway House 0.92 0.93 1.04 1.20 2.34 1.13 1.59 2.24
Community Mental Health Center 1.19 1.27 1.21 3.33 2.57 1.27* 2.19 2.06
Other Outpatient 1.43 1.50 1.54 2.49 2.78 2.77 2.44 3.41
Other 1.02 0.88 0.96 2.09 1.79 1.30* 1.01 1.54
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

129
Table C.1.7 Standard Errors - Percentage Distribution of Substance Abuse Treatment Facilities,
by Selected Facility Characteristics and by Level of Affiliation with Other Facilities:
National Estimates, October 1, 1996
Level of Affiliationa
Total Parent Affiliate None
Number of Facilities (weighted estimate) 267.40 148.0 208.0 161.8
Percent of All Facilities . 1.1 1.2 1.2
Percent of Facilities with Affiliation Type . 1.10 1.24 1.19
Facility Type of Carea
Hospital Inpatient Only 0.20 0.2 0.4 0.4
Non-Hospital Residential Only 0.84 1.8 1.2 1.6
Outpatient Methadone Only 0.21 0.3 0.3 0.5
Outpatient Non-Methadone Only 1.05 2.5 1.8 2.0
Combination Facilities 0.89 2.1 1.3 1.5
Facility Sizea (on October 1, 1996)
Small (<17 clients) 1.32 2.9 2.2 2.2
Medium (17-40) 1.17 2.1 2.0 2.7
Large (41-100) 1.12 3.3 1.8 2.0
Very Large (>100) 1.00 2.2 1.5 2.0
Ownershipa
Private For-Profit 1.44 2.0 1.8 3.1
Private Non-Profit 1.45 2.6 1.9 2.9
Public 0.80 1.8 1.4 1.2
Percent Public Revenuea
0% 1.07 2.1 1.4 2.1
1-50% 1.17 2.1 1.8 2.4
51-90% 1.39 2.9 1.9 2.5
91-99% 1.17 2.6 2.0 2.1
100% 0.87 1.6 1.5 1.3
Unknown % 0.57 0.6* 0.7 1.6*
Urbanicitya
Metro: Large Metro (1 million+ pop) 1.21 2.4 1.8 2.6
Medium Metro (250,000 - 1 million pop) 1.07 3.0 1.8 2.0
Small Metro (< 250,000 pop) 1.04 1.6 1.6 2.1
Non-metro: Urban (20,000+ pop) 0.65 1.1 1.1 1.0
Small Urban (2,500 - 19,999 pop) 1.01 2.3 1.4 1.6
Rural (< 2,500 pop) 0.43 1.0* 0.6* 0.8
Number of Treatment Servicesa
Low (0-5) 0.92 1.7 1.1 2.3
Medium (6-8) 1.56 3.2 1.9 3.0
High (9-11) 1.46 2.8 2.0 2.5
See notes at end of table. (continued)

130
Table C.1.7 (continued)

Level of Affiliationa
Total Parent Affiliate None
a
Number of Support Services
None 0.90 1.8 1.3 1.8
Low (1-2) 1.42 3.0 2.2 2.7
Medium (3-4) 1.32 2.7 1.8 2.7
High (5-8) 0.89 2.3 1.4 1.6
Client-to-Staff Ratio (Direct-Care FTEs)a
Low (4 or less) 1.38 2.5 2.1 2.7
Medium (>4 to 14) 1.39 2.7 2.0 3.0
High (more than 14) 1.31 2.8 2.1 2.3
Facility Settinga,b
Hospital (inpatient or outpatient) 0.98 1.9 1.6 1.9
Non-Hospital Residential, Therapeutic Community or
Halfway House 0.92 2.3 1.3 2.2
Community Mental Health Center 1.19 2.4 1.8 1.7
Other Outpatient 1.43 2.7 2.0 2.7
Other 1.02 1.8 1.0 2.9
a
See Appendix B for definition of variables.
b
Categories are not mutually exclusive and may add to greater than 100.0 percent.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted
with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

131
 Table C.1.8 Standard Errors - Number and Percentage of Substance Abuse Treatment Facilities with Affiliation with Other
Organizations, and Service Provided by Affiliated Organizations, by Facility Type of Care: National Estimates, October 1,
1996
Facility Type of Care
Outpatient
Hospital Non-Hospital Non-
All Inpatient Residential Methadone Methadone Combination
Affiliations Facilities Only Only Only Only Facilities
Total Number of Facilities (national estimates) 267.4 25.0 107.7 24.8 236.3 113.7
Number of Facilities with Affiliationsa 246.7 22.0 91.4 18.1 224.1 98.5
Percent with Affiliations 1.27 2.82 2.68 2.73 1.91 3.12
Types of Organizations Affiliated with Percent of Affiliated
Facilitiesa,b
Hospital 1.69 4.12 1.63 3.00 2.49 5.25
Substance abuse treatment facility 1.71 1.99 3.25 3.05 2.46 3.94
Administrative office 1.85 3.92 2.94 3.18 2.73 5.86
Government agency 0.96 1.53 1.42 1.29 1.50 2.14
132

Other 1.89 2.66 2.90 1.22 2.70 3.45

Types of Services Provided by Other Organizationa,b
Financial 1.26 3.39 1.92 2.65 1.79 4.09
Personnel 1.43 2.31 2.71 0.97 2.00 4.56
Pricing 1.87 2.71 2.90 3.34 2.85 3.47
Treatment protocols 1.83 4.11 3.49 3.02 2.59 4.19
Client intake/assessment 1.84 4.39 3.32 2.97 2.56 4.24
a
Facilities with affiliations are those that indicated in ADSS Phase I question A11 that they were legally part of another organization.
b
Not mutually exclusive categories.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
Table C.2.1 Standard Errors - Number of Substance Abuse Treatment Clients, by Selected Facility
Characteristics, Point-Prevalence Count, Annual Admissions, and Annual Discharges: National
Estimates, October 1, 1996
Point Prevalence Annual Data
Clients in Treatment on
October 1, 1996 Admissions Discharges
[Q-B1] N Percent N Percent N Percent
Total Number of Clients 42,787.2 . 198,089.9 . 182,788.9 .
Client's Type of Care
Hospital Inpatient 1,079.4 0.15 64,526.3 2.16 66,851.8 2.67
Non-Hospital Residential 13,867.0 1.63 103,794.6 3.59 97,217.4 4.01
Outpatient Methadone 9,453.5 1.41 8,188.6 0.34 6,096.3 0.31
Outpatient Non-Methadone 38,487.7 6.49 136,520.5 5.86 119,751.2 5.97
Facility Settinga
Hospital (inpatient and outpatient) 12,245.6 1.03 118,884.1 2.20 112,199.8 2.39
Non-Hospital Residential,
Therapeutic Community or
Halfway House 18,539.5 1.53 113,717.8 2.20 108,163.8 2.40
Community Mental Health Center 14,511.5 1.18 63,723.1 1.43 58,257.8 1.53
Other Outpatient 30,724.0 1.69 124,274.0 2.18 113,628.6 2.33
Other 18,042.9 1.51 56,774.5 1.39 54,472.5 1.50
Ownership
Private For-Profit 12,527.0 1.10 121,508.4 2.37 115,991.3 2.56
Private Non-Profit 28,943.6 1.69 132,505.4 2.23 119,882.8 2.36
Public 23,119.7 1.70 63,920.5 1.35 49,935.1 1.31
Percent Public Revenue
0% 11,615.0 0.96 29,129.4 0.75 25,927.0 0.81
1-50% 14,154.5 1.22 78,728.3 1.97 79,170.1 2.17
51-90% 28,039.8 1.78 131,258.3 2.25 123,138.1 2.50
91-100% 15,983.5 1.36 71,193.7 1.55 54,658.0 1.48
100% 10,893.6 0.91 73,339.5 1.60 66,775.3 1.73
Unknown 3,306.6 0.31 75,597.9* 1.73* 75,497.5* 2.02*
Urbanicityb
Metro: Small Metro 20,098.5 1.68 60,241.2 1.32 55,480.3 1.43
Medium Metro 18,262.7 1.55 89,364.5 2.02 83,884.6 2.22
Large Metro 26,521.1 1.81 136,519.3 2.08 126,180.5 2.29
Non-Metro: Rural 3,176.9 0.30 16,509.3* 0.38* 15,969.7* 0.43*
Small Urban 11,071.1 0.95 41,571.8 0.94 33,508.1 0.90
Urban 8,068.0 0.69 69,221.5 1.54 67,726.5 1.77
Level of Affiliationc
Parent Facility 20,592.0 1.58 91,251.5 1.64 86,047.7 1.88
Affiliate 25,906.6 1.86 94,193.6 2.03 85,328.8 2.31
Non-Affiliate 24,073.1 1.74 124,564.0 2.19 119,774.9 2.44
a
Not mutually exclusive.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities responded to affiliation.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

133
Table C.2.2 Standard Errors - Percentage Distribution of Substance Abuse Treatment Clients, by Selected
Facility Characteristics and by Client Type of Care: National Estimates, October 1, 1996
Client Type of Care
Outpatient
Hospital Non-Hospital Outpatient Non-
Totala Inpatient Residential Methadone Methadone
Total Number of Clients 42,787.2 1,079.4 13,867.0 9,453.5 38,487.7
Percent of Clients . . . . .
Gender [Q-B2a]
Male 0.60 1.46 1.96 0.91 0.66
Female 0.57 1.33 1.96 0.92 0.61
Unknown 0.26 0.83* 0.11* 0.72* 0.34
Race/Ethnicity [Q-B2b]
White, non-Hispanic 0.98 2.51 1.56 1.42 1.19
Black, non-Hispanic 0.83 1.74 1.35 1.02 1.03
Hispanic 0.47 1.92 0.94 0.80 0.53
Asian or Pacific Islander 0.20 0.02 0.25* 0.21 0.26
American Indian or Alaskan Native 0.35 0.42* 0.97 0.05 0.35
Unknown 0.45 1.62* 0.67* 1.06* 0.48
Age [Q-B2c]
Under 18 1.12 0.94 1.55 0.11* 1.42
18-24 0.39 2.03 1.08 0.36 0.45
25-34 0.77 1.95 1.21 1.14 0.90
35-44 0.66 1.74 0.80 1.05 0.81
45 and older 0.37 1.68 0.47 1.06 0.47
Unknown 0.58 1.54* 0.32 1.10 0.76
Primary Source of Payment [Q-B2d]
No payment 0.54 0.90 1.48 0.95 0.65
Client self-payment 0.98 0.75 1.39 1.82 1.23
Private health insurance (fee-for-service) 0.63 1.52 0.63 0.69* 0.86
Private health insurance (HMO, PPO,
managed care) 0.70 2.85 0.92 0.59 0.91
Medicaid 0.81 2.26 1.40 1.52 0.92
Medicare 0.39 2.00 0.41* 0.69 0.66
Other public payment 1.05 1.83 2.17 1.87 1.20
Unknown 0.41 1.40* 0.38 0.84* 0.52
Referral Sourceb [Q-B6]
Other treatment facility 0.55 1.32 1.64 0.78 0.48
Criminal justice system 1.04 0.97 1.36 1.49 1.35
Self-referred/voluntary 0.72 1.99 1.07 1.85 0.81
Family 0.31 0.91 0.45 0.24 0.39
Friend 0.17 0.40 0.17 0.66 0.22
Employer 0.39 1.82 0.35 0.09 0.46
Health care or mental health providers 0.43 1.79 0.83 0.34 0.53
Welfare offices or other social service
agencies 0.45 0.73 1.26 0.45 0.49
Other 0.43 0.89 0.41 0.21 0.56
See notes at end of table. (continued)

134
Table C.2.2 (continued)

Client Type of Care

Outpatient
Hospital Non-Hospital Outpatient Non-
Totala Inpatient Residential Methadone Methadone
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 0.44 1.15 0.56 0.80 0.42
Cocaine (including crack) 0.65 1.98 1.38 0.08 0.78
Benzodiazepines 0.15 0.77 0.15 0.05* 0.24
Barbiturates 0.08 0.08 0.13 0.01* 0.10
Amphetamines 0.29 0.44 0.63 0.00 0.35
Marijuana/hashish/THC 0.67 0.60 1.11 0.03* 0.82
PCP/LSD 0.21 0.01 0.17 0.01* 0.28
Alcohol 0.80 2.31 1.49 0.01* 1.03
Other drugs (not alcohol) 0.25 0.55 0.51 0.04* 0.30
Unknown 0.41 1.06 0.58 0.79* 0.55
a
Total is not the sum of the four types of care because it is based on the overall client count variables instead of the sum of individual care
variables.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the referral source
information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

135
Table C.2.3 Standard Errors - Percentage Distribution of Substance Abuse Treatment Clients, by Selected
Facility Characteristics and by Treatment Setting: National Estimates, October 1, 1996
Clients in Treatment Settingsa
Non-Hospital
Inpatient or Residential, Community
Outpatient Therapeutic Mental
Hospital Community, or Health Other
Total Setting Halfway House Center Outpatient Other
Total Number of Clients 42,787.2 12,245.6 18,539.5 14,511.5 30,724.0 18,042.9
Percent of Clients . . . . . .
Gender [Q-B2a]
Male 0.6 1.2 1.9 1.0 0.8 1.8
Female 0.6 1.2 1.9 0.9 0.7 1.7
Unknown 0.3 0.6* 0.2* 0.6* 0.5* 0.3*
Race/Ethnicity [Q-B2b]
White, non-Hispanic 1.0 2.7 1.5 2.4 1.5 3.0
Black, non-Hispanic 0.8 2.3 1.3 2.4 1.1 2.0
Hispanic 0.5 1.1 1.0 0.9 0.8 1.2
Asian or Pacific Islander 0.2 0.4* 0.3* 0.9* 0.4 1.2*
American Indian or Alaskan Native 0.3 0.5* 1.0 0.4 0.6 1.1*
Unknown 0.4 1.1 0.5 1.1 0.5 0.5
Age [Q-B2c]
Under 18 1.1 3.1* 1.6 2.6 1.4 2.7
18-24 0.4 0.9 1.2 1.2 0.6 1.3
25-34 0.8 2.0 1.2 1.7 0.9 2.0
35-44 0.7 1.9 0.9 1.6 0.7 1.9
45 and older 0.4 1.1 0.5 0.9 0.6 1.1
Unknown 0.6 1.1 0.4 1.5* 0.9 1.1
Primary Source of Payment [Q-B2d]
No payment 0.5 0.9 1.3 1.2 0.8 2.1
Client self-payment 1.0 0.9 1.4 2.4 1.5 3.5
Private health insurance (fee-for-service) 0.6 3.1 0.6 0.8 0.9 2.4
Private health insurance (HMO, PPO,
managed care) 0.7 2.9 0.6 1.0 1.0 2.6
Medicaid 0.8 1.6 1.5 2.1 1.2 2.6
Medicare 0.4 2.0 0.5* 0.6 0.5 0.8*
Other public payment 1.0 2.0 2.2 3.2 1.7 2.7
Unknown 0.4 0.7 0.4 0.7 0.8 2.1*
Referral Sourceb [Q-B6]
Other treatment facility 0.5 1.2 1.7 1.1 0.5 1.2
Criminal justice system 1.0 1.2 1.4 2.5 1.7 4.0
Self-referred/voluntary 0.7 1.8 1.1 1.6 1.1 2.7
Family 0.3 1.3 0.5 0.8 0.4 1.0
Friend 0.2 0.4 0.4 0.4 0.2 0.8
Employer 0.4 1.3 0.3 0.3 0.6 1.9*
Health care or mental health providers 0.4 1.6 0.8 0.9 0.6 1.8
Welfare offices or other social service
agencies 0.4 1.4 1.3 0.8 0.6 1.6
Other 0.4 0.7 0.6 1.0 0.9 0.9
See notes at end of table. (continued)

136
Table C.2.3 (continued)

Clients in Treatment Settingsa

Non-Hospital
Inpatient or Residential, Community
Outpatient Therapeutic Mental
Hospital Community, or Health Other
Total Setting Halfway House Center Outpatient Other
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 0.4 1.3 0.6 0.5 0.6 0.7
Cocaine (including crack) 0.6 1.8 1.3 1.4 0.9 1.8
Benzodiazepines 0.1 0.6 0.2 0.3 0.1 0.3
Barbiturates 0.1 0.1 0.1* 0.1 0.1 0.2
Amphetamines 0.3 0.7 0.7 0.3 0.5 1.5
Marijuana/hashish/THC 0.7 1.2 1.1 1.6 1.0 1.7
PCP/LSD 0.2 0.1 0.1 0.3* 0.4* 0.4*
Alcohol 0.8 2.0 1.3 1.9 1.3 2.7
Other drugs (not alcohol) 0.2 0.7 0.5 0.5 0.4 0.4
Unknown 0.4 1.2 0.5 1.1 0.5 1.0*
a
Not mutually exclusive.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the referral source
information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

137
Table C.2.4 Standard Errors - Percentage Distribution of Substance Abuse Treatment Clients, by
Selected Facility Characteristics and by Facility Ownership: National Estimates,
October 1, 1996
Clients in Ownership Types
Private For- Private Non-
Totala Profit Profit Public
Total Number of Clients 42,787.2 12,527.0 28,943.6 23,119.7
Percent of Clients . . . .
Gender [Q-B2a]
Male 0.60 1.20 0.86 2.10
Female 0.57 1.02 0.87 2.10
Unknown 0.26 0.92* 0.24 0.34*
Race/Ethnicity [Q-B2b]
White, non-Hispanic 0.98 2.17 1.14 2.43
Black, non-Hispanic 0.83 1.92 0.92 1.70
Hispanic 0.47 0.80 0.69 0.75
Asian or Pacific Islander 0.20 0.11 0.29* 0.61
American Indian or Alaskan Native 0.35 0.26 0.36 1.91
Unknown 0.45 1.22 0.43 0.76
Age [Q-B2c]
Under 18 1.12 2.02 1.33 1.18
18-24 0.39 0.71 0.53 1.61
25-34 0.77 1.65 0.86 1.12
35-44 0.66 1.62 0.78 1.16
45 and older 0.37 0.81 0.46 0.95
Unknown 0.58 1.22 0.64 1.10
Primary Source of Payment [Q-B2d]
No payment 0.54 0.25 0.77 1.75
Client self-payment 0.98 2.65 1.04 2.13
Private health insurance (fee-for-service) 0.63 2.33 0.61 0.59
Private health insurance (HMO, PPO, managed care) 0.70 2.41 0.60 0.83
Medicaid 0.81 0.93 1.08 2.09
Medicare 0.39 1.50 0.34 0.75
Other public payment 1.05 0.95 1.53 2.79
Unknown 0.41 1.36 0.40 0.92
Referral Sourceb [Q-B6]
Other treatment facility 0.55 1.10 0.75 1.00
Criminal justice system 1.04 2.43 1.30 2.08
Self-referred/voluntary 0.72 1.76 0.85 1.79
Family 0.31 1.04 0.34 0.64
Friend 0.17 0.54 0.14 0.22
Employer 0.39 1.63 0.22 0.30
Health care or mental health providers 0.43 1.13 0.58 0.92
Welfare offices or other social service agencies 0.45 0.94 0.57 0.79
Other 0.43 0.92 0.59 0.83
See notes at end of table. (continued)

138
Table C.2.4 (continued)

Clients in Ownership Types

Private For- Private Non-
Totala Profit Profit Public
Principal Drug of Abuse [Q-B2e]
Heroin/other opiates 0.44 1.09 0.44 0.79
Cocaine (including crack) 0.65 1.45 0.76 1.44
Benzodiazepines 0.15 0.52 0.10 0.12
Barbiturates 0.08 0.12 0.11 0.13*
Amphetamines 0.29 0.56 0.37 0.68
Marijuana/hashish/THC 0.67 0.85 0.94 0.89
PCP/LSD 0.21 0.36* 0.23 0.20*
Alcohol 0.80 1.70 0.96 1.91
Other drugs (not alcohol) 0.25 0.26 0.37 0.58
Unknown 0.41 0.54 0.54 0.97
a
Total is not the sum of the four types of care because it is based on the overall client count variables instead of the sum of
individual care variables.
b
At least 99 percent of facilities responded to referral source. For the 15 percent of facilities with multiple types of care, the
referral source information for all clients combined was applied to clients in each specific type of care.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

139
Table C.2.5 Standard Errors - Percentage of Clients Receiving Treatment for Alcohol Abuse
Only, Drug Abuse Only, or Both, by Selected Facility Characteristics: National
Estimates, October 1, 1996
Percent of Clients
Both
Alcohol Drug Alcohol and
[Q-B7] Total Abuse Only Abuse Only Drug Abuse Unknown
Total . 0.72 0.68 1.00 0.19
Facility Type of Care
Hospital Inpatient Only . 2.65 1.40 2.77 1.68
Non-Hospital Residential Only . 1.12 1.17 1.54 0.58*
Outpatient Methadone Only . 0.19* 0.96 0.94 0.01
Outpatient Non-Methadone Only . 1.06 0.98 1.40 0.25*
Combination Facilities . 1.47 1.42 2.29 0.04*
Facility Settinga
Hospital (inpatient and outpatient) . 2.04 1.42 3.10 0.35
Non-Hospital Residential, Therapeutic
Community or Halfway House . 1.11 0.97 1.46 0.50*
Community Mental Health Center . 2.02 1.07 2.38 0.48*
Other Outpatient . 1.17 1.09 1.41 0.23*
Other . 2.63 1.78 3.06 0.62*
Ownership
Private For-Profit . 1.74 1.32 2.27 .
Private Non-Profit . 0.94 0.81 1.18 0.29
Public . 1.75 1.25 2.06 0.21*
Percent Public Revenue
0% . 2.30 2.08 3.06 0.65*
1-50% . 1.97 1.04 2.33 0.52*
51-90% . 1.31 1.00 1.75 0.35*
91-99% . 1.76 1.61 2.40 0.12*
100% . 2.14 2.87 2.94 0.60*
Unknown % 7.51 3.31 9.30 .
Urbanicityb
Metro: Small Metro . 2.74 1.81 3.89 0.78*
Medium Metro . 1.73 1.22 2.14 0.41*
Large Metro . 1.08 1.09 1.44 0.19*
Non-metro: Rural . 5.30 2.21 5.59 4.21*
Small Urban . 2.02 1.38 1.94 0.61*
Urban . 2.92 1.29 2.85 0.34*
Level of Affiliationc
Parent . 1.34 1.13 1.58 0.02*
Affiliate . 1.18 0.99 1.64 0.35*
Non-Affiliate . 1.56 0.91 1.75 0.28*
a
Not mutually exclusive.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities provided affiliation.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

140
Table C.2.6 Standard Errors - Facilities Offering Programs for Special Populations and Number
of Special Population Clients Admitted in 12-Month Period: National Estimates,
October 1, 1996
Facilities Clients
Percent of
Number of Clients Clients Admitted
Admitted in 12- in 12-Month
N Percent Month Period Period
All Facilities 267.4 . 198,089.9 .
Admitted Specific Clients [Q-C4]
Pregnant women 205.6 1.51 3,157.6 0.13
SSI/SSDI 231.9 1.46 39,906.3 1.35
Active-TB 92.9 0.79 1,325.6 0.04
HIV-positive 190.5 1.29 13,226.3 0.41
AIDS-diagnosed 148.7 1.19 14,836.0* 0.39
Had Special Programs [Q-B10]
Women 189.2 1.31
Pregnant women 143.9 1.08
Adolescents 223.2 1.47
DWI/DUI 205.9 1.50
AIDS/HIV 168.1 1.29
Dual Diagnosis 206.8 1.40
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

141
Table C.2.7 Standard Errors - Percentage of Facilities That Admitted Special Client Types: National
Estimates, October 1, 1996
Percentages of Facilities That Admitted Three Types Percentages of Facilities with
of Clientsa Clients in Treatment Populationb
Ado- Dual
Pregnant Active HIV AIDS Women lescents Diagnosis
Women SSI/SSDI TB Positive Diagnosed [Q-B2-pt [Q-B2-pt [Q-B9-pt
[Q-C4] [Q-C4] [Q-C4] [Q-C4] [Q-C4] prev] prev] prev]
Total 1.51 1.46 0.79 1.29 1.19 0.88 1.53 1.13
Facility Type of Care
Hospital Inpatient Only 3.56 3.75 2.94 3.41 3.28 3.18 1.64 3.27
Non-Hospital Residential Only 2.59 2.62 1.92 2.87 2.54 2.63 2.15 2.63
Outpatient Methadone Only 2.83 2.59 3.43 1.20 3.17 0.14 0.91* 0.96
Outpatient Non-Methadone Only 2.06 1.93 0.94 1.90 1.61 1.16 2.27 1.61
Combination Facilities 3.90 4.18 2.73 2.90 3.35 1.22 3.13 2.01
Facility Settingc
Hospital (inpatient and
outpatient) 4.01 4.39 2.51 4.05 4.40 2.52 3.20 2.85
Non-Hospital Residential,
Therapeutic Community or
Halfway House 3.64 3.19 1.99 3.88 2.97 2.30 3.18 2.04
Community Mental Health
Center 2.83 2.26 1.63 2.88 2.25 2.19 2.10 2.22
Other Outpatient 2.19 1.93 0.98 2.27 1.54 0.92 2.22 1.91
Other 4.63 4.35 1.69 4.43 3.92 2.60 5.14 4.35
Ownership
Private For-Profit 3.44 3.19 1.60 3.17 3.35 2.14 3.61 2.86
Private Non-Profit 1.70 1.60 1.03 1.75 1.56 1.08 1.78 1.68
Public 3.64 3.32 2.34 3.84 3.31 1.32 3.35 1.69
Percent Public Revenue
0% 3.82 3.52 1.26 3.30 3.45 3.55 4.19 3.58
1-50% 3.60 3.42 1.65 3.13 2.96 1.51 3.06 2.73
51-90% 2.65 2.56 1.57 2.69 2.22 1.53 2.29 2.02
91-99% 4.07 3.57 1.96 3.95 3.40 2.39 3.40 2.87
100% 4.11 4.04 2.74 4.06 3.57 2.19 4.05 4.44
Unknown % 8.68* 9.21 6.48* 10.35 13.07* 5.22 9.98* 4.71
Urbanicityd
Metro: Small Metro 5.40 5.37 2.26 4.96 3.69 4.07 5.30 3.85
Medium Metro 3.24 3.31 1.33 3.50 3.07 2.16 3.47 2.93
Large Metro 2.52 1.94 1.46 2.08 2.05 1.11 1.90 1.63
Non-metro: Rural 11.68 6.84 6.76* 10.21* 5.81* 8.43 9.67 8.36
Small Urban 3.94 3.73 2.32 3.44 3.45 1.70 4.37 3.17
Urban 5.06 5.07 2.75 5.11 3.63 1.89 4.92 4.76
See notes at end of table. (continued)

142
Table C.2.7 (continued)

Percentages of Facilities That Admitted Three Types Percentages of Facilities with

of Clientsa Clients in Treatment Populationb
Ado- Dual
Pregnant Active HIV AIDS Women lescents Diagnosis
Women SSI/SSDI TB Positive Diagnosed [Q-B2-pt [Q-B2-pt [Q-B9-pt
[Q-C4] [Q-C4] [Q-C4] [Q-C4] [Q-C4] prev] prev] prev]
Level of Affiliatione
Parent Facility 2.86 2.92 1.89 3.22 2.71 1.45 3.15 2.79
Affiliate 2.27 2.14 1.19 1.96 1.82 1.40 2.14 1.67
Non-Affiliate 2.74 2.67 1.47 2.64 2.49 1.87 2.89 2.41
a
95 percent of facilities responded to active TB question; 94 percent responded to HIV-positive question; and 93 percent responded to AIDS
question.
b
96 percent of facilities responded to dual-diagnosis question.
c
Not mutually exclusive.
d
Based on Beale code (Butler & Beale, 1994).
e
At least 99 percent of facilities responded to affiliation question.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

143
Table C.2.8 Standard Errors - Percentage of Facilities That Admitted Special Population Clients
and Have Special Programs for Them: National Estimates, October 1, 1996
AIDS or
HIV- Dual
Pregnant Positive Diagnosisb
[Q-B10] Womena Womena Adolescentsa Clientsa [Q-B9]
Total 1.33 1.84 2.06 1.75 1.59
Facility Type of Care
Hospital Inpatient Only 2.59 3.57 3.74 3.07 3.58
Non-Hospital Residential Only 3.11 4.29 7.78 3.34 3.15
Outpatient Methadone Only 2.61 2.62 . 3.35 2.81
Outpatient Non-Methadone Only 1.75 2.53 2.42 2.63 2.14
Combination Facilities 3.52 2.96 5.00 3.48 4.86
Facility Settingc
Hospital (inpatient and outpatient) 3.97 3.27 7.32 4.44 4.41
Non-Hospital Residential, Therapeutic
Community or Halfway House 3.79 4.74 5.16 5.09 3.08
Community Mental Health Center 2.85 3.60 5.21 3.01 2.64
Other Outpatient 2.13 2.52 3.26 2.29 2.21
Other 4.33 5.88 6.13 5.37 5.58
Ownership
Private For-Profit 3.61 2.05 5.09 4.68 4.41
Private Non-Profit 1.79 2.39 2.50 2.26 2.06
Public 3.28 4.06 5.91 4.22 3.67
Percent Public Revenue
0% 3.71 3.79 8.68 2.85 6.08
1-50% 3.29 2.37 5.04 4.31 4.50
51-90% 2.38 2.42 3.83 3.24 2.50
91-99% 3.61 4.06 5.71 3.87 4.20
100% 5.03 5.75 6.89 5.12 5.43
Unknown % 15.34* 6.23* 23.94* 21.40* 14.71*
Urbanicityd
Metro: Small Metro 5.57 7.12 7.39 5.10 6.19
Medium Metro 3.10 3.37 4.92 3.14 3.58
Large Metro 2.14 2.73 3.61 2.28 2.61
Non-metro: Rural 9.07* 12.06 14.79 17.21* 11.17
Small Urban 3.84 4.41 5.43 6.62 5.03
Urban 5.07 4.07 7.61 3.56 5.52
Level of Affiliatione
Parent Facility 2.92 4.09 3.55 3.44 3.17
Affiliate 2.03 2.70 3.76 2.50 2.53
Non-Affiliate 2.78 2.85 3.80 3.26 3.07
a
99 percent of facilities responded to special programs question.
b
96 percent of facilities responded to dual-diagnosis question.
c
Not mutually exclusive.
d
Based on Beale code (Butler & Beale, 1994).
e
99 percent of facilities responded to affiliation question.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices,
correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

144
Table C.3.1 Standard Errors - Percentage of Facilities in the Treatment System Offering
Treatment and Support Services: National Estimates
Percent of Responding
Facilities Offering Servicea
Services [Q-C9]
Treatment Services
Individual therapy 0.41
Comprehensive assessment/diagnosis 0.60
Group therapy, not including relapse prevention 1.27
Family counseling 0.95
Aftercare 1.04
Relapse prevention groups 1.26
Self-help or mutual-help groups 1.63
Outcome followup 1.67
Combined substance abuse and mental health treatment 1.40
Detoxification 1.03
Acupuncture 0.43
Support Services
HIV/AIDS education/counseling/support 1.27
Transportation 1.33
TB screening 1.31
Employment counseling/training 1.45
Smoking cessation 1.12
Academic education/GED classes 0.97
Child care 0.90
Prenatal care 0.79
a
More than 99 percent of facilities responded to each service question.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies,
Substance Abuse and Mental Health Services Administration.

145
Table C.3.2a Standard Errors - Percentage of Facilities Offering Treatment Services, by Selected Facility
Characteristics: National Estimates

Combined Substance Abuse

Group Therapy, Not Incl.
Assessment/Diagnosis

Self-Help or Mutual-

Outcome Follow-Up

& Mental Health Tx

Relapse Prevention

Relapse Prevention
Individual Therapy

Family Counseling
Comprehensive

Detoxification

Acupuncture
Help Groups

Aftercare
Groups
Treatment Services
[All services from Q-C9]
All Facilitiesa 0.61 0.42 1.27 0.96 1.25 1.62 1.03 1.67 1.41 1.01 0.42
Facility Type of Care
Hospital Inpatient Only 1.25 2.89 2.73 2.41 2.73 3.04 2.68 3.55 3.39 1.33 0.79
Non-Hospital Residential Only 2.04 1.24 1.42 2.36 1.80 1.41 2.44 1.81 2.77 2.19 1.17
Outpatient Methadone Only 1.86 0.70 2.30 2.67 2.65 3.19 2.51 3.07 3.06 2.96 2.20
Outpatient Non-Methadone Only 0.70 0.53 2.00 1.30 2.01 2.49 1.41 2.45 1.95 1.15 0.55
Combination Facilities 0.88 0.51 0.09 1.88 1.08 2.34 1.34 2.39 2.71 3.48 1.07
Facility Size
Small (<17 clients) 1.60 1.22 3.43 2.30 3.08 3.04 2.17 3.48 2.89 2.47 0.65
Medium (17-40) 1.21 0.83 1.89 1.19 2.60 3.22 2.39 3.02 2.82 2.93 0.90
Large (41-100) 0.87 0.28 0.88 1.69 2.46 2.83 1.74 2.51 2.53 2.20 0.94
Very Large (>100) 1.12 0.73 0.59 1.66 1.75 2.19 1.58 2.24 2.37 1.82 0.93
Ownership
Private For-Profit 1.48 1.22 3.07 2.44 3.69 3.47 2.63 3.34 2.98 2.73 1.29
Private Non-Profit 0.68 0.43 1.05 1.04 1.64 1.81 1.12 1.89 2.04 1.37 0.50
Public 1.59 0.96 1.59 2.94 2.53 3.72 2.61 2.90 3.00 2.95 1.23
Percent Public Revenue
0% 1.49 1.74 2.91 2.88 3.96 4.10 3.19 4.17 3.40 2.29 0.81
1-50% 1.19 0.90 1.80 2.12 2.82 3.00 2.28 3.30 2.91 2.92 0.95
51-90% 1.40 0.65 1.10 1.57 2.16 2.54 1.37 2.20 2.70 2.05 0.87
91-99% 0.95 0.99 1.19 2.23 3.31 3.65 2.26 3.68 3.32 2.09 0.84
100% 1.69 0.26 3.86 3.34 2.73 3.90 3.74 4.31 4.40 2.61 1.78
Unknown % 1.11 0.96 10.00 0.98 10.26 10.57 10.40 10.65 4.04 11.37 0.79*
Urbanicityb
Metro: Small Metro 3.04 0.76 4.32 4.29 5.18 5.28 2.59 5.74 4.83 3.52 0.26*
Medium Metro 1.08 0.51 1.71 2.07 2.77 3.10 2.17 2.69 3.36 2.36 0.90
Large Metro 0.70 0.80 1.62 1.32 1.82 2.16 1.61 2.21 1.79 1.61 0.84
Non-metro: Rural 0.99 1.08 6.22 1.24 9.19 10.47 8.71 10.26 11.10 7.66* .
Small Urban 1.82 0.76 2.48 1.64 3.64 3.97 2.59 3.87 4.02 3.46 0.36*
Urban 2.11 1.88 2.04 2.69 3.52 5.11 4.83 3.79 5.01 4.09 0.99*
Level of Affiliationc
Parent Facility 1.16 0.72 1.47 1.90 2.07 2.62 1.74 2.37 2.72 2.37 1.11
Affiliate 0.73 0.54 1.21 1.23 1.75 2.10 1.33 2.57 1.99 1.62 0.58
Non-Affiliate 1.58 0.94 2.07 1.87 2.29 2.92 2.39 2.61 2.72 2.19 0.79
See notes at end of table. (continued)

146
Table C.3.2a (continued)

Combined Substance Abuse

Group Therapy, Not Incl.
Assessment/Diagnosis

Self-Help or Mutual-

Outcome Follow-Up

& Mental Health Tx

Relapse Prevention

Relapse Prevention
Individual Therapy

Family Counseling
Comprehensive

Detoxification

Acupuncture
Help Groups

Aftercare
Groups
Treatment Services
[All services from Q-C9]
Facility Settingd
Hospital (inpatient and outpatient) 0.89 0.88 1.28 0.87 2.24 2.46 1.42 2.29 1.65 3.98 1.00
Non-Hospital Residential,
Therapeutic Community or
Halfway House 1.46 0.66 0.81 1.98 1.25 1.72 1.75 1.57 2.43 2.36 0.89
Community Mental Health Center 1.26 0.95 3.80 1.23 3.64 3.94 2.59 3.89 3.28 2.29 0.48
Other Outpatient 0.76 0.63 1.45 1.49 2.04 2.39 1.73 2.30 2.24 1.30 0.72
Other 2.36 1.32 4.59 3.55 5.09 4.88 4.63 5.02 4.16 2.59 1.70
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities responded to affiliation.
d
Not mutually exclusive.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

147
Table C.3.2b Standard Errors - Percentage of Facilities Offering Support Services, by Selected Facility
Characteristics: National Estimates

HIV/AIDS Education/

Academic Education/
Counseling/Training
Counseling/Support

Smoking Cessation
Transportation

TB Screening

Prenatal Care
GED Classes
Employment

Child Care
Support Services
[All services from Q-C9]
All Facilitiesa 1.26 1.32 1.33 1.43 1.10 0.96 0.90 0.78
Facility Type of Care
Hospital Inpatient Only 3.83 3.26 2.41 2.96 3.78 1.83 0.46* 3.15
Non-Hospital Residential Only 1.70 1.91 2.99 2.37 2.44 2.54 1.96 1.87
Outpatient Methadone Only 1.93 2.60 0.67 2.72 1.35 2.32 0.76 2.18
Outpatient Non-Methadone Only 1.89 1.83 1.69 1.93 1.57 1.03 1.22 0.71
Combination Facilities 2.51 3.59 2.45 4.16 3.29 2.68 2.40 3.48
Facility Size
Small (<17 clients) 3.16 3.30 3.42 3.25 2.42 2.11 2.07 1.70
Medium (17-40) 3.07 3.10 2.76 3.58 2.74 2.10 1.54 1.94
Large (41-100) 2.70 2.51 2.87 2.99 2.14 1.98 2.04 1.52
Very Large (>100) 1.96 2.12 2.43 1.99 1.79 1.38 1.68 1.26
Ownership
Private For-Profit 3.12 3.57 2.99 2.30 2.64 1.32 1.21 1.56
Private Non-Profit 1.51 1.86 1.69 1.86 1.56 1.30 1.23 0.81
Public 2.67 3.49 3.47 3.45 3.35 2.87 3.26 2.83
Percent Public Revenue
0% 3.78 3.88 3.17 3.32 4.46 2.12* 1.96* 1.43
1-50% 3.22 3.28 2.72 3.15 2.50 1.72 1.49 2.21
51-90% 2.04 2.26 2.26 2.35 2.17 1.71 1.71 1.35
91-99% 3.19 3.22 4.14 3.18 2.84 3.13 2.17 2.41
100% 3.08 3.88 4.42 4.36 3.43 3.33 2.64 2.50
Unknown % 9.05 12.59* 11.93 5.31* 6.00* 2.16* 0.93* 1.56*
Urbanicityb
Metro: Small Metro 4.89 5.69 5.15 4.97 4.34 4.19 3.55 2.75
Medium Metro 2.76 3.03 2.84 3.09 2.79 1.70 1.41 1.53
Large Metro 1.73 2.23 2.14 2.28 1.83 1.63 1.33 1.30
Non-metro: Rural 10.21 10.91 8.96* 8.54* 6.16* 6.71* 3.06* 3.13*
Small Urban 4.34 4.10 3.59 4.12 3.62 2.23 3.26 1.68
Urban 4.72 5.41 4.87 4.49 4.44 2.37 3.49 2.12
Level of Affiliationc
Parent Facility 2.54 2.73 2.70 3.44 2.56 2.23 2.00 2.11
Affiliate 1.81 2.04 1.94 2.31 1.67 1.51 1.29 1.41
Non-Affiliate 2.48 2.85 2.90 2.41 2.31 1.74 1.47 1.11
See notes at end of table. (continued)

148
Table C.3.2b (continued)

HIV/AIDS Education/

Academic Education/
Counseling/Training
Counseling/Support

Smoking Cessation
Transportation

TB Screening

Prenatal Care
GED Classes
Employment

Child Care
Support Services
[All services from Q-C9]
Facility Settingd
Hospital (inpatient and outpatient) 2.95 4.09 3.88 3.58 3.34 2.17 1.89 2.73
Non-Hospital Residential, Therapeutic Community or
Halfway House 1.44 1.71 2.48 2.43 2.32 2.39 1.85 1.76
Community Mental Health Center 3.26 3.66 2.88 3.37 2.83 1.48 2.33 1.12
Other Outpatient 1.68 1.81 1.82 2.32 1.68 1.40 1.19 1.00
Other 4.22 4.66 4.22 4.15 4.33 3.21 2.76 2.25
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities responded to affiliation.
d
Not mutually exclusive.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

149
Table C.3.3 Standard Errors - Percentage Distribution of Facilities Offering Varying Number of Services, by
Facility Characteristics: National Estimates
Number of Treatment Services Number of Support Services
Low Medium High None Low Medium High
a
All Facilities 0.92 1.56 1.46 0.90 1.42 1.32 0.89
Facility Type of Care
Hospital Inpatient Only 1.80 3.38 3.21 1.81 3.22 3.24 2.75
Non-Hospital Residential Only 1.79 2.73 2.81 0.52* 1.53 2.47 2.67
Outpatient Methadone Only 2.36 2.57 2.40 0.14* 2.63 2.72 2.46
Outpatient Non-Methadone Only 1.40 2.31 2.13 1.45 2.09 1.53 0.83
Combination Facilities 0.65* 2.81 2.87 0.80* 2.79 4.23 3.46
Facility Size
Small (<17 clients) 2.10 3.22 3.01 1.93 3.13 3.01 2.01
Medium (17-40) 2.06 3.36 2.92 2.32 3.35 3.53 1.91
Large (41-100) 1.41 2.94 3.09 1.61 3.01 2.58 1.65
Very Large (>100) 1.36 2.32 2.23 1.32 2.35 1.94 1.93
Ownership
Private For-Profit 2.88 3.90 4.00 2.84 3.59 3.15 1.44
Private Non-Profit 0.81 1.85 1.80 0.97 1.70 1.50 1.21
Public 2.26 3.49 3.20 1.40 2.91 3.60 2.65
Percent Public Revenue
0% 3.42 4.64 4.60 3.45 4.09 3.40 1.05*
1-50% 2.03 3.41 3.53 2.64 3.68 3.29 1.88
51-90% 1.43 2.16 2.16 1.52 2.50 2.26 1.65
91-99% 1.70 3.31 2.94 0.94* 3.17 2.69 2.65
100% 2.24 4.13 4.37 2.40* 4.24 4.30 3.06
Unknown % 10.00* 8.39 11.28 3.83* 11.51 12.29 1.84
Urbanicityb
Metro: Small Metro 2.96 5.27 4.70 2.77 5.16 4.14 3.62
Medium Metro 1.81 2.83 2.95 1.75 3.16 2.88 1.87
Large Metro 1.57 2.42 2.28 1.22 1.94 1.96 1.28
Non-metro: Rural 9.44* 10.60 8.87* 9.50* 11.11 8.80* 3.10*
Small Urban 2.05* 3.45 3.43 3.66 4.14 3.77 2.07
Urban 2.62 4.85 4.79 4.62* 4.56 4.60 3.37
Level of Affiliationc
Parent Facility 1.66 3.21 2.78 1.81 2.99 2.68 2.26
Affiliate 1.09 1.94 1.99 1.29 2.17 1.81 1.35
Non-Affiliate 2.28 3.04 2.53 1.79 2.69 2.72 1.59
Client/Staff Ratioc
Low (0-4) 1.39 2.49 2.47 0.95 3.15 2.72 2.03
Medium (>4-14) 1.70 2.74 2.61 1.81 2.77 2.33 1.41
High (>14) 1.41 2.29 1.72 1.70 2.31 1.74 1.25
See notes at end of table. (continued)

150
Table C.3.3 (continued)

Number of Treatment Services Number of Support Services

Low Medium High None Low Medium High
Facility Settingd
Hospital (inpatient and outpatient) 0.56 2.88 2.95 1.41 4.17 3.78 2.29
Non-Hospital Residential, Therapeutic
Community or Halfway House 1.15 2.63 2.68 0.63* 1.41 2.42 2.39
Community Mental Health Center 1.85 3.76 3.44 2.62 3.26 2.98 1.79
Other Outpatient 1.78 2.36 1.84 1.49 2.11 1.80 1.09
Other 4.82 5.45 4.44 3.99 5.63 3.80 3.09
a
At least 99 percent of facilities responded to the service questions.
b
Based on Beale code (Butler & Beale, 1994).
c
At least 99 percent of facilities responded to affiliation and client/staff questions.
d
Not mutually exclusive.
Note: Each row adds to 100 percent within each section (treatment services or support services).
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional
facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental
Health Services Administration.

151
 Table C.3.4 Standard Errors - Percentage of Facilities, by Staffing Category and Mean Staff per Facility: National Estimates
Percent of Facilities with Staff in
Each "Time" Category (all
facilities) Mean Staff Per Facility

Mean Staffa Mean FTE

Percent of per Facility Staffb per Mean FTE
Facilities (for facilities Facility (for Mean Staffa per Staffb per
with Staff with staff facilities with Facility (all Facility (all
Category Full-Time Part-Time Contract category) staff category) facilities) facilities)
Total Staff 0.09 0.84 1.43 1.70 1.33 0.84 1.33 0.84
Physicians 1.52 0.93 1.34 1.49 0.08 0.06 0.05 0.04
Registered Nurses 1.28 1.08 1.19 0.68 0.51 0.49 0.20 0.19
Other Medical Personnel 1.08 0.80 1.00 0.60 0.38 0.30 0.10 0.08
Any Medical Staff 1.50 1.05 1.60 1.45 0.48 0.42 0.31 0.27
Doctoral Level Counselors 1.30 0.86 0.82 1.12 0.06 0.12 0.03 0.04
Master's Level Counselors 1.29 1.31 1.30 1.36 0.11 0.15 0.10 0.13
Any Graduate-Degreed Counseling Staff 1.20 1.31 1.36 1.53 0.13 0.17 0.12 0.15
152

Other Degreed Counselors 1.60 1.53 1.24 0.77 0.10 0.19 0.08 0.14
Non-Degreed Counselors 1.54 1.39 1.11 0.73 0.14 0.17 0.09 0.12
Any BA or Non-Degreed Counseling Staff 1.27 1.23 1.45 0.96 0.17 0.24 0.15 0.22
All Other Staff 0.94 1.40 1.34 0.69 0.37 0.38 0.33 0.34
a
The mean was calculated by adding all full-time, part-time, and contract staff, and dividing by the total number of facilities to obtain a facility mean for each staffing category.
b
Part-time and contract staff were counted as .41 FTE, based on ADSS Phase II data.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense facilities, and
Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Table C.3.5a Standard Errors - Percentage Distribution of Full-Time, Part-Time, and Contract Staff, by Staff Type: National
Estimatesa
Full-Time Part-Time Contract
N Percent N Percent N Percent
Total Staff 6,580.9 . 2,354.8 . 1,895.2 .
Physicians 289.4 0.3 265.3 1.0 576.1 5.7
Registered Nurses 2,022.2 2.0 627.4 2.1 310.8 1.9
Other Medical Personnel 793.0 0.9 426.8 1.4 460.5* 2.5
Total Medical Staff 2,507.9 2.7 1,140.3 4.2 1,059.3 8.8
Doctoral Level Counselors 177.9 0.2 137.7 0.5 212.8 1.9
Master's Level Counselors 850.7 1.4 475.3 1.8 525.4 4.1
Total Graduate-Degreed Counseling Staff 899.8 1.5 543.2 2.1 637.7 5.6
Other Degreed Counselors 822.2 1.3 416.7 1.5 232.6 1.6
Non-Degreed Counselors 884.9 1.4 514.5 1.7 161.7 1.1
Total BA and Non-Degreed Counseling Staff 1,447.9 2.5 751.0 2.8 286.8 2.2
All Other Staff 3,463.6 4.4 885.7 3.6 537.7 3.3
153

a
This table is based on data from the estimated 11,782 facilities (about 95 percent of the universe) that reported their staff by full-time, part-time and contract.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.

Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
 Table C.3.5b Standard Errors - Number and Percentage Distribution of Staff Type, by "Time" Category in the Treatment System:
National Estimatesa
Total Full-Time Part-Time Contract

N Percent N Percent N Percent N Percent

Physicians 686.1 . 289.4 2.9 265.3 4.6 576.1 8.0
Registered Nurses 2,394.2 . 2,022.2 17.0 627.4 7.4 310.8 2.1
Other Medical Personnel 1,261.5 . 793.0 12.1 426.8 6.9 460.5* 4.6
Total Medical Staff 3,786.9 . 2,507.9 9.1 1,140.3 5.5 1,059.3 4.0
Doctoral Level Counselors 351.0 . 177.9 5.0 137.7 4.1 212.8 7.9
Master's Level Counselors 1,325.5 . 850.7 5.5 475.3 2.3 525.4 2.8
Total Graduate-Degreed Counseling Staff 1,534.5 . 899.8 4.9 543.2 2.2 637.7 3.1
Other Degreed Counselors 1,124.6 . 822.2 6.5 416.7 2.4 232.6 1.4
Non-Degreed Counselors 1,236.2 . 884.9 7.3 514.5 3.0 161.7 1.0
Total BA and Non-Degreed Counseling Staff 2,066.0 . 1,447.9 5.9 751.0 2.2 286.8 0.9
All Other Staff 4,033.5 . 3,463.6 10.0 885.7 2.9 537.7 1.0
a
This table is based on data from the estimated 11,782 facilities that reported their staff by full-time, part-time and contract.
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be interpreted with caution.
154

Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo practices, correctional facilities, Department of Defense
facilities, and Indian Health Service facilities.

Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance Abuse and Mental Health Services Administration.
Table C.3.5c Standard Errors - Number and Percentage Distribution of FTE Staff, by Staffing
Categories: National Estimatesa
FTE Staffb
N Percent
Total 9,835.5 .
Physicians 497.1 0.5
Registered Nurses 2,402.3 1.7
Other Medical Personnel 1,027.0 0.8
Total Medical Staff 3,447.1 2.7
Doctoral Level Counselors 451.9 0.4
Master's Level Counselors 1,548.9 1.6
Total Graduate-Degreed Counseling Staff 1,802.1 1.8
Other Degreed Counselors 1,922.8 1.6
Non-Degreed Counselors 1,599.4 1.4
Total BA and Non-Degreed Counseling Staff 3,124.0 2.8
All Other Staff 4,389.1 3.6
a
This table is based on data from an estimated 12,387 facilities, including 605 facilities that could not report their staff by
full-time, part-time, and contract. These 605 facilities could only report staff numbers in terms of full-time equivalents.
b
Part-time and contract staff were counted as .41 FTE, based on Phase II data.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies,
Substance Abuse and Mental Health Services Administration.

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Table C.3.6 Standard Errors - Mean Ratio of Clients to FTE Staff,a by Facility Characteristics:
National Estimates
Mean Ratios
Clients to Direct- Clients to All
Clients to All Care Staffb Other Staffc
Staffb [Q-A9a-h] [Q-A9a-g] [Q-A9h]
All Facilities 0.39 0.52 1.63
Facility Type of Care
Hospital Inpatient Only 0.07 0.08 0.54
Non-Hospital Residential Only 0.09 0.23 0.54
Outpatient Methadone Only 0.47 0.53 3.85
Outpatient Non-Methadone Only 0.62 0.83 2.60
Combination Facilities 0.43 0.67 2.65
Facility Size
Small (<17 clients) 0.29 0.36 0.44
Medium (17-40) 0.76 0.75 1.42
Large (41-100) 0.52 0.96 2.80
Very Large (>100) 0.75 1.00 4.27
Ownership
Private For-Profit 0.75 1.01 4.35
Private Non-Profit 0.47 0.66 1.83
Public 0.98 1.16 4.15
Percent Public Revenue
0% 1.16 1.60 6.84
1-50% 0.78 0.93 3.32
51-90% 0.75 0.97 3.18
91-99% 0.65 0.90 2.89
100% 0.72 1.31 3.10
Unknown % 0.83 2.21 5.69
Urbanicityd
Metro: Small Metro 0.87 1.24 4.73
Medium Metro 1.16 1.43 3.67
Large Metro 0.38 0.56 2.55
Non-metro: Rural 4.36* 5.06 5.39
Small Urban 1.01 1.31 4.26
Urban 1.21 1.75 3.76
Level of Affiliatione
Parent Facility 0.59 0.79 3.12
Affiliate 0.59 0.75 2.32
Non-Affiliate 0.63 0.96 3.15
Number of Treatment Services
Low (0-5) 0.98 1.27 5.74
Medium (6-8) 0.54 0.77 1.91
High (9-11) 0.53 0.69 2.55
See notes at end of table. (continued)

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Table C.3.6 (continued)

Mean Ratios
Clients to Direct- Clients to All
Clients to All Care Staffb Other Staffc
Staffb [Q-A9a-h] [Q-A9a-g] [Q-A9h]
Number of Support Services
None 1.13 1.48 6.18
Low (1-2) 0.74 1.08 3.42
Medium (3-4) 0.57 0.69 2.11
High (5-8) 0.54 0.81 2.67
Facility Settingf
Hospital (inpatient and outpatient) 0.40 0.51 2.56
Non-Hospital Residential, Therapeutic
Community or Halfway House 0.23 0.39 1.31
Community Mental Health Center 1.15 1.68 4.12
Other Outpatient 0.62 0.76 2.97
Other 0.88 1.28 4.17
a
Part-time and contract staff were counted as .41 FTE, based on Phase II data.
b
At least 99 percent of facilities responded to staffing questions.
c
At least 89 percent of facilities reported having "other staff."
d
Based on Beale code (Butler & Beale, 1994).
e
At least 99 percent of facilities responded to affiliation.
f
Not mutually exclusive
* The Coefficient of Variation (CV) for this estimate is greater than or equal to 0.3, indicating this number should be
interpreted with caution.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies, Substance
Abuse and Mental Health Services Administration.

157
Table C.3.7 Standard Errors - Percentage of Staff Certified in Substance Abuse Treatment and
Mean Ratio of Clients to Staff Certified in Substance Abuse Treatment, by Facility
Characteristics: National Estimates
Percent of Direct-Care Mean Ratio of Clients
Staff Certified in to Staff Certified in
Substance Abuse Substance Abuse
[Q-A10] Treatmenta Treatmentb
All Facilities 1.12 1.30
Facility Type of Care
Hospital Inpatient Only 1.68 0.38
Non-Hospital Residential Only 2.88 0.49
Outpatient Methadone Only 1.06 8.85
Outpatient Non-Methadone Only 1.55 1.85
Combination Facilities 2.44 2.07
Facility Size
Small (<17 clients) 3.66 0.35
Medium (17-40) 2.13 0.69
Large (41-100) 1.96 1.30
Very Large (>100) 1.38 4.08
Ownership
Private For-Profit 2.47 2.63
Private Non-Profit 1.47 1.48
Public 2.82 3.65
Percent Public Revenue
0% 2.63 5.77
1-50% 2.67 1.76
51-90% 2.34 2.27
91-99% 2.52 2.38
100% 2.67 3.59
Unknown % 4.53 3.04
Urbanicityc
Metro: Small Metro 4.83 2.21
Medium Metro 2.96 3.35
Large Metro 1.26 1.89
Non-Metro: Rural 9.61 7.20
Small Urban 3.28 2.34
Urban 3.33 4.19
Level of Affiliationd
Parent Facility 2.00 2.55
Affiliate 1.96 1.47
Non-Affiliate 2.12 3.42
Number of Treatment Services
Low (0-5) 2.58 3.20
Medium (6-8) 1.87 1.40
High (9-11) 1.68 2.72
See notes at end of table. (continued)

158
Table C.3.7 (continued)

Percent of Direct-Care Mean Ratio of Clients

Staff Certified in to Staff Certified in
Substance Abuse Substance Abuse
[Q-A10] Treatmenta Treatmentb
Number of Support Services
None 4.19 2.34
Low (1-2) 1.95 2.42
Medium (3-4) 1.79 2.29
High (5-8) 1.98 2.96
Facility Settinge
Hospital (inpatient or outpatient) 2.34 1.87
Non-Hospital Residential, Therapeutic Community or
Halfway House 2.44 0.84
Community Mental Health Center 3.10 3.66
Other Outpatient 1.75 2.15
Other 3.19 2.12
a
At least 88 percent of facilities provided number of direct-care staff (not FTEs).
b
At least 99 percent of facilities reported having staff certified in substance abuse treatment.
c
Based on Beale code (Butler & Beale, 1994).
d
At least 99 percent of facilities provided affiliation.
e
Not mutually exclusive.
Exclusions: ADSS Phase I excludes intake/referral-only facilities, halfway houses without paid counseling staff, solo
practices, correctional facilities, Department of Defense facilities, and Indian Health Service facilities.
Source: Alcohol and Drug Services Study (ADSS), Phase I facilities data (weighted). Office of Applied Studies,
Substance Abuse and Mental Health Services Administration.

159